Download:
pdf |
pdfForm Approved
OMB No. 0920-xxxx
Exp. Date: xx/xx/xxxx
Attachments 2f-2g-2h: First Follow-up Core Survey for SEED 1-3 Caregivers
Public reporting burden of this collection of information is estimated to average 40 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 currently 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
Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333: ATTN: PRA (0920-xxxx).
SEED Follow-Up Health and Development Core Survey
Contents
A. General Health .................................................................................................................................................................... 2
Height and Weight .............................................................................................................................................................. 2
Dental Health ...................................................................................................................................................................... 3
Sleep Health ........................................................................................................................................................................ 3
Gastrointestinal Health ....................................................................................................................................................... 4
Diagnosed Conditions ......................................................................................................................................................... 5
Medical Conditions ......................................................................................................................................................... 5
Behavioral, Developmental, or Mental Health Conditions ............................................................................................. 7
Food Allergies and Dietary Restrictions .............................................................................................................................. 8
Communication Abilities ..................................................................................................................................................... 9
Level of Support Needed .................................................................................................................................................. 10
B. Service Needs and Utilization ........................................................................................................................................... 11
Health Services .................................................................................................................................................................. 11
Experience with Child’s Health Care Providers ............................................................................................................. 13
Education Services ............................................................................................................................................................ 15
Developmental Services .................................................................................................................................................... 16
Medications ...................................................................................................................................................................... 20
Complementary and Alternative Treatments ................................................................................................................... 21
C. Community and Social Participation ................................................................................................................................. 23
D. Bullying and Discrimination .............................................................................................................................................. 25
E. Child Safety........................................................................................................................................................................ 27
F. You and Your Family .......................................................................................................................................................... 29
Your Health ....................................................................................................................................................................... 30
G. Household Information .................................................................................................................................................... 34
H. Individual Strengths .......................................................................................................................................................... 36
1
A. General Health
1. In general, how would you describe this child’s health?
Excellent
Very Good
Good
Fair
Poor
Height and Weight
2. How tall is this child now (without shoes)?
Please use a tape measure to measure the height. Have this child back up to a wall with the back of the
head, shoulder blades, buttocks, and heels touching the wall. Lay a hard-backed book or other flat item
from this child’s head to the wall and level with the floor. Mark the wall under the book and then measure
from the floor to the mark. Please tell us the height to the nearest quarter inch.
If your child does not agree to be measured, please record the most recent height measure you recall,
such as from a past doctor visit.
______inches (measured with tape measure for this study)
OR
______inches (recalled height from past measurement, such as doctor visit)
OR
______I don’t know
3. How much does this child weigh now (without shoes)? Please weigh this child on a scale if possible. If your
child does not agree to be weighed; please record the most recent weight you recall.
_____ pounds (weighed on scale at home)
OR
_____ pounds (recalled weight from past measurement, such as doctor visit)
OR
_____ I don’t know
2
Dental Health
4. DURING THE PAST 12 MONTHS, has this child had FREQUENT or CHRONIC difficulty with any of the
following? Please provide a response for each item listed below. If your child does not have any of the
conditions listed below, please select 'No'.
Don’t Know
Yes
No
Toothaches
Bleeding gums
Decayed teeth or cavities
Sleep Health
5. The next set of questions will ask you about your child’s typical sleep schedule during the week and on
weekends.
SLEEP SCHEDULE ON WEEKDAYS
What is their typical bedtime on WEEKDAYS?
Bedtime: _____:______ ☐AM/☐PM
(Sunday night – Thursday night)
When do they usually wake up on WEEKDAYS?
Wake-up time: _____:______ ☐AM/☐PM
(Monday morning – Friday morning)
SLEEP SCHEDULE ON WEEKENDS
What is their typical bedtime on WEEKENDS?
Bedtime: _____:______ ☐AM/☐PM
(Friday night and Saturday night)
When do they usually wake up on WEEKENDS?
Wake-up time: _____:______ ☐AM/☐PM
(Saturday morning and Sunday mornings)
6. DURING A TYPICAL WEEK, does this child have FREQUENT or CHRONIC difficulty with any of the following?
Falling asleep at night
Staying asleep at night
Sleeping too much (day or night)
Waking up feeling well rested
Unintentionally falling asleep during the day
Snoring loudly during sleep
Stop breathing during sleep
Is restless and moves a lot during sleep
Wets the bed at night
3
Yes
No
Don’t Know
7. How confident do you feel in your ability to assess your child's sleep habits and/or sleep problems?
Not confident at all
Slightly confident
Fairly confident
Completely confident
Gastrointestinal Health
8. DURING THE PAST 12 MONTHS, has this child had FREQUENT or CHRONIC difficulty with any of the
following? Please provide a response for each item listed below. If your child does not have any of the
conditions listed below, please select 'No'.
9.
Yes
No
Abdominal pain
Don’t
Know
Constipation
Diarrhea
Gaseousness or bloating
Incontinence (loss of bladder control)
Soilage (accidental bowel movements)
Nausea or vomiting
Reflux
Swallowing
How confident do you feel in your ability to assess your child's gastrointestinal symptoms?
Not confident at all
Slightly confident
Fairly confident
Completely confident
4
Diagnosed Conditions
10. Next please tell us whether this child has any of the health conditions listed below.
Please answer question A for all conditions in the table below even if this child does not have any of the
conditions. Please answer questions B and C for only the conditions this child ever had.
Medical Conditions
Question A:
Has a doctor or other health care provider ever told you that
this child has any of the following medical or genetic
conditions?
