Appx B-1 - NSCAW Child Remote Interview

Y_YAINTRO. I’m calling today about a research study, called the National Survey of Child and Adolescent Well-Being sponsored by the Administration for Children and Families (ACF). You took part in an earlier round of the study. Our next round of interviews is underway. We recently sent you a letter and a fact describing this next phase in more detail. Did you have a chance to review the materials?

1 = YES (GOTO YA_Review)

2 = NO (GOTO YA_NoReview)

YA_NoReview

Before we begin, I must review the consent form with you to ensure you are fully informed about study participation and your rights as a respondent. This will take just a few minutes.

GOTO YA_FULLCON (VERSION 2YA)

YA_Review

This study is sponsored by the Administration for Children and Families, a part of the U.S. Department of Health and Human Services. We are following up with over 4,000 families roughly 36 months after the initial interview. Your interview for this round of the study will take approximately 45 minutes to complete. There are two parts: first a telephone survey, and then a web survey. The telephone interview includes questions about your community environment, social supports in your life, income, employment, and independent living skills. The web survey includes questions that you can answer on your own time and in private and includes questions about services you might have received, substance abuse, delinquency, involvement with the law, coercion, and intimate partner violence. Knowledge gained from this study will improve child welfare services and programs. Any data you provide will only be used by qualified individuals for research purposes. The only exceptions to this promise of confidentiality are if you tell me you intend to seriously harm yourself or someone else, or if a child in your care is in danger. In this situation I may need to notify a mental health professional or other authorities.

Your participation is voluntary. You may consider some of the questions to be sensitive and some of the questions may also make you feel certain emotions, such as sadness. Remember you can choose not to answer any questions you do not want to answer, and you can stop the interview at any time. If you become upset at any time during the interview and wish to speak to a mental health professional about how you are feeling, I will provide you with the toll-free hotline numbers to call. A $50 electronic gift card will be sent to you after the telephone and web surveys. We may also telephone you in the future to check on the quality of my work during this interview.

Do you have any questions before we begin? ANSWER RESPONDENT QUESTIONS.

Can we go ahead and get started?

1 = YES, AGREES TO STUDY PARTICIPATION

2 = NO, DOES NOT AGREE TO STUDY PARTICIPATION

IF R STILL UNWILLING TO PARTICIPATE: Thank you for your time. END CALL. DOCUMENT THE SITUATION.

YA_FUTURE

At some point in the future, a different group of researchers may take over this study. If that happens, with your consent, we would give your contact information to the other group.

Do you agree to have your contact information given to another research company if they start doing the study?

1 = YES, AGREES TO HAVE CONTACT INFORMATION GIVEN TO ANOTHER RESEARCH COMPANY IF THEY START DOING THE STUDY.

2 = NO, DOES NOT AGREE TO HAVE CONTACT INFORMATION GIVEN TO ANOTHER RESEARCH COMPANY IF THEY START DOING THE STUDY.

YA_CARI

We also use a laptop quality control system for this study The system runs on my computer. This system will make audio recordings of what you and I say to each other during the interview. Neither you nor I will know when the computer records what we say. Project staff at RTI will listen to the recordings only to review my work. The recordings will be destroyed at the end of the study after data have been cleaned and analyzed.

Do you we have your permission to run this system during the interview?

1= YES, AGREES TO HAVING PARTS OF INTERVIEW RECORDED BY COMPUTER.

2 = NO, DOES NOT AGREE TO HAVING PARTS OF INTERVIEW RECORDED BY COMPUTER.

EMANCIPATED YOUTH INFORMED CONSENT SCRIPTS

Y_EYINTRO. I’m calling today about a research study, called the National Survey of Child and Adolescent Well-Being sponsored by the Administration for Children and Families (ACF). You took part in an earlier round of the study. Our next round of interviews is underway. We recently sent you a letter and a fact describing this next phase in more detail. Did you have a chance to review the materials?

1 = YES (GOTO EY_Review)

2 = NO (GOTO EY_NoReview)

EY_NoReview

Before we begin, I must review the consent form with you to ensure you are fully informed about study participation and your rights as a respondent. This will take just a few minutes.

GOTO EY_FULLCON (VERSION 2X)

EY_Review

This study is sponsored by the Administration for Children and Families, a part of the U.S. Department of Health and Human Services. We are following up with over 4,000 families roughly 36 months after the initial interview. Your interview for this round of the study will take approximately 45 minutes to complete. There are two parts: first a telephone survey, and then a web survey. The telephone interview includes questions about your community environment, schooling, social supports in your life, income, employment, and independent living skills. The web survey includes questions that you can answer on your own time and in private and includes questions about services you might have received, substance abuse, delinquency, involvement with the law, and coercion. Knowledge gained from this study will improve child welfare services and programs. Any data you provide will only be used by qualified individuals for research purposes. The only exceptions to this promise of confidentiality are if you tell me you intend to seriously harm yourself or someone else, or if a child in your care is in danger. In this situation I may need to notify a mental health professional or other authorities.

Do you have any questions before we begin? ANSWER RESPONDENT QUESTIONS.

Can we go ahead and get started?

1 = YES, AGREES TO STUDY PARTICIPATION

2 = NO, DOES NOT AGREE TO STUDY PARTICIPATION

IF R STILL UNWILLING TO PARTICIPATE: Thank you for your time. END CALL. DOCUMENT THE SITUATION.

EY_FUTURE

At some point in the future, a different group of researchers may take over this study. If that happens, with your consent, we would give your contact information to the other group.

Do you agree to have your contact information given to another research company if they start doing the study?

1 = YES, AGREES TO HAVE CONTACT INFORMATION GIVEN TO ANOTHER RESEARCH COMPANY IF THEY START DOING THE STUDY.

2 = NO, DOES NOT AGREE TO HAVE CONTACT INFORMATION GIVEN TO ANOTHER RESEARCH COMPANY IF THEY START DOING THE STUDY.

EY_CONTACTCG

For youth that have lived with a caregiver in the last three months, we would like to contact this person for an interview with your permission. Are you currently living with a parent or caregiver or have you lived with a parent or caregiver within the last three months?

1 = YES, CHILD IS CURRENTLY LIVING WITH CAREGIVER AND HAS LIVED WITH A CAREGIVER IN THE LAST THREE MONTHS

2 = NO, CHILD HAS NOT LIVED WITH A CAREGIVER RECENTLY [GOTO EY_CARI)

EY_PERCG

Do we have permission to approach your current caregiver or most recent caregiver for an interview?

1 = YES, PROVIDES PERMISSION TO CONTACT CURRENT/MOST RECENT CAREGIVER FOR AN INTERVIEW

2 = NO, DOES NOT PROVIDE PERMISSION TO CONTACT CURRENT/MOST RECENT CAREGIVER FOR AN INTERVIEW (FINALIZE CORRESPONDING CG CASE AS REFUSAL BY OTHER)

EY_CARI

Do you we have your permission to run this system during the interview?

1= YES, AGREES TO HAVING PARTS OF INTERVIEW RECORDED BY COMPUTER.

2 = NO, DOES NOT AGREE TO HAVING PARTS OF INTERVIEW RECORDED BY COMPUTER.

CAREGIVER PERMISSION FOR MINORS

Y_CGPERM

Hello, my name is ______________.

We recently sent you a letter and fact sheet about a research study you and your family are taking part in. We are contacting you because you or your child participated in an initial interview with us (INSERT LAST INTERVIEW DATE). We would like to speak with your child, <INSERT CHILD’S NAME>, for a follow-up interview. This interview will be conducted over the telephone and over the Internet.

Did you have time to review the materials?

1 = YES (GOTO Y_CGPERM1)

2 = NO (GOTO Y_CGNOREVIEW)

Y_CGPERM1

This study is sponsored by the Administration for Children and Families, a part of the U.S. Department of Health and Human Services. We are following up with over 4,000 children and their caregivers roughly 36 months after the initial interview. The interview with your child will last around 45 minutes. There are two parts to your child’s interview: first a telephone survey, and then a web survey. The interview will ask your child about their development, family experiences, school, and relationships with friends. At the end of the telephone survey, we will provide your child with a secure web link and a PIN to complete the rest of the questions online where they can work at their own pace and answer questions in private. The questions on the Internet will ask your child about services received, substance abuse, delinquency, sexual activity, and involvement with the law. Knowledge gained from this study will improve child welfare services and programs.

Any data your child provides will only be used by qualified individuals for research purposes. We will not tell anyone your child’s answers unless we are worried about your child’s safety. If your child tells us they might hurt themselves or someone else, we may tell someone. If they tell us someone hurts them, we will inform the appropriate authorities to keep people safe.

Your child’s participation is voluntary. Remember your child can choose not to answer any questions they do not want to answer, and your child can stop the interview at any time. Your child will receive a $20 electronic gift card plus a small gift of equal value for completing the telephone and web surveys. We may also telephone you in the future to check on the quality of my work during this interview.

Do you have any questions before we begin? ANSWER RESPONDENT QUESTIONS.

Do I have your permission to speak with your child?

1 = YES, CAREGIVER PROVIDES PERMISSION FOR CHILD TO PARTICIPATE

2 = NO, CAREGIVER DOES NOT PROVIDE PERMISSION FOR THE CHILD TO PARTICIPATE

IF CAREGIVER UNWILLING TO ALLOW CHILD TO PARTICIPATE: Thank you for your time. END CALL. DOCUMENT THE SITUATION.

Y_CGINCEN

If your child chooses to take part, they will receive a $20 gift card plus a small gift of equal value. How would you like this delivered to your child?

1 = BY PARENT E-MAIL (GOTO Y_EMAIL)

2 = BY CHILD E-MAIL (GOTO Y_EMAIL)

3 = BY MAIL (GOTO Y_PARINCENADD)

4 = PARENT DECLINES INCENTIVE

Y_EMAIL

Please tell me the email address you would like us to use to deliver the gift card to your child.

INTERVIEWER: EMAIL SHOULD BE FORMATTED AS [email protected] (E.G., [email protected])

PLEASE ENTER E-MAIL ADDRESS AND CONFIRM WITH CAREGIVER BY READING IT BACK TO THEM.

EMAIL: ____________________ [open fill, constraint:80 letters, Mask: $@]

Y_PARINCENADD

Please give us the best address to mail the instructions for redeeming your child’s gift card. Please allow two weeks for delivery.

Please provide your complete address.

STREET ADDRESS:

ADDRESS2:

CITY, STATE, ZIP:

Y_CGPERFUTURE

At some point in the future, a different group of researchers may take over this study. If that happens, with your consent, we would give contact information for you and your child to the other group.

Do you agree to have your contact information given to another research company if they start doing the study?

1 = YES, AGREES TO HAVE CONTACT INFORMATION GIVEN TO ANOTHER RESEARCH COMPANY IF THEY START DOING THE STUDY.

2 = NO, DOES NOT AGREE TO HAVE CONTACT INFORMATION GIVEN TO ANOTHER RESEARCH COMPANY IF THEY START DOING THE STUDY.

Y_CGPERMCARI

We also use a laptop quality control system for this study The system runs on my computer. This system will make audio recordings of what the child and I say to each other during the interview. Neither the child nor I will know when the computer records what we say. Project staff at RTI will listen to the recordings only to review my work. The recordings will be destroyed at the end of the study after data have been cleaned and analyzed.

Do you we have your permission to run this system during your child’s interview?

1= YES, AGREES TO HAVING PARTS OF INTERVIEW RECORDED BY COMPUTER.

2 = NO, DOES NOT AGREE TO HAVING PARTS OF INTERVIEW RECORDED BY COMPUTER.

Y_CGNOReview

Before we begin, I must review the consent form with you to ensure you are fully informed about study participation and your rights as a respondent. This will take just a few minutes.

GOTO FULL CAREGIVER PERMISSION FOR CHILD PARTICIPATION STATEMENT (VERSION 2DL)

Y_CHAVAIL

Thank you. Is <CHILD FIRST NAME> currently available to join us on the phone now?

1 = YES (GOTO Y_ASSENT)

2 = NO, CHILD NOT AVAILABLE (SET CALLBACK)

YOUTH ASSENT SCRIPTS

Y_ASSENT.

Hello, my name is ____________. Your parent has given permission for you to talk with me today.

GOTO FULL YOUTH ASSENT STATEMENT (VERSION 2I)

Y_TBINTRO (MINOR ASSENT TEACH-BACK PROCESS)

I want to make sure I was clear when I talked to you about the survey and went through the assent process. I would like to ask you a few questions to make sure you understand what agreeing to take part means. This is a way for me to review with you anything where you might still have questions.

INTERVIEWER: ENTER 1 TO CONTINUE

Y_TB1. First, please tell me what you think is involved in joining this study?

1 = CORRECT RESPONSE: SURVEYS/ANSWERING QUESTIONS/45-MINUTE SURVEY BY PHONE AND INTERNET

2 = INCORRECT RESPONSE OR MINOR SAYS DON’T KNOW

Y_TB2. Are you required to join and complete this survey?

1 = CORRECT RESPONSE: NO

2 = INCORRECT RESPONS: YES OR DON’T KNOW

Y_TB3. What will happen if you do not answer all the survey questions or want to stop the interview early?

1 = CORRECT RESPONSE: NOTHING. I CAN DECLINE/REFUSE TO ANSWER ANY QUESTION OR LEAVE AT ANY TIME.

2 = INCORRECT RESPONSE OR MINOR SAYS DON’T KNOW

Y_TB4. We will not tell anyone that you are taking part in this survey or share your information. There is an exception to this. Can you tell me what that is?

1 = CORRECT RESPONSE: SELF-HARM or HARM TO OTHERS

2 = INCORRECT RESPONSE OR MINOR SAYS DON’T KNOW

LOGIC before: IF R answered items Y_TB1 – Y_TB4 correctly (=1) GOTO Y_TB5.

Y_TB5. INTERVIEWER: THIS RESPONDENT SUCCESSFULLY COMPLETED THE ASSENT COMPREHENSION ASSESSMENT. PRESS 1 TO CONTINUE.

IF R answered any items incorrectly for Y_TB1-Y_TB4 (=2), GOTO Y_TB6.

Y_TB6. INTERVIEWER: BASED ON THE MINOR’S RESPONSES, YOU WILL NEED TO READ THE ASSENT SCRIPT AGAIN.

1 = TRY AGAIN (GOTO Y_TB1)

2 = DO NOT CONTINUE: MINOR NOT ABLE TO PASS COMPREHENSON

ASSESSMENT AFTER THREE ATTEMPTS

IF_Y_TB6 = 1

Y_MPART (YOUTH ASSENT INDICATOR)

Do you agree to participate in today’s interview?

1 = YOUTH AGREES TO STUDY PARTICIPATION

2 = YOUTH DOES NOT AGREE TO STUDY PARTICIPATION

Y_MCARI (YOUTH CARI INDICATOR)

We also use a laptop quality control system for this study The system runs on my computer. This system will make audio recordings of what you and I say to each other during the interview. Neither you nor I will know when the computer records what we say. My bosses at RTI will listen to the recordings only to review my work.

Do you we have your okay to run this system during the interview?

1= YES, YOUTH AGREES TO HAVING PARTS OF INTERVIEW RECORDED BY COMPUTER.

2 = NO, YOUTH DOES NOT AGREE TO HAVING PARTS OF INTERVIEW RECORDED BY COMPUTER.

IF Y_TB6 = 2

Y_TBEND. Thank you for taking the time to discuss the survey with me. There are many reasons people are eligible or not eligible to complete the survey. Unfortunately, we will not be able to continue with the survey.

PRIVACY

Because you may not want others to hear the responses to some of our questions, I’d like to be sure you’re in a private area. Are you in an area where you can answer these questions privately?

1 = YES: PROCEED

2 = NO: Please move to a more private area. Do you need more time?

YES: PAUSE, THEN CONTINUE

NO: CONTINUE

CHILD HOUSEHOLD MODULE

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Logic before:

IF CHILD AGE > 10, FILL: Hi, my name is _____________. Today

I'm going to ask you some questions about you, your family, friends, and school. If you have a

question or are not sure about something, tell me. The important thing is that you tell me what you

really feel or think. All your answers will be kept private. If you want to take a break, just let me

know. Before we get started, let me verify some of the information I have about you. IF YA+EY,

FILL: Hi, my name is _____________. Today I’m going to ask you some questions about you,

your family, and your life experiences. All your answers will be kept private. Before we get started,

let me verify some of the information I have about you.

Y_CH0 [ YCH0 ] NO LABEL

^Fills.Y_CH0

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

Question Fill: ^FillY_CH0

overten Hi, my name is ___________________. Today I'm going to ask you some

questions about you, your family, friends, and school. If you have a

question or are not sure about something, tell me. The important thing is

that you tell me what you really feel or think. All your answers will be kept

private. If you want to take a break, just let me know. Before we get

started, let me verify some of the information I have about you.

YA_EY Hi, my name is _____________. Today I’m going to ask you some

questions about you, your family, and your life experiences. All your

answers will be kept private. Before we get started, let me verify some of

the information I have about you.

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Y_CH0a1 [ YCH0a1 ] NO LABEL

INTERVIEWER: THIS IS FOR VERIFYING THE CHILD'S NAME:

^Fills.Y_CH0a1

FIRST:@|@|@|@B^CHILD_FName@B

MIDDLE INITIAL: @|@B^CHILD_MName@B

LAST: @|@|@|@B^CHILD_LName@B

Is this correct?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Question Fill: ^FillY_CH0a1

elevenmore First, let me verify your name.

Logic after:

IF = 1, GOTO Y_CH1a

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Y_CH0b [ YCH0b ] NO LABEL

CORRECT FIRST NAME, AS NEEDED:

FIRST NAME:

Question Type: STRING[20]

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Y_CH0c [ YCH0c ] NO LABEL

CORRECT MIDDLE INITIAL, AS NEEDED:

MIDDLE INITIAL:

Question Type: STRING[20], empty

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Y_CH0d [ YCH0d ] NO LABEL

CORRECT LAST NAME, AS NEEDED:

LAST NAME:

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Y_CH1a [ YCH1a ] Correct DOB(YN2T)

^Fills.Y_CH1a

@B^DOB_Mo_Txt ^DOB_Dy, ^DOB_Yr@B

IS THIS CORRECT?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Question Fill: ^FillY_CH1a

elevenmore Let me verify your date of birth.

Logic after:

IF Y_CH1a = Yes GOTO Y_CH2a

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Y_CH1m [ YCH1m ] CH DOB month

INTERVIEWER: CORRECT MONTH OF BIRTH IF NEEDED.

MONTH:

Question Type: TMonth

jan 1 January

feb 2 February

mar 3 March

apr 4 April

may 5 May

jun 6 June

jul 7 July

aug 8 August

sep 9 September

oct 10 October

nov 11 November

dec 12 December

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Y_CH1d [ YCH1d ] CH DOB day

INTERVIEWER: CORRECT DAY OF BIRTH IF NEEDED.

DAY:

Question Type: 1..31

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Y_CH1y [ YCH1y ] CH DOB year

INTERVIEWER: CORRECT YEAR OF BIRTH IF NEEDED.

YEAR:

Question Type: 1980..2013

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Logic before:

So you are (FILL COMPUTED AGE BASED ON DOB

ENTERED IN Y_CH1a) years old?

Y_CH2a [ YCH2a ] CH age

^CH2a_Fill

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH2a = No GO BACK TO CORRECT Y_CH1a

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Logic before:

IF CHILD AGE IS >=11, GOTO Y_CH3b

Y_CH3a [ YCH3a ] CH gender

CODE CHILD'S GENDER.

THE CONTROL CARD INDICATES THAT THIS CHILD RESPONDENT IS A ^Fills.Gender. IF THIS

IS NOT CORRECT, VERIFY THAT YOU ARE INTERVIEWING THE CORRECT CHILD BEFORE

CONTINUING.

Question Type: TGenderC

male 1 MALE

female 2 FEMALE

Question Fill: ^FillGender

male MALE

female FEMALE

Logic after:

IF CHILD AGE IS < 4, GOTO Y_CH4d

IF CHILD AGE IS >=4 GOTO Y_CH5

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Y_CH3b

What sex were you assigned at birth, on your original birth certificate?

1 Male

2 Female

----------------------------------------------------------------------------------------------------------------

Y_CH3c

How do you describe yourself?

1 Male

2 Female

3 Transgender

4 Do not identify as male, female, or transgender

Logic after:

GOTO Y_CH5

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IF CHILD AGE > 10,

GOTO Y_CH7a; IF YA+EY, GOTO Y_CH8aa

Y_CH5 [ YCH5 ] NO LABEL

Hi, my name is _____________. Today I'm going to ask you some questions about you, your

family, friends, and school.

If you have a question or are not sure about something, tell me. The important thing is that you

tell me what you really feel or think. All your answers will be kept private. If you want to take a

break, just let me know.

PRESS "1" AND [ENTER] TO CONTINUE.

Question Type: TCont

Continue 1 Continue

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Y_CH6a [ YCH6a ] CH name(YN2T)

What is your first name?

FIRST NAME:

Question Type: STRING[30]

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Y_CH7a [ YCH7a ] CH has nickname(YN2T)

Do you have a nickname you like to be called other than ^CHILD?

INTERVIEWER NOTE: IF NICKNAME IS ENTERED, THEN INTERVIEWER WILL ADDRESS

CHILD BY NICKNAME FOR REMAINDER OF INTERVIEW.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH7a = No GOTO Y_CH8aa

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Y_CH7b [ YCH7b ] CH nickname

What is it?

NICKNAME:

Question Type: STRING[30]

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Logic before:

IF CHILD AGE IS 11 OR OLDER, OR YA+EY, ASK Y_CH8aa. ELSE, GOTO Y_CH8a

Y_CH8aa [ YCH8aa ] CH Spanish Hispanic or Latino?

Are you Spanish, Hispanic, or Latino?

Question Type: TCH8aa

no 1 No, not Spanish/Hispanic/Latino

mex 2 Yes, Mexican, Mexican-American, Chicano

pr 3 Yes, Puerto Rican

cuba 4 Yes, Cuban

other 5 Yes, Other

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Logic before:

IF CHILD AGE < 6, GOTO Y_CH9a

Y_CH8a [ YCH8a ] Labels are in Logic After

USE CARD 0. What race are you?

CODE ALL THAT APPLY.

NOTE: IF CHILD CANNOT REPORT HIS/HER RACE, CODE "DON'T KNOW." @BDO NOT

CODE RACE BASED ON YOUR OBSERVATION@B.

Question Type: TRaceC

amerind 1 AMERICAN INDIAN OR ALASKA NATIVE

asian 2 ASIAN

black 3 BLACK OR AFRICAN AMERICAN

pacislandr 4 NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

white 5 WHITE

Logic after:

IF YA+EY, GOTO Y_CH9Ya; YCH8TG_1--CH American Indian/Alaskan Native; YCH8TG_2--CH

Asian; YCH8TG_3--CH Black or African American; YCH8TG_4--CH Native Hawaiian/other Pac.

Islander; YCH8TG_5--CH White; YCH8TG_6--DK; YCH8TG_7--RF

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Logic before:

Y_CH9a [ YCH9a ] CH school status

Do you go to school or do your parents teach you at home?

FR NOTE: ATTENDING SCHOOL VIRTUALLY OR ONLINE SHOULD BE CONSIDERED AS “GOING TO SCHOOL”

NOTE: CODE CHILDREN ON SUMMER BREAK FROM SCHOOL AS "1."

Question Type: TCH9a

inschool 1 GO TO SCHOOL

homeschooled 2 TAUGHT AT HOME

neither 3 NEITHER

Logic after:

IF Y_CH9a = 2 OR 3 GOTO Y_CH9ba; IF RESPONSE <> 1, SCHOOL STATUS = 0 (NO)

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Y_CH9aa [ YCH9aa ] CH attends school regularly

Do you go regularly, that is, most school days?

FR NOTE: CHILDREN WHO ATTEND SCHOOL VIRTUALLY OR ONLINE DURING COVID ARE CONSIDERED ENROLLED.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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Logic before:

ASK Y_CH9ba-Y_CH9dn IF CHILD AGE IS 12 OR HIGHER AND NOT EMANCIPATED; ELSE GO

TO Y_CH9Ya

Y_CH9ba [ YCH9c ] Work for pay outside your home in last 4 wks?

In the last 4 weeks, did you work--for pay--for anyone outside your home? This includes both

regular jobs and things like baby-sitting or yard work.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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Y_CH9cn [ YCH9cn ] How many hrs do you work for pay in a typical non-summer wk?

How many hours do you spend working for pay in a typical non-summer week?

HOURS:

Question Type: 0..145

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Y_CH9dn [ YCH9dn ] How many hrs do you work for pay in a typical summer wk?

How many hours do you spend working for pay in a typical summer week?

HOURS:

Question Type: 0..97

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Logic before:

IF AGE IS >=18 OR EMANCIPATED YOUTH, ASK Y_CH9Ya. ELSE, SKIP TO Y_CH10a.

Y_CH9Ya [ YCH9Ya ] Highest Grade compl. in school

What is the highest grade in school @Byou have completed@B? Please include vocational or

technical training and any years in college you may have completed.

Question Type: TCH9Ya

preschool 44 NURSERY SCHOOL/PRESCHOOL/HEAD START

kindergrtn 55 KINDERGARTEN

first 1 FIRST GRADE

second 2 SECOND GRADE

third 3 THIRD GRADE

fourth 4 FOURTH GRADE

fifth 5 FIFTH GRADE

sixth 6 SIXTH GRADE

seventh 7 SEVENTH GRADE

eighth 8 EIGHTH GRADE

ninth 9 NINTH GRADE

tenth 10 TENTH GRADE

eleventh 11 ELEVENTH GRADE

twelfth 12 TWELFTH GRADE

vocatech 13 VOCATIONAL/TECHNICAL

college 14 ANY YEAR OF COLLEGE

ungraded 17 UNGRADED PLACEMENT

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Y_CH9Yb [ Y_CH9Yb] CH repeated any grades since last interview

Since ^Global.LastInt, have you repeated any grades?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Y_CH9Yc [ Y_CH9Yc ] Labels are in Logic After

Which grades have you repeated?

CODE ALL THAT APPLY.

Question Type: TGrdRepS

kindergrtn 55 KINDERGARTEN

first 1 FIRST GRADE

second 2 SECOND GRADE

third 3 THIRD GRADE

fourth 4 FOURTH GRADE

fifth 5 FIFTH GRADE

sixth 6 SIXTH GRADE

seventh 7 SEVENTH GRADE

eighth 8 EIGHTH GRADE

ninth 9 NINTH GRADE

tenth 10 TENTH GRADE

eleventh 11 ELEVENTH GRADE

twelfth 12 TWELFTH GRADE

Y_CH9Yaa [ YCH9Yaa ] Do you have high school diploma?

Do you have a high school diploma?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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Y_CH9Yba [ YCH9Yba ] Do you have a GED?

Do you have a GED?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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Y_CH9Yca [ YCH9Yca ] Currently enrolled in school?

Are you currently enrolled in school?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH9Yca = No GOTO Y_CH9Yfa

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Y_CH9Yda [ YCH9Yda ] What type of school attend?

What type of school do you attend?

Question Type: TCH9Yda

jrhigh 0 Junior High or Middle School

hs 1 High School

voctech 2 Vocational/Technical School

commcoll 3 Community College (2-year)

college 4 4-Year College

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Y_CH9Yea [ YCH9Yea ] Part-time/full-time student?

Are you a part-time or full-time student?

Question Type: TCH9Yea

part 1 Part time

full 2 Full time

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Y_CH9Yfa [ YCH9Yfa ] How far in school do you think you will get?

As things stand now, how far in school do you think you will get?

Question Type: TCH9Yfa

lessthanhs 1 Less than high school graduation

ged 2 GED or other equivalency only

hs 3 High school graduation only

oneortwoyr 4 Attend or complete a 1- or 2-year program in a community college or

vocational school

somecollege 5 Attend college, but not complete a 4- or 5-year degree

collegegrad 6 Graduate from college (4- or 5-year degree)

masters 7 Obtain a Master's degree or equivalent

doctorate 8 Obtain a Ph.D., M.D., or other advanced degree

---------------------------------------------------------------------------------

Logic before:

IF CHILD IS EMANCIPATED OR YOUNG ADULT (18+), GOTO Y_CH24a.

INTERVIEWER: ^CHILD'S PRIMARY CAREGIVER'S RELATIONSHIP TO ^CHILD FROM CID IS

@B^CAREGIVER_A@B.

Y_CH10a

INTERVIEWER: IS THE CHILD LIVING IN A FAMILY SETTING?

A FAMILY SETTING INCLUDES LIVING WITH A BIRTH PARENT, ADOPTIVE PARENT, RELATIVES, FICTIVE KIN, OR FOSTER PARENTS.

Question Type: TYN

yes 1 YES [GO TO Y_CH11a]

no 2 NO [GO TO Y_CH11b]

---------------------------------------------------------------------------------

INTERVIEWER: ^CHILD'S PRIMARY CAREGIVER'S RELATIONSHIP TO ^CHILD FROM CID IS

@B^CAREGIVER_A@B.

Y_CH11a

FROM THE CATEGORIES BELOW, WHAT BEST DESCRIBES ^CHILD'S FAMILY SETTING?

With one or both birth parents
With one or both adoptive parents
With relatives oR FICTIVE KIN (E.G. GODPARENTS or FAMILY FRIEND)
With non-relatives IN A FOSTER HOME

---------------------------------------------------------------------------------

Y_CH11b

FROM THE CATEGORIES BELOW, WHAT BEST DESCRIBES ^CHILD'S NON-FAMILY SETTING?

