Parent Survey of Health 2021

Form Approved

OMB No. 0920-new

Expiration Date: ##/##/20##

Client	NORC Public Health/CDC DASH
Project Name	National Adolescent Health Survey – Parent Survey MAIN
Project Number	8644
Survey length (median)	20 minute survey
Population	Age 18+ parent of child age 15-17
Pretest	N=9; 2020 pilot to be conducted with OMB waiver
Main	N=1217 (to yield ~900 dyad with teen interview)
MODE	Web/Phone
Language	English
Sample Source	AmeriSpeak
Incentive	20,000
Survey description	Parent Survey of Health 2021
Eligibility Rate	100%

Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-new).

Standard demographic preloads:

Var Name	Include on Preload Testing-page?	Var Type	Var length	Variable Label
S_AGE	Y	Numeric	5	Age
S_GENDER	Y	String	8	Gender
S_RACETH	Y	Numeric	8	Race/ethnicity
S_EDUC	N	Numeric	6	Education
S_EDUC5	Y	Numeric	4	5-level education
S_MARITAL	Y	Numeric	9	Marital Status
S_EMPLOY	Y	Numeric	8	Current employment status
S_INCOME	N	Numeric	8	Household income
S_HHINC_4	N	Numeric	4	4-level income
S_HHINC_9	N	Numeric	4	9-level income
S_STATE	Y	String	7	State
S_METRO	N	Numeric	7	Metropolitan area flag
S_INTERNET	N	Numeric	10	Household internet access
S_HOUSING	N	Numeric	9	Home ownership
S_HOME_TYPE	N	Numeric	11	Building type of panelist’s residence
S_PHONESERVC	N	Numeric	11	Telephone service for the household
S_HHSIZE	N	Numeric	8	Household size (including children)
S_HH01	N	Numeric	6	Number of HH members age 0-1
S_HH25	N	Numeric	6	Number of HH members age 2-5
S_HH612	N	Numeric	7	Number of HH members age 6-12
S_HH1317	N	Numeric	8	Number of HH members age 13-17
S_HH18OV	N	Numeric	8	Number of HH members age 18+
S_file_date	N	Date	11
S_GENFRACE	N	Numeric	8	GenF custom race

These populated as a pre-load when the panelists get sampled into the survey

Standard sample preloads

Variable Name	Include on Preload Testing-only page?	Variable Type	Variable Label
Username	N	Numeric	Analogous to Member_PIN
P_Batch	N	Numeric	Batch Number (if only one assignment, then everyone will be 1)
Dialmode	N	Numeric	CATI Dialmode (predictive, preview, etc)
P_LCS	N	Numeric	Life cycle stage, 0=released but not touched
Y_FCELLP	N	String
Surveylength	N	Numeric	Estimated length of survey
Incentwcomma	N	String	Study specific
P_Hold01	N	Numeric	Prevents dialing cases without phone numbers
PANEL_TYPE	Y	Numeric	1 AmeriSpeak 2 Next Generation 3 GenF Extended (not in use) 4 AmeriSpeak Teen Panel 11 Former UTellUs 20 Lucid 21 SSI 50 Household 13-17 51 Household < 13 52 Household Adult

Custom survey-specific preloads: NONE

This survey will use the following RND_xx variables: none

PHONE SCRIPTS

[CATI - OUTBOUND]

INTRO

Hello, my name is $I. I'm calling from AmeriSpeak by NORC. May I please speak with [FIRSTNAME]?

[IF RESPONDENT IS AVAILABLE]

Thank you for your continued participation in AmeriSpeak. I am calling to let you know that your next survey is available. The survey takes approximately [SURVEYLENGTH] minutes to complete. If you complete the survey, you will receive [INCENTWCOMMA] AmeriPoints for your time. We will keep all of your answers confidential. Shall we proceed?

Great. As always, for quality assurance purposes, this call may be recorded or monitored.

[CATI-INBOUND]

INTRO

Thank you for calling AmeriSpeak by NORC.  My name is $I.  How are you today?

And are you calling to take your next survey?

I just need to confirm that I'm speaking with [FIRSTNAME] [LASTNAME]. Is that you?

Great. This survey takes approximately [SURVEYLENGTH] minutes to complete over the phone and you will receive [INCENTWCOMMA] AmeriPoints for your time.  We will keep all of your answers confidential. 

As always, for quality assurance purposes, this call may be recorded or monitored.

Shall we proceed?

[CATI-CALLBACK]

CBINTRO

Hello, my name is $I. I'm calling from AmeriSpeak by NORC. We previously spoke with [FIRSTNAME] about completing an AmeriSpeak survey. Is [FIRSTNAME] available?

[IF RESPONDENT IS AVAILABLE]

Hello, my name is $I, calling from AmeriSpeak by NORC. We previously spoke with you about completing an AmeriSpeak survey. Are you available now to continue?

As always, for quality assurance purposes, this call may be recorded or monitored.

[DISPLAY THIS AM LANGUAGE IF SurveyAccessEnd-CALLDATE>1 DAY]

[CATI-MISSED OUTBOUND, ANSWERING MACHINE]

AM1

Hello, this message is [FIRSTNAME] [LASTNAME]. I'm calling from AmeriSpeak from NORC to let you know that you have a survey waiting for you. The survey will take approximately [SURVEYLENGTH] minutes and you will receive [INCENTWCOMMA] AmeriPoints for your time. Call us toll-free at 888-326-9424 and enter your PIN number, [MEMBER_PIN], to complete your survey and receive rewards. Thank you.

[DISPLAY THIS AM LANGUAGE IF SurveyAccessEnd-CALLDATE>1 DAY]

[CATI-ANSWERING MACHINE MISSED APPOINTMENT CALLBACK]

AMHARD

Hello, this message is for [FIRSTNAME] and I'm calling from AmeriSpeak from NORC. When we spoke previously, you requested that we call you back <at this time>. I'm sorry that we've missed you. We'll try to contact you again soon but please feel free to return our call any time at 888-326-9424 and enter your PIN number, [MEMBER_PIN], to complete your survey and receive rewards. Thank you.

[DISPLAY THIS AM LANGUAGE IF SurveyAccessEnd-CALLDATE>1 DAY]

[CATI-ANSWERING MACHINE MISSED CALLBACK]

AMSOFT

Hello, this message is for [FIRSTNAME]. I am calling from AmeriSpeak from NORC. We are calling you back to complete your AmeriSpeak survey. Remember, you will receive rewards for completing this survey. I'm sorry that we've missed you. We'll try to contact you again soon but please feel free to return our call any time at 888-326-9424 and enter your PIN number, [MEMBER_PIN], to complete this survey. Thank you.

[DISPLAY THIS AM LANGUAGE IF SurveyAccessEnd-CALLDATE=1 DAY]

[CATI-NEARING END OF FIELD, ANSWERING MACHINE]

AMEND

Hello, this message is for [FIRSTNAME]. I'm calling from AmeriSpeak from NORC to let you know that a survey will be ending tomorrow. We’d love to hear from you so please call us toll-free at 888-326-9424 and enter your PIN number, [MEMBER_PIN], to complete your survey and receive rewards. Thank you.

Please include the following options for all questions in CATI:

77 DON’T KNOW

99 REFUSED

Please code refusals in CAWI:

98 IMPLICIT REFUSAL, WEB SKIP

Do not code 77 Don’t Know/99 Refused options in CAWI unless written in item response options

Text shown in green includes researcher notes and should not be included in the programming.

[START OF SURVEY]

CREATE DATA-ONLY VARIABLE: QUAL

1=Qualified Complete

2=Not Qualified

3=In progress

AT START OF SURVEY COMPUTE QUAL=3 “IN PROGRESS”

CREATE MODE_START

1=CATI

2=CAWI

[DISPLAY – WINTRO_1]

Thank you for agreeing to participate in our new AmeriSpeak survey! As always, your answers are confidential.

Please use the "Continue" and "Previous" buttons to navigate between the questions within the questionnaire. Do not use your browser buttons.