Question B:
How old was this child
when you were first told
he or she had the
condition?
Question C:
Does this child currently
have the condition?
Food allergy
Skin allergy or eczema
Seasonal allergy or hay fever
____ Years
____ Years
____ Years
Yes No Don’t Know
Yes No Don’t Know
Yes No Don’t Know
Drug allergy, specify: ________
Other, specify: ________
____ Years
Yes No Don’t Know
Please provide a response for each condition listed below. If your child
does not have any of the conditions listed below, please select ‘No’.
Allergy
(Write in 0 if less than 1
year)
Yes No Don’t Know
(If yes, check all that apply)
Arthritis
Yes No Don’t Know
____ Years
Yes No Don’t Know
Asthma
Yes No Don’t Know
____ Years
Yes No Don’t Know
Brain injury, concussion,
or head injury
Yes No Don’t Know
____ Years
Yes No Don’t Know
Cancer
Yes No Don’t Know
____ Years
Yes No Don’t Know
Celiac disease
Yes No Don’t Know
____ Years
Yes No Don’t Know
Crohn’s disease
Yes No Don’t Know
____ Years
Yes No Don’t Know
Cystic fibrosis
Yes No Don’t Know
____ Years
Yes No Don’t Know
Diabetes (uses insulin)
Yes No Don’t Know
____ Years
Yes No Don’t Know
Yes No Don’t Know
____ Years
Yes No Don’t Know
Yes No Don’t Know
____ Years
Yes No Don’t Know
Fragile X Syndrome
Yes No Don’t Know
____ Years
Yes No Don’t Know
Frequent or severe
headaches, including
migraine
Yes No Don’t Know
____ Years
Yes No Don’t Know
Diabetes (does not use
insulin)
Epilepsy or seizure
disorder
5
Heart condition
Yes No Don’t Know
____ Years
Yes No Don’t Know
High cholesterol
Yes No Don’t Know
____ Years
Yes No Don’t Know
Hypertension or high
blood pressure
Yes No Don’t Know
____ Years
Yes No Don’t Know
Irritable bowel syndrome
Yes No Don’t Know
____ Years
Yes No Don’t Know
Yes No Don’t Know
____ Years
Yes No Don’t Know
Sickle cell
anemia/thalassemia/oth
er hereditary anemias
Sleep-Wake disorder
Yes No Don’t Know
(If yes, check all that apply)
____ Years
Yes No Don’t Know
Insomnia
Restless Leg Syndrome
Narcolepsy
____ Years
____ Years
____ Years
Yes No Don’t Know
Yes No Don’t Know
Other, specify: ________
____ Years
Sleep Apnea
Yes No Don’t Know
Yes No Don’t Know
Ulcerative colitis
Yes No Don’t Know
____ Years
Yes No Don’t Know
Other genetic or
inherited condition
Specify:_____________
Yes No Don’t Know
____ Years
Yes No Don’t Know
6
Behavioral, Developmental, or Mental Health Conditions
Question A:
Has a doctor or other health care provider ever told you that
this child has any of the following behavioral, developmental,
or mental health conditions?
Question B:
How old was this
child when you
were first told he or
she had the
Please provide a response for each condition listed below. If your child condition?
does not have any of the conditions listed below, please select ‘No’.
Attention-Deficit/Hyperactivity
disorder, combined or hyperactive or
inattentive type
(ADD or ADHD)
Anxiety disorder (This includes
Question C:
Does this child
currently have the
condition?
(Write in 0 if less than
1 year)
Yes No Don’t Know
____ Years
Yes No Don’t Know
Yes No Don’t Know
____ Years
Yes No Don’t Know
Autism, Asperger’s disorder, pervasive
developmental disorder, or autism
spectrum disorder
Yes No Don’t Know
____ Years
Yes No Don’t Know
Bipolar disorder
Yes No Don’t Know
____ Years
Yes No Don’t Know
Cerebral palsy
Yes No Don’t Know
____ Years
Yes No Don’t Know
Depressive disorder
Yes No Don’t Know
____ Years
Yes No Don’t Know
Developmental coordination
disorder, or motor delay
Yes No Don’t Know
____ Years
Yes No Don’t Know
Feeding or eating disorder
Yes No Don’t Know
____ Years
Yes No Don’t Know
Global developmental delay
Yes No Don’t Know
____ Years
Yes No Don’t Know
Intellectual disability
Yes No Don’t Know
____ Years
Yes No Don’t Know
Learning disability
Specify: _________________
Yes No Don’t Know
____ Years
Yes No Don’t Know
Obsessive-compulsive disorder
Yes No Don’t Know
____ Years
Yes No Don’t Know
Yes No Don’t Know
____ Years
Yes No Don’t Know
Yes No Don’t Know
____ Years
Yes No Don’t Know
things like self-hitting, scratching, skin
picking, or head banging)
Yes No Don’t Know
____ Years
Yes No Don’t Know
Sensory integration disorder
Yes No Don’t Know
____ Years
Yes No Don’t Know
generalized anxiety disorder, panic disorder,
specific phobia, agoraphobia, selective
mutism, or social anxiety disorder)
Oppositional defiant or conduct
disorder
Schizophrenia or other psychotic
disorder
Self-injurious behavior (This includes
7
Question A:
Has a doctor or other health care provider ever told you that
this child has any of the following behavioral, developmental,
or mental health conditions?
Please provide a response for each condition listed below. If your child
does not have any of the conditions listed below, please select ‘No’.
