Child Interview - 18-month follow-up

OPRE Study: National Survey of Child and Adolescent Well-Being Second Cohort (NSCAW III): Data Collection [Longitudinal Study]

Appx B_NSCAW III_Child Interview_Revised_August2022_Clean

Child Interview - 18-month follow-up

OMB: 0970-0202

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Appendix B: Child Interview and Assessments



QY – Up-Front Module B-1

CH – Household Module B-7

KB – Cognitive Status Assessment: KBIT-2 B-35

BD - Cognitive Status Assessment: BDI B-36

NI – Neurodevelopmental Impairment Assessment: BINS B-37

CO – Communication Assessment: PLS-5 B-70

WJ - Woodcock-Johnson III Assessment B-71

CN - Community Environment B-72

SE - School Engagement B-74

RR - Relationship with Peers B-77

PM – Parental Monitoring B-83

GR – Persistence/Grit B-88

SF – Self-Esteem B-90

IP – Independent Living B-92

OH – Out-of-Home Care B-99

AO – Family Contacts for Adopted Youth B-110

SW – Child Satisfaction with Caseworker Services B-118

FE - Future Expectations B-121

SU - Social Support B-122

PE - Physical Health B-125

YH – Health and Services B-136

CD – Children’s Depression Inventory 2: CDI-2 B-174

TR – Mental Heatlh: Trauma B-175

YA – Youth Activities B-180

YB - Youth Behavior B-182

ER – Employment/Resources to Live B-226

YI - Young Adult and Emancipated Youth: Income B-246

AC - ACASI Introduction B-250

RC - Relationship with Caregiver(s) B-253

CL - Closeness to Caregiver(s) B-258

EV - Exposure to Violence B-263

SV – Services Received B-281

SA - Substance Abuse B-284

SX - Sexual Activity B-288

DE - Delinquency B-293

VC - Victimization and Adverse Experiences B-313

HT – Human Trafficking Exposure B-321

IJ - Injuries B-322

YL – Involvement with the Law B-327

YM – Discipline and Child Maltreatment B-331

YD – Dating Violence B-345

AF - ACASI Finish B-349

CM – Child Maltreatment B-350

LO - Locator Form B-359

LK – Permission for Data Linkage B-373

VO – Verifications/Change of Address/Payment B-375

EF - Executive Functioning B-377

CC - Child Interview Close B-378





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Child Interview

================================================================================

QY - CHILD Up-Front Module

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

Y_QY_BGN [ YQY_BGN ] NoDeliv

@bCASE ID: ^main_case.zrid


Subject: ^main_case.subject


Adult: ^main_case.ad_last ^main_case.ad_first


Child: ^main_case.childfull

Child's DOB: ^strChildDOB

Child's age: ^AgeYY

Child's sex: ^Global.sex


@sIF INFORMATION ABOVE IS CORRECT, PRESS "1" AND ENTER TO CONTINUE.


IF INFORMATION ABOVE IS INCORRECT, CLOSE THE INTERVIEW TO RETURN TO CMS.@s


@B

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

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

Y_QY0a [ YQY0a ] NO LABEL

INTERVIEWER: PRESS 1 FOR @bPERMISSION@b FORMS IN DOCMAN. PLEASE CHOOSE

AND READ THE CORRECT CONSENT OR PERMISSION FORM FROM DOCMAN BASED ON

THE CHILD'S AGE AND OBTAIN SIGNATURE. AFTER COLLECTING SIGNATURE AND

FINALIZING FORM, YOU WILL THEN BE BROUGHT BACK TO THE INTERVIEW.


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

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

Y_QYCO1 Start CO DocMan

@bSTART DOCMAN PERMISSION FORM@b


INTERVIEWER: PRESS UP ARROW IF YOU WANT TO GO TO PREVIOUS SCREEN.

Question Type: BDocMan

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

Logic before:

If status from DocMan=491 ask Y_QYCO2 else ask Y_QYCO3

Y_QYCO2 [ YQYCO2 ] End CO DocMan

@bDOCMAN PERMISSION FORM IS COMPLETED@b


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

Logic after:

Skip to Y_QY0ab

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

Y_QYCO3 [ YQYCO3 ] NO LABEL

@bDOCMAN PERMISSION FORM IS NOT COMPLETED@b

Question Type: TDMR1F, noDK, noRF

_1 1 REDO THE FORM IN DOCMAN

_2 2 RESPONDENT REFUSED TO COMPLETE ELECTRONIC FORM BUT

SIGNED PAPER FORM

_3 3 A TECHNICAL PROBLEM PREVENTED THE ELECTRONIC FORM

FROM BEING COMPLETED BUT RESPONDENT SIGNED PAPER

FORM

_4 4 EXIT - RESPONDENT REFUSES SO THERE'S NO INTERVIEW

Logic after:

If 1 GOTO Y_QYCO1

If 4 EXIT interview

IF 3 Ask Y_QYCO4

ELSE GOTO Y_QY0b

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

Y_QYCO4 [ YQYCO4 ] NO LABEL

@bDOCMAN PERMISSION FORM IS NOT COMPLETED@b


GIVE DETAILS ABOUT THE TECHNICAL PROBLEM:

Question Type: STRING[60]

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

Y_QY0b [ YQY0b ] NO LABEL

^Fills.Y_QY0b


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

Question Fill: ^FillY_QY0b

need INTERVIEWER: PRESS 1 FOR @bCAREGIVER 2 PERMISSION@b

FORMS IN DOCMAN. PLEASE CHOOSE AND READ THE CORRECT

PERMISSION FORM FROM DOCMAN BASED ON CHILD'S AGE AND

OBTAIN SIGNATURE. AFTER COLLECTING SIGNATURE AND

FINALIZING FORM, YOU WILL THEN BE BROUGHT BACK TO THE

INTERVIEW.

no_need INTERVIEWER: THE @bCAREGIVER 2 CONSENT@b FORM IS NOT

NEEDED FOR THIS CHILD. SELECT “FORM NOT NEEDED” IN

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

Y_QYC21 Start C2 DocMan

@bSTART DOCMAN CAREGIVER 2 PERMISSION FORM@b


INTERVIEWER: PRESS UP ARROW IF YOU WANT TO GO TO PREVIOUS SCREEN.

Question Type: BDocMan

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

Logic before:

If status from DocMan=491 ask Y_QYCO2 else ask Y_QYCO3

Y_QYC22 [ YQYC22 ] End C2 DocMan

@bDOCMAN PERMISSION FORM CAREGIVER 2 IS COMPLETED@b


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

Logic after:

Skip to Y_QY0ab

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

Y_QYC23 [ YQYC23 ] NO LABEL

@bDOCMAN PERMISSION FORM CAREGIVER 2 IS NOT COMPLETED@b

Question Type: TDMR3F, noDK, noRF

_1 1 REDO THE FORM IN DOCMAN

_2 2 PAPER FORM USED, WILL SCAN BECAUSE R REFUSED

ELECTRONIC SIGNATURE

_3 3 PAPER FORM USED, WILL SCAN BECAUSE OF TECHNICAL ISSUES

_4 4 NO 2CG SIGNATURE REQUIRED; INCAPACITY

_5 5 NO 2CG SIGNATURE REQUIRED; NOT REASONABLY AVAILABLE

_6 6 NO 2CG SIGNATURE REQUIRED; NOT LG/BIO/ADOP/CG

_7 7 NO 2CG SIGNATURE REQUIRED; HOUSEHOLD SITUATION

_8 8 A TECHNICAL PROBLEM PREVENTED FROM CODING OUT THE

FORM

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Y_QYC24 [ YQYC24 ] NO LABEL

@bDOCMAN PERMISSION FORM CAREGIVER 2 IS NOT COMPLETED@b


GIVE DETAILS ABOUT THE TECHNICAL PROBLEM:

Question Type: STRING[60]

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Logic before:

IF CHILD IS 7-17 and is not emancipated ASK Y_QY0b. ELSE, GOTO Y_QY0aa.

Y_QY0ab [ YQY0ab ] NO LABEL

^Fills.Y_QY0ab


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

Question Fill: ^FillY_QY0ab

need NTERVIEWER: PRESS 1 FOR @bASSENT@b FORMS IN DOCMAN.

PLEASE CHOOSE AND READ THE CORRECT CONSENT/ASSENT

FORM FROM DOCMAN BASED ON CHILD'S AGE AND OBTAIN

SIGNATURE. AFTER COLLECTING SIGNATURE AND FINALIZING

FORM, YOU WILL THEN BE BROUGHT BACK TO THE INTERVIEW.

no_need INTERVIEWER: THE @bASSENT@b FORM IS NOT NEEDED FOR

THIS CHILD. SELECT “FORM NOT NEEDED” IN DOCMAN.

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

Y_QYAS1 Start AS DocMan

@bSTART DOCMAN ASSENT FORM@b


INTERVIEWER: PRESS UP ARROW IF YOU WANT TO GO TO PREVIOUS SCREEN.

Question Type: BDocMan

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

Logic before:

If status from DocMan=491 ask Y_QYAS2 else ask Y_QYAS3

Y_QYAS2 [ YQYAS2 ] End AS DocMan

@bDOCMAN ASSENT FORM IS COMPLETED@b


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

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

Y_QYAS3 [ YQYAS3 ] NO LABEL

@bDOCMAN ASSENT FORM IS NOT COMPLETED@b

Question Type: TDMR1F, noDK, noRF

_1 1 REDO THE FORM IN DOCMAN

_2 2 RESPONDENT REFUSED TO COMPLETE ELECTRONIC FORM BUT

SIGNED PAPER FORM

_3 3 A TECHNICAL PROBLEM PREVENTED THE ELECTRONIC FORM

FROM BEING COMPLETED BUT RESPONDENT SIGNED PAPER

FORM

_4 4 EXIT - RESPONDENT REFUSES SO THERE'S NO INTERVIEW

Logic after:

If 1 GOTO Y_QYAS1

If 4 EXIT interview

IF 3 Ask Y_QYAS4

ELSE GOTO Y_QY0aa

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Y_QYAS4 [ YQYAS4 ] NO LABEL

@bDOCMAN ASSENT FORM IS NOT COMPLETED@b


GIVE DETAILS ABOUT THE TECHNICAL PROBLEM:

Question Type: STRING[60]

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

Logic before:

P_do_CARI

Y_QY0aa [ YQY0aa ] Record interview?

INTERVIEWER: DID R AGREE TO THE USE OF CARI FOR RECORDING THE INTERVIEW?

Question Type: Bconsent

Logic after:

IF Y_QY0aa = Yes GOTO Y_QYEND

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Logic before:

P_not_cari

Y_QY0ba [ YQY0ba ] I need to confirm, u do not wnt interview recorded, correct?

I just need to confirm that you do not want this interview to be recorded. Is that correct?

Question Type: TYesNoC, noDK, noRF

Yes 1 YES

No 2 NO

Logic after:

IF Y_QY0ba = No GO BACK TO CORRECT Y_QY0aa

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Y_QYEND [ YQYEND ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue



CH - CHILD HOUSEHOLD MODULE

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Logic before:

IF CHILD AGE < 5, FILL: ADDRESS PARENT: I'd like to do several activities that involve ^CHILD.

Before we get started, let me verify a few pieces of information in our records.; IF CHILD AGE 5-10,

FILL: ADDRESS PARENT: Before I get started with ^CHILD's interview, I want to verify a few pieces

of information in our records.; IF CHILD AGE > 10, FILL: Hi, my name is _____________. Today

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

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

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

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

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

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

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

Y_CH0 [ YCH0 ] NO LABEL

^Fills.Y_CH0


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

Question Fill: ^FillY_CH0

under5 ADDRESS PARENT: I'd like to do several activities that involve

^Global.Child. Before we get started, let me verify a few pieces of

information in our records.

fivetoten ADDRESS PARENT: Before I get started with ^Global.Child's interview, I

want to verify a few pieces of information in our records.

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

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

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

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

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

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

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

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

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

the information I have about you.

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

Y_CH0a1 [ YCH0a1 ] NO LABEL

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


^Fills.Y_CH0a1


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

MIDDLE INITIAL: @|@B^CHILD_MName@B

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


Is this correct?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Question Fill: ^FillY_CH0a1

lessthan11 ADDRESS PARENT: First, let me verify ^Global.CHILD's name.

elevenmore First, let me verify your name.

Logic after:

IF = 1, GOTO Y_CH1a

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

Y_CH0b [ YCH0b ] NO LABEL

CORRECT FIRST NAME, AS NEEDED:


FIRST NAME:

Question Type: STRING[20]

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

Y_CH0c [ YCH0c ] NO LABEL

CORRECT MIDDLE INITIAL, AS NEEDED:


MIDDLE INITIAL:

Question Type: STRING[20], empty

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

Y_CH0d [ YCH0d ] NO LABEL

CORRECT LAST NAME, AS NEEDED:


LAST NAME:

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Logic before:

IF CHILD AGE < 11: ADDRESS PARENT: Let me verify ^CHILD’s date of birth.; ELSE: Let me

verify your date of birth.

Y_CH1a [ YCH1a ] Correct DOB(YN2T)

^Fills.Y_CH1a


@B^DOB_Mo_Txt ^DOB_Dy, ^DOB_Yr@B


IS THIS CORRECT?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Question Fill: ^FillY_CH1a

lessthan11 ADDRESS PARENT: Let me verify ^Global.CHILD's date of birth.

elevenmore Let me verify your date of birth.

Logic after:

IF Y_CH1a = Yes GOTO Y_CH2a

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Y_CH1m [ YCH1m ] CH DOB month

INTERVIEWER: CORRECT MONTH OF BIRTH IF NEEDED.


MONTH:

Question Type: TMonth

jan 1 January

feb 2 February

mar 3 March

apr 4 April

may 5 May

jun 6 June

jul 7 July

aug 8 August

sep 9 September

oct 10 October

nov 11 November

dec 12 December

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

Y_CH1d [ YCH1d ] CH DOB day

INTERVIEWER: CORRECT DAY OF BIRTH IF NEEDED.


DAY:

Question Type: 1..31

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Y_CH1y [ YCH1y ] CH DOB year

INTERVIEWER: CORRECT YEAR OF BIRTH IF NEEDED.


YEAR:

Question Type: 1980..2013

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

Logic before:

IF CHILD AGE < 11: ADDRESS PARENT: So ^CHILD is (FILL COMPUTED AGE BASED ON DOB

ENTERED IN Y_CH1a) years old?; ELSE: So you are (FILL COMPUTED AGE BASED ON DOB

ENTERED IN Y_CH1a) years old?

Y_CH2a [ YCH2a ] CH age

^CH2a_Fill

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH2a = No GO BACK TO CORRECT Y_CH1a

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Logic before:

IF CHILD AGE IS >=11, GOTO Y_CH3b

Y_CH3a [ YCH3a ] CH sex

CODE CHILD'S SEX.


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

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

CONTINUING.

Question Type: TSexC

male 1 MALE

female 2 FEMALE

Question Fill: ^FillSex

male MALE

female FEMALE



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

Logic before:

IF CHILD AGE >= 4, GOTO Y_CH5

Y_CH4d [ YCH4d ] Head circumference in centimeters, #1

ADDRESS PARENT: As part of this study, we'd like to find out how tall ^CHILD is, how much

^Fills.HeShe weighs, and the size of ^Fills.HisHer head.


MEASURE AND RECORD HEIGHT, WEIGHT, AND HEAD CIRCUMFERENCE.


@BBE SURE TO USE THE BOTTOM RED ARROW OF THE MEASURING TAPE IN ORDER TO

GET MEASUREMENT IN CENTIMETERS.@B


HEAD SIZE IN @BCENTIMETERS@B:

Question Type: 0..100

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

Y_CH4D2 [ YCH4D2 ] Head circumference in centimeters, #2

ROUND 2:

ADDRESS PARENT: As part of this study, we'd like to find out how tall ^CHILD is, how much

^Fills.HeShe weighs, and the size of ^Fills.HisHer head.


MEASURE AND RECORD HEIGHT, WEIGHT, AND HEAD CIRCUMFERENCE.


@BBE SURE TO USE THE BOTTOM RED ARROW OF THE MEASURING TAPE IN ORDER TO

GET MEASUREMENT IN CENTIMETERS.@B


HEAD SIZE IN @BCENTIMETERS@B:

Question Type: 0..100

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

Y_CH4D3 [ YCH4D3 ] Head circumference in centimeters, #3

ROUND 3:

ADDRESS PARENT: As part of this study, we'd like to find out how tall ^CHILD is, how much

^Fills.HeShe weighs, and the size of ^Fills.HisHer head.


MEASURE AND RECORD HEIGHT, WEIGHT, AND HEAD CIRCUMFERENCE.


@BBE SURE TO USE THE BOTTOM RED ARROW OF THE MEASURING TAPE IN ORDER TO

GET MEASUREMENT IN CENTIMETERS.@B


HEAD SIZE IN @BCENTIMETERS@B:

Question Type: 0..100

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

Logic before:

IF CHILD AGE >= 4, GOTO Y_CH5

Y_CH4a [ YCH4a ] Height, feet, #1

ADDRESS PARENT: As part of this study, we'd like to find out how tall ^CHILD is, how much

^Fills.HeShe weighs, and the size of ^Fills.HisHer head.


MEASURE AND RECORD HEIGHT, WEIGHT, AND HEAD CIRCUMFERENCE.


HEIGHT IN FEET AND INCHES:


ENTER FEET:

Question Type: 1..4

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Logic before:

IF CHILD AGE >= 4, GOTO Y_CH5

Y_CH4b [ YCH4b ] Height, inches, #1

ADDRESS PARENT: As part of this study, we'd like to find out how tall ^CHILD is, how much

^Fills.HeShe weighs, and the size of ^Fills.HisHer head.


MEASURE AND RECORD HEIGHT, WEIGHT, AND HEAD CIRCUMFERENCE.


HEIGHT IN FEET AND INCHES:


ENTER INCHES:

Question Type: 0..11

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

Y_CH4A2 [ YCH4A2 ] Height, feet, #2

ROUND 2:

ADDRESS PARENT: As part of this study, we'd like to find out how tall ^CHILD is, how much

^Fills.HeShe weighs, and the size of ^Fills.HisHer head.


MEASURE AND RECORD HEIGHT, WEIGHT, AND HEAD CIRCUMFERENCE.


HEIGHT IN FEET AND INCHES:


ENTER FEET:

Question Type: 1..4

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

Y_CH4B2 [ YCH4B2 ] Height, inches, #2

ROUND 2:

ADDRESS PARENT: As part of this study, we'd like to find out how tall ^CHILD is, how much

^Fills.HeShe weighs, and the size of ^Fills.HisHer head.


MEASURE AND RECORD HEIGHT, WEIGHT, AND HEAD CIRCUMFERENCE.


HEIGHT IN FEET AND INCHES:


ENTER INCHES:

Question Type: 0..11

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

Y_CH4A3 [ YCH4A3 ] Height, feet, #3

ROUND 3:

ADDRESS PARENT: As part of this study, we'd like to find out how tall ^CHILD is, how much

^Fills.HeShe weighs, and the size of ^Fills.HisHer head.


MEASURE AND RECORD HEIGHT, WEIGHT, AND HEAD CIRCUMFERENCE.


HEIGHT IN FEET AND INCHES:


ENTER FEET:

Question Type: 1..4

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

Y_CH4B3 [ YCH4B3 ] Height, inches, #3

ROUND 3:

ADDRESS PARENT: As part of this study, we'd like to find out how tall ^CHILD is, how much

^Fills.HeShe weighs, and the size of ^Fills.HisHer head.


MEASURE AND RECORD HEIGHT, WEIGHT, AND HEAD CIRCUMFERENCE.


HEIGHT IN FEET AND INCHES:


ENTER INCHES:

Question Type: 0..11

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

Logic before:

IF CHILD AGE >= 4, GOTO Y_CH5

Y_CH4c [ YCH4c ] Weight in lbs, #1

ADDRESS PARENT: As part of this study, we'd like to find out how tall ^CHILD is, how much

^Fills.HeShe weighs, and the size of ^Fills.HisHer head.


MEASURE AND RECORD HEIGHT, WEIGHT, AND HEAD CIRCUMFERENCE.


WEIGHT:

Question Type: 1..100

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

Y_CH4C2 [ YCH4C2 ] Weight in lbs, #2

ROUND 2:

ADDRESS PARENT: As part of this study, we'd like to find out how tall ^CHILD is, how much

^Fills.HeShe weighs, and the size of ^Fills.HisHer head.


MEASURE AND RECORD HEIGHT, WEIGHT, AND HEAD CIRCUMFERENCE.


WEIGHT:

Question Type: 1..100

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

Y_CH4C3 [ YCH4C3 ] Weight in lbs, #3

ROUND 3:

ADDRESS PARENT: As part of this study, we'd like to find out how tall ^CHILD is, how much

^Fills.HeShe weighs, and the size of ^Fills.HisHer head.


MEASURE AND RECORD HEIGHT, WEIGHT, AND HEAD CIRCUMFERENCE.


WEIGHT:

Question Type: 1..100

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

Y_CH4cka [ YCH4cka ] NO LABEL

INTERVIEWER: YOU HAVE ENTERED THE FOLLOWING MEASUREMENTS FOR ^CHILD:


HEAD SIZE = @|@B^Y_CH4d@B CENTIMETERS

@|@|@|@B^Y_CH4D2@B CENTIMETERS

@|@|@|@B^Y_CH4D3@B CENTIMETERS


HEIGHT = @|@B^Y_CH4a@B FEET, @B^Y_CH4b@B INCHES TALL

@|@|@B^Y_CH4A2@B FEET, @B^Y_CH4B2@B INCHES TALL

@|@|@B^Y_CH4A3@B FEET, @B^Y_CH4B3@B INCHES TALL


WEIGHT = @|@B^Y_CH4c@B POUNDS

@|@|@B^Y_CH4C2@B POUNDS

@|@|@B^Y_CH4C3@B POUNDS


IS THIS INFORMATION CORRECT?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH4cka = No GOTO Y_CH4a

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

Logic before:

IF CHILD AGE < 5, GOTO Y_CH8a; IF CHILD AGE 5-10, GOTO Y_CH5; IF CHILD AGE > 10,

GOTO Y_CH7a; IF YA+EY, GOTO Y_CH8aa

Y_CH5 [ YCH5 ] NO LABEL

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

family, friends, and school.


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

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

break, just let me know.


PRESS "1" AND [ENTER] TO CONTINUE.

Question Type: TCont

Continue 1 Continue

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

Y_CH6a [ YCH6a ] CH name(YN2T)

What is your first name?


FIRST NAME:

Question Type: STRING[30]

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

Y_CH7a [ YCH7a ] CH has nickname(YN2T)

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


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

CHILD BY NICKNAME FOR REMAINDER OF INTERVIEW.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH7a = No GOTO Y_CH8aa

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

Y_CH7b [ YCH7b ] CH nickname

What is it?


NICKNAME:

Question Type: STRING[30]

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

Logic before:

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

Y_CH8aa [ YCH8aa ] CH Spanish Hispanic or Latino?

Are you Spanish, Hispanic, or Latino?

Question Type: TCH8aa

no 1 No, not Spanish/Hispanic/Latino

mex 2 Yes, Mexican, Mexican-American, Chicano

pr 3 Yes, Puerto Rican

cuba 4 Yes, Cuban

other 5 Yes, Other

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

Logic before:

IF CHILD AGE < 6, GOTO Y_CH9a

Y_CH8a [ YCH8a ] Labels are in Logic After

USE CARD 0. What race are you?


CODE ALL THAT APPLY.


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

CODE RACE BASED ON YOUR OBSERVATION@B.

Question Type: TRaceC

amerind 1 AMERICAN INDIAN OR ALASKA NATIVE

asian 2 ASIAN

black 3 BLACK OR AFRICAN AMERICAN

pacislandr 4 NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

white 5 WHITE

Logic after:

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

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

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

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


Y_CH3b

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

1 Female (Girl)

2 Male (Boy)

3) DON’T KNOW

4) PREFER NOT TO ANSWER



IF AGE IS 11-18+ , ASK Y_CH3c. ELSE, SKIP TO Y_CH4d or Y_CH4a.


Y_CH3c

What is your current gender?

1 Female (Girl)

2 Male (Boy)

3 Transgender

4 [IF Y_CH8a =1} Two-Spirit

5) I use a different term

6) DON’T KNOW

7) PREFER NOT TO ANSWER


IF Y_CH3c = 5, ASK Y_CH3cOTH

Y_CH3cOTH

What is the term that you use?

[TEXT BOX]

DON’T KNOW

PREFER NOT TO ANSWER



Logic before:

IF CHILD AGE <5, GOTO Y_CH10a

Y_CH9a [ YCH9a ] CH school status

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

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


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

Question Type: TCH9a

inschool 1 GO TO SCHOOL

homeschooled 2 TAUGHT AT HOME

neither 3 NEITHER

Logic after:

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

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

Y_CH9aa [ YCH9aa ] CH attends school regularly

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

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

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

Logic before:

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

TO Y_CH9Ya

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

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

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

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

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

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


HOURS:

Question Type: 0..145

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

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

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


HOURS:

Question Type: 0..97

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

Logic before:

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

Y_CH9Ya [ YCH9Ya ] Highest Grade compl. in school

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

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

Question Type: TCH9Ya

preschool 44 NURSERY SCHOOL/PRESCHOOL/HEAD START

kindergrtn 55 KINDERGARTEN

first 1 FIRST GRADE

second 2 SECOND GRADE

third 3 THIRD GRADE

fourth 4 FOURTH GRADE

fifth 5 FIFTH GRADE

sixth 6 SIXTH GRADE

seventh 7 SEVENTH GRADE

eighth 8 EIGHTH GRADE

ninth 9 NINTH GRADE

tenth 10 TENTH GRADE

eleventh 11 ELEVENTH GRADE

twelfth 12 TWELFTH GRADE

vocatech 13 VOCATIONAL/TECHNICAL

college 14 ANY YEAR OF COLLEGE

ungraded 17 UNGRADED PLACEMENT

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

Y_CH9Yaa [ YCH9Yaa ] Do you have high school diploma?

Do you have a high school diploma?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

Y_CH9Yba [ YCH9Yba ] Do you have a GED?

Do you have a GED?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

Y_CH9Yca [ YCH9Yca ] Currently enrolled in school?

Are you currently enrolled in school?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH9Yca = No GOTO Y_CH9Yfa

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

Y_CH9Yda [ YCH9Yda ] What type of school attend?

What type of school do you attend?

Question Type: TCH9Yda

jrhigh 0 Junior High or Middle School

hs 1 High School

voctech 2 Vocational/Technical School

commcoll 3 Community College (2-year)

college 4 4-Year College

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

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

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

Question Type: TCH9Yea

part 1 Part time

full 2 Full time

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

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

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

Question Type: TCH9Yfa

lessthanhs 1 Less than high school graduation

ged 2 GED or other equivalency only

hs 3 High school graduation only

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

vocational school

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

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

masters 7 Obtain a Master's degree or equivalent

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

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

Logic before:

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

Y_CH10a [ YCH10a ] CH in OOH care

INTERVIEWER: IS CHILD LIVING IN OUT-OF-HOME CARE (E.G. FOSTER HOME, ETC.)?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH10a = No GOTO Y_CH12a

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

Y_CH11a [ YCH11a ] Type of OOH care

INTERVIEWER: IN WHAT TYPE OF OUT-OF-HOME SETTING IS ^CHILD LIVING?

Question Type: TCH11a

foster 1 FOSTER HOME

relhome 2 KIN-CARE SETTING (RELATIVE'S HOME)

respgm 3 TREATMENT FOSTER CARE, SPECIALIZED FOSTER CARE, OR

FAMILY FOSTER AGENCY

group 4 GROUP HOME OR RESIDENTIAL FACILITY

other 5 SOME OTHER OUT-OF-HOME CARE ARRANGEMENT

Logic after:

IF Y_CH11a = 4 OR 5, GOTO Y_CH12a

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

Y_CH11aa [ YCH11aa ] Caregiver is CH legal guardian

INTERVIEWER: IS THE CAREGIVER CHILD'S LEGAL GUARDIAN?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

Y_CH12a [ YCH12a ] Correct name of primary CG

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


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

MIDDLE INITIAL:@|@B^CAREGIVER_A_MName@B

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


IS THIS CORRECT?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH12a = Yes GOTO Y_CH13a

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

Y_CH12f [ YCH12f ] CH primary CG-first name

INTERVIEWER: CORRECT FIRST NAME IF NEEDED.


FIRST NAME:

Question Type: STRING[30]

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

Y_CH12m [ YCH12m ] CH primary CG-middle name

INTERVIEWER: CORRECT MIDDLE NAME IF NEEDED.


MIDDLE NAME:

Question Type: STRING[30], empty

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

Y_CH12l [ YCH12l ] CH primary CD-last name

INTERVIEWER: CORRECT LAST NAME IF NEEDED.


LAST NAME:

Question Type: STRING[40]

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

Y_CH14a [ YCH14a ] Primary CG relationship to CH

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

@B^CAREGIVER_A@B.


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

Question Type: TCH14a

biomom 1 BIOLOGICAL MOTHER

stepmom 2 STEP-MOTHER

adoptmom 3 ADOPTIVE MOTHER

fostmom 4 FOSTER MOTHER

sister 5 SISTER

aunt 6 AUNT

grandma 7 GRANDMOTHER

biodad 8 BIOLOGICAL FATHER

stepdad 9 STEP-FATHER

adoptdad 10 ADOPTIVE FATHER

fostdad 11 FOSTER FATHER

brother 12 BROTHER

uncle 13 UNCLE

grandpa 14 GRANDFATHER

otherrel 95 OTHER RELATIVE

othernonrel 96 OTHER NON-RELATIVE

Logic after:

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

GOTO Y_CH14c; RELATIONSHIP BECOMES CAREGIVER_A FILL

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

Logic before:

IF Y_CH14a = 95, ELSE GOTO Y_CH14c

Y_CH14b [ YCH14b ] Specify CG other relative relationship to CH

SPECIFY OTHER RELATIVE RELATIONSHIP


RELATIONSHIP:

Question Type: STRING[30]

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

Logic before:

IF Y_CH14a = 96, ELSE GOTO Y_CH15prea

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

SPECIFY OTHER NON-RELATIVE RELATIONSHIP


RELATIONSHIP:

Question Type: STRING[30]

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

Y_CH15prea [ YCH5prea ] Is there a secondary CG for CH

INTERVIEWER: IS THERE A SECONDARY CAREGIVER FOR THE CHILD?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

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

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

Y_CH15a [ YCH15a ] Correct name of secondary CG

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


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

MIDDLE INITIAL:@|@B^CAREGIVER_B_MName@B

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


IS THIS CORRECT?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH15a = Yes GOTO Y_CH16a



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

Y_CH15f [ YCH15f ] CH secondary CG-first name

INTERVIEWER: CORRECT FIRST NAME IF NEEDED.


FIRST NAME:

Question Type: STRING[30]

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

Y_CH15m [ YCH15m ] CH secondary CG-middle name

INTERVIEWER: CORRECT MIDDLE NAME IF NEEDED.


MIDDLE NAME:

Question Type: STRING[30], empty

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

Y_CH15l [ YCH15l ] CH secondary CG-last name

INTERVIEWER: CORRECT LAST NAME IF NEEDED.


LAST NAME:

Question Type: STRING[40]

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

Y_CH17a [ YCH17a ] Secondary CG relationship to CH

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


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

Question Type: TCH14a

biomom 1 BIOLOGICAL MOTHER

stepmom 2 STEP-MOTHER

adoptmom 3 ADOPTIVE MOTHER

fostmom 4 FOSTER MOTHER

sister 5 SISTER

aunt 6 AUNT

grandma 7 GRANDMOTHER

biodad 8 BIOLOGICAL FATHER

stepdad 9 STEP-FATHER

adoptdad 10 ADOPTIVE FATHER

fostdad 11 FOSTER FATHER

brother 12 BROTHER

uncle 13 UNCLE

grandpa 14 GRANDFATHER

otherrel 95 OTHER RELATIVE

othernonrel 96 OTHER NON-RELATIVE

Question Fill: ^FillY_CH17a

cg2 INTERVIEWER: CURRENT SECONDARY CAREGIVER'S

RELATIONSHIP TO THE CHILD IS

Logic after:

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

GOTO Y_CH17c; RELATIONSHIP BECOMES CAREGIVER_B FILL

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

Logic before:

IF Y_CH17a = 95, ELSE GOTO Y_CH17c

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

SPECIFY OTHER RELATIVE RELATIONSHIP


RELATIONSHIP:

Question Type: STRING[30]

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

Logic before:

IF Y_CH17a = 96, ELSE GOTO Y_CH18a

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

SPECIFY OTHER NON-RELATIVE RELATIONSHIP


RELATIONSHIP:

Question Type: STRING[30]

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

Logic before:

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


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

Y_CH18a [ YCH18a ] How long CH lived with CG

^CH18a_Fill


NUMBER:

Question Type: 0..500

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

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

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

Question Type: TCH18b

days 1 DAYS

weeks 2 WEEKS

months 3 MONTHS

years 4 YEARS

Logic after:

GOTO Y_CH19a

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

Logic before:

IF Y_CH10a = YES CONTINUE; ELSE GOTO Y_CHEND

Y_CH19a [ YCH19a ] Bio Mother still living

^Fills.Y_CH19a

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Question Fill: ^FillY_CH19a

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

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

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

Y_CH20a [ YCH20a ] Bio Father still living

^Fills.Y_CH20a

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Question Fill: ^FillY_CH20a

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

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

Logic after:

GOTO Y_CHEND

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

Logic before:

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

QUESTIONS. ELSE, GOTO C_CHEND.

Y_CH24a [ YCH24a ] CH Born in US

Were you born in the United States?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH24a = 2 GOTO Y_CH27a

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

Y_CH25a [ YCH25c ] In what city were you born?

In what city and state were you born?


CITY:

Question Type: STRING[30]

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

Y_CH25b [ YCH25s ] In what state were you born?

(In what city and state were you born?)


STATE:

Question Type: STRING[2]

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

Y_CH27a [ YCH27a ] First name confirmation

Next, I need to record the first name of each adult living in this household. By "living in this

household" I mean each adult who considers this their current primary residence, or who stays

here at least three nights per week, every week.


Let's start with you. Your first name is ^CHILD. Is that correct?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH27a = 1 GOTO Y_CH28a

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

Y_CH27b [ YCH27aa ] What is your first name?

What is your first name?


FIRST NAME:

Question Type: STRING[20]

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

Y_CH28a [ YCH28a ] NO LABEL

What are the first names of the other adults, age 18 or over who live here? Not including you, let's

start with the oldest and work down to the youngest adult in this household. (RECORD ON GRID

BELOW.)


Now, I'd like to know the names of all children and teenagers aged 17 and under living in this

household. Let's start with the oldest and work down to the youngest child in this household.


FIRST NAME:

Question Type: TStr_20a, EMPTY

_20 1 String[20]

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

Logic before:

IF NO OTHER HH MEMBERS IN Y_CH28a, GO TO Y_CH32a. ELSE, CONTINUE. NEXT PERSON

LISTED IN Y_CH28a AS VARIABLE <PERSON>

Y_CH29a [ YCH29ax ] Labels are in Logic After

USE CARD 1. Let's talk about ^PERSON. Looking again at Card 1, what is ^PERSON's

relationship to you? (PROBE TO DETERMINE BIOLOGIC, STEP, ADOPTIVE, FOSTER, ETC.)

Question Type: TCG29aAr

biomom 2 MOTHER (BIOLOGICAL)

biodad 3 FATHER (BIOLOGICAL)

stepmom 4 STEP-MOTHER

stepdad 5 STEP-FATHER

adoptmom 6 ADOPTIVE MOTHER

adoptdad 7 ADOPTIVE FATHER

fostmom 8 FOSTER MOTHER

fostdad 9 FOSTER FATHER

sister 10 FULL SISTER

brother 11 FULL BROTHER

halfsis 12 HALF SISTER

halfbro 13 HALF BROTHER

stepsis 14 STEP-SISTER

stepbro 15 STEP-BROTHER

fostsis 16 FOSTER SISTER

fostbro 17 FOSTER BROTHER

adoptsis 18 ADOPTIVE SISTER

adoptbro 19 ADOPTIVE BROTHER

bioson 20 SON (BIOLOGICAL)

biodaughter 21 DAUGHTER (BIOLOGICAL)

adoptson 22 ADOPTIVE SON

adoptdaughter 23 ADOPTIVE DAUGHTER

stepson 24 STEP-SON

stepdaughter 25 STEP-DAUGHTER

fostson 26 FOSTER SON

fostdaughter 27 FOSTER DAUGHTER

spouse 30 SPOUSE (HUSBAND/WIFE)

partner 31 UNMARRIED PARTNER, BOYFRIEND/GIRLFRIEND

aunt 40 AUNT

uncle 41 UNCLE

greataunt 42 GREAT AUNT

greatuncle 43 GREAT UNCLE

cousin 44 COUSIN

niece 45 NIECE

nephew 46 NEPHEW

matgrandma 50 MATERNAL GRANDMOTHER

patgrandma 51 PATERNAL GRANDMOTHER

matgrandpa 52 MATERNAL GRANDFATHER

patgrandpa 53 PATERNAL GRANDFATHER

matgrgrandma 54 MATERNAL GREAT-GRANDMOTHER

patgrgrandma 55 PATERNAL GREAT-GRANDMOTHER

matgrgrandpa 56 MATERNAL GREAT-GRANDFATHER

patgrgrandpa 57 PATERNAL GREAT-GRANDFATHER

otherrel 60 OTHER BLOOD RELATIVE

partnerrel 70 RELATIVE OF UNMARRIED PARTNER (BOYFRIEND/GIRLFRIEND)

roommate 80 ROOMMATE

othernonrel 81 OTHER NON-RELATIVE

Logic after:

YCH29ax_1 --Relationship of first other adult age 18 or over; YCH29ax_2 --Relationship of second

other adult age 18 or over; YCH29ax_3 --Relationship of third other adult age 18 or over;

YCH29ax_4 --Relationship of fourth other adult age 18 or over; YCH29ax_5 --Relationship of fifth

other adult age 18 or over; YCH29ax_6 --Relationship of sixth other adult age 18 or over;

YCH29ax_7 --Relationship of seventh other adult age 18 or over; YCH29ax_8 --Relationship of

eighth other adult age 18 or over; YCH29ax_9 --Relationship of ninth other adult age 18 or over;

YCH29ax_10 --Relationship of tenth other adult age 18 or over

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

Y_CH29y [ YCH29y ] Labels are in Logic After

How old is ^PERSON?


YEARS OLD:

Question Type: Array[1..10] of 0..97

Logic after:

YCH29y_1 --Age of first other adult age 18 or over; YCH29y_2 --Age of second other adult age 18

or over; YCH29y_3 --Age of third other adult age 18 or over; YCH29y_4 --Age of fourth other adult

age 18 or over; YCH29y_5 --Age of fifth other adult age 18 or over; YCH29y_6 --Age of sixth other

adult age 18 or over; YCH29y_7 --Age of seventh other adult age 18 or over; YCH29y_8 --Age of

eighth other adult age 18 or over; YCH29y_9 --Age of ninth other adult age 18 or over; YCH29y_10 -

-Age of tenth other adult age 18 or over

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

Y_CH29ba [ YCH29ba ] Labels are in Logic After

IF SEX UNCLEAR, ASK: Is ^PERSON male or female?

Question Type: TGenr10F

male 1 MALE

female 2 FEMALE

Logic after:

GO BACK TO Y_CH29a UNTIL ALL ROSTER MEMBERS IN Y_CH28a ARE COVERED.;

YCH29ba_1 --Sex of first other adult age 18 or over; YCH29ba_2 --Sex of second other adult

age 18 or over; YCH29ba_3 --Sex of third other adult age 18 or over; YCH29ba_4 --Sex of

fourth other adult age 18 or over; YCH29ba_5 --Sex of fifth other adult age 18 or over;

YCH29ba_6 --Sex of sixth other adult age 18 or over; YCH29ba_7 --Sex of seventh other

adult age 18 or over; YCH29ba_8 --Sex of eighth other adult age 18 or over; YCH29ba_9 --

Sex of ninth other adult age 18 or over; YCH29ba_10 --Sex of tenth other adult age 18 or over

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

Y_CH30 [ YCH30 ] NO LABEL

HOUSEHOLD ROSTER ACCURACY CHECK:


RESPONDENT: ^Global.Child, AGE: ^Global.CHILD_AGE, SEX: ^Global.Sex


^HHRoster

Question Type: TCH30F

cont 1 CONTINUE

change 2 MAKE CHANGES

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

Y_CH32a [ YCH32a ] Marital status

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


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

WHAT RESPONDENT THINKS HIS/HER MARITAL STATUS IS.

Question Type: TCH32a

married 1 Married,

separated 2 Separated,

divorced 3 Divorced,

widowed 4 Widowed, or

never 5 Have you never been married?

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

Logic before:

ASK Y_CH33bm-Y_CH33by IF ANY Y_CH29A = 30; ELSE GOTO Y_CH35a

Y_CH33bm [ YCH33bm ] NO LABEL

What is your spouse's date of birth?


MONTH:

Question Type: TMonth

jan 1 January

feb 2 February

mar 3 March

apr 4 April

may 5 May

jun 6 June

jul 7 July

aug 8 August

sep 9 September

oct 10 October

nov 11 November

dec 12 December

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

Y_CH33bd [ YCH33bd ] NO LABEL

What is your spouse's date of birth?


DAY:

Question Type: 1..31

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

Y_CH33by [ YCH33by ] NO LABEL

What is your spouse's date of birth?


YEAR:

Question Type: 1950..2008

Logic after:

GOTO Y_CH35a

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

Logic before:

IF ANY Y_CH29a = 20 OR 21, GOTO Y_CH36a; ELSE ASK Y_CH35a

Y_CH35a [ YCH35b ] Have any children

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

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH35a = 2 GOTO Y_CH41a

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

Y_CH36a [ YCH36a ] Number of births

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

Question Type: 0..10

Question Fill: ^FillCH36a

female given birth to

male fathered

Logic after:

IF 0 GOTO Y_CH41a

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

Y_CH36aa [ YCH36aa ] NO LABEL

Please give me the first name of the ^Fills.CH36aa you have ^Fills.CH36a.

Question Type: TStr_20a

_20 1 String[20]

Question Fill: ^FillCH36aa

one child

moreone children

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

Y_CH_Kids Questions Y_CH37a - Y_CH40a are in Y_CH_Kids

Question Type: ARRAY[1..10] OF BY_CH_Kids

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

Logic before:

REPEAT Y_CH37a through Y_CH40a FOR EACH CHILD LISTED IN Y_CH36aa

Y_CH37a [ YCH37a ] Labels are in Logic After

CHILD IN QUESTION: ^Y_CH36aa[L]


Does ^Y_CH36aa[L] live with you?

Question Type: TCH37a

yes 1 YES

no 2 NO

deceased 3 CHILD IS DECEASED

Logic after:

IF Y_CH37a = 1 GOTO Y_CH38ca; IF Y_CH37a = 2 GOTO Y_CH38a; IF Y_CH37a = 3 GOTO

Y_CH41a; YCH37aa--Child 1 live with R; YCH37ba--Child 2 live with R; YCH37ca--Child 3 live with

R; YCH37da--Child 4 live with R; YCH37ea--Child 5 live with R; YCH37fa--Child 6 live with R;

YCH37ga--Child 7 live with R; YCH37ha--Child 8 live with R; YCH37ia--Child 9 live with R; YCH37ja-

-Child 10 live with R

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

Y_CH38a [ YCH38a ] Labels are in Logic After

CHILD IN QUESTION: ^Y_CH36aa[L]


Do you have contact with ^Y_CH36aa[L]?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH38a = 1 GOTO Y_CH38aa; IF Y_CH38a = 2 GOTO Y_CH38ba; YCH38aa--R has contact

with child 1; YCH38ba--R has contact with child 2; YCH38ca--R has contact with child 3;

YCH38da--R has contact with child 4; YCH38ea--R has contact with child 5; YCH38fa--R has

contact with child 6; YCH38ga--R has contact with child 7; YCH38ha--R has contact with child 8;

YCH38ia--R has contact with child 9; YCH38ja--R has contact with child 10

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

Y_CH38aa [ YCH38aa ] Labels are in Logic After

CHILD IN QUESTION: ^Y_CH36aa[L]


How often do you see ^Y_CH36aa[L]? Would you say...

Question Type: TCH38aa

never 1 never,

lessonce 2 less than once a month,

oncetwice 3 once or twice a month,

oncewk 4 about once a week,

sevweek 5 several times a week, or

everyday 6 every day?

Logic after:

YCH38aaa--How often R see child 1; YCH38aba--How often R see child 2; YCH38aca--How often R

see child 3; YCH38ada--How often R see child 4; YCH38aea--How often R see child 5; YCH38afa--

How often R see child 6; YCH38aga--How often R see child 7; YCH38aha--How often R see child 8;

YCH38aia--How often R see child 9; YCH38aja--How often R see child 10

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

Y_CH38ba [ YCH38bax ] Labels are in Logic After

USE CARD 3. Who does ^Y_CH36aa[L] live with? Looking at Card 3, tell me the person's

relationship to you.

Question Type: TCH29a

biomom 2 MOTHER (BIOLOGICAL)

biodad 3 FATHER (BIOLOGICAL)

stepmom 4 STEP-MOTHER

stepdad 5 STEP-FATHER

adoptmom 6 ADOPTIVE MOTHER

adoptdad 7 ADOPTIVE FATHER

fostmom 8 FOSTER MOTHER

fostdad 9 FOSTER FATHER

sister 10 FULL SISTER

brother 11 FULL BROTHER

halfsis 12 HALF SISTER

halfbro 13 HALF BROTHER

stepsis 14 STEP-SISTER

stepbro 15 STEP-BROTHER

fostsis 16 FOSTER SISTER

fostbro 17 FOSTER BROTHER

adoptsis 18 ADOPTIVE SISTER

adoptbro 19 ADOPTIVE BROTHER

bioson 20 SON (BIOLOGICAL)

biodaughter 21 DAUGHTER (BIOLOGICAL)

adoptson 22 ADOPTIVE SON

adoptdaughter 23 ADOPTIVE DAUGHTER

stepson 24 STEP-SON

stepdaughter 25 STEP-DAUGHTER

fostson 26 FOSTER SON

fostdaughter 27 FOSTER DAUGHTER

spouse 30 SPOUSE (HUSBAND/WIFE)

partner 31 UNMARRIED PARTNER, BOYFRIEND/GIRLFRIEND

aunt 40 AUNT

uncle 41 UNCLE

greataunt 42 GREAT AUNT

greatuncle 43 GREAT UNCLE

cousin 44 COUSIN

niece 45 NIECE

nephew 46 NEPHEW

matgrandma 50 MATERNAL GRANDMOTHER

patgrandma 51 PATERNAL GRANDMOTHER

matgrandpa 52 MATERNAL GRANDFATHER

patgrandpa 53 PATERNAL GRANDFATHER

matgrgrandma 54 MATERNAL GREAT-GRANDMOTHER

patgrgrandma 55 PATERNAL GREAT-GRANDMOTHER

matgrgrandpa 56 MATERNAL GREAT-GRANDFATHER

patgrgrandpa 57 PATERNAL GREAT-GRANDFATHER

otherrel 60 OTHER BLOOD RELATIVE

partnerrel 70 RELATIVE OF UNMARRIED PARTNER (BOYFRIEND/GIRLFRIEND)

roommate 80 ROOMMATE

othernonrel 81 OTHER NON-RELATIVE

Logic after:

YCH38baxa--Relation to R: Person child 1 lives with; YCH38bbxa--Relation to R: Person child 2

lives with; YCH38bcxa--Relation to R: Person child 3 lives with; YCH38bdxa--Relation to R: Person

child 4 lives with; YCH38bexa--Relation to R: Person child 5 lives with; YCH38bfxa--Relation to R:

Person child 6 lives with; YCH38bgxa--Relation to R: Person child 7 lives with; YCH38bhxa--

Relation to R: Person child 8 lives with; YCH38bixa--Relation to R: Person child 9 lives with;

YCH38bjxa--Relation to R: Person child 10 lives with

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

Y_CH38ca [ YCH38ca ] Labels are in Logic After

CHILD IN QUESTION: ^Y_CH36aa[L]


Do you have legal custody of ^Y_CH36aa[L]?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH38ca = 1 GOTO Y_CH39a; IF Y_CH38ca = 2 GOTO Y_CH39a; YCH38caa--R has legal

custody of child 1; YCH38cba--R has legal custody of child 2; YCH38cca--R has legal custody of

child 3; YCH38cda--R has legal custody of child 4; YCH38cea--R has legal custody of child 5;

YCH38cfa--R has legal custody of child 6; YCH38cga--R has legal custody of child 7; YCH38cha--R

has legal custody of child 8; YCH38cia--R has legal custody of child 9; YCH38cja--R has legal

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

Y_CH39a [ YCH39a ] Labels are in Logic After

CHILD IN QUESTION: ^Y_CH36aa[L]


Are you the primary caregiver for ^Y_CH36aa[L]? That is, are you the person who makes the

decisions about care, including daily routine, health care, and child care?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH39a = 1 GOTO Y_CH40a; IF Y_CH39a = 2 GOTO Y_CH39aa; YCH39aa--R primary

caregiver to child 1; YCH39ba--R primary caregiver to child 2; YCH39ca--R primary caregiver to

child 3; YCH39da--R primary caregiver to child 4; YCH39ea--R primary caregiver to child 5;

YCH39fa--R primary caregiver to child 6; YCH39ga--R primary caregiver to child 7; YCH39ha--R

primary caregiver to child 8; YCH39ia--R primary caregiver to child 9; YCH39ja--R primary caregiver

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

Y_CH39aa [ YCH39aax ] Labels are in Logic After

USE CARD 3. Who is the primary caregiver for ^Y_CH36aa[L]? Looking at Card 3, tell me the

person's relationship to you.