[DISPLAY]

INTRO_PAR.

We'll start with some questions you may have answered previously. We re-ask these questions from time to time as your answers may have changed.  

[MP] [DOUBLE PROMPT]

S1.

Which of the following applies to your household? You <u><i>currently</i> live</u> with…  

[CAWI - REMOVE BOLD] <i> Please select all that apply. </i>

[CATI] SELECT ALL THAT APPLY

1. Other <u>adults</u> related to you by birth or marriage

2. Other <u>adults not</u> related to you by birth or marriage

3. Children under the age of 18 for who <u>you are a parent or legal guardian</u>

4. Children under the age of 18 for who you are <u>not</u> a parent or legal guardian

5. None of the above, [CAWI: I; CATI: you] live alone [SP]

[SHOW IF S1=3]

[NUMBOX]

S2.

For your children under the age of 18 <u><i>currently</u></i> living in your household for whom you are a parent or legal guardian, <u>how many</u> are in the following age categories?  

CATI: PLEASE ENTER 77 FOR DON'T KNOW & 99 FOR REFUSED

[NUMBOX; RANGE 0-12] S2A. Your children age 0-4

[NUMBOX; RANGE 0-12] S2B. Your children age 5-9

[NUMBOX; RANGE 0-12] S2C. Your children age 10-14

[NUMBOX; RANGE 0-12] S2D. Your children age 15-17

[DOUBLE PROMPT, CUSTOM PROMPT TEXT "We are asking for a name, nickname, or initial so we can refer to this child in the rest of the survey. If you choose to continue without providing a name, we will refer to this child as 'your child' throughout the survey."]

[SHOW IF S2D=1-12]

[TEXTBOX]

S3.

[IF S2D>1]Think about your children between the ages 15-17. We are going to ask you questions about the one who had the most recent birthday. Please enter the child's first name, nickname, or initial, so we can refer to him or her in our questions.  

[IF S2D=1] We are going to ask you questions about your child between 15 and 17 years of age. Please enter that child's first name, nickname, or initial, so we can refer to him or her in our questions.  

CATI: IF SELECTING 77 OR 99, TELL INTERVIEWERS “We are asking for a name, nickname, or initial so we can refer to this child in the rest of the survey. If you choose to continue without providing a name, we will refer to this child as 'your child' throughout the survey.”

[SMALL TEXTBOX]

CREATE DOV_CHILDNAME [STRING]

IF S3=77, 98, 99 (no valid response) DOV_CHILDNAME=your child

ELSE DOV_CHILDNAME=S3 TEXT RESPONSE

[SHOW IF S2D=1-12]

[SP, DOUBLE PROMPT]

CONSENT.

We are asking you to take part in this survey on a series of topics about your teen [IF S3 FILLED, PIPE-IN " DOV_CHILDNAME"], including their mental health, sexual and reproductive health, social support systems, and school environment. This will take you about 15 minutes to finish, depending on your answers.

Important things you should know are:

• The Teen and Parent Surveys of Health are being conducted by NORC on behalf of the U.S. Centers for Disease Control and Prevention’s (CDC) Division of Adolescent and School Health.

• The survey is voluntary; you can choose whether or not to take it, and you can stop taking the survey at any time.

• We would encourage you to take the survey at any time when you have privacy.

• You will be compensated for your time with [INCENTWCOMMA] AmeriPoints for completing the survey.

If you have any questions or concerns about your participation in this study, you can contact AmeriSpeak Support at [email protected] or call (888) 326-9424.

Are you willing to complete this survey?

CAWI:

1. Yes

2. No

CATI:

1. YES

2. NO

CREATE DATA-ONLY VARIABLE: DOV_STUDYELIG [SP]

0=not study eligible

1=study eligible

9=unknown eligibility

ASSIGN DOV_STUDYELIG ACCORDING TO THIS LOGIC, IN PRIORITY

1. IF S1=3 and S2D=1-12 and CONSENT=1 DOV_STUDYELIG=1

2. IF (S1<>3 and S1<>77, 98, 99) or S2D=0 or CONSENT=2 DOV_STUDYELIG=0

3. IF S1=77, 98, 99 or S2D=77, 98, 99 or CONSENT=77, 98, 99 DOV_STUDYELIG=9

IF DOV_STUDYELIG=0 SET QUAL=2, SET CO_DATE and TERMINATE

IF DOV_STUDYELIG=9 SET QUAL=9, SET CO_DATE and TERMINATE

 CASE DISPOSITION=SCREENED OUT

 GO TO TERMSORRY

 No back (disable browser back button)

 auto redirect to member portal after 10 seconds

[NO PIMS TRANSACTION]

[SHOW IF TERMINATED]

TERMSORRY. 

Thank you for your time today. Unfortunately you are not eligible for this study. We value your opinion and hope that you will participate in future AmeriSpeak surveys.

We will redirect you to the AmeriSpeak Member Portal in [n] seconds.

[SET QUAL=2 “Not Qualified” and END INTERVIEW, no incentive given]

[REMOVE “PREVIOUS” BUTTON FROM PAGE]

[CAWI NO BACK – disable web browser back button]

CAWI auto-redirect to MEMBER PORTAL in 10 seconds, display remaining number of seconds in [n]

[DOUBLE PROMPT]

[NUMBOX]

QTAGE.

How old is [DOV_CHILDNAME]?  

CATI: PLEASE ENTER A NUMBER BETWEEN 15 AND 17

[NUMBOX, range=15-17]

[DOUBLE PROMPT]

[SP]

QTGEN1.

What sex was [DOV_CHILDNAME] assigned at birth?  

1. Male

2. Female

[SP]

QTGEN2.

How does [DOV_CHILDNAME] currently describe their gender?

1. Male

2. Female

3. Transgender

4. None of the above

[SP]

QTETH

What is [DOV_CHILDNAME]’s ethnicity?

RESPONSE OPTIONS:

1. Hispanic or Latino

2. Not Hispanic or Latino

[MP]

QTRACE

What is [DOV_CHILDNAME]’s race?

[CAWI - REMOVE BOLD] <i> Please select all that apply. </i>

[CATI] SELECT ALL THAT APPLY

RESPONSE OPTIONS:

1. American Indian/Alaskan Native

2. Asian

3. Native Hawaiian/Pacific Islander

4. Black or African American

5. White

Section A. Family Protective Factors

[SP]

Q1_A

In the past 12 months, which of the following ways did [DOV_CHILDNAME] attend school a MAJORITY of the time? By majority we mean most of the time or more than half.

RESPONSE OPTIONS:

1. In-person full time

2. Virtual/online full-time

3. Hybrid format-- In-person PART-TIME and virtual PART-TIME (meaning a combination of in-person attendance and virtual learning that follows a consistent schedule)

4. Homeschool (meaning enrolled in an official or formal homeschool program)

5. Other, please specify: [TEXTBOX]

6. Not enrolled in school in the past 12 months

[SHOW IF Q1A=1-5]

[SP]

Q1.

Is [DOV_CHILDNAME] currently enrolled in school?

[REMOVE BOLD] <i>If [DOV_CHILDNAME] is currently on a school break but will be in school when session resumes, [CAWI: please mark yes. CATI: it will be considered as yes]</i>

CAWI:

1. Yes

2. No

CATI:

1. YES

2. NO

[SHOW IF Q1=1]

[SP]

Q1_B

In the past 14 days, how has [DOV_CHILDNAME] attended school?

1. In-person full time

2. Virtual/online full-time

3. Hybrid format-- In-person PART-TIME and virtual PART-TIME (meaning a combination of in-person attendance and virtual learning that follows a consistent schedule)

4. Homeschool (meaning enrolled in an official or formal homeschool program)

5. Other, please specify: [TEXTBOX]

[GRID, SP]

Q2.