Speech or other language disorder
Yes No Don’t Know
Substance-related & addictive
disorders
Yes No Don’t Know
(If yes, check all that apply)
Question B:
How old was this
child when you were
first told he or she
had the condition?
Question C:
Does this child
currently have the
condition?
(Write in 0 if less than 1
year)
____ Years
Yes No Don’t Know
Tobacco
Alcohol
Opioids (e.g., OxyContin,
____ Years
____ Years
Yes No Don’t Know
Yes No Don’t Know
____ Years
Yes No Don’t Know
Other, specify: ________
____ Years
Yes No Don’t Know
Tourette syndrome
Yes No Don’t Know
____ Years
Yes No Don’t Know
Any other behavioral,
developmental, or mental health
disorder
Specify: ______________________
Yes No Don’t Know
____ Years
Yes No Don’t Know
Vicodin, Morphine, Fentanyl)
Food Allergies and Dietary Restrictions
11. Do you currently avoid any foods or food ingredients for this child because of a known or suspected food
allergy or intolerance?
Yes, diagnosed food allergy
Yes, suspected food allergy
Yes, confirmed or suspected food intolerance
No (Skip to question 13)
12. Which foods or food ingredients do you currently avoid for this child? (Check all that apply)
Cow's milk or other dairy products
Soy milk or other soy food
Eggs or egg products
Peanuts, peanut butter, or peanut oil
Other nuts (like almonds, pecans, walnuts)
Sesame seeds or sesame seed oil
Fish (like salmon, codfish, tuna)
Crustacean shellfish (like shrimp, crab, lobster)
Beef, pork, chicken, turkey, or another animal meat
Wheat, gluten, or wheat starch
Other grain or cereal (like oats, barley)
Fruit or fruit juice
Vegetables
Artificial colors or flavors
Sulfites
Other, specify________________________
None of these
8
Communication Abilities
13. Does this child use verbal communication, such as words or noises, to communicate with people?
Verbally communicates using words easily
Verbally communicates using words with a little trouble
Verbally communicates using words with a lot of trouble
Verbally communicates with noises
Does not verbally communicate
14. Does this child communicate with people using any of the following non-verbal methods of
communication?
Yes
No
Sign language
Lip reading
Simple hand movements
Facial gestures
Eye contact
Communication board
Other electronic device
(e.g., uses a tablet, laptop, or smartphone to communicate without talking)
9
Level of Support Needed
15. Children and adolescents have different levels of support needs. Overall, how much support does your
child need to manage these aspects of life?
No support
A little support
A lot of support
Understanding and communicating
Moving and getting around
Attending to hygiene, dressing, eating, and
staying alone
Interacting with other people
Domestic responsibilities, leisure, work,
and school
Joining in community activities,
participating in society
10
B. Service Needs and Utilization
Health Services
1. Is there a place that this child usually goes when he or she is sick, or you need advice about his or her
health?
Yes
No (Skip to question 3)
2. If yes, where does this child USUALLY go first? (Check one box only)
Doctor’s Office
Hospital Emergency Department
Hospital Outpatient Department
Clinic or Health Center
Retail Store or “minute clinic”
School (Nurse’s Office, Athletic Trainer’s Office, etc.)
Some other place, specify: _________
11
3. DURING THE PAST 12 MONTHS, did this child see a doctor, nurse, or other health care professional for
routine preventative care (such as well-child visits or check-ups) or sick-child care?
Yes
No (Skip to question 4)
Type of provider
Question A
Question B
Question C
Number of visits in past 12
months
If your child received routine
preventative care, how much of a
problem was it to get service from this
type of provider?
If your child received sick-child
care, how much of a problem was it
to get service from this type of
provider?
Not a problem
Not a problem
Small problem
Small problem
Big problem
Big problem
Did not receive this type of care in the
last 12 months
Did not receive this type of care in
the last 12 months
Not a problem
Not a problem
Small problem
Small problem
Big problem
Big problem
Did not receive this type of care in
the last 12 months
Did not receive this type of care in
the last 12 months
Not a problem
Not a problem
Small problem
Small problem
Big problem
Big problem
Did not receive this type of care in
the last 12 months
Did not receive this type of care in
the last 12 months
# of visits for routine
preventative care: _______
Not a problem
Not a problem
# of visits for
sick-child care:
Small problem
Small problem
Big problem
Big problem
Did not receive this type of care in
the last 12 months
Did not receive this type of care in
the last 12 months
# of visits for routine
preventative care: _______
Not a problem
Not a problem
# of visits for
sick-child care:
Small problem
Small problem
Big problem
Big problem
Did not receive this type of care in
the last 12 months
Did not receive this type of care in
the last 12 months
# of visits for routine
preventative care: _______
Not a problem
Not a problem
# of visits for
sick-child care:
Small problem
Small problem
Big problem
Big problem
Did not receive this type of care in
the last 12 months
Did not receive this type of care in
the last 12 months
Complete each blank.
(Write in 0 if no visits)
# of visits for routine
preventative care: _______
Dentist or oral health provider
# of visits for
sick-child care:
_______
# of visits for routine
preventative care: _______
Hearing care provider
# of visits for
sick-child care:
_______
# of visits for routine
preventative care: _______
Vision care provider
General Physician or Medical
care provider
Medical specialist care
provider, specify:
__________________
Psychologist, psychiatrist,
counselor, therapist, or mental
health care provider (circle
type)
# of visits for
sick-child care:
_______
_______
_______
_______
4. DURING THE PAST 12 MONTHS, how many times did this child visit a hospital emergency department?
No visits
12
1 visit
2 or more visits
5. DURING THE PAST 12 MONTHS, how many times was this child hospitalized for any reason?
No hospitalizations
1 visit
2 or more hospitalizations
6. DURING THE PAST 12 MONTHS, was there any time when this child needed healthcare, but it was not
received? By health care, we mean medical care as well as other kinds of care like dental care, vision care,
and mental health services.