Question Type: TCH29a

biomom 2 MOTHER (BIOLOGICAL)

biodad 3 FATHER (BIOLOGICAL)

stepmom 4 STEP-MOTHER

stepdad 5 STEP-FATHER

adoptmom 6 ADOPTIVE MOTHER

adoptdad 7 ADOPTIVE FATHER

fostmom 8 FOSTER MOTHER

fostdad 9 FOSTER FATHER

sister 10 FULL SISTER

brother 11 FULL BROTHER

halfsis 12 HALF SISTER

halfbro 13 HALF BROTHER

stepsis 14 STEP-SISTER

stepbro 15 STEP-BROTHER

fostsis 16 FOSTER SISTER

fostbro 17 FOSTER BROTHER

adoptsis 18 ADOPTIVE SISTER

adoptbro 19 ADOPTIVE BROTHER

bioson 20 SON (BIOLOGICAL)

biodaughter 21 DAUGHTER (BIOLOGICAL)

adoptson 22 ADOPTIVE SON

adoptdaughter 23 ADOPTIVE DAUGHTER

stepson 24 STEP-SON

stepdaughter 25 STEP-DAUGHTER

fostson 26 FOSTER SON

fostdaughter 27 FOSTER DAUGHTER

spouse 30 SPOUSE (HUSBAND/WIFE)

partner 31 UNMARRIED PARTNER, BOYFRIEND/GIRLFRIEND

aunt 40 AUNT

uncle 41 UNCLE

greataunt 42 GREAT AUNT

greatuncle 43 GREAT UNCLE

cousin 44 COUSIN

niece 45 NIECE

nephew 46 NEPHEW

matgrandma 50 MATERNAL GRANDMOTHER

patgrandma 51 PATERNAL GRANDMOTHER

matgrandpa 52 MATERNAL GRANDFATHER

patgrandpa 53 PATERNAL GRANDFATHER

matgrgrandma 54 MATERNAL GREAT-GRANDMOTHER

patgrgrandma 55 PATERNAL GREAT-GRANDMOTHER

matgrgrandpa 56 MATERNAL GREAT-GRANDFATHER

patgrgrandpa 57 PATERNAL GREAT-GRANDFATHER

otherrel 60 OTHER BLOOD RELATIVE

partnerrel 70 RELATIVE OF UNMARRIED PARTNER (BOYFRIEND/GIRLFRIEND)

roommate 80 ROOMMATE

othernonrel 81 OTHER NON-RELATIVE

Logic after:

YCH39aaxa--Relation to R: prim cg to child 1; YCH39abxa--Relation to R: prim cg to child 2;

YCH39acxa--Relation to R: prim cg to child 3; YCH39adxa--Relation to R: prim cg to child 4;

YCH39aexa--Relation to R: prim cg to child 5; YCH39afxa--Relation to R: prim cg to child 6;

YCH39agxa--Relation to R: prim cg to child 7; YCH39ahxa--Relation to R: prim cg to child 8;

YCH39aixa--Relation to R: prim cg to child 9; YCH39ajxa--Relation to R: prim cg to child 10

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

Logic before:

ASK Y_CH40a IF Y_CH37a = 2; ELSE GO TO Y_CH37a FOR NEXT CHILD LISTED IN Y_CH36aa

Y_CH40a [ YCH40a ] Labels are in Logic After

During the last 12 months, did you make any child support payments to support ^Y_CH36aa[L]?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

YCH40aa--Make support payments for child 1; YCH40ba--Make support payments for child 2;

YCH40ca--Make support payments for child 3; YCH40da--Make support payments for child 4;

YCH40ea--Make support payments for child 5; YCH40fa--Make support payments for child 6;

YCH40ga--Make support payments for child 7; YCH40ha--Make support payments for child 8;

YCH40ia--Make support payments for child 9; YCH40ja--Make support payments for child 10

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

Y_CH41a [ YCH41a ] Number times moved in last 12 months

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

the last 12 months?


NUMBER:

Question Type: 0..100

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

Y_CH42a [ YCH42a ] Type of housing

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

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

Question Type: TCH42a

own 1 Own

rent 2 Rent

staying 3 Just staying there

other 4 Other

Logic after:

IF Y_CH42a = 1, 3 OR 4 GOTO Y_CH45a

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

Y_CH43a [ YCH43a ] Housing in R name

Is that place in your name? Is your name on the lease or rental agreement?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

Y_CH44a [ YCH44a ] Live in public housing

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

public agency?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

Logic before:

IF Y_CH29a = 2 GOTO Y_CH47a

Y_CH45a [ YCH45a ] Know bio mother

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

mom?


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

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH45a = 2 GOTO Y_CH47a

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

Y_CH46a [ YCH46a ] How often have contact with bio mother

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

Question Type: TCH46a

never 1 never,

lessonce 2 less than once a month,

oncetwice 3 once or twice a month,

oncewk 4 about once a week,

sevweek 5 several times a week, or

everyday 6 every day?

deceased 7 BIOLOGICAL MOTHER IS DECEASED

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

Logic before:

IF Y_CH29a = 3 GOTO Y_CH49a

Y_CH47a [ YCH47a ] Know bio father

Do you know your biological dad?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH47a = 2 GOTO Y_CH49a

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

Y_CH48a [ YCH48a ] How often have contact with bio father

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

Question Type: TCH48a

never 1 never,

lessonce 2 less than once a month,

oncetwice 3 once or twice a month,

oncewk 4 about once a week,

sevweek 5 several times a week, or

everyday 6 every day?

deceased 7 BIOLOGICAL FATHER IS DECEASED

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

Y_CH49a [ YCH49a ] Have bio siblings

Do you have biological siblings?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH49a = 2 GOTO Y_CH51a

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

Y_CH50a [ YCH50a ] How often have contact with bio siblings

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

Question Type: TCH50a

never 1 never,

lessonce 2 less than once a month,

oncetwice 3 once or twice a month,

oncewk 4 about once a week,

sevweek 5 several times a week, or

everyday 6 every day?

deceased 7 BIOLOGICAL SIBLINGS ARE DECEASED

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

Y_CH51a [ YCH51a ] Have contact w/other family members

Are there other members of your family such as aunts, uncles, or cousins, that you like to see?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_CH51a = 2 GOTO Y_CHEND

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

Y_CH52a [ YCH52a ] How often have contact w/oth fam members

About how often do you see or have contact with them? Would you say...

Question Type: TCH52a

never 1 never,

once 2 once in a while,

sometimes 3 sometimes, or

usually 4 usually?

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

Y_CH_END [ YCH_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue



KB - CHILD COGNITIVE STATUS: KBIT-2 MODULE


Source: Kaufman Brief Intelligence Test, Second Edition (KBIT-2): by Alan Kaufman and Nadeen Kaufman; Pearson; copyright 2004. Standardized assessment tool measuring abilities through two scales: a Crystallized (Verbal) Scale containing verbal knowledge and riddles items, and a Fluid (Nonverbal) Scale /Matrices. Not administered for Spanish-language interviews. For children age 4 and above.

BD - CHILD COGNITIVE STATUS: BDI-COGNITIVE MODULE


Battelle Developmental Inventory & Screening Test, Second Edition (BDI-2): Cognitive Skills. Newborg (2004, 2016); Houghton, Mifflin, Harcourt. Cognitive skills; administered to age 4 and older if K-BIT score=0.





NI - CHILD NEURODEVELOPMENTAL IMPAIRMENT: BINS MODULE

Skip Logic:

IF AGE > 2, SKIP TO NEXT SECTION

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

Y_NI_BGN [ YNI_BGN ] NoDeliv

CHILD NEURODEVELOPMENTAL IMPAIRMENT: BINS MODULE


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

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

Logic before:

IF AGE IS 3 TO 4 MONTHS OLD, CONTINUE. ELSE, SKIP TO Y_NIb1a.

Y_NIa1a [ YNIa1a ] BINS 3-4 Mths Item 1:

@BEyes Follow Ring@B


@BMATERIALS:@B RING WITH STRING

@BPOSITION:@B LYING DOWN, FACE UP


@BADMINISTRATION: @B

- FROM BEHIND INFANT, HOLD STRING SO THAT RING IS 8 INCHES ABOVE INFANT'S

EYES, WITH LOWER EDGE AT MIDLINE.

- ATTRACT HIS/HER GAZE TO RING AND SLOWLY MOVE IT TO HIS/HER RIGHT, THEN

LEFT, AND BACK TO MIDLINE, HORIZONTALLY, KEEPING IT 8 INCHES ABOVE INFANT (1

EXCURSION).

- IF HIS/HER GAZE LEAVES THE RING, GET ATTENTION AGAIN AND PROCEED.

- DO 3 EXCURSIONS MAXIMUM.


@BSCORING: @B

1 = EYES FOLLOW RING @UTHROUGH 1 COMPLETE EXCURSION@U, EVEN IF THEY

BREAK AWAY ONCE OR TWICE DURING EACH EXCURSION.

0 = @UUNABLE@U TO FOLLOW RING @UTHROUGH 1 EXCURSION@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIa1b [ YNIa1b ] BINS 3-4 Mths Item 2:

@BReaches for Hanging Ring@B


@BMATERIALS:@B RING WITH STRING

@BPOSITION:@BLYING DOWN, FACE UP


@BADMINISTRATION:@B

- SCORE THIS ITEM IF INFANT HAS ALREADY REACHED FOR AN OBJECT.

- IF NOT, HOLD RING BY STRING 8 INCHES ABOVE HIS/HER EYES AT HIS/HER MIDLINE.

- MOVE RING SLIGHTLY TO ATTRACT ATTENTION, AND THEN HOLD STILL.

- IF HE/SHE DOES NOT REACH FOR RING, PLACE IT IN HIS/HER HAND AND ALLOW TO

HOLD BRIEFLY, AND THEN RE-ADMINISTER.


@BSCORING:@B

1 = INFANT @UINCREASES HAND MOVEMENT@U, PURPOSELY MOVES ARM(S),

@UOR@U MARKEDLY INCREASES @UARM MOVEMENT IN THE RING'S GENERAL

DIRECTION@U. (CONTACT WITH RING IS NOT NEEDED.)

0 = DOES @UNOT@U DO THE ABOVE, OR ARM @UMOVEMENT IS INCIDENTALLY IN

DIRECTION OF@U RING, @UOR NOT IN DIRECTION OF RING@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIa1c [ YNIa1c ] BINS 3-4 Mths Item 3:

@BHolds Head Erect and Steady for 15 Seconds@B


@BMATERIALS:@B NONE

@BPOSITION:@B HELD TO YOUR SHOULDER


@BADMINISTRATION:@B

- PLACE YOUR FINGERS ALONG BACK OF INFANT'S NECK TO SUPPORT HEAD.

- LIFT TO UPRIGHT POSITION, RESTING HIS/HER HEAD ON YOUR SHOULDER.

- MOVE ONE HAND TO SUPPORT INFANT'S BACK.

- CAREFULLY REMOVE YOUR HAND FROM THE NECK ACCORDING TO HIS/HER ABILITY

TO LIFT HEAD FROM SHOULDER AND HOLD IT ERECT.


@BSCORING:@B

1 = HOLDS HEAD @UERECT AND STEADY@U FOR APPROXIMATELY @U15 SECONDS@U.


0 = DOES @UNOT@U LIFT HEAD, HEAD BOBS OR FLOPS AROUND, OR HEAD IS ERECT

FOR @ULESS THAN 15 SECONDS@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIa1d [ YNIa1d ] BINS 3-4 Mths Item 4:

@BAdjusts Head to Line Up Head with Body@B

@BMATERIALS:@B NONE

@BPOSITION:@B LYING DOWN, FACE DOWN


@BADMINISTRATION: @B

- LIFT INFANT BY SIDES OF CHEST, TO 8-10 INCHES ABOVE EXAM SURFACE.

- HOLD HORIZONTAL TO SURFACE, FACE DOWN.


@BSCORING:@B

1 = BRIEFLY @UADJUSTS HEAD IN LINE WITH BODY@U OR RAISED SLIGHTLY UP.

0 = @UHEAD DROOPS@U TOWARD EXAM SURFACE.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIa1e [ YNIa1e ] BINS 3-4 Mths Item 5:

@BDemonstrates Optimal Muscle Tone in Forearms, Biceps, and Shoulders@B

@BMATERIALS:@B NONE

@BPOSITION:@B LYING DOWN, FACE UP


@BADMINISTRATION:@B

- STAND AT INFANT'S FEET AND LEAN OVER HIM/HER.

- LIGHTLY GRASP THE WRISTS AND EXTEND ARMS UNTIL APPROXIMATELY PARALLEL

TO BODY.

- BEND ARMS UNTIL FOREARMS ARE PRESSED AGAINST BICEPS, THEN EXTEND AGAIN.


- REPEAT 2 OR 3 TIMES TO TEST RESISTANCE.

- THEN MOVE ARMS FROM SIDES TO PERPENDICULAR (AT A 90 DEGREE ANGLE) WITH

BODY, OUT TO SIDES, 2 OR 3 TIMES.

- USE SMOOTH, CONTINUOUS MOTION.


@BSCORING:@B

1 = FOREARMS, BICEPS, SHOULDERS EXERT @UMODERATE RESISTANCE@U WHEN

ARMS ARE EXTENDED BOTH PARALLEL AND PERPENDICULAR (AT A 90 DEGREE ANGLE)

TO BODY.

0 = @ULITTLE OR NO RESISTANCE@U EXERTED BY MUSCLES, @UOR@U THEY ARE

TIGHT AND @UDIFFICULT TO EXTEND@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIa1f [ YNIa1f ] BINS 3-4 Mths Item 6:

@BDemonstrates Optimal Muscle Tone in Legs and Hips@B


@BMATERIALS:@B NONE

@BPOSITION:@B LYING DOWN, FACE UP


@BADMINISTRATION:@B

- STAND AT INFANT'S FEET AND LEAN OVER HIM/HER.

- LIGHTLY GRASP HIS/HER ANKLES AND PUSH LEGS UP, BENDING KNEES, UNTIL YOU

FEEL RESISTANCE.

- GENTLY PULL LEGS TO EXTENDED POSITION AND RELEASE.

- REPEAT 2 OR 3 TIMES.

- PUSH LEGS UP AGAIN, BENDING KNEES, UNTIL RESISTANCE, SLIDE YOUR THUMBS

UP TO THE INSIDE OF KNEES AND PUSH LEGS OUTWARD FROM MIDLINE TO FORM A 120

DEGREE ANGLE.

- THEN EXTEND LEGS AS YOU BRING THEM BACK TO MIDLINE.

- REPEAT 2 OR 3 TIMES WITH A SMOOTH AND CONTINUOUS MOTION.


@BSCORING:@B

1 = LEGS AND HIPS EXERT @UMODERATE RESISTANCE@U WHEN LEGS BENT AND

PUSHED UP AND PUSHED OUT; BENDS LEGS IN @URELAXED@U MANNER WHEN

EXTENDED LEGS ARE @URELEASED@U.

0 = DURING EITHER MANEUVER LEG OR HIP SHOWS @ULITTLE OR NO RESISTANCE@U,

OR SHOWS @UEXAGGERATED OR NO BENDING WHEN RELEASED@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIa2g [ YNIa2g ] BINS 3-4 Mths Item 7:

@BSits with Slight Support for 10 seconds@B


@BMATERIALS:@B NONE

@BPOSITION:@B SEATED


@BADMINISTRATION:@B

- SEAT INFANT WITH LEGS SLIGHTLY BENT AND SPREAD TO 45 DEGREE ANGLE.

- SUPPORT THE LOWER BACK AND GRADUALLY LOOSEN YOUR HOLD ON THE INFANT

ACCORDING TO HIS/HER ABILITY TO SIT UNSUPPORTED.


@BSCORING:@B

1 = SITS WITH SUPPORT FOR AT LEAST @U10 SECONDS@U.

0 = SITS WITH SUPPORT @ULESS THAN 10 SECONDS@U OR @UDOESN'T TENSE

MUSCLES@U IN AN EFFORT TO STAY SITTING.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIa2h [ YNIa2h ] BINS 3-4 Mths Item 8:

@BLooks at Pellet with Smooth and Coordinated Eye Movements@B


@BMATERIALS:@B SUGAR PELLET

@BPOSITION:@B SEATED


@BTELL CAREGIVER: This pellet is sugar and won't harm (him/her).@B


@BADMINISTRATION:@B

- OBSERVE ABILITY TO VISUALLY FOCUS ON OBJECTS PLACED BEFORE HIM/HER AND

IF EYE MOVEMENTS ARE SMOOTH AND COORDINATED.

- IF UNABLE TO OBSERVE GAZE, PLACE PELLET ON EXAM SURFACE ABOUT 18 IN.

FROM INFANT.

- IF INFANT DOES NOT IMMEDIATELY REGARD PELLET, TAP NEAR IT AND QUICKLY

MOVE HAND AWAY.


@BSCORING:@B

1 = LOOKS AT PELLET FOR AT LEAST @U3 SECONDS@U. @UBOTH EYES SHOULD BE

COORDINATED@U AND CONVERGE (COME TOGETHER) ON THE PELLET.

0 = EYES @UCROSS@U, OSCILLATE (MOVE BACK AND FORTH), OR @UWANDER@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIa2i [ YNIa2i ] BINS 3-4 Mths Item 9:

@B*Vocalizes Two Different Sounds@B


@BMATERIALS:@B NONE

@BPOSITION:@B UNSPECIFIED


@BADMINISTRATION:@B

- THROUGHOUT THE EXAM LISTEN FOR ANY VOCALIZATIONS (SOUNDS) INFANT

PRODUCES FREELY.

- IF HE/SHE DOES NOT VOCALIZE, ASK CAREGIVER: @BDoes ^CHILD make any sounds?

What are they? Please help me get (him/her) to make these sounds.@B


@BSCORING:@B

1 = VOCALIZES AT LEAST @UTWO DIFFERENT@U SOUNDS.

0 = VOCALIZES @UFEWER THAN TWO@U SOUNDS.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIa2j [ YNIa2j ] BINS 3-4 Mths Item 10:

@B*Fingers Hands in Play@B


@BMATERIALS:@B NONE

@BPOSITION:@B SITTING OR LYING


@BADMINISTRATION:@B THROUGHOUT EXAM OBSERVE INFANT'S BEHAVIOR WHEN

SITTING OR LYING QUIETLY; FREE TO FOLLOW HIS/HER OWN INTERESTS.


@BSCORING:@B

1 = @UPURPOSELY@U FINGERS ONE HAND WITH THE OTHER.

0 = @UHANDS DON'T@U PLAY WITH EACH OTHER @UOR@U HANDS CONTACT EACH

OTHER @UINCIDENTALLY@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIa2k [ YNIa2k ] BINS 3-4 Mths Item 11:

@B*Demonstrates Coordinated Movement of Arms and Legs@B


@BMATERIALS:@B NONE

@BPOSITION:@B UNSPECIFIED


@BADMINISTRATION:@B THROUGHOUT THE EXAM OBSERVE THE QUALITY OF THE

INFANT'S ARM AND LEG MOVEMENTS.


@BSCORING:@B

1 = MOVEMENTS ARE @USMOOTH@U, MUSCLES ARE NEITHER RIGID NOR FLOPPY,

THERE IS @UBALANCE OF BENDING AND STRAIGHTENING@U.

0 = MOVEMENT IS @UJERKY@U, ERRATIC, OR CLUMSY; MUSCLES ARE EITHER @URIGID

OR FLOPPY@U, OR @UPREDOMINANTLY BENT OR STRAIGHTENED@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

Logic after:

GOTO Y_NIEND

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

Logic before:

IF AGE IS 5 TO 6 MONTHS OLD, CONTINUE. ELSE, SKIP TO Y_NIc1a.

Y_NIb1a [ YNIb1a ] BINS 5-6 Mths Item 1:

@Blooks at Pellet with Smooth and Coordinated Eye Movements@B


@BMATERIALS:@B SUGAR PELLET

@BPOSITION:@B SEATED


@BTELL CAREGIVER: This pellet is sugar and won't harm (him/her).@B


@BADMINISTRATION:@B

- OBSERVE ABILITY TO VISUALLY FOCUS ON OBJECTS PLACED BEFORE HIM/HER AND

IF EYE MOVEMENTS ARE SMOOTH AND COORDINATED.

- IF UNABLE TO OBSERVE GAZE, PLACE PELLET ON EXAM SURFACE ABOUT 18 IN.

FROM INFANT.

- IF INFANT DOES NOT IMMEDIATELY REGARD PELLET, TAP NEAR IT AND QUICKLY

MOVE HAND AWAY.


@BSCORING:@B

1 = LOOKS AT PELLET FOR AT LEAST @U3 SECONDS@U. @UBOTH EYES SHOULD BE

COORDINATED@U AND CONVERGE (COME TOGETHER) ON THE PELLET.

0 = EYES @UCROSS@U, OSCILLATE (MOVE BACK AND FORTH), OR @UWANDER@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIb1b [ YNIb1b ] BINS 5-6 Mths Item 2:

@BSeparates Thumb from Fingers to grasp Cube (grasps one side of the cube with thumb and a

different side with the fingers)@B


@BMATERIALS:@B CUBE

@BPOSITION:@B SEATED


@BADMINISTRATION:@B

- PLACE CUBE ON EXAM SURFACE, IN FRONT OF INFANT AND WITHIN REACH.

- IF HE/SHE DOES NOT IMMEDIATELY GRASP THE CUBE, ATTRACT ATTENTION BY

TAPPING THE CUBE ON THE EXAM SURFACE AND QUICKLY MOVE HAND AWAY.


@BSCORING:@B

1 = GRASPS CUBE WITH HAND SO THAT @UTHUMB IS SEPARATED OR INDEPENDENT

FROM FINGERS OR PALM@U; OR HOLDS CUBE BETWEEN THE PAD OF THUMB AND THE

PADS OF ANY FINGERTIPS.

0 = DOES @UNOT GRASP WITH THUMB SEPARATED OR INDEPENDENT@U FROM

FINGERS OR PALM.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIb1c [ YNIb1c ] BINS 5-6 Mths Item 3:

@B*Bangs in Play@B


@BMATERIALS:@B SPOON, CUBE, OR HARD OBJECT

@BPOSITION:@B SEATED


@BADMINISTRATION:@B

- THROUGHOUT THE EXAM OBSERVE INFANT TO SEE IF HE/SHE USES AN OBJECT TO

PURPOSELY BANG ANY SURFACE.

- IF HE/SHE DOES NOT DISPLAY THIS BEHAVIOR, OFFER THE SPOON, CUBE, OR HARD

OBJECT, PLACING IT IN HIS/HER HAND IF NECESSARY.


@BSCORING:@B

1 = @UPURPOSELY@U BANGS IN PLAY WITH AN OBJECT ANY TIME DURING EXAM.

0 = @UONLY INCIDENTALLY@U CONTACTS EXAM SURFACE WITH AN OBJECT, EVEN IF

THAT CONTACT PRODUCES A NOISE, OR ONLY BANGS WITH HANDS.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIb1d [ YNIb1d ] BINS 5-6 Mths Item 4:

@B*Transfers Object from Hand to Hand@B


@BMATERIALS:@B RING, SPOON, OR OTHER OBJECT

@BPOSITION:@B SEATED


@BADMINISTRATION:@B

- THROUGHOUT THE EXAM OBSERVE WHETHER THE INFANT TRANSFERS AN OBJECT

FROM ONE HAND TO THE OTHER.

- IF YOU DO NOT OBSERVE THIS, PLACE AN OBJECT IN THE INFANT'S HANDS AND

WATCH FOR TRANSFER FROM HAND TO HAND.


@BSCORING:@B

1 = TRANSFERS OBJECT FROM @UHAND TO HAND@U.

0 = TRANSFER OCCURS ONLY WHEN FREE HAND CONTACTS OBJECT @UBY

CHANCE@U, INFANT @URELEASES@U THE OBJECT FROM HAND @UAND PICKS IT UP

WITH THE OTHER@U, OR USES @UOTHER PART@U OF THE BODY TO FACILITATE

@UTRANSFER@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIb1e [ YNIb1e ] BINS 5-6 Mths Item 5:

@B*Looks for Fallen Spoon@B


@BMATERIALS:@B SPOON

@BPOSITION:@B SEATED


@BADMINISTRATION:@B

- THROUGHOUT EXAM OBSERVE WHETHER INFANT VISUALLY SEARCHES FOR

OBJECTS THAT ARE MOVED OUT OF FIELD OF VISION.

- IF YOU DO NOT OBSERVE THIS, PLACE A HARD SURFACE ON CARPET NEXT TO TABLE

EDGE NEAR INFANT.

- PLACE A SPOON ON THE TABLE EDGE ABOVE THE HARD SURFACE; HOLD IT IN

PLACE WITH THE ROUND END OF SPOON EXTENDING PAST THE TABLE EDGE.

- WHEN THE INFANT IS ATTENDING THE SPOON (GET ATTENTION WITH A SOUND IF

NEEDED), LET THE SPOON FALL AND LAND NOISILY.


@BSCORING:@B

1 = SEARCHES FOR FALLEN SPOON BY @ULOOKING TOWARD FLOOR@U WHERE IT

FELL.

0 = @UDOES NOT LOOK IN DIRECTION@U OF FALLEN SPOON.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIb1f [ YNIb1f ] BINS 5-6 Mths Item 6:

@BSits with Slight Support for 10 Seconds@B


@BMATERIALS:@B NONE

@BPOSITION:@B SEATED


@BADMINISTRATION:@B

- SEAT INFANT WITH LEGS SLIGHTLY BENT AND SPREAD TO 45 DEGREE ANGLE.

- SUPPORT THE LOWER BACK AND GRADUALLY LOOSEN YOUR HOLD ON THE INFANT

ACCORDING TO HIS/HER ABILITY TO SIT UNSUPPORTED.


@BSCORING:@B

1 = SITS WITH SUPPORT FOR AT LEAST @U10 SECONDS@U.

0 = SITS WITH SUPPORT @ULESS THAN 10 SECONDS@U OR @UDOESN'T TENSE

MUSCLES@U IN AN EFFORT TO STAY SITTING.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIb2g [ YNIb2g ] BINS 5-6 Mths Item 7:

@BMoves Forward Using Prewalking Methods@B


@BMATERIALS:@B BELL

@BPOSITION:@B LYING DOWN, FACE DOWN


@BADMINISTRATION:@B

- PLACE INFANT LYING DOWN, FACE DOWN ON FLOOR AND OBSERVE MODE OF

LOCOMOTION (MOVEMENT OR MOTION).

- IF INFANT DOES NOT BEGIN TO MOVE FORWARD, PLACE A BELL ON THE FLOOR IN

FRONT OF HIM/HER BUT OUT OF REACH.


@BSCORING:@B

1 = MAKES PROGRESS OF @U9 IN. OR MORE@U, ON HANDS AND KNEES, ON STOMACH

USING ARMS TO PULL, @UON HANDS AND FEET@U, @UOR@U ON @UBUTTOCKS@U.

0 = MAKES @UNO ATTEMPT TO MOVE@U IN ANY OF THESE WAYS @UOR@U MOVES

@ULESS THAN 9 INCHES@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIb2h [ YNIb2h ] BINS 5-6 Mths Item 8:

@BDemonstrates Optimal Muscle Tone While Pulling to Sitting Position@B


@BMATERIALS:@B NONE

@BPOSITION:@B LYING DOWN, FACE UP


@BCAUTION: IF INFANT'S HEAD COMPLETELY FALLS BACK WHEN HE/SHE BEGINS TO

PULL UPWARD, DISCONTINUE.@B


@BADMINISTRATION:@B

- STAND AT INFANT'S FEET AND LEAN OVER HIM/HER.

- PLACE YOUR THUMBS IN THE PALMS OF INFANT'S HANDS AND WRAP YOUR FINGERS

AROUND THE BACK OF HIS/HER HANDS.

- ALLOW INFANT TO PULL TO A SITTING POSITION AND STANDING POSITION IF ABLE.

- GRADUALLY RAISE YOUR HANDS AS THE INFANT PULLS UP, BUT DO NOT PULL INFANT

UP.


@BSCORING:@B

1 = FLEXOR TONE IN HIS/HER UPPER BODY (ARMS, SHOULDERS, UPPER BACK)

INCREASES SO THAT YOU @UCAN FEEL HIM/HER PULLING UPWARD@U.

0 = UPPER BODY IS WEAK AND INFANT @UDOES NOT PULL TOWARD YOU@U, @UOR@U

IF HE/SHE PULLS TOWARD YOU BUT UPPER BODY @UTONE IS RIGID@U AND ARMS

AND BACK @ULOCK IN A STIFF POSITION@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIb2i [ YNIb2i ] BINS 5-6 Mths Item 9:

@BDemonstrates Optimal Muscle Tone in Forearms, Biceps, and Shoulders@B


@BMATERIALS:@B NONE

@BPOSITION:@B LYING DOWN, FACE UP


@BADMINISTRATION:@B

- STAND AT INFANT'S FEET AND LEAN OVER HIM/HER.

- LIGHTLY GRASP THE WRISTS AND EXTEND ARMS UNTIL APPROXIMATELY PARALLEL

TO BODY.

- BEND ARMS UNTIL FOREARMS ARE PRESSED AGAINST BICEPS, AND THEN EXTEND

AGAIN.

- REPEAT 2 OR 3 TIMES TO TEST RESISTANCE.

- THEN MOVE ARMS FROM SIDES TO PERPENDICULAR (AT A 90 DEGREE ANGLE) WITH

BODY, OUT TO SIDES, 2 OR 3 TIMES.

- USE SMOOTH, CONTINUOUS MOTION.


@BSCORING:@B

1 = FOREARMS, BICEPS, SHOULDERS EXERT @UMODERATE RESISTANCE@U WHEN

ARMS ARE EXTENDED BOTH PARALLEL AND PERPENDICULAR (AT A 90 DEGREE ANGLE)

TO BODY.

0 = @ULITTLE OR NO RESISTANCE@U EXERTED BY MUSCLES, @UOR@U THEY ARE

TIGHT AND @UDIFFICULT TO EXTEND@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIb2j [ YNIb2j ] BINS 5-6 Mths Item 10:

@BDemonstrates Optimal Muscle Tone in Legs and Hips@B


@BMATERIALS:@B NONE

@BPOSITION:@B LYING DOWN, FACE UP


@BADMINISTRATION:@B

- STAND AT INFANT'S FEET AND LEAN OVER HIM/HER.

- LIGHTLY GRASP THE ANKLES, PUSH LEGS UP, BENDING KNEES, UNTIL YOU FEEL

RESISTANCE.

- GENTLY PULL LEGS TO EXTENDED POSITION AND RELEASE.

- REPEAT 2 OR 3 TIMES.

- PUSH LEGS UP AGAIN, BENDING KNEES, UNTIL RESISTANCE, SLIDE YOUR THUMBS

UP TO THE INSIDE OF KNEES AND PUSH LEGS OUTWARD FROM MIDLINE TO FORM A 120

DEGREE ANGLE.

- THEN EXTEND LEGS AS YOU BRING THEM BACK TO MIDLINE.

- REPEAT 2 OR 3 TIMES WITH A SMOOTH AND CONTINUOUS MOTION.


@BSCORING:@B

1 = LEGS AND HIPS EXERT @UMODERATE RESISTANCE@U WHEN LEGS BENT AND

PUSHED UP AND PUSHED OUT; BENDS LEGS IN @URELAXED@U MANNER WHEN

EXTENDED LEGS ARE @URELEASED@U.

0 = DURING EITHER MANEUVER LEG OR HIP SHOWS @ULITTLE OR NO RESISTANCE@U,

OR SHOWS @UEXAGGERATED OR NO@U BENDING WHEN RELEASED.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIb2k [ YNIb2k ] BINS 5-6 Mths Item 11:

@B*Vocalizes One Vowel Sound@B


@BMATERIALS:@B NONE

@BPOSITION:@B UNSPECIFIED


@BADMINISTRATION:@B

- THROUGHOUT THE EXAM LISTEN FOR ANY DISTINCT VOWEL SOUNDS SUCH AS "AA,

OO, A, AH, UH, EE, EH" THAT INFANT PRODUCES FREELY.

- IF HE/SHE DOES NOT VOCALIZE, ASK CAREGIVER: @B"Does ^CHILD make sounds?

What are they? Please help me get (him/her) to make these sounds."@B


@BSCORING:@B

1 = VOCALIZES AT LEAST @UONE VOWEL@U SOUND. THE SOUND NEED NOT HAVE

MEANING TO THE INFANT.

0 = DOES @UNOT@U VOCALIZE AT LEAST ONE VOWEL SOUND.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIb2l [ YNIb2l ] BINS 5-6 Mths Item 12:

@B*Demonstrates Coordinated Movement of Arms and Legs@B


@BMATERIALS:@B NONE

@BPOSITION:@B UNSPECIFIED


@BADMINISTRATION:@B

THROUGHOUT THE EXAM OBSERVE THE QUALITY OF THE INFANT'S ARM AND LEG

MOVEMENTS.


@BSCORING:@B

1 = MOVEMENTS ARE @USMOOTH@U, MUSCLES ARE NEITHER RIGID NOR FLOPPY,

THERE IS @UBALANCE OF BENDING AND STRAIGHTENING@U.

0 = MOVEMENTS @UJERKY@U, ERRATIC, OR CLUMSY, MUSCLES ARE EITHER @URIGID

OR FLOPPY@U, OR @UPREDOMINANTLY BENT OR STRAIGHTENED@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIb2m [ YNIb2m ] BINS 5-6 Mths Item 13:

@B*Imitates Others@B


@BMATERIALS:@B NONE

@BPOSITION:@B UNSPECIFIED


@BADMINISTRATION:@B

THROUGHOUT THE EXAM OBSERVE WHETHER INFANT IMITATES CAREGIVER'S OR YOUR

BEHAVIOR OR BODY GESTURES, OR SOUND THAT HE/SHE HEARS.


@BSCORING:@B

1 = @UIMITATES@U A FACIAL EXPRESSION, A NOISE, OR A MOVEMENT OR GESTURE

MADE BY YOU, CAREGIVER, OR TOY.

0 = DOES @UNOT@U PRODUCE AT LEAST ONE IMITATION.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

Logic after:

GOTO Y_NIEND

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

Logic before:

IF AGE IS 7 TO 10 MONTHS OLD, CONTINUE. ELSE, SKIP TO Y_NId1a.

Y_NIc1a [ YNIc1a ] BINS 7-10 Mths Item 1:

@BUses Pads of Fingertips to Grasp Pellet@B


@BMATERIALS:@B SUGAR PELLET

@BPOSITION:@B SEATED


@BTELL CAREGIVER: This pellet is sugar and won't harm (him/her).@B


@BADMINISTRATION:@B

- PLACE THE PELLET ON THE EXAM SURFACE IN FRONT OF INFANT AND WITHIN REACH.


- ATTRACT INFANT'S ATTENTION BY TAPPING NEAR PELLET.

- TIP THE EDGE OF PELLET, MAKING IT ROCK, THEN REMOVE YOUR HAND WHILE IT IS

MOVING.


@BSCORING:@B

1 = USES THE @UPAD OF THUMB AND@U THE @UPADS OF ANY FINGERTIPS@U TO

GRASP PELLET.

0 = DOES @UNOT@U GRASP PELLET @UOR@U GRASPS IT @UWITHOUT@U USING THE

PADS OF THUMB AND FINGERTIPS.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIc1b [ YNIc1b ] BINS 7-10 Mths Item 2:

@BRings Bell Purposely@B


@BMATERIALS:@B BELL

@BPOSITION:@B SEATED


@BADMINISTRATION:@B

- HOLD BELL IN FRONT OF INFANT AND SEVERAL INCHES ABOVE EXAM SURFACE.

- GENTLY RING THE BELL WHILE INFANT IS LOOKING AT IT; THEN SET IT DOWN WITHIN

REACH.

- IF INFANT DOES NOT PICK UP BELL, RING IT AGAIN SLIGHTLY HARDER; THEN HAND IT

TO HIM/HER.

- IF HE/SHE BANGS IT ON EXAM SURFACE, MOVE HIM/HER AWAY FROM IT ONCE

HE/SHE HAS BELL.


@BSCORING:@B

1 = HOLDS BELL BY HANDLE AND @UPURPOSELY@U RINGS IT, SHOWING EVIDENCE OF

LISTENING TO SOUND OR OF IMITATIVE SHAKING.

0 = @UONLY ACCIDENTALLY@U RINGS BELL WHEN BANGING IT OR INSPECTING IT.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIc1c [ YNIc1c ] BINS 7-10 Mths Item 3:

@B*Looks for Fallen Spoon@B


@BMATERIALS:@B SPOON

@BPOSITION:@B SEATED


@BADMINISTRATION:@B

- THROUGHOUT EXAM OBSERVE WHETHER INFANT VISUALLY SEARCHES FOR

OBJECTS THAT ARE MOVED OUT OF FIELD OF VISION.

- IF YOU DO NOT OBSERVE THIS, PLACE A HARD SURFACE ON CARPET NEXT TO TABLE

EDGE NEAR INFANT.

- PLACE A SPOON ON THE TABLE EDGE ABOVE THE HARD SURFACE; HOLD IT IN

PLACE WITH THE ROUND END OF SPOON EXTENDING PAST THE TABLE EDGE.

- WHEN THE INFANT IS ATTENDING THE SPOON (GET ATTENTION WITH A SOUND IF

NEEDED), LET THE SPOON FALL AND LAND NOISILY.


@BSCORING:@B

1 = SEARCHES FOR FALLEN SPOON BY @ULOOKING TOWARD FLOOR@U WHERE IT

FELL.

0 = DOES @UNOT LOOK IN DIRECTION@U OF FALLEN SPOON.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIc1d [ YNIc1d ] BINS 7-10 Mths Item 4:

@BLifts Inverted Cup@B


@BMATERIALS:@B CUP, BALL, CUBE, OR ANY TOY THAT FITS UNDER CUP

@BPOSITION:@B SEATED


@BADMINISTRATION:@B

- PLACE THE CUP AND TOY ON THE EXAM SURFACE WITHIN THE REACH OF INFANT

AND GIVE HIM/HER TIME TO EXPLORE THEM.

- THEN RETRIEVE THEM FROM HIM/HER AND QUICKLY COVER THE TOY WITH THE

INVERTED CUP WITH THE HANDLE TOWARD THE INFANT.

- SAY TO INFANT, @B"Find the toy; you find the toy"@B OR A SIMILAR PHRASE.


@BSCORING:@B

1 = LIFTS THE CUP @UTO FIND HIDDEN OBJECT@U. AN INFANT AWARE THAT THE

OBJECT IS UNDER THE CUP USUALLY @UFOCUSES HIS/HER GAZE ON WHERE OBJECT

IS, NOT CUP@U, AS HE/SHE LIFTS CUP.

0 = PICKS UP CUP TO PLAY WITH IT AND @UONLY INCIDENTALLY@U NOTICES THE TOY.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIc1e [ YNIc1e ] BINS 7-10 Mths Item 5:

@BDemonstrates Optimal Muscle Tone in Forearms, Biceps, and Shoulders@B


@BMATERIALS:@B NONE

@BPOSITION:@B LYING DOWN, FACE UP


@BADMINISTRATION:@B

- STAND AT INFANT'S FEET AND LEAN OVER HIM/HER.

- LIGHTLY GRASP THE WRISTS AND EXTEND ARMS UNTIL APPROXIMATELY PARALLEL

TO BODY.

- BEND ARMS UNTIL FOREARMS ARE PRESSED AGAINST BICEPS, AND THEN EXTEND

AGAIN.

- REPEAT 2 OR 3 TIMES TO TEST RESISTANCE.

- THEN MOVE ARMS FROM SIDES TO PERPENDICULAR (AT A 90 DEGREE ANGLE) WITH

BODY, OUT TO SIDES, 2 OR 3 TIMES.

- USE SMOOTH, CONTINUOUS MOTION.


@BSCORING:@B

1 = FOREARMS, BICEPS, SHOULDERS EXERT @UMODERATE RESISTANCE@U WHEN

ARMS ARE EXTENDED BOTH PARALLEL AND PERPENDICULAR (AT A 90 DEGREE ANGLE)

TO BODY.

0 = @ULITTLE OR NO RESISTANCE@U EXERTED BY MUSCLES, @UOR@U THEY ARE

TIGHT AND @UDIFFICULT TO EXTEND@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIc1f [ YNIc1f ] BINS 7-10 Mths Item 6:

@BDemonstrates Optimal Muscle Tone in Legs and Hips@B


@BMATERIALS:@B NONE

@BPOSITION:@B LYING DOWN, FACE UP


@BADMINISTRATION:@B

- STAND AT INFANT'S FEET AND LEAN OVER HIM/HER.

- LIGHTLY GRASP THE ANKLES, PUSH LEGS UP, BENDING KNEES, UNTIL YOU FEEL

RESISTANCE.

- GENTLY PULL LEGS TO EXTENDED POSITION AND RELEASE.

- REPEAT 2 OR 3 TIMES.

- PUSH LEGS UP AGAIN, BENDING KNEES, UNTIL RESISTANCE, SLIDE YOUR THUMBS

UP TO THE INSIDE OF KNEES AND PUSH LEGS OUTWARD FROM MIDLINE TO FORM A 120

DEGREE ANGLE.

- THEN EXTEND LEGS AS YOU BRING THEM BACK TO MIDLINE.

- REPEAT 2 OR 3 TIMES WITH A SMOOTH AND CONTINUOUS MOTION.


@BSCORING:@B

1 = LEGS AND HIPS EXERT @UMODERATE RESISTANCE@U WHEN LEGS BENT AND

PUSHED UP AND PUSHED OUT; BENDS LEGS IN @URELAXED@U MANNER WHEN

EXTENDED LEGS ARE @URELEASED@U.

0 = DURING EITHER MANEUVER LEG OR HIP SHOWS @ULITTLE OR NO RESISTANCE@U,

OR SHOWS @UEXAGGERATED OR NO@U BENDING)WHEN RELEASED.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIc2g [ YNIc2g ] BINS 7-10 Mths Item 7:

@BSits Alone for 30 Seconds@B


@BMATERIALS:@B NONE

@BPOSITION:@B SEATED


@BADMINISTRATION:@B

- SEAT INFANT WITH LEGS SLIGHTLY BENT AND SPREAD TO 45 DEGREE ANGLE.

- SUPPORT THE LOWER BACK AND GRADUALLY LOOSEN YOUR HOLD ON THE INFANT

ACCORDING TO HIS/HER ABILITY TO SIT UNSUPPORTED.


@BSCORING:@B

1 = SITS @UALONE@U STEADILY FOR AT LEAST @U30 SECONDS@U, WITH BACK FAIRLY

STRAIGHT.

0 = @USLUMPS@U EXCESSIVELY, @UPROPS UP WITH ARMS, OR@U SITS WITHOUT

SUPPORT @UFEWER THAN 30 SECONDS@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIc2h [ YNIc2h ] BINS 7-10 Mths Item 8:

@BMoves Forward Using Prewalking Methods@B


@BMATERIALS:@B BELL

@BPOSITION:@B LYING DOWN, FACE DOWN


@BADMINISTRATION:@B

- PLACE INFANT LYING DOWN, FACE DOWN ON FLOOR AND OBSERVE MODE OF

LOCOMOTION (MOVEMENT OR MOTION).

- IF INFANT DOES NOT BEGIN TO MOVE FORWARD, PLACE A BELL ON THE FLOOR IN

FRONT OF HIM/HER BUT OUT OF REACH.


@BSCORING:@B

1 = MAKES PROGRESS OF @U9 IN. OR MORE@U, ON HANDS AND KNEES, ON STOMACH

USING ARMS TO PULL, @UON HANDS AND FEET@U, @UOR@U ON @UBUTTOCKS@U.

0 = MAKES @UNO ATTEMPT TO MOVE@U IN ANY OF THESE WAYS @UOR@U MOVES

@ULESS THAN 9 INCHES@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIc2i [ YNIc2i ] BINS 7-10 Mths Item 9:

@BUses Early Stepping Movements@B


@BMATERIALS:@B NONE

@BPOSITION:@B UPRIGHT


@BADMINISTRATION:@B

HOLD INFANT UNDER HIS/HER ARMS IN AN UPRIGHT POSITION, FACING YOU, SO THAT

HIS/HER FEET TOUCH FLOOR OR EXAM SURFACE.


@BSCORING:@B

1 = MAKES STEPPING MOVEMENTS THAT @UPROPEL HIM/HER FORWARD@U, EVEN IF

HE/SHE DOES NOT FULLY SUPPORT HIS/HER OWN WEIGHT.

0 = INFANT MAKES @UNO@U STEPPING MOVEMENTS.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIc2j [ YNIc2j ] BINS 7-10 Mths Item 10:

@BRaises Self to Standing Position@B


@BMATERIALS:@B BELL, BLANKET OR MAT IF NEEDED

@BPOSITION:@B LYING DOWN, FACE UP


@BADMINISTRATION:@B

LIE THE INFANT ON THE FLOOR CLOSE TO A CHAIR (PLACE A BLANKET OR MAT ON THE

FLOOR IF NEEDED). SHAKE THE BELL AND THEN PLACE IT ON THE EDGE OF THE CHAIR.



@BSCORING:@B

1 = RAISES UP TO A @USTANDING POSITION@U, USING CHAIR OR OTHER OBJECT FOR

SUPPORT.