How much do you know about…

	[CAWI: I; CATI: You] know a lot	[CAWI: I; CATI: You] know a moderate amount	[CAWI: I; CATI: You] know a little	[CAWI: I; CATI: You] don't know anything
Q2A. Who [DOV_CHILDNAME]’s friends are
Q2B. How [DOV_CHILDNAME] spends their money
Q2C. [SHOW IF Q1=1] Where [DOV_CHILDNAME] is after school
Q2D. Where [DOV_CHILDNAME] is when they go out
Q2E. What [DOV_CHILDNAME] does with their free time
Q2F. What [DOV_CHILDNAME] does online
Q2G. Who [DOV_CHILDNAME] texts with

[GRID, SP]

Q5.

In the past 30 days, how often have you…

	More than a few times	A few times	Once or twice	Never
Restricted or blocked certain websites that [DOV_CHILDNAME] might use
Restricted the amount of time [DOV_CHILDNAME] spends online
Monitored or tracked what [DOV_CHILDNAME] is doing online, such as reading [DOV_CHILDNAME]'s texts, installing an app on [DOV_CHILDNAME]'s phone, or checking [DOV_CHILDNAME]'s Instagram or Snapchat account or search history

[SP]

Q5d.

Do you follow [DOV_CHILDNAME] on social media accounts they regularly use?

CAWI:

1. Yes

2. No

CATI:

1. YES

2. NO

[SP]

[CAWI: IF S3=77,98,99, PIPE-IN "my child" INSTEAD OF "your child"

CATI: IF S3=77,98,99, PIPE-IN "your child"]

Q4.

How much do you agree or disagree with the following statement?

"[CAWI: I; CATI: You] have rules and consequences for [DOV_CHILDNAME]’s behavior (e.g., curfews, punishments for breaking rules)."

1. Strongly agree

2. Agree

3. Neither agree nor disagree

4. Disagree

5. Strongly disagree

[GRID, SP; 4, 5, 4, 4]

Q6.

During the <u>past 12 months,</u> how often have you talked with [DOV_CHILDNAME] about each of the following?

	More than a few times	A few times	Once or twice	Never
Treating people [DOV_CHILDNAME] dates respectfully or being treated respectfully
Sexting (sending, receiving, or forwarding sexually suggestive messages, images, or videos via cell phones, emails, instant messages (IM), or online social networks)
[DOV_CHILDNAME]'s decisions about whether to have sex
How to create and maintain healthy, respectful romantic relationships
The importance of giving and receiving consent for sex
How to say no to sex
How to prevent pregnancy
How to prevent sexually transmitted infections (STIs), including HIV
Where to get healthcare services for sexual and reproductive health, like birth control or STI testing
Where to get help for stress, anxiety, and depression
Dangers of smoking cigarettes, using e-cigarettes or vaping devices, drinking alcohol, and using marijuana or other drugs
How to avoid online risks like chatting with strangers
How to keep information private while using the internet
[DOV_CHILDNAME]’s relationships with their friends
Treating people of different races or ethnicities with respect
How [DOV_CHILDNAME] is doing in school
The range of sexual orientations (such as gay, lesbian, bisexual, heterosexual) and gender identities (such as cisgender, non-binary/conforming, transgender)

[GRID, SP]

Q7.

Have you <u>ever</u> talked with [DOV_CHILDNAME] about the following?

	[CAWI: Yes; CATI: YES]	[CAWI: No; CATI: NO]
Where [DOV_CHILDNAME] can go to receive health care
What to expect during an appointment with a healthcare provider (such as a doctor or nurse)
Preparing for time alone with a healthcare provider

[GRID, SP]

[CAWI: IF S3=77,98,99, PIPE-IN "my child" INSTEAD OF "your child"

CATI: IF S3=77,98,99, PIPE-IN "your child"]

Q8.

How much do you agree or disagree with the following statements?

	Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
[CAWI: I; CATI: You] have the information [CAWI: I; CATI: you] need to talk to [DOV_CHILDNAME] about sex.
[CAWI: I am; CATI: You are] comfortable talking to [DOV_CHILDNAME] about sex.

[GRID, SP]

[CAWI: IF S3=77,98,99, PIPE-IN "my child" INSTEAD OF "your child"

CATI: IF S3=77,98,99, PIPE-IN "your child"]

Q9.

How much do you agree or disagree with the following statements?

	Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
[CAWI: I; CATI: You] have the information [CAWI: I; CATI: you] need to talk to [DOV_CHILDNAME] about how [DOV_CHILDNAME] is feeling (for instance, stressed, anxious, or depressed).
[CAWI: I am; CATI: You are] comfortable talking to [DOV_CHILDNAME] about how [DOV_CHILDNAME] is feeling (for instance, stressed, anxious, or depressed).

[SP]

[CAWI: IF S3=77,98,99, PIPE-IN "my child" INSTEAD OF "your child"

CATI: IF S3=77,98,99, PIPE-IN "your child"]

Q3.

How much do you agree or disagree with the following statement?

"[CAWI: I am; CATI: You are] satisfied with the way [DOV_CHILDNAME] and [CAWI: I; CATI: you] communicate."

1. Strongly agree

2. Agree

3. Neither agree nor disagree

4. Disagree

5. Strongly disagree

Section D. Health Education

[DISPLAY – SECTD_INTRO]

People get information from many different sources. The next questions are about where <u>you</u> get information about parenting and teen health and well-being, including sexual and reproductive health and mental health. <u>Sexual and reproductive health</u> refers to topics like sex, sexuality, relationships, or other issues like how to prevent sexually transmitted infections (STIs) or unintended pregnancies. <u>Mental health</u> includes things like stress, anxiety, and depression.

[GRID, SP]

Q19.

Have you ever received information about parenting and teen health (e.g., physical/emotional/social well-being) from the following sources?

	[CAWI: Yes; CATI: YES]	[CAWI: No; CATI: NO]
[CAWI: My; CATI: Your] healthcare provider
[DOV_CHILDNAME]’s healthcare provider
[DOV_CHILDNAME]’s school
An Internet search (such as a Google search)
Social media (such as Twitter, Instagram, or YouTube)
[CAWI: My; CATI: Your] partner
[CAWI: My; CATI: Your] family
[CAWI: My; CATI: Your] friends
Faith leader
Parent organizations/support groups
Other, please specify: __[IF Q19K=1 SHOW SMALL TEXTBOX]

[DISPLAY – SECTD_1]

We’d now like to ask about information you have received about different topics related to parenting a teenager, including supporting their mental health and sexual and reproductive health.

[LOOP THROUGH Q20A thru Q20k, SHOW Q20 FOR EVERY Q19=1]

[GRID, SP]

Q20.

When you received information from <u>[For both CAWI & CATI, insert Q19a-k CATI version of text, first letter lower-case; For Q19i, insert “a faith leader”]</u> did you receive any information about…

	[CAWI: Yes; CATI: YES]	[CAWI: No; CATI: NO]
General strategies for parenting teens
General information about teen sexual and reproductive health
General information about teen mental health
How to talk to [DOV_CHILDNAME] about sexual and reproductive health
How to talk to [DOV_CHILDNAME] about mental health
Where teens can get sexual and reproductive health services
Where teens can get mental health services
How to address challenging teen behaviors
General information about teen substance use
How teens can create and maintain healthy, respectful romantic relationships
How to talk to [DOV_CHILDNAME] about the range of sexual orientations (such as gay, lesbian, bisexual, heterosexual) and gender identities (such as cisgender, non-binary/conforming, transgender)
How to help [DOV_CHILDNAME] avoid online risks like chatting with strangers
How to help [DOV_CHILDNAME] keep information private while using the internet

CREATE DATA-ONLY VARIABLE: DOV_MENTHEALTH_A thru _K [SP]

0 = did not receive mental health info in Q20A-Q20K loop

1 = received mental health info in Q20A-K loop

IF any (Q20A_C, Q20A_E, Q20A_G)=1 DOV_MENTHEALTH=1

…(B thru J)…

­­­IF any (Q20K_C, Q20K_E, Q20K_G)=1 DOV_MENTHEALTH=1

ELSE DOV_MENHEALTH=0

CREATE DATA-ONLY VARIABLE: DOV_SEXHEALTH [SP]

0 = did not receive sexual reproductive health info in Q20A-Q20K loop

1 = received sexual reproductive health info in Q20A-K loop

IF any (Q20A_B, Q20A_D, Q20A_F, Q20A_J, Q20A_K)=1 DOV_SEXTHEALTH=1

…(B thru J loop)…

­­­IF any (Q20K_B, Q20K_D, Q20K_F, Q20K_J, Q20K_K =1 DOV_SEXTHEALTH=1

ELSE DOV_SEXTHEALTH=0

[SHOW IF DOV_MENTHEALTH=1]

[GRID, SP; show numeric labels]

Q21.