Yes
No (Skip to question 9)
7. If yes, which types of care were NOT received? (Check all that apply)
Dental Care
Hearing Care
Medical care, routine preventative
Medical care, sick or urgent care
Medical care, hospital emergency
Medical care, specialist
Mental Health Services
Vision Care
Other, Specify _________
8. Which of the following contributed to this child not receiving needed healthcare services? “Yes” means it
was a factor in not receiving services and “no” means it was not a factor. (Check one in each row)
This child did not have health insurance that covered the services needed
This child was not eligible for the services
The services this child needed were not available in this child’s area
There were problems getting an appointment when this child needed one
There were problems with getting transportation or child care
The (clinic/doctor’s) office wasn’t open when this child needed care
There were issues related to cost
There were issues related to COVID-19 (e.g., concerned about being around
others at doctor’s office who may have been exposed to COVID-19)
The child’s behaviors limited ability to attend or complete a visit
Other (Specify:________________________)
Experience with Child’s Health Care Providers
13
Yes
No
9. Do you have one or more persons you think of as this child’s personal doctor or nurse? A personal doctor
or nurse is a health professional who knows this child well and is familiar with this child’s health history.
This can be a general doctor, a pediatrician, a specialist doctor, a nurse practitioner, or a physician’s
assistant.
Yes, one person
Yes, more than one person
No
10. Answer the following questions only if this child had a health care visit IN THE PAST 12 MONTHS.
Otherwise, Skip to question 17 in this section.
DURING THE PAST 12 MONTHS, how often did this child’s doctors or other health care providers:
Never
Sometimes
Usually
Always
Show sensitivity to your family’s values and
customs?
Provide the specific information you needed
concerning this child?
Help you feel like a partner in this child’s care?
Spend enough time with this child?
Listen carefully to you?
11. DURING THE PAST 12 MONTHS, were any decisions needed about this child’s health care services or
treatment, such as whether to start or stop a prescription or therapy services, get a referral to a specialist,
or have a medical procedure?
Yes
No (Skip to question 13)
12. DURING THE PAST 12 MONTHS, how often did this child’s doctors or other healthcare providers:
(Check one in each row)
Discuss with you the range of options to consider
for his or her health care or treatment?
Make it easy for you to raise concerns or disagree
with recommendations for this child’s health care?
Work with you to decide together which health
care and treatment choices would be best for this
child?
Never
Sometimes
Usually
Always
13. Does anyone help you arrange or coordinate this child’s care among the different doctors or services that
this child uses?
14
Yes
No
Did not see more than one health care provider in past 12 months (Skip to question 15)
14. DURING THE PAST 12 MONTHS, have you felt that you could have used extra help arranging or
coordinating this child’s care among the different health care providers or services?
Yes
No
15. DURING THE PAST 12 MONTHS, did this child’s health care provider communicate with this child’s school,
childcare provider, or special education program?
Yes
No (Skip to question 17)
Did not need health care provider to communicate with these providers (Skip to question 17)
16. If yes, overall, how satisfied are you with the health care provider’s communication with the school,
childcare provider, or special education program?
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
Health Insurance
17. Is your child currently covered by ANY kind of health insurance or health coverage plan?
Yes
No (Skip to question 20)
18. If yes, please tell us which types of health insurance plans CURRENTLY include coverage for your child.
Yes
No
a. Insurance through a current or former employer or union
☐
☐
b. Insurance purchased directly from an insurance company
☐
☐
c. Medicaid, Medical Assistance, or any kind of government-assistance plan
☐
☐
d. TRICARE or other military health care
☐
☐
e. Indian Health Service
☐
☐
☐
☐
f. Any other type of health insurance or health coverage plan, specify:
__________________
15
19. Thinking specifically about your child’s mental or behavioral health needs, how often does this child’s
health insurance offer benefits or cover services that meet these needs?
Always
Usually
Sometimes
Never
This child does not use mental or behavioral health services
Education Services
20. DURING THE PAST 12 MONTHS, has this child attended school?
Yes (Skip to question 22)
No
21. If no, is your child not in school now because they… (Check one then skip to question 28)
Graduated with regular high school diploma (e.g., the standard high school diploma awarded to
students after completing standard high school curriculum & exit exams)
Graduate with certificate of completion (e.g., certificate or alternative diploma awarded to high
school students in special education)
Took a test for a diploma without taking all of their high school classes (e.g., GED)
Dropped out or stopped going
Was suspended
Was expelled
Is older than the school age limit
Some other reason, specify: ______________________
Please skip to question 28
22. If yes, which of the following best describes the school this child currently attends (or most recently
attended)? If this child currently attends 2 schools, describe the school where he or she spends the most
time. If this child only attends a school that offers instruction on a specific topic rather than general
education check “other (specify).”