In an emergency shelter
In a specialized or therapeutic foster home or therapeutic home
In a group home
In a residential treatment facility
IN A psychiatric hospital
In a medical hospital or facility
In a place of detention (e.g., juvenile detention, juvenile or adult corrections)
In transitional independent living Apartment, HOME, OR FACILITY
CHILD LIVES ON OWN (INCLUDES SCHOOL/COLLEGE, MILITARY, ETC.)
Whereabouts unknown, runaway
OTHER

Logic after:

IF Y_CH11b >= 3, GOTO Y_CH12a

INTERVIEWER:

^CHILD’S CURRENT CAREGIVER FROM THE CID IS @B^CAREGIVER_A@B.

^CHILD’S LEGAL GUARDIAN FROM THE CID IS <INSERT LG FROM CID>.

Y_CH11aa [ YCH11aa ] Caregiver is CH legal guardian

INTERVIEWER: IS THE CAREGIVER CHILD'S LEGAL GUARDIAN?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_CH12a [ YCH12a ] Correct name of primary CG

INTERVIEWER: VERIFY THAT ^CHILD'S PRIMARY CAREGIVER IS:

FIRST:@|@|@|@B^CAREGIVER_A_FName@B

MIDDLE INITIAL:@|@B^CAREGIVER_A_MName@B

LAST:@|@|@|@B^CAREGIVER_A_LName@B

IS THIS CORRECT?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH12a = Yes GOTO Y_CH13a

---------------------------------------------------------------------------------

Y_CH12f [ YCH12f ] CH primary CG-first name

INTERVIEWER: CORRECT FIRST NAME IF NEEDED.

FIRST NAME:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Y_CH12m [ YCH12m ] CH primary CG-middle name

INTERVIEWER: CORRECT MIDDLE NAME IF NEEDED.

MIDDLE NAME:

Question Type: STRING[30], empty

---------------------------------------------------------------------------------

Y_CH12l [ YCH12l ] CH primary CD-last name

INTERVIEWER: CORRECT LAST NAME IF NEEDED.

LAST NAME:

Question Type: STRING[40]

---------------------------------------------------------------------------------

Y_CH14a [ YCH14a ] Primary CG relationship to CH

INTERVIEWER: ^CHILD'S PRIMARY CAREGIVER'S RELATIONSHIP TO ^CHILD FROM CID IS

@B^CAREGIVER_A@B.

INTERVIEWER: CODE CURRENT PRIMARY CAREGIVER'S RELATIONSHIP TO ^CHILD.

Question Type: TCH14a

biomom 1 BIOLOGICAL MOTHER

stepmom 2 STEP-MOTHER

adoptmom 3 ADOPTIVE MOTHER

fostmom 4 FOSTER MOTHER

sister 5 SISTER

aunt 6 AUNT

grandma 7 GRANDMOTHER

biodad 8 BIOLOGICAL FATHER

stepdad 9 STEP-FATHER

adoptdad 10 ADOPTIVE FATHER

fostdad 11 FOSTER FATHER

brother 12 BROTHER

uncle 13 UNCLE

grandpa 14 GRANDFATHER

otherrel 95 OTHER RELATIVE

othernonrel 96 OTHER NON-RELATIVE

Logic after:

IF Y_CH14a = 1-14, GOTO Y_CH15prea; IF Y_CH14a = 95, GOTO Y_CH14b; IF Y_CH14a = 96,

GOTO Y_CH14c; RELATIONSHIP BECOMES CAREGIVER_A FILL

---------------------------------------------------------------------------------

Logic before:

IF Y_CH14a = 95, ELSE GOTO Y_CH14c

Y_CH14b [ YCH14b ] Specify CG other relative relationship to CH

SPECIFY OTHER RELATIVE RELATIONSHIP

RELATIONSHIP:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Logic before:

IF Y_CH14a = 96, ELSE GOTO Y_CH15prea

Y_CH14c [ YCH14c ] Specify CG other non-relative relationship to CH

SPECIFY OTHER NON-RELATIVE RELATIONSHIP

RELATIONSHIP:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Y_CH15prea [ YCH5prea ] Is there a secondary CG for CH

INTERVIEWER: IS THERE A SECONDARY CAREGIVER FOR THE CHILD?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH15prea = Yes GOTO Y_CH15a. ELSE, GOTO Y_CH18a.

---------------------------------------------------------------------------------

Y_CH15a [ YCH15a ] Correct name of secondary CG

INTERVIEWER: VERIFY THAT ^CHILD'S CURRENT SECONDARY CAREGIVER IS:

FIRST:@|@|@|@B^CAREGIVER_B_FName@B

MIDDLE INITIAL:@|@B^CAREGIVER_B_MName@B

LAST:@|@|@|@B^CAREGIVER_B_LName@B

IS THIS CORRECT?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH15a = Yes GOTO Y_CH16a

---------------------------------------------------------------------------------

Y_CH15f [ YCH15f ] CH secondary CG-first name

INTERVIEWER: CORRECT FIRST NAME IF NEEDED.

FIRST NAME:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Y_CH15m [ YCH15m ] CH secondary CG-middle name

INTERVIEWER: CORRECT MIDDLE NAME IF NEEDED.

MIDDLE NAME:

Question Type: STRING[30], empty

---------------------------------------------------------------------------------

Y_CH15l [ YCH15l ] CH secondary CG-last name

INTERVIEWER: CORRECT LAST NAME IF NEEDED.

LAST NAME:

Question Type: STRING[40]

---------------------------------------------------------------------------------

Y_CH17a [ YCH17a ] Secondary CG relationship to CH

^Fills.Y_CH17a @B^CAREGIVER_B@B^Fills.OnlyDot

INTERVIEWER: CODE ^CH17a_Fill SECONDARY CAREGIVER'S RELATIONSHIP TO ^CHILD.

Question Type: TCH14a

biomom 1 BIOLOGICAL MOTHER

stepmom 2 STEP-MOTHER

adoptmom 3 ADOPTIVE MOTHER

fostmom 4 FOSTER MOTHER

sister 5 SISTER

aunt 6 AUNT

grandma 7 GRANDMOTHER

biodad 8 BIOLOGICAL FATHER

stepdad 9 STEP-FATHER

adoptdad 10 ADOPTIVE FATHER

fostdad 11 FOSTER FATHER

brother 12 BROTHER

uncle 13 UNCLE

grandpa 14 GRANDFATHER

otherrel 95 OTHER RELATIVE

othernonrel 96 OTHER NON-RELATIVE

Question Fill: ^FillY_CH17a

cg2 INTERVIEWER: CURRENT SECONDARY CAREGIVER'S

RELATIONSHIP TO THE CHILD IS

Logic after:

IF Y_CH17a = 1-14, GOTO Y_CH18n; IF Y_CH17a = 95, GOTO Y_CH17b; IF Y_CH17a = 96,

GOTO Y_CH17c; RELATIONSHIP BECOMES CAREGIVER_B FILL

---------------------------------------------------------------------------------

Logic before:

IF Y_CH17a = 95, ELSE GOTO Y_CH17c

Y_CH17b [ YCH17b ] Specify secondary CG other relative relationship to CH

SPECIFY OTHER RELATIVE RELATIONSHIP

RELATIONSHIP:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Logic before:

IF Y_CH17a = 96, ELSE GOTO Y_CH18a

Y_CH17c [ YCH17c ] Specify secondary CG other non-relative relationship to CH

SPECIFY OTHER NON-RELATIVE RELATIONSHIP

RELATIONSHIP:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Logic before:

[IF CHILD AGE < 11: ADDRESS PARENT/GUARDIAN: How long has ^CHILD lived with you?]

[ELSE: How long have you lived with your [FILL RELATIONSHIP FROM Y_CH14, OR Y_CH12

Y_CH18a [ YCH18a ] How long CH lived with CG

^CH18a_Fill

NUMBER:

Question Type: 0..500

---------------------------------------------------------------------------------

Y_CH18u [ YCH18u ] # of D/W/M/Y CH lived with CG

(Is that the number of days, weeks, months, or years?)

Question Type: TCH18b

days 1 DAYS

weeks 2 WEEKS

months 3 MONTHS

years 4 YEARS

Logic after:

GOTO Y_CH19a

---------------------------------------------------------------------------------

Logic before:

IF Y_CH10a = NO OR Y_CH11a = 2, 3, OR 4, CONTINUE; ELSE GOTO Y_CHEND

Y_CH19a [ YCH19a ] Bio Mother still living

^Fills.Y_CH19a

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Question Fill: ^FillY_CH19a

lessthan11 Is ^Global.CHILD's biological mother still living?

elevenmore ASK IF NECESSARY: Is your biological mother still living?

---------------------------------------------------------------------------------

Y_CH20a [ YCH20a ] Bio Father still living

^Fills.Y_CH20a

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Question Fill: ^FillY_CH20a

lessthan11 Is ^Global.CHILD's biological father still living?

elevenmore ASK IF NECESSARY: Is your biological father still living?

Logic after:

GOTO Y_CHEND

---------------------------------------------------------------------------------

Logic before:

IF CHILD AGE IS 18 OR OLDER OR CHILD IS EMANCIPATED, CONTINUE WITH REAMINING

QUESTIONS. ELSE, GOTO C_CHEND.

Y_CH24a [ YCH24a ] CH Born in US

Were you born in the United States?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH24a = 2 GOTO Y_CH27a

---------------------------------------------------------------------------------

Logic before:

ASK IF Y_CH24a = 2

Y_CH26a

In what country were you born?

MEXICO..................................................................................................1

GUATEMALA..........................................................................................2

CUBA.....................................................................................................3

DOMINICAN REPUBLIC........................................................................................ ... 4

INDIA......................................................................................................5

CHINA....................................................................................................6

PHILIPPINES.........................................................................................7

JAPAN....................................................................................................8

KOREA...................................................................................................9

VIETNAM...............................................................................................10

GUAM.....................................................................................................11

SAMOA..................................................................................................12

OTHER (SPECIFY)................................................................................13

Y_CH26aa

Logic before:

ASK IF Y_CH26a = 13

ENTER OTHER COUNTRY: _____________________________

--------------------------------------------------------------------------------

Y_CH26n [YCH26n ] Total years YA lived in US

How many years all together have you been living in the U.S.?

(COUNT THE SUM OF ALL TIME SPENT IN THE U.S., EVEN IF NOT CONTINUOUS.)

YEARS:

Question Type: 0..95

Y_CH24b

how many adults, age 18 or over are living in this household?

Y_CH24c

Including you, how many children, age 17 or younger are living in this household?

---------------------------------------------------------------------------------

Y_CH32a [ YCH32a ] Marital status

Now I have a few more questions about you. Please look at Card 2. Are you currently...

NOTE: "MARRIED" CAN INCLUDE LEGAL AND COMMON LAW MARRIAGES, DEPENDING ON

WHAT RESPONDENT THINKS HIS/HER MARITAL STATUS IS.

Question Type: TCH32a

married 1 Married,

separated 2 Separated,

divorced 3 Divorced,

widowed 4 Widowed, or

never 5 Have you never been married?

---------------------------------------------------------------------------------

Logic before:

---------------------------------------------------------------------------------

Logic before:

Y_CH35a [ YCH35b ] Have any children

Do you have any biological children, including any living outside the household?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH35a = 2 GOTO Y_CH41a

---------------------------------------------------------------------------------

Y_CH36a [ YCH36a ] Number of births

How many children have you ^Fills.CH36a? Please include any children living outside the

Question Type: 0..10

Question Fill: ^FillCH36a

female given birth to

male fathered

Logic after:

IF 0 GOTO Y_CH41a

---------------------------------------------------------------------------------

Y_CH41a [ YCH41a ] Number times moved in last 12 months

Now let's talk about the place where you're living these days. How many times have you moved in

the last 12 months?

NUMBER:

Question Type: 0..100

---------------------------------------------------------------------------------

Y_CH42a [ YCH42a ] Type of housing

Think about the place that you are currently staying. Do you own that place, rent that place, are

you just staying there, or do you have some other type of arrangement?

Question Type: TCH42a

own 1 Own

rent 2 Rent

staying 3 Just staying there

other 4 Other

Logic after:

IF Y_CH42a = 1, 3 OR 4 GOTO Y_CH45a

---------------------------------------------------------------------------------

Y_CH44a [ YCH44a ] Live in public housing

Is your place in a public housing project, is it owned by the local housing authority, or some other

public agency?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

Y_CH45a [ YCH45a ] Know bio mother

Now I would like to ask some questions about your biological family. Do you know your biological

mom?

(IF NECESSARY, PROBE: THE MOM WHO GAVE BIRTH TO YOU.)

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH45a = 2 GOTO Y_CH47a

---------------------------------------------------------------------------------

Y_CH46a [ YCH46a ] How often have contact with bio mother

About how often do you see or have contact with your biological mom? Would you say...

Question Type: TCH46a

never 1 never,

lessonce 2 less than once a month,

oncetwice 3 once or twice a month,

oncewk 4 about once a week,

sevweek 5 several times a week, or

everyday 6 every day?

deceased 7 BIOLOGICAL MOTHER IS DECEASED

---------------------------------------------------------------------------------

Logic before:

Y_CH47a [ YCH47a ] Know bio father

Do you know your biological dad?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH47a = 2 GOTO Y_CH49a

---------------------------------------------------------------------------------

Y_CH48a [ YCH48a ] How often have contact with bio father

About how often do you see or have contact with your biological dad? Would you say...

Question Type: TCH48a

never 1 never,

lessonce 2 less than once a month,

oncetwice 3 once or twice a month,

oncewk 4 about once a week,

sevweek 5 several times a week, or

everyday 6 every day?

deceased 7 BIOLOGICAL FATHER IS DECEASED

---------------------------------------------------------------------------------

Y_CH49a [ YCH49a ] Have bio siblings

Do you have biological siblings?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH49a = 2 GOTO Y_CH51a

---------------------------------------------------------------------------------

Y_CH50a [ YCH50a ] How often have contact with bio siblings

About how often do you see or have contact with your biological siblings? Would you say...

Question Type: TCH50a

never 1 never,

lessonce 2 less than once a month,

oncetwice 3 once or twice a month,

oncewk 4 about once a week,

sevweek 5 several times a week, or

everyday 6 every day?

deceased 7 BIOLOGICAL SIBLINGS ARE DECEASED

---------------------------------------------------------------------------------

Y_CH_END [ YCH_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

CHILD COMMUNITY ENVIRONMENT MODULE

---------------------------------------------------------------------------------

Logic before:

IF CHILD IS EMANCIPATED OR CHILD IS YOUNG ADULT (18+), CONTINUE. ELSE, GOTO

Y_CNEND.

---------------------------------------------------------------------------------

Y_CN6a [ YCN6a ] EmanCH cmpr neighborhd safety

For these next items, please think about how your neighborhood compares to most other

neighborhoods.

Is your neighborhood...

Question Type: TSafe

safer 1 safer,

assafe 2 about the same, or

notsafe 3 not as safe as most neighborhoods?

---------------------------------------------------------------------------------

Logic after:

Y_CNEND

CHILD RELATIONSHIP WITH PEERS

---------------------------------------------------------------------------------

Logic before:

IF AGE < 7 OR CHILD IS YOUNG ADULT (18+) OR EMANCIPATED, GOTO Y_RREND. ELSE, CONTINUE

Now I’m going to ask you about your relationships with other kids at school and in your neighborhood. Please think about your experiences in the past 12 months.

IF Y_CH9a = 2 or 3, GOTO Y_RR2.

Y_RR1

Please look at Card 5. In the past 12 months, how well did Fill PRIMARY CAREGIVER'S RELATIONSHIP TO ^CHILD know your peers at school? Would you say…

1 Very well

2 Moderately well

3 Not well at all

4 Not at all

Y_RR2

In the past 12 months, how well did Fill PRIMARY CAREGIVER'S RELATIONSHIP TO ^CHILD know your peers in the neighborhood? Would you say…

1 Very well

2 Moderately well

3 Not well at all

4 Not at all

IF Y_CH9a = 2 or 3, GOTO Y_RR4. Y_RR3

In the past 12 months, how well did Fill SECONDARY CAREGIVER'S RELATIONSHIP TO ^CHILD know your peers at school? Would you say…

1 Very well

2 Moderately well

3 Not well at all

4 Not at all

Y_RR4

In the past 12 months, how well did Fill SECONDARY CAREGIVER'S RELATIONSHIP TO ^CHILD know your peers in the neighborhood? Would you say…

1 Very well

2 Moderately well

3 Not well at all

4 Not at all

IF Y_CH9a = 2 or 3, GOTO Y_RR6.

Y_RR5

Please look at Card 6. In the past 12 months, what percentage of your peers at school were friendly toward you? Would you say…

1 Very few (LESS THAN 25%)

2 Some (AROUND 25%)

3 About half (50%)

4 Most (AROUND 75%)

5 Almost all (MORE THAN 75%)

Y_RR6

In the past 12 months, what percentage of your peers in the neighborhood were friendly toward you? Would you say…

1 Very few (LESS THAN 25%)

2 Some (AROUND 25%)

3 About half (50%)

4 Most (AROUND 75%)

5 Almost all (MORE THAN 75%)

IF Y_CH9a = 2 or 3, GOTO Y_RR8.

Y_RR7

In the past 12 months, what percentage of your peers at school were unfriendly toward you? Would you say…

1 Very few (LESS THAN 25%)

2 Some (AROUND 25%)

3 About half (50%)

4 Most (AROUND 75%)

5 Almost all (MORE THAN 75%)

Y_RR8

In the past 12 months, what percentage of your peers in the neighborhood were unfriendly toward you? Would you say…

1 Very few (LESS THAN 25%)

2 Some (AROUND 25%)

3 About half (50%)

4 Most (AROUND 75%)

5 Almost all (MORE THAN 75%)

Y_RR9

In the past 12 months, what percentage of your peers ignored you, or were simply neutral about you? Would you say…

1 Very few (LESS THAN 25%)

2 Some (AROUND 25%)

3 About half (50%)

4 Most (AROUND 75%)

5 Almost all (MORE THAN 75%)

IF Y_CH9a = 2 or 3, GOTO Y_RR12.

Y_RR10

In the past 12 months, what percentage of your friends were well behaved in school? Would you say…

1 Very few (LESS THAN 25%)

2 Some (AROUND 25%)

3 About half (50%)

4 Most (AROUND 75%)

5 Almost all (MORE THAN 75%)

Y_RR11

In the past 12 months, how often did you spend time with kids who took school seriously and completed their homework? Would you say…

1 Never

2 Hardly ever

3 Sometimes

4 Most of the time

5 Always

Y_RR12

How often did you spend time with kids who were involved in positive school or community activities? Would you say…

1 Never

2 Hardly ever

3 Sometimes

4 Most of the time

5 Always

Y_RR13

Please look at Card 6. In the past 12 months, what percentage of your friends misbehaved or broke rules? Would you say…

1 Very few (LESS THAN 25%)

2 Some (AROUND 25%)

3 About half (50%)

4 Most (AROUND 75%)

5 Almost all (MORE THAN 75%)

Y_RR14

In the past 12 months, what percentage of your friends experimented with smoking or other substances? Would you say…

1 Very few (LESS THAN 25%)

2 Some (AROUND 25%)

3 About half (50%)

4 Most (AROUND 75%)

5 Almost all (MORE THAN 75%)

Y_RR15

In the past 12 months, what percentage of your friends dressed or acted like a gang member? Would you say…

1 Very few (LESS THAN 25%)

2 Some (AROUND 25%)

3 About half (50%)

4 Most (AROUND 75%)

5 Almost all (MORE THAN 75%)

Y_RR16

In the past 12 months, what percentage of your friends were older? Would you say…

1 Very few (LESS THAN 25%)

2 Some (AROUND 25%)

3 About half (50%)

4 Most (AROUND 75%)

5 Almost all (MORE THAN 75%)

Y_RR17

In the past 12 months, what percentage of your friends did not attend school? Would you say…

1 Very few (LESS THAN 25%)

2 Some (AROUND 25%)

3 About half (50%)

4 Most (AROUND 75%)

5 Almost all (MORE THAN 75%)

Y_RR18

In the past 12 months, what percentage of your friends spread rumors or set up conflicts with peers? Would you say…

1 Very few (LESS THAN 25%)

2 Some (AROUND 25%)

3 About half (50%)

4 Most (AROUND 75%)

5 Almost all (MORE THAN 75%)

Y_RR19

Has anyone teased you or called you names recently?

1 YES

2 NO

Logic after:

If Y_RR19 = NO, GOTO Y_RR20

Y_RR19a

How often? Would you say…

1 Most days

2 About once a week

3 Less than once a week

Y_RR19b

How upsetting was it that you were teased? Would you say…

1 Not at all

2 A bit

3 I was quite upset

Y_RR20

Has anyone spread rumors about you recently?

1 YES

2 NO

Logic after:

If Y_RR20 = NO, GOTO Y_RR21

Y_RR20a

How often? Would you say…

1 Most days

2 About once a week

3 Less than once a week

Y_RR20b

How upsetting were the rumors? Would you say…

1 Not at all

2 A bit

3 I was quite upset

Y_RR21

Have you been deliberately left out of things recently?

1 YES

2 NO

Logic after:

If Y_RR21 = NO, GOTO Y_RR22

Y_RR21a

How often? Would you say…

1 Most days

2 About once a week

3 Less than once a week

Y_RR21b

How upsetting was it being left out of things? Would you say…

1 Not at all

2 A bit

3 I was quite upset

IF Y_CH9a = 2 or 3, GOTO Y_RREND.

Y_RR22

Have you been threatened physically or actually hurt by another kid at school recently?

1 YES

2 NO

Logic after:

If Y_RR22 = NO, GOTO Y_RREND

Y_RR22a

How often? Would you say…

1 Most days

2 About once a week

3 Less than once a week

Y_RR22b

How upsetting was it being threatened or hurt? Would you say…

1 Not at all

2 A bit

3 I was quite upset

Y_RREND

CHILD PARENTAL MONITORING MODULE

---------------------------------------------------------------------------------

Logic before:

IF AGE < 10, GOTO Y_PMEND. IF CHILD IS YOUNG ADULT (18+) OR EMANCIPATED, GOTO

Y_PMEND. NOT FOR EY OR YA. ELSE, CONTINUE.

Y_PM7a [ YPM7a ] How often CG talks about what you do for coming day

Now I'd like to talk with you about how often you and your ^Global.CAREGIVER_A talk about

different things, like your friends, where and when you go out, and when you'll be back.

USE CARD 7. For the next questions, pick your answer from this card. @BIn the past 6

months@B, how often did your ^Global.CAREGIVER_A talk to you about what you were going to

do for the @Bcoming@B day?

Question Type: TPMFreq

almstnvr 1 Almost never

oncinawhl 2 Once in a while

sometimes 3 Sometimes

often 4 Often

almstalwys 5 Almost always

---------------------------------------------------------------------------------

Y_PM8a [ YPM8a ] How often CG talks about what you did during the day

@BIn the past 6 months@B, how often did your ^Global.CAREGIVER_A talk to you about what

you had @Bactually@B done during the day?

Question Type: TPMFreq

almstnvr 1 Almost never

oncinawhl 2 Once in a while

sometimes 3 Sometimes

often 4 Often

almstalwys 5 Almost always

---------------------------------------------------------------------------------

Y_PM9a [ YPM9a ] How often CG talks about how school is going

How often did your ^Global.CAREGIVER_A talk to you about how things were going at school?

FR NOTE; IF THE CHILD SAYS THEY ARE NOT ATTENDING SCHOOL IN PERSON, PROMPT THAT ONLINE/VIRTUAL LEARNING SHOULD BE CONSIDERED.

Question Type: TPMFreq

almstnvr 1 Almost never

oncinawhl 2 Once in a while

sometimes 3 Sometimes

often 4 Often

almstalwys 5 Almost always

---------------------------------------------------------------------------------

Y_PM14a [ YPM14a ] How often CG knows you come home late?

If you did not come home by the time that you were supposed to be in, how often would your

^Global.CAREGIVER_A know?

Question Type: TPMFreqC

almstnvr 1 ALMOST NEVER

oncinawhl 2 ONCE IN A WHILE

sometimes 3 SOMETIMES

often 4 OFTEN

almstalwys 5 ALMOST ALWAYS

---------------------------------------------------------------------------------

Y_PM17a [ YPM17a ] How often your CG knows who you are with when away from home

How often does your ^Global.CAREGIVER_A know @Bwho@B you are with when you are away

from home?

Question Type: TPMFreqC

almstnvr 1 ALMOST NEVER

oncinawhl 2 ONCE IN A WHILE

sometimes 3 SOMETIMES

often 4 OFTEN

almstalwys 5 ALMOST ALWAYS

---------------------------------------------------------------------------------

Y_PM18a [ YPM18a ] How often CG knows when you will be home when you are out

When you are out, how often does your ^Global.CAREGIVER_A know what time you will be home?

Question Type: TPMFreqC

almstnvr 1 ALMOST NEVER

oncinawhl 2 ONCE IN A WHILE

sometimes 3 SOMETIMES

often 4 OFTEN

almstalwys 5 ALMOST ALWAYS

---------------------------------------------------------------------------------

Y_PM23a [ YPM23a ] When you & CG are home, how often CG knows what you're doing

When you and your ^Global.CAREGIVER_A are both at home, how often does ^Fills.HeShe know

what you are doing?

Question Type: TPMFreqC

almstnvr 1 ALMOST NEVER

oncinawhl 2 ONCE IN A WHILE

sometimes 3 SOMETIMES

often 4 OFTEN

almstalwys 5 ALMOST ALWAYS

---------------------------------------------------------------------------------

PERSISTENCE/GRIT

IF CHILD AGE IS 11 OR OLDER OR CHILD IS A YOUNG ADULT (18+) OR EMANCIPATED YOUTH, CONTINUE. ELSE, GOTO Y_GREND.

Now I’m going to read some sayings. For each one, you can tell me how much the saying describes you.

Y_3

New ideas and projects sometimes distract me from previous ones. Would you say…

1=Very much like me

2=Mostly like me

3=Somewhat like me

4=Not much like me

5=Not like me at all

Y_GR2

Setbacks (delays and obstacles) don’t discourage me. I bounce back from disappointments faster than most people. Would you say…

1=Very much like me

2=Mostly like me

3=Somewhat like me

4=Not much like me

5=Not like me at all

Y_GR3

I have been obsessed with a certain idea or project for a short time but later lost interest. Would you say…

1=Very much like me

2=Mostly like me

3=Somewhat like me

4=Not much like me

5=Not like me at all

Y_GR 4

I am a hard worker. Would you say…

1=Very much like me

2=Mostly like me

3=Somewhat like me

4=Not much like me

5=Not like me at all

Y_GR5

I often set a goal but later choose to pursue (follow) a different one. Would you say…

1=Very much like me

2=Mostly like me

3=Somewhat like me

4=Not much like me

5=Not like me at all

Y_GR6

I have difficulty maintaining (keeping) my focus on projects that take more than a few months to complete. Would you say…

1=Very much like me

2=Mostly like me

3=Somewhat like me

4=Not much like me

5=Not like me at all

Y_GR7

I finish whatever I begin. Would you say…

1=Very much like me

2=Mostly like me

3=Somewhat like me

4=Not much like me

5=Not like me at all

Y_GR8

I am diligent (hard working and careful). Would you say…

1=Very much like me

2=Mostly like me

3=Somewhat like me

4=Not much like me

5=Not like me at all

Y_GREND.

SELF-ESTEEM

IF CHILD AGE IS 11 OR OLDER OR CHILD IS A YOUNG ADULT (18+) OR EMANCIPATED YOUTH, CONTINUE. ELSE, GOTO Y_SFEND.

Now I’m going to read a list of feelings people may have about themselves. For each one, please tell me if you strongly agree, agree, disagree, or strongly disagree.

Y_SF1

I feel that I am a person of worth, at least on an equal plane to others. Would you say that you…

1=Strongly agree

2=Agree

3=Disagree

4=Strongly disagree

Y_SF2

I feel that I have a number of good qualities. Would you say that you…

1=Strongly agree

2=Agree

3=Disagree

4=Strongly disagree

Y_SF3

All in all, I am inclined to feel that I am a failure. Would you say that you…

1=Strongly agree

2=Agree

3=Disagree

4=Strongly disagree

Y_SF4

I am able to do things as well as most other people. Would you say that you…

1=Strongly agree

2=Agree

3=Disagree

4=Strongly disagree

Y_SF5

I feel I do not have much to be proud of. Would you say that you…

1=Strongly agree

2=Agree

3=Disagree

4=Strongly disagree

Y_SF6

I take a positive attitude toward myself. Would you say that you…

1=Strongly agree

2=Agree

3=Disagree

4=Strongly disagree

Y_SF7

On the whole, I’m satisfied with myself. Would you say that you…

1=Strongly agree

2=Agree

3=Disagree

4=Strongly disagree

Y_SF8

I wish I could have more respect for myself. Would you say that you…

1=Strongly agree

2=Agree

3=Disagree

4=Strongly disagree

Y_SF9

I certainly feel useless at times. Would you say that you…

1=Strongly agree

2=Agree

3=Disagree

4=Strongly disagree

Y_SF10

At times, I think I am no good at all. Would you say that you…

1=Strongly agree

2=Agree

3=Disagree

4=Strongly disagree

Y_SFEND

CHILD INDEPENDENT LIVING MODULE

---------------------------------------------------------------------------------

Y_IP_BGN [ YIP_BGN ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

---------------------------------------------------------------------------------

Logic before:

IF CHILD AGE = 14 OR OLDER OR CHILD IS EMANCIPATED OR CHILD IS YOUNG

ADULT (18+), GOTO Y_IP1. ELSE, GOTO Y_IPEND.Now I would like to ask you about how prepared you feel to live on your own, pursue your educational goals, manage your finances, and a few other things. I am also going to ask you about any services or training that you may have received to prepare you for each of these.

Y_IP3

How prepared do you feel to get income assistance, like TANF or SNAP or food stamps?