0 = INFANT DOES @UNOT@U RISE UP TO A STANDING POSITION.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIc2k [ YNIc2k ] BINS 7-10 Mths Item 11:

@B*Vocalizes Three Different Vowel-Consonant Combinations@B


@BMATERIALS:@B NONE

@BPOSITION:@B UNSPECIFIED


@BADMINISTRATION:@B

- THROUGHOUT THE EXAM LISTEN FOR DISTINCT VOWEL-CONSONANT COMBINATIONS

SUCH AS "ADA, MA, BA, GOO, UM, AN" THAT INFANT PRODUCES FREELY.

- IF HE/SHE DOES NOT VOCALIZE, ASK CAREGIVER: @B"Does ^CHILD make sounds?

What are they? Please help me get (him/her) to make these sounds."@B


@BSCORING:@B

1 = VOCALIZES AT LEAST @UONE VOWEL-CONSONANT COMBINATION, AND THE TOTAL

REPORTED BY CAREGIVER PLUS THE TOTAL PRODUCED BY INFANT IS AT LEAST

THREE@U.

0 = @UTOTAL NUMBER@U OF VOWEL-CONSONANT COMBINATIONS BOTH PRODUCED,

AND REPORTED BY CAREGIVER @UEQUALS TWO OR FEWER@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIc2l [ YNIc2l ] BINS 7-10 Mths Item 12:

@B*Responds to Spoken Request@B


@BMATERIALS:@B NONE

@BPOSITION:@B UNSPECIFIED


@BADMINISTRATION:@B

- THROUGHOUT THE EXAM OBSERVE WHETHER THE INFANT RESPONDS TO A SPOKEN

REQUEST.

- IF YOU DO NOT OBSERVE A RESPONSE, HAVE THE CAREGIVER VERBALLY REQUEST

THE INFANT PERFORM AN ACTION WITHOUT GESTURING. ASK CAREGIVER: @BPlease

ask ^CHILD to do something (he/she) knows how to do. Don't make any gestures, just ask with

words.@B

- IF THE CAREGIVER USES GESTURES, HAVE THE CAREGIVER GIVE A DIFFERENT

REQUEST WITHOUT GESTURES.


@BSCORING:@B

1 = @URESPONDS IN APPROPRIATE MANNER@U TO A VERBAL REQUEST, INCLUDING

TEST QUESTIONS YOU'VE ASKED. COMMON EXAMPLES: WAVE BYE, PAT-A-CAKE,

SHOW ME YOUR NOSE.

0 = @UFAILS TO RESPOND@U TO THE SPOKEN REQUEST.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIc2m [ YNIc2m ] BINS 7-10 Mths Item 13:

@B*Demonstrates Coordinated Movement of Arms and Legs@B


@BMATERIALS:@B NONE

@BPOSITION:@B UNSPECIFIED


@BADMINISTRATION:@B

THROUGHOUT THE EXAM OBSERVE THE QUALITY OF THE INFANT'S ARM AND LEG

MOVEMENTS.


@BSCORING:@B

1 = MOVEMENTS ARE @USMOOTH@U, MUSCLES ARE NEITHER RIGID NOR FLOPPY,

THERE IS @UBALANCE OF BENDING AND STRAIGHTENING@U.

0 = MOVEMENTS @UJERKY@U, ERRATIC, OR CLUMSY, MUSCLES ARE EITHER @URIGID

OR FLOPPY@U, OR @UPREDOMINANTLY BENT OR STRAIGHTENED@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

Logic after:

GOTO Y_NIEND

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

Logic before:

IF AGE IS 11 TO 15 MONTHS OLD, CONTINUE. ELSE, SKIP TO Y_NIe1a.

Y_NId1a [ YNId1a ] BINS 11-15 Mths Item 1:

@BRemoves Pellet from Bottle@B

@BMATERIALS:@B SUGAR PELLET AND BOTTLE

@BPOSITION:@B SEATED


@BTELL CAREGIVER: This pellet is sugar and won't harm (him/her).@B


@BADMINISTRATION:@B

- PLACE THE PELLET AND BOTTLE ON THE EXAM SURFACE IN FRONT OF INFANT.

- WHILE HE/SHE IS WATCHING, PUT THE PELLET IN THE BOTTLE AND SHAKE IT SO

HE/SHE CAN SEE IT THERE.

- HAND BOTTLE TO INFANT. SAY "Now get it out."


@BSCORING:@B

1 = REMOVES PELLET FROM BOTTLE USING SOME FORM OF @UPURPOSEFUL

EFFORT@U LIKE DUMPING PELLET OR SHAKING BOTTLE.

0 = @UUNSUCCESSFUL@U AT REMOVING PELLET @UOR@U ONLY DOES SO

@UACCIDENTALLY@U AS HE/SHE PLAYS WITH BOTTLE.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NId1b [ YNId1b ] BINS 11-15 Mths Item 2:

@BPuts Three Cubes in Cup@B


@BMATERIALS:@B CUP AND SIX CUBES

@BPOSITION:@B SEATED


@BADMINISTRATION:@B

- PLACE CUP WITHIN INFANT'S REACH, HANDLE TOWARD YOU.

- PLACE A CUBE IN THE CUP; TAKE IT OUT AND HAND TO INFANT.

- SAY @B"Put the block in the cup. Put it in the cup."@B

- POINT FROM CUBE TO CUP.

- IF THE INFANT RELEASES CUBE INTO THE CUP, GET OUT FIVE MORE CUBES.

- SAY @B"Put the blocks in the cup. Put them all in the cup."@B POINT LIKE BEFORE.


@BSCORING:@B

1 = PUTS AT LEAST @U3 CUBES@U INSIDE THE CUP @U AT ANY ONE TIME@U.

0 = PLACES @UONLY ONE OR TWO CUBES@U IN THE CUP @UAT ANY ONE TIME@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NId1c [ YNId1c ] BINS 11-15 Mths Item 3:

@BImitates Crayon Stroke@B


@BMATERIALS:@B TWO CRAYONS, BLANK SHEET OF WHITE PAPER

@BPOSITION:@B SEATED


@BADMINISTRATION:@B

- PLACE THE PAPER ON THE EXAM SURFACE IN FRONT OF THE INFANT.

- PLACE ONE CRAYON ON THE PAPER, WITH TIP POINTING AWAY FROM HIM/HER.

- WITH THE OTHER CRAYON, DRAW A STRAIGHT VERTICAL LINE ON THE PAPER,

MOVING THE CRAYON RAPIDLY TOWARD THE INFANT.

- SAY @B"See? It goes zip! You do it!"@B


@BSCORING:@B

1 = HE/SHE @UPRODUCES A STROKE@U IN ANY DIRECTION.

0 = INFANT DOES @UNOT@U MARK ON THE PAPER.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NId1d [ YNId1d ] BINS 11-15 Mths Item 4:

@BDemonstrates Optimal Muscle Tone in Forearms, Biceps, and Shoulders@B


@BMATERIALS:@B NONE

@BPOSITION:@B LYING DOWN, FACE UP


@BADMINISTRATION:@B

- STAND AT INFANT'S FEET AND LEAN OVER HIM/HER.

- LIGHTLY GRASP THE WRISTS AND EXTEND ARMS UNTIL APPROXIMATELY PARALLEL

TO BODY.

- BEND ARMS UNTIL FOREARMS ARE PRESSED AGAINST BICEPS, AND THEN EXTEND

AGAIN.

- REPEAT 2 OR 3 TIMES TO TEST RESISTANCE.

- THEN MOVE ARMS FROM SIDES TO PERPENDICULAR (AT A 90 DEGREE ANGLE) WITH

BODY, OUT TO SIDES, 2 OR 3 TIMES.

- USE SMOOTH, CONTINUOUS MOTION.


@BSCORING:@B

1 = FOREARMS, BICEPS, SHOULDERS EXERT @UMODERATE RESISTANCE@U WHEN

ARMS ARE EXTENDED BOTH PARALLEL AND PERPENDICULAR (AT A 90 DEGREE ANGLE)

TO BODY.

0 = @ULITTLE OR NO RESISTANCE@U EXERTED BY MUSCLES, @UOR@U THEY ARE

TIGHT AND @UDIFFICULT TO EXTEND@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NId1e [ YNId1e ] BINS 11-15 Mths Item 5:

@BDemonstrates Optimal Muscle Tone in Legs and Hips@B


@BMATERIALS:@B NONE

@BPOSITION:@B LYING DOWN, FACE UP


@BADMINISTRATION:@B

- STAND AT INFANT'S FEET AND LEAN OVER HIM/HER.

- LIGHTLY GRASP THE ANKLES, PUSH LEGS UP, BENDING KNEES, UNTIL YOU FEEL

RESISTANCE.

- GENTLY PULL LEGS TO EXTENDED POSITION AND RELEASE.

- REPEAT 2 OR 3 TIMES.

- PUSH LEGS UP AGAIN, BENDING KNEES, UNTIL RESISTANCE, SLIDE YOUR THUMBS

UP TO THE INSIDE OF KNEES AND PUSH LEGS OUTWARD FROM MIDLINE TO FORM A 120

DEGREE ANGLE.

- THEN EXTEND LEGS AS YOU BRING THEM BACK TO MIDLINE.

- REPEAT 2 OR 3 TIMES WITH A SMOOTH AND CONTINUOUS MOTION.


@BSCORING:@B

1 = LEGS AND HIPS EXERT @UMODERATE RESISTANCE@U WHEN LEGS BENT AND

PUSHED UP AND PUSHED OUT; BENDS LEGS IN @URELAXED@U MANNER WHEN

EXTENDED LEGS ARE @URELEASED@U.

0 = DURING EITHER MANEUVER LEG OR HIP SHOWS @ULITTLE OR NO RESISTANCE@U,

OR SHOWS @UEXAGGERATED OR NO@U BENDING WHEN RELEASED.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NId1f [ YNId1f ] BINS 11-15 Mths Item 6:

@B*Walks Alone@B


@BMATERIALS:@B NONE

@BPOSITION:@B STANDING


@BADMINISTRATION:@B

- THROUGHOUT THE EXAM OBSERVE THE INFANT TO SEE IF SHE WALKS ALONE.

- IF HE/SHE DOES NOT WALK ALONE SPONTANEOUSLY, STAND HIM/HER ON THE

FLOOR WITH ARMS EXTENDED TO SHOULDER HEIGHT.

- MAKE SURE NO SUPPORTING OBJECT IS IN REACH.

- SLOWLY LOOSEN HOLD ACCORDING TO ABILITY TO STAND UNSUPPORTED.

- YOU MAY ENCOURAGE HIM/HER TO WALK BY STANDING IN FRONT AND HOLDING OUT

YOUR ARMS.

- KEEP YOUR HANDS CLOSE TO INFANT IN CASE HE/SHE LOSES BALANCE.


@BSCORING:@B

1 = TAKES AT LEAST @U3 STEPS WITHOUT SUPPORT@U, EVEN IF GAIT (WALK) IS STIFF-

LEGGED AND WOBBLY AND ELBOWS ARE BENT AND HELD AT ELBOW OR SHOULDER

HEIGHT.

0 = DOES @UNOT@U TAKE 3 STEPS WITHOUT SUPPORT, @USTUMBLES@U WHILE

TAKING STEPS, WALKS TIPTOE, @OR HOLDS ARM(S) IN ABNORMAL POSTURE@U (E.G.

UPPER ARMS AT SIDE, ELBOWS BENT, FOREARMS PERPENDICULAR TO SIDES, AND

HANDS FISTED.)

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NId2g [ YNId2g ] BINS 11-15 Mths Item 7:

@B*Imitates Words@B


@BMATERIALS:@B NONE

@BPOSITION:@B UNSPECIFIED


@BADMINISTRATION:@B

- THROUGHOUT THE EXAM OBSERVE WHETHER INFANT IMITATES ANY WORD YOU OR

CAREGIVER SAYS.

- IF THE INFANT HAS NOT, USE A PLAYFUL TONE OF VOICE TO SAY SEVERAL WORDS

SUCH AS@B@IMAMA, DADA, ALL GONE, UH-OH, UP, BALL, THAT, THANK YOU, AND

BABY.@B@I

- THE CAREGIVER MAY ALSO TRY TO ELICIT IMITATION OF WORDS IN THE SAME

MANNER.


@bSCORING:@b

1 = IMITATES AT LEAST @UONE WORD IMMEDIATELY@U AFTER IT IS SAID. (EVEN IF THE

IMITATION CONSISTS OF VOWELS ONLY.)

0 = DOES @UNOT@U IMITATE WORD IMMEDIATELY AFTER SAID @UOR REPEATS@U

ONLY A WORD OR SOUND @UNONSPECIFICALLY THROUGHOUT THE EXAM@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NId2h [ YNId2h ] BINS 11-15 Mths Item 8:

@B*Responds to Spoken Request@B


@BMATERIALS:@B NONE

@BPOSITION:@B UNSPECIFIED


@BADMINISTRATION:@B

- THROUGHOUT THE EXAM OBSERVE WHETHER THE INFANT RESPONDS TO A SPOKEN

REQUEST.

- IF YOU DO NOT OBSERVE A RESPONSE, HAVE THE CAREGIVER VERBALLY REQUEST

THE INFANT PERFORM AN ACTION WITHOUT GESTURING. ASK CAREGIVER: @BPlease

ask ^CHILD to do something (he/she) knows how to do. Don't make any gestures, just ask with

words.@B

- IF THE CAREGIVER USES GESTURES, HAVE THE CAREGIVER GIVE A DIFFERENT

REQUEST WITHOUT GESTURES.


@BSCORING:@B

1 = @URESPONDS IN APPROPRIATE MANNER@U TO VERBAL REQUEST, INCLUDING

TEST QUESTIONS YOU'VE ASKED. COMMON EXAMPLES: WAVE BYE, PAT-A-CAKE,

SHOW ME YOUR NOSE.

0 = @UFAILS TO RESPOND@U TO THE SPOKEN REQUEST.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NId2i [ YNId2i ] BINS 11-15 Mths Item 9:

@B*Listens Selectively to Two Familiar Words@B


@BMATERIALS:@B NONE

@BPOSITION:@B UNSPECIFIED


@BADMINISTRATION:@B

- THROUGHOUT EXAM OBSERVE WHETHER INFANT SELECTIVELY LISTENS TO FAMILIAR

WORDS SUCH AS BABY, KITTY, MAMA, OR SHOE.

- IF THE INFANT DOES NOT SPONTANEOUSLY DO THIS, HAVE CAREGIVER ATTRACT

INFANT'S ATTENTION AND TALK TO HIM/HER USING WORDS UNFAMILIAR TO INFANT.

THEN HAVE CAREGIVER, WITH NO VOLUME CHANGE OR EMPHASIS, USE WORDS THAT

PROBABLY ARE FAMILIAR INTERSPERSED AMONG UNFAMILIAR WORDS.

- TELL CAREGIVER: @BPlease attract ^CHILD's attention and talk to (him/her) using words

(he/she) will not recognize. Then every few words, without changing how loud you say them, say a

word (he/she) does know. Some examples of words (he/she) may know are baby, kitty, mama,

or shoe.@B

- OBSERVE INFANT'S RESPONSE.


@BSCORING:@B

1 = RESPONDS @UDIFFERENTIALLY@U TO AT LEAST @UTWO@U FAMILIAR WORDS BY

@UCHANGING FACIAL EXPRESSION, VOCALIZING, OR IMITATING THE WORDS@U.

0 = @UFAILS TO RESPOND@U TO AT LEAST TWO FAMILIAR WORDS.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NId2j [ YNId2j ] BINS 11-15 Mths Item 10:

@B*Uses Gesture to Make Wants Known@B


@BMATERIALS:@B NONE

@BPOSITION:@B UNSPECIFIED


@BADMINISTRATION:@B

- THROUGHOUT THE EXAM OBSERVE THE INFANT TO SEE IF HE/SHE USES A GESTURE

OR TOY TO TRY TO COMMUNICATE WITH YOU OR CAREGIVER.

- FOR EXAMPLE, NOTICE WHETHER INFANT REACHES FOR, POINTS TOWARD, OR

PUSHES AWAY OBJECTS IN AN EVIDENT GESTURE OF COMMUNICATION.

- IF UNSURE ABOUT WHETHER THE INFANT MADE A PARTICULAR GESTURE, YOU CAN

VERIFY YOUR IMPRESSION WITH THE CAREGIVER.

ASK CAREGIVER: @BI thought I saw ^CHILD (describe gesture you saw child make). Did you

see that or is that something (he/she) does?@B


@BSCORING:@B

1 = USES AT LEAST @UONE@U GESTURE TO MAKE WANTS KNOWN.

0 = MAKES @UNO@U COMMUNICATIVE GESTURE.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NId2k [ YNId2k ] BINS 11-15 Mths Item 11:

@B*Demonstrates Coordinated Movement of Arms and Legs@B


@BMATERIALS:@B NONE

@BPOSITION:@B UNSPECIFIED


@BADMINISTRATION:@B

THROUGHOUT THE EXAM OBSERVE THE QUALITY OF THE INFANT'S ARM AND LEG

MOVEMENTS.


@BSCORING:@B

1 = MOVEMENTS ARE @USMOOTH@U, MUSCLES ARE NEITHER RIGID NOR FLOPPY,

THERE IS @UBALANCE OF BENDING AND STRAIGHTENING@U.

0 = MOVEMENTS @UJERKY@U, ERRATIC, OR CLUMSY, MUSCLES ARE EITHER @URIGID

OR FLOPPY@U, OR @UPREDOMINANTLY BENT OR STRAIGHTENED@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

Logic after:

GOTO Y_NIEND

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

Logic before:

IF AGE IS 16 TO 20 MONTHS OLD, CONTINUE. ELSE, SKIP TO Y_NIf1a.

Y_NIe1a [ YNIe1a ] BINS 16-20 Mths Item 1:

@BImitates Crayon Stroke@B


@BMATERIALS:@B TWO CRAYONS, BLANK SHEET OF WHITE PAPER

@BPOSITION:@B SEATED


@BADMINISTRATION:@B

- PLACE THE PAPER ON THE EXAM SURFACE IN FRONT OF THE INFANT.

- PLACE ONE CRAYON ON THE PAPER, WITH TIP POINTING AWAY FROM HIM/HER.

- WITH THE OTHER CRAYON, DRAW A STRAIGHT VERTICAL LINE ON THE PAPER,

MOVING THE CRAYON RAPIDLY TOWARD THE INFANT.

- SAY @B"See? It goes zip! You do it!"@B


@BSCORING:@B

1 = HE/SHE @UPRODUCES A STROKE@U IN ANY DIRECTION.

0 = INFANT DOES @UNOT@U MARK ON THE PAPER.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIe1b [ YNIe1b ] BINS 16-20 Mths Item 2:

@BRemoves Pellet from Bottle@B


@BMATERIALS:@B SUGAR PELLET AND BOTTLE

@BPOSITION:@B SEATED


@BTELL CAREGIVER: This pellet is sugar and won't harm (him/her).@B


@BADMINISTRATION:@B

- PLACE THE PELLET AND BOTTLE ON THE EXAM SURFACE IN FRONT OF INFANT.

- WHILE HE/SHE IS WATCHING, PUT THE PELLET IN THE BOTTLE AND SHAKE IT SO

HE/SHE CAN SEE IT THERE.

- HAND BOTTLE TO INFANT. SAY "Now get it out."


@BSCORING:@B

1 = REMOVES PELLET FROM BOTTLE USING SOME FORM OF @UPURPOSEFUL

EFFORT@U LIKE DUMPING PELLET OR SHAKING BOTTLE.

0 = @UUNSUCCESSFUL@U AT REMOVING PELLET @UOR@U ONLY DOES SO

@UACCIDENTALLY@U AS HE/SHE PLAYS WITH BOTTLE.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIe1c [ YNIe1c ] BINS 16-20 Mths Item 3:

@BPlaces Three Pieces in Puzzle Board@B


@BMATERIALS:@B BLUE PUZZLE BOARD AND PUZZLE PIECES

@BPOSITION:@B SEATED


@BADMINISTRATION:@B

- PLACE ALL PIECES ON EXAM SURFACE IN FRONT OF YOU.

- PLACE THE PUZZLE BOARD (BLUE SIDE UP) ON THE EXAM SURFACE IN FRONT OF

INFANT.

- HAND INFANT A ROUND PIECE.

- MOTION TOWARD HOLES.

- SAY @B"Put the block in its hole. Put it where it belongs."@B

- THEN ALTERNATELY HAND THE INFANT A SQUARE PIECE AND A ROUND PIECE, ONE

AT A TIME, UNTIL HE/SHE HAS PLACED EACH TO HIS/HER SATISFACTION.


@BSCORING:@B

1 = CORRECTLY PLACES AT LEAST @U3 PIECES@U; TO BE CORRECTLY PLACED, THE

PIECE MUST BE @UCOMPLETELY SEATED IN THE PROPER HOLE@U (CHILD MAY NOT

STACK PIECES ON TOP OF OTHERS.).

0 = DOES @UNOT@U CORRECTLY PLACE AT LEAST THREE PIECES.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIe1d [ YNIe1d ] BINS 16-20 Mths Item 4:

@BNames Three Objects@B


@BMATERIALS:@B BALL, CRAYON, SPOON, AND CUP

@BPOSITION:@B SEATED


@BADMINISTRATION:@B

- PLACE THE FOUR OBJECTS ON THE EXAM SURFACE WITHIN THE INFANT'S REACH.

- GIVE HIM/HER TIME TO EXPLORE THE OBJECTS.

- AS HE/SHE PICKS UP AN OBJECT, ASK, @B"What is that? What do you have?"@B

- IF INFANT DOES NOT EXPLORE OBJECTS, PICK UP OBJECTS ONE AT A TIME AND ASK,

@B"What is this? What do I have?"@B


@BSCORING:@B

1 = CORRECTLY NAMES AT LEAST @U3 OBJECTS. DISREGARD POOR

PRONUNCIATION@U. YOU MAY VERIFY WITH CAREGIVER THAT NAME GIVEN IS THE

NAME INFANT COMMONLY GIVES OBJECT.

0 = DOES @UNOT@U CORRECTLY NAME AT LEAST 3 OBJECTS, NAME IS

@UUNRECOGNIZABLE@U, @UUSED RANDOMLY@U THROUGHOUT EXAM, @UOR USED

FOR OTHER OBJECTS@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIe1e [ YNIe1e ] BINS 16-20 Mths Item 5:

@BBuilds Tower of Six Cubes@B


@BMATERIALS:@B SIX CUBES

@BPOSITION:@B SEATED


@BADMINISTRATION:@B

- PLACE ALL CUBES ON EXAM SURFACE IN FRONT OF YOU.

- STACK THREE OF THE CUBES, ASKING, @B"See my tower?"@B

- PLACE THREE CUBES IN FRONT OF INFANT AND SAY, @B"Use these blocks to make a

big tower."@B

- LEAVE YOUR TOWER STANDING AS A MODEL, BUT ALLOW HIM/HER TO USE CUBES

FROM YOURS.

- IF INFANT CONSTRUCTS A TOWER OF THREE CUBES, UNSTACK THE THREE CUBES IN

YOUR TOWER AND PLACE IN FRONT OF INFANT, SAY, @B"Make your tower as big as you

can. Use all the blocks."@B

- IF INFANT APPEARS CONFUSED BY THE ADDITIONAL CUBES OR BEGINS TO TAKE

CUBES APART, ENCOURAGE HIM/HER AGAIN TO STACK THE CUBES.

- DO NOT DIRECT OR GUIDE THE BUILDING OF THE STRUCTURE IN ANY MANNER.


@BSCORING:@B

1 = @USTACKS ALL 6 CUBES@U TO CONSTRUCT A TOWER.

0 = DOES @UNOT@U STACK ALL 6 CUBES. DO NOT COUNT A CUBE AS PART OF THE

TOWER UNLESS THE INFANT RELEASES IT AND IT REMAINS BALANCED.@U DO NOT

COUNT THE CUBE IF IT CAUSES THE STRUCTURE TO FALL@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIe1f [ YNIe1f ] BINS 16-20 Mths Item 6:

@BPoints to Three of Doll's Body Parts@B


@BMATERIALS:@B DOLL

@BPOSITION:@B SEATED


@BADMINISTRATION:@B

- HOLD THE DOLL WITHIN REACH; SAY, @B"Show me the doll's hair", "Where is the doll's

hair?", or "Hair?"@B

- USE THE SAME PROCEDURE FOR:


MOUTH@|@|EYES


EARS@|@|@|FEET


HANDS@|@|NOSE


@BSCORING:@B

1 = CORRECTLY POINTS TO AT LEAST @U3 OF THE DOLL'S BODY PARTS@U IN

RESPONSE TO YOUR REQUESTS.

0 = POINTS TO @UFEWER THAN 3@U BODY PARTS.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIe2g [ YNIe2g ] BINS 16-20 Mths Item 7:

@B*Walks Quickly with Coordination@B


@BMATERIALS:@B BALL

@BPOSITION:@B STANDING


@BADMINISTRATION:@B

- THROUGHOUT THE EXAM OBSERVE INFANT TO SEE IF HE/SHE WALKS QUICKLY

WITHOUT SUPPORT.

- IF THE INFANT DOES NOT, ROLL THE BALL ACROSS THE FLOOR AND ENCOURAGE

HIM/HER TO RUN BY SAYING, @B"Hurry. Get the ball. Run and get it."@B


@BSCORING:@B

1 = TAKES AT LEAST @U6 STEPS WITHOUT SUPPORT@U AND IN A NOTICEABLY

@UFASTER@U SPEED @UTHAN HIS/HER USUAL WALKING SPEED@U.

0 = WALK IS @USTIFF-LEGGED@U AND @UWOBBLY OR@U HE/SHE TAKES @UFEWER

THAN 6 STEPS@U, @USTUMBLES@U WHILE TAKING STEPS, WALKS @UTIPTOE@U,

BENDS ARM(S) WITH FIST(S) HELD AT ELBOW OR SHOULDER HEIGHT, @UMOVES ONE

ARM MORE@U THAN THE OTHER, @UOR@U HOLDS ARM(S) IN @UABNORMAL

POSTURE@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIe2h [ YNIe2h ] BINS 16-20 Mths Item 8:

@BWalks up Stairs with Help@B


@BMATERIALS:@B STAIRS, AND TOY THAT INTERESTS THE INFANT

@BPOSITION:@B STANDING


@BCAUTION: DO NOT USE AN OPEN STAIRCASE OR STAIRCASE WITH AN OPEN

RAILING.@B


@BADMINISTRATION:@B

- PLACE INFANT AT THE BOTTOM OF A SET OF STAIRS.

- IF HE/SHE DOES NOT SPONTANEOUSLY BEGIN TO CLIMB STAIRS, PLACE A TOY ON

THE FOURTH OR FIFTH STEP.

- ENCOURAGE HIM/HER TO RETRIEVE IT.

- STAND CLOSE TO INFANT IN CASE HE/SHE LOSES BALANCE.

- THE INFANT MAY HOLD YOUR HAND OR RAILING FOR SUPPORT.


@BSCORING:@B

1 = WALKS UP AT LEAST @U2 STEPS@U. INFANT @UMAY HOLD THE RAIL OR YOUR

HAND@U FOR SUPPORT. YOU MAY ALSO GIVE CREDIT IF INFANT WALKS UP STAIRS

WITHOUT SUPPORT.

0 = INFANT WALKS UP @UFEWER THAN 2 STEPS@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIe2i [ YNIe2i ] BINS 16-20 Mths Item 9:

@B*Imitates Two-Word Sentence@B


@BMATERIALS:@B NONE

@BPOSITION:@B UNSPECIFIED


@BADMINISTRATION:@B

- THROUGHOUT THE EXAM LISTEN TO HEAR INFANT IMITATE ANY MULTIPLE-WORD

SENTENCES YOU OR CAREGIVER SAY.

- IF NOT, TELL INFANT IN PLAYFUL WAY, @B"Say Mama go, Daddy eat, Baby drink, Go

home, What's this?, Put here,"@B (OR ANY OTHER MULTIPLE-WORD SENTENCE THE

INFANT MAY KNOW).

- YOU MAY REPEAT THE SENTENCE SEVERAL TIMES.


@BSCORING:@B

1 = IMITATES AT LEAST A @UTWO-WORD@U SENTENCE. @UDISREGARD POOR

PRONUNCIATION@U.

0 = VOCALIZATIONS (SOUNDS) ARE USED @UNONSPECIFICALLY OR REPEATEDLY@U

THROUGHOUT THE EXAM @UOR@U HE/SHE IMITATES @UONLY ONE@U WORD.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIe2j [ YNIe2j ] BINS 16-20 Mths Item 10:

@B*Combines Word and Gesture@B


@BMATERIALS:@B NONE

@BPOSITION:@B UNSPECIFIED


@BADMINISTRATION:@B

- THROUGHOUT EXAM OBSERVE WHETHER INFANT SIMULTANEOUSLY AND

APPROPRIATELY USES A GESTURE AND WORD(S) TO EXPRESS HIM/HERSELF.

- FOR EXAMPLE, INFANT SAYS MOMMY AND POINTS TO MOTHER, OR BALL AND

REACHES FOR BALL.


@BSCORING:@B

1 = @UCOMBINES@U A GESTURE AND WORD(S).

0 = DOES @UNOT@U COMBINE A GESTURE AND WORD(S).

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIe2k [ YNIe2k ] BINS 16-20 Mths Item 11:

@B*Absence of Drooling and Motor Overflow (One Hand Mimics the Other Involuntarily)@B


@BMATERIALS:@B NONE

@BPOSITION:@B UNSPECIFIED


@BADMINISTRATION:@B

THROUGHOUT THE EXAM OBSERVE WHETHER INFANT DROOLS AND WHETHER ONE OF

HIS/HER HANDS MIMICS OR MIRRORS, IN AN INVOLUNTARY FASHION, THE ACTIVITIES OF

THE OTHER.


@BSCORING:@B

1 = DOES @UNOT SHOW EXCESSIVE DROOL@U AROUND MOUTH OR ANY DROOLING

AROUND COLLAR, @UAND NEITHER HAND MIMICS OR MIRRORS@U ACTIVITIES OF THE

OTHER MORE THAN HALF THE TIME.

0 = @UDROOLS EXCESSIVELY@U ON CLOTHING, @UOR@U IF @UEITHER OF THE HANDS

MIRRORS OR MIMICS@U THE OTHER MORE THAN HALF THE TIME.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

Logic after:

GOTO Y_NIEND

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

Logic before:

IF AGE IS 21 TO 24 MONTHS OLD, CONTINUE. ELSE, SKIP TO Y_NIEND.

Y_NIf1a [ YNIf1a ] BINS 21-24 Mths Item 1:

@BPlaces Three Pieces in Puzzle Board@B


@BMATERIALS:@B BLUE PUZZLE BOARD AND PUZZLE PIECES

@BPOSITION:@B SEATED


@BADMINISTRATION:@B

- PLACE ALL PIECES ON EXAM SURFACE IN FRONT OF YOU.

- PLACE THE PUZZLE BOARD (BLUE SIDE UP) ON THE EXAM SURFACE IN FRONT OF

INFANT.

- HAND INFANT A ROUND PIECE.

- MOTION TOWARD HOLES.

- SAY @B"Put the block in its hole. Put it where it belongs."@B

- THEN ALTERNATELY HAND THE INFANT A SQUARE PIECE AND A ROUND PIECE, ONE

AT A TIME, UNTIL HE/SHE HAS PLACED EACH TO HIS/HER SATISFACTION.


@BSCORING:@B

1 = CORRECTLY PLACES @UAT LEAST 3 PIECES@U; TO BE CORRECTLY PLACED, THE

PIECE MUST BE @UCOMPLETELY SEATED IN THE PROPER HOLE@U (CHILD MAY NOT

STACK PIECES ON TOP OF OTHERS.).

0 = DOES @UNOT@U CORRECTLY PLACE AT LEAST THREE PIECES.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIf1b [ YNIf1b ] BINS 21-24 Mths Item 2:

@BBuilds Tower of Six Cubes@B


@BMATERIALS:@B SIX CUBES

@BPOSITION:@B SEATED


@BADMINISTRATION:@B

- PLACE ALL CUBES ON EXAM SURFACE IN FRONT OF YOU.

- STACK THREE OF THE CUBES, ASKING, @B"See my tower?"@B

- PLACE THREE CUBES IN FRONT OF INFANT AND SAY, @B"Use these blocks to make a

big tower."@B

- LEAVE YOUR TOWER STANDING AS A MODEL, BUT ALLOW HIM/HER TO USE CUBES

FROM YOURS.

- IF INFANT CONSTRUCTS A TOWER OF THREE CUBES, UNSTACK THE THREE CUBES IN

YOUR TOWER AND PLACE IN FRONT OF INFANT, SAY, @B"Make your tower as big as you

can. Use all the blocks."@B

- IF INFANT APPEARS CONFUSED BY THE ADDITIONAL CUBES OR BEGINS TO TAKE

CUBES APART, ENCOURAGE HIM/HER AGAIN TO STACK THE CUBES.

- DO NOT DIRECT OR GUIDE THE BUILDING OF THE STRUCTURE IN ANY MANNER.


@BSCORING:@B

1 = @USTACKS ALL 6 CUBES@U TO CONSTRUCT A TOWER.

0 = DOES @UNOT@U STACK ALL 6 CUBES. DO NOT COUNT A CUBE AS PART OF THE

TOWER UNLESS THE INFANT RELEASES IT AND IT REMAINS BALANCED. @UDO NOT

COUNT THE CUBE IF IT CAUSES THE STRUCTURE TO FALL@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIf1c [ YNIf1c ] BINS 21-24 Mths Item 3:

@BNames Four Pictures@B


@BMATERIALS:@B STIMULUS CARDS A AND B

@BPOSITION:@B SEATED


@BADMINISTRATION:@B

- PLACE STIMULUS CARD A FLAT ON EXAM SURFACE, DIRECTLY IN FRONT OF THE

INFANT.

- POINT TO THE DOG, ASK, @B"What is this?"@B OR @B"Tell me what this is."@B

- REGARDLESS OF INFANT'S RESPONSE, POINT TO OTHER PICTURES ON PAGE,

ASKING, @B"What is this?"@B FOR EACH ONE.

- TO ENCOURAGE FURTHER RESPONSES, SHOW PLEASED ACCEPTANCE OF ANY

ANSWER GIVEN.

- RETURN ONCE TO ANY PICTURES NOT NAMED CORRECTLY.

- NOW PLACE STIMULUS CARD B ON EXAM SURFACE, DIRECTLY IN FRONT OF INFANT,

STARTING WITH CLOCK, ASK THE NAME FOR EACH PICTURE.

- RETURN ONCE TO PICTURES NOT NAMED CORRECTLY.

- AFTER GIVING THE INFANT TWO CHANCES TO NAME EACH PICTURE ON EACH CARD,

SAY WITHOUT POINTING, @B"Show me the (name of picture). Put your finger on the (name of

picture)."@B


@BSCORING:@B

1 = @UCORRECTLY@U NAMES @UAT LEAST 4 OF THE PICTURES@U. CORRECT NAMING

INCLUDES GIVING THE CLASS OF OBJECT (E.G. DOG, PUPPY) BUT NOT PROPER NOUNS

(SPOT FOR DOG). @UDISREGARD POOR PRONUNCIATION@U.

0 = CORRECTLY NAMES @UFEWER THAN 4 PICTURES@U.

@B**NOTE ANSWER TO THIS ITEM. YOU WILL NEED TO KNOW IT IN Y_NIf1d@B

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIf1d [ YNIf1d ] BINS 21-24 Mths Item 4:

@BIdentifies Four Pictures@B


@BMATERIALS:@B STIMULUS CARD

@BPOSITION:@B SEATED


@BADMINISTRATION:@B

SCORE THIS ITEM FROM THE PREVIOUS ITEM ADMINISTRATION.


@BSCORING:@B

1 = @UCORRECTLY@U NAMES OR INDICATES @UAT LEAST 4 PICTURES@U. CORRECTLY

NAMING INCLUDES GIVING THE CLASS OF OBJECT (E.G. DOG, PUPPY) BUT NOT

PROPER NOUNS (SPOT FOR DOG). @UDISREGARD POOR PRONUNCIATION@U.

0 = CORRECTLY NAMES OR INDICATES @UFEWER THAN 4 PICTURES@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIf1e [ YNIf1e ] BINS 21-24 Mths Item 5:

@BPoints to Three of Doll's Body Parts@B


@BMATERIALS:@B DOLL

@BPOSITION:@B SEATED


@BADMINISTRATION:@B

- HOLD THE DOLL WITHIN REACH; SAY, @B"Show me the doll's hair", "Where is the doll's

hair?", or "Hair?"@B

- USE THE SAME PROCEDURE FOR:


MOUTH@|@|@|@|EYES


EARS@|@|@|@|FEET


HANDS@|@|@|@|NOSE


@BSCORING:@B

1 = CORRECTLY POINTS TO AT LEAST @U3 OF THE DOLL'S BODY PARTS@U IN

RESPONSE TO YOUR REQUESTS.

0 = POINTS TO @UFEWER THAN 3@U BODY PARTS.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIf1f [ YNIf1f ] BINS 21-24 Mths Item 6:

@BNames Three Objects@B


@BMATERIALS:@B BALL, CRAYON, SPOON, AND CUP

@BPOSITION:@B SEATED


@BADMINISTRATION:@B

- PLACE THE FOUR OBJECTS ON THE EXAM SURFACE WITHIN THE INFANT'S REACH.

- GIVE HIM/HER TIME TO EXPLORE THE OBJECTS.

- AS HE/SHE PICKS UP AN OBJECT, ASK, @B"What is that? What do you have?"@B

- IF INFANT DOES NOT EXPLORE OBJECTS, PICK UP OBJECTS ONE AT A TIME AND ASK,

@B"What is this? What do I have?"@B


@BSCORING:@B

1 = @UCORRECTLY@U NAMES @UAT LEAST 3 OBJECTS@U. @UDISREGARD POOR

PRONUNCIATION@U. YOU MAY VERIFY WITH CAREGIVER THAT NAME GIVEN IS THE

NAME INFANT COMMONLY GIVES OBJECT.

0 = DOES @UNOT@U CORRECTLY NAME AT LEAST 3 OBJECTS, NAME IS

@UUNRECOGNIZABLE, USED RANDOMLY@U THROUGHOUT EXAM, @UOR USED FOR

OTHER OBJECTS@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIf2g [ YNIf2g ] BINS 21-24 Mths Item 7:

@B*Runs with Coordination@B


@BMATERIALS:@B BALL

@BPOSITION:@B STANDING


@BADMINISTRATION:@B

- THROUGHOUT THE EXAM OBSERVE INFANT TO SEE IF HE/SHE RUNS WITHOUT

SUPPORT.

- IF THE INFANT DOES NOT, ROLL THE BALL A CROSS THE FLOOR AND ENCOURAGE

HIM/HER TO RUN BY SAYING, @B"Hurry. Get the ball. Run and get it."@B


@BSCORING:@B

1 = TAKES AT LEAST @U6 STEPS WITH GOOD COORDINATION@U, A RAPID, EVEN GAIT

(RUN), AND A NARROW BASE OF SUPPORT (LEGS UNDER TORSO).

0 = RUN IS STIFF-LEGGED AND @UWOBBLY OR@U HE/SHE TAKES @UFEWER THAN 6

STEPS RUNNING@U, @USTUMBLES@U WHILE TAKING STEPS, RUNS @UTIPTOE@U,

BENDS ARM(S) WITH FIST(S) HELD AT ELBOW OR SHOULDER HEIGHT, @UMOVES ONE

ARM MORE@U THAN THE OTHER, OR HOLDS ARM(S) IN @UABNORMAL POSTURE@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIf2h [ YNIf2h ] BINS 21-24 Mths Item 8:

@BKicks Ball@B


@BMATERIALS:@B BALL

@BPOSITION:@B STANDING


@BADMINISTRATION:@B

- PLACE THE BALL ON THE FLOOR IN FRONT OF YOU.

- GENTLY SWING YOUR FOOT BEHIND YOU AND THEN OUT IN FRONT TO KICK THE BALL.


- RETRIEVE THE BALL AND PLACE IT IN FRONT OF INFANT.

- ENCOURAGE THE INFANT TO KICK THE BALL.


@BSCORING:@B

1 = @UMAINTAINS BALANCE@U WHILE KICKING THE BALL FORWARD AT LEAST @UTWO

FEET@U.

0 = DOES @UNOT CONTACT@U BALL WITH FOOT, @ULOSES BALANCE, OR@U KICKS

THE BALL @UFEWER THAN TWO FEET@U.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIf2i [ YNIf2i ] BINS 21-24 Mths Item 9:

@BJumps off Floor@B


@BMATERIALS:@B NONE

@BPOSITION:@B UNSPECIFIED


@BADMINISTRATION:@B

- STAND THE INFANT ON THE FLOOR.

- YOU OR THE CAREGIVER SHOULD TAKE A SMALL JUMP, FEET TOGETHER, WHILE

SAYING TO INFANT, @B"Watch me jump."@B

- THEN ENCOURAGE THE INFANT TO JUMP.


@BSCORING:@B

1 = JUMPS OFF THE FLOOR, EITHER WITH FEET TOGETHER OR LEADING WITH ONE, BUT

@UBOTH FEET ARE IN THE AIR AT SOME POINT@U DURING THE JUMP.

0 = DOES @UNOT SIMULTANEOUSLY RAISE BOTH FEET@U OFF FLOOR.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIf2j [ YNIf2j ] BINS 21-24 Mths Item 10:

@BJumps from Bottom Step@B


@BMATERIALS:@B STAIRS

@BPOSITION:@B STANDING


@BADMINISTRATION:@B

- POSITION THE INFANT ON THE LOWEST STEP, FACING YOU.

- THEN STAND IN FRONT OF THE INFANT AND ASK HIM/HER TO JUMP TO THE FLOOR BY

SAYING, @B"Jump. Jump to me."@B

- BE READY TO CATCH THE INFANT IN CASE HE/SHE LOSES BALANCE, BUT DO NOT

HOLD HIS/HER HAND.

- YOU MAY DEMONSTRATE JUMPING ONCE.


@BSCORING:@B

1 = JUMPS TO FLOOR, EITHER WITH FEET TOGETHER OR LEADING WITH ONE FOOT, AS

LONG AS @UBOTH ARE OFF THE FLOOR AT THE SAME TIME@U.

0 = DOES @UNOT@U JUMP SO THAT @UBOTH FEET@U ARE IN THE AIR AT @UTHE

SAME TIME@U AT SOME POINT @UOR LOSES BALANCE@U WHEN HE/SHE LANDS.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIf2k [ YNIf2k ] BINS 21-24 Mths Item 11:

@B*Uses Two-Word Utterance (Spoken Phrase)@B


@BMATERIALS:@B NONE

@BPOSITION:@B UNSPECIFIED


@BADMINISTRATION:@B

- THROUGHOUT THE EXAM LISTEN FOR INFANT'S MULTIPLE-WORD UTTERANCES

(SPOKEN PHRASES) IN WHICH EACH WORD SIGNIFIES A DIFFERENT CONCEPT.

- SOME COMMON EXAMPLES: WANT JUICE, WHAT THAT?, WHERE DADA? AND GIVE

ME.


@BSCORING:@B

1 = PRODUCES AT LEAST ONE @UTWO-WORD@U UTTERANCE (SPOKEN PHRASE),

EACH DENOTING A DIFFERENT CONCEPT. THEY MUST BE @UUSED IN APPROPRIATE

MANNER AND SEPARATED BY A DISTINCT PAUSE@U.

0 = DOES @UNOT@U PRODUCE A TWO-WORD UTTERANCE (SPOKEN PHRASE),

@UOR@U USES WORDS THAT ONLY DENOTE ONE CONCEPT (E.G. GREAT BIG),

@UOR@U WORDS LEARNED IN ROTE FASHION (E.G. ALL GONE).

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIf2l [ YNIf2l ] BINS 21-24 Mths Item 12:

@B*Speaks Intelligibly (Understandably)@B


@BMATERIALS:@B NONE

@BPOSITION:@B UNSPECIFIED


@BADMINISTRATION:@B

- THROUGHOUT THE EXAM ATTEND TO INFANT'S SPEECH AND YOUR ABILITY TO

UNDERSTAND TO WHAT HE/SHE IS SAYING.

- IF YOU ARE IN DOUBT OF WHAT HE/SHE IS SAYING, VERIFY YOUR INTERPRETATION

WITH THAT OF CAREGIVER. ASK CAREGIVER: @BI thought I heard ^CHILD say (repeat some

things you have heard child say). Is that what she/he was saying or was it something else?@B


@BSCORING:@B

1 = ROUGHLY @U50% OR MORE@U OF SPEECH IS INTELLIGIBLE.

0 = @ULESS THAN 50% OR MORE@U OF SPEECH IS INTELLIGIBLE.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

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

Y_NIf2m [ YNIf2m ] BINS 21-24 Mths Item 13:

@B*Absence of Drooling and Motor Overflow (One Hand Mimics the Other Involuntarily)@B


@BMATERIALS:@B NONE

@BPOSITION:@B UNSPECIFIED


@BADMINISTRATION:@B

THROUGHOUT THE EXAM OBSERVE WHETHER INFANT DROOLS AND WHETHER ONE OF

HIS/HER HANDS MIMICS OR MIRRORS, IN AN INVOLUNTARY FASHION, THE ACTIVITIES OF

THE OTHER.


@BSCORING:@B

1 = DOES @UNOT SHOW EXCESSIVE DROOL@U AROUND MOUTH OR ANY DROOLING

AROUND COLLAR, @UAND NEITHER HAND MIMICS OR MIRRORS@U ACTIVITIES OF THE

OTHER MORE THAN HALF THE TIME.

0 = @UDROOLS EXCESSIVELY@U ON CLOTHING, @UOR@U IF @UEITHER OF THE HANDS

MIRRORS OR MIMICS@U THE OTHER MORE THAN HALF THE TIME.

Question Type: TNI

optimal 1 OPTIMAL

nonoptimal 0 NON-OPTIMAL

Logic after:

GOTO Y_NIEND

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

Y_NI_END [ YNI_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

Logic after:

Y_NIEND

CO - CHILD COMMUNICATION: PLS-5 MODULE


Preschool Language Scales, Fifth Edition (PLS-5); Zimmerman, Steiner, & Pond (2011); Pearson; Standardized assessment tool comprised of two scales: expressive communication and auditory comprehension; total language score computed.



WJ - Woodcock-Johnson III


Woodcock-Johnson III Tests of Achievement (WJ-III) Woodcock, Mather & McGrew (2004); Houghton, Mifflin, Harcourt.


Children 11 and older are administered the Letter-Word Identification and Applied Problems modules.


Children under age 11 are administered the Letter-Word Identification, Applied Problems, and Passage Comprehension modules.


CN - CHILD COMMUNITY ENVIRONMENT MODULE

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

Logic before:

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

Y_CNEND.

Y_CN1a [ YCN1a ] EmanCH neighborhd-assault/mug

USE CARD 4. Now I'd like to ask you some questions about your neighborhood and community.

For each item I read, please tell me if this issue is not a problem at all, somewhat of a problem,

or a big problem in your neighborhood. Please pick your answer from Card 4.


NOTE: ALL QUESTIONS IN THIS SECTION REFER TO "CURRENT" PROBLEMS.


Assaults and muggings? Would you say this is…

Question Type: TProblem

notaprob 1 not a problem at all,

someprob 2 somewhat of a problem, or

bigprob 3 a big problem in your neighborhood?

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

Y_CN2a [ YCN2a ] EmanCH neighborhd-gangs

USE CARD 4. Delinquent gangs or drug gangs? Would you say this is...

Question Type: TProblem

notaprob 1 not a problem at all,

someprob 2 somewhat of a problem, or

bigprob 3 a big problem in your neighborhood?

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

Y_CN3a [ YCN3a ] EmanCH neighborhd-drug use/dealing

USE CARD 4. Open drug use or drug dealing?