A regular public school that serves a wide variety of students
A regular private school that serves a wide variety of students
A school that serves only children with disabilities
A charter school or alternative school
An “online” school
Home instruction by a professional
Home schooling by a parent
16
A vocational/technical school (voc-tech)
2-year community college
4-year college or university
Medical or mental health facility, convalescent hospital, institution for people with disabilities,
correctional or juvenile justice facility
Other (Specify) _____________
23. Which of the following best describes this child’s classroom setting:
Regular classroom with a wide variety of students
o Typical classroom with classroom support (for example, pull out or in class; one-to-one
(1-to-1) aide; Collaborative Team Teaching (CTT) or Integrated Co-teaching (ICT) classroom)
o Typical classroom without support
Special education classroom for students with disabilities or special needs
Mix of regular and special education classrooms
Does not apply because this child is home-schooled or not attending school
24. What grade is this child currently in? (If summer, what is the highest grade level this child has already
completed)?
Pre-school
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
Some college, but less than 1 year
1 or more years of college, please indicate most recent year completed below
☐Freshman
☐ Sophomore ☐Junior
☐Senior
Does not apply, my child did not attend a typical public or private school
Don’t know
Other, specify: _____________________
25. DURING THE PAST 12 MONTHS, about how many days did this child miss school because of illness or
injury?
No missed school days
1-3 days
4-6 days
7-10 days
11 or more days
26. DURING THE PAST 12 MONTHS, how many times has this child’s school contacted you or another adult in
your household about any problems he or she is having with school?
No calls
1 time
17
2 or more times
27. DURING THE PAST 12 MONTHS, how many times has this child been suspended or expelled from school?
None
1 time
2 or more times
28. Since starting kindergarten, has this child repeated any grades?
Yes
No
29. Has this child ever changed schools or educational setting because his or her education needs were not
being met?
Yes
No
30. Have you ever been involved in mediation, a due process hearing, or litigation concerning the child’s
education services?
Yes
No
31. Has this child EVER received special education or early intervention services such as an Individualized
Education Plan (IEP), 504 plan, tutoring, classroom aide, reader/interpreter, communication device,
enrichment program, pull-out program, or accelerated curriculum?
Yes
No, my child has never had a plan or services for special education (Skip to question 34)
32. If yes, please indicate below which of the following plans or services your child has received
18
Question A:
Question B:
Question C:
Has your child ever received one of these plans or services?
If yes, at what age
in years did your
child first receive
the plan or
service?
Does the child
currently have
this plan or
received this
service IN THE
PAST 12
MONTHS?
Please provide a response for each plan or service listed below. If your
child did not receive a plan or service listed below, please select 'No'
Individualized Education Plan or IEP (used for
special education services in children 3 or older)
504 Plan (sometimes used for special education
services instead of or in addition to an IEP)
Gifted and talented services, such as enrichment,
pull-out program, or accelerated curriculum
Tutoring
Classroom aide
Reader/interpreter
Communication device or other electronic device
(e.g., tablet, laptop, smartphone) to assist with
classwork or to communicate without talking
Other plan or service, specify
__________________________________
Yes No Don’t Know
____Years
Yes No
Yes No Don’t Know
____Years
Yes No
Yes No Don’t Know
____Years
Yes No
Yes No Don’t Know
____Years
Yes No
Yes No Don’t Know
____Years
Yes No
Yes No Don’t Know
____Years
Yes No
Yes No Don’t Know
____Years
Yes No
Yes No Don’t Know
____Years
Yes No
33. Overall, how satisfied are you with the educational plans or services your child has received?
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
Developmental Services
19
34. Please tell us whether this child has ever used any of the developmental services or supports listed below.
These types of services might be received through the school, a healthcare provider, or some other person
or place such as an independent therapist.
Please answer question A for all services and supports in the table below, even if the child does not use the
service or support. Please answer questions B, C, and D for only services and supports the child ever
received.
If Question A is YES, please answer Questions B to D.
If yes, has this child received the service or
support DURING THE PAST 12 MONTHS?
Question A:
Has this child EVER received …
Question B:
Question C:
Question D:
If yes, at what age in
years did your child
first receive this
service?
Received THROUGH
SCHOOL DURING PAST
12 MONTHS?
Received OUTSIDE OF
SCHOOL DURING PAST
12 MONTHS?
Audiology or hearing services?
Yes No Don’t Know
____Years
Yes No Don’t Know
Yes No Don’t Know
Behavioral therapy, such as
applied behavior analysis?
Yes No Don’t Know
____Years
Yes No Don’t Know
Yes No Don’t Know
Occupational therapy or
sensory therapy?
Yes No Don’t Know
____Years
Yes No Don’t Know
Yes No Don’t Know
Physical therapy?
Yes No Don’t Know
____Years
Yes No Don’t Know
Yes No Don’t Know
Psychological or mental health
services or counseling?
Yes No Don’t Know
____Years
Yes No Don’t Know
Yes No Don’t Know
Social skills therapy or training?
Yes No Don’t Know
____Years
Yes No Don’t Know
Yes No Don’t Know
Speech or language therapy?
Yes No Don’t Know
____Years
Yes No Don’t Know
Yes No Don’t Know
Other services?
Specify:_______________
Yes No Don’t Know
____Years
Yes No Don’t Know
Yes No Don’t Know
35. Overall, how satisfied are you with the developmental services or supports your child has received?
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
My child did not receive any developmental services or supports
Medications
20
36. Please tell us whether this child has taken medication because of the difficulties noted below. The
medication can be prescription or over the counter.
Please answer question A for all conditions that may be treated with medication, even if the child does not
take medication. Please answer questions B and C for only those conditions that are treated with
medication.