Please rate how useful the <u>mental health information</u> was you’ve gotten from the following source(s), 5 being very useful and 1 being not useful at all.

	(Very useful) 5	4	3	2	(Not useful at all) 1
[SHOW IF any (Q20A_C, Q20A_E, Q20A_G)=1] [CAWI: My; CATI: Your] healthcare provider
[SHOW IF any (Q20B_C, Q20B_E, Q20B_G)=1] [DOV_CHILDNAME]’s healthcare provider
[SHOW IF any (Q20C_C, Q20C_E, Q20C_G)=1] [DOV_CHILDNAME]’s school
[SHOW IF any (Q20D_C, Q20D_E, Q20D_G)=1] An Internet search (such as a Google search)
[SHOW IF any (Q20E_C, Q20E_E, Q20E_G)=1] Social media (such as Facebook, Twitter, or Instagram)
[SHOW IF any (Q20F_C, Q20F_E, Q20F_G)=1] [CAWI: My; CATI: Your] partner
[SHOW IF any (Q20G_C, Q20G_E, Q20G_G)=1] [CAWI: My; CATI: Your] family
[SHOW IF any (Q20H_C, Q20H_E, Q20H_G)=1] [CAWI: My; CATI: Your] friends
[SHOW IF any (Q20I_C, Q20I_E, Q20I_G)=1] Faith leader
[SHOW IF any (Q20J_C, Q20J_E, Q20J_G)=1] Parent organizations/support groups
[SHOW IF any (Q20K_C, Q20K_E, Q20K_G)=1] [INSERT Q19k TEXT RESPONSE]

[GRID, SP; 4, 4, 4]

Q22.

How comfortable or uncomfortable would you feel with [DOV_CHILDNAME] getting mental health information from the following sources?

	Very comfortable	Comfortable	Neither comfortable nor uncomfortable	Uncomfortable	Very uncomfortable
Health classes in school
A healthcare provider (outside of school)
School nurse or other healthcare provider in school
Another adult at school like a teacher, coach, or counselor
An Internet search (such as a Google search)
A website specifically for teens
A medical website
Social media (such as Twitter, Instagram, or YouTube)
You
[DOV_CHILDNAME]’s friends
[DOV_CHILDNAME]’s siblings
A person [DOV_CHILDNAME] is in a romantic relationship with (like a boyfriend or girlfriend)

[SHOW IF DOV_SEXHEALTH=1]

[GRID, SP]

Q23.

The next questions are similar to ones you just answered about finding information about mental health. This time, we want you to think about where you find information about <u>sexual and reproductive health</u>. Please rate how useful the sexual and reproductive health information was you’ve gotten from the following source(s), 5 being very useful and 1 being not useful at all.

	(Very useful) 5	4	3	2	(Not useful at all) 1
[SHOW IF any(Q20A_B, Q20A_D, Q20A_F, Q20A_J, Q20A_K)=1] [CAWI: My; CATI: Your] healthcare provider
[SHOW IF any(Q20B_B, Q20B_D, Q20B_F, Q20B_J, Q20B_K)=1] [DOV_CHILDNAME]’s healthcare provider
[SHOW IF any(Q20C_B, Q20C_D, Q20C_F, Q20C_J, Q20C_K)=1] [DOV_CHILDNAME]’s school
[SHOW IF any(Q20D_B, Q20D_D, Q20D_F, Q20D_J, Q20D_K)=1] An Internet search (such as a Google search)
[SHOW IF any(Q20E_B, Q20E_D, Q20E_F, Q20E_J, Q20E_K)=1] Social media (such as Facebook, Twitter, or Instagram)
[SHOW IF any(Q20F_B, Q20F_D, Q20F_F, Q20F_J, Q20F_K)=1] [CAWI: My; CATI: Your] partner
[SHOW IF any(Q20G_B, Q20G_D, Q20G_F, Q20G_J, Q20G_K)=1] [CAWI: My; CATI: Your] family
[SHOW IF any(Q20H_B, Q20H_D, Q20H_F, Q20H_J, Q20H_K)=1] [CAWI: My; CATI: Your] friends
[SHOW IF any(Q20I_B, Q20I_D, Q20I_F, Q20I_J, Q20I_K)=1] Faith leader
[SHOW IF any(Q20J_B, Q20J_D, Q20J_F, Q20J_J, Q20J_K)=1] Parent organizations/support groups
[SHOW IF any(Q20K_B, Q20K_D, Q20K_F, Q20K_J, Q20K_K)=1] [INSERT Q19K TEXT RESPONSE]

[GRID, SP; 4, 4, 4]

Q24.

How comfortable or uncomfortable would you feel with [DOV_CHILDNAME] getting sexual and reproductive health information from the following sources?

	Very comfortable	Comfortable	Neither comfortable nor uncomfortable	Uncomfortable	Very uncomfortable	Does not apply
Health classes in school
A healthcare provider (outside of school)
School nurse or other healthcare provider in school
Another adult at school like a teacher, coach, or counselor
An Internet search (such as a Google search)
A website specifically for teens
A medical website
Social media (such as Twitter, Instagram, or YouTube)
You
[DOV_CHILDNAME]’s friends
[DOV_CHILDNAME]’s siblings
A person [DOV_CHILDNAME] is in a romantic relationship with (like a boyfriend or girlfriend)

[GRID, SP; 3, 4, 3, 2, 2]

Q26.

The following topics and skills are commonly taught in school health education. Select when you feel the topic is most appropriate to be taught to students. Select one response for each health topic.

	Appropriate topic for students in: middle school only	Appropriate topic for students in: high school only	Appropriate topic for students in both middle and high school	Not an appropriate topic to be taught in school
The benefits of not having sex (i.e., being sexually abstinent)
How to create and maintain healthy, respectful romantic relationships
The range of sexual orientations (such as gay, lesbian, bisexual, heterosexual) and gender identities (such as cisgender, non-binary/conforming, transgender)
How to talk with parents/caregivers about sex and relationship issues
The importance of giving and receiving consent for sex
How to reduce risk related to sexually transmitted infections (STIs), including HIV
The importance of preventing pregnancy
How to obtain and use condoms
Methods of birth control to prevent pregnancy (such as IUD or implant; shot, patch, ring, pills, condoms)
Using a doctor or clinic for health services including STI/HIV testing and treatment, pregnancy testing, and getting condoms and birth control
How alcohol and other drug use can impact decision making during sex
Recognizing if you or someone else is experiencing physical violence, sexual harassment, abuse, assault or rape
Where to get help for someone (either yourself or a friend) who is thinking or talking about suicide
How to handle challenging emotions such as anger, stress, anxiety, frustration, disappointment, or sadness

[GRID, SP; 3, 3, 3]

[SHOW IF Q1=1]

[CAWI:

IF S3=77,98,99 and DOV_CHILDNAME does NOT start the grid item label, PIPE-IN "my child" INSTEAD OF "your child";

IF S3=77,98,99 and DOV_CHILDNAME starts the grid item label, PIPE-IN "My child" INSTEAD OF "your child"

CATI:

IF S3=77,98,99 and DOV_CHILDNAME does NOT start the grid item label, PIPE-IN "your child"

IF S3=77,98,99 and DOV_CHILDNAME starts the grid item label, PIPE-IN "Your child"]

Q27.

Based on your experiences with health education at your child’s school, how much do you agree or disagree with the following statements?

	Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
The health education at [DOV_CHILDNAME]’s school is providing them with skills needed to be healthier.
[DOV_CHILDNAME]’s school provides teachers with the right training and classroom materials to effectively deliver health education.
[CAWI: I; CATI: You] believe [DOV_CHILDNAME]’s school district should provide health education at every grade-level (Kindergarten – Grade 12).
[CAWI: I am; CATI: You are] engaged in [DOV_CHILDNAME]’s school health education program (such as, helping with curriculum review or being a member of a wellness council).
[CAWI: I; CATI: You] enjoy participating with [DOV_CHILDNAME] in health-related assignments and projects at home.
[DOV_CHILDNAME] and [CAWI: I; CATI: you] talk more at home about important health issues as a result of their sexual health education lessons or assignments.
[CAWI: I; CATI: You] feel relieved that [DOV_CHILDNAME] is receiving health education at school so that [CAWI: I; CATI: you] don’t have to talk to [DOV_CHILDNAME] about some of these issues.
The school’s sexual health education makes it easier for [CAWI: me; CATI: you] to talk to [DOV_CHILDNAME] about sexual health issues.
The school’s sexual education raises subjects that [CAWI: I; CATI: you] don’t think [DOV_CHILDNAME] should be discussing.

Section B. Mental Health

[DISPLAY – SECTB_INTRO]

This section contains questions about <u>mental health.</u> Mental health includes things like stress, anxiety, and depression. The first few questions are about <u>you.</u> As always, your answers are confidential.

INSERT FOOTER <center> These questions may be difficult to answer. Please click here for a list of mental health and suicide prevention resources. </center>

Link behind “here”: 8644 CDC DASH NAHS Parent CAWI Help Button.pdf

[SP]

Q11.

Have you ever been diagnosed with a behavioral, developmental, emotional, or mental health condition for which treatment, therapy, or counseling may be needed?

Examples may include anxiety, depression, attention deficit disorder or ADHD, autism spectrum disorder, learning or intellectual disability, speech or other language disorder.

CAWI:

1. Yes

2. No

99. Prefer not to answer

CATI:

1. YES

2. NO

99. PREFER NOT TO ANSWER

INSERT FOOTER <center> These questions may be difficult to answer. Please click here for a list of mental health and suicide prevention resources. </center>

Link behind “here”: 8644 CDC DASH NAHS Parent CAWI Help Button.pdf

[SHOW IF Q11=1]

[SP]

Q12.

Are you <u>currently</u> receiving treatment for a mental health disorder, including medication and/or seeing a mental health professional or therapist?

CAWI:

1. Yes

2. No

99. Prefer not to answer

CATI:

1. YES

2. NO

99. PREFER NOT TO ANSWER

INSERT FOOTER <center> These questions may be difficult to answer. Please click here for a list of mental health and suicide prevention resources. </center>

Link behind “here”: 8644 CDC DASH NAHS Parent CAWI Help Button.pdf

[SP]

Q13.

Now we'll ask some questions about <u>[DOV_CHILDNAME]</u>’s mental health.

During the past <u>12 months,</u> how often has [DOV_CHILDNAME]’s mental health interfered with their ability to do things other young people their age do?

1. Always

2. Most of the time

3. Sometimes

4. Rarely

5. Never

INSERT FOOTER <center> These questions may be difficult to answer. Please click here for a list of mental health and suicide prevention resources. </center>

Link behind “here”: 8644 CDC DASH NAHS Parent CAWI Help Button.pdf

[GRID, SP; 5, 4]

Q14.

To the best of your knowledge, how often do you think [DOV_CHILDNAME] has been bothered by each of the following symptoms during the past <u>2 weeks?</u>

	Nearly every day	More than half the days	A few days	Not at all	Don't know
Feeling down, depressed, irritable or hopeless
Little interest or pleasure in doing things
Trouble falling asleep, staying asleep, or sleeping too much
Poor appetite, weight loss, or over-eating
Feeling tired, or having little energy
Feeling bad about themselves - feeling like a failure, or that they had let themselves or the family down
Trouble concentrating on things like school work, reading, or watching TV
Moving or speaking so slowly that other people could have noticed. Or the opposite-- being so fidgety or restless that they were moving around a lot more than usual
Thoughts that they would be better off dead, or of hurting themselves in some way

INSERT FOOTER <center> These questions may be difficult to answer. Please click here for a list of mental health and suicide prevention resources. </center>

Link behind “here”: 8644 CDC DASH NAHS Parent CAWI Help Button.pdf

[DISPLAY – SECTB_1]

Sometimes people feel so depressed about the future that they may consider attempting suicide, that is, taking some action to end their own life. The next questions ask about [DOV_CHILDNAME]’s sad feelings and attempted suicide.

INSERT FOOTER <center> These questions may be difficult to answer. Please click here for a list of mental health and suicide prevention resources. </center>

Link behind “here”: 8644 CDC DASH NAHS Parent CAWI Help Button.pdf

[SP]

Q15.

During the past <u>12 months,</u> did [DOV_CHILDNAME] ever feel so sad or hopeless that [DOV_CHILDNAME] stopped doing some usual activities?

CAWI:

1. Yes

2. No

77. Don’t know

CATI:

1. YES

2. NO

77. DON’T KNOW

INSERT FOOTER <center> These questions may be difficult to answer. Please click here for a list of mental health and suicide prevention resources. </center>

Link behind “here”: 8644 CDC DASH NAHS Parent CAWI Help Button.pdf

[SP]

Q16.

To your knowledge, during the past <u>12 months,</u> did [DOV_CHILDNAME] ever <u>seriously</u> consider attempting suicide?

CAWI:

1. Yes

2. No

77. Don’t know

CATI:

1. YES

2. NO

77. DON’T KNOW

INSERT FOOTER <center> These questions may be difficult to answer. Please click here for a list of mental health and suicide prevention resources. </center>

Link behind “here”: 8644 CDC DASH NAHS Parent CAWI Help Button.pdf

Section C. Adverse Childhood Events

[GRID, SP; 4, 3, 4, 4, 4] [do not show numeric labels]

[IF DOV_CHILDNAME starts the grid item label and S3=77,98,99, PIPE-IN "Your child" INSTEAD OF "your child"]

Q18.

Many young people experience stressful life events that can affect their health and development. Please read the statements below and mark all that [DOV_CHILDNAME] has experienced at any point since [DOV_CHILDNAME] was born.

	[CAWI: Yes; CATI: YES]	[CAWI: No; CATI: NO]
Their parents or primary caregivers were separated or divorced	1	2
[DOV_CHILDNAME] lived in a household with a member who served time in jail or prison
[DOV_CHILDNAME] lived with a household member who was depressed, mentally ill or attempted suicide
[DOV_CHILDNAME] saw or heard household members hurt or threaten to hurt each other
A household member swore at, insulted, humiliated, or put down [DOV_CHILDNAME] in a way that scared them OR a household member acted in a way that made [DOV_CHILDNAME] afraid that they might be physically hurt
Someone touched [DOV_CHILDNAME]’s private parts or asked them to touch their private parts in a sexual way that was unwanted, against their will, or made them feel uncomfortable
More than once, [DOV_CHILDNAME] went without food, clothing, a place to live, or had no one to protect them
Someone pushed, grabbed, slapped or threw something at [DOV_CHILDNAME] OR hit them so hard that they were injured or had marks
[DOV_CHILDNAME] lived with someone who had a problem with drinking or using drugs
[DOV_CHILDNAME] often felt unsupported, unloved and/or unprotected
[DOV_CHILDNAME] has been in foster care
[DOV_CHILDNAME] experienced harassment or bullying at school
[DOV_CHILDNAME] lived with a parent or primary caregiver who died
[DOV_CHILDNAME] has been separated from their primary caregiver through deportation or immigration
[DOV_CHILDNAME] had a serious medical procedure or life-threatening illness
[DOV_CHILDNAME] has often seen or heard violence in the neighborhood or in their school neighborhood
[DOV_CHILDNAME] has been detained, arrested or incarcerated
[DOV_CHILDNAME] has often been treated badly because of race, ethnicity, gender, sexual orientation, place of birth, disability or religion
[DOV_CHILDNAME] has experienced verbal or physical abuse or threats from a romantic partner (i.e. boyfriend or girlfriend)

INSERT FOOTER <center> These questions may be difficult to answer. Please click here for a list of mental health and suicide prevention resources. </center>

Link behind “here”: 8644 CDC DASH NAHS Parent CAWI Help Button.pdf

Section E. Health Services

[GRID, SP]

[CAWI: IF S3=77,98,99, PIPE-IN "my child" INSTEAD OF "your child"

CATI: IF S3=77,98,99, PIPE-IN "your child"]

Q28.