(Would you say this is...READ CATEGORIES AS NEEDED.)


NOTE: THIS MEANS VISIBLE OR PUBLIC DRUG USE.

Question Type: TProblem

notaprob 1 not a problem at all,

someprob 2 somewhat of a problem, or

bigprob 3 a big problem in your neighborhood?

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

Y_CN4a [ YCN4a ] EmanCH neighborhd-unsupervised kids

USE CARD 4. Unsupervised children?


(Would you say this is...READ CATEGORIES AS NEEDED.)

Question Type: TProblem

notaprob 1 not a problem at all,

someprob 2 somewhat of a problem, or

bigprob 3 a big problem in your neighborhood?

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

Y_CN5a [ YCN5a ] EmanCH neighborhd-teenagers

USE CARD 4. Groups of teenagers hanging out in public places and making a nuisance of

themselves?


(Would you say this is...READ CATEGORIES AS NEEDED.)

Question Type: TProblem

notaprob 1 not a problem at all,

someprob 2 somewhat of a problem, or

bigprob 3 a big problem in your neighborhood?

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

Y_CN6a [ YCN6a ] EmanCH cmpr neighborhd safety

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

neighborhoods.


Is your neighborhood...

Question Type: TSafe

safer 1 safer,

assafe 2 about the same, or

notsafe 3 not as safe as most neighborhoods?

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

Y_CN7a [ YCN7a ] EmanCH cmpr neighbors help

Does your neighborhood have...

Question Type: TNbrHlp

morehelp 1 more neighbors help each other,

samehelp 2 about the same number of neighbors help each other, or

fewhelp 3 fewer neighbors help each other than most neighborhoods?

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

Y_CN8a [ YCN8a ] EmanCH cmpr involved parents

Does your neighborhood have...

Question Type: TParents

moreinv 1 more involved parents,

sameinv 2 about the same number of involved parents, or

fewerinv 3 fewer involved parents than most neighborhoods?

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

Y_CN9a [ YCN9a ] EmanCH cmpr neighborhd a place to live

Is your neighborhood...

Question Type: TNHood

better 1 a better place to live,

aboutsame 2 about the same, or

worse 3 a worse place to live than most neighborhoods?

Logic after:

Y_CNEND



SE - CHILD SCHOOL ENGAGEMENT MODULE

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

Logic before:

IF AGE < 6, CHILD IS NOT IN SCHOOL, OR CHILD IS HOME-SCHOOLED, GOTO Y_SEEND. IF

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

Y_SE0 [ YSE0 ] NO LABEL

USE CARD 1. Now I'm going to ask you how often you have different types of feelings about

school. For each question, pick @Bone@B answer from this card. You can pick never,

sometimes, often, or almost always. For example, suppose I asked you how often you bring a

lunch from home to school. If you don't ever bring your lunch, you would pick the answer "never."

If you do this every once in a while, you would pick "sometimes." If you do this a lot, you would

pick "often." If you always or almost always do this, you would pick "almost always."


Okay, let's start. Honest answers are important, so please tell me what you really feel or think.

Your answers will be kept private. No one will tell your family or teachers anything about your

answers.


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

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

Y_SE1a [ YSE1a ] enjoys being in school

USE CARD 1. How often do you enjoy being in school? Would you say...

FR NOTE: IF CHILD SAYS THEY ARE NOT ATTENDING SCHOOL IN PERSON, PLEASE ASK THEM TO THINK ABOUT THEIR CURRENT SITUATION (REMOTE LEARNING EXPERIENCE).

Question Type: TSEFrq1F

never 1 never

sometimes 2 sometimes

often 3 often, or

always 4 almost always

notapp 5 NOT APPLICABLE (IF VOLUNTEERED NOT IN SCHOOL OR "HOME-

SCHOOLED")

Logic after:

IF Y_SE1a = 5 GOTO Y_SEEND

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

Y_SE2a [ YSE2a ] hates being in school

USE CARD 1. How often do you hate being in school? Would you say...

Question Type: TSEFrq2F

never 1 never

sometimes 2 sometimes

often 3 often, or

always 4 almost always

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

Y_SE3a [ YSE3a ] try to do best work in school

USE CARD 1. How often do you try to do your best work in school? (Would you say never,

sometimes, often, or almost always?)

Question Type: TSEFrq2C

never 1 NEVER

sometimes 2 SOMETIMES

often 3 OFTEN

always 4 ALMOST ALWAYS

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

Y_SE4a [ YSE4a ] finds school work too hard

USE CARD 1. How often do you find the school work too hard to understand? (Would you say

never, sometimes, often, or almost always?)

Question Type: TSEFrq2C

never 1 NEVER

sometimes 2 SOMETIMES

often 3 OFTEN

always 4 ALMOST ALWAYS

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

Y_SE5a [ YSE5a ] finds class interesting

USE CARD 1. How often do you find your classes interesting? (Would you say never,

sometimes, often, or almost always?)

Question Type: TSEFrq2C

never 1 NEVER

sometimes 2 SOMETIMES

often 3 OFTEN

always 4 ALMOST ALWAYS

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

Y_SE6a [ YSE6a ] fails to complete assignments

USE CARD 1. How often do you fail to complete or turn in your assignments? (Would you say

never, sometimes, often, or almost always?)

Question Type: TSEFrq2C

never 1 NEVER

sometimes 2 SOMETIMES

often 3 OFTEN

always 4 ALMOST ALWAYS

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

Y_SE7a [ YSE7a ] sent to office/stay after school

USE CARD 1. How often do you get sent to the office, or have to stay after school, because you

misbehaved? (Would you say never, sometimes, often, or almost always?)

Question Type: TSEFrq2C

never 1 NEVER

sometimes 2 SOMETIMES

often 3 OFTEN

always 4 ALMOST ALWAYS

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

Y_SE8a [ YSE8a ] get along w/ teachers

USE CARD 1. How often do you get along with your teachers? (Would you say never,

sometimes, often, or almost always?)

Question Type: TSEFrq2C

never 1 NEVER

sometimes 2 SOMETIMES

often 3 OFTEN

always 4 ALMOST ALWAYS

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

Y_SE9a [ YSE9a ] listen carefully in school

USE CARD 1. How often do you listen carefully or pay attention in school? (Would you say

never, sometimes, often, or almost always?)

Question Type: TSEFrq2C

never 1 NEVER

sometimes 2 SOMETIMES

often 3 OFTEN

always 4 ALMOST ALWAYS

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

Y_SE10a [ YSE10a ] get homework done

USE CARD 1. How often do you get your homework done? (Would you say never, sometimes,

often, or almost always?)

Question Type: TSEFrq2C

never 1 NEVER

sometimes 2 SOMETIMES

often 3 OFTEN

always 4 ALMOST ALWAYS

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

Y_SE11a [ YSE11a ] get along w/other students

USE CARD 1. How often do you get along with other students? (Would you say never,

sometimes, often, or almost always?)

Question Type: TSEFrq2C

never 1 NEVER

sometimes 2 SOMETIMES

often 3 OFTEN

always 4 ALMOST ALWAYS

Logic after:

GOTO Y_SEEND

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

Y_SE_END [ YSE_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

Logic after:

Y_SEEND



RR - CHILD RELATIONSHIP WITH PEERS

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

Logic before:

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


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


Y_RR1

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

1 Very well

2 Moderately well

3 Not well at all

4 Not at all

Y_RR2

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

1 Very well

2 Moderately well

3 Not well at all

4 Not at all

Y_RR3

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

1 Very well

2 Moderately well

3 Not well at all

4 Not at all


Y_RR4

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

1 Very well

2 Moderately well

3 Not well at all

4 Not at all

Y_RR5

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

1 Very few (LESS THAN 25%)

2 Some (AROUND 25%)

3 About half (50%)

4 Most (AROUND 75%)

5 Almost all (MORE THAN 75%)


Y_RR6

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

1 Very few (LESS THAN 25%)

2 Some (AROUND 25%)

3 About half (50%)

4 Most (AROUND 75%)

5 Almost all (MORE THAN 75%)


Y_RR7

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

1 Very few (LESS THAN 25%)

2 Some (AROUND 25%)

3 About half (50%)

4 Most (AROUND 75%)

5 Almost all (MORE THAN 75%)


Y_RR8

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

1 Very few (LESS THAN 25%)

2 Some (AROUND 25%)

3 About half (50%)

4 Most (AROUND 75%)

5 Almost all (MORE THAN 75%)


Y_RR9

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

1 Very few (LESS THAN 25%)

2 Some (AROUND 25%)

3 About half (50%)

4 Most (AROUND 75%)

5 Almost all (MORE THAN 75%)


Y_RR10

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

1 Very few (LESS THAN 25%)

2 Some (AROUND 25%)

3 About half (50%)

4 Most (AROUND 75%)

5 Almost all (MORE THAN 75%)


Y_RR11

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


1 Never

2 Hardly ever

3 Sometimes

4 Most of the time

5 Always


Y_RR12

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


1 Never

2 Hardly ever

3 Sometimes

4 Most of the time

5 Always


Y_RR13

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

1 Very few (LESS THAN 25%)

2 Some (AROUND 25%)

3 About half (50%)

4 Most (AROUND 75%)

5 Almost all (MORE THAN 75%)



Y_RR14

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

1 Very few (LESS THAN 25%)

2 Some (AROUND 25%)

3 About half (50%)

4 Most (AROUND 75%)

5 Almost all (MORE THAN 75%)


Y_RR15

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

1 Very few (LESS THAN 25%)

2 Some (AROUND 25%)

3 About half (50%)

4 Most (AROUND 75%)

5 Almost all (MORE THAN 75%)


Y_RR16

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

1 Very few (LESS THAN 25%)

2 Some (AROUND 25%)

3 About half (50%)

4 Most (AROUND 75%)

5 Almost all (MORE THAN 75%)


Y_RR17

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

1 Very few (LESS THAN 25%)

2 Some (AROUND 25%)

3 About half (50%)

4 Most (AROUND 75%)

5 Almost all (MORE THAN 75%)


Y_RR18

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

1 Very few (LESS THAN 25%)

2 Some (AROUND 25%)

3 About half (50%)

4 Most (AROUND 75%)

5 Almost all (MORE THAN 75%)


Y_RR19

Has anyone teased you or called you names recently?

1 YES

2 NO


Logic after:

If Y_RR19 = NO, GOTO Y_RR20


Y_RR19a

How often? Would you say…

1 Most days

2 About once a week

3 Less than once a week

Y_RR19b

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

1 Not at all

2 A bit

3 I was quite upset


Y_RR20

Has anyone spread rumors about you recently?

1 YES

2 NO


Logic after:

If Y_RR20 = NO, GOTO Y_RR21


Y_RR20a

How often? Would you say…

1 Most days

2 About once a week

3 Less than once a week


Y_RR20b

How upsetting were the rumors? Would you say…

1 Not at all

2 A bit

3 I was quite upset


Y_RR21

Have you been deliberately left out of things recently?

1 YES

2 NO


Logic after:

If Y_RR21 = NO, GOTO Y_RR22


Y_RR21a

How often? Would you say…

1 Most days

2 About once a week

3 Less than once a week


Y_RR21b

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

1 Not at all

2 A bit

3 I was quite upset


Y_RR22

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

1 YES

2 NO


Logic after:

If Y_RR22 = NO, GOTO Y_RREND


Y_RR22a

How often? Would you say…

1 Most days

2 About once a week

3 Less than once a week


Y_RR22b

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

1 Not at all

2 A bit

3 I was quite upset


Y_RREND




PM - CHILD PARENTAL MONITORING MODULE

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

Logic before:

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

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

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

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

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


USE CARD 4. For the next questions, pick your answer from this card. @BIn the past 6

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

do for the @Bcoming@B day?

Question Type: TPMFreq

almstnvr 1 Almost never

oncinawhl 2 Once in a while

sometimes 3 Sometimes

often 4 Often

almstalwys 5 Almost always

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

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

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

you had @Bactually@B done during the day?

Question Type: TPMFreq

almstnvr 1 Almost never

oncinawhl 2 Once in a while

sometimes 3 Sometimes

often 4 Often

almstalwys 5 Almost always

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

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

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

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

Question Type: TPMFreq

almstnvr 1 Almost never

oncinawhl 2 Once in a while

sometimes 3 Sometimes

often 4 Often

almstalwys 5 Almost always

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

Y_PM10a [ YPM10a ] How often do you have set time to be home on school nights

How often do you have a set time to be home on @Bschool nights@B?

Question Type: TPMFreqC

almstnvr 1 ALMOST NEVER

oncinawhl 2 ONCE IN A WHILE

sometimes 3 SOMETIMES

often 4 OFTEN

almstalwys 5 ALMOST ALWAYS

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

Logic before:

IF Y_PM10a = 2, 3, 4, 5 CONTINUE, ELSE SKIP TO Y_PM12a

Y_PM11 [ YPM11 ] What time school nights? (hour)

What time is that?


HOUR:

Question Type: 1..12

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

Y_PM11m [ YPM11m ] What time school nights? (minute)

(What time is that?)


MINUTE:

Question Type: 0..59

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

Y_PM11am [ YPM11am ] What time school nights? (am/pm)

(What time is that?) Is that AM or PM?

Question Type: TAMPM

am 1 AM

pm 2 PM

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

Y_PM12a [ YPM12a ] How often do you have a set time to be home weekend nights

How often do you have a set time to be home on @Bweekend nights@B?

Question Type: TPMFreqC

almstnvr 1 ALMOST NEVER

oncinawhl 2 ONCE IN A WHILE

sometimes 3 SOMETIMES

often 4 OFTEN

almstalwys 5 ALMOST ALWAYS

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

Logic before:

IF Y_PM12a = 2, 3, 4, 5 CONTINUE, ELSE SKIP TO Y_PM15a

Y_PM13 [ YPM13 ] What time weekend nights? (hour)

What time is that?


HOUR:

Question Type: 1..12

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

Y_PM13m [ YPM13m ] What time weekend nights? (minute)

(What time is that?)


MINUTE:

Question Type: 0..59

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

Y_PM13am [ YPM13am ] What time weekend nights (am/pm)

(What time is that?) Is that AM or PM?

Question Type: TAMPM

am 1 AM

pm 2 PM

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

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

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

^Global.CAREGIVER_A know?

Question Type: TPMFreqC

almstnvr 1 ALMOST NEVER

oncinawhl 2 ONCE IN A WHILE

sometimes 3 SOMETIMES

often 4 OFTEN

almstalwys 5 ALMOST ALWAYS

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

Y_PM15a [ YPM15a ] Allowed to leave house of CG is not at home?

If your ^Global.CAREGIVER_A is not at home, are you allowed to leave the house?

Question Type: TPMFreqC

almstnvr 1 ALMOST NEVER

oncinawhl 2 ONCE IN A WHILE

sometimes 3 SOMETIMES

often 4 OFTEN

almstalwys 5 ALMOST ALWAYS

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

Logic before:

IF Y_PM15a = 2, 3, 4, 5 CONTINUE. ELSE SKIP TO Y_PM18a

Y_PM16a [ YPM16a ] How often leave a note or call CG about where you are going?

How often do you leave a note for your ^Global.CAREGIVER_A or call ^Fills.HimHer about where

you are going?

Question Type: TPMFreqC

almstnvr 1 ALMOST NEVER

oncinawhl 2 ONCE IN A WHILE

sometimes 3 SOMETIMES

often 4 OFTEN

almstalwys 5 ALMOST ALWAYS

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

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

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

from home?

Question Type: TPMFreqC

almstnvr 1 ALMOST NEVER

oncinawhl 2 ONCE IN A WHILE

sometimes 3 SOMETIMES

often 4 OFTEN

almstalwys 5 ALMOST ALWAYS

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

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

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

Question Type: TPMFreqC

almstnvr 1 ALMOST NEVER

oncinawhl 2 ONCE IN A WHILE

sometimes 3 SOMETIMES

often 4 OFTEN

almstalwys 5 ALMOST ALWAYS

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

Y_PM19a [ YPM19a ] When CG is not home, hos often you know how to get in touch

When your ^Global.CAREGIVER_A is not home, how often do you know how to get in touch with

^FILLS.himher?

Question Type: TPMFreqC

almstnvr 1 ALMOST NEVER

oncinawhl 2 ONCE IN A WHILE

sometimes 3 SOMETIMES

often 4 OFTEN

almstalwys 5 ALMOST ALWAYS

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

Y_PM20a [ YPM20a ] Where do you usually go right after school?

Where do you @Busually@B go right after school?

Question Type: TPM20a

supvhome 1 HOME, SUPERVISED (ADULT OR RESPONSIBLE MINOR PRESENT)

unsupvhome 2 HOME, UNSUPERVISED

supvothr 3 SOMEWHERE ELSE, SUPERVISED (ADULT OR RESPONSIBLE

MINOR PRESENT)

unsupvothr 4 SOMEWHERE ELSE, UNSUPERVISED

othrdkifsupv 5 SOMEWHERE ELSE, DON'T KNOW IF SUPERVISED

other 6 OTHER

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

Y_PM21a [ YPM21a ] Where do you usally stay in the evening

Where do you @Busually@B stay in the evening?

Question Type: TPM20a

supvhome 1 HOME, SUPERVISED (ADULT OR RESPONSIBLE MINOR PRESENT)

unsupvhome 2 HOME, UNSUPERVISED

supvothr 3 SOMEWHERE ELSE, SUPERVISED (ADULT OR RESPONSIBLE

MINOR PRESENT)

unsupvothr 4 SOMEWHERE ELSE, UNSUPERVISED

othrdkifsupv 5 SOMEWHERE ELSE, DON'T KNOW IF SUPERVISED

other 6 OTHER

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

Y_PM22a [ YPM22a ] Where do you usually stay on the weekends?

Where do you @Busually@B stay on the weekends?

Question Type: TPM20a

supvhome 1 HOME, SUPERVISED (ADULT OR RESPONSIBLE MINOR PRESENT)

unsupvhome 2 HOME, UNSUPERVISED

supvothr 3 SOMEWHERE ELSE, SUPERVISED (ADULT OR RESPONSIBLE

MINOR PRESENT)

unsupvothr 4 SOMEWHERE ELSE, UNSUPERVISED

othrdkifsupv 5 SOMEWHERE ELSE, DON'T KNOW IF SUPERVISED

other 6 OTHER

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

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

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

what you are doing?

Question Type: TPMFreqC

almstnvr 1 ALMOST NEVER

oncinawhl 2 ONCE IN A WHILE

sometimes 3 SOMETIMES

often 4 OFTEN

almstalwys 5 ALMOST ALWAYS

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

Y_PM24a [ YPM24a ] How many of your friends does CG know?

How many of your friends does your ^Global.CAREGIVER_A know?

Question Type: TPM24a

none 0 None

afew 1 A few

several 2 Several

most 3 Most

all 4 All

GR - PERSISTENCE/GRIT

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


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

Y_GR1

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

1=Very much like me

2=Mostly like me

3=Somewhat like me

4=Not much like me

5=Not like me at all


Y_GR2

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

1=Very much like me

2=Mostly like me

3=Somewhat like me

4=Not much like me

5=Not like me at all


Y_GR3

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

1=Very much like me

2=Mostly like me

3=Somewhat like me

4=Not much like me

5=Not like me at all


Y_GR 4

I am a hard worker. Would you say…

1=Very much like me

2=Mostly like me

3=Somewhat like me

4=Not much like me

5=Not like me at all


Y_GR5

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

1=Very much like me

2=Mostly like me

3=Somewhat like me

4=Not much like me

5=Not like me at all




Y_GR6

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

1=Very much like me

2=Mostly like me

3=Somewhat like me

4=Not much like me

5=Not like me at all


Y_GR7

I finish whatever I begin. Would you say…

1=Very much like me

2=Mostly like me

3=Somewhat like me

4=Not much like me

5=Not like me at all


Y_GR8

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

1=Very much like me

2=Mostly like me

3=Somewhat like me

4=Not much like me

5=Not like me at all



Y_GREND.



SF - SELF-ESTEEM

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


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


Y_SF1

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

1=Strongly agree

2=Agree

3=Disagree

4=Strongly disagree


Y_SF2

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

1=Strongly agree

2=Agree

3=Disagree

4=Strongly disagree


Y_SF3

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

1=Strongly agree

2=Agree

3=Disagree

4=Strongly disagree


Y_SF4

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

1=Strongly agree

2=Agree

3=Disagree

4=Strongly disagree


Y_SF5

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

1=Strongly agree

2=Agree

3=Disagree

4=Strongly disagree


Y_SF6

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

1=Strongly agree

2=Agree

3=Disagree

4=Strongly disagree


Y_SF7

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

1=Strongly agree

2=Agree

3=Disagree

4=Strongly disagree


Y_SF8

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

1=Strongly agree

2=Agree

3=Disagree

4=Strongly disagree


Y_SF9

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

1=Strongly agree

2=Agree

3=Disagree

4=Strongly disagree


Y_SF10

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

1=Strongly agree

2=Agree

3=Disagree

4=Strongly disagree


Y_SFEND



IP - CHILD INDEPENDENT LIVING MODULE

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

Y_IP_BGN [ YIP_BGN ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

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

Logic before:

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

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

Y_IP1

How prepared do you feel to continue and achieve your education or job training goals? This may include goals like earning your high school diploma or G.E.D., completing a vocational training program, or going to college.

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED


Y_IP2

How prepared do you feel to live independently? This includes day-to-day responsibilities like keeping good hygiene, buying food and preparing meals, doing laundry, cleaning, and maintaining and repairing household items.

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED


Y_IP3

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

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED


Y_IP4

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

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED




Y_IP5

How prepared do you feel to manage your physical health? This includes things like following a healthy diet, exercising, accessing your health records, knowing about your health insurance, using first aid to treat minor injuries, recognizing when you become sick and knowing how to make an appointment, following through with your doctor’s instructions, and making regular check-up appointments with your doctor or dentist.

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED



Y_IP6

How prepared do you feel to deal with issues of substance abuse? This includes things like knowing how drugs can be harmful, staying away from situations that make you want to use, hanging out with friends who don’t use, and knowing where to get treatment.

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED


Y_IP7

How prepared do you feel to make decisions about family planning? This includes using contraception to avoid unplanned pregnancy, and waiting to have a child until you are financially and emotionally ready.

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED


Y_IP8a

How prepared do you feel to manage these aspects of your mental health?

Paying attention to changes in your mood, being able to calm yourself down when you get upset, and findings ways to relax when you feel stressed out

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED


Y_IP8b

[How prepared do you feel to manage these aspects of your mental health?]

Talking to others about things that are bothering you

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED


Y_IP8c

[How prepared do you feel to manage these aspects of your mental health?]

Knowing how to make an appointment with a psychiatrist or therapist and following through with your psychiatrist or therapists instructions

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED





Y_IP9a

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

Knowing where to look for a job

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED


Y_IP9b

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

Writing a resume

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED


Y_IP9c

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

Completing a job application

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED


Y_IP9d

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

Participating in a job interview

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED


Y_IP9e

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

Negotiating job wages and benefits

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED



Y_IP10a

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

Searching for an apartment

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED




Y_IP10b

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

Completing an apartment application

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED


Y_IP10c

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

Learning about security deposits and utility set-up

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED


Y_IP10d

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

Signing a lease

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED


Y_IP10e

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

Checking my credit score

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED




Y_IP11a

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

Using a checking or savings account

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED


Y_IP11b

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

Planning a budget to pay bills and buy things you need

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED


Y_IP11c

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

Completing tax returns

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED


Y_IP11d

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

Avoiding credit card debt

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED


Y_IP11e

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

Saving or investing money for the future

1=VERY PREPARED

2=PREPARED

3=SOMEWHAT PREPARED

4=NOT PREPARED


Y_IP26a [ YIP26a ] CW discussed after 18/live independently

[IF LIVING SITUATION = IN-HOME OR YOUNG ADULT] Has anyone (including your parents, caseworker or other trusted adult) ever talked with you about what life will be like when you need to live independently?

Question Type: TYesNoC

Yes 1 YES

No 2 NO


Y_IP26b [ YIP26a ] CW discussed after 18/foster care

[IF LIVING SITUATION = OOH, INCLUDING FOSTER CARE, FORMAL KIN, GROUP HOME/RESIDENTIAL OR OTHER OOH.] Has anyone (including a parent, caseworker or other trusted adult) ever talked with you about what life will be like when you leave foster care?

Question Type: TYesNoC

Yes 1 YES

No 2 NO



Y_IP28a [ YIP28a ] CG suggested independent living classes

[IF LIVING SITUATION = IN-HOME OR YOUNG ADULT] Has anyone (including a parent, caseworker or other trusted adult) ever suggested any independent living or life skills training programs or classes to help you prepare for being on your own?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Y_IP28b

[IF LIVING SITUATION = OOH, INCLUDING FOSTER CARE, FORMAL KIN, GROUP HOME/RESIDENTIAL OR OTHER OOH] Has anyone (including a parent, caseworker or other trusted adult) ever suggested any independent living or life skills training programs or classes to help you prepare to leave foster care?

Question Type: TYesNoC

Yes 1 YES

No 2 NO


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

Y_IP30a [ YIP54a ] Ever attend class for living on own

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

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:


Y_IP30b [ YIP30a ] CH took independent living class

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

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_IP30a = NO, DK, RE, GOTO Y_IP33a

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

Y_IP70a [ YIP70a ] Have Social Security card

Do you have a Social Security card?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

Y_IP71a [ YIP71a ] Have copy of birth cirtificate

Do you have a copy of your birth certificate?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

Y_IP72a [ YIP72a ] Have drivers license

Do you have a driver's license?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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



Y_IP73a [ YIP73a ] Have state-issued photo ID

Do you have a state-issued photo ID?

Question Type: TYesNoC

Yes 1 YES

No 2 NO


Y_IP74

Do you have a checking or savings account?

Question Type: TYesNoC

Yes 1 YES

No 2 NO


Y_IP75

Do you have a cell phone?

Question Type: TYesNoC

Yes 1 YES

No 2 NO


Y_IP76

Do you have regular access to the internet?

Question Type: TYesNoC

Yes 1 YES

No 2 NO


Y_IP77

Do you own a working vehicle, such as a car, van, truck, jeep-like vehicle or motorcycle?

Question Type: TYesNoC

Yes 1 YES

No 2 NO




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

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

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


Y_OH1a

Now I would like to ask you about your overall experience in the foster care system.


Think about how many different foster homes, group homes, or residential treatment centers you have been in since first entering the foster care system.


First, how many FOSTER HOMES, including foster homes with relatives and nonrelatives, have you been in since first entering the foster care system?


INTERVIEWER: PLACEMENT INTO THE SAME HOME TWICE SHOULD BE COUNTED AS TWO HOMES.

0-30 ZERO THROUGH THIRTY

31 MORE THAN THIRTY

Y_OH1b

How many GROUP HOMES, RESIDENTIAL TREATMENT CENTERS or CHILD CARING INSTITUTIONS have you been in since first entering the foster care system?


INTERVIEWER: PLACEMENT INTO THE SAME HOME TWICE SHOULD BE COUNTED AS TWO HOMES.

0-30 ZERO THROUGH THIRTY

31 MORE THAN THIRTY


Y_OH1c

Have you ever had foster parents who were relatives of yours?

1 YES

2 NO


Y_OH1d

Are you now in a foster placement where the plan of your social worker or your foster parents is that you will be adopted by the family that you are living with?

1 YES

2 NO


Y_OH1e

Have you ever, in the past, been in a foster placement where the plan of your social worker or your foster parents was that you would be adopted by that family, but the adoption didn’t work out?

1 YES

2 NO


Y_OH1f

Have you ever been adopted?

1 YES

2 NO


Y_OH1g

Now I would like to ask you some questions about the people you live with and how it is to live

here.


SHOWCARD #1

Some people feel close to one or more of their caregivers, others don't feel close at all. Think about your current caregiver. Would you say that you feel very close, somewhat close, not very close, or not at all close to your caregiver these days?

INTERVIEWER: IF R SAYS "close to some, not others" PROBE FOR CLOSEST ATTACHMENT AND CODE THAT ONE: "What about the one you feel closest to, do you feel..."


1 VERY CLOSE

2 SOMEWHAT CLOSE

3 NOT VERY CLOSE

4 NOT AT ALL CLOSE


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

Logic before:

IF Y_CH11a = 1 or 2, ASK Y_OH2a. ELSE, GO TO Y_OH3a.

Y_OH2a [ YOH2a ] Does OOH CH feel like part of family

Do you feel like you're part of this family?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

Y_OH3a [ YOH3a ] Can OOH CH live there until grown up

Can you keep living here until you grow up?


NOTE: THIS QUESTION REFERS TO WHETHER THE CHILD THINKS HE/SHE IS ALLOWED

TO KEEP LIVING HERE, NOT WHETHER THE CHILD WANTS TO KEEP LIVING HERE.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

F Y_CH11a = 4, ASK Y_OH3b. ELSE, GO TO Y_OH4a.

Y_OH3b

Some people feel close to an adult in their group home or residential treatment center, others don't feel close at all. Think about the adults that work at your group home or center, would you say that you feel very close, somewhat close, not very close, or not at all close to those adults these days?


INTERVIEWER: IF R SAYS "close to some, not others" PROBE FOR CLOSEST ATTACHMENT AND CODE THAT ONE: "What about the one you feel closest to, do you feel..."


1 VERY CLOSE

2 SOMEWHAT CLOSE

3 NOT VERY CLOSE

4 NOT AT ALL CLOSE



Logic before:

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

Y_OH4a [ YOH4a ] Does OOH CH know bio mom

Do you know your biological mom, or birth mom?


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

BIRTH TO YOU)

Question Type: TYesNoC

Yes 1 YES

No 2 NO


Y_OH4b

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


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


1 VERY CLOSE

2 SOMEWHAT CLOSE

3 NOT VERY CLOSE

4 NOT AT ALL CLOSE


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

Logic before:

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

Y_OH4xa [ YOH4xa ] Does OOH CH know bio father

Do you know your biological dad?


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

Question Type: TYesNoC

Yes 1 YES

No 2 NO


Y_OH4c

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


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


1 VERY CLOSE

2 SOMEWHAT CLOSE

3 NOT VERY CLOSE

4 NOT AT ALL CLOSE

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

Y_OH5 [ YOH5T ] Labels are in Logic After

USE CARD 5. If you could live with anyone, who would it be? (DO NOT PROBE AFTER INITIAL

RESPONSE.) (CODE ALL THAT APPLY.)

Question Type: TYOH5S

biomom 1 MOTHER (BIOLOGICAL)

biodad 2 FATHER (BIOLOGICAL)

stepmom 3 STEP-MOTHER

stepdad 4 STEP-FATHER

grandma 5 GRANDMOTHER

grgrandma 6 GREAT GRANDMOTHER

grandpa 7 GRANDFATHER

grgrandpa 8 GREAT GRANDFATHER

auntuncle 9 AUNT/UNCLE

grauntuncle 10 GREAT AUNT/UNCLE

biosib 11 BIOLOGICAL SIBLING(S)

fostsib 12 FOSTER SIBLING(S)

otherrel 13 OTHER RELATIVE

neighbor 14 NEIGHBOR

friend 15 FRIEND

boygirlfriend 16 GIRLFRIEND/BOYFRIEND

currfosparent 17 CURRENT FOSTER PARENT

frmrfosparent 18 FORMER FOSTER PARENT

newfosthome 19 NEW (OR UNSPECIFIED) FOSTER HOME

currgrouphome 20 CURRENT GROUP/RESIDENTIAL SETTING

frmrgrouphome 21 FORMER GROUP/RESIDENTIAL SETTING

newgrouphome 22 NEW (OR UNSPECIFIED) GROUP OR RESIDENTIAL TREATMENT

SETTING

juvjustice 23 INCARCERATION/JUVENILE JUSTICE

teacher 24 TEACHER/CHILD CARE/OTHER KNOWN PROVIDER

alone 25 BY MYSELF/ALONE

other 26 OTHER

Logic after:

YOH5T_1 --BIOLOGICAL MOTHER; YOH5T_2 --BIOLOGICAL FATHER; YOH5T_3 --STEP

MOTHER; YOH5T_4 --STEP FATHER; YOH5T_5 --GRANDMOTHER; YOH5T_6 --GREAT

GRANDMOTHER; YOH5T_7 --GRANDFATHER; YOH5T_8 --GREAT GRANDFATHER; YOH5T_9 --

AUNT/UNCLE; YOH5T_10 --GREAT AUNT/UNCLE; YOH5T_11 --BIOLGICAL SIBLING(S);

YOH5T_12 --FOSTER SIBLING(S); YOH5T_13 --OTHER RELATIVE; YOH5T_14 --NEIGHBOR;

YOH5T_15 --FRIEND; YOH5T_16 --GIRLFRIEND/BOYFRIEND; YOH5T_17 --CURRENT FOSTER

PARENT; YOH5T_18 --FORMER FOSTER PARENT; YOH5T_19 --NEW(OR UNSPECIFIED)

FOSTER HOME; YOH5T_20 --CURRENT GROUP OR RES SETTING; YOH5T_21 --FORMER

GROUP OR RES SETTING; YOH5T_22 --NEW GROUP OR RES TREAT. SETTING; YOH5T_23 --

INCARCERATION/JUVENILE JUSTICE; YOH5T_24 --TEACHER/CHILD CARE/OTHER KNOWN

PROV; YOH5T_25 --BY MYSELF/ALONE; YOH5T_26--OTHER; YOH5T_27--DK; YOH5T_28--RF

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

Y_OH9a [ YOH9a ] OOH CH asked to stop living there

Have you ever asked someone if you could leave here or stop living here?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

Y_OH10a [ YOH10a ] OOH CH tried to leave here before

Have you ever tried to leave here before?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

IF Y_CH11A = 4 THEN GO TO Y_OH20A

Y_OH18a [ YOH18a ] OOH CH moved into diff neigh

When you moved away from your home to a(n) ^Fills.OH_ICC12, different things in your life might

have changed. The next questions ask whether or not certain things changed for you.


Did you move to a different neighborhood when you moved into your ^Fills.OH_ICC12?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Question Fill: ^FillOH_ICC12

fosterhome foster home

grouphome group home

respgm residential program

relhome relative's home

other other home

Logic after:

IF Y_OH18a = 2 GOTO Y_OH20a

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

Y_OH20a [ YOH20a ] OOH CH goes to diff school

Do you go to a different school than you used to as a result of your move to a(n) ^Fills.OH_ICC12?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Question Fill: ^FillOH_ICC12

fosterhome foster home

grouphome group home

respgm residential program

relhome relative's home

other other home

Logic after:

IF Y_OH20a = 2 GOTO Y_OH22a

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

Y_OH21a [ YOH21a ] Is OOH CH new school worse/same/better

Is your new school worse, the same, or better than the school you used to go to?

Question Type: TSmBtr

worse 1 WORSE

same 2 SAME

better 3 BETTER

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

Y_OH22a [ YOH22a ] OOH CH has diff friends

Do you have different friends now as a result of your move to a(n) ^Fills.OH_ICC12?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Question Fill: ^FillOH_ICC12

fosterhome foster home

grouphome group home

respgm residential program

relhome relative's home

other other home

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

Y_OH23a [ YOH23a ] OOH CH sees old friends

Do you still see any of the friends you had before you came to live here?

Question Type: TYesNoC

Yes 1 YES

No 2 NO


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

Y_OH25n [ YOH25n ] How long OOH CH gone to current school (#)

How long have you gone to the school you go to now?


NUMBER:

Question Type: 0..1000

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

Y_OH25u [ YOH25ux ] How long OOH CH @ current school y/m/w/d

Is that the number of years, months, or days?

Question Type: TOH25u

yrs 1 YEARS

mos 2 MONTHS

weeks 3 WEEKS

days 4 DAYS

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

Logic before:

IF Y_OH20a <> 1, GOTO Y_OH28a

Y_OH26a [ YOH26a ] # schools attended by OOH CH since not w/parents

How many schools have you gone to since you stopped living with your parents?


NUMBER OF SCHOOLS:

Question Type: 0..25


Y_OH26b [ YOH26a ] # schools attended by OOH CH in past 12 mths

How many schools have you gone to in the past 12 months?


NUMBER OF SCHOOLS:

Question Type: 0..25



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

Y_OH30a [ YOH30a ] OOH CH have contact w/mom

Now I would like to ask you about your biological or birth mom.

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

Question Type: TFrqVst

never 1 never,

lessoncemo 2 less than once a month,

onceamo 3 once or twice a month,

onceawk 4 about once a week,

moreonceawk 5 several times a week, or

everyday 6 everyday?

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

Logic before:

IF Y_OH30a = 1, GOTO Y_OH38a

Y_OH33 [ YOH33T ] Labels are in Logic After

Where do the visits take place?


CODE ALL THAT APPLY.

Question Type: TYOH33S

currhome 1 PRESENT HOME

wlfragncy 2 CHILD WELFARE AGENCY

txcenter 3 TREATMENT CENTER/AGENCY/PROGRAM

momshome 4 MOTHER'S HOME

othrhome 5 OTHER HOME

othrloc 6 SOME OTHER LOCATION

Logic after:

YOH33T_1 --PRESENT HOME; YOH33T_2 --CHILD WELFARE AGENCY; YOH33T_3 --

TREATMENT CTR/AGENCY/PROG; YOH33T_4 --MOTHERS HOME; YOH33T_5 --OTHER HOME;

YOH33T_6 --SOME OTHER LOCATION; YOH33T_7--DK; YOH33T_8--RF

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

Y_OH33a

Now I am going to ask you a question about how well your biological mother gets along with your foster family or group home or center staff.


In the past year, did your biological mother ever meet or talk with your current foster family or a member of your group home staff?

1 YES

2 NO


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

Y_OH40a [ YOH40a ] OOH CH has contact w/dad

Now I would like to ask you about your biological dad.


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

Question Type: TFrqVst

never 1 never,

lessoncemo 2 less than once a month,

onceamo 3 once or twice a month,

onceawk 4 about once a week,

moreonceawk 5 several times a week, or

everyday 6 everyday?

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

Logic before:

IF Y_OH40a = 1, GOTO Y_OH48a

Y_OH43 [ YOH43T ] Labels are in Logic After

Where do the visits take place?


CODE ALL THAT APPLY.

Question Type: TYOH43S

currhome 1 PRESENT HOME

wlfragncy 2 CHILD WELFARE AGENCY

txcenter 3 TREATMENT CENTER/AGENCY/PROGRAM

dadshome 4 FATHER'S HOME

othrhome 5 OTHER HOME

othrloc 6 SOME OTHER LOCATION

Logic after:

YOH43T_1 --FATHERS HOME; YOH43T_2 --CHILD WELFARE AGENCY; YOH43T_3 --

TREATMENT CTR/AGENCY/PROGRAM; YOH43T_4 --MOTHERS HOME; YOH43T_5 --OTHER

HOME; YOH43T_6 --SOME OTHER LOCATION; YOH43T_7--DK; YOH43T_8--RF

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

Y_OH43

Now I am going to ask you a question about how well your biological father gets along with your foster family or group home or center staff.


In the past year, did your biological father ever meet or talk with your current foster family or a member of your group home staff?

1 YES

2 NO


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

Y_OH48a [ YOH48a ] OOH CH has siblings not w/CH now

Do you have any biological or adopted brothers or sisters who do @Bnot@B live with you now?


NOTE: SIBLINGS HERE SHOULD INCLUDE BIOLOGICAL OR ADOPTIVE SIBLINGS. HOWEVER, IF

CHILD FEELS OTHER CHILDREN ARE HIS/HER SIBLINGS (E.G., FOSTER SIBLINGS,

COUSINS), THEY CAN BE INCLUDED TOO.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_OH48a = 2 GO TO Y_OH56

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

Y_OH53a [ YOH53 ] Labels are in Logic After

About how often do you see or have contact with ^Y_OH49[J]? Would you say...

Question Type: TFqVstAr

never 1 never,

lessoncemo 2 less than once a month,

onceamo 3 once or twice a month,

onceawk 4 about once a week,

moreonceawk 5 several times a week, or

everyday 6 everyday?

Logic after:

YOH531a--CH has contact w/sibling not w/ OOH CH - 1; YOH532a--CH has contact w/sibling not

w/ OOH CH - 2; YOH533a--CH has contact w/sibling not w/ OOH CH - 3; YOH534a--CH has

contact w/sibling not w/ OOH CH - 4; YOH535a--CH has contact w/sibling not w/ OOH CH - 5;

YOH536a--CH has contact w/sibling not w/ OOH CH - 6; YOH537a--CH has contact w/sibling not

w/ OOH CH - 7; YOH538a--CH has contact w/sibling not w/ OOH CH - 8; YOH539a--CH has

contact w/sibling not w/ OOH CH - 9; YOH5310a--CH has contact w/sibling not w/ OOH CH - 10


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

Y_OH60a [ YOH60a ] OOH CH wants to see other family members

Are there other members of your family such as aunts, uncles, or cousins, that you like to see?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_OH60a = 2 GOTO Y_OH62a

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

Y_OH61a [ YOH61a ] How often OOH CH sees family

How often do you get to see them? Would you say...

Question Type: TFrqRels

nvr 1 never,

onceinawhl 2 only once in a while,

sometimes 3 sometimes, or

usually 4 usually?


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

Y_OH63a [ YOH63a ] OOH CH lived w/o parents in other OOH care

Have you lived without your biological parents in any other foster homes, relatives' homes, or places beside

your own home?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_OH63a = 2 GOTO Y_OHEND

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

Y_OH64a [ YOH64a ] Why OOH CH left last foster home

Think about the @Blast@B foster home, relative's home, or place you lived without your parents.

Why did you leave that place?

Question Type: TWhyLeft

crgvrdied 1 CAREGIVER DIED, MOVED, RETIRED, MARRIED, DIVORCED, GOT

SICK, OR HAD OTHER CHILDREN

crgvrwanted 2 CAREGIVER WANTED CHILD TO LEAVE

childasked 3 CHILD ASKED TO LEAVE

didntgetalong 4 CAREGIVER AND CHILD'S SIBLING(S) DID NOT GET ALONG

childmoved 5 CHILD MOVED TO GET BACK TOGETHER WITH SIBLING(S)

gotintrbl 6 CHILD GOT IN TROUBLE TOO MUCH IN SCHOOL/NEIGHBORHOOD

intrblgnrl 7 CHILD GOT IN TROUBLE TOO MUCH (IN GENERAL)

senthome 8 CHILD WAS SENT HOME (OR TO LIVE WITH RELATIVE)

housingprob 9 SOMETHING HAPPENED TO PHYSICAL STRUCTURE OF HOUSING

(e.g. FIRE, FLOOD, HOME WAS CLOSED, ETC.)

ranaway 10 CHILD RESPONDENT RAN AWAY

childdk 11 NO ONE TOLD CHILD RESPONDENT WHY

other 12 OTHER

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

Y_OH68a [ YOH68a ] Who decided OOH CH would leave

Who decided that you would leave?

Question Type: TYOH67a

mom 1 MOTHER

dad 2 FATHER

stepmom 3 STEP-MOTHER

stepdad 4 STEP-FATHER

grandma 5 GRANDMOTHER

grandpa 6 GRANDFATHER

aunt 7 AUNT

uncle 8 UNCLE

brother 9 BROTHER

sister 10 SISTER

otherrel 11 OTHER RELATIVE

currfosparent 12 CURRENT FOSTER PARENT/GROUP OR RESIDENTIAL CARE

PROVIDER

caseworker 13 CASEWORKER/THERAPIST

judge 14 JUDGE/COURT

respondent 15 RESPONDENT (e.g. CHILD SAYS "ME/I DID")

other 16 OTHER

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

Y_OH69a [ YOH69a ] OOH CHs involvement w/decison

How much were you involved in this decision? Would you say ...

Question Type: TInvlved

notatall 1 not at all,

alittle 2 a little,

somewhat 3 somewhat,

quiteabit 4 quite a bit, or

alot 5 a lot?


Y_OH70a

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


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

SHOWCARD #


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

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


1 VERY STRONGLY AGREE

2 STRONGLY AGREE

3 AGREE

4 NEITHER AGREE NOR DISAGREE

5 DISAGREE

6 STRONGLY DISAGREE

7 VERY STRONGLY DISAGREE


Y_OH71a


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

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


1 VERY STRONGLY AGREE

2 STRONGLY AGREE

3 AGREE

4 NEITHER AGREE NOR DISAGREE

5 DISAGREE

6 STRONGLY DISAGREE

7 VERY STRONGLY DISAGREE



IF Y_CH11a = 1 THEN ASK Y_OH72A


Y_OH72a

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

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


1 VERY STRONGLY AGREE

2 STRONGLY AGREE

3 AGREE

4 NEITHER AGREE NOR DISAGREE

5 DISAGREE

6 STRONGLY DISAGREE

7 VERY STRONGLY DISAGREE


IF Y_CH11a = 4 THEN ASK Y_OH73A


Y_OH73a

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

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

1 VERY STRONGLY AGREE

2 STRONGLY AGREE

3 AGREE

4 NEITHER AGREE NOR DISAGREE

5 DISAGREE

6 STRONGLY DISAGREE

7 VERY STRONGLY DISAGREE


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

Y_OH_END [ YOH_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

Logic after:

Y_OHEND

AO - CHILD FAMILY CONTACTS FOR ADOPTED YOUTH MODULE

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

Logic before:

IF CH14a = 3 or 10 AND CHILD AGE IS =>6, CONTINUE. ELSE GOTO END. NOT

ADMINISTERED IF CHILD IS EMANCIPATED OR IS YOUNG ADULT (18+).

Y_AO0a [ YAO0a ] adopted CH knows he/she is adopted

INTERVIEWER: DOES CHILD KNOW THAT HE/SHE IS ADOPTED?

Question Type: TChKnow

Yes 1 YES

No 2 NO

Logic after:

IF Y_AO0a = 2 SKIP TO Y_AOEND

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

Y_AO1a [ YAO1a ] adopted CH likes people they live with

Now I would like to ask you some questions about the people you live with and how it is to live

here.


Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

Logic before:

IF CH11a = 1 or 2, ASK Y_AO2a. ELSE, GOTO Y_AO3a.

Y_AO2a [ YAO2a ] adopted CH feels like part of family

Do you feel like you're part of this family?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

Y_AO3a [ YAO3a ] adopted CH live w/ family until CH grows up

Can you keep living here until you grow up?


NOTE: THIS QUESTION REFERS TO WHETHER THE CHILD THINKS HE/SHE IS ALLOWED

TO KEEP LIVING HERE, NOT WHETHER THE CHILD WANTS TO KEEP LIVING HERE.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

Logic before:

IF Y_CH19a = 2 [BIOLOGICAL MOTHER DEAD], GOTO Y_AO4xa

Y_AO4a [ YAO4a ] adopted CH knows biological mom

Do you know your biological mom, or birth mom?


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

BIRTH TO YOU)

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

Logic before:

IF Y_CH20a = 2 [BIOLOGICAL FATHER DEAD], GOTO Y_AO5

Y_AO4xa [ YAO4xa ] adopted CH knows biological dad

Do you know your biological dad?


(IF NECESSARY, PROBE: I MEAN YOUR ORIGINAL BIRTH DAD)

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

Y_AO5 [ YAO5TG ] Labels are in Logic After

USE CARD 7. If you could live with anyone, who would it be? (DO NOT PROBE AFTER INITIAL

RESPONSE.) (CODE ALL THAT APPLY.)