Question A:
Question B:
Question C:
DURING THE PAST 12 MONTHS, has this child taken
any medication because of difficulties noted below at
least once per month for at least 3 months?
If yes to Question A, did
the child take a
medication prescribed by
a doctor or other
healthcare provider?
If yes to Question A, did the
child take an over-thecounter medication?
Aggression
Yes No Don’t Know
Yes No Don’t Know
Yes No Don’t Know
Anxiety
Yes No Don’t Know
Yes No Don’t Know
Yes No Don’t Know
Asthma
Yes No Don’t Know
Yes No Don’t Know
Yes No Don’t Know
Attention, concentration, or
hyperactivity
Yes No Don’t Know
Yes No Don’t Know
Yes No Don’t Know
Autism
Yes No Don’t Know
Yes No Don’t Know
Yes No Don’t Know
Depression
Yes No Don’t Know
Yes No Don’t Know
Yes No Don’t Know
Gastrointestinal problems
Yes No Don’t Know
Yes No Don’t Know
Yes No Don’t Know
Repetitive behaviors
Yes No Don’t Know
Yes No Don’t Know
Yes No Don’t Know
Restricted interests
Yes No Don’t Know
Yes No Don’t Know
Yes No Don’t Know
Obsessive Compulsive
Disorder
Yes No Don’t Know
Yes No Don’t Know
Yes No Don’t Know
Yes No Don’t Know
Yes No Don’t Know
Yes No Don’t Know
Yes No Don’t Know
Yes No Don’t Know
Yes No Don’t Know
Yes No Don’t Know
Yes No Don’t Know
Yes No Don’t Know
Seizures
Self-injurious behaviors
(This includes things like selfhitting, scratching, skin picking, or
head banging)
Sleep problems
Complementary and Alternative Treatments
37. DURING THE PAST 12 MONTHS, did your child use any type of complementary or alternative health care or
treatment to help improve or manage their behavior or development? This could be acupuncture, animal
21
therapy, art or music therapy, relaxation or mindfulness therapy, special diets or supplements, or other
alternative treatments.
Yes
No (Skip to Section C)
38. If yes, please select all below that apply. Where relevant, please include these regardless of how it was given
(e.g., pill, spray, cream, injection, etc.)
Acupuncture
Animal therapy
Arts therapy (includes music, art, dance, or drama/acting therapy)
Auditory integration
Chiropractic care
Wellness or Mindfulness (includes massage therapy, relaxation therapy, meditation, and yoga)
Vitamin or mineral supplements (includes supplements of any vitamin, folic acid, omega-3 FA
and fish oils, and multi-vitamin and/or multi-mineral)
CBD/cannabis (e.g., CBD oil, marijuana, hash, weed, THC edibles)
Melatonin
Oxytocin
Special diet such as gluten-free casein-free (GFCF), gluten-free only, casein-free only, Feingold
diet, ketogenic diet)
Other (specify): ________________
22
C. Community and Social Participation
1. DURING THE PAST 12 MONTHS, did this child participate in:
(Check one in each row)
Yes
No
Any sports team or sports lessons after school or on weekends?
Any clubs or organizations after school or on weekends?
Any other organized activities or lessons, such as music, dance, language, or other
arts after school or on weekends?
Any type of community service or volunteer work at school, church, or in the
community?
Any work, including regular jobs as well as babysitting, cutting grass, or other
occasional work?
2. DURING THE PAST 2 WEEKS, did this child:
Yes
No
Get together socially with friends or neighbors?
Talk with friends or neighbors on the telephone, video conferencing system, or social
media APP (e.g., SnapChat, Facebook, etc.)?
Get together with ANY relatives not including those who live with you?
Go to church, temple, or another place of worship for services or other activities?
Go to a show or movie, sports events, club meeting, after school class or other group
event?
Go out to eat at a restaurant?
3. DURING THE PAST WEEK, on how many days was this child physically active for at least 60 minutes per
day? Add all the time that he or she spent in any kind of physical activity that increased his or her heart
rate and made him or her breathe hard some of the time.
0 days
1 day
2 days
3 days
4 days
5 days
6 days
Every day
I don’t know
23
4. ON AN AVERAGE WEEKDAY, about how much time does this child usually spend watching TV programs or
movies, including streaming services such as Netflix, Hulu, Apple+?
None
Less than 1 hour
1 hour
2 hours
3 hours
4 or more hours
I don’t know
5. ON AN AVERAGE WEEKDAY, about how much time does your child usually spend playing on an electronic
device? This does NOT include doing schoolwork or watching TV shows, movies, or videos on
YouTube/TikTok.
None
Less than 1 hour
1 hour
2 hours
3 hours
4 or more hours
I don’t know
24
D. Bullying and Discrimination
1. DURING THE PAST 12 MONTHS, has this child faced a barrier to community or social participation because
of:
Yes
No
A physical environment that is not accessible?
Lack of assistive or adaptive technology?
Negative attitudes towards people with disability?
A service, system, or policy that prevents equal participation for everyone?
2. Discrimination occurs when people are unfairly treated because they are perceived as different from
others. Disability is any condition of the body or mind that makes it more difficult for the person with the
condition to do certain activities and interact with the world around them.
Has this child been discriminated against because of a disability?