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED

Y_IP4

How prepared do you feel to use public transportation, like a city bus, subway or metro system?

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED

Y_IP9b

[How prepared do you feel for the following activities that may be helpful in getting and keeping a job?]

Writing a resume

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED

Y_IP9e

[How prepared do you feel for the following activities that may be helpful in getting and keeping a job?]

Negotiating job wages and benefits

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED

Y_IP10b

[How prepared do you feel for the following activities that may be helpful in finding and keeping a place to live?]

Completing an apartment application

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED

Y_IP10c

[How prepared do you feel for the following activities that may be helpful in finding and keeping a place to live?]

Learning about security deposits and utility set-up

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED

Y_IP10d

[How prepared do you feel for the following activities that may be helpful in finding and keeping a place to live?]

Signing a lease

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED

Y_IP10e

[How prepared do you feel for the following activities that may be helpful in finding and keeping a place to live?]

Checking my credit score

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED

Y_IP11c

[How prepared do you feel for the following activities that may be helpful in managing your money and making good financial decisions?]

Completing tax returns

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED

Y_IP11d

[How prepared do you feel for the following activities that may be helpful in managing your money and making good financial decisions?]

Avoiding credit card debt

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED

---------------------------------------------------------------------------------

Y_IP30a [ YIP54a ] Ever attend class for living on own

[IF LIVING SITUATION = IN-HOME OR YOUNG ADULT] Have you ever attended any classes or group sessions that were intended to help you get ready for being on your own?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

Y_IP30b [ YIP30a ] CH took independent living class

[IF LIVING SITUATION = OOH, INCLUDING FOSTER CARE, FORMAL KIN, GROUP HOME/RESIDENTIAL OR OTHER OOH] Have you attended any independent living or life skills training programs or classes to help you prepare to leave foster care?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_IP30a = NO, DK, RE, GOTO Y_IP33a

---------------------------------------------------------------------------------

Y_IP70a [ YIP70a ] Have Social Security card

Do you have a Social Security card?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_IP75

Do you have a cell phone?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Y_IP76

Do you have regular access to the internet?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

CHILD QUESTIONS FOR CHILDREN IN OUT-OF-HOME CARE MODULE

---------------------------------------------------------------------------------

ADMINISTER MODULE IF SETTING IS OOH & (AGE >= 6) & (CHILD is not emancipated or young adult (18+))

Logic before:

IF BIO-MOTHER IS DEAD, Y_CH19a = 2, GOTO Y_OH4xa

Y_OH4a [ YOH4a ] Does OOH CH know bio mom

Do you know your biological mom, or birth mom?

(IF NECESSARY, PROBE: I MEAN THE MOM WHO GAVE

BIRTH TO YOU)

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Y_OH4b

Some people feel close to their mother, father or other relatives, others don't feel close at all.

In general, would you say that you feel very close, somewhat close, not very close, or not at all close to your biological mother these days?

1 VERY CLOSE

2 SOMEWHAT CLOSE

3 NOT VERY CLOSE

4 NOT AT ALL CLOSE

---------------------------------------------------------------------------------

Logic before:

IF BIO-FATHER IS DEAD, Y_CH20a = 2, GOTO Y_OH5a

Y_OH4xa [ YOH4xa ] Does OOH CH know bio father

Do you know your biological dad?

(IF NECESSARY, PROBE: I MEAN YOUR REAL DAD)

Question Type: TYesNoC

Yes 1 YES

No 2 NO

IF Y_OH4xa = 2, skip to Y_OH5.

Y_OH4c

Some people feel close to their mother, father or other relatives, others don't feel close at all.

In general, would you say that you feel very close, somewhat close, not very close, or not at all close to your biological father these days?

1 VERY CLOSE

2 SOMEWHAT CLOSE

3 NOT VERY CLOSE

4 NOT AT ALL CLOSE

---------------------------------------------------------------------------------

Y_OH70a

I have some statements here that describe some ideas people have about the foster care system.

Please let me know how much you agree or disagree with the following statements.

USE CARD 10. Generally I am satisfied with my experience in the foster care system.

(Would you say that you very strongly agree, strongly agree, agree, neither agree nor disagree, disagree, strongly disagree or very strongly disagree?)

1 VERY STRONGLY AGREE

2 STRONGLY AGREE

3 AGREE

4 NEITHER AGREE NOR DISAGREE

5 DISAGREE

6 STRONGLY DISAGREE

7 VERY STRONGLY DISAGREE

Y_OH71a

Overall, social workers have been a help to me while I was in the foster care system.

(Would you say that you very strongly agree, strongly agree, agree, neither agree nor disagree, disagree, strongly disagree or very strongly disagree?)

1 VERY STRONGLY AGREE

2 STRONGLY AGREE

3 AGREE

4 NEITHER AGREE NOR DISAGREE

5 DISAGREE

6 STRONGLY DISAGREE

7 VERY STRONGLY DISAGREE

IF Y_CH11a = 4 THEN ASK Y_OH72A

Y_OH72a

All in all foster parents have been a help to me.

(Would you say that you very strongly agree, strongly agree, agree, neither agree nor disagree, disagree, strongly disagree or very strongly disagree?)

1 VERY STRONGLY AGREE

2 STRONGLY AGREE

3 AGREE

4 NEITHER AGREE NOR DISAGREE

5 DISAGREE

6 STRONGLY DISAGREE

7 VERY STRONGLY DISAGREE

IF Y_CH11b = 3 THEN ASK Y_OH73A

Y_OH73a

All in all the counselors or staff of the group homes, child caring institutions or residential treatment centers have been a help to me.

(Would you say that you very strongly agree, strongly agree, agree, neither agree nor disagree, disagree, strongly disagree or very strongly disagree?)

1 VERY STRONGLY AGREE

2 STRONGLY AGREE

3 AGREE

4 NEITHER AGREE NOR DISAGREE

5 DISAGREE

6 STRONGLY DISAGREE

7 VERY STRONGLY DISAGREE

---------------------------------------------------------------------------------

Y_OH_END [ YOH_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

Logic after:

Y_OHEND

CHILD SATISFACTION WITH CASEWORKER SERVICES MODULE

---------------------------------------------------------------------------------

Logic before:

IF AGE < 13 OR CHILD IS YOUNG ADULT (18+) OR EMANCIPATED, GOTO Y_SWEND. ELSE,

CONTINUE.

Y_SW1a [ YSW1a ] CH met w/CW in past 6M

Now I would like to ask some questions about the experiences that you've had with caseworkers

or social workers from the child welfare agency over the ^Fills.Y_SW1a1. Honest answers are

important, so please tell me what you really feel or think. Your answers will be kept private. No

one will tell your caseworkers or social workers anything about your answers.

Have you met with a caseworker or social worker in the past ^Fills.Y_SW1a2 months?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Question Fill: ^FillY_SW1a1

waveone @Bpast 6 months@B

wavetwo @Bpast 18 months@B

Logic after:

IF Y_SW1a = 2 GOTO Y_SWEND

---------------------------------------------------------------------------------

Y_SW4a [ YSW4a ] Did CW listen to CH

Overall, how much do you feel the caseworkers or social workers you met with listened to you?

Would you say they listened to you...

Question Type: TYSW4a

never 1 never

notoften 2 not very often

sometime 3 some of the time, or

alltime 4 all of the time

---------------------------------------------------------------------------------

Y_SW5a [ YSW5a ] Did CW understand CH situation

How well do you feel that the caseworkers or social workers understood you and your situation?

Would you say...

Question Type: TYSW5a

notwell 1 not well at all

somewhat 2 somewhat, or

verywell 3 very well

Y_SW7a

How many times during the past year did you have face to face visits or phone contact with your attorney or someone from your attorney’s office?

NUMBER: __________

[RANGE: 0 – 60]

[SOFT RANGE CHECK FOR VALUES OF 31 – 60]

Y_SW8a

Have you ever attended court proceedings regarding your case?

1 YES

2 NO

---------------------------------------------------------------------------------

Y_SW_END [ YSW_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

CHILD SOCIAL SUPPORT MODULE

---------------------------------------------------------------------------------

Logic before:

IF WAVE = 1 OR 2 OR 3 AND CHILD IS EMANCIPATED OR IF CHILD IS YOUNG ADULT (18+),

CONTINUE. ELSE, GOTO Y_SUEND.

Y_SU15a [ YSU15a ] Others might do for you or give you (Intro)

Now I'm going to ask you about some things that other people might do for you or give you that

may be helpful or supportive.

USE CARD 14. As I read each statement, please tell me which answer is closest to your

situation. Here is an example: I get enough free time. If you answer '4', it means that you get

@Balmost as much@B free time as you would like, but @Bnot quite as much@B as you would

like.

Answer each statement as best you can. Remember, there are no right or wrong answers. Here

is the first statement:

I get love and affection.

Question Type: TSU15a

a1 1 1 = I GET MUCH LESS THAN I WOULD LIKE

a2 2 2

a3 3 3

a4 4 4

a5 5 5 = I GET AS MUCH AS I LIKE

---------------------------------------------------------------------------------

Y_SU16a [ YSU16a ] Talk to someone about personal or family problems

Chances to talk to someone I trust about my personal and family problems

Question Type: TSU15a

a1 1 1 = I GET MUCH LESS THAN I WOULD LIKE

a2 2 2

a3 3 3

a4 4 4

a5 5 5 = I GET AS MUCH AS I LIKE

---------------------------------------------------------------------------------

Y_SU17a [ YSU17a ] Talk to someone about problems at work or with housework

Chances to talk to someone I trust about problems at work or with my housework

Question Type: TSU15a

a1 1 1 = I GET MUCH LESS THAN I WOULD LIKE

a2 2 2

a3 3 3

a4 4 4

a5 5 5 = I GET AS MUCH AS I LIKE

---------------------------------------------------------------------------------

Y_SU18a [ YSU18a ] Invitations to go out and do things with other people

Invitations to go out and do things with other people

Question Type: TSU15a

a1 1 1 = I GET MUCH LESS THAN I WOULD LIKE

a2 2 2

a3 3 3

a4 4 4

a5 5 5 = I GET AS MUCH AS I LIKE

---------------------------------------------------------------------------------

Y_SU19a [ YSU19a ] People who care about what happens to me

People who care about what happens to me

Question Type: TSU15a

a1 1 1 = I GET MUCH LESS THAN I WOULD LIKE

a2 2 2

a3 3 3

a4 4 4

a5 5 5 = I GET AS MUCH AS I LIKE

---------------------------------------------------------------------------------

Y_SU20a [ YSU20a ] Chances to talk about money matters

Chances to talk about money matters

Question Type: TSU15a

a1 1 1 = I GET MUCH LESS THAN I WOULD LIKE

a2 2 2

a3 3 3

a4 4 4

a5 5 5 = I GET AS MUCH AS I LIKE

---------------------------------------------------------------------------------

Y_SU21a [ YSU21a ] Useful advice about important things in life

Useful advice about important things in life

Question Type: TSU15a

a1 1 1 = I GET MUCH LESS THAN I WOULD LIKE

a2 2 2

a3 3 3

a4 4 4

a5 5 5 = I GET AS MUCH AS I LIKE

---------------------------------------------------------------------------------

Y_SU22a [ YSU22a ] Help when I need transportation

Help when I need transportation

Question Type: TSU15a

a1 1 1 = I GET MUCH LESS THAN I WOULD LIKE

a2 2 2

a3 3 3

a4 4 4

a5 5 5 = I GET AS MUCH AS I LIKE

---------------------------------------------------------------------------------

Y_SU23a [ YSU23a ] Help when I'm sick in bed

Help when I'm sick in bed

Question Type: TSU15a

a1 1 1 = I GET MUCH LESS THAN I WOULD LIKE

a2 2 2

a3 3 3

a4 4 4

a5 5 5 = I GET AS MUCH AS I LIKE

---------------------------------------------------------------------------------

Y_SU24a [ YSU24a ] Help around the house

Help around the house

Question Type: TSU15a

a1 1 1 = I GET MUCH LESS THAN I WOULD LIKE

a2 2 2

a3 3 3

a4 4 4

a5 5 5 = I GET AS MUCH AS I LIKE

---------------------------------------------------------------------------------

Logic before:

IF R REPORTS HAVING A CHILD CONTINUE, ELSE SKIP TO Y_SUEND

IF Y_CH39a = NO, ELSE SKIP TO Y_SUEND

Y_SU25a [ YSU25a ] Help taking care of my child(ren)

Help taking care of my child(ren)

Question Type: TSU15a

a1 1 1 = I GET MUCH LESS THAN I WOULD LIKE

a2 2 2

a3 3 3

a4 4 4

a5 5 5 = I GET AS MUCH AS I LIKE

Logic after:

Y_SUEND

---------------------------------------------------------------------------------

Y_SU_END [ YSU_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

CHILD PHYSICAL HEALTH MODULE

---------------------------------------------------------------------------------

Logic before:

IF CHILD IS EMANCIPATED OR YOUNG ADULT (18+), CONTINUE. ELSE, GOTO Y_PEEND.

Y_PE1a [ YPE1a ] Eman CH health in general

The next questions are about your health and the activities you might do. This information will be

used to keep track of how you feel and how well you are able to do your usual activities. If you are

unsure about how to answer a question, please give the best answer you can.

In general, would you say your health is...

Question Type: TPE1a

excellent 1 excellent

vgood 2 very good

good 3 good

fair 4 fair, or

poor 5 poor?

---------------------------------------------------------------------------------

Y_PE2a [ YPE2a ] Eman CH health limits activities

How much does your health now limit you in @Bmoderate activities@B, such as moving a table,

pushing a vacuum cleaner, bowling, or playing golf. Would you say you are...

Question Type: TPE2a

alot 1 limited a lot

alittle 2 limited a little, or

notlimited 3 not limited at all?

---------------------------------------------------------------------------------

Y_PE3a [ YPE3a ] Eman CH health limits climb stairs

How much does your health now limit you in climbing @Bseveral@B flights of stairs? Would you

say you are...

NOTE: "SEVERAL" MEANS TWO OR MORE.

Question Type: TPE2a

alot 1 limited a lot

alittle 2 limited a little, or

notlimited 3 not limited at all?

---------------------------------------------------------------------------------

Y_PE4a [ YPE4a ] Eman CH health limits work/actv

During the past @B4 weeks@B, have you accomplished less than you would like in your work or

other regular daily activities as a result of your @Bphysical@B health?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_PE5a [ YPE5a ] Eman CH health limits kind of work

During the past @B4 weeks@B, were you limited in the @Bkind@B of work or other activities

you could do as a result of your physical health?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_PE6a [ YPE6a ] Eman CH emotional prob limit work

During the past @B4 weeks@B, have you accomplished less than you would like in your work or

other regular daily activities as a result of any @Bemotional@B problems such as feeling

depressed or anxious?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_PE7a [ YPE7a ] Eman CH emotional prob limit work quality

During the past @B4 weeks@B, did you feel you didn't do work or other activities as carefully as

usual as a result of any emotional problems such as feeling depressed or anxious?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_PE8a [ YPE8a ] Eman CH pain interfere norml work

During the past @B4 weeks@B, how much did @Bpain@B interfere with your normal work,

including both work outside the home and housework? Would you say...

Question Type: TPE8a

notatall 1 not at all

alittle 2 a little bit

moderately 3 moderately

quite 4 quite a bit, or

extremely 5 extremely?

---------------------------------------------------------------------------------

Y_PE9a [ YPE9a ] Eman CH felt calm and peaceful

USE Card 15. The next questions are about how you feel and how things have been with you

during the past @B4 weeks@B. For each question, please look at Card 6 and tell me which

answer comes closest to the way you have been feeling.

During the past @B4 weeks@B, how much of the time have you felt calm and peaceful? Would

you say...

Question Type: TPE9a

all 1 all of the time

most 2 most of the time

goodbit 3 a good bit of the time

some 4 some of the time

little 5 a little of the time, or

none 6 none of the time?

---------------------------------------------------------------------------------

Y_PE10a [ YPE10a ] Eman CH have a lot of energy

USE Card 15. During the past @B4 weeks@B, how much of the time did you have a lot of

energy? Would you say...

Question Type: TPE9a

all 1 all of the time

most 2 most of the time

goodbit 3 a good bit of the time

some 4 some of the time

little 5 a little of the time, or

none 6 none of the time?

---------------------------------------------------------------------------------

Y_PE11a [ YPE11a ] Eman CH felt downhearted/blue

USE Card 15. During the past @B4 weeks@B, how much of the time have you felt downhearted

and blue? Would you say...

Question Type: TPE9a

all 1 all of the time

most 2 most of the time

goodbit 3 a good bit of the time

some 4 some of the time

little 5 a little of the time, or

none 6 none of the time?

---------------------------------------------------------------------------------

Y_PE12a [ YPE12a ] Eman CH phy/emo prob lmt socializ

USE Card 15. During the past @B4 weeks@B, how much of the time has your physical health or

emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?

Would you say...

Question Type: TPE9a

all 1 all of the time

most 2 most of the time

goodbit 3 a good bit of the time

some 4 some of the time

little 5 a little of the time, or

none 6 none of the time?

---------------------------------------------------------------------------------

Y_PE13ft [ YPE13ft ] Eman CH Height in feet

Can you tell me approximately what your height is?

FEET:

Question Type: 1..7

---------------------------------------------------------------------------------

Y_PE13in [ YPE13in ] Eman CH Height in inches

Can you tell me approximately what your height is?

INCHES:

Question Type: 0..11

---------------------------------------------------------------------------------

Y_PE14a [ YPE14a ] Eman CH Weight in pounds

Can you tell me approximately what your weight is?

POUNDS:

Question Type: 50..500

---------------------------------------------------------------------------------

Y_PE15a [ YPE15a ] Eman CH over/under wieght

Do you consider yourself now to be...

Question Type: TPE15a

over 1 Overweight

under 2 Underweight, or

right 3 About the right weight?

---------------------------------------------------------------------------------

Y_PE16a [ YPE16a ] Eman CH like to weigh more or less

Would you like to weigh...

Question Type: TPE16a

more 1 more

less 2 less

same 3 stay about the same?

---------------------------------------------------------------------------------

Y_PE17a [ YPE17a ] Eman CH =tTried to lose weight

During the past 12 months have you tried to lose weight?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_PE18a [ YPE18ax ] Eman CH days eat veg/fruit per week

On a typical day, not including potato chips or French fries, how often do you eat vegetables or

drink 100% vegetable juice?

Question Type: TPE18a

threemore 1 Three or more times a day

twice 2 Twice a day

once 3 Once a day

less 4 Less than once a day

---------------------------------------------------------------------------------

Y_PE18aa [ YPE18aa ] how often does Eman CH eat fruit or drink fruit juice

On a typical day, how often do you eat fruit or drink 100% fruit juice?

Question Type: TPE18a

threemore 1 Three or more times a day

twice 2 Twice a day

once 3 Once a day

less 4 Less than once a day

---------------------------------------------------------------------------------

Y_PE19a [ YPE19a ] Days Eman CH exercise 30 min+ per week

In a typical week, how many days do you engage in exercise that lasts 30 minutes or more?

# OF DAYS:

Question Type: 0..7

---------------------------------------------------------------------------------

Y_PE20a1a [ YPE20a1a ] Bst of your knwldg, do you currently have asthma?

To the best of your knowledge, do you currently have any of the following:

Asthma?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_PE20a2a [ YPE20a2a ] Bst of your knwldg, do you currently have ADD or ADHD?

(To the best of your knowledge, do you currently have any of the following:)

Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder, that is ADD or ADHD?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_PE20a3a [ YPE20a3a ] Bst of your knwldg, do you currently have autism or ASD?

(To the best of your knowledge, do you currently have any of the following:)

Autism, Asperger’s Disorder, pervasive developmental disorder, or other Autism Spectrum Disorder, that is ASD?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_PE20a6a [ YPE20a6a ] Bst of ur knwldg, do u crrntly hve dep/anxiety/eting dis

(To the best of your knowledge, do you currently have any of the following:)

Depression, anxiety, an eating disorder, or other emotional problems?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_PE20a7a [ YPE20a7a ] Bst of your knwldg, do you currently have diabetes?

(To the best of your knowledge, do you currently have any of the following:)

Diabetes?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_PE20a7a = 1 GOTO Y_PE20a8a; IF Y_PE20a7a = 2 GOTO Y_PE20a9a)

---------------------------------------------------------------------------------

Y_PE20a8a [ YPE20a8a ] Do you use insulin?

Do you use insulin?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_PE20a9a [ YPE20a9a ] Bst of your knwldg, do you currently have heart problem?

(To the best of your knowledge, do you currently have any of the following:)

A heart problem, including congenital heart disease?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_PE20a10a [ YPE20a10a ] Bst of your knwldg, do you currently have bld prblms?

(To the best of your knowledge, do you currently have any of the following:)

Blood problems such as anemia or sickle cell disease? Please do not include Sickle Cell Trait.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_PE20a11a [ YPE20a11a ] Bst of your knwldg, do you currently have cystic fibrosis?

(To the best of your knowledge, do you currently have any of the following:)

Cystic Fibrosis?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_PE20a12a [ YPE20a12a ] Bst of your knwldg, do you currently have cerebral palsy?

(To the best of your knowledge, do you currently have any of the following:)

Cerebral Palsy?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_PE20a13a [ YPE20a13a ] Bst of your knwldg, do you currently have mscular dystrophy?

(To the best of your knowledge, do you currently have any of the following:)

Muscular Dystrophy?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_PE20a14a [ YPE20a14a ] Bst of ur knwldg, do u crrntly hve eplpsy/othr sezur disord?

(To the best of your knowledge, do you currently have any of the following:)

Epilepsy or other seizure disorder?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_PE20a15a [ YPE20a15a ] Bst of your knwldg, do you crrntly have migrane/frnt hdachs?

(To the best of your knowledge, do you currently have any of the following:)

Migraine or frequent headaches?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_PE20a16a [ YPE20a16a ] Bst of ur knwldg, do u crrntly hve arthritis/othr jnt prblm?

(To the best of your knowledge, do you currently have any of the following:)

Arthritis or other joint problems?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_PE20a19a [ YPE20a19a ] Bst of your knwldg, do you currently have dental prlblms?

(To the best of your knowledge, do you currently have any of the following:)

Dental problems?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_PE20a21a [ YPE20a21a ] Bst of your knwldg, do you currently have rptd ear infction?

(To the best of your knowledge, do you currently have any of the following:)

Repeated ear infections?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_PE20a24a [ YPE20a24a ] Bst of your knwldg, do you currently have bck/nck prblms?

(To the best of your knowledge, do you currently have any of the following:)

Back or neck problems?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_PE20a25a [ YPE20a25a ] Bst of ur knwldg, do u crntly hve hyprtnsion/high bld prsur?

(To the best of your knowledge, do you currently have any of the following:)

Hypertension or high blood pressure?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_PE20a26a [ YPE20a26a ] Bst of your knwldg, do you currently have AIDS?

(To the best of your knowledge, do you currently have any of the following:)

AIDS?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_PE20a27a [ YPE20a27a ] Bst of your knwldg, do you currently have STD?

(To the best of your knowledge, do you currently have any of the following:)

Sexually transmitted disease, such as Chlamydia or Gonorrhea?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_PE20a28a [ YPE20a28a ] Bst of your knwldg, do you currently have chrnic bronchitis?

(To the best of your knowledge, do you currently have any of the following:)

Chronic bronchitis?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_PE20a30a [ YPE20a30a ] Bst of your knwldg, do you currently have othr resp prblm?

(To the best of your knowledge, do you currently have any of the following:)

Other health problems?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_PE20a31a = 1 GOTO Y_PE20a32a; IF Y_PE20a31a = 2 GOTO Y_PE20a

---------------------------------------------------------------------------------

Y_PE20a32 [ YPE20a32 ] What other health problems do you currently have?

What other health problems do you currently have?

PROBLEM:

Question Type: STRING[50]

---------------------------------------------------------------------------------

Logic before:

IF ANY Y_PE20a1a THROUGH Y_PE20a32 = YES, CONTINUE. ELSE, SKIP TO Y_PE21a. ASK

Y_PE20a FOR EACH CONDITION ANSWERED YES in Y_PE20a1a through Y_PE20a32.

Y_PE20a [ YPE20a ] Labels are in Logic After

Does ^Fills.Y_PE20a currently limit you in any way? Would you say...

Question Type: TPE20a

no 1 no, not currently limited by this condition

yeslittle 2 yes, limited a little

yesalot 3 yes, limited a lot

Question Fill: ^FillY_PE20a

asthma asthma

add Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder

autism autism or Autism Spectrum Disorder

depression depression, anxiety, an eating disorder, or another emotional problem

diabetes diabetes

heartprob a heart problem

bloodprob a blood problem such as anemia or sickle cell disease

cysticfib cystic fibrosis

cerpalsy cerebral palsy

muscdystr muscular dystrophy

epilepsy epilepsy or another seizure disorder

migraine migraine or frequent headache

arthritis arthritis or another joint problem

allergies an allergy

dentalprob a dental problem

eczema eczema or another skin disease

earinf repeated ear infection

visionprob a vision problem

hearingprob a hearing problem

backprob a back or neck problem

hypertension hypertension or high blood pressure

AIDS AIDS

std sexually transmitted disease

bronchitis chronic bronchitis

sinusitis sinusitis

otherresp another respiratory problem

otherprob another health problem

Logic after:

REPEAT FOR EACH CONDITION ANSWERED YES IN Y_PE20a1a through Y_PE20a32.;

YPE20a_1 --Currently limited by asthma; YPE20a_2 --Currently limited by ADD; YPE20a_3 --

Currently limited by autism; YPE20a_4 --Currently limited by down syndrome; YPE20a_5 --

Currently limited by mental retardation; YPE20a_6 --Currently limited by depression; YPE20a_7 --

Currently limited by diabetes; YPE20a_8 --Currently limited by heart problems; YPE20a_9 --

Currently limited by blood problem; YPE20a_10 --Currently limited by cystic fibrosis; YPE20a_11 --

Currently limited by cerebral palsy; YPE20a_12 --Currently limited by muscular dystrophy;

YPE20a_13 --Currently limited by epilepsy; YPE20a_14 --Currently limited by migrane; YPE20a_15

--Currently limited by arthritis; YPE20a_16 --Currently limited by allergies; YPE20a_17 --Currently

limited by dental problem; YPE20a_18 --Currently limited by eczema or another skin disease;

YPE20a_19 --Currently limited by repeated ear infection; YPE20a_20 --Currently limited by vision

problem; YPE20a_21 --Currently limited by hearing problem; YPE20a_22 --Currently limited by

back or neck problem; YPE20a_23 --Currently limited by hypertension; YPE20a_24 --Currently

limited by AIDS; YPE20a_25 --Currently limited by STDs; YPE20a_26 --Currently limited by

chronic bronchitis; YPE20a_27 --Currently limited by sinusitis; YPE20a_28 --Currently limited by

another respiratory problem; YPE20a_29 --Currently limited by anotehr health problem

---------------------------------------------------------------------------------

Y_PE21a [ YPE21a ] Eman CH take meds for chron phys/mental cond

Do you, or has a doctor told you to, regularly take medicine or prescription drugs related to a

chronic physical or mental condition?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Logic before:

IF Y_PE21a = 1, CONTINUE. ELSE, SKIP TO Y_PEEND.

Y_PE21aa [ YPE21aa ] Labels are in Logic After

For which of the following conditions do you take prescribed medication? Do you take prescribed

medication for...

CODE ALL THAT APPLY.

Question Type: TPE21aS

diabetes 1 Diabetes

asthma 2 Asthma

hypertension 3 High blood pressure

migraine 4 Migraine headaches

depression 5 Depression

anxiety 6 Anxiety

add 7 Attention Deficit Disorder

pain 8 Pain

epilepsy 9 Epilepsy or seizures

allergies 10 Allergies

thyroid 11 Thyroid problems

acidrflx 12 Acid reflux

cholesterol 13 Cholesterol

heartrelated 14 Heart-related illness

other 15 Other

Logic after:

GOTO Y_PEEND; YPE21a1--Take meds for diabetes; YPE21a2--Take meds for asthma;

YPE21a3--Take meds for high blood pressure; YPE21a4--Take meds for migraine headaches;

YPE21a5--Take meds for depression; YPE21a6--Take meds for anxiety; YPE21a7--Take meds for

attention deficit disorder; YPE21a8--Take meds for pain; YPE21a9--Take meds for epilepsy or

seizures; YPE21a10--Take meds for allergies; YPE21a11--Take meds for thyroid problems;

YPE21a12--Take meds for acid reflux; YPE21a13--Take meds for cholesterol; YPE21a14--Take

meds for heart related illness; YPE21a15--Take meds for other; YPE21a16--Take meds for - DK;

---------------------------------------------------------------------------------

Y_PE_END [ YPE_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

CHILD HEALTH AND SERVICES MODULE

---------------------------------------------------------------------------------

Y_YH3a33 [ YYH3a33 ] Ever tkn med prsrbd by dr or clin for em/behav prblms?

To your knowledge, have you @Bever taken any medication@B prescribed by a doctor or clinician

for emotional or behavioral problems?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_YH3a34 [ YYH3a34 ] Dr or clinician ever rcmmend you take med for emo/beh prblms

Has a doctor or clinician @Bever recommended you take medication@B for emotional or

behavioral problems?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH3a34 = 2 GOTO Y_YH4a

---------------------------------------------------------------------------------

Y_YH3a35 [ YYH3a35 ] Start taking med after dr or clinican recommended you take

After a doctor or clinician recommended you take medication for emotional or behavioral

problems, @Bdid you start taking@B the medication?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH3a35 = 1 GOTO Y_YH3a38

---------------------------------------------------------------------------------

Y_YH3a36 [ YYH3a36 ] Labels are in Logic After

I'm going to read a list of reasons why some people sometimes choose not to take medication.