Question Type: TLivRelS

biomom 1 MOTHER (BIOLOGICAL)

biodad 2 FATHER (BIOLOGICAL)

stepmom 3 STEP-MOTHER

stepdad 4 STEP-FATHER

grandma 5 GRANDMOTHER

grgrandma 6 GREAT GRANDMOTHER

grandpa 7 GRANDFATHER

grgrandpa 8 GREAT GRANDFATHER

auntuncle 9 AUNT/UNCLE

grauntuncle 10 GREAT AUNT/UNCLE

biosib 11 BIOLOGICAL SIBLING(S)

fossib 12 FOSTER SIBLING(S)

otherrel 13 OTHER RELATIVE

neighbor 14 NEIGHBOR

friend 15 FRIEND

girlboyfriend 16 GIRLFRIEND/BOYFRIEND

currfosparent 17 CURRENT FOSTER PARENT

frmrfosparent 18 FORMER FOSTER PARENT

newfosparent 19 NEW (OR UNSPECIFIED) FOSTER HOME

currgrouphome 20 CURRENT GROUP/RESIDENTIAL SETTING

frmrgrouphome 21 FORMER GROUP/RESIDENTIAL SETTING

newgrouphome 22 NEW (OR UNSPECIFIED) GROUP OR RESIDENTIAL TREATMENT

SETTING

adoptparent 23 ADOPTIVE MOTHER/FATHER

teacher 24 TEACHER/CHILD CARE/OTHER KNOWN PROVIDER

alone 25 BY MYSELF/ALONE

other 26 OTHER

Logic after:

YAO5TG1--CH would like to live w biological mom; YAO5TG2--CH would like to live w biological

dad; YAO5TG3--CH would like to live w step mother; YAO5TG4--CH would like to live w step father;

YAO5TG5--CH would like to live w grandmother; YAO5TG6--CH would like toLive w

greatGrandmother; YAO5TG7--CH would like to live w grandfather; YAO5TG8--CH would like toLive

w greatGrandFather; YAO5TG9--CH would like to live w aunt/uncle; YAO5TG10--CH would like

toLive w great aunt/uncle; YAO5TG11--CH would like to live w bio siblings; YAO5TG12--CH would

like to live w foster siblings; YAO5TG13--CH would like to live w other relative; YAO5TG14--CH

would like to live w neighbor; YAO5TG15--CH would like to live w friend; YAO5TG16--CH would like

to live w girl/boy friend; YAO5TG17--CH would like toLive w curr fostrParent; YAO5TG18--CH would

like live w formerFosterParent; YAO5TG19--CH would like live w new foster home; YAO5TG20--CH

would like live w curr group setting; YAO5TG21--CH would like live w formerGroupSetting;

YAO5TG22--CH would like live w new group setting; YAO5TG23--CH would like live w new adoptv

mom/dad; YAO5TG24--CH would like live w teachr/careProvidr; YAO5TG25--CH would like live

alone; YAO5TG26--CH would like live w other; YAO5TG27--CH would like to live w - DK;

YAO5TG28--CH would like to live w - RF

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

Y_AO6a [ YAO6a ] adopted CH asked if they could leave

Have you ever asked someone if you could leave here or stop living here?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

Y_AO7a [ YAO7a ] adopted CH has tried to leave

Have you ever tried to leave here before?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

Y_AO8a [ YAO8a ] adopted CH wants this to be permanent home

Do you want this to be your permanent or forever home?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

Logic before:

IF MOTHER IS DEAD Y_CH19a = 2, OR IF Y_AO4a <> 1, GOTO Y_AO23

Y_AO19 [ YAO19TG ] Labels are in Logic After

Now I would like to ask you about your biological mom.


Please tell me whether or not you do any of the following with your biological mom.


CODE ALL THAT APPLY

Question Type: TDowMomS

visit 1 Spend time with or visit face to face

talk 2 Talk or text on the phone

social media 3 Keep in touch through Facebook, Instagram or other social media site

presents 4 Receive cards or presents

none 5 NONE

Logic after:

IF "NONE" AND ANY OTHER CATEGORY SELECTED, ERROR: "INTERVIEWER: IF "NONE" IS

SELECTED, NO OTHER CATEGORY SHOULD BE SELECTED."; YAO19TG1--CH spend time

with or visit w bio mom; YAO19TG2--CH talk on the phone w bio mom; YAO19TG3--CH receive

cards/presents from bio mom; YAO19TG4--CH does not do anything w bio mom; YAO19TG5--CH

does w bio mom - DK; YAO19TG6--CH does w bio mom - RF

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

Logic before:

If AO19, 1 = Y CONTINUE, ELSE GOTO AO21

Y_AO20a [ YAO20a ] How often adopted CH visits bio mom

USE CARD 8. About how often do you spend time with or visit with your biological mom? Would

you say…

Question Type: TFrqVst

never 1 never,

lessoncemo 2 less than once a month,

onceamo 3 once or twice a month,

onceawk 4 about once a week,

moreonceawk 5 several times a week, or

everyday 6 everyday?

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

Logic before:

IF Y_AO19, 2 = Y, CONTINUE. ELSE, GOTO Y_AO22a.

Y_AO21a [ YAO21a ] adopted CH talks with bio mom

USE CARD 8. About how often do you talk on the phone with your biological mom? Would you

Question Type: TFrqVst

never 1 never,

lessoncemo 2 less than once a month,

onceamo 3 once or twice a month,

onceawk 4 about once a week,

moreonceawk 5 several times a week, or

everyday 6 everyday?

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

Logic before:

IF FATHER IS DEAD, Y_CH20a = 2, OR IF Y_AO4xa <> 1, GOTO Y_AO27a

Y_AO23 [ YAO23TG ] Labels are in Logic After

Now I would like to ask you about your biological dad. Please tell me whether or not you do any of

the following with your biological dad:


CODE ALL THAT APPLY

Question Type: TDowMomS

visit 1 Spend time with or visit face to face

talk 2 Talk or text on the phone

social media 3 Keep in touch through Facebook, Instagram or other social media site

presents 4 Receive cards or presents

none 5 NONE

Logic after:

IF "NONE" AND ANY OTHER CATEGORY SELECTED, ERROR: "INTERVIEWER: IF "NONE" IS

SELECTED, NO OTHER CATEGORY SHOULD BE SELECTED."; YAO23TG1--CH spend time with or visit face to facewith or visit w bio dad; YAO23TG2--CH talk or text on the phone w bio dad; YAO23TG3--CH keep in touch through Facebook, Instagram or other social media site with bio dad;

YAO23TG4--CH receive cards/presents from bio dad; YAO23TG5--CH does not do anything w bio dad; YAO23TG6—CH does w bio dad - DK; YAO23TG7--CH does w bio dad - RF

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

Logic before:

IF Y_A023, 1 = Y, CONTINUE. ELSE, GOTO Y_AO25a.

Y_AO24a [ YAO24a ] How often adopted CH visits bio dad

USE CARD 8. About how often do you spend time with or visit with your biological dad? Would

you say…

Question Type: TFrqVst

never 1 never,

lessoncemo 2 less than once a month,

onceamo 3 once or twice a month,

onceawk 4 about once a week,

moreonceawk 5 several times a week, or

everyday 6 everyday?

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

Logic before:

IF AO23, 2 = Y, CONTINUE. ELSE, GOTO Y_AO26a.

Y_AO25a [ YAO25a ] adopted CH talks with bio dad

USE CARD 8. About how often do you talk on the phone with your biological dad? Would you

Question Type: TFrqVst

never 1 never,

lessoncemo 2 less than once a month,

onceamo 3 once or twice a month,

onceawk 4 about once a week,

moreonceawk 5 several times a week, or

everyday 6 everyday?

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

Y_AO27a [ YAO27a ] Any bio siblings not living w/ adopted CH

Do you have any biological brothers or sisters who do @Bnot@B live with you now?


NOTE: BIOLOGICAL SIBLINGS INCLUDE BIOLOGICAL OR ADOPTIVE SIBLINGS. HOWEVER,

IF CHILD FEELS OTHER CHILDREN ARE HIS/HER Biological SIBLINGS (E.G., FOSTER

SIBLINGS, COUSINS), THEY CAN BE INCLUDED TOO.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_AO27a = 2 GO TO Y_AO36a

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

Y_AO32 [ YAO32 ] Labels are in Logic After

Now I would like to ask you about ^Y_AO28[J]. Please tell me whether or not you do any of the

following with ^Y_AO28[J]:


CODE ALL THAT APPLY

Question Type: TDowSibS

visit 1 Spend time with or visit face to face

talk 2 Talk or text on the phone

social media 3 Keep in touch through Facebook, Instagram or other social media site

presents 4 Receive cards or presents

none 5 NONE


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

Logic before:

IF Y_AO32, 2 = Y, CONTINUE. ELSE, GOTO Y_AO35a.

Y_AO34a [ YAO34a ] Labels are in Logic After

USE CARD 8. About how often do you talk on the phone with ^Y_AO28[J]? Would you say…

Question Type: TFrqVst

never 1 never,

lessoncemo 2 less than once a month,

onceamo 3 once or twice a month,

onceawk 4 about once a week,

moreonceawk 5 several times a week, or

everyday 6 everyday?

Logic after:

YAO34aa--adopted CH Sibling #1 - Ch talks w on phone; YAO34ba--adopted CH Sibling #2 - Ch

talks w on phone; YAO34ca--adopted CH Sibling #3 - Ch talks w on phone; YAO34da--adopted CH

Sibling #4 - Ch talks w on phone; YAO34ea--adopted CH Sibling #5 - Ch talks w on phone;

YAO34fa--adopted CH Sibling #6 - Ch talks w on phone; YAO34ga--adopted CH Sibling #7 - Ch

talks w on phone; YAO34ha--adopted CH Sibling #8 - Ch talks w on phone; YAO34ia--adopted CH

Sibling #9 - Ch talks w on phone; YAO34ja--adopted CH Sibling #10 - Ch talks w on phone

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

Y_AO36a [ YAO36a ] Other bio relative adopted CH like contact with

Are there other members of your biological family such as aunts, uncles, or cousins, that you like

to see, talk to or get a letter from?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_AO36a = 2 GOTO Y_AO41a

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

Y_AO37a [ YAO37a ] adopted CH sees other bio relatives

How often do you get to see them? Would you say...

Question Type: TFrqRels

nvr 1 never,

onceinawhl 2 only once in a while,

sometimes 3 sometimes, or

usually 4 usually?

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

Y_AO42a [ YAO42a ] CW talk with adopted CH about being adopted

Did your caseworker talk with you about being adopted by this family?

Question Type: TYN

yes 1 YES

no 2 NO

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

Y_AO43a [ YAO43a ] adopted CH want to be adopted by family

Did you want to be adopted by this family?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

GOTO Y_AOEND

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

Y_AO_END [ YAO_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

Logic after:

Y_AOEND



SW - CHILD SATISFACTION WITH CASEWORKER SERVICES MODULE

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

Logic before:

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

CONTINUE.

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

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

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

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

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


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

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Question Fill: ^FillY_SW1a1

waveone @Bpast 6 months@B

wavetwo @Bpast 18 months@B

Logic after:

IF Y_SW1a = 2 GOTO Y_SWEND

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

Y_SW2a [ YSW2a ] How long ago CH met w/CW(#)

About how long ago was the last time you met with a child welfare caseworker or social worker?


NUMBER:

Question Type: 1..130

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

Y_SW2u [ YSW2u ] # of D/W/M when CH met w/CW

About how long ago was the last time you met with a child welfare caseworker or social worker?


(Is that days, weeks, or months?)

Question Type: TDWM

days 1 DAYS

weeks 2 WEEKS

months 3 MONTHS

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

Logic before:

IF (Wave = 1 AND ((Y_SW2a > 24 AND Y_SW2u = weeks) OR (Y_SW2a > 6 AND Y_SW2u =

months))) OR (Wave >= 2 AND ((Y_SW2a > 72 AND Y_SW2u = weeks) OR (Y_SW2a > 18 AND

Y_SW2u = months)))

Y_SW2cka [ YSW2cka ] CK for when/how long CH met w/CW(CH3T)

Perhaps I entered something incorrectly into the computer. Earlier you mentioned that you met

with a caseworker or social worker in the past ^Fills.Y_SW1a2 months, however I have entered in

the computer that your last visit with a caseworker or social worker was ^Y_SW2a

^Fills.Y_SW2aa ago. Which information needs to be corrected?

Question Type: TYSW2aa

didmeet 1 DID R MEET WITH CASEWORKER IN PAST 6 (OR 18) MONTHS

time 2 TIME OF LAST VISIT WITH CASEWORKER

Question Fill: ^FillY_SW2aa

days days

weeks weeks

months months

Logic after:

IF Y_SW2cka = 1 GOTO Y_SW1a ("INTERVIEWER: PLEASE RECORD THE ANSWER TO

QUESTION Y_SW1a AGAIN."); IF Y_SW2cka = 2 GOTO Y_SW2a ("INTERVIEWER: PLEASE

RECORD THE ANSWER TO QUESTION Y_SW2a AGAIN.")


Y_SW2d

How many times during the past year, did you have face to face visits with a social worker?


0-50 ZERO THROUGH FIFTY

51 MORE THAN FIFTY


Y_SW2e

How many times during the past year, did a social worker talk to you on the phone?


0-50 ZERO THROUGH FIFTY

51 MORE THAN FIFTY



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

Y_SW3a [ YSW3a ] past 6M # diff CWs CH met

In the past ^Fills.Y_SW1a2 months, how many different child welfare caseworkers or social

workers have you met with?


NUMBER:

Question Type: 1..20

Question Fill: ^FillY_SW1a2

waveone 6

wavetwo 18

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

Y_SW4a [ YSW4a ] Did CW listen to CH

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

Would you say they listened to you...

Question Type: TYSW4a

never 1 never

notoften 2 not very often

sometime 3 some of the time, or

alltime 4 all of the time

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

Y_SW5a [ YSW5a ] Did CW understand CH situation

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

Would you say...

Question Type: TYSW5a

notwell 1 not well at all

somewhat 2 somewhat, or

verywell 3 very well


Y_SW7a

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


0-30 ZERO THROUGH THIRTY

31 MORE THAN THIRTY

Y_SW8a

Have you ever attended court proceedings regarding your case?


1 YES

2 NO



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

Y_SW_END [ YSW_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

FE - CHILD FUTURE EXPECTATIONS MODULE

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

Logic before:

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

CONTINUE.

Y_FE1a [ YFE1a ] Chances live to be at least 35

USE CARD 9. The next questions ask about what you think will happen to you in the future. For

each question, pick one of the answers on this card.


What do you think are the chances you will live to be at least 35? Would you say…

Question Type: TChance

noway 1 no chance

maybe 2 some chance

fiftyfifty 3 about 50-50

likely 4 pretty likely, or

willhappen 5 it will happen


Y_FE5a [ YFE5a ] Chances grad from high school

USE CARD 9. What do you think are the chances you will graduate from high school? (Would

you say no chance, some chance, about 50-50, pretty likely, or it will happen?)

Question Type: TChace2C

noway 1 NO CHANCE

maybe 2 SOME CHANCE

fiftyfifty 3 ABOUT 50-50

likely 4 PRETTY LIKELY

willhappen 5 IT WILL HAPPEN

didhappen 6 IT ALREADY HAPPENED

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

Y_FE6a [ YFE6a ] Chances have a good job by 30

USE CARD 9. What do you think are the chances you will have a good job by age 30? (Would

you say no chance, some chance, about 50-50, pretty likely, or it will happen?)

Question Type: TChanceC

noway 1 NO CHANCE

maybe 2 SOME CHANCE

fiftyfifty 3 ABOUT 50-50

likely 4 PRETTY LIKELY

willhappen 5 IT WILL HAPPEN

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

Y_FE7a [ YFE7a ] Chances have child/family

USE CARD 9. What do you think are the chances you will have children and raise a family when

you are older? (Would you say no chance, some chance, about 50-50, pretty likely, or it will

Question Type: TChace2C

noway 1 NO CHANCE

maybe 2 SOME CHANCE

fiftyfifty 3 ABOUT 50-50

likely 4 PRETTY LIKELY

willhappen 5 IT WILL HAPPEN

didhappen 6 IT ALREADY HAPPENED



SU - CHILD SOCIAL SUPPORT MODULE

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

Logic before:

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

CONTINUE. ELSE, GOTO Y_SUEND.

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

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

may be helpful or supportive.


USE CARD 5. As I read each statement, please tell me which answer is closest to your

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

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

like.


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

is the first statement:


I get love and affection.

Question Type: TSU15a

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

a2 2 2

a3 3 3

a4 4 4

a5 5 5 = I GET AS MUCH AS I LIKE

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

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

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

Question Type: TSU15a

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

a2 2 2

a3 3 3

a4 4 4

a5 5 5 = I GET AS MUCH AS I LIKE

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

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

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

Question Type: TSU15a

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

a2 2 2

a3 3 3

a4 4 4

a5 5 5 = I GET AS MUCH AS I LIKE

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

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

Invitations to go out and do things with other people

Question Type: TSU15a

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

a2 2 2

a3 3 3

a4 4 4

a5 5 5 = I GET AS MUCH AS I LIKE

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

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

People who care about what happens to me

Question Type: TSU15a

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

a2 2 2

a3 3 3

a4 4 4

a5 5 5 = I GET AS MUCH AS I LIKE

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

Y_SU20a [ YSU20a ] Chances to talk about money matters

Chances to talk about money matters

Question Type: TSU15a

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

a2 2 2

a3 3 3

a4 4 4

a5 5 5 = I GET AS MUCH AS I LIKE

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

Y_SU21a [ YSU21a ] Useful advice about important things in life

Useful advice about important things in life

Question Type: TSU15a

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

a2 2 2

a3 3 3

a4 4 4

a5 5 5 = I GET AS MUCH AS I LIKE

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

Y_SU22a [ YSU22a ] Help when I need transportation

Help when I need transportation

Question Type: TSU15a

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

a2 2 2

a3 3 3

a4 4 4

a5 5 5 = I GET AS MUCH AS I LIKE

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

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

Help when I'm sick in bed

Question Type: TSU15a

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

a2 2 2

a3 3 3

a4 4 4

a5 5 5 = I GET AS MUCH AS I LIKE

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

Y_SU24a [ YSU24a ] Help around the house

Help around the house

Question Type: TSU15a

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

a2 2 2

a3 3 3

a4 4 4

a5 5 5 = I GET AS MUCH AS I LIKE

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

Logic before:

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

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

Help taking care of my child(ren)

Question Type: TSU15a

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

a2 2 2

a3 3 3

a4 4 4

a5 5 5 = I GET AS MUCH AS I LIKE

Logic after:

Y_SUEND

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

Y_SU_END [ YSU_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue



PE - CHILD PHYSICAL HEALTH MODULE

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

Logic before:

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

Y_PE1a [ YPE1a ] Eman CH health in general

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

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

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


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

Question Type: TPE1a

excellent 1 excellent

vgood 2 very good

good 3 good

fair 4 fair, or

poor 5 poor?

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

Y_PE2a [ YPE2a ] Eman CH health limits activities

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

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

Question Type: TPE2a

alot 1 limited a lot

alittle 2 limited a little, or

notlimited 3 not limited at all?

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

Y_PE3a [ YPE3a ] Eman CH health limits climb stairs

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

say you are...


NOTE: "SEVERAL" MEANS TWO OR MORE.

Question Type: TPE2a

alot 1 limited a lot

alittle 2 limited a little, or

notlimited 3 not limited at all?

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

Y_PE4a [ YPE4a ] Eman CH health limits work/actv

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

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

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

Y_PE5a [ YPE5a ] Eman CH health limits kind of work

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

you could do as a result of your physical health?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

Y_PE6a [ YPE6a ] Eman CH emotional prob limit work

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

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

depressed or anxious?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

Y_PE7a [ YPE7a ] Eman CH emotional prob limit work quality

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

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

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

Y_PE8a [ YPE8a ] Eman CH pain interfere norml work

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

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

Question Type: TPE8a

notatall 1 not at all

alittle 2 a little bit

moderately 3 moderately

quite 4 quite a bit, or

extremely 5 extremely?

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

Y_PE9a [ YPE9a ] Eman CH felt calm and peaceful

USE Card 6. The next questions are about how you feel and how things have been with you

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

answer comes closest to the way you have been feeling.


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

you say...

Question Type: TPE9a

all 1 all of the time

most 2 most of the time

goodbit 3 a good bit of the time

some 4 some of the time

little 5 a little of the time, or

none 6 none of the time?

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

Y_PE10a [ YPE10a ] Eman CH have a lot of energy

USE Card 6. During the past @B4 weeks@B, how much of the time did you have a lot of

energy? Would you say...

Question Type: TPE9a

all 1 all of the time

most 2 most of the time

goodbit 3 a good bit of the time

some 4 some of the time

little 5 a little of the time, or

none 6 none of the time?

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

Y_PE11a [ YPE11a ] Eman CH felt downhearted/blue

USE Card 6. During the past @B4 weeks@B, how much of the time have you felt downhearted

and blue? Would you say...

Question Type: TPE9a

all 1 all of the time

most 2 most of the time

goodbit 3 a good bit of the time

some 4 some of the time

little 5 a little of the time, or

none 6 none of the time?

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

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

USE Card 6. During the past @B4 weeks@B, how much of the time has your physical health or

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

Would you say...

Question Type: TPE9a

all 1 all of the time

most 2 most of the time

goodbit 3 a good bit of the time

some 4 some of the time

little 5 a little of the time, or

none 6 none of the time?

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

Y_PE13ft [ YPE13ft ] Eman CH Height in feet

Can you tell me approximately what your height is?


FEET:

Question Type: 1..7

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

Y_PE13in [ YPE13in ] Eman CH Height in inches

Can you tell me approximately what your height is?


INCHES:

Question Type: 0..11

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

Y_PE14a [ YPE14a ] Eman CH Weight in pounds

Can you tell me approximately what your weight is?


POUNDS:

Question Type: 50..500

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

Y_PE15a [ YPE15a ] Eman CH over/under wieght

Do you consider yourself now to be...

Question Type: TPE15a

over 1 Overweight

under 2 Underweight, or

right 3 About the right weight?

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

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

Would you like to weigh...

Question Type: TPE16a

more 1 more

less 2 less

same 3 stay about the same?

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

Y_PE17a [ YPE17a ] Eman CH =tTried to lose weight

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

Question Type: TYN

yes 1 YES

no 2 NO

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

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

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

drink 100% vegetable juice?

Question Type: TPE18a

threemore 1 Three or more times a day

twice 2 Twice a day

once 3 Once a day

less 4 Less than once a day

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

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

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

Question Type: TPE18a

threemore 1 Three or more times a day

twice 2 Twice a day

once 3 Once a day

less 4 Less than once a day

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

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

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


# OF DAYS:

Question Type: 0..7

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

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

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


Asthma?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

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

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


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

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

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

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


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

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

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

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

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


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

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

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

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


Diabetes?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

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

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

Y_PE20a8a [ YPE20a8a ] Do you use insulin?

Do you use insulin?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

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

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


A heart problem, including congenital heart disease?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

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

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


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

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

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

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


Cystic Fibrosis?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

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

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


Cerebral Palsy?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

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

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


Muscular Dystrophy?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

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

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


Epilepsy or other seizure disorder?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

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

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


Migraine or frequent headaches?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

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

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


Arthritis or other joint problems?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

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

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


Dental problems?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

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

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


Repeated ear infections?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

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

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


Back or neck problems?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

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

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


Hypertension or high blood pressure?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

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

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


AIDS?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

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

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


Sexually transmitted disease, such as Chlamydia or Gonorrhea?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

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

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


Chronic bronchitis?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

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

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


Other respiratory problems?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

Y_PE20a31a [ YPE20a31a ] Bst of your knwldg, do you currently have othr hlth prblm?

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


Other health problems?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

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

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

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

What other health problems do you currently have?


PROBLEM:

Question Type: STRING[50]

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

Logic before:

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

Y_PE20a FOR EACH CONDITION ANSWERED YES in Y_PE20a1a through Y_PE20a32.

Y_PE20a [ YPE20a ] Labels are in Logic After

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

Question Type: TPE20a

no 1 no, not currently limited by this condition

yeslittle 2 yes, limited a little

yesalot 3 yes, limited a lot

Question Fill: ^FillY_PE20a

asthma asthma

add Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder

autism autism or Autism Spectrum Disorder

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

diabetes diabetes

heartprob a heart problem

bloodprob a blood problem such as anemia or sickle cell disease

cysticfib cystic fibrosis

cerpalsy cerebral palsy

muscdystr muscular dystrophy

epilepsy epilepsy or another seizure disorder

migraine migraine or frequent headache

arthritis arthritis or another joint problem

allergies an allergy

dentalprob a dental problem

eczema eczema or another skin disease

earinf repeated ear infection

visionprob a vision problem

hearingprob a hearing problem

backprob a back or neck problem

hypertension hypertension or high blood pressure

AIDS AIDS

std sexually transmitted disease

bronchitis chronic bronchitis

sinusitis sinusitis

otherresp another respiratory problem

otherprob another health problem

Logic after:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

chronic physical or mental condition?

Question Type: TYN

yes 1 YES

no 2 NO

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

Logic before:

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

Y_PE21aa [ YPE21aa ] Labels are in Logic After

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

medication for...


CODE ALL THAT APPLY.

Question Type: TPE21aS

diabetes 1 Diabetes

asthma 2 Asthma

hypertension 3 High blood pressure

migraine 4 Migraine headaches

depression 5 Depression

anxiety 6 Anxiety

add 7 Attention Deficit Disorder

pain 8 Pain

epilepsy 9 Epilepsy or seizures

allergies 10 Allergies

thyroid 11 Thyroid problems

acidrflx 12 Acid reflux

cholesterol 13 Cholesterol

heartrelated 14 Heart-related illness

other 15 Other

Logic after:

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

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

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

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

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

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

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

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

Y_PE_END [ YPE_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue



YH - CHILD HEALTH AND SERVICES MODULE

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


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

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

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

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

for emotional or behavioral problems?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

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

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

behavioral problems?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH3a34 = 2 GOTO Y_YH4a

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

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

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

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

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH3a35 = 1 GOTO Y_YH3a38

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

Y_YH3a36 [ YYH3a36 ] Labels are in Logic After

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

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


CODE ALL THAT APPLY.

Question Type: TYH3a36S

cost 1 Insurance did not cover medication

sideeffects 2 Concerns about side effects of the medication

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

family 4 Family or friends were concerned about you taking medication

addiction 5 Afraid of getting addicted

badexperience 6 Bad experiences with other clinicians prescribing medications

changeddrs 7 You changed providers

other 8 Other reasons

Logic after:

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

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

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

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

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

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

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

Logic before:

IF Y_YH3a36 = 8, CONTINUE. ELSE, GOTO Y_YH4a

Y_YH3a37 [ YYH3a37 ] Other reason to choose not to take medications

Please specify other reasons.


REASON:

Question Type: STRING[40]

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

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

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

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH3a38 = 2 GOTO Y_YH3a40

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

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

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

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH3a39 = 1 GOTO Y_YH3a42

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

Y_YH3a40 [ YYH3a40 ] Labels are in Logic After

I'm going to read a list of reasons why some people sometimes stop taking medication. Please

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


CODE ALL THAT APPLY.

Question Type: TYH3a40S

cost 1 Insurance did not cover medication

sideeffects 2 Concerns about side effects of the medication

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

family 4 Family or friends were concerned about you taking medication

addiction 5 Afraid of getting addicted

badexperience 6 Bad experiences with other clinicians prescribing medications

changeddrs 7 You changed providers

sitchanged 8 Your living situation changed

drsaidstop 9 Doctor said to stop

drmoved 10 Doctor left or moved away

rxproblems 11 Problems getting prescription from doctor's office

other 12 Other

Logic after:

YYH3a_40_1--Why not still taking med - Insurance did not cover medication; YYH3a_40_2--Why

not still taking med - Concerns about side effects meds; YYH3a_40_3--Why not still taking med -

Got bettr, didn't nd med any more; YYH3a_40_4--Why not still taking med - Family/friends

concerned abt med; YYH3a_40_5--Why not still taking med - Afraid of getting addicted;

YYH3a_40_6--Why not still taking med - Bad experiences with medications; YYH3a_40_7--Why

not still taking med - You changed providers; YYH3a_40_8--Why not still taking med - Your living

situation changed; YYH3a_40_9--Why not still taking med - Doctor said to stop; YYH3a_40_10--

Why not still taking med - Doctor left or moved away; YYH3a_40_11--Why not still taking med -

Probs gettng prscript frm Dr offc; YYH3a_40_12--Why not still taking med - Other reasons;

YYH3a_40_13--Why not still taking med - DK; YYH3a_40_14--Why not still taking med - RF

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

Logic before:

IF Y_YH3a40 = 12, CONTINUE. ELSE, GOTO Y_YH4a

Y_YH3a41 [ YYH3a41 ] Other reason for stop taking medications.

Please specify other reasons.


REASON:

Question Type: STRING[40]

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

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

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



Question Type: 1..10

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

Y_YH3a43 [ YYH3a43 ] Crrntly taking these name brand meds for emot/behav prblms

INTERVIEWER NOTE: PLEASE ASK CAREGIVER TO GET MEDICATION BOTTLES FOR

REFERENCE. IF MEDICATION BOTTLES ARE AVAILABLE, IT IS OKAY FOR YOU TO FIND

THE NAMES ON THE LISTS AND ANSWER THE QUESTION ACCORDINGLY, JUST

CONFIRMING WITH THE CG.


Please look at Card 7. Are you currently taking any of these brand name medications for

emotional or behavioral problems?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH3a43 = 1 GOTO Y_YH3a44; IF Y_YH3a43 = 2 GOTO Y_YH3a45

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

Y_YH3a44 [ YYH3a44 ] Labels are in Logic After

Please tell me which brand name medications you are currently taking?


CODE ALL THAT APPLY.

Question Type: TYH3a44S

abilify 1 ABILIFY

adderall 2 ADDERALL

anafranil 3 ANAFRANIL

artane 4 ARTANE

asendin 5 ASENDIN

atarax 6 ATARAX

aventil 7 AVENTIL HCL

benadryl 8 BENADRYL

carbatrol 9 CARBATROL

catapres 10 CATAPRES

celexa 11 CELEXA

cibalith 12 CIBALITH

cogentin 13 COGENTIN

compazine 14 COMPAZINE

concerta 15 CONCERTA

cylert 16 CYLERT

cymbalta 17 CYMBALTA

depakene 18 DEPAKENE

depakote 19 DEPAKOTE

desyrel 20 DESYREL

dexedrine 21 DEXEDRINE

effexor 22 EFFEXOR

elavil 23 ELAVIL

eskalith 24 ESKALITH

focalin 25 FOCALIN

geodon 26 GEODON

haldol 27 HALDOL

lamictal 28 LAMICTAL

lexapro 29 LEXAPRO

limbitrol 30 LIMBITROL

lithobid 31 LITHOBID

loxitane 32 LOXITANE

ludiomil 33 LUDIOMIL

luvox 34 LUVOX

melatonin 35 MELATONIN

mellaril 36 MELLARIL

metadate 37 METADATE

methylin 38 METHYLIN

moban 39 MOBAN

navene 40 NAVENE

norpramine 41 NORPRAMINE

orap 42 ORAP

pamelor 43 PAMELOR

paxil 44 PAXIL

pexeva 45 PEXEVA

prolixin 46 PROLIXIN

prozac 47 PROZAC

remeron 48 REMERON

risperdal 49 RISPERDAL

ritalin 50 RITALIN

seroquel 51 SEROQUEL

serzone 52 SERZONE

sinequan 53 SINEQUAN

stelazine 54 STELAZINE

strattera 55 STRATTERA

surmontil 56 SURMONTIL

symbyax 57 SYMBYAX

tegretol 58 TEGRETOL

tenex 59 TENEX

thorazine 60 THORAZINE

tofranil 61 TOFRANIL

topamax 62 TOPAMAX

trilafon 63 TRILAFON

vistaril 64 VISTARIL

wellbutrin 65 WELLBUTRIN

zoloft 66 ZOLOFT

zyprexa 67 ZYPREXA

Logic after:

YYH3a_44_1--Brand Name med currently taking - ABILIFY; YYH3a_44_2--Brand Name med

currently taking - ADDERALL; YYH3a_44_3--Brand Name med currently taking - ANAFRANIL;

YYH3a_44_4--Brand Name med currently taking - ARTANE; YYH3a_44_5--Brand Name med

currently taking - ASENDIN; YYH3a_44_6--Brand Name med currently taking - ATARAX;

YYH3a_44_7--Brand Name med currently taking - AVENTIL HCL; YYH3a_44_8--Brand Name med

currently taking - BENADRYL; YYH3a_44_9--Brand Name med currently taking - CARBATROL;

YYH3a_44_10--Brand Name med currently taking - CATAPRES; YYH3a_44_11--Brand Name med

currently taking - CELEXA; YYH3a_44_12--Brand Name med currently taking - CIBALITH;

YYH3a_44_13--Brand Name med currently taking - COGENTIN; YYH3a_44_14--Brand Name med

currently taking - COMPAZINE; YYH3a_44_15--Brand Name med currently taking - CONCERTA;

YYH3a_44_16--Brand Name med currently taking - CYLERT; YYH3a_44_17--Brand Name med

currently taking - CYMBALTA; YYH3a_44_18--Brand Name med currently taking - DEPAKENE;

YYH3a_44_19--Brand Name med currently taking - DEPAKOTE; YYH3a_44_20--Brand Name med

currently taking - DESYREL; YYH3a_44_21--Brand Name med currently taking - DEXEDRINE;

YYH3a_44_22--Brand Name med currently taking - EFFEXOR; YYH3a_44_23--Brand Name med

currently taking - ELAVIL; YYH3a_44_24--Brand Name med currently taking - ESKALITH;

YYH3a_44_25--Brand Name med currently taking - FOCALIN; YYH3a_44_26--Brand Name med

currently taking - GEODON; YYH3a_44_27--Brand Name med currently taking - HALDOL;

YYH3a_44_28--Brand Name med currently taking - LAMICTAL; YYH3a_44_29--Brand Name med

currently taking - LEXAPRO; YYH3a_44_30--Brand Name med currently taking - LIMBITROL;

YYH3a_44_31--Brand Name med currently taking - LITHOBID; YYH3a_44_32--Brand Name med

currently taking - LOXITANE; YYH3a_44_33--Brand Name med currently taking - LUDIOMIL;

YYH3a_44_34--Brand Name med currently taking - LUVOX; YYH3a_44_35--Brand Name med

currently taking - MELATONIN; YYH3a_44_36--Brand Name med currently taking - MELLARIL;

YYH3a_44_37--Brand Name med currently taking - METADATE; YYH3a_44_38--Brand Name med

currently taking - METHYLIN; YYH3a_44_39--Brand Name med currently taking - MOBAN;

YYH3a_44_40--Brand Name med currently taking - NAVENE; YYH3a_44_41--Brand Name med

currently taking - NORPRAMINE; YYH3a_44_42--Brand Name med currently taking - ORAP;

YYH3a_44_43--Brand Name med currently taking - PAMELOR; YYH3a_44_44--Brand Name med

currently taking - PAXIL; YYH3a_44_45--Brand Name med currently taking - PEXEVA;

YYH3a_44_46--Brand Name med currently taking - PROLIXIN; YYH3a_44_47--Brand Name med

currently taking - PROZAC; YYH3a_44_48--Brand Name med currently taking - REMERON;

YYH3a_44_49--Brand Name med currently taking - RISPERDAL; YYH3a_44_50--Brand Name med

currently taking - RITALIN; YYH3a_44_51--Brand Name med currently taking - SEROQUEL;

YYH3a_44_52--Brand Name med currently taking - SERZONE; YYH3a_44_53--Brand Name med

currently taking - SINEQUAN; YYH3a_44_54--Brand Name med currently taking - STELAZINE;

YYH3a_44_55--Brand Name med currently taking - STRATTERA; YYH3a_44_56--Brand Name med

currently taking - SURMONTIL; YYH3a_44_57--Brand Name med currently taking - SYMBYAX;

YYH3a_44_58--Brand Name med currently taking - TEGRETOL; YYH3a_44_59--Brand Name med

currently taking - TENEX; YYH3a_44_60--Brand Name med currently taking - THORAZINE;

YYH3a_44_61--Brand Name med currently taking - TOFRANIL; YYH3a_44_62--Brand Name med

currently taking - TOPAMAX; YYH3a_44_63--Brand Name med currently taking - TRILAFON;

YYH3a_44_64--Brand Name med currently taking - VISTARIL; YYH3a_44_65--Brand Name med

currently taking - WELLBUTRIN; YYH3a_44_66--Brand Name med currently taking - ZOLOFT;

YYH3a_44_67--Brand Name med currently taking - ZYPREXA; YYH3a_44_68--Brand Name med

currently taking - DK; YYH3a_44_69--Brand Name med currently taking - RF

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

Y_YH3a45 [ YYH3a45 ] Currently taking these generic meds for emot/behav prblms

Please look at Card 8. Are you currently taking any of these generic medications for emotional or

behavioral problems?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH3a45 = 1 GOTO Y_YH3a46; IF Y_YH3a45 = 2 GOTO Y_YH3a47

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

Y_YH3a46 [ YYH3a46 ] Labels are in Logic After

Please tell me which generic medications you are currently taking?


CODE ALL THAT APPLY.

Question Type: TYH3a46S

amitriptyline 1 AMITRIPTYLINE

amoxapine 2 AMOXAPINE

amphetamine 3 AMPHETAMINE

aripiprazole 4 ARIPIPRAZOLE

atomoxetine 5 ATOMOXETINE

benztropine 6 BENZTROPINE

buproprion 7 BUPROPRION

carbamazepine 8 CARBAMAZEPINE

chlorpromazine 9 CHLORPROMAZINE

citalopram 10 CITALOPRAM

clomipramine 11 CLOMIPRAMINE

clonidine 12 CLONIDINE

desipramine 13 DESIPRAMINE

dexmethyl 14 DEXMETHYLPHENIDATE

dextro 15 DEXTROAMPHETAMINE

diphen 16 DIPHENHYDRAMINE

divalproex 17 DIVALPROEX SODIUM

doxepine 18 DOXEPINE

duloxetine 19 DULOXETINE

escitalopram 20 ESCITALOPRAM

fluoxetine 21 FLUOXETINE

fluphenazine 22 FLUPHENAZINE

fluvoxamine 23 FLUVOXAMINE

guanfacine 24 GUANFACINE

haloperidol 25 HALOPERIDOL

hydroxyzine 26 HYDROXYZINE

imipramine 27 IMIPRAMINE

lamotrigine 28 LAMOTRIGINE

lithiumcarb 29 LITHIUM CARBONATE

lithiumcitr 30 LITHIUM CITRATE

loxapine 31 LOXAPINE

maprotiline 32 MAPROTILINE

melatonin 33 MELATONIN

methylphenidate 34 METHYLPHENIDATE

mirtazapine 35 MIRTAZAPINE

molindone 36 MOLINDONE

nefazodone 37 NEFAZODONE

nortriptyline 38 NORTRIPTYLINE

olanzapine 39 OLANZAPINE

paroxetine 40 PAROXETINE

pemoline 41 PEMOLINE

perphenazine 42 PERPHENAZINE

pimozide 43 PIMOZIDE

prochlorperazine 44 PROCHLORPERAZINE

quetiapine 45 QUETIAPINE

risperidone 46 RISPERIDONE

sertraline 47 SERTRALINE

thioridazine 48 THIORIDAZINE

thiothixine 49 THIOTHIXINE

topiramate 50 TOPIRAMATE

trazodone 51 TRAZODONE

trifluoperazine 52 TRIFLUOPERAZINE

trihexyphenadyl 53 TRIHEXYPHENADYL

trimipramine 54 TRIMIPRAMINE

valproic 55 VALPROIC ACID

venlafaxine 56 VENLAFAXINE

ziprasidone 57 ZIPRASIDONE

Logic after:

YYH3a_46_1--Generic med currently taking - AMITRIPTYLINE; YYH3a_46_2--Generic med

currently taking - AMOXAPINE; YYH3a_46_3--Generic med currently taking - AMPHETAMINE;

YYH3a_46_4--Generic med currently taking - ARIPIPRAZOLE; YYH3a_46_5--Generic med

currently taking - ATOMOXETINE; YYH3a_46_6--Generic med currently taking - BENZTROPINE;

YYH3a_46_7--Generic med currently taking - BUPROPRION; YYH3a_46_8--Generic med currently

taking - CARBAMAZEPINE; YYH3a_46_9--Generic med currently taking - CHLORPROMAZINE;

YYH3a_46_10--Generic med currently taking - CITALOPRAM; YYH3a_46_11--Generic med

currently taking - CLOMIPRAMINE; YYH3a_46_12--Generic med currently taking - CLONIDINE;

YYH3a_46_13--Generic med currently taking - DESIPRAMINE; YYH3a_46_14--Generic med

currently taking - DEXMETHYLPHENIDATE; YYH3a_46_15--Generic med currently taking -

DEXTROAMPHETAMINE; YYH3a_46_16--Generic med currently taking - DIPHENHYDRAMINE;

YYH3a_46_17--Generic med currently taking - DIVALPROEX SODIUM; YYH3a_46_18--Generic

med currently taking - DOXEPINE; YYH3a_46_19--Generic med currently taking - DULOXETINE;

YYH3a_46_20--Generic med currently taking - ESCITALOPRAM; YYH3a_46_21--Generic med

currently taking - FLUOXETINE; YYH3a_46_22--Generic med currently taking - FLUPHENAZINE;

YYH3a_46_23--Generic med currently taking - FLUVOXAMINE; YYH3a_46_24--Generic med

currently taking - GUANFACINE; YYH3a_46_25--Generic med currently taking - HALOPERIDOL;

YYH3a_46_26--Generic med currently taking - HYDROXYZINE; YYH3a_46_27--Generic med

currently taking - IMIPRAMINE; YYH3a_46_28--Generic med currently taking - LAMOTRIGINE;

YYH3a_46_29--Generic med currently taking - LITHIUM CARBONATE; YYH3a_46_30--Generic

med currently taking - LITHIUM CITRATE; YYH3a_46_31--Generic med currently taking -

LOXAPINE; YYH3a_46_32--Generic med currently taking - MAPROTILINE; YYH3a_46_33--Generic

med currently taking - MELATONIN; YYH3a_46_34--Generic med currently taking -

METHYLPHENIDATE; YYH3a_46_35--Generic med currently taking - MIRTAZAPINE;

YYH3a_46_36--Generic med currently taking - MOLINDONE; YYH3a_46_37--Generic med

currently taking - NEFAZODONE; YYH3a_46_38--Generic med currently taking - NORTRIPTYLINE;

YYH3a_46_39--Generic med currently taking - OLANZAPINE; YYH3a_46_40--Generic med

currently taking - PAROXETINE; YYH3a_46_41--Generic med currently taking - PEMOLINE;

YYH3a_46_42--Generic med currently taking - PERPHENAZINE; YYH3a_46_43--Generic med

currently taking - PIMOZIDE; YYH3a_46_44--Generic med currently taking -

PROCHLORPERAZINE; YYH3a_46_45--Generic med currently taking - QUETIAPINE;

YYH3a_46_46--Generic med currently taking - RISPERIDONE; YYH3a_46_47--Generic med

currently taking - SERTRALINE; YYH3a_46_48--Generic med currently taking - THIORIDAZINE;

YYH3a_46_49--Generic med currently taking - THIOTHIXINE; YYH3a_46_50--Generic med currently

taking - TOPIRAMATE; YYH3a_46_51--Generic med currently taking - TRAZODONE;

YYH3a_46_52--Generic med currently taking - TRIFLUOPERAZINE; YYH3a_46_53--Generic med

currently taking - TRIHEXYPHENADYL; YYH3a_46_54--Generic med currently taking -

TRIMIPRAMINE; YYH3a_46_55--Generic med currently taking - VALPROIC ACID; YYH3a_46_56--

Generic med currently taking - VENLAFAXINE; YYH3a_46_57--Generic med currently taking -

ZIPRASIDONE; YYH3a_46_58--Generic med currently taking - DK; YYH3a_46_59--Generic med

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

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

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

checkup?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH4a = 1 GOTO Y_YH14a

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

Logic before:

IF NO CG COMPLETE IN WAVE 1, CONTINUE. ELSE, GOTO Y_YH14a.

Y_YH5a [ YYH5a ] CH ever gone to dentist for checkup

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

Question Type: TYesNoC

Yes 1 YES

No 2 NO

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

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

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

medical facility overnight for an illness or injury?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH14a = 2 GOTO Y_YH17a

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

Y_YH15n [ YYH15a ] # of times CH admtd hosp/med facility

In the past 12 months, how many times have you been admitted?


TIMES:

Question Type: 1..100

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

Y_YH16n [ YYH16a ] Total # days CH in hosp/med facility

In the past 12 months, how many total days did you spend in the hospital or medical facility for

these problems?


Please include the admissions you just mentioned.


DAYS:

Question Type: 1..100

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

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

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

illness or injury?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH17a = 2 GOTO Y_YH19a

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

Y_YH18n [ YYH18a ] # of times CH gone to ER/Urg care

In the last 12 months, how many times have you gone to an emergency room or urgent care

center (for an illness or injury)?


TIMES:

Question Type: 1..100

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

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

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

of a doctor or nurse?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH19a = 2 GOTO Y_YH26a

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

Y_YH20a [ YYH20a ] What happened in CH most recnt serious inj/acc/poison

I'd like to ask a few questions about your @Bmost recent@B serious injury, accident, or

poisoning. What happened?


NOTE: CODE CATEGORY THAT BEST FITS RESPONSE GIVEN.

Question Type: TYH20a

mva_occup 1 MOTOR VEHICLE COLLISION AS OCCUPANT

mva_pedes 2 MOTOR VEHICLE COLLISION AS PEDESTRIAN

bike 3 RIDING A WHEELED TOY OR BIKE

othrtoy 4 OTHER TOY OR ITEM INTENDED FOR CHILD USE

outdoorplay 5 OUTDOOR PLAY INJURY

poisoning 6 POISONING

burn 7 BURN/SMOKE INHALATION

fall 8 FALL

farminjury 9 INJURY WITH AGRICULTURAL EQUIPMENT

equipment 10 EQUIPMENT OR DEVICE NOT INTENDED FOR A CHILD

domviolence 11 DOMESTIC VIOLENCE IN HOUSEHOLD

othrviolence 12 NON-RESIDENT ACT OF VIOLENCE OR CRIME-RELATED

selfinflicted 13 SELF-INFLICTED

animal 14 ANIMAL OR INSECT-INFLICTED

roughhousing 15 ROUGH HOUSING WITH OTHER KIDS/PEERS

drowning 16 NEAR DROWNING

parentinj 17 CHILD INJURED BY PARENT/OTHER ADULT

childinj 18 CHILD INJURED BY OTHER CHILD

other 19 SOMETHING ELSE

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

Y_YH21m [ YYH21m ] CH most recnt serious inj/acc/poison - month

In what month and year did this happen?


MONTH:

Question Type: TMonth

jan 1 January

feb 2 February

mar 3 March

apr 4 April

may 5 May

jun 6 June

jul 7 July

aug 8 August

sep 9 September

oct 10 October

nov 11 November

dec 12 December

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

Y_YH21y [ YYH21y ] CH most recnt serious inj/acc/poison - year

In what month and year did this happen?


YEAR:

Question Type: 2006..2013

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

Y_YH21a [ YYH21CKa ] NO LABEL

We are interested in serious accidents, injuries, or poisonings that occurred in the last 12

months. The date I entered for your most recent injury was more than 12 months ago. Is that the

correct date for your most recent serious accident, injury, or poisoning?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH21a = 1 GOTO Y_YH19a AND CHANGE ANSWER TO "NO"; IF Y_YH21a = 2 GOTO

Y_YH21m AND ENTER CORRECT DATE

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

Y_YH22 [ YYH22 ] Labels are in Logic After

What kind of injuries occurred? (PROBE: ANYTHING ELSE?)


CODE ALL THAT APPLY.