Yes
No, my child has not been discriminated against because a disability (Skip to question 4)
Not applicable, my child does not have a disability (Skip to question 4)
I don’t know (Skip to question 4)
3. If so, who discriminated against this child (check all that apply)?
Employer
Educator
Healthcare provider
Community worker (e.g., staff in shops)
Other; Specify:_____________
4. DURING THE PAST MONTH (30 days), how often has this child been bullied by someone else?
Never (Skip to question 6)
1 time
2-3 times
4 or more times
Don’t know (Skip to question 6)
5. Please check all the ways this child has been bullied.
Yes
Called bad names
Threatened that they would be hurt or hit
Teased, picked on, or made fun of
Pushed or shoved
25
If yes, check if the behavior
occurred in the last 30 days
No
Don’t
Know
Hit, slapped or kicked
Was electronically bullied or experienced cyberbulling (this includes being bullied through texting,
Instagram, Facebook, or other social media)
Ignored or left out of things on purpose
Someone tried to keep others from liking them by
saying something bad or mean about them, or
spreading rumors or lies
Others stole their things
Other - please specify
________________________________________
No
If yes, check if the behavior
occurred in the last 12 months.
Don’t
Know
6. DURING THE PAST MONTH (30 days), how often has this child bullied another child?
Never (Skip to Section E)
1 time
2-3 times
4 or more times
Don’t know (Skip to Section E)
7. In what ways has this child bullied others?
Please check all the ways that this child bullied others.
Yes
Called bad names
Threatened to hurt or hit someone
Teased, picked on, or made fun of someone
Pushed or shoved someone
Hit, slapped or kicked someone
Engaged in electronic or cyber-bulling (this
includes being bullied through texting, Instagram,
Facebook, or other social media)
Ignored someone or left them out of things on
purpose
Tried to keep others from liking someone by
saying mean things about them, or spread rumors
or lies about someone
Stole others’ things
Other - please specify
________________________________________
26
E. Child Safety
1. Some children are likely to wander off and become so lost that it is necessary to search for them.
DURING THE PAST 12 MONTHS, has this child wandered off or became lost from any of these places, even
if it occurred just once. (Check one in each row)
Yes
No
Your home?
Someone else’s home such as a relative, friend,
neighbor, or babysitter?
School, day care, or summer camp?
A store, restaurant, playground, campsite, or any
other public place?
2. Do you currently have any of the following to specifically prevent this child from wandering off or to find
them if they become lost? (Check all that apply)
Yes
No
Fences or gates to your home or property (e.g., pool gate)
Locks, alarms, or cameras to your home or property (e.g., motion
detectors)
Other barriers to your home or property (e.g., window guards)
A tracking device on this child’s accessories, body, or clothing
An APP, feature, or tracking device on this child’s cell phone
3. DURING THE PAST 12 MONTHS, has this child had contact with a law enforcement officer for any reason?
Yes
No (Skip to question 6)
I Don’t Know (Skip to question 6)
4. Did the officer sufficiently explain his or her actions or procedures?
Yes
No
5. Are you satisfied with your child’s interaction(s) with your law enforcement agency?
Yes
No
27
The next question is about events that may have happened during this child’s life. These things can happen to
any family, but some people may feel uncomfortable with these questions. You may skip any questions you do
not want to answer.
6. To the best of your knowledge, has this child ever experienced any of the following?
Yes
No
Parent/guardian divorced or separated
Parent/guardian died
Parent/guardian served time in jail
Was a victim of violence or witnessed violence in their neighborhood
Lived with anyone who was mentally ill, suicidal, or severely depressed
Lived with anyone who had a problem with alcohol or drugs
Treated or judged unfairly because of their race or ethnic group
Treated or judged unfairly because of their sexual orientation or gender
identify
28
F. You and Your Family
The next questions are about you and your family
1. How are you related to this child?
Biological or adoptive mother
Biological or adoptive father
Stepparent
Grandparent
Aunt or uncle
Other relative
Other non-relative, specify:___________________
2. What is your age?
__ __ (Print numbers)
3. What is the highest grade or year of school you have completed?
8th grade or less
9th-12th grade; No diploma
High school graduate or GED completed
Completed a vocational, trade, or business school program
Some college credit, but no degree
Associate Degree (e.g., AA, AS)
Bachelor’s Degree (e.g., BA, BS, AB)
Master’s Degree (e.g., MA, MS, MSW, MBA)
Doctorate (e.g., PhD, EdD) or Professional Degree (e.g., MD, DDS, DVM, JD)
4. Are you currently…?
If more than one, select the one category which best describes you.
Employed for wages
Self-employed
Out of work for less than 1 year
Out of work for 1 year or more
A homemaker
A student
Retired
Unable to work
5. Are you now married, living with a partner together as an unmarried couple, or neither?
Married
Living with a partner together as unmarried couple
29
Neither (Skip to question 8)
Prefer not to answer (Skip to question 8)
6. What is the highest grade or year of school your spouse or partner has completed?
8th grade or less
9th-12th grade; No diploma
High school graduate or GED completed
Completed a vocational, trade, or business school program
Some college credit, but no degree
Associate Degree (e.g., AA, AS)
Bachelor’s Degree (e.g., BA, BS, AB)
Master’s Degree (e.g., MA, MS, MSW, MBA)
Doctorate (e.g., PhD, EdD) or Professional Degree (e.g., MD, DDS, DVM, JD)
7. Is your spouse or partner currently…?
If more than one, select the one category which best describes your spouse or partner.
Employed for wages
Self-employed
Out of work for less than 1 year
Out of work for 1 year or more
A homemaker
A student
Retired
Unable to work
Your Health
The following questions are about your health.