Please respond yes to any of the reasons why you are not taking medication.

CODE ALL THAT APPLY.

Question Type: TYH3a36S

cost 1 Insurance did not cover medication

sideeffects 2 Concerns about side effects of the medication

gotbetter 3 You got better and didn't need medication any more

family 4 Family or friends were concerned about you taking medication

addiction 5 Afraid of getting addicted

badexperience 6 Bad experiences with other clinicians prescribing medications

changeddrs 7 You changed providers

other 8 Other reasons

Logic after:

YYH3a36_1 --Why not taking med - Insurance did not cover medication; YYH3a36_2 --Why not

taking med - Concerns about side effects of the meds; YYH3a36_3 --Why not taking med - Got

better, didn't need med any more; YYH3a36_4 --Why not taking med - Family/friends concerned

about medicatn; YYH3a36_5 --Why not taking med - Afraid of getting addicted; YYH3a36_6 --Why

not taking med - Bad experiences with medications; YYH3a36_7 --Why not taking med - You

changed providers; YYH3a36_8 --Why not taking med - Other reasons; YYH3a36_9--Why not

---------------------------------------------------------------------------------

Y_YH3a38 [ YYH3a38 ] Taken any meds for emo/behav problems in last 12 months?

@BIn the past 12 months@B, have you taken any medication for emotional or behavioral

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH3a38 = 2 GOTO Y_YH3a40

---------------------------------------------------------------------------------

Y_YH3a39 [ YYH3a39 ] Currently taking meds for emo/behav problems?

Are you currently taking any medication for emotional or behavioral problems?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH3a39 = 1 GOTO Y_YH3a42

---------------------------------------------------------------------------------

Y_YH3a42 [ YYH3a42 ] How many pres meds currently taking for emo/behav prblms

How many prescription medications are you currently taking for emotional or behavioral problems?

Question Type: 1..10

---------------------------------------------------------------------------------

Y_YH4a [ YYH4a ] CH gone to Dentist or hygienist past 12 months

@BIn the past 12 months@B, have you gone to a dentist or dental hygienist for a cleaning or a

checkup?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH4a = 1 GOTO Y_YH14a

---------------------------------------------------------------------------------

Logic before:

Y_YH5a [ YYH5a ] CH ever gone to dentist for checkup

Have you @Bever@B gone to a dentist or dental hygienist for a cleaning or a checkup?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_YH14a [ YYH14a ] Ch admtd hosp ovrnght for inj/ill

In the past 12 months, that is, since ^DateYearAgo_Text, have you been admitted to a hospital or

medical facility overnight for an illness or injury?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH14a = 2 GOTO Y_YH17a

---------------------------------------------------------------------------------

Y_YH17a [ YYH17a ] CH go ER/Urg care for ill/inj past 12 months

@BIn the last 12 months@B, have you gone to an emergency room or urgent care center for an

illness or injury?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH17a = 2 GOTO Y_YH19a

---------------------------------------------------------------------------------

Y_YH19a [ YYH19a ] CH had inj/acc/poisn req doc/nurse past 12 months

In the last 12 months, have you had a serious injury, accident, or poisoning that needed the care

of a doctor or nurse?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH19a = 2 GOTO Y_YH30a

---------------------------------------------------------------------------------

ADMINISTER Y_Y30a – Y_YH41 TO EMANCIPATED YOUTH AND YOUNG ADULTS WHO ARE ATTENDING HIGH SCHOOL (Y_CHYda = 1).

---------------------------------------------------------------------------------

Logic before:

IF Y_CH9Yda = 1, CONTINUE. ELSE GOTO Y_YH43a

Y_YH30a [ YYH30a ] Tstd for lrning prob, spec nds, or dev dsblty in lst 12 mnth

@BIn the past 12 months@B have you been tested for learning problems, special needs, or

developmental disabilities by an education or health professional (E.G. SCHOOL

PSYCHOLOGIST, DOCTOR, SPEECH THERAPIST, ETC.)?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH30a = 1 GOTO Y_YH35a; IF Y_YH30a = 2 GOTO Y_YH32a

---------------------------------------------------------------------------------

Y_YH32a [ YYH32a ] Thnk u need to be tstd for lrnng prblms/spec needs/dev dis

How much do you think you @Bneed@B to be tested for learning problems, special needs, or

developmental disabilities? Would you say...

Question Type: TYH32a

alot 1 a lot,

somewhat 2 somewhat,

alittle 3 a little, or

notatall 4 not at all?

IF YH32a = 4, GOTO YH35a

---------------------------------------------------------------------------------

Y_YH33 [ YYH33 ] Labels are in Logic After

Why have you @Bnot been@B tested for learning problems, special needs, or developmental

disabilities?

CODE ALL THAT APPLY.

Question Type: TYH33S

notavail 1 SERVICE NOT AVAILABLE IN THE AREA

waitlist 2 WAIT-LISTED FOR SERVICE

ineligible 3 INELIGIBLE FOR SERVICE

cost 4 SERVICES COULD NOT BE FINANCED

scheduling 5 SCHEDULING PROBLEM OR PROBLEM FINDING CHILD CARE

transportation 6 TRANSPORTATION PROBLEM

covid 7 NOT AVAILABLE DUE TO COVID-19 PANDEMIC

other 8 SOME OTHER REASON

Logic after:

YYH33_1 --Why not tstd lrnng prb/spcl nds/dev dis - Not avlble in area; YYH33_2 --Why not tstd

lrnng prb/spcl nds/dev dis - Wait-listed for; YYH33_3 --Why not tstd lrnng prb/spcl nds/dev dis -

Ineligible for; YYH33_4 --Why not tstd lrnng prb/spcl nds/dev dis - Financing problem; YYH33_5 --

Why not tstd lrnng prb/spcl nds/dev dis - Schdling/chld care; YYH33_6 --Why not tstd lrnng

prb/spcl nds/dev dis - Transportation prb; YYH33_7 --Why not tstd lrnng prb/spcl nds/dev dis -

Some other reason; YYH33_8--Why not tstd lrnng prb/spcl nds/dev dis - DK; YYH33_9--Why not

tstd lrnng prb/spcl nds/dev dis - RF

---------------------------------------------------------------------------------

Y_YH35a [ YYH35a ] Ever told by ed or hlth prof that you have lrning prblms

Have you @Bever@B been told by an education or health professional that you have learning

problems, special needs, or developmental disabilities?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_YH36a [ YYH36a ] Classified in lst 12 mnths as needing special education

Children may qualify for special education services for many reasons, such as autism or the need

for speech or physical therapy.

@BIn the past 12 months@B have you been classified as needing special education? That is,

have you been given an Individual Education Plan (I.E.P.) or an Individual Family and Service Plan

(I.F.S.P.)?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH36a = 2 GOTO Y_YH1ia

---------------------------------------------------------------------------------

Y_YH36ab [ YYH36ab ] Crrntly have IEP or rcvng spcl ed or othr srvces for dsablty

Do you currently have an Individual Education Plan (I.E.P) or are you receiving special education

or other services for a special need or disability?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH36ab = 2 GOTO Y_YH40a

---------------------------------------------------------------------------------

Y_YH37a [ YYH37a ] Labels are in Logic After

What special learning problems or special needs were you told that you have? (PROBE:

ANYTHING ELSE)

CODE ALL THAT APPLY.

Question Type: TYH37aS

autism 1 AUTISM

deafness 2 DEAFNESS

behavioral 3 EMOTIONAL DISTURBANCE (BEHAVIORAL DISORDER)

hearing 4 HEARING IMPAIRMENT

mentalret 5 MENTAL RETARDATION

multdisab 6 MULTIPLE DISABILITIES (COMBINED IMPAIRMENTS THAT

TOGETHER CAUSE SEVERE EDUCATIONAL IMPAIRMENTS, SUCH

AS MENTAL RETARDATION-BLINDNESS)

orthopedic 7 ORTHOPEDIC IMPAIRMENT (PHYSICALLY DISABLING CONDITION,

SUCH AS MISSING LIMB, CEREBRAL PALSY, SPINA BIFIDA,

MUSCULAR DYSTROPHY)

specificld 8 SPECIFIC LEARNING DISABILITY

speech 9 SPEECH OR LANGUAGE IMPAIRMENT

tbi 10 TRAUMATIC BRAIN INJURY

visual 11 VISUAL IMPAIRMENT INCLUDING BLINDNESS

other 12 OTHER PROBLEM/NEED (ADHD, ASTHMA)

developmental 13 DEVELOPMENTAL DELAY

Logic after:

YYH37a_1 --Special learning problems/needs - AUTISM; YYH37a_2 --Special learning

problems/needs - DEAFNESS; YYH37a_3 --Special learning problems/needs - EMOTIONAL

DISTURBANCE; YYH37a_4 --Special learning problems/needs - HEARING IMPAIRMENT;

YYH37a_5 --Special learning problems/needs - MENTAL RETARDATION; YYH37a_6 --Special

learning problems/needs - MULTIPLE DISABILITIES; YYH37a_7 --Special learning problems/needs

- ORTHOPEDIC IMPAIRMENT; YYH37a_8 --Special learning problems/needs - SPECIFIC

LEARNING DISABLTY; YYH37a_9 --Special learning problems/needs - SPEECH/LANGUAGE

IMPAIRMENT; YYH37a_10 --Special learning problems/needs - TRAUMATIC BRAIN INJURY;

YYH37a_11 --Special learning problems/needs - VISUAL IMPAIRMENT; YYH37a_12 --Special

learning problems/needs - OTHER PROBLEM/NEED; YYH37a_13 --Special learning

problems/needs - DEVELOPMENTAL DELAY; YYH37a_14--Special learning problems/needs - DK;

YYH37a_15--Special learning problems/needs - RF

---------------------------------------------------------------------------------

Y_YH40a [ YYH40a ] Think you need special educations services/classes

How much do you think you @Bneed@B special education services or classes? Would you

Question Type: TYH32a

alot 1 a lot,

somewhat 2 somewhat,

alittle 3 a little, or

notatall 4 not at all?

---------------------------------------------------------------------------------

Y_YH41 [ YYH41 ] Labels are in Logic After

Why are you @Bnot@B receiving special education services or classes?

CODE ALL THAT APPLY.

Question Type: TYH41S

notavail 1 SERVICE NOT AVAILABLE IN THE AREA

waitlist 2 WAIT-LISTED FOR SERVICE

ineligible 3 INELIGIBLE FOR SERVICE

cost 4 SERVICES COULD NOT BE FINANCED

scheduling 5 SCHEDULING PROBLEM OR PROBLEM FINDING CHILD CARE

transportation 6 TRANSPORTATION PROBLEM

alreadyrecvd 7 CHILD ALREADY RECEIVED/COMPLETED SERVICE

covid 9 NOT AVAILABLE DUE TO COVID-19 PANDEMIC

other 10 SOME OTHER REASON

Logic after:

YYH41_1 --Why not receiving specl ed - Not avlble in area; YYH41_2 --Why not receiving specl ed -

Wait-listed for; YYH41_3 --Why not receiving specl ed - Ineligible for; YYH41_4 --Why not receiving

specl ed - Financing problem; YYH41_5 --Why not receiving specl ed - Schdling/chld care;

YYH41_6 --Why not receiving specl ed - Transportation prb; YYH41_7 --Why not receiving specl ed

- Already recvd service; YYH41_8 --Why not receiving specl ed - Some other reason; YYH41_9--

Why not receiving specl ed - DK

---------------------------------------------------------------------------------

Y_YH1ia [ YYH1ia ] Place CH usually goes when sick

Is there a place that you usually go when you are sick or you need advice about your health?

Question Type: TYH1ia

yes 1 YES

no 2 THERE IS NO PLACE

yesmore 3 THERE IS MORE THAN ONE PLACE

---------------------------------------------------------------------------------

Logic before:

[IF Y_YH1ia = 1]: What kind of place is it –- a clinic, doctor’s office, emergency room, or some

other place?

[IF Y_YH1ia = 3]: What kind of place do you go to most often -– a clinic, doctor’s office,

emergency room, or some other place?

Y_YH1ja [ YYH1ja ] Kind of place CH goes when sick

^Fills.YH1ja

Question Type: TYH1ja

clinic 1 CLINIC OR HEALTH CENTER

droffice 2 DOCTOR'S OFFICE OR HMO

er 3 HOSPITAL EMERGENCY ROOM

hospout 4 HOSPITAL OUTPATIENT DEPARTMENT

other 5 SOME OTHER PLACE

noplace 6 DOESN'T GO TO ONE PLACE MOST OFTEN

Question Fill: ^FillYH1ja

oneplace What kind of place is it -- a clinic, doctor's office, emergency room, or

some other place?

moreone What kind of place do you go to most often -- a clinic, doctor's office,

emergency room, or some other place?

---------------------------------------------------------------------------------

Y_YH1ka [ YYH1ka ] Place CH goes when sick same for preventative care

Is that ^Fills.YH1ka the same place you usually go when you need routine or preventive care,

such as a physical examination?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Question Fill: ^FillYH1ka

clinic clinic or health center

droffice doctor's office or HMO

er hospital emergency room

hospout hospital outpatient department

Logic after:

IF Y_YH1ka = 1 GOTO Y_YH1lb

---------------------------------------------------------------------------------

Y_YH1la [ YYH1la ] Kind of place CH goes for prevntatve care

What kind of place do you @Uusually@U go when you need routine or preventive care, such as a

physical examination?

Question Type: TYH1la

doesntget 1 DOESN'T GET PREVENTIVE CARE ANYWHERE

clinic 2 CLINIC OR HEALTH CENTER

droffice 3 DOCTOR'S OFFICE OR HMO

er 4 HOSPITAL EMERGENCY ROOM

hospout 5 HOSPITAL OUTPATIENT DEPARTMENT

other 6 SOME OTHER PLACE

noplace 7 DOESN'T GO TO ONE PLACE MOST OFTEN

---------------------------------------------------------------------------------

Y_YH1ma [ YYH1ma ] CH rcv general check-up last 12 months

@BDuring the past 12 months@B did you receive a general check-up when you were not sick or

injured?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_YH1na [ YYH1na ] CH see Dr because sick or injured last 12 months

@BDuring the past 12 months@B, did you see a doctor or other health professional because you

were sick or injured?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_YH1ob [ YYH1ob ] Labels are in Logic After

@BDuring the past 12 months@B, was there any time when you needed any of the following but

couldn't get it because you couldn't afford it...

CODE ALL THAT APPLY.

Question Type: TYH1obS

rxmeds 1 Prescription medicines

mentalhlth 2 Mental health care or counseling

dental 3 Dental care (including check-ups)

glasses 4 Eyeglasses

NONE 5 NONE OF THE ABOVE

Logic after:

YYH1ob_1 --Needed but could not afford - Prescription medicines; YYH1ob_2 --Needed but could

not afford - Mental health care/counseling; YYH1ob_3 --Needed but could not afford - Dental

care(incldng check-ups); YYH1ob_4 --Needed but could not afford - Eyeglasses; YYH1ob_5 --

Needed but could not afford - None of the above; YYH1ob_6--Needed but could not afford - DK;

YYH1ob_7--Needed but could not afford - RF

---------------------------------------------------------------------------------

Y_YH49 [ YYH49 ] NO LABEL

USE CARD 17. Next, I'm going to go through a list of places where you might have gotten help for

emotional, behavioral, learning, attention, or substance abuse problems. Please look at the list of

places on Card 17.

NOTE: "EMOTIONAL, BEHAVIORAL, LEARNING, AND ATTENTION PROBLEMS" INCLUDE

SUICIDE ATTEMPTS, ADD, DEPRESSION, ALCOHOL/DRUG-RELATED PROBLEMS,

INJURING SELF/OTHER, BIPOLAR DISORDER, AGGRESSIVE BEHAVIOR, ETC.

PRESS "1" AND [ENTER] TO CONTINUE.

Question Type: TCont

Continue 1 Continue

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50aa = 1) OR (WAVE >= 2) FILL: In the past 12 months, have you been to...

Y_YH50a1a [ YYH50aa ] Past 12M, been to psych hosp or unit in medical hosp for...?

In the past 12 months, have you been to a @Bpsychiatric hospital or a psychiatric unit in a

medical hospital@B for emotional, behavioral, learning, attention, or substance abuse problems?

NOTE: A PSYCHIATRIC HOSPITAL PROVIDES CARE ONLY FOR PSYCHIATRIC PROBLEMS.

A PSYCHIATRIC UNIT PROVIDES PSYCHIATRIC CARE IN A SPECIALIZED UNIT THAT IS

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50ba = 1) OR (WAVE >= 2) FILL: In the past 12 months, have you been to...

Y_YH50b1a [ YYH50ba ] Past 12M, been t detox unit or inptnt drg or alc unt for...?

In the past 12 months, have you been to a @Bdetox unit or inpatient drug or alcohol unit@B for

emotional, behavioral, learning, attention, or substance abuse problems? (INCLUDE

EMOTIONAL, BEHAVIORAL, LEARNING, ATTENTION, AND SUBSTANCE ABUSE

PROBLEMS.)

NOTE: AN INPATIENT DETOX UNIT OR DRUG/ALCOHOL UNIT PROVIDES INPATIENT

SPECIALIZED TREATMENT FOR SUBSTANCE USE/ABUSE. CAN OCCUR IN A STAND-

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50ca = 1) OR (WAVE >= 2) FILL: In the past 12 months, have you been to...

Y_YH50c1a [ YYH50ca ] Past 12M, been to a hospital medical inpatient unit for...?

In the past 12 months, have you been to a @Bhospital medical inpatient unit@B for emotional,

behavioral, learning, attention, or substance abuse problems? (INCLUDE EMOTIONAL,

BEHAVIORAL, LEARNING, ATTENTION, AND SUBSTANCE ABUSE PROBLEMS.)

NOTE: A HOSPITAL MEDICAL INPATIENT UNIT IS A GENERAL HOSPITAL UNIT NOT

SPECIALLY DESIGNATED FOR TREATMENT OF PSYCHIATRIC OR SUBSTANCE USE

PROBLEMS. TREATMENT, THOUGH, MUST BE FOR MENTAL HEALTH OR SUBSTANCE

ABUSE PROBLEMS.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50da = 1) OR (WAVE >= 2) FILL: In the past 12 months, have you been to...

Y_YH50d1a [ YYH50da ] Past 12M, bn to residntl trtmnt centr or group home for...?

In the past 12 months, have you been to a @Bresidential treatment center or group home@B for

emotional, behavioral, learning, attention, or substance abuse problems? (INCLUDE

EMOTIONAL, BEHAVIORAL, LEARNING, ATTENTION, AND SUBSTANCE ABUSE

PROBLEMS.)

NOTE: A RESIDENTIAL TREATMENT CENTER IS A SELF-CONTAINED TREATMENT FACILITY

(I.E., RESIDENCE IS NOT WITHIN THE COMMUNITY AND CHILD RECEIVES EDUCATION

WITHIN THE CENTER). INCLUDE WILDERNESS CAMPS AND COTTAGES ON THE GROUNDS

OF A SELF-CONTAINED TREATMENT FACILITY. DO NOT INCLUDE DETENTION CENTERS,

TRAINING SCHOOLS, AND JAILS. A GROUP HOME IS A SMALLER RESIDENTIAL

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF Y_YH50ga = 1 OR (WAVE >= 2) FILL: In the past 12 months, have you been to...

Y_YH50g1a [ YYH50ga ] Past 12M, been to day treatment for...?

In the past 12 months, have you been to @Bday treatment@B for emotional, behavioral, learning,

attention, or substance abuse problems? By "day treatment," we mean that you go to a program

@Bevery day or almost every day@B but don't stay overnight.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50ha = 1) OR (WAVE >= 2) FILL: In the past 12 months, have you been to...

Y_YH50h1a [ YYH50ha ] Past 12M, been to outpatient drug or alcohol clinic for...?

In the past 12 months, have you been to an @Boutpatient drug or alcohol clinic@B for any of

these problems? (INCLUDE EMOTIONAL, BEHAVIORAL, LEARNING, ATTENTION, AND

SUBSTANCE ABUSE PROBLEMS.)

NOTE: AN OUTPATIENT DRUG/ALCOHOL CLINIC IS A SUBSTANCE ABUSE TREATMENT

FACILITY THAT PROVIDES OUTPATIENT SERVICES. DO NOT INCLUDE SUBSTANCE ABUSE

SERVICES RECEIVED AT A MENTAL HEALTH CENTER.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50ia = 1) OR (WAVE >= 2) FILL: In the past 12 months, have you been to...

Y_YH50i1a [ YYH50ia ] Past 12M, bn to a mentl hlth or community hlth centr for...?

In the past 12 months, have you been to a @Bmental health or community health center@B for

any of these problems? (INCLUDE EMOTIONAL, BEHAVIORAL, LEARNING, ATTENTION, AND

SUBSTANCE ABUSE PROBLEMS.)

NOTE: A COMMUNITY HEALTH CENTER IS PUBLICLY FUNDED AND PROVIDES GENERAL

HEALTH SERVICES.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50ja = 1) OR (WAVE >= 2) CONTINUE. ELSE GOTO Y_YH50ka.

Y_YH50j1a [ YYH50j1a ] CH rcv priv prof help in last 12 months

^Fills.YH50j1a the past 12 months, have you gotten private professional help from a

@Bpsychiatrist, psychologist, social worker, or psychiatric nurse@B for emotional, behavioral,

learning, attention, or substance abuse problems?

NOTE: CODE "NO" IF CHILD SEES THE PROFESSIONAL THROUGH AN AGENCY FUNDED

BY PUBLIC FUNDS, SUCH AS A PRIVATE PROFESSIONAL WHO SEES PATIENTS AT A

MENTAL HEALTH CENTER WITH WHICH HE/SHE IS AFFILIATED.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Question Fill: ^FillYH50j1a

yesrcvd Not counting help received from a mental health or community health

center, in

norcvd In

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50ka = 1) OR (WAVE >= 2) FILL: In the past 12 months, have you...

Y_YH50k1a [ YYH50ka ] Past 12M, recvd any in-home counslng or crisis srvcs for...?

In the past 12 months, have you received any @Bin-home counseling or in-home crisis

services@B for any of these problems? (INCLUDE EMOTIONAL, BEHAVIORAL, LEARNING,

ATTENTION, AND SUBSTANCE ABUSE PROBLEMS.)

NOTE: THESE INCLUDE SERVICES PROVIDED IN THE FAMILY'S HOME BY PROFESSIONAL

OR PARAPROFESSIONAL IN-HOME WORKERS. MUST BE PART OF A RECOGNIZED IN-

HOME SERVICE PROGRAM. DO NOT INCLUDE HOME VISITS BY CASEWORKERS OR

ISOLATED HOME VISITS BY CASE MANAGERS OR OTHER MENTAL HEALTH CLINICIANS.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50la = 1) OR (WAVE >= 2) FILL: In the past 12 months, have you...

Y_YH50l1a [ YYH50la ] Past 12M, seen your family dr or any other medicl dr for...?

In the past 12 months, have you seen your @Bfamily doctor or any other medical doctor@B for

emotional, behavioral, learning, attention, or substance abuse problems?

NOTE: INCLUDE SERVICES RECEIVED FROM A NON-PSYCHIATRIC MD. INCLUDE ANY

VISITS TO PEDIATRICIAN OR FAMILY DOCTOR IN PRIVATE OR GROUP PRACTICE DURING

WHICH THE PARENT/CHILD SOUGHT HELP FOR EMOTIONAL, BEHAVIORAL, SUBSTANCE

ABUSE PROBLEMS.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50ma = 1) OR (WAVE >= 2) FILL: In the past 12 months, have you...

Y_YH50m1a [ YYH50ma ] Past 12M, been to a hospital emergency room for...?

In the past 12 months, have you been to a @Bhospital emergency room@B for any of these

problems? (INCLUDE EMOTIONAL, BEHAVIORAL, LEARNING, ATTENTION, AND

SUBSTANCE ABUSE PROBLEMS.)

NOTE: ONLY CODE ER VISITS IF THEY WERE RELATED TO MENTAL HEALTH/SUBSTANCE

ABUSE (E.G., BREAKING AN ARM DURING A TANTRUM, HARM DURING A SUICIDE

ATTEMPT, CAR ACCIDENT WHILE CHILD WAS INTOXICATED, BROKEN NOSE DURING

SERIOUS PHYSICAL FIGHT, ETC.). ALSO INCLUDE VISITS TO ER AS PART OF ADMISSIONS

PROCESS TO INPATIENT FACILITY.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50na = 1 AND EMANCIPATED YOUTH) OR (WAVE >= 2)

Y_YH50n1a [ YYH50n1a ] Seen school cnselor, psych, social worker in last 12 months

In the past 12 months, have you seen a @Bschool guidance counselor, school psychologist, or

school social worker@B for emotional, behavioral, learning, attention, or substance abuse

problems or gotten any other sort of help for these problems at school?

FR NOTE; ONLINE VIRTUAL MEETINGS WITH SCHOOL GUIDANCE COUNSELORS, SCHOOL PSYCHOLOGISTS, OR SCHOOL SOCIAL WORKERS SHOULD BE INCLUDED.

NOTE: ONLY INCLUDE VISITS RELATED TO MENTAL HEALTH/SUBSTANCE ABUSE. DO NOT

INCLUDE VISITS RELATED TO SCHOOL CURRICULUM OR COLLEGE/CAREER

COUNSELING. SCHOOL PERSONNEL WHO HANDLE ATTENDANCE ISSUES CAN ALSO BE

INCLUDED HERE IF THEY HAVE DIRECT CONTACT WITH THE CHILD.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50oa = 1 AND EMANCIPATED YOUTH) OR (WAVE >= 2) FILL: In the past 12 months, have you...

Y_YH50o1a

In the past 12 months, have you received services in a @Bspecial classroom in a regular school@B for emotional, behavioral, learning or substance abuse problems?

Question Type: TYN

yes 1 YES

no 2 NO

--------------------------------------------------------------------------------

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50pa = 1 AND EMANCIPATED YOUTH) OR (WAVE >= 2) FILL: In the past 12 months, have you...

Y_YH50p1a

In the past 12 months, have you received special help or tutoring in the @Bregular classroomB@ for emotional, behavioral, learning or substance abuse problems?

FR NOTE; ONLINE HELP OR TUTORING SHOULD BE COUNTED.

Question Type: TYN

yes 1 YES

no 2 NO

--------------------------------------------------------------------------------

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50qa = 1 AND EMANCIPATED YOUTH) OR (WAVE >= 2) FILL: In the past 12 months, have you...

Y_YH50q1a

In the past 12 months, have you received services in a @Bspecial schooB@ l for students with emotional, behavioral, learning, attention, or substance abuse problems?

FR NOTE: ONLINE HELP OR SERVICES OFFERED VIRTUALLY SHOULD BE INCLUDED.

Question Type: TYN

yes 1 YES

no 2 NO

--------------------------------------------------------------------------------

---------------------------------------------------------------------------------

Y_YH52 [ YYH52 ] NO LABEL

In the past 12 months, has a caseworker or agency helped you receive support or assistance for

an alcohol or drug problem?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

LOGIC BEFOR: ASK YH163-YH165 ONLY IF YH50ma = YES OR Y_YH50m1a = YES

Y_YH163 [ YYH163 ] Been in treatmnt for any of these problems in last 12 mnths

Have you been to a @bhospital emergency room@b for emotional,

behavioral, learning, attention, or substance abuse problems in the last 12 months?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH163 = 2 GOTO Y_YH166

---------------------------------------------------------------------------------

Logic before:

IF NO RESPONSE OF 'YES' IN Y_YH50g1a/ga, Y_YH50h1a/ha, Y_YH50i1a/ia, Y_YH50j1a/ja,

Y_YH50k1a/ka, Y_YH50l1a/la, Y_YH50m1a/ma, Y_YH50m1n/na, Y_YH50r1a/ra, CONTINUE. ELSE SKIP TO Y_YH168a

Y_YH166 [ YYH166 ] Referred to any outpatient prof. treatment in last 12 months

In the last 12 months have you been @Breferred to@B any outpatient professional treatment for

emotional, behavioral, learning, attention, or substance abuse problems?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF = 2, SKIP TO 168a

---------------------------------------------------------------------------------

Logic before:

IF WAVE = 2, GO TO Y_YH168a

Y_YH167 [ YYH167 ] Labels are in Logic After

Why are you not receiving this professional treatment?

CODE ALL THAT APPLY.

Question Type: TYH33S

notavail 1 SERVICE NOT AVAILABLE IN THE AREA

waitlist 2 WAIT-LISTED FOR SERVICE

ineligible 3 INELIGIBLE FOR SERVICE

cost 4 SERVICES COULD NOT BE FINANCED

scheduling 5 SCHEDULING PROBLEM OR PROBLEM FINDING CHILD CARE

transportation 6 TRANSPORTATION PROBLEM

covid 7 NOT AVAILABLE DUE TO COVID-19 PANDEMIC

other 8 SOME OTHER REASON

Logic after:

YYH167_1 --Why not receiving this prof trt - Not avlble in area; YYH167_2 --Why not receiving this

prof trt - Wait-listed for; YYH167_3 --Why not receiving this prof trt - Ineligible for; YYH167_4 --Why

not receiving this prof trt - Financing problem; YYH167_5 --Why not receiving this prof trt -

Schdling/chld care; YYH167_6 --Why not receiving this prof trt - Transportation prb; YYH167_7 --

Why not receiving this prof trt - Some other reason; YYH167_8--Why not receiving this prof trt - DK;

YYH167_9--Why not receiving this prof trt - RF

---------------------------------------------------------------------------------

Y_YH168a [ YYH168a ] Currently covered by some type of military health insurance?

The next questions are about health care plans.

Are you currently covered by some type of military health insurance, such as CHAMPUS,

CHAMP-VA, TRICARE, or VA care?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_YH169a [ YYH169a ] Covered by health plan obtained through employer or union?