The following questions are about <u>mental health services at schools</u>. This refers to healthcare services provided by a licensed provider that may include classroom education and individual and group counseling. How much do you agree or disagree with the following statements?

	Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
Having mental health services available at [DOV_CHILDNAME]'s school is important.
Schools are a good place to provide mental health services to young people.
[SHOW IF Q1=1] [CAWI: I; CATI: You] would be comfortable with [DOV_CHILDNAME] using mental health services at their school.
[SHOW IF Q1=1] [CAWI: I; CATI: You] would encourage [DOV_CHILDNAME] to use mental health services at school if they needed such care.

[GRID, SP]

[CAWI: IF S3=77,98,99, PIPE-IN "my child" INSTEAD OF "your child"

CATI: IF S3=77,98,99, PIPE-IN "your child"]

Q29.

The following questions are about <u>sexual and reproductive health services at schools</u>. This refers to healthcare services provided by a licensed provider that may include education, screening for sexually transmitted infections and counseling, and provision of methods of birth control. How much do you agree or disagree with the following statements?

	Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
Having sexual and reproductive health services available at [DOV_CHILDNAME]'s school is important.
Schools are a good place to provide sexual and reproductive health services to young people.
[CAWI: I; CATI: You] would be comfortable with [DOV_CHILDNAME] using sexual and reproductive health services at their school.
[CAWI: I; CATI: You] would encourage [DOV_CHILDNAME] to use sexual and reproductive health services at school if they needed such care.

[DISPLAY – SECTE_1]

Now we'd like to ask about [DOV_CHILDNAME]'s experiences with healthcare providers.

[SP]

Q30.

Is [DOV_CHILDNAME] currently covered by any kind of health insurance or health plan?

CAWI RESPONSE OPTIONS:

1. Yes

2. No

CATI RESPONSE OPTIONS:

1. YES

2. NO

[SHOW IF Q30=1]

[SP]

Q30A.

What kind of health insurance does [DOV_CHILDNAME] currently have?

RESPONSE OPTIONS:

1. Public insurance (such as Medicaid, CHIP)

2. Private insurance

77. [CAWI:I; CATI: You] don’t know

[SP]

Q31.

Where does [DOV_CHILDNAME] usually go for healthcare? Mark the one best option.

1. Doctor’s office or clinic

2. School-based health center

3. School nurse’s office

4. Emergency room

5. Health department

6. Community health center

7. Family planning center (e.g., Planned Parenthood)

8. Urgent care or walk-in clinic (e.g., Minute Clinic, CVS, Walgreens)

9. Other, please specify: __[SMALL TEXTBOX]____

10. No usual place

11. [CAWI: I’m; CATI: You’re] not sure

[SP]

Q32.

How long has [DOV_CHILDNAME] been seeing their primary or regular provider? By regular provider, we mean a pediatrician or general or family physician, physician’s assistant, or nurse practitioner [DOV_CHILDNAME] sees for general, routine healthcare.

1. 1 year or less

2. More than 1 year but less than 2 years

3. More than 2 years but less than 5 years

4. More than 5 years

5. [DOV_CHILDNAME] doesn't have a regular provider

77. Don’t know

[SP]

Q33.

The next question asks about [DOV_CHILDNAME]’s last preventive care visit. Preventive visits are visits to a doctor or other healthcare provider for a routine exam or checkup. This does not include times someone goes to a healthcare provider because they are sick or injured.

When was the last time [DOV_CHILDNAME] had a preventive care visit, such as a physical or checkup?

1. 1 year or less

2. More than 1 year but less than 2 years

3. Between 2 years and 5 years

4. More than 5 years

5. Never

77. Don't know

[SHOW IF Q33=1,2,3,4]

[SHOW IF Q33=1,2,3]
nendant.
tex question.
een[GRID, SP; 4, 4, 4, 4]

Q34.

Did you and [DOV_CHILDNAME] talk about the following topics as a result of their last preventive visit?

	[CAWI: Yes; CATI: YES]	[CAWI: No; CATI: NO]	[CAWI: I; CATI: You] don’t remember
	1	2	77
A. Mental health and emotional issues (such as stress, anxiety, and depression)
B. Substance use (such as alcohol, tobacco, vaping, marijuana or other drugs)
C. Gender identity (how [DOV_CHILDNAME] sees their own gender)
D. Whether [DOV_CHILDNAME] has had sex
E. Consent for sex
F. How to say no to sex
G. Sexual orientation (for example, being attracted to boys or girls)
H. Sexuality and sexual health
I. How to prevent sexually transmitted infections (STIs), including HIV
J. Methods of birth control
K. How to get sexual and reproductive health services (such as getting birth control or testing for sexually transmitted infections (STIs), including HIV)
L. Where to get mental health care
M. The importance of communication with parents
N. Use of technology/screen time/media use
O. Getting a healthy amount of sleep
P. Developing teen strengths (qualities that help teens become healthy, contributing adults)

[GRID, SP; 4, 4, 4, 4]

Q35.

During a preventive visit, how important do you think it is that a provider talks with [DOV_CHILDNAME] about the following topics?

	Very important	Moderately important	A little important	Not at all important
Mental health and emotional issues (such as stress, anxiety, and depression)
Substance use (such as alcohol, tobacco, vaping, marijuana or other drugs)
Gender identity (how [DOV_CHILDNAME] sees their own gender)
Whether [DOV_CHILDNAME] has had sex
Consent for sex
How to say no to sex
Sexual orientation (for example, being attracted to boys or girls)
Sexuality and sexual health
How to prevent sexually transmitted infections (STIs), including HIV
Methods of birth control
How to get sexual and reproductive health services (such as getting birth control or testing for sexually transmitted infections (STIs), including HIV)
Where to get mental health care
The importance of communication with parents
Use of technology/screen time/media use
Getting a healthy amount of sleep
Developing teen strengths (qualities that help teens become healthy, contributing adults)

[GRID, SP; 4, 4, 4,4]

Q36.

The next questions ask about [DOV_CHILDNAME]’s time alone with a healthcare provider (such as a doctor or a nurse practitioner), without a parent or caregiver in the room. This could include a time when you stepped out of the room during [DOV_CHILDNAME]’s appointment so that they could talk with their provider privately or a time when [DOV_CHILDNAME] had a healthcare visit on their own.

[SPACE]

How comfortable or uncomfortable would you be with [DOV_CHILDNAME] discussing the following topics with their regular healthcare provider <u>without you in the room</u>?

	Very comfortable	Somewhat comfortable	Neither comfortable nor uncomfortable	Somewhat uncomfortable	Very uncomfortable
Mental health and emotional issues (such as stress, anxiety, and depression)
Substance use (such as alcohol, tobacco, vaping, marijuana or other drugs)
Gender identity (whether someone’s sex at birth matches the way they think or feel about their gender)
Whether [DOV_CHILDNAME] has had sex
Consent for sex
How to say no to sex
Sexual orientation (for example, being attracted to boys or girls)
Sexuality and sexual health
How to prevent sexually transmitted infections (STIs), including HIV
Methods of birth control
How to get sexual and reproductive health services (such as getting birth control or testing for sexually transmitted infections (STIs), including HIV)
Where to get mental health care
The importance of communication with parents
Use of technology/screen time/media use
Getting a healthy amount of sleep
Developing teen strengths (qualities that help teens become healthy, contributing adults)

[SP]

Q37.