Question Type: TYH22S

brkenbone 1 BROKEN BONES OR DISLOCATED JOINTS

sprain 2 SPRAIN, STRAIN OR PULLED MUSCLE

cut 3 WOUND: CUTS, SCRAPES, PUNCTURE

concussion 4 HEAD INJURY, CONCUSSION

bruise 5 BRUISE, CONTUSION, INTERNAL BLEEDING

burn 6 BURN, SCALD

poisoning 7 ILLNESS OF EFFECT FROM POISONS, MEDICINES

substabuse 8 DRUGS, ALCOHOL ABUSE, ETC.

unconscious 9 LOST CONSCIOUSNESS (FOR MORE THAN 30 SECONDS)

choking 10 LODGED OBJECT IN THROAT

teeth 11 INJURY TO TEETH

eyes 12 INJURY TO EYES

shock 13 ELECTRICAL SHOCK

bite 14 STING, BITE

seizure 15 SEIZURE

internal 16 INTERNAL ORGAN INJURY

other 17 SOME OTHER INJURY

Logic after:

YYH22_1 --Broken bones or dislocated joints; YYH22_2 --Sprain strain or pulled muscle; YYH22_3

--Wound: cuts scrapes puncture; YYH22_4 --Head injury concussion; YYH22_5 --Bruise contusion

internal bleeding; YYH22_6 --Burn scald; YYH22_7 --Illness of effect from poisons medicine;

YYH22_8 --Drugs alcohol abuse etc.; YYH22_9 --Lost consciousness (> 30 seconds); YYH22_10 -

-Lodged object in throat; YYH22_11 --Injury to teeth; YYH22_12 --Injury to eyes; YYH22_13 --

Electrical shock; YYH22_14 --Sting bite; YYH22_15 --Seizure; YYH22_16 --Internal organ injury;

YYH22_17 --Some other injury; YYH22_18--DK; YYH22_19--RF

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

Logic before:

IF WAVE > 1, GOTO Y_YH24a

Y_YH23a [ YYH23a ] Where CH when most recnt serious inj/acc/poison happened

Where were you when this happened?

Question Type: TYH23a

athome 1 OWN HOME (INDOORS OR OUTDOORS)

daycare 2 DAY CARE/BABYSITTER/OTHER HOME (INDOORS OR OUTDOORS)

school 3 AT SCHOOL (INDOORS OR OUTDOORS)

other 4 SOMEWHERE ELSE (PARK, ETC.)

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

Y_YH24a [ YYH24a ] CH stay ovrnight in hosp for most recnt serious inj/acc

Did you have to stay overnight in the hospital?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH24a = 2 GOTO Y_YH30a

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

Y_YH25n [ YYH25a ] Nights CH in hosp for most recnt serious inj/acc (#)

How many nights did you spend in the hospital?

NIGHTS:

Question Type: 1..365


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

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

Logic before:

IF Y_CH9Yda = 1, CONTINUE. ELSE GOTO Y_YH43a

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

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

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

PSYCHOLOGIST, DOCTOR, SPEECH THERAPIST, ETC.)?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

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

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

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

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

developmental disabilities? Would you say...

Question Type: TYH32a

alot 1 a lot,

somewhat 2 somewhat,

alittle 3 a little, or

notatall 4 not at all?

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

Y_YH33 [ YYH33 ] Labels are in Logic After

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

disabilities?


CODE ALL THAT APPLY.

Question Type: TYH33S

notavail 1 SERVICE NOT AVAILABLE IN THE AREA

waitlist 2 WAIT-LISTED FOR SERVICE

ineligible 3 INELIGIBLE FOR SERVICE

cost 4 SERVICES COULD NOT BE FINANCED

scheduling 5 SCHEDULING PROBLEM OR PROBLEM FINDING CHILD CARE

transportation 6 TRANSPORTATION PROBLEM

other 7 SOME OTHER REASON

Logic after:

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

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

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

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

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

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

tstd lrnng prb/spcl nds/dev dis - RF

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

Y_YH35a [ YYH35a ] Ever told by ed or hlth prof that you have lrning prblms

Have you @Bever@B been told by an education or health professional that you have learning

problems, special needs, or developmental disabilities?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_YH36a [ YYH36a ] Classified in lst 12 mnths as needing special education

Children may qualify for special education services for many reasons, such as autism or the need

for speech or physical therapy.


@BIn the past 12 months@B have you been classified as needing special education? That is,

have you been given an Individual Education Plan (I.E.P.) or an Individual Family and Service Plan

(I.F.S.P.)?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH36a = 2 GOTO Y_YH38ab

---------------------------------------------------------------------------------

Y_YH36ab [ YYH36ab ] Crrntly have IEP or rcvng spcl ed or othr srvces for dsablty

Do you currently have an Individual Education Plan (I.E.P) or are you receiving special education

or other services for a special need or disability?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH36ab = 2 GOTO Y_YH40a

---------------------------------------------------------------------------------

Y_YH37a [ YYH37a ] Labels are in Logic After

What special learning problems or special needs were you told that you have? (PROBE:

ANYTHING ELSE)


CODE ALL THAT APPLY.

Question Type: TYH37aS

autism 1 AUTISM

deafness 2 DEAFNESS

behavioral 3 EMOTIONAL DISTURBANCE (BEHAVIORAL DISORDER)

hearing 4 HEARING IMPAIRMENT

mentalret 5 MENTAL RETARDATION

multdisab 6 MULTIPLE DISABILITIES (COMBINED IMPAIRMENTS THAT

TOGETHER CAUSE SEVERE EDUCATIONAL IMPAIRMENTS, SUCH

AS MENTAL RETARDATION-BLINDNESS)

orthopedic 7 ORTHOPEDIC IMPAIRMENT (PHYSICALLY DISABLING CONDITION,

SUCH AS MISSING LIMB, CEREBRAL PALSY, SPINA BIFIDA,

MUSCULAR DYSTROPHY)

specificld 8 SPECIFIC LEARNING DISABILITY

speech 9 SPEECH OR LANGUAGE IMPAIRMENT

tbi 10 TRAUMATIC BRAIN INJURY

visual 11 VISUAL IMPAIRMENT INCLUDING BLINDNESS

other 12 OTHER PROBLEM/NEED (ADHD, ASTHMA)

developmental 13 DEVELOPMENTAL DELAY

Logic after:

YYH37a_1 --Special learning problems/needs - AUTISM; YYH37a_2 --Special learning

problems/needs - DEAFNESS; YYH37a_3 --Special learning problems/needs - EMOTIONAL

DISTURBANCE; YYH37a_4 --Special learning problems/needs - HEARING IMPAIRMENT;

YYH37a_5 --Special learning problems/needs - MENTAL RETARDATION; YYH37a_6 --Special

learning problems/needs - MULTIPLE DISABILITIES; YYH37a_7 --Special learning problems/needs

- ORTHOPEDIC IMPAIRMENT; YYH37a_8 --Special learning problems/needs - SPECIFIC

LEARNING DISABLTY; YYH37a_9 --Special learning problems/needs - SPEECH/LANGUAGE

IMPAIRMENT; YYH37a_10 --Special learning problems/needs - TRAUMATIC BRAIN INJURY;

YYH37a_11 --Special learning problems/needs - VISUAL IMPAIRMENT; YYH37a_12 --Special

learning problems/needs - OTHER PROBLEM/NEED; YYH37a_13 --Special learning

problems/needs - DEVELOPMENTAL DELAY; YYH37a_14--Special learning problems/needs - DK;

YYH37a_15--Special learning problems/needs - RF

---------------------------------------------------------------------------------

Y_YH40a [ YYH40a ] Think you need special educations services/classes

How much do you think you @Bneed@B special education services or classes? Would you

Question Type: TYH32a

alot 1 a lot,

somewhat 2 somewhat,

alittle 3 a little, or

notatall 4 not at all?

---------------------------------------------------------------------------------

Y_YH41 [ YYH41 ] Labels are in Logic After

Why are you @Bnot@B receiving special education services or classes?


CODE ALL THAT APPLY.

Question Type: TYH41S

notavail 1 SERVICE NOT AVAILABLE IN THE AREA

waitlist 2 WAIT-LISTED FOR SERVICE

ineligible 3 INELIGIBLE FOR SERVICE

cost 4 SERVICES COULD NOT BE FINANCED

scheduling 5 SCHEDULING PROBLEM OR PROBLEM FINDING CHILD CARE

transportation 6 TRANSPORTATION PROBLEM

alreadyrecvd 7 CHILD ALREADY RECEIVED/COMPLETED SERVICE

other 8 SOME OTHER REASON

Logic after:

YYH41_1 --Why not receiving specl ed - Not avlble in area; YYH41_2 --Why not receiving specl ed -

Wait-listed for; YYH41_3 --Why not receiving specl ed - Ineligible for; YYH41_4 --Why not receiving

specl ed - Financing problem; YYH41_5 --Why not receiving specl ed - Schdling/chld care;

YYH41_6 --Why not receiving specl ed - Transportation prb; YYH41_7 --Why not receiving specl ed

- Already recvd service; YYH41_8 --Why not receiving specl ed - Some other reason; YYH41_9--

Why not receiving specl ed - DK

---------------------------------------------------------------------------------

Y_YH1ia [ YYH1ia ] Place CH usually goes when sick

Is there a place that you usually go when you are sick or you need advice about your health?

Question Type: TYH1ia

yes 1 YES

no 2 THERE IS NO PLACE

yesmore 3 THERE IS MORE THAN ONE PLACE

---------------------------------------------------------------------------------

Logic before:

IF Y_YH1ia = 2, CONTINUE. ELSE, GOTO Y_YH1ja.

Y_YH1ib [ YYH1ib ] Main reason you do not have a usual source of health care

What is the @Bmain@B reason you do not have a usual source of health care?

Question Type: TYH1ib

neversick 1 SELDOM OR NEVER GETS SICK

newtoarea 2 RECENTLY MOVED INTO AREA

dkwhere 3 DON'T KNOW WHERE TO GO FOR CARE

unavail 4 USUAL SOURCE OF MEDICAL CARE IN THIS AREA IS NO LONGER

AVAILABLE

language_ 5 CAN'T FIND A PROVIDER WHO SPEAKS SAME LANGUAGE

different 6 LIKES TO GO TO DIFFERENT PLACES FOR DIFFERENT HEALTH

NEEDS

newinsurance 7 JUST CHANGED INSURANCE PLANS

selftreat 8 DON'T USE DOCTORS/TREAT MYSELF

cost 9 COST OF MEDICAL CARE

other 10 OTHER REASON

Logic after:

GOTO Y_YH1la

---------------------------------------------------------------------------------

Logic before:

[IF Y_YH1ia = 1]: What kind of place is it –- a clinic, doctor’s office, emergency room, or some

other place?


[IF Y_YH1ia = 3]: What kind of place do you go to most often -– a clinic, doctor’s office,

emergency room, or some other place?

Y_YH1ja [ YYH1ja ] Kind of place CH goes when sick

^Fills.YH1ja

Question Type: TYH1ja

clinic 1 CLINIC OR HEALTH CENTER

droffice 2 DOCTOR'S OFFICE OR HMO

er 3 HOSPITAL EMERGENCY ROOM

hospout 4 HOSPITAL OUTPATIENT DEPARTMENT

other 5 SOME OTHER PLACE

noplace 6 DOESN'T GO TO ONE PLACE MOST OFTEN

Question Fill: ^FillYH1ja

oneplace What kind of place is it -- a clinic, doctor's office, emergency room, or

some other place?

moreone What kind of place do you go to most often -- a clinic, doctor's office,

emergency room, or some other place?

---------------------------------------------------------------------------------

Y_YH1ka [ YYH1ka ] Place CH goes when sick same for preventative care

Is that ^Fills.YH1ka the same place you usually go when you need routine or preventive care,

such as a physical examination?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Question Fill: ^FillYH1ka

clinic clinic or health center

droffice doctor's office or HMO

er hospital emergency room

hospout hospital outpatient department

Logic after:

IF Y_YH1ka = 1 GOTO Y_YH1lb

---------------------------------------------------------------------------------

Y_YH1la [ YYH1la ] Kind of place CH goes for prevntatve care

What kind of place do you @Uusually@U go when you need routine or preventive care, such as a

physical examination?

Question Type: TYH1la

doesntget 1 DOESN'T GET PREVENTIVE CARE ANYWHERE

clinic 2 CLINIC OR HEALTH CENTER

droffice 3 DOCTOR'S OFFICE OR HMO

er 4 HOSPITAL EMERGENCY ROOM

hospout 5 HOSPITAL OUTPATIENT DEPARTMENT

other 6 SOME OTHER PLACE

noplace 7 DOESN'T GO TO ONE PLACE MOST OFTEN

---------------------------------------------------------------------------------

Y_YH1lb [ YYH1lb ] See a particular prvder where u usually go for routine care

Do you usually see a @Bparticular provider@B at the place where you usually go for routine or

preventive care, such as a physical examination?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_YH1ma [ YYH1ma ] CH rcv general check-up last 12 months

@BDuring the past 12 months@B did you receive a general check-up when you were not sick or

injured?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_YH1na [ YYH1na ] CH see Dr because sick or injured last 12 months

@BDuring the past 12 months@B, did you see a doctor or other health professional because you

were sick or injured?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_YH1ob [ YYH1ob ] Labels are in Logic After

@BDuring the past 12 months@B, was there any time when you needed any of the following but

couldn't get it because you couldn't afford it...


CODE ALL THAT APPLY.

Question Type: TYH1obS

rxmeds 1 Prescription medicines

mentalhlth 2 Mental health care or counseling

dental 3 Dental care (including check-ups)

glasses 4 Eyeglasses

NONE 5 NONE OF THE ABOVE

Logic after:

YYH1ob_1 --Needed but could not afford - Prescription medicines; YYH1ob_2 --Needed but could

not afford - Mental health care/counseling; YYH1ob_3 --Needed but could not afford - Dental

care(incldng check-ups); YYH1ob_4 --Needed but could not afford - Eyeglasses; YYH1ob_5 --

Needed but could not afford - None of the above; YYH1ob_6--Needed but could not afford - DK;

YYH1ob_7--Needed but could not afford - RF

---------------------------------------------------------------------------------

Y_YH49 [ YYH49 ] NO LABEL

USE CARD 9. Next, I'm going to go through a list of places where you might have gotten help for

emotional, behavioral, learning, attention, or substance abuse problems. Please look at the list of

places on Card 9.


NOTE: "EMOTIONAL, BEHAVIORAL, LEARNING, AND ATTENTION PROBLEMS" INCLUDE

SUICIDE ATTEMPTS, ADD, DEPRESSION, ALCOHOL/DRUG-RELATED PROBLEMS,

INJURING SELF/OTHER, BIPOLAR DISORDER, AGGRESSIVE BEHAVIOR, ETC.


PRESS "1" AND [ENTER] TO CONTINUE.

Question Type: TCont

Continue 1 Continue

---------------------------------------------------------------------------------

Logic before:

IF NO CG COMPLETE IN WAVE 1, ELSE GOTO Y_YH50a1a: Have you ever been to...

Y_YH50aa [ YYH50a ] CH ever been psych hosp/unit

Have you ever been to a @Bpsychiatric hospital or a psychiatric unit in a medical hospital@B for

emotional, behavioral, learning, attention, or substance abuse problems?


NOTE: A PSYCHIATRIC HOSPITAL PROVIDES CARE ONLY FOR PSYCHIATRIC PROBLEMS.

A PSYCHIATRIC UNIT PROVIDES PSYCHIATRIC CARE IN A SPECIALIZED UNIT THAT IS

WITHIN A MEDICAL HOSPITAL OFFERING CARE FOR A WIDE RANGE OF ILLNESSES.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50aa = 1) OR (WAVE >= 2) FILL: In the past 12 months, have you been to...

Y_YH50a1a [ YYH50aa ] Past 12M, been to psych hosp or unit in medical hosp for...?

In the past 12 months, have you been to a @Bpsychiatric hospital or a psychiatric unit in a

medical hospital@B for emotional, behavioral, learning, attention, or substance abuse problems?



NOTE: A PSYCHIATRIC HOSPITAL PROVIDES CARE ONLY FOR PSYCHIATRIC PROBLEMS.

A PSYCHIATRIC UNIT PROVIDES PSYCHIATRIC CARE IN A SPECIALIZED UNIT THAT IS

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF NO CG COMPLETE IN WAVE 1, ELSE GOTO Y_YH50b1a: Have you ever been to...

Y_YH50ba [ YYH50b ] CH ever been detox/drg/alc unit

Have you ever been to a @Bdetox unit or inpatient drug or alcohol unit@B for emotional,

behavioral, learning, attention, or substance abuse problems?

(INCLUDE EMOTIONAL, BEHAVIORAL, LEARNING, ATTENTION, AND SUBSTANCE ABUSE

PROBLEMS.)


NOTE: AN INPATIENT DETOX UNIT OR DRUG/ALCOHOL UNIT PROVIDES INPATIENT

SPECIALIZED TREATMENT FOR SUBSTANCE USE/ABUSE. CAN OCCUR IN A STAND-

ALONE TREATMENT UNIT, A PSYCHIATRIC HOSPITAL, OR A GENERAL HOSPITAL.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50ba = 1) OR (WAVE >= 2) FILL: In the past 12 months, have you been to...

Y_YH50b1a [ YYH50ba ] Past 12M, been t detox unit or inptnt drg or alc unt for...?

In the past 12 months, have you been to a @Bdetox unit or inpatient drug or alcohol unit@B for

emotional, behavioral, learning, attention, or substance abuse problems? (INCLUDE

EMOTIONAL, BEHAVIORAL, LEARNING, ATTENTION, AND SUBSTANCE ABUSE

PROBLEMS.)


NOTE: AN INPATIENT DETOX UNIT OR DRUG/ALCOHOL UNIT PROVIDES INPATIENT

SPECIALIZED TREATMENT FOR SUBSTANCE USE/ABUSE. CAN OCCUR IN A STAND-

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF NO CG COMPLETE IN WAVE 1, ELSE GOTO Y_YH50c1a: Have you ever been to...

Y_YH50ca [ YYH50c ] CH ever been hosp med inpatient unit

Have you ever been to a @Bhospital medical inpatient unit@B for emotional, behavioral, learning,

attention, or substance abuse problems? (INCLUDE EMOTIONAL, BEHAVIORAL, LEARNING,

ATTENTION, AND SUBSTANCE ABUSE PROBLEMS.)


NOTE: A HOSPITAL MEDICAL INPATIENT UNIT IS A GENERAL HOSPITAL UNIT NOT

SPECIALLY DESIGNATED FOR TREATMENT OF PSYCHIATRIC OR SUBSTANCE USE

PROBLEMS. TREATMENT, THOUGH, MUST BE FOR MENTAL HEALTH OR SUBSTANCE

ABUSE PROBLEMS.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50ca = 1) OR (WAVE >= 2) FILL: In the past 12 months, have you been to...

Y_YH50c1a [ YYH50ca ] Past 12M, been to a hospital medical inpatient unit for...?

In the past 12 months, have you been to a @Bhospital medical inpatient unit@B for emotional,

behavioral, learning, attention, or substance abuse problems? (INCLUDE EMOTIONAL,

BEHAVIORAL, LEARNING, ATTENTION, AND SUBSTANCE ABUSE PROBLEMS.)


NOTE: A HOSPITAL MEDICAL INPATIENT UNIT IS A GENERAL HOSPITAL UNIT NOT

SPECIALLY DESIGNATED FOR TREATMENT OF PSYCHIATRIC OR SUBSTANCE USE

PROBLEMS. TREATMENT, THOUGH, MUST BE FOR MENTAL HEALTH OR SUBSTANCE

ABUSE PROBLEMS.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF NO CG COMPLETE IN WAVE 1, ELSE GOTO Y_YH50d1a: Have you ever been to...

Y_YH50da [ YYH50d ] CH ever been res trtmnt cntr or group home

Have you ever been to a @Bresidential treatment center or group home@B for emotional,

behavioral, learning, attention, or substance abuse problems? (INCLUDE EMOTIONAL,

BEHAVIORAL, LEARNING, ATTENTION, AND SUBSTANCE ABUSE PROBLEMS.)


NOTE: A RESIDENTIAL TREATMENT CENTER IS A SELF-CONTAINED TREATMENT FACILITY

(I.E., RESIDENCE IS NOT WITHIN THE COMMUNITY AND CHILD RECEIVES EDUCATION

WITHIN THE CENTER). INCLUDE WILDERNESS CAMPS AND COTTAGES ON THE GROUNDS

OF A SELF-CONTAINED TREATMENT FACILITY. DO NOT INCLUDE DETENTION CENTERS,

TRAINING SCHOOLS, AND JAILS. A GROUP HOME IS A SMALLER RESIDENTIAL

TREATMENT CENTER.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50da = 1) OR (WAVE >= 2) FILL: In the past 12 months, have you been to...

Y_YH50d1a [ YYH50da ] Past 12M, bn to residntl trtmnt centr or group home for...?

In the past 12 months, have you been to a @Bresidential treatment center or group home@B for

emotional, behavioral, learning, attention, or substance abuse problems? (INCLUDE

EMOTIONAL, BEHAVIORAL, LEARNING, ATTENTION, AND SUBSTANCE ABUSE

PROBLEMS.)


NOTE: A RESIDENTIAL TREATMENT CENTER IS A SELF-CONTAINED TREATMENT FACILITY

(I.E., RESIDENCE IS NOT WITHIN THE COMMUNITY AND CHILD RECEIVES EDUCATION

WITHIN THE CENTER). INCLUDE WILDERNESS CAMPS AND COTTAGES ON THE GROUNDS

OF A SELF-CONTAINED TREATMENT FACILITY. DO NOT INCLUDE DETENTION CENTERS,

TRAINING SCHOOLS, AND JAILS. A GROUP HOME IS A SMALLER RESIDENTIAL

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF NO CG COMPLETE IN WAVE 1, ELSE GOTO Y_YH50g1a: Have you ever been to...

Y_YH50ga [ YYH50g ] CH ever been day trtmnt

Have you ever been to @Bday treatment@B for emotional, behavioral, learning, attention, or

substance abuse problems? By "day treatment," we mean that you go to a program @Bevery

day or almost every day@B but don't stay overnight.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF Y_YH50ga = 1 OR (WAVE >= 2) FILL: In the past 12 months, have you been to...

Y_YH50g1a [ YYH50ga ] Past 12M, been to day treatment for...?

In the past 12 months, have you been to @Bday treatment@B for emotional, behavioral, learning,

attention, or substance abuse problems? By "day treatment," we mean that you go to a program

@Bevery day or almost every day@B but don't stay overnight.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF NO CG COMPLETE IN WAVE 1, ELSE GOTO Y_YH50h1a: Have you ever been to...

Y_YH50ha [ YYH50h ] CH ever been outpatient drg/alc clinic

Have you ever been to an @Boutpatient drug or alcohol clinic@B for emotional, behavioral,

learning, attention, or substance abuse problems? (INCLUDE EMOTIONAL, BEHAVIORAL,

LEARNING, ATTENTION, AND SUBSTANCE ABUSE PROBLEMS.)


NOTE: AN OUTPATIENT DRUG/ALCOHOL CLINIC IS A SUBSTANCE ABUSE TREATMENT

FACILITY THAT PROVIDES OUTPATIENT SERVICES. DO NOT INCLUDE SUBSTANCE ABUSE

SERVICES RECEIVED AT A MENTAL HEALTH CENTER.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50ha = 1) OR (WAVE >= 2) FILL: In the past 12 months, have you been to...

Y_YH50h1a [ YYH50ha ] Past 12M, been to outpatient drug or alcohol clinic for...?

In the past 12 months, have you been to an @Boutpatient drug or alcohol clinic@B for any of

these problems? (INCLUDE EMOTIONAL, BEHAVIORAL, LEARNING, ATTENTION, AND

SUBSTANCE ABUSE PROBLEMS.)


NOTE: AN OUTPATIENT DRUG/ALCOHOL CLINIC IS A SUBSTANCE ABUSE TREATMENT

FACILITY THAT PROVIDES OUTPATIENT SERVICES. DO NOT INCLUDE SUBSTANCE ABUSE

SERVICES RECEIVED AT A MENTAL HEALTH CENTER.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF NO CG COMPLETE IN WAVE 1, ELSE GOTO Y_YH50i1a: Have you ever been to...

Y_YH50ia [ YYH50i ] CH ever been mntl hlth/comm hlth cntr

Have you ever been to a @Bmental health or community health center@B for emotional,

behavioral, learning, attention, or substance abuse problems? (INCLUDE EMOTIONAL,

BEHAVIORAL, LEARNING, ATTENTION, AND SUBSTANCE ABUSE PROBLEMS.)


NOTE: A COMMUNITY HEALTH CENTER IS PUBLICLY FUNDED AND PROVIDES GENERAL

HEALTH SERVICES.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50ia = 1) OR (WAVE >= 2) FILL: In the past 12 months, have you been to...

Y_YH50i1a [ YYH50ia ] Past 12M, bn to a mentl hlth or community hlth centr for...?

In the past 12 months, have you been to a @Bmental health or community health center@B for

any of these problems? (INCLUDE EMOTIONAL, BEHAVIORAL, LEARNING, ATTENTION, AND

SUBSTANCE ABUSE PROBLEMS.)


NOTE: A COMMUNITY HEALTH CENTER IS PUBLICLY FUNDED AND PROVIDES GENERAL

HEALTH SERVICES.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF Y_YH50ia = 1, FILL: Not counting help received from a mental health or community health

center, have you ever gotten private professional help from a @Bpsychiatrist, psychologist, social

worker, or psychiatric nurse@B for emotional, behavioral, learning, attention, or substance abuse

Y_YH50ja [ YYH50ja ] CH ever rcv priv prof help

^Fills.YH50ja you ever gotten private professional help from a @Bpsychiatrist, psychologist, social

worker, or psychiatric nurse@B for emotional, behavioral, learning, attention, or substance abuse

problems?


NOTE: CODE "NO" IF CHILD SEES THE PROFESSIONAL THROUGH AN AGENCY FUNDED

BY PUBLIC FUNDS, SUCH AS A PRIVATE PROFESSIONAL WHO SEES PATIENTS AT A

MENTAL HEALTH CENTER WITH WHICH HE/SHE IS AFFILIATED.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Question Fill: ^FillYH50ja

yesrcvd Not counting help received from a mental health or community health

center, have

norcvd Have

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50ja = 1) OR (WAVE >= 2) CONTINUE. ELSE GOTO Y_YH50ka.

Y_YH50j1a [ YYH50j1a ] CH rcv priv prof help in last 12 months

^Fills.YH50j1a the past 12 months, have you gotten private professional help from a

@Bpsychiatrist, psychologist, social worker, or psychiatric nurse@B for emotional, behavioral,

learning, attention, or substance abuse problems?


NOTE: CODE "NO" IF CHILD SEES THE PROFESSIONAL THROUGH AN AGENCY FUNDED

BY PUBLIC FUNDS, SUCH AS A PRIVATE PROFESSIONAL WHO SEES PATIENTS AT A

MENTAL HEALTH CENTER WITH WHICH HE/SHE IS AFFILIATED.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Question Fill: ^FillYH50j1a

yesrcvd Not counting help received from a mental health or community health

center, in

norcvd In

---------------------------------------------------------------------------------

Logic before:

IF NO CG COMPLETE IN WAVE 1, ELSE GOTO Y_YH50k1a: Have you ever...

Y_YH50ka [ YYH50k ] CH ever rcv in-home counslng/crisis svc

Have you ever received any @Bin-home counseling or in-home crisis services@B for emotional,

behavioral, learning, attention, or substance abuse problems? (INCLUDE EMOTIONAL,

BEHAVIORAL, LEARNING, ATTENTION, AND SUBSTANCE ABUSE PROBLEMS.)


NOTE: THESE INCLUDE SERVICES PROVIDED IN THE FAMILY'S HOME BY PROFESSIONAL

OR PARAPROFESSIONAL IN-HOME WORKERS. MUST BE PART OF A RECOGNIZED IN-

HOME SERVICE PROGRAM. DO NOT INCLUDE HOME VISITS BY CASEWORKERS OR

ISOLATED HOME VISITS BY CASE MANAGERS OR OTHER MENTAL HEALTH CLINICIANS.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50ka = 1) OR (WAVE >= 2) FILL: In the past 12 months, have you...

Y_YH50k1a [ YYH50ka ] Past 12M, recvd any in-home counslng or crisis srvcs for...?

In the past 12 months, have you received any @Bin-home counseling or in-home crisis

services@B for any of these problems? (INCLUDE EMOTIONAL, BEHAVIORAL, LEARNING,

ATTENTION, AND SUBSTANCE ABUSE PROBLEMS.)


NOTE: THESE INCLUDE SERVICES PROVIDED IN THE FAMILY'S HOME BY PROFESSIONAL

OR PARAPROFESSIONAL IN-HOME WORKERS. MUST BE PART OF A RECOGNIZED IN-

HOME SERVICE PROGRAM. DO NOT INCLUDE HOME VISITS BY CASEWORKERS OR

ISOLATED HOME VISITS BY CASE MANAGERS OR OTHER MENTAL HEALTH CLINICIANS.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF NO CG COMPLETE IN WAVE 1, ELSE GOTO Y_YH50l1a: Have you ever...

Y_YH50la [ YYH50l ] CH ever seen fam doc/othr med doc

Have you ever seen your @Bfamily doctor or any other medical doctor@B for emotional,

behavioral, learning, attention, or substance abuse problems?


NOTE: INCLUDE SERVICES RECEIVED FROM A NON-PSYCHIATRIC MD. INCLUDE ANY

VISITS TO PEDIATRICIAN OR FAMILY DOCTOR IN PRIVATE OR GROUP PRACTICE DURING

WHICH THE PARENT/CHILD SOUGHT HELP FOR EMOTIONAL, BEHAVIORAL, SUBSTANCE

ABUSE PROBLEMS.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50la = 1) OR (WAVE >= 2) FILL: In the past 12 months, have you...

Y_YH50l1a [ YYH50la ] Past 12M, seen your family dr or any other medicl dr for...?

In the past 12 months, have you seen your @Bfamily doctor or any other medical doctor@B for

emotional, behavioral, learning, attention, or substance abuse problems?


NOTE: INCLUDE SERVICES RECEIVED FROM A NON-PSYCHIATRIC MD. INCLUDE ANY

VISITS TO PEDIATRICIAN OR FAMILY DOCTOR IN PRIVATE OR GROUP PRACTICE DURING

WHICH THE PARENT/CHILD SOUGHT HELP FOR EMOTIONAL, BEHAVIORAL, SUBSTANCE

ABUSE PROBLEMS.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF NO CG COMPLETE IN WAVE 1, ELSE GOTO Y_YH50m1a: Have you ever...

Y_YH50ma [ YYH50m ] CH ever been to hosp emer room

Have you ever been to a @Bhospital emergency room@B for emotional, behavioral, learning,

attention, or substance abuse problems? (INCLUDE EMOTIONAL, BEHAVIORAL, LEARNING,

ATTENTION, AND SUBSTANCE ABUSE PROBLEMS.)


NOTE: ONLY CODE ER VISITS IF THEY WERE RELATED TO MENTAL HEALTH/SUBSTANCE

ABUSE (E.G., BREAKING AN ARM DURING A TANTRUM, HARM DURING A SUICIDE

ATTEMPT, CAR ACCIDENT WHILE CHILD WAS INTOXICATED, BROKEN NOSE DURING

SERIOUS PHYSICAL FIGHT, ETC.). ALSO INCLUDE VISITS TO ER AS PART OF ADMISSIONS

PROCESS TO INPATIENT FACILITY.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50ma = 1) OR (WAVE >= 2) FILL: In the past 12 months, have you...

Y_YH50m1a [ YYH50ma ] Past 12M, been to a hospital emergency room for...?

In the past 12 months, have you been to a @Bhospital emergency room@B for any of these

problems? (INCLUDE EMOTIONAL, BEHAVIORAL, LEARNING, ATTENTION, AND

SUBSTANCE ABUSE PROBLEMS.)


NOTE: ONLY CODE ER VISITS IF THEY WERE RELATED TO MENTAL HEALTH/SUBSTANCE

ABUSE (E.G., BREAKING AN ARM DURING A TANTRUM, HARM DURING A SUICIDE

ATTEMPT, CAR ACCIDENT WHILE CHILD WAS INTOXICATED, BROKEN NOSE DURING

SERIOUS PHYSICAL FIGHT, ETC.). ALSO INCLUDE VISITS TO ER AS PART OF ADMISSIONS

PROCESS TO INPATIENT FACILITY.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF NO CG COMPLETE IN WAVE 1 AND Y_CH9Yda = 1, ELSE GOTO Y_YH50n1a: Have you ever…

Y_YH50na [ YYH50na ] Ever seen school cnselor, psych, social worker

Have you ever seen a @Bschool guidance counselor, school psychologist, or school social

worker@B for emotional, behavioral, learning, attention, or substance abuse problems or gotten

any other sort of help for these problems at school?


NOTE: ONLY INCLUDE VISITS RELATED TO MENTAL HEALTH/SUBSTANCE ABUSE. DO NOT

INCLUDE VISITS RELATED TO SCHOOL CURRICULUM OR COLLEGE/CAREER

COUNSELING. SCHOOL PERSONNEL WHO HANDLE ATTENDANCE ISSUES CAN ALSO BE

INCLUDED HERE IF THEY HAVE DIRECT CONTACT WITH THE CHILD.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50na = 1 AND EMANCIPATED YOUTH) OR (WAVE >= 2)

Y_YH50n1a [ YYH50n1a ] Seen school cnselor, psych, social worker in last 12 months

In the past 12 months, have you seen a @Bschool guidance counselor, school psychologist, or

school social worker@B for emotional, behavioral, learning, attention, or substance abuse

problems or gotten any other sort of help for these problems at school?

FR NOTE: ONLINE VIRTUAL MEETINGS WITH SCHOOL GUIDANCE COUNSELORS, SCHOOL PSYCHOLOGISTS, OR SCHOOL SOCIAL WORKERS SHOULD BE INCLUDED.


NOTE: ONLY INCLUDE VISITS RELATED TO MENTAL HEALTH/SUBSTANCE ABUSE. DO NOT

INCLUDE VISITS RELATED TO SCHOOL CURRICULUM OR COLLEGE/CAREER

COUNSELING. SCHOOL PERSONNEL WHO HANDLE ATTENDANCE ISSUES CAN ALSO BE

INCLUDED HERE IF THEY HAVE DIRECT CONTACT WITH THE CHILD.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF NO CG COMPLETE IN WAVE 1 AND EMANCIPATED YOUTH, ELSE GOTO Y_YH50o1a: Have you ever...

Y_YH50oa

Have you ever received services in a special classroom in a regular school for emotional, behavioral, learning or substance abuse problems?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50oa = 1 AND EMANCIPATED YOUTH) OR (WAVE >= 2) FILL: In the past 12 months, have you...

Y_YH50o1a

In the past 12 months, have you received services in a special classroom in a regular school for emotional, behavioral, learning or substance abuse problems?

Question Type: TYN

yes 1 YES

no 2 NO

--------------------------------------------------------------------------------

Logic before:

F NO CG COMPLETE IN WAVE 1 AND EMANCIPATED YOUTH, ELSE GOTO Y_YH50p1a: Have you ever...

Y_YH50pa

Have you ever received special help or tutoring in the regular classroom for emotional, behavioral, learning or substance abuse problems?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50pa = 1 AND EMANCIPATED YOUTH) OR (WAVE >= 2) FILL: In the past 12 months, have you...

Y_YH50p1a

In the past 12 months, have you received special help or tutoring in the regular classroom for emotional, behavioral, learning or substance abuse problems?

FR NOTE: ONLINE HELP OR TUTORING SHOULD BE COUNTED.

Question Type: TYN

yes 1 YES

no 2 NO


--------------------------------------------------------------------------------

Logic before:

F NO CG COMPLETE IN WAVE 1 AND EMANCIPATED YOUTH, ELSE GOTO Y_YH50q1a: Have you ever...

Y_YH50qa

Have you ever received services in a special school for students with emotional, behavioral, learning, attention, or substance abuse problems?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50qa = 1 AND EMANCIPATED YOUTH) OR (WAVE >= 2) FILL: In the past 12 months, have you...

Y_YH50q1a

In the past 12 months, have you received services in a special school for students with emotional, behavioral, learning, attention, or substance abuse problems?

FR NOTE: ONLINE HELP OR SERVICES OFFERED VIRTUALLY SHOULD BE INCLUDED.

Question Type: TYN

yes 1 YES

no 2 NO

--------------------------------------------------------------------------------


Logic before:

F NO CG COMPLETE IN WAVE 1, ELSE GOTO Y_YH50r1a: Have you ever...

Y_YH50ra

Have you ever received outpatient help or treatment from an in-person or online self-help or support group (like peer counseling or Alcoholics Anonymous)?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Logic before:

IF (Y_YH50ra = 1) OR (WAVE >= 2) FILL: In the past 12 months, have you...

Y_YH50r1a

received outpatient help or treatment from an in-person or online self-help or support group (like peer counseling or Alcoholics Anonymous)?

Question Type: TYN

yes 1 YES

no 2 NO


---------------------------------------------------------------------------------

Logic before:

IF WAVE = 1 AND IF NO RESPONSES Y_YH50aa to Y_YH50na = 1, GO TO Y_YH166a. ELSE,

CONTINUE.

IF WAVE >= 2 AND NO RESPONSES Y_YH50a1a to Y_YH50n1a = 1, GO TO Y_YH166a. ELSE,

CONTINUE.

Y_YH51 [ YYH51 ] NO LABEL

Now I want to ask you some questions about the types of services you received for emotional,

behavioral, learning, attention, or substance abuse problems.


PRESS "1" AND [ENTER] TO CONTINUE.

Question Type: TCont

Continue 1 Continue

---------------------------------------------------------------------------------

Y_YH52 [ YYH52 ] NO LABEL

In the past 12 months, has a caseworker or agency helped you receive support or assistance for

an alcohol or drug problem?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_YH140 Questions Y_YH140m - Y_YH146 are in Y_YH140m

Question Type: ARRAY[1..5] OF BY_YH140

---------------------------------------------------------------------------------

Logic before:

PROGRAMMER: IF WAVE = 1 REPEAT Y_YH140m TO Y_YH146 FOR EACH 'YES' RESPONSE

TO Y_YH50aa, Y_YH50ba, Y_YH50ca, Y_YH50da, Y_YH50ea, IF WAVE = 2 REPEAT

Y_YH140m TO Y_YH146 FOR EACH 'YES' RESPONSE TO Y_YH50a1a, Y_YH50b1a,

Y_YH50c1a, Y_YH50d1a, Y_YH50e1a, Use the corresponding fill for each outpatient venue as

follows: WAVE 1/Y_YH50aa FILL: psychiatric hospital or a psychiatric unit in a medical hospital

Y_YH50ba FILL: detox unit or inpatient drug or alcohol unit Y_YH50ca FILL: hospital medical

inpatient unit Y_YH50da FILL: residential treatment center or group home Y_YH50ea FILL:

emergency shelter WAVE 2/Y_YH50a1a FILL: psychiatric hospital or a psychiatric unit in a

medical hospital Y_YH50b1a FILL: detox unit or inpatient drug or alcohol unit Y_YH50c1a FILL:

hospital medical inpatient unit Y_YH50d1a FILL: residential treatment center or group home

---------------------------------------------------------------------------------

Y_YH141 [ YYH141 ] Labels are in Logic After

In the last 12 months, how many times have you been admitted to a @B^Fills.YH140m@B?


TIMES:

Question Type: 0..100

Question Fill: ^FillYH140m

psych psychiatric hospital or a psychiatric unit in a medical hospital

detox detox unit or inpatient drug or alcohol unit

inpatient hospital medical inpatient unit

resid residential treatment center or group home

shelter emergency shelter

Logic after:

YYH141_1 --How many times admitted in last 12 months?; YYH141_2 --How many times admitted

in last 12 months?; YYH141_3 --How many times admitted in last 12 months?; YYH141_4 --How

many times admitted in last 12 months?; YYH141_5 --How many times admitted in last 12 months?


Y_YH141a


THIS QUESTION IS NOT ASKED FOR THERAPUTIC FOSTER CARE


Now I am going to read a list of the types of treatment, services, and counseling programs that might be provided in @b^fills.Y_YH_Venue@b. In your most recent admission to a @b^fills.Y_YH_Venue@b, did you

CODE ALL THAT APPLY

1=Receive therapy or counseling

2=Have case management or a contact person who coordinated his/her services

3=Receive medications

4=Receive evaluations or testing


---------------------------------------------------------------------------------

---------------------------------------------------------------------------------

Logic before:

IF Y_YH141 >1 FILL: "admitted this most recent time." ELSE FILL:"admitted."

Y_YH144 [ YYH144 ] Labels are in Logic After

USE CARD 10. Please look at Card 10 and tell me why you were ^Fills.YH144


CODE ALL THAT APPLY.

Question Type: TYH144S

Emotional 1 EMOTIONAL OR BEHAVIORAL HEALTH PROBLEMS

AlcoholDrug 2 ALCOHOL OR DRUG ABUSE PROBLEMS


Question Fill: ^FillYH144

once admitted.

moreonce admitted this most recent time.

---------------------------------------------------------------------------------

Y_YH142 [ YYH142 ] Labels are in Logic After

Are you still there?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

YYH142_1 --Still where you were admitted?; YYH142_2 --Still where you were admitted?;

YYH142_3 --Still where you were admitted?; YYH142_4 --Still where you were admitted?;

YYH142_5 --Still where you were admitted?


Y_YH146 [ YYH146 ] Labels are in Logic After

Why did you leave this facility?


CODE ALL THAT APPLY.

Question Type: TYH146S

planned 1 PLANNED TERMINATION OF TREATMENT

wasnthelping 2 DIDN'T THINK IT WAS HELPING

improved 3 IMPROVED SO STOPPED GOING

didntunderstand 4 FELT "PROVIDER" DID NOT UNDERSTAND WHAT THE PROBLEM

WAS

disagreed 5 DISAGREED WITH "PROVIDER" ABOUT WHAT SHOULD BE DONE

badexperience 6 HAD A BAD EXPERIENCE WITH THIS "PROVIDER"

discriminated 7 FELT DISCRIMINATED AGAINST

prvdrmoved 8 "PROVIDER" WAS NO LONGER AVAILABLE (MOVED OR LEFT

SETTING)

refused 9 REFUSED TO GO

inslimited 10 INSURANCE/MANAGED CARE COMPANY LIMITED TREATMENT

cost 11 TOO EXPENSIVE

moved 12 MOVED

other 13 OTHER

Logic after:

YYH146_1_1 --Adm #1, why left facility - PLANNED TERMINATION OF TREATMENT;

YYH146_1_10 --Adm #1, why left facility - INS/MANAGED CARE CO LIMITED TRT; YYH146_1_11

--Adm #1, why left facility - TOO EXPENSIVE; YYH146_1_12 --Adm #1, why left facility - MOVED;

YYH146_1_13 --Adm #1, why left facility - OTHER; YYH146_1_2 --Adm #1, why left facility -

DIDN'T THINK IT WAS HELPING; YYH146_1_3 --Adm #1, why left facility - IMPROVED SO

STOPPED GOING; YYH146_1_4 --Adm #1, why left facility - PROVIDER DID NOT UNDRSTND

PRB; YYH146_1_5 --Adm #1, why left facility - DISAGRD W PROVIDER ABT SERVICE;

YYH146_1_6 --Adm #1, why left facility - BAD EXPERIENCE WITH PROVIDER; YYH146_1_7 --

Adm #1, why left facility - FELT DISCRIMINATED AGAINST; YYH146_1_8 --Adm #1, why left

facility - PROVIDER NO LONGER AVAILABLE; YYH146_1_9 --Adm #1, why left facility -

REFUSED TO GO; YYH146_2_1 --Adm #2, why left facility - PLANNED TERMINATION OF

TREATMENT; YYH146_2_10 --Adm #2, why left facility - INS/MANAGED CARE CO LIMITED TRT;

YYH146_2_11 --Adm #2, why left facility - TOO EXPENSIVE; YYH146_2_12 --Adm #2, why left

facility - MOVED; YYH146_2_13 --Adm #2, why left facility - OTHER; YYH146_2_2 --Adm #2, why

left facility - DIDN'T THINK IT WAS HELPING; YYH146_2_3 --Adm #2, why left facility -

IMPROVED SO STOPPED GOING; YYH146_2_4 --Adm #2, why left facility - PROVIDER DID NOT

UNDRSTND PRB; YYH146_2_5 --Adm #2, why left facility - DISAGRD W PROVIDER ABT

SERVICE; YYH146_2_6 --Adm #2, why left facility - BAD EXPERIENCE WITH PROVIDER;

YYH146_2_7 --Adm #2, why left facility - FELT DISCRIMINATED AGAINST; YYH146_2_8 --Adm

#2, why left facility - PROVIDER NO LONGER AVAILABLE; YYH146_2_9 --Adm #2, why left

facility - REFUSED TO GO; YYH146_3_1 --Adm #3, why left facility - PLANNED TERMINATION

OF TREATMENT; YYH146_3_10 --Adm #3, why left facility - INS/MANAGED CARE CO LIMITED

TRT; YYH146_3_11 --Adm #3, why left facility - TOO EXPENSIVE; YYH146_3_12 --Adm #3, why

left facility - MOVED; YYH146_3_13 --Adm #3, why left facility - OTHER; YYH146_3_2 --Adm #3,

why left facility - DIDN'T THINK IT WAS HELPING; YYH146_3_3 --Adm #3, why left facility -

IMPROVED SO STOPPED GOING; YYH146_3_4 --Adm #3, why left facility - PROVIDER DID NOT

UNDRSTND PRB; YYH146_3_5 --Adm #3, why left facility - DISAGRD W PROVIDER ABT

SERVICE; YYH146_3_6 --Adm #3, why left facility - BAD EXPERIENCE WITH PROVIDER;

YYH146_3_7 --Adm #3, why left facility - FELT DISCRIMINATED AGAINST; YYH146_3_8 --Adm

#3, why left facility - PROVIDER NO LONGER AVAILABLE; YYH146_3_9 --Adm #3, why left

facility - REFUSED TO GO; YYH146_4_1 --Adm #4, why left facility - PLANNED TERMINATION

OF TREATMENT; YYH146_4_10 --Adm #4, why left facility - INS/MANAGED CARE CO LIMITED

TRT; YYH146_4_11 --Adm #4, why left facility - TOO EXPENSIVE; YYH146_4_12 --Adm #4, why

left facility - MOVED; YYH146_4_13 --Adm #4, why left facility - OTHER; YYH146_4_2 --Adm #4,

why left facility - DIDN'T THINK IT WAS HELPING; YYH146_4_3 --Adm #4, why left facility -

IMPROVED SO STOPPED GOING; YYH146_4_4 --Adm #4, why left facility - PROVIDER DID NOT

UNDRSTND PRB; YYH146_4_5 --Adm #4, why left facility - DISAGRD W PROVIDER ABT

SERVICE; YYH146_4_6 --Adm #4, why left facility - BAD EXPERIENCE WITH PROVIDER;

YYH146_4_7 --Adm #4, why left facility - FELT DISCRIMINATED AGAINST; YYH146_4_8 --Adm

#4, why left facility - PROVIDER NO LONGER AVAILABLE; YYH146_4_9 --Adm #4, why left

facility - REFUSED TO GO; YYH146_5_1 --Adm #5, why left facility - PLANNED TERMINATION

OF TREATMENT; YYH146_5_10 --Adm #5, why left facility - INS/MANAGED CARE CO LIMITED

TRT; YYH146_5_11 --Adm #5, why left facility - TOO EXPENSIVE; YYH146_5_12 --Adm #5, why

left facility - MOVED; YYH146_5_13 --Adm #5, why left facility - OTHER; YYH146_5_2 --Adm #5,

why left facility - DIDN'T THINK IT WAS HELPING; YYH146_5_3 --Adm #5, why left facility -

IMPROVED SO STOPPED GOING; YYH146_5_4 --Adm #5, why left facility - PROVIDER DID NOT

UNDRSTND PRB; YYH146_5_5 --Adm #5, why left facility - DISAGRD W PROVIDER ABT

SERVICE; YYH146_5_6 --Adm #5, why left facility - BAD EXPERIENCE WITH PROVIDER;

YYH146_5_7 --Adm #5, why left facility - FELT DISCRIMINATED AGAINST; YYH146_5_8 --Adm

#5, why left facility - PROVIDER NO LONGER AVAILABLE; YYH146_5_9 --Adm #5, why left

facility - REFUSED TO GO; YYH146_1_14--Adm #1, why left facility - DK; YYH146_1_15--Adm #1,

why left facility - RF; YYH146_2_14--Adm #2, why left facility - DK; YYH146_2_15--Adm #2, why

left facility - RF; YYH146_3_14--Adm #3, why left facility - DK; YYH146_3_15--Adm #3, why left

facility - RF; YYH146_4_14--Adm #4, why left facility - DK; YYH146_4_15--Adm #4, why left facility

- RF; YYH146_5_14--Adm #5, why left facility - DK; YYH146_5_15--Adm #5, why left facility - RF

---------------------------------------------------------------------------------

Y_YH153 Questions Y_YH153m - Y_YH161 are in Y_YH153m

Question Type: ARRAY[1..7] OF BY_YH153

---------------------------------------------------------------------------------

Logic before:

PROGRAMMER: IF WAVE = 1 REPEAT Y_YH153m TO Y_YH161 FOR EACH 'YES' RESPONSE

TO Y_YH50ga, Y_YH50ha, Y_YH50ia, Y_YH50ja, Y_YH50ka, Y_YH50la, IF WAVE = 2 REPEAT

Y_YH153m TO Y_YH161 FOR EACH 'YES' RESPONSE TO Y_YH50g1a, Y_YH50h1a,

Y_YH50i1a, Y_YH50j1a, Y_YH50k1a, Y_YH50la. Use the corresponding fill for each outpatient

venue as follows: IF Y_YH50ga = 1, FILL "day treatment"; IF Y_YH50ha = 1, FILL "an outpatient

drug or alcohol clinic"; IF Y_YH50ia = 1, FILL "a mental health or community health center"; IF

Y_YH50ja = 1, FILL "a psychiatrist, psychologist, social worker, or psychiatric nurse"; IF

Y_YH50ka = 1, FILL "in-home counseling or in-home crisis services"; IF Y_YH50la = 1, FILL "a

family doctor or any other medical doctor"; IF Y_YH50na = 1, FILL "a school guidance counselor,

school psychologist, or school social worker"; IF Y_YH50g1a = 1, FILL "day treatment"; IF

Y_YH50h1a = 1, FILL "an outpatient drug or alcohol clinic"; IF Y_YH50i1a = 1, FILL "a mental

health or community health center"; IF Y_YH50j1a = 1, FILL "a psychiatrist, psychologist, social

worker, or psychiatric nurse"; IF Y_YH50k1a = 1, FILL "in-home counseling or in-home crisis

services"; IF Y_YH50l1a = 1, FILL "a family doctor or any other medical doctor"; IF Y_YH50n1a =

1, FILL "a school guidance counselor, school psychologist, or school social worker"

---------------------------------------------------------------------------------

Y_YH154 [ YYH154 ] Labels are in Logic After

Have you ^Fills.YH153m1 @Bin the last 12 months@B^Fills.YH153m2?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Question Fill: ^FillYH153m1

daytx been to day treatment

outpatnt been to an outpatient drug or alcohol clinic

mental been to a mental health or community health center

psych gotten private professional help from a psychiatrist, psychologist, social

worker, or psychiatric nurse

inhome received in-home counseling or in-home crisis services

familydr seen a family doctor or any other medical doctor

school seen a school guidance counselor, school psychologist, or school social

worker

Question Fill: ^FillYH153m2

for_ ·for emotional, behavioral, learning, attention, or substance abuse

not_for ·

Logic after:

IF Y_YH154 = 2 GOTO Y_YH156m; YYH154_1 --Have you had this service in the last 12 months?;

YYH154_2 --Have you had this service in the last 12 months?; YYH154_3 --Have you had this

service in the last 12 months?; YYH154_4 --Have you had this service in the last 12 months?;

YYH154_5 --Have you had this service in the last 12 months?; YYH154_6 --Have you had this

service in the last 12 months?; YYH154_7 --Have you had this service in the last 12 months?