^Fills.YH141a health insurance plan obtained through a current or past employer or union?

Please remember to include coverage you may have through another family member's plan.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Question Fill: ^FillYH141a

yesmil Other than military health insurance, are you covered by any other

nomil Are you covered by a

---------------------------------------------------------------------------------

Y_YH170a [ YYH170a ] At this time, are you covered by Medicaid?

Medicaid is a program for health care for persons in need. It is different from Medicare, which is a

health insurance program for persons 65 and older and some disabled persons under 65. The

Medicaid program in ^Fills.Y_YH_State is also called

^Fills.Y_YH_MediFill^Fill_or^Fills.Y_YH_CHIPFill.

At this time, are you covered by Medicaid?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Question Fill: ^FillYH142a

statehas The Medicaid program in ^Fills.Y_YH_State is also called

^Fills.Y_YH_MediFill or ^Fills.Y_YH_CHIPFill.

Logic after:

IF Y_YH170a = 2, DK OR REF, GO TO Y_YH171a; ELSE GO TO Y_YH172a

---------------------------------------------------------------------------------

Y_YH172a [ YYH172a ] Are you covered by the Indian Health Service?

Are you covered by the Indian Health Service?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_YH173a [ YYH173a ] Covered by any other type of health insurance

Are you covered by any other type of health insurance that I have not mentioned, such as

Medicare or insurance purchased directly from an insurance company?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF Y_YH168a = 2 AND Y_YH169a = 2 AND Y_YH170a = 2 AND Y_YH171a = 2 AND Y_YH172a =

2 AND Y_YH173a = 2 AND Y_YH174a = 2, CONTINUE. ELSE, GOTO Y_YH176a

Y_YH175a [ YYH175a ] What is the main reason you do not have health insurance?

Please look at Card 19. What is the main reason you do not have health insurance?

Question Type: TYH149a

lostjob 1 PERSON IN FAMILY WITH HEALTH INSURANCE LOST JOB OR CHANGED EMPLOYERS

divorced 2 GOT DIVORCED OR SEPARATED/DEATH OF SPOUSE OR PARENT

ineligible 3 BECAME INELIGIBLE BECAUSE OF AGE/LEFT SCHOOL

notoffered 4 EMPLOYER DOES NOT OFFER COVERAGE/OR NOT ELIGIBLE FOR COVERAGE

cost 5 COST IS TO HIGH

refused 6 INSURANCE COMPANY REFUSED COVERAGE

postpreg 7 MEDICAID/MEDICAL PLAN STOPPED AFTER AFTER PREGNANCY

newjob 8 LOST MEDICAID/MEDICAL PLAN BECAUSE OF NEW JOB OR INCREASE IN INCOME

lostmedicaid 9 LOST MEDICAID (OTHER)other

10 OTHER

Logic after:

GOTO Y_YHEND

---------------------------------------------------------------------------------

Y_YH177 [ YYH177 ] Any time without health insurance in last 12 months

During the past 12 months, was there any time when you did not have any health insurance?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

GOTO Y_YHEND

---------------------------------------------------------------------------------

Y_YH_END [ YYH_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

CHILDREN’S DEPRESSION INVENTORY

Logic before:

IF AGE = 7+, ADMINISTER CDI. ELSE, GOTO Y_CDEND. IF CHILD IS EMANCIPATED OR

YOUNG ADULT (18+), GOTO Y_CDEND. THIS SECTION IS SKIPPED FOR SPANISH-

LANGUAGE INTERVIEWS.

Y_CD1a [ YCD1a ] How CH has felt in past 2W(CD1T)

USE CARD 10. Kids sometimes have certain feelings and ideas. I am going to read 3 sentences

and I want you to pick the sentence that comes the closest to saying how you have felt in the

@bpast 2 weeks@b. Then I will read 3 more sentences, and you can pick again. As I read the

sentences, you can follow along on this card. Remember that all your answers are private.

Let's start with the first three sentences. POINT TO FIRST QUESTION ON CARD. Which one of

these three sentences @Bbest@B says how you have felt in the past 2 weeks? (READ LIST.)

Question Type: TYCD1a

onceinawhl 1 I am sad once in a while.

manytms 2 I am sad many times.

allthetm 3 I am sad all the time.

---------------------------------------------------------------------------------

Y_CD2a [ YCD2a ] How CH has felt in past 2W(CD2T)

USE CARD 10. Which one of these sentences @Bbest@B says how

you have felt in the past 2 weeks? (READ LIST.)

Question Type: TYCD2a

nothing 1 Nothing will ever work out for me.

notsure 2 I am not sure if things will work out for me.

willwork 3 Things will work out for me O.K.

---------------------------------------------------------------------------------

Y_CD3a [ YCD3a ] How CH has felt(CD3T)

USE CARD 10. Which of these @Bbest@B says how you have felt?

(READ LIST.)

Question Type: TYCD3a

okay 1 I do most things O.K.

manywrong 2 I do many things wrong.

allwrong 3 I do everything wrong.

---------------------------------------------------------------------------------

Y_CD7a [ YCD7a ] How CH has felt(CD7T)

USE CARD 11. Which of these @Bbest@B says how you have felt?

(READ LIST.)

Question Type: TYCD7a

hate 1 I hate myself.

donotlike 2 I do not like myself.

like 3 I like myself.

---------------------------------------------------------------------------------

Y_CD10a [ YCD10a ] How CH has felt(CD10T)

USE CARD 12. Which of these @Bbest@B says how you have felt?

(READ LIST.)

Question Type: TYCD10a

everyday 1 I feel like crying every day.

manydays 2 I feel like crying many days.

onceinawhl 3 I feel like crying once in a while.

---------------------------------------------------------------------------------

Y_CD11a [ YCD11a ] How CH has felt(CD11T)

USE CARD 12. Which of these @Bbest@B says how you have felt?

(READ LIST.)

Question Type: TYCD11a

allthetm 1 Things bother me all the time.

manytms 2 Things bother me many times.

onceinawhl 3 Things bother me once in a while.

---------------------------------------------------------------------------------

Y_CD14a [ YCD14a ] How CH has felt(CD14T)

USE CARD 13. Which of these @Bbest@B says how you have felt?

(READ LIST.)

Question Type: TYCD14a

lookok 1 I look O.K.

badthings 2 There are some bad things about my looks.

lookugly 3 I look ugly.

---------------------------------------------------------------------------------

Y_CD20a [ YCD20a ] How CH has felt in past 2W(CD20T)

USE CARD 14. Which of these @Bbest@B says how you have felt in

the past 2 weeks? (READ LIST.)

Question Type: TYCD20a

notalone 1 I do not feel alone.

alonealot 2 I feel alone many times.

alonealwys 3 I feel alone all the time.

---------------------------------------------------------------------------------

Y_CD22a [ YCD22a ] How CH has felt(CD22T)

USE CARD 15. Which of these @Bbest@B says how you have felt?

(READ LIST.)

Question Type: TYCD22a

manyfriends 1 I have plenty of friends.

somefriends 2 I have some friends but I wish I had more.

nofriends 3 I do not have any friends.

---------------------------------------------------------------------------------

Y_CD25a [ YCD25a ] How CH has felt(CD25T)

USE CARD 16. Which of these @Bbest@B says how you have felt?

(READ LIST.)

Question Type: TYCD25a

nobody 1 Nobody really loves me.

notsure 2 I am not sure if anybody loves me.

iamsure 3 I am sure that somebody loves me.

---------------------------------------------------------------------------------

Logic after:

GOTO Y_CDEND

CHILD MENTAL HEALTH: TRAUMA MODULE

---------------------------------------------------------------------------------

Y_TR_BGN [ YTR_BGN ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

---------------------------------------------------------------------------------

Logic before:

IF AGE < 8 GOTO Y_TREND; IF EMANCIPATED OR YOUNG ADULT (18+), GOT TO Y_TR11a

Y_TR1a [ YTR1a ] Trauma Symptom Chklist :bad dreams or nightmares

USE CARD 27. Now I am going to ask you how often different things happen to you. Pick your

answer from this card.

Tell me whether these things happen never, sometimes, lots of times, or almost all of the time.

Bad dreams or nightmares. Would you say this happens to you...

Question Type: Toften

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR2a [ YTR2a ] Trauma Symptom Chklist: scary ideas

USE CARD 27. Scary ideas or pictures just pop into my head. Would you say this happens to

Question Type: Toften

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR3a [ YTR3a ] Trauma Symptom Chklist: rmbrng thngs CH doesn't like

USE CARD 27. Remembering things that happened that I didn't like. (How often does this

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR4a [ YTR4a ] Trauma Symptom Chklist: going away in CH mind

USE CARD 27. Going away in my mind, trying not to think. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR5a [ YTR5a ] Trauma Symptom Chklist: rmbrng scary thngs

USE CARD 27. Remembering scary things. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR6a [ YTR6a ] Trauma Symptom Chklist: feeling scared of men

USE CARD 27. Feeling scared of men. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR7a [ YTR7a ] Trauma Symptom Chklist: feeling scared of women

USE CARD 27. Feeling scared of women. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR8a [ YTR8a ] Trauma Symptom Chklist: can't stop thnkng of something bad

USE CARD 27. Can't stop thinking about something bad that happened to me. (How often does

this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR9a [ YTR9a ] Trauma Symptom Chklist: rmbrng thngs I don't want to

USE CARD 27. Remembering things I don't want to remember. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR10a [ YTR10a ] Trauma Symptom Chklist: wshng bad thngs never happened

USE CARD 27. Wishing bad things had never happened. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

Logic after:

Y_TREND

---------------------------------------------------------------------------------

Logic before:

IF CHILD IS EMANCIPATED OR YOUNG ADULT (18+), CONTINUE. ELSE, GOTO Y_TREND

Y_TR11a [ YTR11a ] YA Trauma Symptom Chklist: bad dreams or nightmares

USE Card 27. Now I am going to ask you how often different things happen to you. Pick your

answer from this card. Tell me whether these things happen never, sometimes, lots of times, or

almost all of the time.

Nightmares or bad dreams. Would you say this happens to you…

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR12a [ YTR12a ] YA Trauma Symptom Chklist: flashbacks or sudden memories

USE Card 27. Flashbacks or sudden memories or images of upsetting things. Would you say this

happens to you…

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR13a [ YTR13a ] YA Trauma Symptom Chklist: feeling like outside body

USE Card 27. Feeling like you were outside of your body. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR14a [ YTR14a ] YA Trauma Symptom Chklist: sudden disturbing memories

USE Card 27. Sudden disturbing memories when you were not expecting them. (How often does

this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR15a [ YTR15a ] YA Trauma Symptom Chklist: mind going blank

USE Card 27. Your mind going blank. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR16a [ YTR16a ] YA Trauma Symptom Chklist: feel wtchng self frm far away

USE Card 27. Feeling like you were watching yourself from far away. (How often does this

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR17a [ YTR17a ] YA Trauma Symptom Chklist: not feeling like real self

USE Card 27. Not feeling like your real self. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR18a [ YTR18a ] YA Trauma Symptom Chklist: not being able to feel emotions

USE Card 27. Not being able to feel your emotions. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR19a [ YTR19a ] YA Trauma Symptom Chklist: absent-mindedness

USE Card 27. Absent-mindedness. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR20a [ YTR20a ] YA Trauma Symptom Chklist: sdnly rmbrng smthng upstng in pst

USE Card 27. Suddenly remembering something upsetting from your past. (How often does this

happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR21a [ YTR21a ] YA Trauma Symptom Chklist: sdnly rmnded of smthng bad

USE Card 27. Suddenly being reminded of something bad. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR22a [ YTR22a ] YA Trauma Symptom Chklist: violent dreams

USE Card 27. Violent dreams. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR23a [ YTR23a ] YA Trauma Symptom Chklist: seng/hrng smthng upstng erlyr lfe

USE Card 27. Just for a moment, seeing or hearing something upsetting that happened earlier in

your life. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR24a [ YTR24a ] YA Trauma Symptom Chklist: frghtng/upstng thghts pop nto mnd

USE Card 27. Frightening or upsetting thoughts popping into your mind. (How often does this

happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR25a [ YTR25a ] YA Trauma Symptom Chklist: flng like thngs not real

USE Card 27. Feeling like things weren't real. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR26a [ YTR26a ] YA Trauma Symptom Chklist: flng like in dream

USE Card 27. Feeling like you were in a dream. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR27a [ YTR27a ] YA Trauma Symptom Chklist: daydreaming

USE Card 27. Daydreaming. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR_END [ YTR_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

CHILD YOUTH BEHAVIOR MODULE

---------------------------------------------------------------------------------

Y_YB_BGN [ YYB_BGN ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

---------------------------------------------------------------------------------

Logic before:

IF AGE < 11 GOTO Y_YBEND. IF CHILD IS YOUNG ADULT (18+) OR EMANCIPATED, GOTO

Y_YB113A.

Y_YB1a [ YYB1a ] CH acts too young for age

USE CARD 28. Now I am going to read you different sentences that sometimes describe kids.

Tell me how true each sentence has been for you in the past @B6 months@B. Pick an answer

from this card: not true, somewhat or sometimes true, or very true or often true. Remember to tell

me what you really think. Your answers will be kept private.

I act too young for my age. Would you say…

Question Type: TTrue

not_true 1 not true,

some_true 2 somewhat or sometimes true, or

very_true 3 very true or often true?

---------------------------------------------------------------------------------

Y_YB2a [ YYB2a ] CH has allergy

I have an allergy. Would you say...

Question Type: TTrue

not_true 1 not true,

some_true 2 somewhat or sometimes true, or

very_true 3 very true or often true?

---------------------------------------------------------------------------------

Y_YB2aa [ YYB2aa ] CH drink alcohol without parents approval

I drink alcohol without my parents' approval. Would you say...

Question Type: TTrue

not_true 1 not true,

some_true 2 somewhat or sometimes true, or

very_true 3 very true or often true?

---------------------------------------------------------------------------------

Y_YB3a [ YYB3a ] CH argues a lot

I argue a lot. (Would you say this is not true, somewhat or sometimes true, or very true or often

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB4a [ YYB4a ] CH has asthma

I have asthma. (Would you say this is not true, somewhat or sometimes true, or very true or often

true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB4aa [ YYB4aa ] CH failes to finish things started

I fail to finish things that I start. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB5a [ YYB5a ] CH acts like opposite sex

I act like the opposite sex. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB5aa [ YYB5aa ] Very little CH enjoys

There is very little that I enjoy. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB6a [ YYB6a ] CH likes animals

I like animals. (Would you say this is not true, somewhat or sometimes true, or very true or often

true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB7a [ YYB7a ] CH likes to brag

I brag. (Would you say this is not true, somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB8a [ YYB8a ] CH has trbl concentrating or paying attention

I have trouble concentrating or paying attention. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB9a [ YYB9a ] CH can't get mind off certain things

I can't get my mind off certain thoughts. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB10a [ YYB10a ] CH has trble sitting still

I have trouble sitting still. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB11a [ YYB11a ] CH is too dpndnt on adults

I'm too dependent on adults. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB12a [ YYB12a ] CH feels lonley

I feel lonely. (Would you say this is not true, somewhat or sometimes true, or very true or often

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB13a [ YYB13a ] CH feels confused or in a fog

I feel confused or in a fog. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB14a [ YYB14a ] CH crys a lot

I cry a lot. (Would you say this is not true, somewhat or sometimes true, or very true or often

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB15a [ YYB15a ] CH is pretty honest

I am pretty honest. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB16a [ YYB16a ] CH is mean to others

I am mean to others. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB17a [ YYB17a ] CH day dreams a lot

I daydream a lot. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB18a [ YYB18a ] CH deliberately trys to hurt/kill self

I deliberately try to hurt or kill myself. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

Logic after:

IF Y_YB18a = 1, GOTO Y_YB19a

---------------------------------------------------------------------------------

Y_YB19a [ YYB19a ] CH trys to get a lot of attention

I try to get a lot of attention. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB20a [ YYB20a ] CH detroys own things

I destroy my own things. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB21a [ YYB21a ] CH detroys things belonging to others

I destroy things belonging to others. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB22a [ YYB22a ] CH disobeys parents

I disobey my parents. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB23a [ YYB23a ] CH disobeys at school

I disobey at school. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

FR NOTE: IF CHILD SAYS THEY DID NOT PHYSICALLY ATTEND SCHOOL, ASK THEM TO RESPOND THINKING ABOUT THEIR ONLINE/VIRTUAL EXPERIENCE.

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB24a [ YYB24a ] CH doesn't eat as well as CH should

I don't eat as well as I should. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB25a [ YYB25a ] CH doesn't get along with other kids

I don't get along with other kids. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB26a [ YYB26a ] CH doesn't feel quilty aftr doing something CH shouldn't

I don't feel guilty after doing something I shouldn't. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB27a [ YYB27a ] CH is jealous of othrs

I am jealous of others. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB28a [ YYB28a ] CH help othrs if they need help

I am willing to help others when they need help. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB28aa [ YYB28aa ] CH breaks rules at home school or elsewhere

I break rules at home, school, or elsewhere. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB29a [ YYB29a ] CH afraid crtn animals, situations. places othr thn school

I am afraid of certain animals, situations, or places, other than school. (Would you say this is not

true, somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB30a [ YYB30a ] CH afraid of going to school

I am afraid of going to school. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB31a [ YYB31a ] CH afraid might thnk/do something bad

I am afraid I might think or do something bad. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB32a [ YYB32a ] CH feels has to be perfect

I feel that I have to be perfect. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB33a [ YYB33a ] CH feels no on loves CH

I feel that no one loves me. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB34a [ YYB34a ] CH feels othrs out to get CH

I feel that others are out to get me. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB35a [ YYB35a ] CH feels worthless/inferior

I feel worthless or inferior. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB36a [ YYB36a ] CH accidently gets hurt a lot

I accidentally get hurt a lot. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB37a [ YYB37a ] CH gets in many fights

I get in many fights. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB38a [ YYB38a ] CH gets teased a lot

I get teased a lot. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB39a [ YYB39a ] CH hangs with kids who get in trbl

I hang around with kids who get in trouble. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB40a [ YYB40a ] CH hears sounds/voices

I hear sounds or voices that other people think aren't there. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB41a [ YYB41a ] CH acts without stopping to think

I act without stopping to think. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB42a [ YYB42a ] CH rather be alone than w/ othrs

I would rather be alone than with others. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB43a [ YYB43a ] CH lies or cheats

I lie or cheat. (Would you say this is not true, somewhat or sometimes true, or very true or often

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB44a [ YYB44a ] CH bites fingernails

I bite my fingernails. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB45a [ YYB45a ] CH nervous or tense

I am nervous or tense. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB46a [ YYB46a ] Parts of CH body twitch or mk nrvous mvmnts

Parts of my body twitch or make nervous movements. (Would you say this is not true, somewhat

or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB47a [ YYB47a ] CH has nightmares

I have nightmares. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB48a [ YYB48a ] CH not liked by othr kids

I am not liked by other kids. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB49a [ YYB49a ] CH does crtn thngs better than most kids

I can do certain things better than most kids. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB50a [ YYB50a ] CH too fearful/anxious

I am too fearful or anxious. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB51a [ YYB51a ] CH feels dizzy

I feel dizzy. (Would you say this is not true, somewhat or sometimes true, or very true or often

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB52a [ YYB52a ] CH feels quilty

I feel too guilty. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB53a [ YYB53a ] CH eats too much

I eat too much. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB54a [ YYB54a ] CH feels over tired

I feel overtired. (Would you say this is not true, somewhat or sometimes true, or very true or often

true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB55a [ YYB55a ] CH is overweight

I am overweight. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB56aa [ YYB56aa ] CH has aches/pains w/out med cause

I have aches or pains (not stomach or headaches) without a known medical cause. (Would you

say this is not true, somewhat or sometimes true, or very true or often true.)

NOTE: "WITHOUT KNOWN MEDICAL CAUSE" MEANS FOR UNKNOWN OR UNDIAGNOSED

REASONS.

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB56ba [ YYB56ba ] CH has headaches w/out med cause

I have headaches without a known medical cause. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

NOTE: "WITHOUT KNOWN MEDICAL CAUSE" MEANS FOR UNKNOWN OR UNDIAGNOSED

REASONS.

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB56ca [ YYB56ca ] CH has nausea/feels sick w/out med cause

I have nausea or feel sick without a known medical cause. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

NOTE: "WITHOUT KNOWN MEDICAL CAUSE" MEANS FOR UNKNOWN OR UNDIAGNOSED

REASONS.

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB56da [ YYB56da ] CH has prblms w/ eyes w/out med cause not fxd by glasses

I have problems with my eyes that are not corrected by glasses and do not have a known medical

cause. (Would you say this is not true, somewhat or sometimes true, or very true or often true.)

NOTE: "WITHOUT KNOWN MEDICAL CAUSE" MEANS FOR UNKNOWN OR UNDIAGNOSED

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB56ea [ YYB56ea ] CH has rashes/skin prblms w/out med cause

I have rashes or other skin problems without a known medical cause. (Would you say this is not

true, somewhat or sometimes true, or very true or often true.)

NOTE: "WITHOUT KNOWN MEDICAL CAUSE" MEANS FOR UNKNOWN OR UNDIAGNOSED

REASONS.

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB56fa [ YYB56fa ] CH has stomach aches/craps w/out med cause

I have stomach aches or cramps without a known medical cause. (Would you say this is not

true, somewhat or sometimes true, or very true or often true.)

NOTE: "WITHOUT KNOWN MEDICAL CAUSE" MEANS FOR UNKNOWN OR UNDIAGNOSED

REASONS.

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB56ga [ YYB56ga ] CH vomits w/out med cause

I have vomiting, throwing up without a known medical cause. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

NOTE: "WITHOUT KNOWN MEDICAL CAUSE" MEANS FOR UNKNOWN OR UNDIAGNOSED

REASONS.

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB56ha [ YYB56ha ] CH has othr phys prblms w/out med cause

I have other physical problems without a known medical cause. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

NOTE: "WITHOUT KNOWN MEDICAL CAUSE" MEANS FOR UNKNOWN OR UNDIAGNOSED

REASONS.

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB57a [ YYB57a ] CH physically attacks people

I physically attack people. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB58a [ YYB58a ] CH picks skin or othr body parts

I pick my skin or other parts of my body. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB59a [ YYB59a ] CH can be pretty friendly

I can be pretty friendly. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB60a [ YYB60a ] CH trys new things

I like to try new things. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB61a [ YYB61a ] CH school work is poor

My school work is poor. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB62a [ YYB62a ] CH is poorly coordinated and clumsy

I am poorly coordinated or clumsy. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB63a [ YYB63a ] CH rather be w/ oldr kds than kds own age

I would rather be with older kids than with kids my own age. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB64a [ YYB64a ] CH rather w/ yngr kds thn kds own age

I would rather be with younger kids than with kids my own age. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB65a [ YYB65a ] CH refuses to talk

I refuse to talk. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB66a [ YYB66a ] CH repeats certain acts over and over

I repeat certain acts over and over. (Would you say this is not true, somewhat or sometimes true,

or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB67a [ YYB67a ] CH runs away from home

I run away from home. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB68a [ YYB68a ] CH screams a lot

I scream a lot. (Would you say this is not true, somewhat or sometimes true, or very true or often

true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB69a [ YYB69a ] CH is secretive

I am secretive or keep things to myself. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB70a [ YYB70a ] CH see thngs othrs thnk are not there

I see things that other people think aren't there. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB71a [ YYB71a ] CH is self-concious or esily embrassed

I am self-conscious or easily embarrassed. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB72a [ YYB72a ] CH sets fires

I set fires. (Would you say this is not true, somewhat or sometimes true, or very true or often

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB73a [ YYB73a ] CH works well w/ hands

I can work well with my hands. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB74a [ YYB74a ] CH shows off

I show off or clown. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB75a [ YYB75a ] CH is shy

I am shy. (Would you say this is not true, somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB76a [ YYB76a ] CH sleeps less than most kids

I sleep less than most kids. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB77a [ YYB77a ] CH sleeps more than most kids during day and/or night

I sleep more than most kids during the day and/or night. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB78a [ YYB78a ] CH has good imagination

I have a good imagination. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB78aa [ YYB78aa ] CH is inattentive or easily distracted

I am inattentive or easily distracted. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB79a [ YYB79a ] CH has speech prblm

I have a speech problem. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB80a [ YYB80a ] CH stands up for rights

I stand up for my rights. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB81a [ YYB81a ] CH steals at home

I steal at home. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB82a [ YYB82a ] CH steals from places othr than home

I steal from places other than home. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB83a [ YYB83a ] CH stores up things not needed

I store up things I don't need. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB84a [ YYB84a ] CH does things othrs think are strange

I do things other people think are strange. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB85a [ YYB85a ] CH has thoughts that othrs think are strange

I have thoughts that other people would think are strange. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB86a [ YYB86a ] CH is stubborn

I am stubborn. (Would you say this is not true, somewhat or sometimes true, or very true or often

true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB87a [ YYB87a ] CH moods/feelings change suddenly

My moods or feelings change suddenly. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

---------------------------------------------------------------------------------

Y_YB88a [ YYB88a ] CH enjoys being with othrs

I enjoy being with other people. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB89a [ YYB89a ] CH is suspicious

I am suspicious. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB90a [ YYB90a ] CH swears/uses dirty language

I swear or use dirty language. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB91a [ YYB91a ] CH thinks about killing self

I think about killing myself. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

Logic after:

IF Y_YB91a = 1, GOTO Y_YB92a)

---------------------------------------------------------------------------------

Y_YB92a [ YYB92a ] CH makes othrs laugh

I like to make others laugh. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB93a [ YYB93a ] CH talks too much

I talk too much. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB94a [ YYB94a ] CH teases othrs a lot

I tease others a lot. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB95a [ YYB95a ] CH has a hot temper

I have a hot temper. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB96a [ YYB96a ] CH thinks about sex too much

I think about sex too much. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB97a [ YYB97a ] CH threatens to hurt people

I threaten to hurt people. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB98a [ YYB98a ] CH likes to help othrs

I like to help others. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB99a [ YYB99a ] CH too concerned about being neat/clean

I am too concerned about being neat or clean. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB99aa [ YYB99aa ] CH smokes chew or sniff tobacco

I smoke, chew, or sniff tobacco. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB100a [ YYB100a ] CH has trbl sleeping

I have trouble sleeping. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB101a [ YYB101a ] CH cuts classes or skips school

I cut classes or skip school. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB102a [ YYB102a ] CH doesn't have much money

I don't have much energy. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB103a [ YYB103a ] CH is unhappy/sad/depressed

I am unhappy, sad, or depressed. (Would you say this is not true, somewhat or sometimes true,

or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB104a [ YYB104a ] CH is louder than othr kids

I am louder than other kids. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB105a [ YYB105a ] CH used alcohol/drugs for non-med purposes

I use alcohol or drugs for non-medical purposes. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB106a [ YYB106a ] CH tries to be fair to othrs

I try to be fair to others. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB107a [ YYB107a ] CH enjoys a good joke

I enjoy a good joke. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB108a [ YYB108a ] CH lkes to take life easy

I like to take life easy. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB109a [ YYB109a ] CH tris to help othrs when CH can

I try to help other people when I can. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB110a [ YYB110a ] CH wishes CH was opposite sex

I wish I were of the opposite sex. (Would you say this is not true, somewhat or sometimes true,

or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB111a [ YYB111a ] CH keeps from getting involved with othrs

I keep from getting involved with others. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB112a [ YYB112a ] CH worries a lot

I worry a lot. (Would you say this is not true, somewhat or sometimes true, or very true or often

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

Logic after:

GOTO Y_YBEND

---------------------------------------------------------------------------------

Logic before:

IF CHILD IS EMANCIPATED OR YOUNG ADULT (18+), CONTINUE. ELSE, GOTO Y_YBEND.

Y_YB113a [ YYB113a ] YA is too forgetfull

USE Card 28. Now I am going to read you different sentences that may sometimes describe you.

Tell me how true each sentence has been for you in the past @B6 months@B. Pick an answer

from this card: not true, somewhat or sometimes true, or very true or often true. Remember to tell

me what you really think. Your answers will be kept private.

I am too forgetful. Would you say…

Question Type: TTrue

not_true 1 not true,

some_true 2 somewhat or sometimes true, or

very_true 3 very true or often true?

---------------------------------------------------------------------------------

Y_YB114a [ YYB114a ] YA makes good use of opportunities

I make good use of my opportunities. Would you say...

Question Type: TTrue

not_true 1 not true,

some_true 2 somewhat or sometimes true, or

very_true 3 very true or often true?

---------------------------------------------------------------------------------

Y_YB115a [ YYB115a ] YA argues a lot

I argue a lot. Would you say...

Question Type: TTrue

not_true 1 not true,

some_true 2 somewhat or sometimes true, or

very_true 3 very true or often true?