Has a doctor or healthcare provider ever spent any time alone with [DOV_CHILDNAME] without a parent or caregiver in the room?

CAWI:

1. Yes

2. No

77. Don’t know

CATI:

1. YES

2. NO

77. DON’T KNOW

[SHOW IF Q37=1 and (Q33=1-4)]

[SP]

Q37A.

The last time [DOV_CHILDNAME] had a preventive care visit, did a doctor or other health provider spend any time alone with [DOV_CHILDNAME] without a parent or caregiver in the exam room?

CAWI:

1. Yes

2. No

77. Don’t know

CATI:

1. YES

2. NO

77. DON’T KNOW

[SHOW IF Q37=1 or Q37A=1]

[SP]

Q37B.

Did you talk with [DOV_CHILDNAME] about what they discussed with their healthcare provider during their most recent time alone with a healthcare provider?

CAWI:

1. Yes

2. No

77. Don’t know

CATI:

1. YES

2. NO

77. DON’T KNOW

[NUMBOX 0-18]

Q40.

At what age do you think someone should start having time alone with a provider?

CATI: PLEASE ENTER A NUMBER BETWEEN 0 AND 18

[numbox 0-18] years old

[SHOW IF Q37=2, 77, 98, 99]

[SP]

Q38.

How comfortable or uncomfortable would you be with [DOV_CHILDNAME] having time alone with a provider?

1. Very comfortable

2. Somewhat comfortable

3. Neither comfortable nor uncomfortable

4. Somewhat uncomfortable

5. Very uncomfortable

[SHOW IF Q38=4, 5]

[MP]

Q39.

What would make you feel more comfortable with [DOV_CHILDNAME] having time alone with a provider?

[CAWI - REMOVE BOLD] <i> Please select all that apply. </i>

[CATI] SELECT ALL THAT APPLY

1. Knowing ahead of time that [DOV_CHILDNAME] would have time alone with a provider

2. Preparing questions for the provider ahead of time

3. Knowing that [DOV_CHILDNAME] knows enough about their health history to talk with the provider

4. Having another staff person (e.g., a nurse, medical assistant) in the exam room too

5. Knowing the types of things the provider will talk about with [DOV_CHILDNAME]

6. Knowing that [DOV_CHILDNAME] is comfortable having time alone with a provider

7. Knowing other parents who are comfortable with their teen(s) having time alone with a provider

8. Other, please specify: __[SMALL TEXTBOX]____

9. None of the above [SP]

[GRID, SP; 3, 3]

[CAWI:

IF S3=77,98,99 and DOV_CHILDNAME does NOT start the grid item label, PIPE-IN "my child" INSTEAD OF "your child";

IF S3=77,98,99 and DOV_CHILDNAME starts the grid item label, PIPE-IN "My child" INSTEAD OF "your child"

CATI:

IF S3=77,98,99 and DOV_CHILDNAME does NOT start the grid item label, PIPE-IN "your child"

IF S3=77,98,99 and DOV_CHILDNAME starts the grid item label, PIPE-IN "Your child"]

Q41.

Please rate your level of agreement with the following statements about when [DOV_CHILDNAME] sees their healthcare provider.

	Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
[DOV_CHILDNAME] would prefer that [CAWI: I’m; CATI: you’re] in the room for the entire visit.
[CAWI: I; CATI: You] prefer that [CAWI: I’m; CATI: you’re] in the room with [DOV_CHILDNAME] for the entire visit.
If [CAWI: I; CATI: you] were present, it might change what [DOV_CHILDNAME] talked with their provider about.
Having time alone with their provider would help [DOV_CHILDNAME] feel in charge of their health.
It's the responsibility of a good parent to support their child having time alone with their provider.
Time alone would help [DOV_CHILDNAME] develop a better relationship with their provider.

[GRID; SP]

Q43.

Has [DOV_CHILDNAME]'s healthcare provider ever talked to you about the following?

	[CAWI: Yes; CATI: YES]	[CAWI: No; CATI: NO]
The importance of [DOV_CHILDNAME] having time alone with the provider during a clinic visit
State laws about teen's rights to get services without your knowledge
Clinic or provider policies about confidentiality

[GRID, SP]

[CAWI: IF S3=77,98,99, PIPE-IN "my child" INSTEAD OF "your child"

CATI: IF S3=77,98,99, PIPE-IN "your child"]

Q44.

Thinking about [DOV_CHILDNAME]’s regular provider, how much do you agree or disagree with the following statements? By regular provider, we mean a pediatrician or general or family physician, physician’s assistant, or nurse practitioner they see for general, routine healthcare.

	Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
[CAWI: I; CATI: You] get the information [CAWI: I; CATI: you] need about [DOV_CHILDNAME]’s health from their healthcare provider
[DOV_CHILDNAME]’s healthcare provider spends enough time with them
[CAWI: I; CATI: You] receive information and resources from [DOV_CHILDNAME]’s healthcare provider that helps [CAWI: me; CATI: you] know how best to support [DOV_CHILDNAME]’s health
[CAWI: I; CATI: You] trust the information [DOV_CHILDNAME]’s healthcare provider gives [CAWI: me; CATI: you] about [DOV_CHILDNAME]’s health
[CAWI: I; CATI: You] trust the treatment, (e.g., vaccines, medicine) [DOV_CHILDNAME]’s healthcare provider recommends for [DOV_CHILDNAME].
[DOV_CHILDNAME]’s healthcare provider treats them in a supportive and caring manner
[DOV_CHILDNAME]’s healthcare provider helps [CAWI: me; CATI: you] feel like a partner in [DOV_CHILDNAME]’s care

[GRID, SP; 3, 4]

Q45.

The following is a list of ways that [DOV_CHILDNAME]’s regular provider could offer you information and resources to support [DOV_CHILDNAME]’s health. How likely or unlikely are you to access the information if provided in each of the following ways?

	Very likely	Moderately likely	Neither likely nor unlikely	Moderately unlikely	Very unlikely
Through an emailed link to an online tool that gives you recommended information and other resources based on your interests
Through a tablet computer (e.g., iPad) you receive in the waiting room to view videos and information while your teen sees their provider
Through a printed handout
Through a one-on-one in-person conversation with a doctor, nurse, or other clinic staff
Through a phone/video conversation with a clinic staff person
Through an online class or workshop
Through an emailed link to an online tool that gives you recommended information and other resources based on your interests

[SP]

Q46.

Do you have access to [DOV_CHILDNAME]'s medical record? This may include online access such as through an electronic health portal.

CAWI:

1. Yes

2. No

77. Don’t know

CATI:

1. YES

2. NO

77. DON’T KNOW

[SP]

Q46A.

Have you ever learned about [DOV_CHILDNAME] receiving sexual and reproductive health care from a bill or insurance explanation of benefits?

CAWI:

1. Yes

2. No

77. Don’t know

CATI:

1. YES

2. NO

77. DON’T KNOW

[SP]

Q47.

During the past <u>12 months,</u> has [DOV_CHILDNAME] received any treatment or counseling from a mental health professional? Mental health professionals include psychiatrists, psychologists, psychiatric nurses, and clinical social workers.

1. Yes

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

3. No, this child did not need to see a mental health professional

77. Don't know

[SHOW IF Q47=1,2, 77, 98, 99]

[SP]

Q48.

During the past <u>12 months,</u> have you seen or talked to a mental health professional about [DOV_CHILDNAME]'s mental health?

CAWI:

1. Yes

2. No

77. Don't know

99. Prefer not to answer

CATI:

1. YES

2. NO

77. DON’T KNOW

99. PREFER NOT TO ANSWER

[SP]

Q49.

During the past <u>12 months,</u> have you seen or talked to anyone such as a teacher, principal, pastor, or coach about [DOV_CHILDNAME]'s mental health?

CAWI:

1. Yes

2. No

77. Don't know

99. Prefer not to answer

CATI:

1. YES

2. NO

77. DON’T KNOW

99. PREFER NOT TO ANSWER

[SHOW IF Q47=1,2]

[SP]

Q50.