---------------------------------------------------------------------------------

Y_YH154a [ YYH154a ] Labels are in Logic After

In the last 12 months, how many times have you @B^Fills.YH153m1@B^Fills.YH153m2?


NUMBER:

Question Type: 1..365

Question Fill: ^FillYH153m1

daytx been to day treatment

outpatnt been to an outpatient drug or alcohol clinic

mental been to a mental health or community health center

psych gotten private professional help from a psychiatrist, psychologist, social

worker, or psychiatric nurse

inhome received in-home counseling or in-home crisis services

familydr seen a family doctor or any other medical doctor

school seen a school guidance counselor, school psychologist, or school social

worker

Question Fill: ^FillYH153m2

for_ ·for emotional, behavioral, learning, attention, or substance abuse

not_for ·

Logic after:

YYH154a_1 --How many times had this service in the last 12 months?; YYH154a_2 --How many

times had this service in the last 12 months?; YYH154a_3 --How many times had this service in

the last 12 months?; YYH154a_4 --How many times had this service in the last 12 months?;

YYH154a_5 --How many times had this service in the last 12 months?; YYH154a_6 --How many

times had this service in the last 12 months?; YYH154a_7 --How many times had this service in


Y_YH154b


DO NOT ADMINISTER Y_YH154b FOR THE FOLLOWING:

FAMILY DOCTOR (YYH50la),

A SPECIAL CLASSROOM (YYH50oa),

SPECIAL HELP/TUTORING (YYH50pa),

SERVICES IN A SPECIAL SCHOOL (YYH50qa), OR

IN-PERSON OR ONLINE SUPPORT GROUP (YYH50ra).


Now I am going to read a list of the types of treatment, services, and counseling program that might be provided in @b^fills.Y_YH_Venue@b. When you received services from the @b^fills.Y_YH_Venue@b, did you

CODE ALL THAT APPLY

1=Receive therapy or counseling

2=Have case management or contact person who coordinated his/her services

3=Receive medications DO NOT INCLUDE CATEGORY FOR SCHOOL-BASED PROVIDERS

4=Receive evaluations or testing



---------------------------------------------------------------------------------

Logic before:

Are you still {FILL AS DESCRIBED ABOVE AS WELL AS LEAD-IN}: going to day treatment;

going to an outpatient drug or alcohol clinic; going to a mental health or community health center;

getting private professional help from a psychiatrist, psychologist, social worker, or psychiatric

nurse; receiving in-home counseling or in-home crisis services; seeing a family doctor or any other

medical doctor; seen a school guidance counselor, school psychologist, or school social worker }

for {if Y_YH50ga/g1a, Y_YH50ha/h1a, Y_YH50ia/i1a, Y_YH50ja/j1a, Y_YH50ka/k1a,

Y_YH50la/l1a, FILL: emotional, behavioral, learning, attention, or substance abuse problems}?

Y_YH155 [ YYH155 ] Labels are in Logic After


DO NOT ADMINISTER Y_YH155 FOR THE FOLLOWING:

A SPECIAL CLASSROOM (YYH50oa),

SPECIAL HELP/TUTORING (YYH50pa),

SERVICES IN A SPECIAL SCHOOL (YYH50qa), OR

IN-PERSON OR ONLINE SUPPORT GROUP (YYH50ra).



Are you still ^Fills.YH155^Fills.YH153m2?

Question Type: TYesNoC

Yes 1 YES {GO TO Y_YH158}

No 2 NO

Question Fill: ^FillYH155

daytx going to day treatment

outpatnt going to an outpatient drug or alcohol clinic

mental going to a mental health or community health center

psych getting private professional help from a psychiatrist, psychologist, social

worker, or psychiatric nurse

inhome receiving in-home counseling or in-home crisis services

school seeing a school guidance counselor, school psychologist, or school

social worker

Logic after:

IF Y_YH155 = 1 GOTO Y_YH158; YYH155_1 --Are you still receiving this service?; YYH155_2 --

Are you still receiving this service?; YYH155_3 --Are you still receiving this service?; YYH155_4 --

Are you still receiving this service?; YYH155_5 --Are you still receiving this service?; YYH155_6 --

Are you still receiving this service?; YYH155_7 --Are you still receiving this service?

---------------------------------------------------------------------------------

Y_YH157 [ YYH157 ] Labels are in Logic After

DO NOT ADMINISTER Y_YH157 FOR THE FOLLOWING:

A SPECIAL CLASSROOM (YYH50oa),

SPECIAL HELP/TUTORING (YYHS50pa),

SERVICES IN A SPECIAL SCHOOL (YYH50qa), OR

IN-PERSON OR ONLINE SUPPORT GROUP (YYH50ra).



What were the reasons you stopped treatment?


CODE ALL THAT APPLY.

Question Type: TYH157S

planned 1 PLANNED TERMINATION OF TREATMENT

wasnthelping 2 DIDN'T THINK IT WAS HELPING

improved 3 IMPROVED SO STOPPED GOING

didntunderstand 4 FELT "PROVIDER" DID NOT UNDERSTAND WHAT THE PROBLEM

WAS

disagreed 5 DISAGREED WITH "PROVIDER" ABOUT WHAT SHOULD BE DONE

badexperience 6 HAD A BAD EXPERIENCE WITH THIS "PROVIDER"

discriminated 7 FELT DISCRIMINATED AGAINST

prvdrmoved 8 "PROVIDER" WAS NO LONGER AVAILABLE (MOVED OR LEFT

SETTING)

refused 9 REFUSED TO GO

inslimited 10 INSURANCE/MANAGED CARE COMPANY LIMITED TREATMENT

cost 11 TOO EXPENSIVE

moved 12 CHILD MOVED

other 13 OTHER

Logic after:

YYH157_1_1 --Trt #1, Why stopped trt - PLANNED TERMINATION OF TREATMENT;

YYH157_1_10 --Trt #1, Why stopped trt - INS/MANAGED CARE CO LIMITED TRTMNT;

YYH157_1_11 --Trt #1, Why stopped trt - TOO EXPENSIVE; YYH157_1_12 --Trt #1, Why stopped

trt - CHILD MOVED; YYH157_1_13 --Trt #1, Why stopped trt - OTHER; YYH157_1_2 --Trt #1, Why

stopped trt - DIDN'T THINK IT WAS HELPING; YYH157_1_3 --Trt #1, Why stopped trt -

IMPROVED SO STOPPED GOING; YYH157_1_4 --Trt #1, Why stopped trt - PROVIDER DID NOT

UNDRSTND PROBLM; YYH157_1_5 --Trt #1, Why stopped trt - DISAGRD W PROVIDER ABOUT

SERVICE; YYH157_1_6 --Trt #1, Why stopped trt - BAD EXPERIENCE WITH PROVIDER;

YYH157_1_7 --Trt #1, Why stopped trt - FELT DISCRIMINATED AGAINST; YYH157_1_8 --Trt #1,

Why stopped trt - PROVIDER NO LONGER AVAILABLE; YYH157_1_9 --Trt #1, Why stopped trt -

REFUSED TO GO; YYH157_2_1 --Trt #2, Why stopped trt - PLANNED TERMINATION OF

TREATMENT; YYH157_2_10 --Trt #2, Why stopped trt - INS/MANAGED CARE CO LIMITED

TRTMNT; YYH157_2_11 --Trt #2, Why stopped trt - TOO EXPENSIVE; YYH157_2_12 --Trt #2,

Why stopped trt - CHILD MOVED; YYH157_2_13 --Trt #2, Why stopped trt - OTHER; YYH157_2_2

--Trt #2, Why stopped trt - DIDN'T THINK IT WAS HELPING; YYH157_2_3 --Trt #2, Why stopped

trt - IMPROVED SO STOPPED GOING; YYH157_2_4 --Trt #2, Why stopped trt - PROVIDER DID

NOT UNDRSTND PROBLM; YYH157_2_5 --Trt #2, Why stopped trt - DISAGRD W PROVIDER

ABOUT SERVICE; YYH157_2_6 --Trt #2, Why stopped trt - BAD EXPERIENCE WITH PROVIDER;

YYH157_2_7 --Trt #2, Why stopped trt - FELT DISCRIMINATED AGAINST; YYH157_2_8 --Trt #2,

Why stopped trt - PROVIDER NO LONGER AVAILABLE; YYH157_2_9 --Trt #2, Why stopped trt -

REFUSED TO GO; YYH157_3_1 --Trt #3, Why stopped trt - PLANNED TERMINATION OF

TREATMENT; YYH157_3_10 --Trt #3, Why stopped trt - INS/MANAGED CARE CO LIMITED

TRTMNT; YYH157_3_11 --Trt #3, Why stopped trt - TOO EXPENSIVE; YYH157_3_12 --Trt #3,

Why stopped trt - CHILD MOVED; YYH157_3_13 --Trt #3, Why stopped trt - OTHER; YYH157_3_2

--Trt #3, Why stopped trt - DIDN'T THINK IT WAS HELPING; YYH157_3_3 --Trt #3, Why stopped

trt - IMPROVED SO STOPPED GOING; YYH157_3_4 --Trt #3, Why stopped trt - PROVIDER DID

NOT UNDRSTND PROBLM; YYH157_3_5 --Trt #3, Why stopped trt - DISAGRD W PROVIDER

ABOUT SERVICE; YYH157_3_6 --Trt #3, Why stopped trt - BAD EXPERIENCE WITH PROVIDER;

YYH157_3_7 --Trt #3, Why stopped trt - FELT DISCRIMINATED AGAINST; YYH157_3_8 --Trt #3,

Why stopped trt - PROVIDER NO LONGER AVAILABLE; YYH157_3_9 --Trt #3, Why stopped trt -

REFUSED TO GO; YYH157_4_1 --Trt #4, Why stopped trt - PLANNED TERMINATION OF

TREATMENT; YYH157_4_10 --Trt #4, Why stopped trt - INS/MANAGED CARE CO LIMITED

TRTMNT; YYH157_4_11 --Trt #4, Why stopped trt - TOO EXPENSIVE; YYH157_4_12 --Trt #4,

Why stopped trt - CHILD MOVED; YYH157_4_13 --Trt #4, Why stopped trt - OTHER; YYH157_4_2

--Trt #4, Why stopped trt - DIDN'T THINK IT WAS HELPING; YYH157_4_3 --Trt #4, Why stopped

trt - IMPROVED SO STOPPED GOING; YYH157_4_4 --Trt #4, Why stopped trt - PROVIDER DID

NOT UNDRSTND PROBLM; YYH157_4_5 --Trt #4, Why stopped trt - DISAGRD W PROVIDER

ABOUT SERVICE; YYH157_4_6 --Trt #4, Why stopped trt - BAD EXPERIENCE WITH PROVIDER;

YYH157_4_7 --Trt #4, Why stopped trt - FELT DISCRIMINATED AGAINST; YYH157_4_8 --Trt #4,

Why stopped trt - PROVIDER NO LONGER AVAILABLE; YYH157_4_9 --Trt #4, Why stopped trt -

REFUSED TO GO; YYH157_5_1 --Trt #5, Why stopped trt - PLANNED TERMINATION OF

TREATMENT; YYH157_5_10 --Trt #5, Why stopped trt - INS/MANAGED CARE CO LIMITED

TRTMNT; YYH157_5_11 --Trt #5, Why stopped trt - TOO EXPENSIVE; YYH157_5_12 --Trt #5,

Why stopped trt - CHILD MOVED; YYH157_5_13 --Trt #5, Why stopped trt - OTHER; YYH157_5_2

--Trt #5, Why stopped trt - DIDN'T THINK IT WAS HELPING; YYH157_5_3 --Trt #5, Why stopped

trt - IMPROVED SO STOPPED GOING; YYH157_5_4 --Trt #5, Why stopped trt - PROVIDER DID

NOT UNDRSTND PROBLM; YYH157_5_5 --Trt #5, Why stopped trt - DISAGRD W PROVIDER

ABOUT SERVICE; YYH157_5_6 --Trt #5, Why stopped trt - BAD EXPERIENCE WITH PROVIDER;

YYH157_5_7 --Trt #5, Why stopped trt - FELT DISCRIMINATED AGAINST; YYH157_5_8 --Trt #5,

Why stopped trt - PROVIDER NO LONGER AVAILABLE; YYH157_5_9 --Trt #5, Why stopped trt -

REFUSED TO GO; YYH157_6_1 --Trt #6, Why stopped trt - PLANNED TERMINATION OF

TREATMENT; YYH157_6_10 --Trt #6, Why stopped trt - INS/MANAGED CARE CO LIMITED

TRTMNT; YYH157_6_11 --Trt #6, Why stopped trt - TOO EXPENSIVE; YYH157_6_12 --Trt #6,

Why stopped trt - CHILD MOVED; YYH157_6_13 --Trt #6, Why stopped trt - OTHER; YYH157_6_2

--Trt #6, Why stopped trt - DIDN'T THINK IT WAS HELPING; YYH157_6_3 --Trt #6, Why stopped

trt - IMPROVED SO STOPPED GOING; YYH157_6_4 --Trt #6, Why stopped trt - PROVIDER DID

NOT UNDRSTND PROBLM; YYH157_6_5 --Trt #6, Why stopped trt - DISAGRD W PROVIDER

ABOUT SERVICE; YYH157_6_6 --Trt #6, Why stopped trt - BAD EXPERIENCE WITH PROVIDER;

YYH157_6_7 --Trt #6, Why stopped trt - FELT DISCRIMINATED AGAINST; YYH157_6_8 --Trt #6,

Why stopped trt - PROVIDER NO LONGER AVAILABLE; YYH157_6_9 --Trt #6, Why stopped trt -

REFUSED TO GO; YYH157_7_1 --Trt #7, Why stopped trt - PLANNED TERMINATION OF

TREATMENT; YYH157_7_10 --Trt #7, Why stopped trt - INS/MANAGED CARE CO LIMITED

TRTMNT; YYH157_7_11 --Trt #7, Why stopped trt - TOO EXPENSIVE; YYH157_7_12 --Trt #7,

Why stopped trt - CHILD MOVED; YYH157_7_13 --Trt #7, Why stopped trt - OTHER; YYH157_7_2

--Trt #7, Why stopped trt - DIDN'T THINK IT WAS HELPING; YYH157_7_3 --Trt #7, Why stopped

trt - IMPROVED SO STOPPED GOING; YYH157_7_4 --Trt #7, Why stopped trt - PROVIDER DID

NOT UNDRSTND PROBLM; YYH157_7_5 --Trt #7, Why stopped trt - DISAGRD W PROVIDER

ABOUT SERVICE; YYH157_7_6 --Trt #7, Why stopped trt - BAD EXPERIENCE WITH PROVIDER;

YYH157_7_7 --Trt #7, Why stopped trt - FELT DISCRIMINATED AGAINST; YYH157_7_8 --Trt #7,

Why stopped trt - PROVIDER NO LONGER AVAILABLE; YYH157_7_9 --Trt #7, Why stopped trt -

REFUSED TO GO; YYH157_1_14--Trt #1, Why stopped trt - DK; YYH157_1_15--Trt #1, Why

stopped trt - RF; YYH157_2_14--Trt #2, Why stopped trt - DK; YYH157_2_15--Trt #2, Why stopped

trt - RF; YYH157_3_14--Trt #3, Why stopped trt - DK; YYH157_3_15--Trt #3, Why stopped trt -

RF; YYH157_4_14--Trt #4, Why stopped trt - DK; YYH157_4_15--Trt #4, Why stopped trt - RF;

YYH157_5_14--Trt #5, Why stopped trt - DK; YYH157_5_15--Trt #5, Why stopped trt - RF;

YYH157_6_14--Trt #6, Why stopped trt - DK; YYH157_6_15--Trt #6, Why stopped trt - RF;

YYH157_7_14--Trt #7, Why stopped trt - DK; YYH157_7_15--Trt #7, Why stopped trt - RF

---------------------------------------------------------------------------------

Logic before:

How many days per week [IF Y_YH155 = 1, FILL: do you {FILL AS DESCRIBED ABOVE AS

WELL AS LEAD-IN}:; go to day treatment; go to an outpatient drug or alcohol clinic; go to a mental

health or community health center; get private professional help from a psychiatrist, psychologist,

social worker, or psychiatric nurse; receive in-home counseling or in-home crisis services; see a

family doctor or any other medical doctor; seen a school guidance counselor, school psychologist,

or school social worker } for {if Y_YH50ga/g1a, Y_YH50ha/h1a, Y_YH50ia/i1a, Y_YH50ja/j1a,

Y_YH50ka/k1a, Y_YH50la/l1a, FILL: emotional, behavioral, learning, attention, or substance abuse

problems}?/IF Y_YH155=2, FILL: did you {FILL AS DESCRIBED ABOVE AS WELL AS LEAD-IN}:

go to day treatment; go to an outpatient drug or alcohol clinic; go to a mental health or community

health center; get private professional help from a psychiatrist, psychologist, social worker, or

psychiatric nurse; receive in-home counseling or in-home crisis services; see a family doctor or any

other medical doctor; seen a school guidance counselor, school psychologist, or school social

worker }] in the past 12 months for {if Y_YH50ga/g1a, Y_YH50ha/h1a, Y_YH50ia/i1a,

Y_YH50ja/j1a, Y_YH50ka/k1a, Y_YH50la/l1a, FILL: emotional, behavioral, learning, attention, or

substance abuse problems}?

Y_YH158 [ YYH158 ] Labels are in Logic After

How many days per week ^Fills.YH158^Fills.YH153m2?


NOTE: AS NEEDED, PROMPT R TO THINK OF AVERAGE NUMBER OF DAYS PER WEEK

DURING WEEKS WHEN SERVICES WERE RECEIVED.


DAYS:

Question Type: 0..7

Question Fill: ^FillYH158

currdaytx do you go to day treatment

curroutpatnt do you go to an outpatient drug or alcohol clinic

currmental do you go to a mental health or community health center

currpsych do you get private professional help from a psychiatrist, psychologist,

social worker, or psychiatric nurse

currinhome do you receive in-home counseling or in-home crisis services

currfamilydr do you see a family doctor or any other medical doctor

currschool do you see a school guidance counselor, school psychologist, or school

social worker

daytx did you go to day treatment

outpatnt did you go to an outpatient drug or alcohol clinic

mental did you go to a mental health or community health center

psych did you get private professional help from a psychiatrist, psychologist,

social worker, or psychiatric nurse

inhome did you receive in-home counseling or in-home crisis services

familydr did you see a family doctor or any other medical doctor

school did you see a school guidance counselor, school psychologist, or school

social worker

Logic after:

YYH158_1 --Days per week do/did you rcve this srvce in past 12 months?; YYH158_2 --Days per

week do/did you rcve this srvce in past 12 months?; YYH158_3 --Days per week do/did you rcve

this srvce in past 12 months?; YYH158_4 --Days per week do/did you rcve this srvce in past 12

months?; YYH158_5 --Days per week do/did you rcve this srvce in past 12 months?; YYH158_6 --

Days per week do/did you rcve this srvce in past 12 months?; YYH158_7 --Days per week do/did

you rcve this srvce in past 12 months?

---------------------------------------------------------------------------------

Logic before:

How many hours per day [IF Y_YH155 = 1, FILL: are/IF Y_YH155 = 2, FILL: were] you {FILL AS

DESCRIBED ABOVE AS WELL AS LEAD-IN}: going to day treatment; going to an outpatient drug

or alcohol clinic; going to a mental health or community health center; getting private professional

help from a psychiatrist, psychologist, social worker, or psychiatric nurse; receiving in-home

counseling or in-home crisis services; seeing a family doctor or any other medical doctor; seen a

school guidance counselor, school psychologist, or school social worker } for {if Y_YH50ga/g1a,

Y_YH50ha/h1a, Y_YH50ia/i1a, Y_YH50ja/j1a, Y_YH50ka/k1a, Y_YH50la/l1a, FILL: emotional,

behavioral, learning, attention, or substance abuse problems}?

Y_YH159 [ YYH159 ] Labels are in Logic After

How many hours per day ^Fills.YH159^Fills.YH153m2?


NOTE: ENTER AVERAGE LENGTH OF EACH SESSION IN NUMBER OF HOURS.


HOURS PER DAY:

Question Type: 0..24

Question Fill: ^FillYH159

daytxcurr are you going to day treatment

outpatntcurr are you going to an outpatient drug or alcohol clinic

mentalcurr are you going to a mental health or community health center

psychcurr are you getting private professional help from a psychiatrist, psychologist,

social worker, or psychiatric nurse

inhomecurr are you receiving in-home counseling or in-home crisis services

familydrcurr are you seeing a family doctor or any other medical doctor

schoolcurr are you seeing a school guidance counselor, school psychologist, or

school social worker

daytx were you going to day treatment

outpatnt were you going to an outpatient drug or alcohol clinic

mental were you going to a mental health or community health center

psych were you getting private professional help from a psychiatrist,

psychologist, social worker, or psychiatric nurse

inhome were you receiving in-home counseling or in-home crisis services

familydr were you seeing a family doctor or any other medical doctor

school were you seeing a school guidance counselor, school psychologist, or

school social worker

Logic after:

YYH159_1 --Hours per day are/were you receiving this service?; YYH159_2 --Hours per day

are/were you receiving this service?; YYH159_3 --Hours per day are/were you receiving this

service?; YYH159_4 --Hours per day are/were you receiving this service?; YYH159_5 --Hours per

day are/were you receiving this service?; YYH159_6 --Hours per day are/were you receiving this

service?; YYH159_7 --Hours per day are/were you receiving this service?

---------------------------------------------------------------------------------

Y_YH161 [ YYH161 ] Labels are in Logic After

USE CARD 10. Please look at Card 10. Please tell me why you ^Fills.YH161.


CODE ALL THAT APPLY.

Question Type: TYH161S

Emotional 1 EMOTIONAL OR BEHAVIORAL HEALTH PROBLEMS

AlcoholDrug 2 ALCOHOL OR DRUG ABUSE PROBLEMS


Question Fill: ^FillYH161

current are receiving this service

past received this service the most recent time

---------------------------------------------------------------------------------

Y_YH163 [ YYH163 ] Been in treatmnt for any of these problems in last 12 mnths

Have you been there for any of these problems in the last 12 months?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YH163 = 2 GOTO Y_YH166

---------------------------------------------------------------------------------

Y_YH164 [ YYH164 ] Times in hosp emerg room for emot, behav, learn, subst abuse

In the last 12 months, how many times have you been to a hospital emergency room for

emotional, behavioral, learning, attention, or substance abuse problems?


NOTE: ONLY CODE ER VISITS IF THEY WERE RELATED TO MENTAL HEALTH/SUBSTANCE

ABUSE (E.G., BREAKING AN ARM DURING A TANTRUM, HARM DURING A SUICIDE

ATTEMPT, CAR ACCIDENT WHILE CHILD WAS INTOXICATED, BROKEN NOSE DURING

SERIOUS PHYSICAL FIGHT, ETC.). ALSO INCLUDE VISITS TO ER AS PART OF ADMISSIONS

PROCESS TO INPATIENT FACILITY.


TIMES:

Question Type: 0..300

---------------------------------------------------------------------------------

Y_YH165 [ YYH165 ] Labels are in Logic After

USE CARD 10. Please look at Card 10 and tell me why you went to the emergency room the

@Blast time@B.


CODE ALL THAT APPLY.

Question Type: TYH165S

Emotional 1 EMOTIONAL OR BEHAVIORAL HEALTH PROBLEMS

AlcoholDrug 2 ALCOHOL OR DRUG ABUSE PROBLEMS


---------------------------------------------------------------------------------

Logic before:

IF NO RESPONSE OF 'YES' IN Y_YH50g1a/ga, Y_YH50h1a/ha, Y_YH50i1a/ia, Y_YH50j1a/ja,

Y_YH50k1a/ka, Y_YH50l1a/la, Y_YH50m1a/ma, CONTINUE. ELSE SKIP TO Y_YH168a

Y_YH166 [ YYH166 ] Referred to any outpatient prof. treatment in last 12 months

In the last 12 months have you been @Breferred to@B any outpatient professional treatment for

emotional, behavioral, learning, attention, or substance abuse problems?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF = 2, SKIP TO 168a

---------------------------------------------------------------------------------

Logic before:

IF WAVE = 2, GO TO Y_YH168a

Y_YH167 [ YYH167 ] Labels are in Logic After

Why are you not receiving this professional treatment?


CODE ALL THAT APPLY.

Question Type: TYH33S

notavail 1 SERVICE NOT AVAILABLE IN THE AREA

waitlist 2 WAIT-LISTED FOR SERVICE

ineligible 3 INELIGIBLE FOR SERVICE

cost 4 SERVICES COULD NOT BE FINANCED

scheduling 5 SCHEDULING PROBLEM OR PROBLEM FINDING CHILD CARE

transportation 6 TRANSPORTATION PROBLEM

other 7 SOME OTHER REASON

Logic after:

YYH167_1 --Why not receiving this prof trt - Not avlble in area; YYH167_2 --Why not receiving this

prof trt - Wait-listed for; YYH167_3 --Why not receiving this prof trt - Ineligible for; YYH167_4 --Why

not receiving this prof trt - Financing problem; YYH167_5 --Why not receiving this prof trt -

Schdling/chld care; YYH167_6 --Why not receiving this prof trt - Transportation prb; YYH167_7 --

Why not receiving this prof trt - Some other reason; YYH167_8--Why not receiving this prof trt - DK;

YYH167_9--Why not receiving this prof trt - RF

---------------------------------------------------------------------------------

Y_YH168a [ YYH168a ] Currently covered by some type of military health insurance?

The next questions are about health care plans.


Are you currently covered by some type of military health insurance, such as CHAMPUS,

CHAMP-VA, TRICARE, or VA care?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_YH169a [ YYH169a ] Covered by health plan obtained through employer or union?

^Fills.YH141a health insurance plan obtained through a current or past employer or union?

Please remember to include coverage you may have through another family member's plan.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Question Fill: ^FillYH141a

yesmil Other than military health insurance, are you covered by any other

nomil Are you covered by a

---------------------------------------------------------------------------------

Y_YH170a [ YYH170a ] At this time, are you covered by Medicaid?

Medicaid is a program for health care for persons in need. It is different from Medicare, which is a

health insurance program for persons 65 and older and some disabled persons under 65. The

Medicaid program in ^Fills.Y_YH_State is also called

^Fills.Y_YH_MediFill^Fill_or^Fills.Y_YH_CHIPFill.


At this time, are you covered by Medicaid?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Question Fill: ^FillYH142a

statehas The Medicaid program in ^Fills.Y_YH_State is also called

^Fills.Y_YH_MediFill or ^Fills.Y_YH_CHIPFill.

Logic after:

IF Y_YH170a = 2, DK OR REF, GO TO Y_YH171a; ELSE GO TO Y_YH172a

---------------------------------------------------------------------------------

Y_YH172a [ YYH172a ] Are you covered by the Indian Health Service?

Are you covered by the Indian Health Service?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_YH173a [ YYH173a ] Covered by any other type of health insurance

Are you covered by any other type of health insurance that I have not mentioned, such as

Medicare or insurance purchased directly from an insurance company?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF Y_YH168a = 2 AND Y_YH169a = 2 AND Y_YH170a = 2 AND Y_YH171a = 2 AND Y_YH172a =

2 AND Y_YH173a = 2 AND Y_YH174a = 2, CONTINUE. ELSE, GOTO Y_YH176a

Y_YH175a [ YYH175a ] What is the main reason you do not have health insurance?

Please look at Card 11. What is the main reason you do not have health insurance?

Question Type: TYH149a

lostjob 1 Person in family with health insurance lost job or changed employers

divorced 2 Got divorced or separated/death of spouse or parent

ineligible 3 Became ineligible because of age/left school

notoffered 4 Employer does not offer coverage/or not eligible for coverage

cost 5 Cost is too high

refused 6 Insurance company refused coverage

postpreg 7 Medicaid/Medical plan stopped after pregnancy

newjob 8 Lost Medicaid/Medical plan because of new job or increase in income

lostmedicaid 9 Lost Medicaid (other)

other 10 Other

Logic after:

GOTO Y_YHEND

---------------------------------------------------------------------------------

Y_YH176a [ YYH176a ] Same insurance for all of past 12 months

Did you have this same insurance for all of the past 12 months?


[IF MORE THAN ONE PLAN, ANSWER YES IF COVERAGE FOR ANY ONE PLAN WAS FOR

ALL 12 MONTHS.]

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_YH177 [ YYH177 ] Any time without health insurance in last 12 months

During the past 12 months, was there any time when you did not have any health insurance?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

GOTO Y_YHEND

---------------------------------------------------------------------------------

Y_YH_END [ YYH_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue



CD - CHILDREN’S DEPRESSION INVENTORY 2 (CDI-2)


Children’s Depression Inventory 2 (CDI-2), Kovacs (2011), MHS, Inc. Administered to children age 7 and older.




TR - CHILD MENTAL HEALTH: TRAUMA MODULE

---------------------------------------------------------------------------------

Y_TR_BGN [ YTR_BGN ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

---------------------------------------------------------------------------------

Logic before:

IF AGE < 8 GOTO Y_TREND; IF EMANCIPATED OR YOUNG ADULT (18+), GOT TO Y_TR11a

Y_TR1a [ YTR1a ] Trauma Symptom Chklist :bad dreams or nightmares

USE CARD 17. Now I am going to ask you how often different things happen to you. Pick your

answer from this card.

Tell me whether these things happen never, sometimes, lots of times, or almost all of the time.


Bad dreams or nightmares. Would you say this happens to you...

Question Type: Toften

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR2a [ YTR2a ] Trauma Symptom Chklist: scary ideas

USE CARD 17. Scary ideas or pictures just pop into my head. Would you say this happens to

Question Type: Toften

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR3a [ YTR3a ] Trauma Symptom Chklist: rmbrng thngs CH doesn't like

USE CARD 17. Remembering things that happened that I didn't like. (How often does this

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR4a [ YTR4a ] Trauma Symptom Chklist: going away in CH mind

USE CARD 17. Going away in my mind, trying not to think. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR5a [ YTR5a ] Trauma Symptom Chklist: rmbrng scary thngs

USE CARD 17. Remembering scary things. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR6a [ YTR6a ] Trauma Symptom Chklist: feeling scared of men

USE CARD 17. Feeling scared of men. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR7a [ YTR7a ] Trauma Symptom Chklist: feeling scared of women

USE CARD 17. Feeling scared of women. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR8a [ YTR8a ] Trauma Symptom Chklist: can't stop thnkng of something bad

USE CARD 17. Can't stop thinking about something bad that happened to me. (How often does

this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR9a [ YTR9a ] Trauma Symptom Chklist: rmbrng thngs I don't want to

USE CARD 17. Remembering things I don't want to remember. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR10a [ YTR10a ] Trauma Symptom Chklist: wshng bad thngs never happened

USE CARD 17. Wishing bad things had never happened. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

Logic after:

Y_TREND

---------------------------------------------------------------------------------

Logic before:

IF CHILD IS EMANCIPATED OR YOUNG ADULT (18+), CONTINUE. ELSE, GOTO Y_TREND

Y_TR11a [ YTR11a ] YA Trauma Symptom Chklist: bad dreams or nightmares

USE Card 12. Now I am going to ask you how often different things happen to you. Pick your

answer from this card. Tell me whether these things happen never, sometimes, lots of times, or

almost all of the time.


Nightmares or bad dreams. Would you say this happens to you…

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR12a [ YTR12a ] YA Trauma Symptom Chklist: flashbacks or sudden memories

USE Card 12. Flashbacks or sudden memories or images of upsetting things. Would you say this

happens to you…

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR13a [ YTR13a ] YA Trauma Symptom Chklist: feeling like outside body

USE Card 12. Feeling like you were outside of your body. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR14a [ YTR14a ] YA Trauma Symptom Chklist: sudden disturbing memories

USE Card 12. Sudden disturbing memories when you were not expecting them. (How often does

this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR15a [ YTR15a ] YA Trauma Symptom Chklist: mind going blank

USE Card 12. Your mind going blank. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR16a [ YTR16a ] YA Trauma Symptom Chklist: feel wtchng self frm far away

USE Card 12. Feeling like you were watching yourself from far away. (How often does this

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR17a [ YTR17a ] YA Trauma Symptom Chklist: not feeling like real self

USE Card 12. Not feeling like your real self. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR18a [ YTR18a ] YA Trauma Symptom Chklist: not being able to feel emotions

USE Card 12. Not being able to feel your emotions. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR19a [ YTR19a ] YA Trauma Symptom Chklist: absent-mindedness

USE Card 12. Absent-mindedness. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR20a [ YTR20a ] YA Trauma Symptom Chklist: sdnly rmbrng smthng upstng in pst

USE Card 12. Suddenly remembering something upsetting from your past. (How often does this

happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR21a [ YTR21a ] YA Trauma Symptom Chklist: sdnly rmnded of smthng bad

USE Card 12. Suddenly being reminded of something bad. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR22a [ YTR22a ] YA Trauma Symptom Chklist: violent dreams

USE Card 12. Violent dreams. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR23a [ YTR23a ] YA Trauma Symptom Chklist: seng/hrng smthng upstng erlyr lfe

USE Card 12. Just for a moment, seeing or hearing something upsetting that happened earlier in

your life. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR24a [ YTR24a ] YA Trauma Symptom Chklist: frghtng/upstng thghts pop nto mnd

USE Card 12. Frightening or upsetting thoughts popping into your mind. (How often does this

happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR25a [ YTR25a ] YA Trauma Symptom Chklist: flng like thngs not real

USE Card 12. Feeling like things weren't real. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR26a [ YTR26a ] YA Trauma Symptom Chklist: flng like in dream

USE Card 12. Feeling like you were in a dream. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR27a [ YTR27a ] YA Trauma Symptom Chklist: daydreaming

USE Card 12. Daydreaming. (How often does this happen?)

Question Type: TOftenC

never 1 never

sometimes 2 sometimes

lotsoftimes 3 lots of times, or

allthetime 4 almost all of the time

---------------------------------------------------------------------------------

Y_TR_END [ YTR_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

YA - CHILD YOUTH ACTIVITIES MODULE

---------------------------------------------------------------------------------

Logic before:

IF AGE < 11 GOTO Y_YAEND. IF CHILD IS YOUNG ADULT (18+) OR EMANCIPATED YOUTH,

GOTO Y_YAEND.

Y_YA1a [ YYA1a ] YSR Activities:Participate sports

Are there any sports that you like to participate in? (IF NECESSARY: For example: swimming,

baseball, skating, skate boarding, bike riding, fishing, etc.)

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YA1a = NO, DK, RE, GOTO Y_YA5a

---------------------------------------------------------------------------------

Y_YA3a [ YYA3a ] YSR Activities:Participate sports - time

Compared to others your age, about how much time do you spend taking part in these sports?

Would you say the time you spend is...

Question Type: TTime

lessavg 1 less than average

avg 2 average, or

moreavg 3 more than average


---------------------------------------------------------------------------------

Y_YA5a [ YYA5a ] YSR Activities:Hobbies/Activities/Games

Are there any hobbies, activities, and games, other than sports that you like to do? (IF

NECESSARY: For example: cards, books, piano, cars, crafts, etc.)

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YA5a = NO, DK, RE, GOTO Y_YA9a

---------------------------------------------------------------------------------

Y_YA7a [ YYA7a ] YSR Activities:Hobbies/Activities/Games - time

Compared to others your age, how much time do you spend doing these hobbies, activities and

games? Would you say the time you spend is...

Question Type: TTime

lessavg 1 less than average

avg 2 average, or

moreavg 3 more than average

---------------------------------------------------------------------------------

Y_YA9a [ YYA9a ] YSR Activities:Orgnztns/Clubs/Teams/Groups

Do you belong to any organizations, clubs, teams, or groups?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YA9a = NO, DK, RE, GOTO Y_YA12a

---------------------------------------------------------------------------------

Y_YA11a [ YYA11a ] YSR Activities:Orgnztns/Clubs/Teams/Groups - how active

Compared to others your age, how active are you in these groups? Would you say you are...

Question Type: TActive

lessactv 1 less active

avg 2 average, or

moreactv 3 more active



YB - CHILD YOUTH BEHAVIOR MODULE

---------------------------------------------------------------------------------

Y_YB_BGN [ YYB_BGN ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

---------------------------------------------------------------------------------

Logic before:

IF AGE < 11 GOTO Y_YBEND. IF CHILD IS YOUNG ADULT (18+) OR EMANCIPATED, GOTO

Y_YB113A.

Y_YB1a [ YYB1a ] CH acts too young for age

USE CARD 18. Now I am going to read you different sentences that sometimes describe kids.

Tell me how true each sentence has been for you in the past @B6 months@B. Pick an answer

from this card: not true, somewhat or sometimes true, or very true or often true. Remember to tell

me what you really think. Your answers will be kept private.


I act too young for my age. Would you say…

Question Type: TTrue

not_true 1 not true,

some_true 2 somewhat or sometimes true, or

very_true 3 very true or often true?

---------------------------------------------------------------------------------

Y_YB2a [ YYB2a ] CH has allergy

I have an allergy. Would you say...

Question Type: TTrue

not_true 1 not true,

some_true 2 somewhat or sometimes true, or

very_true 3 very true or often true?

---------------------------------------------------------------------------------

Y_YB2aa [ YYB2aa ] CH drink alcohol without parents approval

I drink alcohol without my parents' approval. Would you say...

Question Type: TTrue

not_true 1 not true,

some_true 2 somewhat or sometimes true, or

very_true 3 very true or often true?

---------------------------------------------------------------------------------

Y_YB3a [ YYB3a ] CH argues a lot

I argue a lot. (Would you say this is not true, somewhat or sometimes true, or very true or often

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB4a [ YYB4a ] CH has asthma

I have asthma. (Would you say this is not true, somewhat or sometimes true, or very true or often

true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB4aa [ YYB4aa ] CH failes to finish things started

I fail to finish things that I start. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB5a [ YYB5a ] CH acts like opposite sex

I act like the opposite sex. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB5aa [ YYB5aa ] Very little CH enjoys

There is very little that I enjoy. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB6a [ YYB6a ] CH likes animals

I like animals. (Would you say this is not true, somewhat or sometimes true, or very true or often

true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB7a [ YYB7a ] CH likes to brag

I brag. (Would you say this is not true, somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB8a [ YYB8a ] CH has trbl concentrating or paying attention

I have trouble concentrating or paying attention. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB9a [ YYB9a ] CH can't get mind off certain things

I can't get my mind off certain thoughts. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB10a [ YYB10a ] CH has trble sitting still

I have trouble sitting still. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB11a [ YYB11a ] CH is too dpndnt on adults

I'm too dependent on adults. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB12a [ YYB12a ] CH feels lonley

I feel lonely. (Would you say this is not true, somewhat or sometimes true, or very true or often

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB13a [ YYB13a ] CH feels confused or in a fog

I feel confused or in a fog. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB14a [ YYB14a ] CH crys a lot

I cry a lot. (Would you say this is not true, somewhat or sometimes true, or very true or often

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB15a [ YYB15a ] CH is pretty honest

I am pretty honest. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB16a [ YYB16a ] CH is mean to others

I am mean to others. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB17a [ YYB17a ] CH day dreams a lot

I daydream a lot. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB18a [ YYB18a ] CH deliberately trys to hurt/kill self

I deliberately try to hurt or kill myself. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

Logic after:

IF Y_YB18a = 1, GOTO Y_YB19a

---------------------------------------------------------------------------------

Y_YB18aa [ YYB18aa ] CH had thoughts to hurt/kill self in past 2 wks

Have you had these thoughts in the past 2 weeks?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_YB18ba [ YYB18ba ] CH has plan to carry out thoughts to hurt/kill self

Do you have a plan to carry out these thoughts?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_YB19a [ YYB19a ] CH trys to get a lot of attention

I try to get a lot of attention. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB20a [ YYB20a ] CH detroys own things

I destroy my own things. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB21a [ YYB21a ] CH detroys things belonging to others

I destroy things belonging to others. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB22a [ YYB22a ] CH disobeys parents

I disobey my parents. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB23a [ YYB23a ] CH disobeys at school

I disobey at school. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

FR NOTE: IF CHILD SAYS THEY DID NOT PHYSICALLY ATTEND SCHOOL, ASK THE CHILD TO RESPOND THINKING ABOUT THEIR ONLINE/VIRTUAL EXPERIENCE.

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB24a [ YYB24a ] CH doesn't eat as well as CH should

I don't eat as well as I should. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB25a [ YYB25a ] CH doesn't get along with other kids

I don't get along with other kids. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB26a [ YYB26a ] CH doesn't feel quilty aftr doing something CH shouldn't

I don't feel guilty after doing something I shouldn't. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB27a [ YYB27a ] CH is jealous of othrs

I am jealous of others. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB28a [ YYB28a ] CH help othrs if they need help

I am willing to help others when they need help. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB28aa [ YYB28aa ] CH breaks rules at home school or elsewhere

I break rules at home, school, or elsewhere. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB29a [ YYB29a ] CH afraid crtn animals, situations. places othr thn school

I am afraid of certain animals, situations, or places, other than school. (Would you say this is not

true, somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB30a [ YYB30a ] CH afraid of going to school

I am afraid of going to school. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB31a [ YYB31a ] CH afraid might thnk/do something bad

I am afraid I might think or do something bad. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB32a [ YYB32a ] CH feels has to be perfect

I feel that I have to be perfect. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB33a [ YYB33a ] CH feels no on loves CH

I feel that no one loves me. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB34a [ YYB34a ] CH feels othrs out to get CH

I feel that others are out to get me. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB35a [ YYB35a ] CH feels worthless/inferior

I feel worthless or inferior. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB36a [ YYB36a ] CH accidently gets hurt a lot

I accidentally get hurt a lot. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB37a [ YYB37a ] CH gets in many fights

I get in many fights. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB38a [ YYB38a ] CH gets teased a lot

I get teased a lot. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB39a [ YYB39a ] CH hangs with kids who get in trbl

I hang around with kids who get in trouble. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB40a [ YYB40a ] CH hears sounds/voices

I hear sounds or voices that other people think aren't there. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB41a [ YYB41a ] CH acts without stopping to think

I act without stopping to think. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB42a [ YYB42a ] CH rather be alone than w/ othrs

I would rather be alone than with others. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB43a [ YYB43a ] CH lies or cheats

I lie or cheat. (Would you say this is not true, somewhat or sometimes true, or very true or often

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB44a [ YYB44a ] CH bites fingernails

I bite my fingernails. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB45a [ YYB45a ] CH nervous or tense

I am nervous or tense. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB46a [ YYB46a ] Parts of CH body twitch or mk nrvous mvmnts

Parts of my body twitch or make nervous movements. (Would you say this is not true, somewhat

or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB47a [ YYB47a ] CH has nightmares

I have nightmares. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB48a [ YYB48a ] CH not liked by othr kids

I am not liked by other kids. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB49a [ YYB49a ] CH does crtn thngs better than most kids

I can do certain things better than most kids. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB50a [ YYB50a ] CH too fearful/anxious

I am too fearful or anxious. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB51a [ YYB51a ] CH feels dizzy

I feel dizzy. (Would you say this is not true, somewhat or sometimes true, or very true or often

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB52a [ YYB52a ] CH feels quilty

I feel too guilty. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB53a [ YYB53a ] CH eats too much

I eat too much. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB54a [ YYB54a ] CH feels over tired

I feel overtired. (Would you say this is not true, somewhat or sometimes true, or very true or often

true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB55a [ YYB55a ] CH is overweight

I am overweight. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB56aa [ YYB56aa ] CH has aches/pains w/out med cause

I have aches or pains (not stomach or headaches) without a known medical cause. (Would you

say this is not true, somewhat or sometimes true, or very true or often true.)