---------------------------------------------------------------------------------

Y_YB116a [ YYB116a ] YA works up to ability

I work up to my ability. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB117a [ YYB117a ] YA blames others for own problems

I blame others for my problems. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB118a [ YYB118a ] YA uses drugs for non-med purposes

I use drugs (other than alcohol and nicotine) for nonmedical purposes. (Would you say this is not

true, somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB119a [ YYB119a ] YA brags

I brag. (Would you say this is not true, somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB120a [ YYB120a ] YA has trbl concentrating/paying attention

I have trouble concentrating or paying attention for long. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB121a [ YYB121a ] YA can't get mind off certain things

I can't get my mind off certain thoughts. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB122a [ YYB122a ] YA has trbl sitting still

I have trouble sitting still. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB123a [ YYB123a ] YA is too dependent on others

I am too dependent on others. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB124a [ YYB124a ] YA feels lonely

I feel lonely. (Would you say this is not true, somewhat or sometimes true, or very true or often

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB125a [ YYB125a ] YA feels confused

I feel confused or in a fog. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB126a [ YYB126a ] YA crys a lot

I cry a lot. (Would you say this is not true, somewhat or sometimes true, or very true or often

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB127a [ YYB127a ] YA is pretty honest

I am pretty honest. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB128a [ YYB128a ] YA is mean to othrs

I am mean to others. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB129a [ YYB129a ] YA daydreams a lot

I daydream a lot. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB130a [ YYB130a ] YA deliberately tries to hurt/kill self

I deliberately try to hurt or kill myself. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB131a [ YYB131a ] YA tries to get attention

I try to get a lot of attention. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB132a [ YYB132a ] YA damages or destroys own things

I damage or destroy my things. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB133a [ YYB133a ] YA damages or destroys othrs things

I damage or destroy things belonging to others. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB134a [ YYB134a ] YA worries about future

I worry about my future. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB135a [ YYB135a ] YA breaks rules at work and elsewhere

I break rules at work or elsewhere. (Would you say this is not true, somewhat or sometimes true,

or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB136a [ YYB136a ] YA doesn't eat as well as should

I don't eat as well as I should. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB137a [ YYB137a ] YA doesn't get along well with othrs

I don't get along well with other people. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB138a [ YYB138a ] YA doesn't feel guilty after doing something shouldn't

I don't feel guilty after doing something I shouldn't. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB139a [ YYB139a ] YA jealous of othrs

I am jealous of others. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB140a [ YYB140a ] YA gets along badly with family

I get along badly with my family. (Would you say this is not true, somewhat or sometimes true,

or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB141a [ YYB141a ] YA afraid of certain animals/situations/places

I am afraid of certain animals, situations, or places. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB142a [ YYB142a ] YA has poor relationships with opposite sex

My relations with the opposite sex are poor. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB143a [ YYB143a ] YA afraid might think/do something bad

I am afraid I might think or do something bad. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB144a [ YYB144a ] YA feels need to be perfect

I feel that I have to be perfect. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB145a [ YYB145a ] YA feels no one loves YA

I feel that no one loves me. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB146a [ YYB146a ] YA feels othrs are out to get YA

I feel that others are out to get me. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB147a [ YYB147a ] YA feels worthless/inferior

I feel worthless or inferior. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB148a [ YYB148a ] YA accidentally gets hurt a lot/accident prone

I accidentally get hurt a lot, accident prone. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB149a [ YYB149a ] YA gets in many fights

I get in many fights. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB150a [ YYB150a ] YA has poor relations with neighbors

My relations with neighbors are poor. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB151a [ YYB151a ] YA hangs around people who get into trbl

I hang around people who get in trouble. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB152a [ YYB152a ] YA hears sounds/voices others don't

I hear sounds or voices that other people think aren't there. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB153a [ YYB153a ] YA is impulsive

I am impulsive or act without thinking. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB154a [ YYB154a ] YA would rather be alone than w/t othrs

I would rather be alone than with others. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB155a [ YYB155a ] YA lies/cheats

I lie or cheat. (Would you say this is not true, somewhat or sometimes true, or very true or often

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB156a [ YYB156a ] YA feels overwhelmed by responsibilities

I feel overwhelmed by my responsibilities. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB157a [ YYB157a ] YA is nervous/tense

I am nervous or tense. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB158a [ YYB158a ] Parts of YA body twitch/makes nervous movements

Parts of my body twitch or make nervous movements. (Would you say this is not true, somewhat

or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB159a [ YYB159a ] YA lacks self-confidence

I lack self-confidence. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB160a [ YYB160a ] YA is not liked by othrs

I am not liked by others. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB161a [ YYB161a ] YA can do certain things better than othr people

I can do certain things better than other people. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB162a [ YYB162a ] YA feels fearful/anxious

I am too fearful or anxious. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB163a [ YYB163a ] YA feels dizzy/lightheaded

I feel dizzy or lightheaded. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB164a [ YYB164a ] YA feels guilty

I feel too guilty. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB165a [ YYB165a ] YA has trbl planning for future

I have trouble planning for the future. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB166a [ YYB166a ] YA feels tired w/out good reason

I feel tired without good reason. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB167a [ YYB167a ] YA moods swing between elation and depression

My moods swing between elation and depression. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB168a [ YYB168a ] YA has aches/pains w/out med cause

I have aches and pains without known medical cause. (Would you say this is not true, somewhat

or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB169a [ YYB169a ] YA has headachese w/out med cause

I have headaches without known medical cause. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB170a [ YYB170a ] YA has nausea/feels sick w/out med cause

I have nausea, feel sick without known medical cause. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB171a [ YYB171a ] YA prblms w/ eyes w/out med cause not fixed by glasses

I have problems with eyes (not if corrected by glasses) without known medical cause. (Would

you say this is not true, somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB172a [ YYB172a ] YA has rashes/skin prblms w/out med cause

I have rashes or other skin problems without known medical cause. (Would you say this is not

true, somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB173a [ YYB173a ] YA has stomachaches w/out med cause

I have stomachaches without known medical cause. (Would you say this is not true, somewhat

or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB174a [ YYB174a ] YA vomits w/out med cause

I have vomiting, throwing up without known medical cause. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB175a [ YYB175a ] YA has heart pounding/racing w/out med cause

I have heart pounding or racing without known medical cause. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB176a [ YYB176a ] YA has numbness/tingling in body parts w/out med cause

I have numbness or tingling in body parts without known medical cause. (Would you say this is

not true, somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB177a [ YYB177a ] YA physically attacks people

I physically attack people. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB178a [ YYB178a ] YA picks skin/othr body parts

I pick my skin or other parts of my body. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB179a [ YYB179a ] YA fails to finish things

I fail to finish things I should do. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB180a [ YYB180a ] Very little that YA enjoys

There is very little that I enjoy. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB181a [ YYB181a ] YA work performance is poor

My work performance is poor. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB182a [ YYB182a ] YA is poorly coordinated/clumsy

I am poorly coordinated or clumsy. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB183a [ YYB183a ] YA would rather be with older people than people own age

I would rather be with older people than with people my own age. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB184a [ YYB184a ] YA has trbl setting priorities

I have trouble setting priorities. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB185a [ YYB185a ] YA refuses to talk

I refuse to talk. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB186a [ YYB186a ] YA repeats certain acts over and over

I repeat certain acts over and over. (Would you say this is not true, somewhat or sometimes true,

or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB187a [ YYB187a ] YA has trbl making friends

I have trouble making or keeping friends. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB188a [ YYB188a ] YA screams/yells a lot

I scream or yell a lot. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB189a [ YYB189a ] YA is secretive/keeps things to self

I am secretive or keep things to myself. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB190a [ YYB190a ] YA sees things othrs think aren't there

I see things that other people think aren't there. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB191a [ YYB191a ] YA is self-concious/easily embarrassed

I am self-conscious or easily embarrassed. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB192a [ YYB192a ] YA worris about family

I worry about my family. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB193a [ YYB193a ] YA meets responsibilities to family

I meet my responsibilities to my family. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB194a [ YYB194a ] YA shows off

I show off or clown. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB195a [ YYB195a ] YA is too shy/timid

I am too shy or timid. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB196a [ YYB196a ] YA behavior is irresponsible

My behavior is irresponsible. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB197a [ YYB197a ] YA sleeps more than most othrs during day and/or night

I sleep more than most other people during day and/or night. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB198a [ YYB198a ] YA has trbl making decisions

I have trouble making decisions. (Would you say this is not true, somewhat or sometimes true,

or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB199a [ YYB199a ] YA has speech prblm

I have a speech problem. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB200a [ YYB200a ] YA stands up for rights

I stand up for my rights. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB201a [ YYB201a ] YA behavior is very changable

My behavior is very changeable. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB202a [ YYB202a ] YA steals

I steal. (Would you say this is not true, somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB203a [ YYB203a ] YA eaisly bored

I am easily bored. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB204a [ YYB204a ] YA does things that othrs think are strange

I do things that other people think are strange. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB205a [ YYB205a ] YA has thoughts othrs would think are stange

I have thoughts that other people would think are strange. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB206a [ YYB206a ] YA is stubborn/sullen/irritable

I am stubborn, sullen, or irritable. (Would you say this is not true, somewhat or sometimes true,

or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB207a [ YYB207a ] YA moods/feelings change suddenly

My moods or feelings change suddenly. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB208a [ YYB208a ] YA enjoys being w/ othr people

I enjoy being with people. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB209a [ YYB209a ] YA rushes into things w/out considering risks

I rush into things without considering the risks. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB210a [ YYB210a ] YA drinks too much alcohol/gets drunk

I drink too much alcohol or get drunk. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB211a [ YYB211a ] YA thinks about killing self

I think about killing myself. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB212a [ YYB212a ] YA does things that may cause trbl with law

I do things that may cause me trouble with the law. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB213a [ YYB213a ] YA talks too much

I talk too much. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB214a [ YYB214a ] YA tease othrs a lot

I tease others a lot. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB215a [ YYB215a ] YA has a hot temper

I have a hot temper. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB216a [ YYB216a ] YA thinks about sex too much

I think about sex too much. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB217a [ YYB217a ] YA threatens to hurt people

I threaten to hurt people. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB218a [ YYB218a ] YA likes to help others

I like to help others. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB219a [ YYB219a ] YA dislikes staying in one place for very long

I dislike staying in one place for very long. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB220a [ YYB220a ] YA has trbl sleeping

I have trouble sleeping. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB221a [ YYB221a ] YA stays away from job even when not sick/on vacation

I stay away from my job even when I'm not sick or not on vacation. (Would you say this is not

true, somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB222a [ YYB222a ] YA doesn't have much energy

I don't have much energy. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB223a [ YYB223a ] YA is unhappy/sad/depressed

I am unhappy, sad, or depressed. (Would you say this is not true, somewhat or sometimes true,

or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB224a [ YYB224a ] YA louder than othrs

I am louder than others. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB225a [ YYB225a ] Othrs think YA is disorganized

People think I am disorganized. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB226a [ YYB226a ] YA tries to be fair to othrs

I try to be fair to others. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB227a [ YYB227a ] YA feels can't succeed

I feel that I can't succeed. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB228a [ YYB228a ] YA tends to lose things

I tend to lose things. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB229a [ YYB229a ] YA likes to try new things

I like to try new things. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB230a [ YYB230a ] YA wishes was opposite sex

I wish I were of the opposite sex. (Would you say this is not true, somewhat or sometimes true,

or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB231a [ YYB231a ] YA keeps from getting involved with othrs

I keep from getting involved with others. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB232a [ YYB232a ] YA worries a lot

I worry a lot. (Would you say this is not true, somewhat or sometimes true, or very true or often

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB233a [ YYB233a ] YA worries about relations with opposite sex

I worry about my relations with the opposite sex. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB234a [ YYB234a ] YA fails to pay debts/meet financial responsibilities

I fail to pay my debts or meet other financial responsibilities. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB235a [ YYB235a ] YA feels restless/fidgety

I feel restless or fidgety. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB236a [ YYB236a ] YA gets upset easily

I get upset too easily. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB237a [ YYB237a ] YA has trbl managing money/credit cards

I have trouble managing money or credit cards. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB238a [ YYB238a ] YA is too impatient

I am too impatient. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB239a [ YYB239a ] YA not good at details

I am not good at details. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB240a [ YYB240a ] YA drives too fast

I drive too fast. (Would you say this is not true, somewhat or sometimes true, or very true or often

true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB241a [ YYB241a ] YA tends to be late to appointments

I tend to be late for appointments. (Would you say this is not true, somewhat or sometimes true,

or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB242a [ YYB242a ] YA has trbl keeping a job

I have trouble keeping a job. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB243a [ YYB243a ] YA is a happy person

I am a happy person. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB_END [ YYB_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

CHILD EMPLOYMENT/RESOURCES TO LIVE MODULE

---------------------------------------------------------------------------------

Logic before:

IF CHILD IS EMANCIPATED OR YOUNG ADULT (18+), CONTINUE, ELSE GOTO Y_EREND

Y_ER0a [ YER0a ] NO LABEL

Now I'd like to ask you about any work you may have done. I am going to distinguish between two

types of work. First we will talk about work you may have done for an employer; that is a job

where you had an on-going relationship with a particular employer, for example, working in a

supermarket or restaurant. Then we will talk about informal jobs; that is doing one or a few tasks

for several people and not having a "boss," for example, babysitting or mowing lawns.

First, let's talk about any work you have done for an employer.

Question Type: TCont

Continue 1 Continue

---------------------------------------------------------------------------------

Y_ER1a [ YER1a ] CH currently working full/pt job or jobs

Are you currently working at a full or part-time job or jobs?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_ER1a = 1 GOTO Y_ER3a

---------------------------------------------------------------------------------

Y_ER2a [ YER2a ] CH employed in last 12 months

Have you been employed in the past 12 months?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_ER2a = 2 GOTO Y_ER35a

---------------------------------------------------------------------------------

Y_ER10a [ YER10a ] Hours/week CH usually worked at this job

How many hours per week ^Fills.ER10n at this job?

Question Type: 0..168

Question Fill: ^FillER10n

present do you @Busually@B work

past did you @Busually@B work

---------------------------------------------------------------------------------

Y_ER32a [ YER32a ] CH had other jobs past 12 months (#)

Other than the job you have already told me about, how many jobs have you had in the past 12

months?

Question Type: 0..97

---------------------------------------------------------------------------------

Logic before:

IF Y_ER32a = 0, GOTO Y_ER35a. IF Y_ER32n= 0, GO TO Y_ER35a] In the past 12 months, how

much did you earn from {FILL: this 1 job (IF Y_ER32a = 1); these [FILL: Y_ER32a] jobs (IF

Y_ER32a > 1)

Y_ER33a [ YER33a ] Amount CH earned at other jobs

In the past 12 months, how much did you earn from ^Y_ER33a_Fill?

Question Type: 0..200000

---------------------------------------------------------------------------------

Logic before:

IF Y_ER33a = REF OR DK

Y_ER34a [ YER34a ] Range amount CH earned at other jobs

Would you say it was...

Question Type: TER34a

a1 1 Less than $50

a2 2 More than $50 but less than $100

a3 3 More than $100 but less than $500

a4 4 More than $500

a5 5 More than $1000

a6 6 More than $5000

---------------------------------------------------------------------------------

Y_ER35a [ YER35a ] Freq of CH informal jobs

Now let's talk about informal jobs such as baby-sitting or lawn mowing.

About how often do you do these types of informal jobs? Would you say it is...

Question Type: TER35a

sevxwk 1 Several times a week

onceawk 2 Once a week

twoto3awk 3 2-3 times a month

onceamo 4 Once a month

lessonceamo 5 Less than once a month

never 6 Never

Logic after:

IF Y_ER35a = 6 GO TO Y_ER39a

---------------------------------------------------------------------------------

Y_ER37a [ YER37a ] Amt CH earned all informal jobs

In the past 12 months, how much have you earned from all the informal jobs?

Question Type: 0..200000

---------------------------------------------------------------------------------

Logic before:

IF Y_ER37a = REF or DK

Y_ER38a [ YER38a ] Range of amt CH earned informal jobs

Would you say it was...

Question Type: TER34a

a1 1 Less than $50

a2 2 More than $50 but less than $100

a3 3 More than $100 but less than $500

a4 4 More than $500

a5 5 More than $1000

a6 6 More than $5000

---------------------------------------------------------------------------------

Y_ER39 [ YER39 ] NO LABEL

Now I'd like to ask you about other ways you may have made money or gotten help.

For these next questions we are interested in different kinds of payments that might have been

made directly to you. For these questions, please do not include any payments that were made

to other members of your family or household, even if the payments were used to help pay for

your support.

Question Type: TCont

Continue 1 Continue

---------------------------------------------------------------------------------

Y_ER40a [ YER40a ] CH received unemplymt comp pymt - past 12 months

In the past 12 months, have you received any unemployment compensation payments?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_ER47a [ YER47a ] CH received financial hlp frm agncy/ILP - past 12 months

In the past 12 months, have you received any financial help from the child welfare agency or your

caseworker, mentor, or Independent Living Program?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_ER48a [ YER48a ] CH received financial help rel or friend - past 12 months

In the past 12 months, have you received any financial help from a relative or friend?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_ER49a [ YER49a ] CH received financial hlp community group - past 12 months

In the past 12 months, have you received any financial help from a community group, such as a

church, a community organization, or a family resource center?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_ER58a [ YER58a ] How going CH making ends meet

When it comes to money and making ends meet, how do you think things are going for you?

Would you say you are able to save a little money each month, just getting by, or struggling to

Question Type: TER58a

save 1 Save a little money each month

gettingby 2 Just getting by

struggling 3 Struggling to make it

---------------------------------------------------------------------------------

Y_ER59a [ YER59a ] Housing that CH paid rent/mortgage - last 12 months

Now let's talk about the place where you're living these days.

In the last 12 months, did you ever stay in a place where you were supposed to pay rent or mortgage?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_ER59a = 2 GOTO Y_ER62a

---------------------------------------------------------------------------------

Y_ER60a [ YER60a ] CH ever unable to pay rent/mortgage - last 12 months

Was there ever a time in the last 12 months when you couldn't pay your rent or mortgage on time?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_ER60a = 2 GOTO Y_ER62a

---------------------------------------------------------------------------------

Y_ER62a [ YER62a ] CH evicted/moved b/c couldn't pay - last 12 months

At any time in the last 12 months, were you ever evicted or did you ever have to move out of a

place because you couldn't pay to stay there?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_ER67a [ YER67a ] CH stayed in home of relative - last 12 months

Have you stayed in the home of a relative (in the last 12 months)?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_ER69a [ YER69a ] CH stayed in home of friend - last 12 months

Have you stayed in the home of a friend (in the last 12 months)?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_ER71a [ YER71a ] CH stayed in hotel/motel/SRO

Have you stayed in your own rented room in a motel, hotel, or Single Room Occupancy (in the

last 12 months)?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_ER73a [ YER73a ] CH stayed in car/truck/oth vehicle - last 12 months

Have you stayed in a car, truck, or some other type of vehicle (in the last 12 months)?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_ER75a [ YER75a ] CH stayed in abdoned bldg/outside - last 12 months

Have you stayed in an abandoned building, on the street, or outside somewhere (in the last 12

months)?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Logic before:

IF RESPONDENT IS MALE, GOTO Y_ER79a. ELSE CONTINUE

Y_ER77a [ YER77a ] CH stayed in battered womens shelter - last 12 months

Have you stayed in a shelter for battered women (in the last 12 months)?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_ER78b [ YYD21 ] How much R needed domestic violence svcs - past 12M

In the last 12 months, how much have you needed domestic violence services or help to deal with

an abusive partner? Would you say...

Question Type: TYYV13a

alot 1 a lot,

somewhat 2 somewhat,

alittle 3 a little, or

notatall 4 not at all?

---------------------------------------------------------------------------------

Y_ER79a [ YER79a ] CH stayed in homeless shelter - last 12 months

Have you stayed in a shelter for the homeless (in the last 12 months)?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_ER83a [ YER83a ] CH get food from church/pantry - last 12 months

In the last 12 months, did you ever get emergency food from a church, a food pantry, or food bank?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_ER85a [ YER85a ] CH eat meals at soup kitchen - last 12 months

In the last 12 months, did you ever eat any meals at a soup kitchen?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_ER85a = 2 GOTO Y_ER87a

---------------------------------------------------------------------------------

Y_ER87a [ YER87a ] CH hungry but couldnt buy food - last 12 months

In the last 12 months, were you ever hungry but didn't eat because you couldn't afford enough food?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_ER87a = 2 GOTO Y_ER89a

---------------------------------------------------------------------------------

ADMINISTER Y_ER89 – Y_ER110 TO EMANCIPATED YOUTH AND TO YOUNG ADULTS FROM STATES WITH EXTENDED FOSTER CARE PROGRAMS

Y_ER89 [ YER89 ] NO LABEL

In the last 12 months, has a caseworker or agency helped you to find a job, prepare for your

education, find a place to live, or help with day-to-day activities such as managing finances?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_ER90 [ YER90 ] NO LABEL

In the past 12 months, has a caseworker or agency helped you find services to help you handle

stress or cope with things that come up in your life?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF Y_ER89=yes or

Y_ER90=yes ASK

ELSE GOTO Y_ER108a

Y_ER108 [ YER108 ] NO LABEL

Were any of the services you just reported receiving @bprovided or paid for@b by the child welfare

agency?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

if Y_ER108 <> NO then GOTO Y_ER109

---------------------------------------------------------------------------------

Logic before:

IF WAVE >= 2, ASK

Y_ER108a [ YER108a ] Services paid for by agency

USE CARD 34. Please look at the list of services on Card 34. Since ^lstintdate, have you received

any of these services from the child welfare agency? The agency may have provided the services

directly or paid for you to receive the services somewhere else.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

CARD 34 CONTENTS:

Foster care or kinship care services

Individualized Education Plan (IEP)

Individualized Family Service Plan (IFSP)

Special Education Services

In-home counseling or in-home crisis services

Family counseling

Therapeutic nursery care

Mental health services or treatment

Job-related services

Organized support groups: Alcoholics Anonymous, Parents Anonymous, etc.

Child care services

Services for alcohol or drug problems

Parenting skills training

Training on ways to discipline child

Home management training (e.g., budgeting or planning meals)

Respite care for a child

Transportation help

Case manager visits or other types of contacts with case manager

---------------------------------------------------------------------------------

Logic before:

IF Y_ER108=yes or Y_ER108a = yes then ASK Y_ER109

ELSE SKIP TO Y_ER_END

Y_ER109 [ YER109 ] NO LABEL

What is the name of the caseworker who is most knowledgeable about the services you have

received?

NAME:

Question Type: string[50]

---------------------------------------------------------------------------------

Y_ER110 [ YER110 ] NO LABEL

What is the caseworker's telephone number?

PHONE

Question Type: TPHONE

---------------------------------------------------------------------------------

Y_ER_END [ YER_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

YOUNG ADULT AND EMANCIPATED YOUTH INCOME MODULE

---------------------------------------------------------------------------------

Logic before:

IF CHILD IS EMANCIPATED OR YOUNG ADULT (18+) YEARS OLD, CONTINUE. ELSE GO TO

Y_YIEND

Y_YI1an [ YYI1an ] Available income and income assitance to HH during past 12M

The next questions are about income or income assistance available to your household during the

past 12 months. By household, I mean all of the people who live here. Please remember that all

information you provide will be kept private.

First, I need to know the @Btotal combined income of your family@B from all sources @Bin the

past 12 months@B. Please include your own income and the income of everyone living with you.

This includes money from jobs, net income from business or rent, pensions, dividends, interest,

social security, public assistance programs, welfare, food stamps, child support and income from

any other source such as family or friends and activities such as work "off the books" or "under

the table." If you don't know exactly, your best guess is okay.

Question Type: TCont

Continue 1 Continue

---------------------------------------------------------------------------------

Y_YI2n [ YYI2n ] Best estimate of total family income before taxes past 12M

In the past twelve months, what was the total income of your household from all sources before taxes and other deductions? Please include your own income and the income of everyone living with you

Question Type: 0..999997

Logic after:

IF Y_YI2n = DK or REF, GO TO Y_YI3aa. ELSE GO TO Y_YI2an

---------------------------------------------------------------------------------

Y_YI3_1n [ YYI3_1n ] How many adults including yourself depend on this income

How many adults, including yourself, depend on this income?

NOTE: QUESTION REFERS TO ALL ADULTS, INCLUDING THOSE WHO MAY LIVE IN A

DIFFERENT HOUSEHOLD.

NUMBER OF ADULTS:

Question Type: 1..30

---------------------------------------------------------------------------------

Logic before:

IF CH35a = 1, CONTINUE. ELSE, GOTO Y_YI5

Y_YI3_2n [ YYI3_2n ] How many children depend on this income

How many children depend on this income?

NOTE: QUESTION REFERS TO ALL CHILDREN, INCLUDING THOSE WHO MAY LIVE IN A

DIFFERENT HOUSEHOLD.

NUMBER OF CHILDREN:

Question Type: 0..30

---------------------------------------------------------------------------------

Y_YI5 [ YYI5 ] Labels are in Logic After

In the last 12 months, did anyone in this household receive...

CODE ALL THAT APPLY.

Question Type: TYI5S

1 = WIC (Women Infants, and Children),

2 = [NAME OF STATE SNAP PROGRAM], [NAME OF STATE EBT CARD] Electronic Bank Transfer (EBT) card, or Food Stamps,

3 = Welfare or TANF (PROBE: By welfare or TANF, we mean temporary assistance to needy families, AFDC, or cash welfare) or other public assistance

4 = Housing Support, such as public housing, a voucher or assistance from Section 8),

5 = A disability check (SSI)?

6 = Child care assistance

7 = NONE OF THE ABOVE.

Y_YI12.

Did you receive the Earned Income Tax Credit, or EITC, or any tax refund within the last 12 months?

PROBE IF DON’T KNOW WHAT EITC IS: The federal government has a special rule that allows working people who make less than about $29,000 a year to get a tax refund. It’s called the Earned Income Credit or EIC. Sometimes, if the IRS thinks that someone is eligible for the EIC they send out a letter asking that person to fill out a special form so that they can claim the EIC.

YES ....................................................................... 1

NO ........................................................................ 2

Y_YI12a

Did you or anyone in your household received a “stimulus payment,” that is a coronavirus or COVID-19 related Economic Impact Payment from the Federal Government?

1 YES

2 NO

Y_YI13

How difficult is it for you to pay your bills each month? Would you say you have a…

1 Great deal of difficulty

2 Quite a bit of difficulty

3 Some difficulty

4 A little difficulty

5 No difficulty at all

Y_YI14

Generally, at the end of each month do you end up with…

1 Not enough to make ends meet

2 Almost enough to make ends meet

3 Just enough to make ends meet

4 Some money left over

5 More than enough money left over

TEXT FILLS FOR Y_YI15 – Y_YI18:

IF ONE PERSON IN THE HOUSEHOLD: FILL WITH ‘I’ AND ‘I’.

IF TWO OR MORE PEOPLE IN THE HOUSEHOLD: FILL WITH ‘My family and I’ and ‘we’.

Y_YI15

[I/My family and I] enough money to afford the kind of home [I/we] need. Do you…

1 Strongly disagree

2 Disagree

3 Agree

4 Strongly agree

Y_YI16

[I/My family and I] [have/has] enough money to afford the kind of clothing [I/we] need. Do you…

1 Strongly disagree

2 Disagree

3 Agree

4 Strongly agree

Y_YI17

[I/My family and I] [have/has] enough money to afford the kind of food [I/we] need. Do you…

1 Strongly disagree

2 Disagree

3 Agree

4 Strongly agree

Y_YI18

[I/My family and I] [have/has] enough money to afford the kind of medical care [I/we] need. Do you…

1 Strongly disagree

2 Disagree

3 Agree

4 Strongly agree

Y_YI19

Since the coronavirus or COVID-19 outbreak, has covering your expenses and paying all your bills become more difficult, less difficult or stayed about the same?

1 More difficult

2 Less difficult

3 Stayed about the same

THE LOCATOR MODULE HAS BEEN MOVED. IT WILL BE THE LAST MODULE ADMINISTERED BY PHONE.

CHILD LOCATOR FORM MODULE

---------------------------------------------------------------------------------

Logic before:

IF CHILD IS EMANCIPATED OR IS AGE 16+ (INCLUDING YOUNG ADULTS), ASK Y_LO1.

ELSE, GOTO Y_LOEND.

Y_LO1 [ YLO1 ] NO LABEL

To help us understand how the well-being of youth changes over time, we @Bmay@B contact

you in the future to update our information. I'd like to ask a few questions to help us locate you in

case you move.

Please remember that everything you tell me will be kept private in the ways that were

explained to you at the beginning of the interview.

I'd like to verify your full legal name. Is your full legal name...(READ DISPLAYED NAME.

CORRECT AS NEEDED.)

FIRST NAME: @|@B^CHILD_FName@B

MIDDLE NAME:@|@B^CHILD_MName@B

LAST NAME:@|@|@B^CHILD_LName@B

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_LO1 = 1 GOTO Y_LO2a; IF Y_LO1 = 2 GOTO Y_LO1a

---------------------------------------------------------------------------------

Y_LO1a [ YLO1a ] Eman CH legal first name

INTERVIEWER: CORRECT FIRST NAME AS NEEDED.

FIRST NAME:

Question Type: STRING[20]

---------------------------------------------------------------------------------

Y_LO1b [ YLO1b ] Eman CH legal middle name

INTERVIEWER: CORRECT MIDDLE NAME AS NEEDED.

MIDDLE NAME:

Question Type: STRING[20], empty

---------------------------------------------------------------------------------

Y_LO1c [ YLO1c ] Eman CH legal last name

INTERVIEWER: CORRECT LAST NAME AS NEEDED.

LAST NAME:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Logic before:

IF GENDER = FEMALE, ASK Y_LO2a. ELSE, GOTO Y_LO3a.

Y_LO2a [ YLO2a ] Eman CH maiden name

What is your maiden name?

MAIDEN NAME:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Y_LO5 [ YLO5 ] NO LABEL

Let me confirm your street address. (VERIFY INFORMATION DISPLAYED ON SCREEN.)

STREET ADDRESS@|@B^Street@B

CITY:@|@|@|@B^City@B

STATE:@|@|@B^State@B

ZIP:@|@|@|@B^Zip@B

Is this correct?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_LO5 = 1 GOTO Y_LO6a; IF Y_LO5 = 2 GOTO Y_LO5a

---------------------------------------------------------------------------------

Y_LO5a [ YLO5a ] Eman CH address - street

INTERVIEWER: CORRECT STREET ADDRESS IF NEEDED.