How difficult was it to get the mental health treatment or counseling that [DOV_CHILDNAME] needed?

1. Not difficult

2. Somewhat difficult

3. Very difficult

Section F. Sexual Health

[SP]

Q52.

The next questions ask about [DOV_CHILDNAME]'s sexual activity and sexual health.

To your knowledge, has [DOV_CHILDNAME] ever had sex? By sex we mean vaginal or anal sex.

CAWI:

1. Yes

2. No

77. Don’t know

CATI:

1. YES

2. NO

77. DON’T KNOW

[SHOW IF Q52=1]

[NUMBOX]

[if QTAGE=77,98,99: NUMBOX range 0-17]

Q53.

How old do you think [DOV_CHILDNAME] was when they had vaginal or anal sex for the first time?

CATI: PLEASE ENTER A NUMBER BETWEEN 0 AND YOUR CHILD’S AGE

[numbox 0-QTAGE]

[SHOW IF Q52=1]

[MP]

Q53A.

What does [DOV_CHILDNAME] or [DOV_CHILDNAME]'s partner(s) use <u>to prevent sexually transmitted infections (STIs), including HIV when they have sex </u>?

[CAWI - REMOVE BOLD] <i> Please select all that apply. </i>

[CATI] SELECT ALL THAT APPLY

1. No method to prevent STIs, including HIV [SP]

2. Condom or other barrier methods (e.g., dental dams)

3. HIV pre-exposure prophylaxis (PrEP)

4. Routine STI/HIV testing

5. Mutual monogamy (two partners agreeing to be sexually active with only each other)

6. Some other method

77. [CAWI: I’m; CATI: You’re] not sure [SP]

[SHOW IF Q52=1]

[SP]

Q54.

When [DOV_CHILDNAME] has sex, to the best of your knowledge, does [DOV_CHILDNAME] or [DOV_CHILDNAME]’s partner use any methods to prevent pregnancy?

CAWI:

1. Yes

2. No

77. Don’t know

CATI:

1. YES

2. NO

77. DON’T KNOW

[SHOW IF Q54=1]

[MP]

Q55.

Which method(s) does [DOV_CHILDNAME] or [DOV_CHILDNAME]'s partner use to prevent pregnancy?

[CAWI - REMOVE BOLD] <i> Please select all that apply. </i>

[CATI] SELECT ALL THAT APPLY

1. Birth control pills

2. Condoms

3. An IUD (such as Mirena or ParaGard)

4. An implant (such as Nexplanon)

5. A shot (such as Depo-Provera)

6. A patch (such as Ortho Evra)

7. A birth control ring (such as NuvaRing)

8. Withdrawal (pull-out)

9. Emergency contraception (such as Plan B)

10. Some other method

77. Don't know [SP]

[SP]

Q57.

Have you ever helped [DOV_CHILDNAME] obtain condoms?

CAWI:

1. Yes

2. No

CATI:

1. YES

2. NO

[SHOW IF QTGEN1=2]

[SP]

Q56.

Have you ever helped [DOV_CHILDNAME] obtain a birth control method other than condoms?

CAWI:

1. Yes

2. No

CATI:

1. YES

2. NO

[SP]

Q58.

Have you ever helped [DOV_CHILDNAME] obtain a test for STIs, including HIV?

CAWI:

1. Yes

2. No

CATI:

1. YES

2. NO

[SHOW IF QTGEN1=2]

[GRID,SP]

[CAWI: IF S3=77,98,99, PIPE-IN "my child" INSTEAD OF "your child"

CATI: IF S3=77,98,99, PIPE-IN "your child"]

Q60.

How much do you agree or disagree with the following statements?

	Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree	Don't know
[CAWI: I; CATI: You] would be comfortable with [DOV_CHILDNAME] using oral contraceptives (birth control pills).
[CAWI: I; CATI: You] would be comfortable with [DOV_CHILDNAME] using an intrauterine device or IUD (such as Mirena or ParaGard).
[CAWI: I; CATI: You] would be comfortable with [DOV_CHILDNAME] using an implant (such as Nexplanon).

[GRID, SP]

Q59.

How much do you agree or disagree with the following statements?

	Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree	Don't know
It is safe for a teenager to use oral contraceptives (birth control pills).
It is safe for a teenager to use an intrauterine device or IUD (such as Mirena or ParaGard).
It is safe for a teenager to use an implant (such as Nexplanon).

[MP]

Q60_B.

Do you think [DOV_CHILDNAME] has ever done or experienced the following?

[CAWI - REMOVE BOLD] <i> Please select all that apply. </i>

[CATI] SELECT ALL THAT APPLY

1. Felt pressured to share a sexual photo of themselves with someone 

2. Shared a sexual photo of themselves with someone (through text message, email, IM)

3. Received a sexual photo of someone else 

4. Shared a sexual photo of someone without their permission  

5. Had someone else share a sexual photo of [DOV_CHILDNAME] without [DOV_CHILDNAME]'s permission 

6. None of these [SP]

Section G. Substance Use

[GRID, SP]

Q61.

The last questions are about substance use behaviors. Do you think [DOV_CHILDNAME] has ever done the following?

	[CAWI: Yes; CATI: YES]	[CAWI: No; CATI: NO]
Used electronic vapor products, such as JUUL, SMOK, Suorin, Vuse, and blu. Electronic vapor products include e-cigarettes, vapes, vape pens, e-cigars, e-hookahs, hookah pens, and mods.
[SHOW IF QTGEN1=1,2] Had [IF QTGEN1=2: 4 / IF QTGEN1=1: 5] or more drinks of alcohol in a row, that is, within a couple of hours.
Used marijuana. Marijuana also is called pot or weed. For this question, do not include CBD-only or hemp products, which come from the same plant as marijuana, but do not cause a high when used alone.
Taken prescription pain medicine without a doctor's prescription or differently than how a doctor told them to use it. (Count drugs such as codeine, Vicodin, OxyContin, Hydrocodone, and Percocet.)

RE-COMPUTE QUAL=1 “COMPLETE”

SET CO_DATE, CO_TIME, CO_TIMER VALUES HERE

CREATE MODE_END

1=CATI

2=CAWI

SCRIPTING NOTES: PUT QFINAL1, QFINAL2, QFINAL3 in the same screen.

[SINGLE CHOICE]

QFINAL1.

Thank you for your time today. To help us improve the experience of AmeriSpeak members like yourself, please give us feedback on this survey.

[RED TEXT – CAWI ONLY] If you do not have any feedback for us today, please click “Continue” through to the end of the survey so we can make sure your opinions are counted and for you to receive your AmeriPoints reward.

Please rate this survey overall from 1 to 7 where 1 is Poor and 7 is Excellent.

Poor						Excellent
1	2	3	4	5	6	7

[SINGLE CHOICE – CAWI ONLY]

QFINAL2.

Did you experience any technical issues in completing this survey?

1. Yes – please tell us more in the next question

2. No

[TEXT BOX] [CATI version needs “no” option]

QFINAL3.

Do you have any general comments or feedback on this survey you would like to share? If you would like a response from us, please email [email protected] or call (888) 326-9424.

[DISPLAY]

END.

[CATI version]

Those are all the questions we have. We will add [INCENTWCOMMA] AmeriPoints to your AmeriPoints balance for completing the survey. If you have any questions at all for us, you can email us at [email protected] or call us toll-free at 888-326-9424. Let me repeat that again: email us at [email protected] or call us at 888-326-9424. Thank you for participating in our new AmeriSpeak survey! 

[CAWI version]

Those are all the questions we have. We will add [INCENTWCOMMA] AmeriPoints to your AmeriPoints balance for completing the survey. If you have any questions at all for us, you can email us at [email protected] or call us toll-free at 888-326-9424. Thank you for participating in our new AmeriSpeak survey! 

You can close your browser window now if you wish or click Continue below to be redirected to the AmeriSpeak member website.

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