8. In general, what is your physical health status?
Excellent
Very Good
Good
Fair
Poor
9. DURING THE PAST 2 WEEKS, for about how many days have you felt very healthy and full of energy?
30
Nearly every day
More than half the days
Few days
No days
10. In general, what is your mental or emotional health status?
Excellent
Very Good
Good
Fair
Poor
11. Has a doctor or other healthcare provider EVER told you that you had any of the following?
Yes
No
specific phobia, agoraphobia, selective mutism, or social anxiety disorder)
Obsessive compulsive disorder?
Autism, Asperger’s, pervasive developmental disorder, or autism
spectrum disorder?
Bipolar disorder?
Regulation Disorder, Dysthymia, and Premenstrual dysphoric disorder)
Schizophrenia or other psychotic disorder?
Attention deficit disorder or Attention deficit hyperactivity disorder
(ADD or ADHD)?
Anxiety disorder? (This includes generalized anxiety disorder, panic disorder,
Depression? (This includes Major Depressive Disorder, Disruptive Mood
12. How
well do you
feel that
you are
coping with
the day-today
demands of
raising this
child?
Very well
Somewhat well
Not very well
Not very well at all
13. DURING THE PAST 12 MONTHS, was there someone that you could turn to for day-to-day emotional
support with parenting or raising this child?
Yes
No (Skip to question 15)
14. If yes, did you receive emotional support from (check all that apply):
31
Yes
No
Spouse?
Other family member or close friend?
Health care provider?
Place of worship or religious leader?
Support or advocacy group related to specific health condition?
Peer support group?
Counselor or other mental health professional?
Other person, specify ________________
Yes
No
Gotten less physical activity than you wanted because of the time needed
to care for this child?
Limited your social life because of the time needed to care for this child?
15. DURING THE PAST 12 MONTHS, have you:
Delayed getting health care or dental care for yourself because of the time
needed to care for this child?
16. DURING THE PAST 12 MONTHS, have you needed help with any of the following as a result of parenting
this child?
Yes
No
Finding more time for yourself?
Helping your spouse accept any condition your child might have?
Helping your family discuss problems and reach solutions?
Deciding on and doing recreational activities?
Paying for household expenses, such as food, housing, medical care,
clothing, or transportation?
Getting any special equipment your child needs?
Paying for therapy, day care, or other services your child needs?
Counseling or help in getting a job?
17. Have you or other family members living in your household EVER stopped working or cut down on the
hours you work because of this child’s health or health conditions?
Yes
No
18. Have you or other family members living in your household EVER avoided changing jobs because of
concerns about maintaining health insurance for this child?
Yes
No
19. As a result of parenting this child, do you feel:
32
Yes
No
That this child is much harder to care for than most children his or her age?
That this child does things that bother you a lot?
Angry with this child?
An increased sense of personal strength and confidence?
That your priorities have changed?
A greater appreciation of life?
Pleasure in the child’s accomplishments?
Increased faith/spirituality?
That you have more meaningful relationships?
The child has had a positive effect on the wider community?
33
G. Household Information
1. Is this child of Hispanic, Latino, or Spanish origin? (Check one)
No, not Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin
2. What is this child’s race? (Check all that apply)
☐ White
☐ Korean
☐ Black or African American
☐ Vietnamese
☐ American Indian or Alaska Native
☐ Other Asian
☐ Asian Indian
☐ Native Hawaiian
☐ Chinese
☐ Guamanian or Chamorro
☐ Filipino
☐ Samoan
☐ Japanese
☐ Other Pacific Islander
3. How many other children under the age of 18 years are now living in the household? Not including this
child.
Number of children ____________________________ (If 0, Skip to question 3)
4. Do any of these children have any disability, developmental delay, special need, or condition?
YES
NO
5. How many adults 18 years or older are now living in the household? Not including this child.
Number of adults ____
6. How many of these adults in your household are family members? Family is defined as anyone related to
this child by blood, marriage, adoption, or through foster care.
Number of people ____
34
The next questions are about your total income in the last calendar year before taxes.
Income is important in analyzing the health information we collect. For example, with this information, we can
learn whether people in one income group use certain types of medical services more or less often than those
in another group. Please be assured that, like all other information you have provided, these answers will be
kept strictly private.
7. Think about your total combined family income IN THE LAST CALENDAR YEAR for all members of the family.
What was your yearly total household income before taxes? Include your income, your spouse’s or partner’s
income, and any other income you may have received.
$
,
,
TOTAL AMOUNT
In the last calendar year
If you are unable to provide a specific amount, please indicate an estimated range of total yearly income
below.
$0 to $16,000
$16,001 to $20,000
$20,001 to $24,000
$24,001 to $28,000
$28,001 to $32,000
$32,001 to $40,000
$40,001 to $48,000
$48,001 to $57,000
$57,001 to $60,000
$60,001 to $73,000
$73,001 to $85,000
$85,001 or more
8. DURING THE LAST CALENDAR YEAR, how many people, including yourself and this child, depended on this
income?
Number of people___ ____
35
H. Individual Strengths
The following questions ask about characteristics and abilities you view as individual strengths of your child.
1. Would you say the following are individual strengths of this child?
Yes
No
Courage
Empathy
Forgiveness
Kindness
Gratitude
Humor
Optimism
Resilience
Self-control
Self-efficacy, or belief he or she can be successful
2. Please describe the best things about your child below.
You have reached the end of the survey.
Thank you for participating!
36
| File Type | application/pdf |
| Author | Powell, Patrick (CDC/DDNID/NCBDDD/DHDD) |
| File Modified | 2022-09-01 |
| File Created | 2022-09-01 |