STREET ADDRESS:

Question Type: STRING[50]

---------------------------------------------------------------------------------

Y_LO5b [ YLO5b ] Eman CH address - city

INTERVIEWER: CORRECT CITY IF NEEDED.

CITY:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Y_LO5c [ YLO5c ] Eman CH address - state

INTERVIEWER: CORRECT STATE IF NEEDED.

STATE:

Question Type: STRING[2]

---------------------------------------------------------------------------------

Y_LO5d [ YLO5d ] Eman CH address - zip

INTERVIEWER: CORRECT ZIP IF NEEDED.

ZIP:

Question Type: TZip

---------------------------------------------------------------------------------

Y_LO6a [ YLO6a ] EmanCH at same address in 6mo(ADDRES1T)

Do you expect to be living at this same address or at a different address 6 months from now?

Question Type: TLO6a

same 1 SAME ADDRESS

different 2 DIFFERENT ADDRESS

Logic after:

IF Y_LO6a = 1 GOTO Y_LO10an

---------------------------------------------------------------------------------

Logic before:

IF Y_L06a = DK/RE, ASK Y_LO6aa. ELSE, GOTO Y_LO7.

Y_LO6aa [ YLO6aa ] Better address to contact emanCH (YN2T)

Is there a better address we can use to contact you in the future?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_LO6aa = 2 GOTO Y_LO10an

---------------------------------------------------------------------------------

Y_LO7a [ YLO7a ] EmanCH best future address - street

What is the best address for us to use in the future?

STREET ADDRESS:

NOTE: IF R PLANS TO MOVE, COLLECT AS MUCH INFORMATION AS POSSIBLE ABOUT

NEW LOCATION.

Question Type: STRING[50]

---------------------------------------------------------------------------------

Y_LO7b [ YLO7b ] EmanCH best future address - city

What is the best address for us to use in the future?

CITY:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Y_LO7c [ YLO7c ] EmanCH best future address - state

What is the best address for us to use in the future?

STATE:

Question Type: STRING[2]

---------------------------------------------------------------------------------

Y_LO7d [ YLO7d ] EmanCH best future address - zip code

What is the best address for us to use in the future?

ZIP:

Question Type: TZip

---------------------------------------------------------------------------------

Y_LO8a [ YLO8a ] BestFuture addres emanCH/other(ADRES1T)

Is that your address or the address of another person or place?

Question Type: TLO8a

rsadd 1 RESPONDENT'S ADDRESS

othradd 2 ADDRESS OF SOME OTHER PERSON/PLACE

Logic after:

IF Y_LO8a = 1 GOTO Y_LO10an

---------------------------------------------------------------------------------

Y_LO9a [ YLO9a ] Whose best future address

Whose address is it? (ENTER NAME)

NAME:

Question Type: STRING[40]

---------------------------------------------------------------------------------

Y_LO9b [ YLO9b ] Best future address person relationship

Whose address is it? (ENTER RELATIONSHIP TO RESPONDENT)

RELATIONSHIP:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Y_LO10an [ YLO10an ] NO LABEL

What is your home phone number?

PHONE:

NOTE: ENTER R'S CURRENT HOME PHONE NUMBER. IF R DOES NOT HAVE A PHONE

NUMBER, ENTER 000-000-0000.

Question Type: TPhone

Logic after:

IF RESPONDENT DOS NOT HAVE A PHONE NUMBER OR REFUSES TO PROVIDE ONE, THEN GOTO Y_LO10cn

---------------------------------------------------------------------------------

Y_LO10ba [ YLO10ba ] Best curr phone#-day/evening(PHONE1T)

Is this your day or evening phone number?

Question Type: TLO10ba

day 1 DAY

evening 2 EVENING

both 3 BOTH

---------------------------------------------------------------------------------

Y_LO10cn [ YLO10cn ] NO LABEL

What is your cell phone number?

PHONE:

NOTE: IF R DOES NOT HAVE A CELL NUMBER, ENTER 000-000-0000.

Question Type: TPhone

---------------------------------------------------------------------------------

Y_LO11a [ YLO11a ] Another phone# for emanCH(YN2T)

Is there another phone number to use to reach you?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_LO11a = 2 GOTO Y_LO12ea

---------------------------------------------------------------------------------

Y_LO12aa [ YLO12aa ] Another phone# for eman CH

What is that number?

PHONE:

NOTE: IF R HAS MORE THAN 1 ALTERNATIVE NUMBER, ENTER THE ONE HE/SHE CAN BE

REACHED AT MOST OFTEN.

Question Type: TPhone

---------------------------------------------------------------------------------

Y_LO12ea [ YLO12ea ] NO LABEL

Do you have an email address?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_LO12ea = 2 GOTO Y_LO13a

---------------------------------------------------------------------------------

Y_LO12f [ YLO12f ] NO LABEL

What is your current email address?

EMAIL:

NOTE: EMAIL ADDRESS MUST CONTAIN 2 @@@@ SIGNS (i.e., janedoe@@@@yahoo.com).

Question Type: STRING[50]

---------------------------------------------------------------------------------

Y_LO13a [ YLO13a ] EmanCH provide 1st contact info (YN2T)

We'd also like the names of two relatives or friends @Bwho do not live with you@B but would

always know how to reach you if you moved.

Can you give me the name, address, and telephone number of a relative or friend who would

always know how to reach you if you moved?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_LO13a = 2 GOTO Y_LO19a

---------------------------------------------------------------------------------

Y_LO14a [ YLO14a ] EmanCH contact #1 name

What is the first person's name?

VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.

@BCONTACT PERSON 1:@B

NAME:

Question Type: STRING[40]

---------------------------------------------------------------------------------

Y_LO14b [ YLO14b ] EmanCH contact #1 relationship

What is the first person's relationship to you?

VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.

@BCONTACT PERSON 1:@B

RELATIONSHIP:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Y_LO14c [ YLO14c ] EmanCH contact #1 address-street/POBox

What is the first person's street address?

VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.

@BCONTACT PERSON 1:@B

STREET ADDRESS:

Question Type: STRING[50]

---------------------------------------------------------------------------------

Y_LO14d [ YLO14d ] EmanCH contact #1 address - city

What is the first person's city?

VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.

@BCONTACT PERSON 1:@B

CITY:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Y_LO14e [ YLO14e ] EmanCH contact #1 address - state

What is the first person's state?

VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.

@BCONTACT PERSON 1:@B

STATE:

Question Type: STRING[2]

---------------------------------------------------------------------------------

Y_LO14f [ YLO14f ] End emanCH contact #1 info

What is the first person's zip code?

VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.

@BCONTACT PERSON 1:@B

ZIP:

Question Type: TZip

---------------------------------------------------------------------------------

Y_LO14g [ YLO14g ] EmanCH contact #1 address - phone

What is the first person's telephone number?

VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.

@BCONTACT PERSON 1:@B

PHONE:

NOTE: IF DOES NOT HAVE A PHONE NUMBER, ENTER 000-000-0000.

Question Type: TPhone

---------------------------------------------------------------------------------

Y_LO15a [ YLO15a ] EmanCH provide 2nd contact info (YN2T)

Is there another relative or friend who would always know how to reach you?

NOTE: THIS INFORMATION IS VERY IMPORTANT! ENCOURAGE R TO PROVIDE ADDITIONAL

CONTACT PERSON.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_LO15a = 2 GOTO Y_LO19a

---------------------------------------------------------------------------------

Y_LO16a [ YLO16a ] EmanCH contact #2 name

What is the second person's name?

VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.

@BCONTACT PERSON 2:@B

NAME:

Question Type: STRING[40]

---------------------------------------------------------------------------------

Y_LO16b [ YLO16b ] EmanCH contact #2 relationship

What is the second person's relationship to you?

VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.

@BCONTACT PERSON 2:@B

RELATIONSHIP:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Y_LO16c [ YLO16c ] EmanCH contact #2 address-street/POBox

What is the second person's street address?

VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.

@BCONTACT PERSON 2:@B

STREET ADDRESS:

Question Type: STRING[50]

---------------------------------------------------------------------------------

Y_LO16d [ YLO16d ] EmanCH contact #2 address - city

What is the second person's city?

VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.

@BCONTACT PERSON 2:@B

CITY:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Y_LO16e [ YLO16e ] EmanCH contact #2 address - state

What is the second person's state?

VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.

@BCONTACT PERSON 2:@B

STATE:

Question Type: STRING[2]

---------------------------------------------------------------------------------

Y_LO16f [ YLO16f ] End emanCH contact #2 info

What is the second person's zip code?

VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.

@BCONTACT PERSON 2:@B

ZIP:

Question Type: TZip

---------------------------------------------------------------------------------

Y_LO16g [ YLO16g ] EmanCH contact #2 address - phone

What is the second person's telephone number?

VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.

@BCONTACT PERSON 2:@B

PHONE:

NOTE: IF DOES NOT HAVE A PHONE NUMBER, ENTER 000-000-0000.

Question Type: TPhone

---------------------------------------------------------------------------------

[USE AD HEALTH MODULE FOR COLLECTING AN ENCRYPED SSN FOR THE FOLLOWING QUESTIONS.]

Logic before:

IF WAVE > 1 AND RESPONDENT IS SAME FROM PREVIOUS INTERVIEW, VERIFY

PRELOADED SSN IN Y_LO19a IF AVAILABLE. ELSE, ASK FOR SSN.

Y_LO19a [ YLO19a ] Eman CH social security number

I'd also like to get your Social Security Number. This information will only be used for two things: 1) to help us locate you if you move, and 2) to help us combine your interview data with other data if you give us permission to do so. We will ask you for that permission at the end of the interview. What is your social security number? (PROMPT R TO GET NUMBER

FROM SSN CARD, IF NEEDED.)

SSN:

NOTE: IF R DOES NOT HAVE SSN NUMBER, ENTER 000-00-0000.

Question Type: TSSN

Question Fill: ^FillY_LO19n

donthave I’d also like to get your Social Security Number. This information will only

be used for two things: 1) to help us locate you if you move, and 2) to help us combine your interview data with other data if you give us permission to do so. We will ask you for that permission at the end of the interview. What is your

social security number? (PROMPT R TO GET NUMBER FROM SSN

CARD, IF NEEDED.)

have I also need to verify your social security number. This information will

only be used for two things: 1) to help us locate you if you move, and 2) to help us combine your interview data with other data if you give us permission to do so. We will ask you for that permission at the end of the interview. Is it...(READ

DISPLAYED NUMBER. CORRECT AS NEEDED.)

Logic after

IF REF, GOTO Y_LO19ref

Y_LO19ref

Can you tell me the last four digits of your Social Security Number? Again, this information is only used for two things: 1) to help us locate you if you move, and 2) to help us combine your interview data with other data if you give us permission to do so. We will ask you for that permission at the end of the interview.

Logic after:

Allow 4

---------------------------------------------------------------------------------

Logic before:

IF VERIFYING PRELOADED SSN

Y_LO19b [ YLO19b ] NO LABEL

I also need to verify your social security number. This information will only be used for two things: 1) to help us locate you if you move, and 2) to help us combine your interview data with other data if you give us permission to do so. We will ask you for that permission at the end of the interview. Is it...(READ DISPLAYED NUMBER. CORRECT AS NEEDED.)

PRELOADED SSN ^CHILD_SSN

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF = 1, GOTO P_LO20a

---------------------------------------------------------------------------------

Y_LO19c [ YLO19c ] NO LABEL

What is your correct social security number? (This will only be used for two things: 1) to help us locate you if you move, and 2) to help us combine your interview data with other data if you give us permission to do so. We will ask you for that permission at the end of the interview.)

SSN:

NOTE: IF R DOES NOT HAVE SSN NUMBER, ENTER 000-00-0000.

Question Type: TSSN

---------------------------------------------------------------------------------

Y_LO23a [ YLO23a ] EmanCH name change next 6 months (YN2T)

Do you think your name could change in the next 6 months?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_LO23a = 2 GOTO Y_LO25

---------------------------------------------------------------------------------

Y_LO24a [ YLO24a ] EmanCH future first name

What do you think your name would be changed to? Please tell me the first, middle, and last

name. (IF RESPONDENT DOES NOT KNOW, PRESS F3 -- DON'T KNOW -- FOR ALL 3 NAME

FIELDS.)

INTERVIEWER: UPDATE FIRST NAME AS NEEDED.

Question Type: STRING[20]

---------------------------------------------------------------------------------

Y_LO24b [ YLO24b ] EmanCH future middle name

INTERVIEWER: UPDATE MIDDLE NAME AS NEEDED.

MIDDLE NAME:

Question Type: STRING[20]

---------------------------------------------------------------------------------

Y_LO24c [ YLO24c ] EmanCH future last name

INTERVIEWER: UPDATE LAST NAME AS NEEDED.

LAST NAME:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Y_LO25 [ YLO25 ] NO LABEL

Thank you very much for this information.

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

Logic after:

GOTO Y_LOEND

TRANSITION TO WEB MODULES

For the next part of the survey, we would like you to read the questions and answer them online. You can enter your answers directly into the survey using a phone or computer. The information you provide will be stored in a secure website. You will not be asked to enter any identifying information, such as your name or birthdate. It is important that you complete this part of the survey someplace private, where no one else can see your answers on the screen of your phone or computer. The website is set up so that it will close the survey if you do not enter a response after five minutes. If you are logged out of the survey due to inactivity, you will use a personal identification number to re-enter the survey. Also, you cannot go back and change an answer. These are ways we protect the privacy of your answers.

I will provide you with the web address to access the survey along with your personal identification number .

The website for the survey is: NSCAW3.rti.org

Your personal identification number is: <INSERT PIN>

I can also provide the link to the survey and your personal identification number by email, text message, or both. If you choose text message, it is important that no one else uses the phone where they can see your private information.

Would you prefer to receive the survey link by email, text message, or both?

01 = E-MAIL

02 = TEXT MESSAGE (GOTO TEXT_PREFER)

03 = BOTH

EMAIL_PREFER.

IF Web_Transition = 01 or 03

Please tell me what e-mail address to use.

TEXT_PREFER.

IF Web_Transition = 02 or 03

Please tell me the phone number to use. By doing this, you are confirming that I have your permission to send the survey link to you this way.

PHONE:

TEXT FOR ADOLESCENTS AGE >= 11 and <= 17

If you are feeling upset by the issues discussed in this survey, we have a resource we can share with you. Sometimes it may be helpful to talk to someone about your feelings. We suggest calling the National Lifeline Network where counselors are available to talk at any time of the day or night.

Their toll-free number is 1-800-273-8255.

TEXT FOR YOUNG ADULTS AGE >= 18.

Sometimes the personal issues we have discussed in this survey can cause people to become upset and in need of speaking with a counselor. If you are feeling upset or disturbed by the personal issues we have discussed in this interview and would like to talk with someone about your feelings, we suggest you call your doctor, counselor, or other treatment provider if you are currently under someone’s care.

If not, there is also a National Lifeline Network number you can call where counselors are available to talk at any time of the day or night. They can also give you information about additional mental health services in your area.

Their toll-free number is 1-800-273-8255.

PROGRAMMER NOTE: For web, include “Don’t know/Not sure” AND “Choose not to answer” AS RESPONSE OPTIONS IF A RESPONDENT MOVES FORWARD WITHOUT SELECTING AN ANSWER.

[REVIEW ELEMENTS OF CONSENT FOR PARTICIPATION

---------------------------------------------------------------------------------------------------------------------

START OF WEB SURVEY

This is the a web survey we would like you to complete.

You may consider some of the questions to be sensitive and some of the questions may also make you feel certain emotions, such as sadness.

Remember you can choose not to answer any questions you do not want to answer, and you can stop the interview at any time.

Remember to complete this survey in a private area where others cannot see your screen.

IF ADOLESCENT (CHILD AGE >= 11 and <= 17):

A $20 Amazon gift card plus a small gift of equal value will be sent to you after this web survey.

IF YOUNG ADULT (CHILD AGE >= 18):

A $50 Amazon gift card will be sent to you after this web survey.

By clicking Next, you agree to move forward with the survey.

CHILD CLOSENESS TO CAREGIVER(S) MODULE

---------------------------------------------------------------------------------

Logic before:

IF CHILD IS EMANCIPATED OR YOUNG ADULT (18+), GOTO Y_CLEND

Y_CL_BGN [ YCL_BGN ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

---------------------------------------------------------------------------------

Logic before:

IF AGE < 11, GOTO Y_CLEND. IF CAREGIVER_A IS BLANK, GOTO Y_CL3a

Y_CL1a [ YCL1a ] How close CH feels to CG-A

How close do you feel to your ^CAREGIVER_A? Would you say...

Question Type: TCL1a

notatall 1 not at all

littlebit 2 a little bit

somewhat 3 somewhat

quiteabit 4 quite a bit, or

vclose 5 very close?

---------------------------------------------------------------------------------

Logic before:

IF CAREGIVER_B IS BLANK, GOTO Y_CL5aa

Y_CL3a [ YCL3a ] How close CH feels to CG-B

How close do you feel to your ^CAREGIVER_B? Would you say...

Question Type: TCL1a

notatall 1 not at all

littlebit 2 a little bit

somewhat 3 somewhat

quiteabit 4 quite a bit, or

vclose 5 very close?

---------------------------------------------------------------------------------

Y_CL_END [ YCL_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

CHILD SERVICES RECEIVED MODULE

---------------------------------------------------------------------------------

Logic before:

IF AGE < 11 OR CHILD IS YOUNG ADULT (18+) OR EMANCIPATED, GOTO Y_SVEND. ELSE,

CONTINUE.

Y_SV0 [ YSV0 ] NO LABEL

The following questions ask about services you may have received from different places in the

past 6 months.

Press "1" and the [Enter] key to continue.

Question Type: TCont

Continue 1 Continue

---------------------------------------------------------------------------------

Y_SV1a [ YSV1a ] CH went to peer support groups

A peer support group is a group of young people who meet to talk about things that are important

to them. Usually an adult leads the group, and they might meet at school or a community center.

In the @Bpast 6 months@B have you gone to any peer support groups?

FR NOTE; ONLINE OR VIRTUAL MEETINGS SHOULD BE INCLUDED.

NOTE: PEER SUPPORT GROUPS (LIKE ALATEEN) ARE COMPRISED OF CHILDREN WITH

SIMILAR MEDICAL, EMOTIONAL, PHYSICAL, OR MENTAL HEALTH PROBLEMS (E.G.,

CHILDREN WHO HAVE BEEN ADOPTED, ABUSED, ETC.).

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_SV2a [ YSV2a ] CH went to comm youth ctr

In the @Bpast 6 months@B have you gone to a "drop-in" or community youth center? (These

include community recreation centers, Boys/Girls Clubs, YMCA/YWCA, kids clubs, etc.)

FR NOTE; ONLINE OR VIRTUAL MEETINGS SHOULD BE INCLUDED.

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_SV3a [ YSV3a ] CH recd family plan services

In the @Bpast 6 months@B, have you received any family planning services - like birth control

pills, condoms, or information on making decisions about having sex?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_SV4a [ YSV4a ] CH recd trtmnt for drug/alc probs

In the @Bpast 6 months@B, did you get any kind of professional treatment for an alcohol or drug

problem?

NOTE: TREATMENT SHOULD HAVE BEEN PROVIDED BY A MENTAL HEALTH, MEDICAL, OR

OTHER ALCOHOL/DRUG TREATMENT PROFESSIONAL, NOT BY A CASEWORKER.

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_SV5a [ YSV5a ] CH went to hosp ER

In the @Bpast 6 months@B, did you go to the hospital emergency room for any reason?

NOTE: DO NOT INCLUDE VISITS TO URGENT CARE CENTERS.

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_SV5a = No GOTO Y_SV9a

Y_SV7b [ YSV7a ] Did CH go to ER for illness

In the @Bpast 6 months@B, did you go to the hospital emergency room for an illness?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_SV7b = No GOTO Y_SV7c

---------------------------------------------------------------------------------

Y_SV7bb [ YSV7aa ] #Xs CH went to ER for illness

How many times in the past 6 months have you gone to the hospital emergency room for an

illness?

NOTE: DO NOT INCLUDE VISITS TO URGENT CARE CENTERS.

Question Type: TSV6aa

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourxs 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't gone to the emergency room for this in the past 6 months

---------------------------------------------------------------------------------

Y_SV7c [ YSV7a ] Did CH go to ER for illness

In the @Bpast 6 months@B, did you go to the hospital emergency room for an injury?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_SV7c = No GOTO Y_SV9a

---------------------------------------------------------------------------------

Y_SV7cc [ YSV7aa ] #Xs CH went to ER for illness

How many times in the past 6 months have you gone to the hospital emergency room for an

injury?

NOTE: DO NOT INCLUDE VISITS TO URGENT CARE CENTERS.

Question Type: TSV6aa

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourxs 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't gone to the emergency room for this in the past 6 months

---------------------------------------------------------------------------------

Y_SV9a [ YSV9a ] CH got counsel to deal w/depress

In the @Bpast 6 months@B, did you get any kind of counseling from a school counselor, doctor,

or therapist to help you deal with feeling depressed or blue?

NOTE: DO NOT INCLUDE COUNSELING FROM A CASEWORKER.

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

GOTO Y_SVEND

CHILD SUBSTANCE ABUSE MODULE

---------------------------------------------------------------------------------

Logic before:

IF AGE >= 11, OR CHILD IS EMACIPATED OR YOUNG ADULT (18+), GOTO Y_SA0. ELSE, GO

TO Y_SAEND.

Y_SA0 [ YSA0 ] NO LABEL

The following questions ask about alcohol, different drugs, and tobacco.

Please remember that all your answers are private.

Press "1" and the [Enter] key to continue.

Question Type: TCont

Continue 1 Continue

Y_SA1

During the past 12 months, have you used any alcohol, marijuana, cocaine, heroin, or other substances?

1=YES

2=NO [GO TO Y_SA5]

Y_SA1a

During the past 12 months, have you tried to hide that you were using alcohol, marijuana, or other drugs?

1=YES

2=NO

Y_SA1b

During the past 12 months, have your parents, family, partner, co-workers, classmates, or friends complained about your alcohol, marijuana, or other drug use?

1=YES

2=NO

Y_SA1c

During the past 12 months, have you used alcohol, marijuana, or other drugs weekly?

1=YES

2=NO

Y_SA1d

During the past 12 months, has alcohol, marijuana, or other drug use caused you to feel depressed, nervous, suspicious, uninterested in things, reduced your sexual desire or caused other psychological problems?

1=YES

2=NO

Y_SA1e

During the past 12 months, has alcohol, marijuana, or other drug use caused you to have numbness, tingling, shakes, blackouts, hepatitis, TB, sexually transmitted disease or any other health problems?

1=YES

2=NO

Y_SA2a

During the past 12 months, have you kept using alcohol, marijuana, or other drugs even though you knew it was keeping you from meeting your responsibilities at work, school, or home?

1=YES

2=NO

Y_SA2b

During the past 12 months, have you used alcohol, marijuana, or other drugs where it made the situation unsafe or dangerous for you, such as when you were driving a car, using a machine, or where you might have been forced into sex or hurt?

1=YES

2=NO

Y_SA2c

During the past 12 months, has alcohol, marijuana, or other drug use caused you to have repeated problems with the law?

1=YES

2=NO

Y_SA2d

During the past 12 months, have you kept using alcohol, marijuana, or other drugs even after you knew it could get you into fights or other kinds of legal trouble?

1=YES

2=NO

Y_SA3a

During the past 12 months, have you needed more alcohol, marijuana, or other drugs to get the same high or found that the same amount did not get you as high as it used to?

1=YES

2=NO

Y_SA3b

During the past 12 months, have you had withdrawal problems from alcohol, marijuana, or other drugs like shaking hands, throwing up, having trouble sitting still or sleeping, or have you used any alcohol, marijuana, or other drugs to stop being sick or avoid withdrawal problems?

1=YES

2=NO

Y_SA3c

During the past 12 months, have you used alcohol, marijuana, or other drugs in larger amounts more often or for a longer time than you meant to?

1=YES

2=NO

Y_SA3d

During the past 12 months, have you been unable to cut down or stop using alcohol, marijuana, or other drugs?

1=YES

2=NO

Y_SA3e

During the past 12 months, have you spent a lot of time either getting alcohol, marijuana, or other drugs, using them, or feeling the effects of them (high, sick)?

1=YES

2=NO

Y_SA3f

During the past 12 months, has alcohol, marijuana, or other drugs caused you to give up, reduce or have problems at important activities as work, school, home or social events?

1=YES

2=NO

Y_SA3g

During the past 12 months, have you kept using alcohol, marijuana, or other drugs even after you knew it was causing or adding to medical, psychological or emotional problems you were having?

1=YES

2=NO

For the next set of questions, please answer for the last 90 days that you lived in the community. Do not count days when you were living in a jail, hospital, or other place where you could not use alcohol, marijuana, or other drugs.

Y_SA4b

During the last 90 days that you lived in the community, how many days did you drink beer, wine, or any kind of alcohol?

NUMBER OF DAYS _______

[RANGE: 0 – 90]

Y_SA4c

During the last 90 days that you lived in the community, how many days did you get drunk or have 5 or more drinks at one time?

NUMBER OF DAYS _______

[RANGE: 0 – 90]

Y_SA4d

During the last 90 days that you lived in the community, how many days did you smoke or use any kind of marijuana, blunts, or hashish?

NUMBER OF DAYS _______

[RANGE: 0 – 90]

Y_SA4e

During the last 90 days that you lived in the community, how many days did you use LSD, cocaine, heroin, ecstasy, inhalants, or any other kind of drug?

NUMBER OF DAYS _______ IF NUMBER OF DAYS > 0 THEN ASK Y_SA4EA

[RANGE: 0 – 90]

Y_SA4ea

What did you use? CODE ALL THAT APPLY

1=Cocaine

2=Heroin

3=Ecstasy

4=Inhalants

5=Other kind of drug

Y_SA4f

During the last 90 days that you lived in the community, how many days did you go without using any alcohol, marijuana, or other drug?

NUMBER OF DAYS _______

[RANGE: 0 – 90]

Y_SA5

During the last 90 days that you lived in the community, how many days did you smoke any kind of tobacco?

NUMBER OF DAYS _______

[RANGE: 0 – 90]

CHILD SEXUAL ACTIVITY MODULE

---------------------------------------------------------------------------------

Logic before:

IF AGE < 11, GOTO Y_SXEND. IF CHILD IS YOUNG ADULT (18+) OR EMANCIPATED, CONTINUE.

Y_SX2a

The next questions are about sexual activity. Please remember that your answers are private.

During your life, with whom, if anyone, have you had sexual contact?

1=I have never had sexual contact

2=Females

3=Males

4=Females and males

Y_SX20a [ YSX20a ] Have you ever had sex or sexual intercourse?

Have you ever had sex or sexual intercourse?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_SX20a = 2 GO TO Y_SX_END

---------------------------------------------------------------------------------

Y_SX21a [ YSX21a ] Frst time u had sex, was it frcd or not frcd?

Think about the first time you had sex, would you say it was forced or not forced? "Forced"

means that the sex was against your will, and "not forced" means it was something that you

wanted to happen or that it was okay with you.

Question Type: TYSX21a

forced 1 Forced (it was against my will)

notforced 2 Not forced (I wanted it to happen, or it was okay with me)

---------------------------------------------------------------------------------

Y_SX22a [ YSX22a ] How old were you this first time you had sex?

How old were you this @Bfirst@B time you had sex?

Question Type: TYSX22a

eight 8 8 years old or younger

nine 9 9 years old

ten 10 10 years old

eleven 11 11 years old

twelve 12 12 years old [DO NOT ALLOW IF CHILD AGE = 11]

thirteen 13 13 years old [DO NOT ALLOW IF CHILD AGE <= 12]

fourteen 14 14 years old [DO NOT ALLOW IF CHILD AGE <= 13]

fifteen 15 15 years old [DO NOT ALLOW IF CHILD AGE <= 14]

sixteen 16 16 years old [DO NOT ALLOW IF CHILD AGE <= 15]

seventeen 17 17 years old [DO NOT ALLOW IF CHILD AGE <= 16]

eighteen 18 18 years old or older [DO NOT ALLOW IF CHILD AGE <= 17]

---------------------------------------------------------------------------------

Logic before:

IF Y_SX21a = DK/REF, FOLLOW SAME SKIP PATTERN AS IF SX21a = NO.

Y_SX23a [ YSX23a ] Had sex you wntd to hpn/was forced?

^Fills.Y_SX23a

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_SX23a

forced Have you ever had sex that you wanted to happen or that was okay with

you?

notforced Have you ever had sex that was forced -- that is, that was against your

Logic after:

IF Y_SX23a = 2 GO TO Y_SX25b

---------------------------------------------------------------------------------

Y_SX25b

The last time you had sexual intercourse, did you or your partner use a condom?

1=YES

2=NO

Y_SX25c

Did you drink alcohol or use drugs before you had sexual intercourse the last time?

1=YES

2=NO

Y_SX26a [ YSX26a ] Have you had sex anytime in the past 12 months?

Have you had sex anytime in the past 12 months?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_SX26a = 2 GO TO Y_SX29a

---------------------------------------------------------------------------------

Logic before:

IF R IS MALE fill: gotten someone pregnant; IF R IS FEMALE fill: been pregnant

Y_SX29a [ YSX29a ] How many times have you ever been/gttn someone prgnt?

How many times have you ever ^Fills.Y_SX29a?

Question Type: TYSX29a

never 0 I have never (gotten anyone pregnant/gotten pregnant)

once 1 once

twice 2 two times

thrice 3 three times

fourmore 4 four or more times

Question Fill: ^FillY_SX29a

male gotten someone pregnant

female been pregnant

Logic after:

IF Y_SX29a = 0 GO TO Y_SX32a

---------------------------------------------------------------------------------

Logic before:

IF R IS FEMALE fill: you got pregnant?; IF R IS MALE fill: you got someone pregnant?

Y_SX30a [ YSX30a ] How old wre u the time/frst time you got/got someone prgnt?

How old were you the^Fills.Y_SX30a1 time ^Fills.Y_SX30a2?

Question Type: TYSX30a

ten 10 10 years old

eleven 11 11 years old

twelve 12 12 years old [DO NOT ALLOW IF CHILD AGE = 11]

thirteen 13 13 years old [DO NOT ALLOW IF CHILD AGE <= 12]

fourteen 14 14 years old [DO NOT ALLOW IF CHILD AGE <= 13]

fifteen 15 15 years old [DO NOT ALLOW IF CHILD AGE <= 14]

sixteen 16 16 years old [DO NOT ALLOW IF CHILD AGE <= 15]

seventeen 17 17 years old [DO NOT ALLOW IF CHILD AGE <= 16]

eighteen 18 18 years old or older [DO NOT ALLOW IF CHILD AGE <= 17]

Question Fill: ^FillY_SX30a1

once

moreonce ·first

Question Fill: ^FillY_SX30a2

male you got someone pregnant

female you got pregnant

---------------------------------------------------------------------------------

Y_SX31a [ YSX31a ] How mny chldrn have you had (lvng with you or not)?

How many children have you had, including all children living with you or not?

Question Type: TYSX31a

none 0 I have never had a child

one 1 1 child

two 2 2 children

threemore 3 3 or more children

---------------------------------------------------------------------------------

IF AGE IS >=11 OR EMANCIPATED YOUTH, ASK Y_SX32a. ELSE, SKIP TO Y_SX_END.

Y_SX32a [ YSX33a ] NO LABEL

Which of the following best represents how you think of yourself?

Question Type: Tsexor

_1 1 Straight (heterosexual)

_2 2 Lesbian or Gay

_3 3 Bisexual

_4 4 Something else

_5 5 I don’t know the answer

Y_SX_END [ YSX_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

CHILD DELINQUENCY MODULE

---------------------------------------------------------------------------------

Y_DE_BGN [ YDE_BGN ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

---------------------------------------------------------------------------------

Logic before:

IF AGE <11, GOTO Y_DEEND. IF CHILD IS YOUNG ADULT (18+) OR EMANCIPATED, GOTO

Y_DE7. ELSE, CONTINUE.

---------------------------------------------------------------------------------

Y_DE2a [ YDE2a ] # Xs CH ran away from home - past 6M

The next questions are about your behavior. Please tell me the number of times you've done each

of these things during the past @B6 months@B. Your best guess will do. No one will tell your

family or teachers anything about your answers. Your answers are private.

How many times in the past 6 months have you run away from home?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE4a [ YDE4a ] # Xs CH skipped classes/sch past 6M

How many times in the past 6 months have you skipped classes or school without an excuse?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE6a [ YDE6a ] # Xs CH lied about age for movie past 6M

How many times in the past 6 months have you lied about your age to get into some place or to

buy something, for example lying about your age to get into a movie or to buy alcohol?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE8a [ YDE8a ] # Xs CH hitchicked past 6M

How many times in the past 6 months have you hitchhiked where it was illegal to do so?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE10a [ YDE10a ] # Xs CH carried hidden weapon past 6M

How many times in the past 6 months have you carried a hidden weapon?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE12a [ YDE12a ] # Xs CH unruly in public past 6M

How many times in the past 6 months have you been loud, rowdy, or unruly in a public place so

that people complained about it or you got in trouble?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE14a [ YDE14a ] # Xs CH begged $/things past 6M

How many times in the past 6 months have you begged for money or things from strangers?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE16a [ YDE16a ] # Xs CH drunk in public past 6M

How many times in the past 6 months have you been drunk in a public place?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE16ba [ YDE16ba ] # Xs CH painted graffit past 6M

How many times in the past 6 months have you painted graffiti or signs on someone else's

property or in a public place?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE18a [ YDE18a ] # Xs CH damaged property past 6M

How many times in the past 6 months have you purposely damaged or destroyed property that

did not belong to you, for example, painting, breaking, cutting, or marking up something?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE20a [ YDE20a ] # Xs CH set fire to house/prop past 6M

How many times in the past 6 months have you purposely set fire to a house, building, car, or

other property or tried to do so?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE22a [ YDE22a ] # Xs CH avoided paying past 6M

How many times in the past 6 months have you avoided paying for things such as movies, bus, or

subway rides, food, or computer services?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE24a [ YDE24a ] # Xs CH went in bldg to steal past 6M

How many times in the past 6 months have you gone into or tried to go into a building to steal

something?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE26a [ YDE26a ] # Xs CH stole things < $5 past 6M

How many times in the past 6 months have you stolen or tried to steal things worth $5 or less?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE28a [ YDE28a ] # Xs CH stole items < $5+ > $50 past 6M

How many times in the past 6 months have you stolen or tried to steal things worth between $5

and $50?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE30a [ YDE30a ] # Xs CH stole items < $50+ > $100 past 6M

How many times in the past 6 months have you stolen or tried to steal things worth between $50

and $100?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE32a [ YDE32a ] # Xs CH stole items worth > $100 past 6M

How many times in the past 6 months have you stolen or tried to steal something worth $100 or

more?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE34a [ YDE34a ] # Xs CH took fr store w/o pay past 6M

How many times in the past 6 months have you taken something from a store without paying for

it? This includes times that you have already told about for other questions.

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE36a [ YDE36a ] # Xs CH snatched wallet/purse past 6M

How many times in the past 6 months have you snatched someone's purse or wallet or picked

someone's pocket?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE38a [ YDE38a ] # Xs CH took item fr car past 6M

How many times in the past 6 months have you taken something from a car that did not belong to

you?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE40a [ YDE40a ] # Xs CH bought/sld stolen goods past 6M

How many times in the past 6 months have you knowingly bought, sold or held stolen goods or

tried to do any of these things?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE42a [ YDE42a ] # Xs CH went joyriding past 6M

How many times in the past 6 months have you gone joyriding, that is, taken a motor vehicle,

such as a car or motorcycle, for a ride or drive without the owner's permission?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE44a [ YDE44a ] # Xs CH stole vehicle past 6M

How many times in the past 6 months have you stolen or tried to steal a motor vehicle such as a

car or motorcycle?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE46a [ YDE46a ] # Xs CH used false checks/$ past 6M

How many times in the past 6 months have you used checks illegally or used a slug or fake

money to pay for something?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE48a [ YDE48a ] # Xs CH used cr cards w/o perm past 6M

How many times in the past 6 months have you used or tried to use credit cards or bank cards

without the owner's permission?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE50a [ YDE50a ] # Xs CH sold item above value past 6M

How many times in the past 6 months have you tried to cheat someone by selling them

something that was worthless or not what you said it was?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE52a [ YDE52a ] # Xs CH attacked w/intent to hurt past 6M

How many times in the past 6 months have you attacked someone with a weapon or with the idea

of seriously hurting or killing them?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE54a [ YDE54a ] # Xs CH hit to hurt past 6M

How many times in the past 6 months have you hit someone with the idea of hurting

them^Fills.Y_DE53a?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

Question Fill: ^FillY_DE53a

donebefore ·other than the events you just mentioned

notbefore

---------------------------------------------------------------------------------

Y_DE56a [ YDE56a ] # Xs CH usdd threat/weapon to take $ past 6M

How many times in the past 6 months have you used a weapon, force, or strong-arm methods like

threats to get money or things from people?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE58a [ YDE58a ] # Xs CH threw rocks/bottles past 6M

How many times in the past 6 months have you thrown objects such as rocks or bottles at people

other than the events that you already mentioned?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE60a [ YDE60a ] # Xs CH involved in gang fight past 6M

How many times in the past 6 months have you been involved in a gang fight?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE62a [ YDE62a ] # Xs CH paid for having sex past 6M

How many times in the past 6 months have you been paid for having sexual relations with

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE64a [ YDE64a ] # Xs CH threat other to have sex past 6M

How many times in the past 6 months have you physically hurt or threatened to hurt someone to

get them to have sex with you?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE66a [ YDE66a ] # Xs CH tried sex against will past 6M

How many times in the past 6 months have you had or tried to have sexual relations with

someone against their will? ^Fills.Y_DE65a

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

Question Fill: ^FillY_DE65a

donebefore Do not include the times you just mentioned in the last question.

notbefore

---------------------------------------------------------------------------------

Y_DE68a [ YDE68a ] # Xs CH sold pot/hash past 6M

How many times in the past 6 months have you sold marijuana or hashish (pot, grass, hash)?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE70a [ YDE70a ] # Xs CH sold hard drugs past 6M

How many times in the past 6 months have you sold hard drugs such as heroin, cocaine, or crack?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

---------------------------------------------------------------------------------

Y_DE72a [ YDE72a ] # Xs CH arrested past 6M

How many times in the past 6 months have you been arrested or picked up by the police for

something other than a minor traffic offense?

Question Type: TDE2a

notin6mos 0 I haven't done this in the past 6 months

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE_END [ YDE_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

VICTIMIZATION AND ADVERSE CHILD EXPERIENCES MODULE

---------------------------------------------------------------------------------

Logic before:

IF CHILD IS YOUNG ADULT (18+), CONTINUE. ELSE, GOTO Y_VCEND.

Y_VC7a [ YVC7a ] NO LABEL

Now I would like to ask you some questions about events that may have happened during your childhood. All questions refere to the time before you were 18 years of age. I would like you to remember that your answers to these questions will be completely private.

Press ""1"" and the [Enter] key to continue.

Question Type: TCont

Continue 1 Continue

---------------------------------------------------------------------------------

Y_VC11a [ YVC11a ] Go w/o needed things b/c CG got other things

Did you ever have to go without things that you needed, for example clothes, shoes, school

supplies, food, etc., because your family's paycheck was spent on the adult's interests? For

example, a parent spending money on alcohol, gambling, drugs, fancy cars or clothes, so that

there was little money left over for the children?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_VC13b

Were your parents or caregivers ever separated or divorced?

Question Type: TYN

yes 1 YES

no 2 NO

3 NOT APPLICABLE - DID NOT HAVE MARRIED PARENTS/CAREGIVERS

---------------------------------------------------------------------------------

Y_VC13c

Were any of your caregivers or other adults in your home ever depressed, mentally ill, or suidical?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_VC13d

Were any of your caregivers or other adults in your home problem drinkers or alcoholics, users of illegal drugs, or abusers of prescription medications?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_VC13e

Did any of your caregivers or other adults in your home ever serve time or were sentenced to serve time in a prison, jail, or other correctional facility?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_VC13f

How often did your caregivers or other adults in your home ever slap, hit, kick, punch, or beat each other up? Would you say…

0 Never

1 Once or twice

2 Sometimes

3 Often

4 Very often

Y_VC13g

Before age 18, how often did a caregiver or other adult in your home ever hit, beat, kick, or physically hurt you in any way? Do not include spanking. Would you say…

0 Never

1 Once or twice

2 Sometimes

3 Often

4 Very often

Y_VC13h

How often did a caregiver or adult in your home ever swear at you, insult you, or put you down? Would you say…

0 Never

1 Once or twice

2 Sometimes

3 Often

4 Very often

---------------------------------------------------------------------------------

Y_VC16b

Would you say the following statement is true before you were 18 years old: Someone in your family helped you feel important or special, you felt loved, people in your family looked out for each other and felt close to each other, and your family was a source of strength and support?

1 YES, TRUE

2 NO, NOT TRUE

---------------------------------------------------------------------------------

Y_VC30a [ YVC30a ] Anyone ever have sex w/ CH against will

Did anyone at least five years older than you or an adult ever have intercourse, oral sex, or anal sex with you against your will?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_VC30a = 2 GOTO Y_VC32a

---------------------------------------------------------------------------------

COERCION MODULE

IF CHILD AGE IS 13 OR OLDER OR CHILD IS A YOUNG ADULT (18+) OR EMANCIPATED YOUTH, CONTINUE. ELSE, GOTO Y_HTEND.

Y_HT1

Some people experience difficult situations at work or in other places. I’d like to know if you have ever had any of these experiences.

Have you ever been unable to leave a place you worked or talk to people you wanted to talk to, even when you weren’t working, because the person you worked for threatened or controlled you?

1=YES

2=NO

Y_HT2

Did someone you work for ever refuse to pay what they promised and keep all or most of the money you made?

1=YES

2=NO

Y_HT3

Were you ever physically beaten, slapped, hit, kicked, punched, burned or harmed in any way by someone you work for?

1=YES

2=NO

Y_HT4

Did you ever feel emotionally abused by someone you worked for?

1=YES

2=NO

Y_HT5

Did someone you work for ever ask, pressure, or force you to do something sexually that you did not feel comfortable doing?

1=YES

2=NO

Y_HT6

Were you ever forced to engage in sexual acts with family, friends, clients, or business associates for money or favors, by someone you work for?

1=YES

2=NO

Y_HT7

Did you ever trade sexual acts for food, clothing, money, shelter, favors, or other necessities for survival before you reached the age of 18?

1=YES

2=NO

Y_HTEND

CHILD INVOLVEMENT WITH LAW MODULE

---------------------------------------------------------------------------------

Logic before:

IF CHILD IS EMANCIPATED OR YOUNG ADULT (18+), CONTINUE. ELSE, GOTO Y_YLEND.

Y_YL1a [ YYL1a ] CH ever been arrested for any offense

The next questions are about your involvement with the ^Fills.Y_YL1a1

^Fills.Y_YL1a2

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_YL1a1

waveone law.

wavetwo law in the last 12 months.

Question Fill: ^FillY_YL1a2

waveone Have you @Bever@B been arrested for any offense?

wavetwo @BIn the last 12 months@B, have you been arrested for any offense?

Logic after:

IF Y_YL1a = 2 GOTO Y_YLEND

---------------------------------------------------------------------------------

Y_YL2a [ YYL2a ] # of times CH arrested

How many ^Fills.Y_YL2n have you been arrested?

TIMES ARRESTED:

Question Type: 0..10

Question Fill: ^FillY_YL2n

waveone times

wavetwo times in the last 12 months

Y_YL2b

Since [last interview], have you been arrested or picked up by the police for something

other than a minor traffic offense?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_YL7a [ YYL7 ] Labels are in Logic After

Did you spend time in prison as a result of an arrest since [LAST INTERVIEW]?

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_YL7a

waveone ·arrest?

Logic after:

IF Y_YL7a = 2 GOTO Y_YL3y; YYL7_1a--CH spend time in prison as result of arrest; YYL7_2a--

CH spend time in prison as result of arrest - 2; YYL7_3a--CH spend time in prison as result of

arrest - 3; YYL7_4a--CH time in prison as result of arrest - 4; YYL7_5a--CH time in prison as result

of arrest - 5; YYL7_6a--CH time in prison as result of arrest - 6; YYL7_7a--CH time in prison as

result of arrest - 7; YYL7_8a--CH time in prison as result of arrest - 8; YYL7_9a--CH time in prison

as result of arrest - 9; YYL7_10a--CH time in prison as result of arrest - 10

---------------------------------------------------------------------------------

Y_YL8a [ YYL8 ] Labels are in Logic After

How long were you in prison?

Question Type: TYYL8a

less1mo 1 Less than 1 month

onetothree 2 1 to 3 months

fourtosix 3 4 to 6 months

seventoyr 4 7 months to 1 year

moreyr 5 ^Fills.TY_YL8a

Question Fill: ^FillTY_YL8a

waveone More than 1 year

wavetwo

Logic after:

YYL8_1a--Length of time CH in prison; YYL8_2a--Length of time CH in prison - 2; YYL8_3a--Length

of time CH in prison - 3; YYL8_4a--Length of time CH in prison - 4; YYL8_5a--Length of time CH in

prison - 5; YYL8_6a--Length of time CH in prison - 6; YYL8_7a--Length of time CH in prison - 7;

YYL8_8a--Length of time CH in prison - 8; YYL8_9a--Length of time CH in prison - 9; YYL8_10a--

Length of time CH in prison - 10

---------------------------------------------------------------------------------

Y_YL_END [ YYL_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

CHILD DISCIPLINE AND CHILD MALTREATMENT MODULE

---------------------------------------------------------------------------------

Logic before:

IF CHILD IS EMANCIPATED OR YOUNG ADULT (18+), AND R HAS CHILDREN LIVING WITH

THEM, CONTINUE.

IF CHILD IS EMANCIPATED OR YOUNG ADULT (18+) AND Y_CH39a = NO, SKIP TO Y_YM_END.

Y_YM0 [ YYM0 ] NO LABEL

Children sometimes do things that are wrong, disobey, or make their parents angry. For the next

set of questions, we would like to know what you have done when your child or children did

something wrong or made you upset or angry.

^Fills.Y_YM0

For each question pick an answer that says how many times this has happened in the past

@B12 months@B. If it hasn't happened in the past @B12 months@B, but it did happen before

that, pick the answer "not in the past @B12 months@B, but it happened before." If it has never

happened, pick the answer "this has never happened."

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

Question Fill: ^FillY_YM0

---------------------------------------------------------------------------------

Y_YM1a [ YYM1a ] # Xs explained to your ch why something was wrong - past 12M

In the past @B12 months@B, how many times have you explained to your child or children why

something was wrong?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM2a [ YYM2a ] Put your ch in time-out/sent to room - past 12M

In the past @B12 months@B, how many times have you put your child or children in "time out" or

sent your child or children to his/her room?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM3a [ YYM3a ] Shaken your ch - past 12M

In the past @B12 months@B, how many times have you shaken your child or children?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM4a [ YYM4a ] Hit your ch on bottom w/hard object - past 12M

In the past @B12 months@B, how many times have you hit your child or children on the bottom

with something like a belt, hairbrush, a stick or some other hard object?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM5a [ YYM5a ] Redirect your ch - past 12M

In the past @B12 months@B, how many times have you given your child or children something

else to do instead of what he/she was doing wrong?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM6a [ YYM6a ] Shouted/yelled/screamed your ch - past 12M

In the past @B12 months@B, how many times have you shouted, yelled, or screamed at your

child or children?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM8a [ YYM8a ] Spanked your ch on bottomw w/bare hand - past 12M

In the past @B12 months@B, how many times have you spanked your child or children on the

bottom with your bare hand?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM10a [ YYM10a ] Sworn/cursed at ch - past 12M

In the past @B12 months@B, how many times have you sworn or cursed at your child or children?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM12a [ YYM12a ] Said ch will be sent away/kicked out - past 12M

In the past @B12 months@B, how many times have you said your child or children would be sent

away or kicked out of the house?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM14a [ YYM14a ] Threaten to spank/hit but not do it - past 12M

In the past @B12 months@B, how many times have you threatened to spank or hit your child or

children but did not actually do it?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM16a [ YYM16a ] Slapped ch on hand/arm/leg - past 12M

In the past @B12 months@B, how many times have you slapped your child or children on the

hand, arm, or leg?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM17a [ YYM17a ] Taken away priveleges/grounded - past 12M

In the past @B12 months@B, how many times have you taken away privileges or grounded your

child or children?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM18a [ YYM18a ] Pinched ch - past 12M

In the past @B12 months@B, how many times have you pinched your child or children?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM21a [ YYM21a ] Called ch dumb/lazy/other name - past 12M

In the past @B12 months@B, how many times have you called your child or children dumb or

lazy or some other name like that?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM23 [ YYM23 ] NO LABEL

Sometimes things can get in the way of caring for your child the way you would like to: for

example, money problems, personal problems, or having a lot to do. For the next set of items,

please tell me how many times in the past @B12 months@B this has happened to you in trying

to care for your child.

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

---------------------------------------------------------------------------------

Y_YM24a [ YYM24a ] Leave ch home alone when shouldnt - past 12M

In the past @B12 months@B, how many times have you ever had to leave your child or children

home alone, even when you thought some adult should be with him/her?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM25a [ YYM25a ] Not show/tell ch love him/her - past 12M

In the past @B12 months@B, how many times were you so caught up with problems that you

were not able to show or tell your child or children that you loved him/her?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM26a [ YYM26a ] Unable to ensure ch get food needed - past 12M

In the past @B12 months@B, how many times were you not able to make sure that your child or

children got the food he/she needed?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM27a [ YYM27a ] Unable to get ch to doc as needed - past 12M

In the past @B12 months@B, how many times were you unable to make sure your child or

children got to a doctor or hospital when he/she needed it?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM28a [ YYM28a ] Cdnt take care of ch b/c drunk/high - past 12M

In the past @B12 months@B, how many times were you so drunk or high that you had a problem

taking care of your child or children?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM_END [ YYM_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

DATING VIOLENCE

---------------------------------------------------------------------------------

Logic before:

IF WAVE > 1 AND CHILD IS YOUNG ADULT (18+), CONTINUE. ELSE, GOTO Y_YDEND.

Y_YD1

The next questions ask about your experiences with dating. By dating, we mean spending time with someone you are seeing or going out with. The term date includes both one-time dates and time together as part of longer-term relationships.

Have you dated someone in the past 12 months?

1 YES

2 NO

Logic after:

If Y_YD1 = NO, GOTO END

Please think about things that may have happened during a conflict or argument with someone you are or were dating in the last 12 months. During a conflict or argument, did the following things happen never, seldom, sometimes or often...

Y_YD2

I spoke to him/her in a hostile or mean tone of voice

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YD3

He/she spoke to me in a hostile or mean tone of voice

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YD4

I insulted him/her with put-downs

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YD5

He/she insulted me with put-downs

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YD6

I said things to his/her friends to try and turn them against him/her

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YD7

He/she said things to my friends to try and turn them against me

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YD8

I kicked, hit, or punched him/her

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YD9

He/she kicked, hit, or punched me

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YD10

I slapped or pulled his/her hair

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YD11

He/she slapped or pulled my hair

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YD12

I threatened to hurt him/her

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YD13

He/she threatened to hurt me

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YD14

I threatened to hit or throw something at him/her

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YD15

He/she threatened to hit or throw something at me

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YD16

I spread rumors about him/her

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YD17

He/she spread rumors about me

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YD18

I touched him/her sexually when they didn’t want me to

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YD18

He/she touched me sexually when I didn’t want them to

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YD19

I forced my partner to have sex when they didn’t want to

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YD19

He/she forced me to have sex when I didn’t want to

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YDEND

CHILD MALTREATMENT MODULE

---------------------------------------------------------------------------------

Logic before:

IF AGE < 11 OR CHILD IS EMANCIPATED OR YOUNG ADULT (18+), GOTO Y_CMEND. ELSE,

CONTINUE.

Y_CM1a [ YCM1a ] # Xs parents/adult exp why something was wrng - past 12M

Sometimes parents get angry at their children or lose their tempers. These questions are about

your parents and other adults who have taken care of you and what they did when they got angry

or when you did something they did not like.

For each of the following questions pick an answer that says how many times this has happened

in the past @B12 months@B. If it hasn't happened in the past @B12 months@B, but it did

happen before that, pick the answer "Not in the past @B12 months@B, but it happened before."

If it has never happened, pick the answer "This has never happened."

In the past @B12 months@B, how many times have your parents or other adults who lived with

you explained why something was wrong?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM2a [ YCM2a ] # Xs parents/othr put CH in time out - past 12M

In the past @B12 months@B, how many times have your parents or other adults who lived with

you put you in "time out" or sent you to your room?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM3a [ YCM3a ] # Xs parents/othr shook CH

In the past @B12 months@B, how many times have your parents or other adults who lived with

you shaken you?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM4a [ YCM4a ] # Xs parents/othr hit CH on bottom w/ hard object - past 12M

In the past @B12 months@B, how many times have your parents or other adults who lived with

you hit you on the bottom with something like a belt, hairbrush, a stick or some other hard object?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM5a [ YCM5a ] # Xs parents gave CH something else to do - past 12M

In the past @B12 months@B, how many times have your parents or other adults who lived with

you given you something else to do instead of what you were doing wrong?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM6a [ YCM6a ] # Xs parents/othr yelled at CH - past 12M

In the past @B12 months@B, how many times have your parents or other adults who lived with

you shouted, yelled, or screamed at you?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM8a [ YCM8a ] # Xs parents/othr spanked CH w/hands

In the past @B12 months@B, how many times have your parents or other adults who lived with

you spanked you on the bottom barehanded?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM10a [ YCM10a ] # Xs parents/othr cursed at CH

In the past @B12 months@B, how many times have your parents or other adults who lived with

you sworn or cursed at you?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM12a [ YCM12a ] # Xs parents/othr threat to kick CH out

In the past @B12 months@B, how many times have your parents or other adults who lived with

you said you would be sent away or kicked out of the house?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM14a [ YCM14a ] # Xs parents/othr threat to spank CH

In the past @B12 months@B, how many times have your parents or other adults who lived with

you threatened to spank or hit you but did not actually do it?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM16a [ YCM16a ] # Xs parents/othr slapped CH on body

In the past @B12 months@B, how many times have your parents or other adults who lived with

you slapped you on the hand, arm, or leg?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM17a [ YCM17a ] # Xs parents/othr grounded CH

In the past @B12 months@B, how many times have your parents or other adults who lived with

you taken away privileges or grounded you?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM18a [ YCM18a ] # Xs parents/othr pinched CH

In the past @B12 months@B, how many times have your parents or other adults who lived with

you pinched you?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM21a [ YCM21a ] # Xs parents/othr called CH dumb

In the past @B12 months@B, how many times have your parents or other adults who lived with

you called you dumb or lazy or some other name like that?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Logic after:

GOTO Y_CMEND

CHILD PERMISSION FOR DATA LINKAGE MODULE

---------------------------------------------------------------------------------

Logic before:

IF (AGE >= 13 AND AGE <= 17) or (Child = YA) or (Child = EA) ask Y_LK1 else goto Y_LK1a

Y_LK1 [ YLK1 ] NO LABEL

The information you have provided so far is very helpful to the study. The NSCAW interview with you can be even more useful when we combine your answers with other data. This includes information available now as well as future information. We want to ask for your okay to add other types of information to your survey answers.

We would add three types of information to your interview data.

We would add records collected from child welfare services agencies taking part in the study. Adding this information will help us learn about foster care, adoption, or other services you receive.
We would add information about your household’s income, such as wages and disability benefits from the Social Security Administration and from data available to the Administration for Children and Families—the agency funding the study.
Researchers interested in NSCAW data may wish to add other information in the future. This could include data on county or state child welfare policies.

If you give your okay now, we will collect these other kinds of information to combine with your survey data. Your okay to link your survey data to other information will last until you turn 18 years old unless you change your mind before then. Your okay means we can start adding information about you now or in the future. When you turn 18 years old, we will ask if it is okay to collect information about you as an adult. If you say no then, we will stop adding information about you as an adult and only keep and share the information collected before you turned 18 years old.

How will you add information and who will use it?

We will allow some researchers to do studies using your data that combine your survey answers to other sources. We created a clear plan to protect the data shared with other researchers. The study must first be approved by persons in charge of protecting the rights of those who take part in research studies. Researchers will use the data to write reports. None of these reports will include your name.

What are the risks and benefits for saying OK to this?

We have protections in place to collect and store your information securely. However, there is a small risk. If someone does not follow the rules we set, someone outside the study team might see your information. We reduce this risk by using a study ID and not your name when moving and storing your interview data.

Combining your survey data with other information presents no direct benefits to you. Your decision will not affect any services that you receive now or in the future.

By answering “Yes”, you give your “okay” for us to link your survey data with information in the future. You have the right to say yes or no to this request. Your okay also allows us to share it with researchers for other approved research studies.

If you change your mind, please call Jennifer Keeney, at RTI International RTI) (toll-free at 800-334-8571, extension 23525) or RTI’s Office of Human Research Protections at 1-866-214-2043 (a toll-free number) to record this request.

01 = Yes, I agree to share my NSCAW information with other sources like those listed above. My okay takes effect when RTI releases information from this round to researchers.

02 = No, I do not want to add the other types of information described above to my first NSCAW interview.

[Click here] if you would like to download a copy of this form that you can print.

CHILD VERIFICATIONS/CHANGE OF ADDRESS/PAYMENT MODULE

---------------------------------------------------------------------------------

Logic before:

IF CHILD IS LEGALLY EMANCIPATED PER CID OR AGE IS 18+, CONTINUE. ELSE, GOTO

Y_VOEND.

Y_VO1a [ YVO1 ] NO LABEL

As part of RTI's quality program, we plan to contact a portion of the persons participating in this

survey to verify the work of our interviewers. The questions you

would be asked, if you are selected, are general.

Would you be agreeable to a verification call from our team?

1 = Yes

2 = No

---------------------------------------------------------------------------------

Y_VO4a [ YVO4 ] NO LABEL

To show our appreciation for your time and effort, we would like to send you a link to an Amazon gift card FILL FOR ADOLESCENTS AGE >= 11 and <=17: for $20 plus a small gift of equal value

FILL FOR YOUNG ADULTS AGE >= 18: for $50.

If you do not wish to receive this gift card, please click the box below. Please provide a valid e-mail address for where you would like us to send the gift card.

Allow a week for delivery.

E-mail:

Retype e-mail:

Please click “Next”.

I do not want to receive an Amazon gift card for completing this survey.

CLOSING TEXT FOR ADOLESCENTS AGE >= 11 and <= 17

Their toll-free number is 1-800-273-8255.

Thank you for participating in this survey!

CLOSING TEXT FOR YOUNG ADULTS AGE >= 18.

Finally, sometimes the personal issues brought up in this survey can cause people to become upset and in need of speaking with a counselor. If you are feeling upset or disturbed by the personal issues in this survey and would like to talk with someone about your feelings, we suggest you call your doctor, counselor, or other treatment provider if you are currently under someone’s care.

Their toll-free number is 1-800-273-8255.

Thank you for participating in this survey!

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Smith, Keith R.
File Modified	0000-00-00
File Created	2021-09-08