NOTE: "WITHOUT KNOWN MEDICAL CAUSE" MEANS FOR UNKNOWN OR UNDIAGNOSED

REASONS.

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB56ba [ YYB56ba ] CH has headaches w/out med cause

I have headaches without a known medical cause. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)


NOTE: "WITHOUT KNOWN MEDICAL CAUSE" MEANS FOR UNKNOWN OR UNDIAGNOSED

REASONS.

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB56ca [ YYB56ca ] CH has nausea/feels sick w/out med cause

I have nausea or feel sick without a known medical cause. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)


NOTE: "WITHOUT KNOWN MEDICAL CAUSE" MEANS FOR UNKNOWN OR UNDIAGNOSED

REASONS.

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB56da [ YYB56da ] CH has prblms w/ eyes w/out med cause not fxd by glasses

I have problems with my eyes that are not corrected by glasses and do not have a known medical

cause. (Would you say this is not true, somewhat or sometimes true, or very true or often true.)



NOTE: "WITHOUT KNOWN MEDICAL CAUSE" MEANS FOR UNKNOWN OR UNDIAGNOSED

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB56ea [ YYB56ea ] CH has rashes/skin prblms w/out med cause

I have rashes or other skin problems without a known medical cause. (Would you say this is not

true, somewhat or sometimes true, or very true or often true.)


NOTE: "WITHOUT KNOWN MEDICAL CAUSE" MEANS FOR UNKNOWN OR UNDIAGNOSED

REASONS.

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB56fa [ YYB56fa ] CH has stomach aches/craps w/out med cause

I have stomach aches or cramps without a known medical cause. (Would you say this is not

true, somewhat or sometimes true, or very true or often true.)


NOTE: "WITHOUT KNOWN MEDICAL CAUSE" MEANS FOR UNKNOWN OR UNDIAGNOSED

REASONS.

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB56ga [ YYB56ga ] CH vomits w/out med cause

I have vomiting, throwing up without a known medical cause. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)


NOTE: "WITHOUT KNOWN MEDICAL CAUSE" MEANS FOR UNKNOWN OR UNDIAGNOSED

REASONS.

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB56ha [ YYB56ha ] CH has othr phys prblms w/out med cause

I have other physical problems without a known medical cause. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)


NOTE: "WITHOUT KNOWN MEDICAL CAUSE" MEANS FOR UNKNOWN OR UNDIAGNOSED

REASONS.

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB57a [ YYB57a ] CH physically attacks people

I physically attack people. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB58a [ YYB58a ] CH picks skin or othr body parts

I pick my skin or other parts of my body. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB59a [ YYB59a ] CH can be pretty friendly

I can be pretty friendly. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB60a [ YYB60a ] CH trys new things

I like to try new things. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB61a [ YYB61a ] CH school work is poor

My school work is poor. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB62a [ YYB62a ] CH is poorly coordinated and clumsy

I am poorly coordinated or clumsy. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB63a [ YYB63a ] CH rather be w/ oldr kds than kds own age

I would rather be with older kids than with kids my own age. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB64a [ YYB64a ] CH rather w/ yngr kds thn kds own age

I would rather be with younger kids than with kids my own age. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB65a [ YYB65a ] CH refuses to talk

I refuse to talk. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB66a [ YYB66a ] CH repeats certain acts over and over

I repeat certain acts over and over. (Would you say this is not true, somewhat or sometimes true,

or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB67a [ YYB67a ] CH runs away from home

I run away from home. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB68a [ YYB68a ] CH screams a lot

I scream a lot. (Would you say this is not true, somewhat or sometimes true, or very true or often

true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB69a [ YYB69a ] CH is secretive

I am secretive or keep things to myself. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB70a [ YYB70a ] CH see thngs othrs thnk are not there

I see things that other people think aren't there. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB71a [ YYB71a ] CH is self-concious or esily embrassed

I am self-conscious or easily embarrassed. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB72a [ YYB72a ] CH sets fires

I set fires. (Would you say this is not true, somewhat or sometimes true, or very true or often

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB73a [ YYB73a ] CH works well w/ hands

I can work well with my hands. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB74a [ YYB74a ] CH shows off

I show off or clown. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB75a [ YYB75a ] CH is shy

I am shy. (Would you say this is not true, somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB76a [ YYB76a ] CH sleeps less than most kids

I sleep less than most kids. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB77a [ YYB77a ] CH sleeps more than most kids during day and/or night

I sleep more than most kids during the day and/or night. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB78a [ YYB78a ] CH has good imagination

I have a good imagination. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB78aa [ YYB78aa ] CH is inattentive or easily distracted

I am inattentive or easily distracted. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB79a [ YYB79a ] CH has speech prblm

I have a speech problem. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB80a [ YYB80a ] CH stands up for rights

I stand up for my rights. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB81a [ YYB81a ] CH steals at home

I steal at home. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB82a [ YYB82a ] CH steals from places othr than home

I steal from places other than home. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB83a [ YYB83a ] CH stores up things not needed

I store up things I don't need. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB84a [ YYB84a ] CH does things othrs think are strange

I do things other people think are strange. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB85a [ YYB85a ] CH has thoughts that othrs think are strange

I have thoughts that other people would think are strange. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB86a [ YYB86a ] CH is stubborn

I am stubborn. (Would you say this is not true, somewhat or sometimes true, or very true or often

true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB87a [ YYB87a ] CH moods/feelings change suddenly

My moods or feelings change suddenly. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

---------------------------------------------------------------------------------

Y_YB88a [ YYB88a ] CH enjoys being with othrs

I enjoy being with other people. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB89a [ YYB89a ] CH is suspicious

I am suspicious. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB90a [ YYB90a ] CH swears/uses dirty language

I swear or use dirty language. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB91a [ YYB91a ] CH thinks about killing self

I think about killing myself. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

Logic after:

IF Y_YB91a = 1, GOTO Y_YB92a)

---------------------------------------------------------------------------------

Y_YB91aa [ YYB91aa ] CH had thoughts of killing self in past 2 wks

Have you had these thoughts in the past 2 weeks?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_YB91ba [ YYB91ba ] CH plans to carry out thoughts of killing self

Do you have a plan to carry out these thoughts?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_YB92a [ YYB92a ] CH makes othrs laugh

I like to make others laugh. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB93a [ YYB93a ] CH talks too much

I talk too much. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB94a [ YYB94a ] CH teases othrs a lot

I tease others a lot. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB95a [ YYB95a ] CH has a hot temper

I have a hot temper. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB96a [ YYB96a ] CH thinks about sex too much

I think about sex too much. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB97a [ YYB97a ] CH threatens to hurt people

I threaten to hurt people. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB98a [ YYB98a ] CH likes to help othrs

I like to help others. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB99a [ YYB99a ] CH too concerned about being neat/clean

I am too concerned about being neat or clean. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB99aa [ YYB99aa ] CH smokes chew or sniff tobacco

I smoke, chew, or sniff tobacco. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB100a [ YYB100a ] CH has trbl sleeping

I have trouble sleeping. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB101a [ YYB101a ] CH cuts classes or skips school

I cut classes or skip school. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB102a [ YYB102a ] CH doesn't have much money

I don't have much energy. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB103a [ YYB103a ] CH is unhappy/sad/depressed

I am unhappy, sad, or depressed. (Would you say this is not true, somewhat or sometimes true,

or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB104a [ YYB104a ] CH is louder than othr kids

I am louder than other kids. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB105a [ YYB105a ] CH used alcohol/drugs for non-med purposes

I use alcohol or drugs for non-medical purposes. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB106a [ YYB106a ] CH tries to be fair to othrs

I try to be fair to others. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB107a [ YYB107a ] CH enjoys a good joke

I enjoy a good joke. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB108a [ YYB108a ] CH lkes to take life easy

I like to take life easy. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB109a [ YYB109a ] CH tris to help othrs when CH can

I try to help other people when I can. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB110a [ YYB110a ] CH wishes CH was opposite sex

I wish I were of the opposite sex. (Would you say this is not true, somewhat or sometimes true,

or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB111a [ YYB111a ] CH keeps from getting involved with othrs

I keep from getting involved with others. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB112a [ YYB112a ] CH worries a lot

I worry a lot. (Would you say this is not true, somewhat or sometimes true, or very true or often

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

Logic after:

GOTO Y_YBEND

---------------------------------------------------------------------------------

Logic before:

IF CHILD IS EMANCIPATED OR YOUNG ADULT (18+), CONTINUE. ELSE, GOTO Y_YBEND.

Y_YB113a [ YYB113a ] YA is too forgetfull

USE Card 13. Now I am going to read you different sentences that may sometimes describe you.

Tell me how true each sentence has been for you in the past @B6 months@B. Pick an answer

from this card: not true, somewhat or sometimes true, or very true or often true. Remember to tell

me what you really think. Your answers will be kept private.


I am too forgetful. Would you say…

Question Type: TTrue

not_true 1 not true,

some_true 2 somewhat or sometimes true, or

very_true 3 very true or often true?

---------------------------------------------------------------------------------

Y_YB114a [ YYB114a ] YA makes good use of opportunities

I make good use of my opportunities. Would you say...

Question Type: TTrue

not_true 1 not true,

some_true 2 somewhat or sometimes true, or

very_true 3 very true or often true?

---------------------------------------------------------------------------------

Y_YB115a [ YYB115a ] YA argues a lot

I argue a lot. Would you say...

Question Type: TTrue

not_true 1 not true,

some_true 2 somewhat or sometimes true, or

very_true 3 very true or often true?

---------------------------------------------------------------------------------

Y_YB116a [ YYB116a ] YA works up to ability

I work up to my ability. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB117a [ YYB117a ] YA blames others for own problems

I blame others for my problems. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB118a [ YYB118a ] YA uses drugs for non-med purposes

I use drugs (other than alcohol and nicotine) for nonmedical purposes. (Would you say this is not

true, somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB119a [ YYB119a ] YA brags

I brag. (Would you say this is not true, somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB120a [ YYB120a ] YA has trbl concentrating/paying attention

I have trouble concentrating or paying attention for long. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB121a [ YYB121a ] YA can't get mind off certain things

I can't get my mind off certain thoughts. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB122a [ YYB122a ] YA has trbl sitting still

I have trouble sitting still. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB123a [ YYB123a ] YA is too dependent on others

I am too dependent on others. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB124a [ YYB124a ] YA feels lonely

I feel lonely. (Would you say this is not true, somewhat or sometimes true, or very true or often

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB125a [ YYB125a ] YA feels confused

I feel confused or in a fog. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB126a [ YYB126a ] YA crys a lot

I cry a lot. (Would you say this is not true, somewhat or sometimes true, or very true or often

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB127a [ YYB127a ] YA is pretty honest

I am pretty honest. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB128a [ YYB128a ] YA is mean to othrs

I am mean to others. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB129a [ YYB129a ] YA daydreams a lot

I daydream a lot. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB130a [ YYB130a ] YA deliberately tries to hurt/kill self

I deliberately try to hurt or kill myself. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB131a [ YYB131a ] YA tries to get attention

I try to get a lot of attention. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB132a [ YYB132a ] YA damages or destroys own things

I damage or destroy my things. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB133a [ YYB133a ] YA damages or destroys othrs things

I damage or destroy things belonging to others. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB134a [ YYB134a ] YA worries about future

I worry about my future. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB135a [ YYB135a ] YA breaks rules at work and elsewhere

I break rules at work or elsewhere. (Would you say this is not true, somewhat or sometimes true,

or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB136a [ YYB136a ] YA doesn't eat as well as should

I don't eat as well as I should. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB137a [ YYB137a ] YA doesn't get along well with othrs

I don't get along well with other people. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB138a [ YYB138a ] YA doesn't feel guilty after doing something shouldn't

I don't feel guilty after doing something I shouldn't. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB139a [ YYB139a ] YA jealous of othrs

I am jealous of others. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB140a [ YYB140a ] YA gets along badly with family

I get along badly with my family. (Would you say this is not true, somewhat or sometimes true,

or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB141a [ YYB141a ] YA afraid of certain animals/situations/places

I am afraid of certain animals, situations, or places. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB142a [ YYB142a ] YA has poor relationships with opposite sex

My relations with the opposite sex are poor. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB143a [ YYB143a ] YA afraid might think/do something bad

I am afraid I might think or do something bad. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB144a [ YYB144a ] YA feels need to be perfect

I feel that I have to be perfect. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB145a [ YYB145a ] YA feels no one loves YA

I feel that no one loves me. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB146a [ YYB146a ] YA feels othrs are out to get YA

I feel that others are out to get me. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB147a [ YYB147a ] YA feels worthless/inferior

I feel worthless or inferior. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB148a [ YYB148a ] YA accidentally gets hurt a lot/accident prone

I accidentally get hurt a lot, accident prone. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB149a [ YYB149a ] YA gets in many fights

I get in many fights. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB150a [ YYB150a ] YA has poor relations with neighbors

My relations with neighbors are poor. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB151a [ YYB151a ] YA hangs around people who get into trbl

I hang around people who get in trouble. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB152a [ YYB152a ] YA hears sounds/voices others don't

I hear sounds or voices that other people think aren't there. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB153a [ YYB153a ] YA is impulsive

I am impulsive or act without thinking. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB154a [ YYB154a ] YA would rather be alone than w/t othrs

I would rather be alone than with others. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB155a [ YYB155a ] YA lies/cheats

I lie or cheat. (Would you say this is not true, somewhat or sometimes true, or very true or often

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB156a [ YYB156a ] YA feels overwhelmed by responsibilities

I feel overwhelmed by my responsibilities. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB157a [ YYB157a ] YA is nervous/tense

I am nervous or tense. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB158a [ YYB158a ] Parts of YA body twitch/makes nervous movements

Parts of my body twitch or make nervous movements. (Would you say this is not true, somewhat

or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB159a [ YYB159a ] YA lacks self-confidence

I lack self-confidence. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB160a [ YYB160a ] YA is not liked by othrs

I am not liked by others. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB161a [ YYB161a ] YA can do certain things better than othr people

I can do certain things better than other people. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB162a [ YYB162a ] YA feels fearful/anxious

I am too fearful or anxious. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB163a [ YYB163a ] YA feels dizzy/lightheaded

I feel dizzy or lightheaded. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB164a [ YYB164a ] YA feels guilty

I feel too guilty. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB165a [ YYB165a ] YA has trbl planning for future

I have trouble planning for the future. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB166a [ YYB166a ] YA feels tired w/out good reason

I feel tired without good reason. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB167a [ YYB167a ] YA moods swing between elation and depression

My moods swing between elation and depression. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB168a [ YYB168a ] YA has aches/pains w/out med cause

I have aches and pains without known medical cause. (Would you say this is not true, somewhat

or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB169a [ YYB169a ] YA has headachese w/out med cause

I have headaches without known medical cause. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB170a [ YYB170a ] YA has nausea/feels sick w/out med cause

I have nausea, feel sick without known medical cause. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB171a [ YYB171a ] YA prblms w/ eyes w/out med cause not fixed by glasses

I have problems with eyes (not if corrected by glasses) without known medical cause. (Would

you say this is not true, somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB172a [ YYB172a ] YA has rashes/skin prblms w/out med cause

I have rashes or other skin problems without known medical cause. (Would you say this is not

true, somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB173a [ YYB173a ] YA has stomachaches w/out med cause

I have stomachaches without known medical cause. (Would you say this is not true, somewhat

or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB174a [ YYB174a ] YA vomits w/out med cause

I have vomiting, throwing up without known medical cause. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB175a [ YYB175a ] YA has heart pounding/racing w/out med cause

I have heart pounding or racing without known medical cause. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB176a [ YYB176a ] YA has numbness/tingling in body parts w/out med cause

I have numbness or tingling in body parts without known medical cause. (Would you say this is

not true, somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB177a [ YYB177a ] YA physically attacks people

I physically attack people. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB178a [ YYB178a ] YA picks skin/othr body parts

I pick my skin or other parts of my body. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB179a [ YYB179a ] YA fails to finish things

I fail to finish things I should do. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB180a [ YYB180a ] Very little that YA enjoys

There is very little that I enjoy. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB181a [ YYB181a ] YA work performance is poor

My work performance is poor. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB182a [ YYB182a ] YA is poorly coordinated/clumsy

I am poorly coordinated or clumsy. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB183a [ YYB183a ] YA would rather be with older people than people own age

I would rather be with older people than with people my own age. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB184a [ YYB184a ] YA has trbl setting priorities

I have trouble setting priorities. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB185a [ YYB185a ] YA refuses to talk

I refuse to talk. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB186a [ YYB186a ] YA repeats certain acts over and over

I repeat certain acts over and over. (Would you say this is not true, somewhat or sometimes true,

or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB187a [ YYB187a ] YA has trbl making friends

I have trouble making or keeping friends. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB188a [ YYB188a ] YA screams/yells a lot

I scream or yell a lot. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB189a [ YYB189a ] YA is secretive/keeps things to self

I am secretive or keep things to myself. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB190a [ YYB190a ] YA sees things othrs think aren't there

I see things that other people think aren't there. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB191a [ YYB191a ] YA is self-concious/easily embarrassed

I am self-conscious or easily embarrassed. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB192a [ YYB192a ] YA worris about family

I worry about my family. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB193a [ YYB193a ] YA meets responsibilities to family

I meet my responsibilities to my family. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB194a [ YYB194a ] YA shows off

I show off or clown. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB195a [ YYB195a ] YA is too shy/timid

I am too shy or timid. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB196a [ YYB196a ] YA behavior is irresponsible

My behavior is irresponsible. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB197a [ YYB197a ] YA sleeps more than most othrs during day and/or night

I sleep more than most other people during day and/or night. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB198a [ YYB198a ] YA has trbl making decisions

I have trouble making decisions. (Would you say this is not true, somewhat or sometimes true,

or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB199a [ YYB199a ] YA has speech prblm

I have a speech problem. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB200a [ YYB200a ] YA stands up for rights

I stand up for my rights. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB201a [ YYB201a ] YA behavior is very changable

My behavior is very changeable. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB202a [ YYB202a ] YA steals

I steal. (Would you say this is not true, somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB203a [ YYB203a ] YA eaisly bored

I am easily bored. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB204a [ YYB204a ] YA does things that othrs think are strange

I do things that other people think are strange. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB205a [ YYB205a ] YA has thoughts othrs would think are stange

I have thoughts that other people would think are strange. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB206a [ YYB206a ] YA is stubborn/sullen/irritable

I am stubborn, sullen, or irritable. (Would you say this is not true, somewhat or sometimes true,

or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB207a [ YYB207a ] YA moods/feelings change suddenly

My moods or feelings change suddenly. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB208a [ YYB208a ] YA enjoys being w/ othr people

I enjoy being with people. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB209a [ YYB209a ] YA rushes into things w/out considering risks

I rush into things without considering the risks. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB210a [ YYB210a ] YA drinks too much alcohol/gets drunk

I drink too much alcohol or get drunk. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB211a [ YYB211a ] YA thinks about killing self

I think about killing myself. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB212a [ YYB212a ] YA does things that may cause trbl with law

I do things that may cause me trouble with the law. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB213a [ YYB213a ] YA talks too much

I talk too much. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB214a [ YYB214a ] YA tease othrs a lot

I tease others a lot. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB215a [ YYB215a ] YA has a hot temper

I have a hot temper. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB216a [ YYB216a ] YA thinks about sex too much

I think about sex too much. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB217a [ YYB217a ] YA threatens to hurt people

I threaten to hurt people. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB218a [ YYB218a ] YA likes to help others

I like to help others. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB219a [ YYB219a ] YA dislikes staying in one place for very long

I dislike staying in one place for very long. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB220a [ YYB220a ] YA has trbl sleeping

I have trouble sleeping. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB221a [ YYB221a ] YA stays away from job even when not sick/on vacation

I stay away from my job even when I'm not sick or not on vacation. (Would you say this is not

true, somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB222a [ YYB222a ] YA doesn't have much energy

I don't have much energy. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB223a [ YYB223a ] YA is unhappy/sad/depressed

I am unhappy, sad, or depressed. (Would you say this is not true, somewhat or sometimes true,

or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB224a [ YYB224a ] YA louder than othrs

I am louder than others. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB225a [ YYB225a ] Othrs think YA is disorganized

People think I am disorganized. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB226a [ YYB226a ] YA tries to be fair to othrs

I try to be fair to others. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB227a [ YYB227a ] YA feels can't succeed

I feel that I can't succeed. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB228a [ YYB228a ] YA tends to lose things

I tend to lose things. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB229a [ YYB229a ] YA likes to try new things

I like to try new things. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB230a [ YYB230a ] YA wishes was opposite sex

I wish I were of the opposite sex. (Would you say this is not true, somewhat or sometimes true,

or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB231a [ YYB231a ] YA keeps from getting involved with othrs

I keep from getting involved with others. (Would you say this is not true, somewhat or sometimes

true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB232a [ YYB232a ] YA worries a lot

I worry a lot. (Would you say this is not true, somewhat or sometimes true, or very true or often

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB233a [ YYB233a ] YA worries about relations with opposite sex

I worry about my relations with the opposite sex. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB234a [ YYB234a ] YA fails to pay debts/meet financial responsibilities

I fail to pay my debts or meet other financial responsibilities. (Would you say this is not true,

somewhat or sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB235a [ YYB235a ] YA feels restless/fidgety

I feel restless or fidgety. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB236a [ YYB236a ] YA gets upset easily

I get upset too easily. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB237a [ YYB237a ] YA has trbl managing money/credit cards

I have trouble managing money or credit cards. (Would you say this is not true, somewhat or

sometimes true, or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB238a [ YYB238a ] YA is too impatient

I am too impatient. (Would you say this is not true, somewhat or sometimes true, or very true or

often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB239a [ YYB239a ] YA not good at details

I am not good at details. (Would you say this is not true, somewhat or sometimes true, or very

true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB240a [ YYB240a ] YA drives too fast

I drive too fast. (Would you say this is not true, somewhat or sometimes true, or very true or often

true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB241a [ YYB241a ] YA tends to be late to appointments

I tend to be late for appointments. (Would you say this is not true, somewhat or sometimes true,

or very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB242a [ YYB242a ] YA has trbl keeping a job

I have trouble keeping a job. (Would you say this is not true, somewhat or sometimes true, or

very true or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB243a [ YYB243a ] YA is a happy person

I am a happy person. (Would you say this is not true, somewhat or sometimes true, or very true

or often true.)

Question Type: TTrueC

nottrue 1 NOT TRUE

sometrue 2 SOMEWHAT OR SOMETIMES TRUE

vtrue 3 VERY TRUE OR OFTEN TRUE?

---------------------------------------------------------------------------------

Y_YB_END [ YYB_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

ER - CHILD EMPLOYMENT/RESOURCES TO LIVE MODULE

---------------------------------------------------------------------------------

Logic before:

IF CHILD IS EMANCIPATED OR YOUNG ADULT (18+), CONTINUE, ELSE GOTO Y_EREND

Y_ER0a [ YER0a ] NO LABEL

Now I'd like to ask you about any work you may have done. I am going to distinguish between two

types of work. First we will talk about work you may have done for an employer; that is a job

where you had an on-going relationship with a particular employer, for example, working in a

supermarket or restaurant. Then we will talk about informal jobs; that is doing one or a few tasks

for several people and not having a "boss," for example, babysitting or mowing lawns.


First, let's talk about any work you have done for an employer.

Question Type: TCont

Continue 1 Continue

---------------------------------------------------------------------------------

Y_ER1a [ YER1a ] CH currently working full/pt job or jobs

Are you currently working at a full or part-time job or jobs?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_ER1a = 1 GOTO Y_ER3a

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Y_ER2a [ YER2a ] CH employed in last 12 months

Have you been employed in the past 12 months?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_ER2a = 2 GOTO Y_ER35a

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Y_ER3m [ YER3m ] CH when start job - month

In what month and year did you start this job?


ENTER MONTH

Question Type: TMonth

jan 1 January

feb 2 February

mar 3 March

apr 4 April

may 5 May

jun 6 June

jul 7 July

aug 8 August

sep 9 September

oct 10 October

nov 11 November

dec 12 December

---------------------------------------------------------------------------------

Y_ER3y [ YER3y ] CH when start job - year

(In what month and year did you start this job?)


ENTER YEAR

Question Type: 1990..2013

---------------------------------------------------------------------------------

Logic before:

IF Y_ER1a = 1, GOTO Y_ER5a

Y_ER4m [ YER4m ] CH when leave job - month

In what month and year did you leave this job?


ENTER MONTH

Question Type: TMonth

jan 1 January

feb 2 February

mar 3 March

apr 4 April

may 5 May

jun 6 June

jul 7 July

aug 8 August

sep 9 September

oct 10 October

nov 11 November

dec 12 December

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Y_ER4y [ YER4y ] CH when leave job - year

(In what month and year did you leave this job?)


ENTER YEAR

Question Type: 1990..2013

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Y_ER5a [ YER5a ] CH know the person who hired you

At the time you started this job, did you know the person who hired you?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_ER5a = 2 GOTO Y_ER7a

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Y_ER6a [ YER6a ] Relationship to person who hired CH

Which of the following best describes your relationship to the person who hired you for this job?

Question Type: TER6a

rel 1 Relative

friend 2 Friend of yours

famfriend 3 Friend of your family's

neighbor 4 Neighbor

acquaint 5 Acquaintance

other 6 OTHER

none 7 NONE

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Y_ER7a [ YER7a ] CH recommended job by other person

Was there someone who recommended you, other than the person who hired you?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_ER7a = 2 GOTO Y_ER9a

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Y_ER8a [ YER8a ] Relationship to person who recommended CH

What was that person's relationship to you?

Question Type: TER8a

casewrkr 1 CASEWORKER

ilc 2 INDEPENDENT LIVING COORDINATOR

mentor 3 MENTOR

teacher 4 TEACHER

clergy 5 CLERGYPERSON

parent 6 PARENT

fosparent 7 FOSTER PARENT

otherrel 8 OTHER RELATIVE

friend 9 FRIEND OF YOURS

famfriend 10 FRIEND OF YOUR FAMILY'S

neighbor 11 NEIGHBOR

acquaint 12 ACQUAINTANCE

other 13 OTHER

none 14 NONE

---------------------------------------------------------------------------------

Y_ER9a [ YER9a ] Category of CH current or recent job

USE CARD 14. Please look at Card 14 and tell me which of the categories best describes your

^Fills.ER9a job or occupation.

Question Type: TER9a

office 1 OFFICE WORKER

trade 2 TRADESPERSON

farmer 3 FARMER, FARM MANAGER

laborer 4 LABORER

manager 5 MANAGER

military 6 MILITARY

operator 7 OPERATOR

owner 8 OWNER

prof1 9 PROFESSIONAL 1

prof2 10 PROFESSIONAL 2

protective 11 PROTECTIVE SERVICE

sales 12 SALES

teacher 13 SCHOOL TEACHER

service 14 SERVICE WORKER

technical 15 TECHNICAL

other 16 OTHER

Question Fill: ^FillER9a

present current

past most recent

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Y_ER10a [ YER10a ] Hours/week CH usually worked at this job

How many hours per week ^Fills.ER10n at this job?

Question Type: 0..168

Question Fill: ^FillER10n

present do you @Busually@B work

past did you @Busually@B work

---------------------------------------------------------------------------------

Y_ER11a [ YER11a ] Days CH worked in typical week

In a usual week, on how many days ^Fills.ER11n?

Question Type: 0..7

Question Fill: ^FillER11n

present do you work

past did you work

---------------------------------------------------------------------------------

Y_ER12a [ YER12a ] Of days CH worked number of weekdays

How many of these days ^Fills.ER12n weekdays?

Question Type: 0..5

Question Fill: ^FillER12n

present are

past were

---------------------------------------------------------------------------------

Logic before:

IFY_ER12a = 0, GOTO Y_ER15a

Y_ER13a [ YER13a ] Hours CH worked per day on weekdays

How many hours per day ^Fills.ER13n on weekdays?

Question Type: 0..24

Question Fill: ^FillER13n

present do you usually work

past did you usually work

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Y_ER14a [ YER14a ] Time of day for CH weekday work

^Fills.ER14a the most common time of day for you to work on weekdays?

Question Type: TER14a

morning 1 In the morning (between 6 A.M. and 2 P.M.)

afternoon 2 In the afternoon (between 12 P.M. and 8 P.M.)

evening 3 Evening (between 5 P.M and 11 P.M.)

night 4 Night time (after 11 P.M. before 6 A.M.)

nosingle 5 No single time of day

other 6 Other

Question Fill: ^FillER14a

present What is

past What was

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Y_ER15a [ YER15a ] CH usually work on weekends

^Fills.ER15a on the weekend?

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillER15a

present Do you usually work

past Did you usually work

Logic after:

IF Y_ER15a = 2 GO TO Y_ER17a

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Y_ER16a [ YER16a ] Hours CH usually worked on both wknd days

How many total hours ^Fills.ER16n on the weekend? Please include both days in your estimate.

Question Type: 0..48

Question Fill: ^FillER16n

present do you usually work

past did you usually work

---------------------------------------------------------------------------------

Y_ER17a [ YER17a ] CH unit of payment

^Fills.ER17a by the hour, by the day, the week, or something else?

Question Type: TER17a

hourly 1 Per hour

daily 2 Per day

weekly 3 Per week

biweekly 4 Bi-weekly (every two weeks)

semimonthly 5 Semi-monthly (twice a month)

monthly 6 Per month

yearly 7 Per year

other 8 Other

Question Fill: ^FillER17a

present Are you paid

past Were you paid

Logic after:

IF Y_ER17a = 8, DK, or REF GO TO Y_ER21a

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Y_ER18a [ YER18a ] Amount CH earned per unit of payment

How much ^Fills.ER18n1 per ^Fills.ER18n2?


ENTER DOLLAR AMOUNT

Question Type: 0..200000

Question Fill: ^FillER18n1

present do you usually earn

past did you usually earn

Question Fill: ^FillER18n2

perhr hour

perday day

perwk week

per2wks two weeks

perhalfmo half-month

permo month

peryr year

---------------------------------------------------------------------------------

Y_ER19a [ YER19a ] CH usually receive OT tips bonus

^Fills.ER19a any overtime pay, tips, commissions, bonuses, or other types of pay?

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillER19a

present Do you usually receive

past Did you usually receive

Logic after:

IF Y_ER19a = 2 GOTO Y_ER21a

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Y_ER20a [ YER20a ] CH overtime tips bonus - amount

How much ^Fills.ER20an from overtime pay, tips, commissions, bonuses, or other types of pay?


ENTER DOLLAR AMOUNT

Question Type: 0..200000

Question Fill: ^FillER20an

present do you usually earn

past did you usually earn

---------------------------------------------------------------------------------

Y_ER20b [ YER20b ] CH overtime tips bonus - freq

(How much ^Fills.ER20an from overtime pay, tips, commissions, bonuses, or other types of pay?)



Question Type: TER20ba

perhr 1 Per hour

perday 2 Per day

perwk 3 Per week

other 4 Other

Question Fill: ^FillER20an

present do you usually earn

past did you usually earn

---------------------------------------------------------------------------------

Y_ER21a [ YER21a ] How do/did CH feel about job

Which of the following best describes how you ^Fills.ER21a about your job?

Question Type: TER21a

verymuch 1 Like it very much

fairlywell 2 Like it fairly well

itsokay 3 Think it is okay

dislikesome 4 Dislike it somewhat

dislikevery 5 Dislike it very much

Question Fill: ^FillER21a

present feel

past felt

---------------------------------------------------------------------------------

Y_ER22a [ YER22a ] CH trouble getting along w/ boss

Please look at Card 15. ^Fills.ER22a1, how often ^Fills.ER22a2 trouble:


Getting along with your supervisor?

Question Type: TEROften

never 0 Never

fewtimes 1 Just a few times

onceawk 2 About once a week

almstdaily 3 Almost everyday

everyday 4 Everyday

Question Fill: ^FillER22a1

present Since you started this job

past When you worked at this job

Question Fill: ^FillER22a2

present have you had

past did you have

---------------------------------------------------------------------------------

Y_ER23a [ YER23a ] CH trouble pay attention at work

Please look at Card 15. ^Fills.ER22a1, how often ^Fills.ER22a2 trouble:


Paying attention at work?

Question Type: TEROften

never 0 Never

fewtimes 1 Just a few times

onceawk 2 About once a week

almstdaily 3 Almost everyday

everyday 4 Everyday

Question Fill: ^FillER22a1

present Since you started this job

past When you worked at this job

Question Fill: ^FillER22a2

present have you had

past did you have

---------------------------------------------------------------------------------

Y_ER24a [ YER24a ] CH trouble get along w/ coworker

Please look at Card 15. ^Fills.ER22a1, how often ^Fills.ER22a2 trouble:


Getting along with your co-workers?

Question Type: TEROften

never 0 Never

fewtimes 1 Just a few times

onceawk 2 About once a week

almstdaily 3 Almost everyday

everyday 4 Everyday

Question Fill: ^FillER22a1

present Since you started this job

past When you worked at this job

Question Fill: ^FillER22a2

present have you had

past did you have

---------------------------------------------------------------------------------

Y_ER25a [ YER25a ] CH trouble dealing with customer

Please look at Card 15. ^Fills.ER22a1, how often ^Fills.ER22a2 trouble:


Dealing with customers?

Question Type: TEROften

never 0 Never

fewtimes 1 Just a few times

onceawk 2 About once a week

almstdaily 3 Almost everyday

everyday 4 Everyday

Question Fill: ^FillER22a1

present Since you started this job

past When you worked at this job

Question Fill: ^FillER22a2

present have you had

past did you have

---------------------------------------------------------------------------------

Y_ER26a [ YER26a ] CH trouble arrive ontime to work

Please look at Card 15. ^Fills.ER22a1, how often ^Fills.ER22a2 trouble:


Arriving on time for work?

Question Type: TEROften

never 0 Never

fewtimes 1 Just a few times

onceawk 2 About once a week

almstdaily 3 Almost everyday

everyday 4 Everyday

Question Fill: ^FillER22a1

present Since you started this job

past When you worked at this job

Question Fill: ^FillER22a2

present have you had

past did you have

---------------------------------------------------------------------------------

Logic before:

IF Y_ER1a = 1, GOTO Y_ER31a

Y_ER27a [ YER27a ] Reason why CH left job

Please look at Card 16. Which of the reasons on this card best describes why you left your most

recent job?

Question Type: TER27a

layoff 1 LAYOFF

closed 2 PLANT CLOSED

seasonal 3 END OF TEMPORARY OR SEASONAL JOB

fired 4 DISCHARGED OR FIRED

ended 5 PROGRAM ENDED

didntlike 6 DIDN'T LIKE JOB

preg 7 QUIT FOR PREGNANCY OR FAMILY REASONS

quittolook 8 QUIT TO LOOK FOR ANOTHER JOB

tookanother 9 QUIT TO TAKE ANOTHER JOB

schoolwork 10 QUIT TO DEVOTE MORE TIME TO SCHOOL WORK

backtoschool 11 QUIT TO RETURN TO SCHOOL

other 12 QUIT FOR OTHER REASONS

---------------------------------------------------------------------------------

Y_ER28a [ YER28a ] CH finding work in past 4 wks

Have you been doing anything to find work during the last 4 weeks?

Question Type: TER28a

yes 1 Yes

no 2 No

disabled 3 DISABLED

unable 4 UNABLE TO WORK

Logic after:

IF Y_ER28a = 2 GOTO Y_ER30; IF Y_ER28a = 3 GOTO Y_ER31a; IF Y_ER28a = 4 GOTO

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Y_ER29 [ YER29 ] Labels are in Logic After

USE CARD 17. What are all the things you have done to find work during the last 4 weeks?

INTERVIEWER: PROBE AFTER EACH RESPONSE: Anything else?


[INTERVIEWER: CODE ALL THAT APPLY]

Question Type: TER29S

interview 1 CONTACTED EMPLOYER DIRECTLY/INTERVIEW

pubempagncy 2 CONTACTED PUBLIC EMPLOYMENT AGENCY

privempagncy 3 CONTACT PRIVATE EMPLOYMENT AGENCY

friends 4 CONTACTED FRIENDS OR RELATIVES

school 5 CONTACTED SCHOOL/UNIVERSITY EMPLOYMENT CENTER

resumes 6 SENT OUT RESUMES/FILLED OUT APPLICATIONS

ads 7 PLACED OR ANSWERED ADS

checked 8 CHECKED UNION/PROFESSIONAL REGISTERS

looked 9 LOOKED AT ADS

attended 10 ATTENDED JOB TRAINING PROGRAMS/COURSES

other 11 OTHER

nothing 12 NOTHING OR NO JOB SEARCH ACTIVITY

Logic after:

YER29_1 --Find work: contact employer directly; YER29_2 --Find work: contact public emplymt

agcy; YER29_3 --Find work: contact priv emplymt agcy; YER29_4 --Find work: contact friends or

relative; YER29_5 --Find work: contact sch/univ emplymt ctr; YER29_6 --Find work: sent resume

filled applction; YER29_7 --Find work: placed answered ads; YER29_8 --Find work: checked

union/prof registers; YER29_9 --Find work: looked at ads; YER29_10 --Find work: attend job trning

prgms/cours; YER29_11 --Find work: other; YER29_12 --Find work: nothing/no job search actvty;

YER29_13--Find work: DK; YER29_14--Find work: RF

---------------------------------------------------------------------------------

Logic before:

IF Y_ER28a <> 2 GOTO Y_ER31a

Y_ER30a [ YER30a ] Main reason CH not look for work

USE CARD 18. What is the main reason you were not looking for work during the @Blast 4

weeks@B?

Question Type: TER30F

believed 1 BELIEVED NO WORK AVAILABLE IN LINE OF WORK OR AREA

couldntfind 2 COULDN'T FIND ANY WORK

lacks 3 LACKS NECESSARY SCHOOLING, TRAINING, SKILLS, OR

EXPERIENCE

age 4 EMPLOYERS THINK TOO YOUNG OR TOO OLD

discrimination 5 OTHER TYPES OF DISCRIMINATION

childprobs 6 CHILD CARE PROBLEMS

family 7 FAMILY RESPONSIBILITIES

inschool 8 IN SCHOOL OR OTHER TRAINING

health 9 ILL HEALTH, PHYSICAL DISABILITY

transprobs 10 TRANSPORTATION PROBLEMS

disabled 11 DISABLED

unable 12 UNABLE TO WORK

other 13 OTHER

---------------------------------------------------------------------------------

Logic before:

IF Y_ER2a = 2, GOTO Y_ER35a

Y_ER31a [ YER31a ] CH had other jobs past 12 months

Have you had any other jobs in the past 12 months?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_ER31a = 2 GOTO Y_ER35a

---------------------------------------------------------------------------------

Y_ER32a [ YER32a ] CH had other jobs past 12 months (#)

Other than the job you have already told me about, how many jobs have you had in the past 12

months?

Question Type: 0..97

---------------------------------------------------------------------------------

Logic before:

IF Y_ER32a = 0, GOTO Y_ER35a. IF Y_ER32n= 0, GO TO Y_ER35a] In the past 12 months, how

much did you earn from {FILL: this 1 job (IF Y_ER32a = 1); these [FILL: Y_ER32a] jobs (IF

Y_ER32a > 1)

Y_ER33a [ YER33a ] Amount CH earned at other jobs

In the past 12 months, how much did you earn from ^Y_ER33a_Fill?

Question Type: 0..200000

---------------------------------------------------------------------------------

Logic before:

IF Y_ER33a = REF OR DK

Y_ER34a [ YER34a ] Range amount CH earned at other jobs

Would you say it was...

Question Type: TER34a

a1 1 Less than $50

a2 2 More than $50 but less than $100

a3 3 More than $100 but less than $500

a4 4 More than $500

a5 5 More than $1000

a6 6 More than $5000

---------------------------------------------------------------------------------

Y_ER35a [ YER35a ] Freq of CH informal jobs

Now let's talk about informal jobs such as baby-sitting or lawn mowing.


About how often do you do these types of informal jobs? Would you say it is...

Question Type: TER35a

sevxwk 1 Several times a week

onceawk 2 Once a week

twoto3awk 3 2-3 times a month

onceamo 4 Once a month

lessonceamo 5 Less than once a month

never 6 Never

Logic after:

IF Y_ER35a = 6 GO TO Y_ER39a

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Y_ER36m [ YER36m ] Date CH performed informal job - month

When did you last do this kind of work?


ENTER MONTH

Question Type: TMonth

jan 1 January

feb 2 February

mar 3 March

apr 4 April

may 5 May

jun 6 June

jul 7 July

aug 8 August

sep 9 September

oct 10 October

nov 11 November

dec 12 December

---------------------------------------------------------------------------------

Y_ER36y [ YER36y ] Date CH performed informal job - year

(When did you last do this kind of work?)


ENTER YEAR

Question Type: 1970..2013

---------------------------------------------------------------------------------

Y_ER37a [ YER37a ] Amt CH earned all informal jobs

In the past 12 months, how much have you earned from all the informal jobs?

Question Type: 0..200000

---------------------------------------------------------------------------------

Logic before:

IF Y_ER37a = REF or DK

Y_ER38a [ YER38a ] Range of amt CH earned informal jobs

Would you say it was...

Question Type: TER34a

a1 1 Less than $50

a2 2 More than $50 but less than $100

a3 3 More than $100 but less than $500

a4 4 More than $500

a5 5 More than $1000

a6 6 More than $5000

---------------------------------------------------------------------------------

Y_ER39 [ YER39 ] NO LABEL

Now I'd like to ask you about other ways you may have made money or gotten help.


For these next questions we are interested in different kinds of payments that might have been

made directly to you. For these questions, please do not include any payments that were made

to other members of your family or household, even if the payments were used to help pay for

your support.


Question Type: TCont

Continue 1 Continue

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Y_ER40a [ YER40a ] CH received unemplymt comp pymt - past 12 months

In the past 12 months, have you received any unemployment compensation payments?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_ER47a [ YER47a ] CH received financial hlp frm agncy/ILP - past 12 months

In the past 12 months, have you received any financial help from the child welfare agency or your

caseworker, mentor, or Independent Living Program?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_ER48a [ YER48a ] CH received financial help rel or friend - past 12 months

In the past 12 months, have you received any financial help from a relative or friend?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_ER49a [ YER49a ] CH received financial hlp community group - past 12 months

In the past 12 months, have you received any financial help from a community group, such as a

church, a community organization, or a family resource center?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_ER50a [ YER50a ] CH panhandled begged for money - past 12 months

In the past 12 months, have you panhandled or begged for money?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_ER51a [ YER51a ] CH recycld cans/bottles - past 12 months

In the past 12 months, have you made money by recycling cans, bottles, or other items?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_ER52a [ YER52a ] CH sold blood or plasma - past 12 months

In the past 12 months, have you sold your blood or plasma?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_ER53a [ YER53a ] CH sold/pawned possessions - past 12 months

In the past 12 months, have you sold or pawned any personal possessions?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_ER56a [ YER56a ] CH has credit cards in CH name

Do you have any credit cards in your name?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_ER56a = 2 GOTO Y_ER58a

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Y_ER57a [ YER57a ] How often CH pay off credit cards

How often do you pay them off at the end of the month? Would you say...

Question Type: TER57a

never 1 Never

sometimes 2 Sometimes

mostoftime 3 Most of the time

always 4 Always

---------------------------------------------------------------------------------

Y_ER58a [ YER58a ] How going CH making ends meet

When it comes to money and making ends meet, how do you think things are going for you?

Would you say you are able to save a little money each month, just getting by, or struggling to

Question Type: TER58a

save 1 Save a little money each month

gettingby 2 Just getting by

struggling 3 Struggling to make it

---------------------------------------------------------------------------------

Y_ER59a [ YER59a ] Housing that CH paid rent/mortgage - last 12 months

Now let's talk about the place where you're living these days.


In the last 12 months, did you ever stay in a place where you were supposed to pay rent or

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_ER59a = 2 GOTO Y_ER62a

---------------------------------------------------------------------------------

Y_ER60a [ YER60a ] CH ever unable to pay rent/mortgage - last 12 months

Was there ever a time in the last 12 months when you couldn't pay your rent or mortgage on

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_ER60a = 2 GOTO Y_ER62a

---------------------------------------------------------------------------------

Y_ER61a [ YER61a ] CH unable to pay rent/mortgage ontime - freq

How many times did that happen in the last 12 months?


ENTER TIMES

Question Type: 1..12

---------------------------------------------------------------------------------

Y_ER62a [ YER62a ] CH evicted/moved b/c couldn't pay - last 12 months

At any time in the last 12 months, were you ever evicted or did you ever have to move out of a

place because you couldn't pay to stay there?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_ER63a [ YER63a ] Gas/elect cut off b/c CH not pay bill - last 12 months

In the last 12 months, was the gas or electricity ever turned off because you couldn't pay the bill?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_ER64a [ YER64a ] CH had telephone where living - last 12 months

During the last 12 months have you ever had a telephone where you were living?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_ER64a = 1 GOTO Y_ER66a

---------------------------------------------------------------------------------

Y_ER65a [ YER65a ] No phone b/c CH couldn't afford/other

Was that because you couldn't afford to get a phone or because of some other reason?

Question Type: TER65a

yes 1 Yes, could not afford a phone

no 2 No, some other reason

---------------------------------------------------------------------------------

Y_ER66a [ YER66a ] Phone cut off b/c CH couldnt pay bill - last 12 months

During the last 12 months, was the phone ever shut off or disconnected because you couldn't pay

the bill?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_ER67a [ YER67a ] CH stayed in home of relative - last 12 months

Have you stayed in the home of a relative (in the last 12 months)?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Logic before:

IF Y_ER67a = 1, CONTINUE. ELSE GOTO Y_ER69a

Y_ER68a [ YER68a ] CH stayed in home of relative - time

How much time have you stayed in the homes of relatives in the last 12 months?

Question Type: TER68a

a1 1 Less than 2 weeks

a2 2 At least two weeks, but less than one month

a3 3 At least a month, but less than six months

a4 4 At least six months, but less than 12 months

a5 5 Twelve months

---------------------------------------------------------------------------------

Y_ER69a [ YER69a ] CH stayed in home of friend - last 12 months

Have you stayed in the home of a friend (in the last 12 months)?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Logic before:

IF Y_ER69a = 1, CONTINUE. ELSE GOTO Y_ER71a

Y_ER70a [ YER70a ] Time CH stayed in home of friend - last 12 months

Altogether, in the last 12 months, how much time did you spend staying in the homes of friends?

Question Type: TER68a

a1 1 Less than 2 weeks

a2 2 At least two weeks, but less than one month

a3 3 At least a month, but less than six months

a4 4 At least six months, but less than 12 months

a5 5 Twelve months

---------------------------------------------------------------------------------

Y_ER71a [ YER71a ] CH stayed in hotel/motel/SRO

Have you stayed in your own rented room in a motel, hotel, or Single Room Occupancy (in the

last 12 months)?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Logic before:

IF Y_ER71a = 1, CONTINUE. ELSE GOTO Y_ER73a

Y_ER72a [ YER72a ] Time CH stayed in hotel/motel/SRO - last 12 months

Altogether, in the last 12 months, how much time did you spend in your own rented room in a

hotel, or SRO (Single Room Occupancy)?

Question Type: TER68a

a1 1 Less than 2 weeks

a2 2 At least two weeks, but less than one month

a3 3 At least a month, but less than six months

a4 4 At least six months, but less than 12 months

a5 5 Twelve months

---------------------------------------------------------------------------------

Y_ER73a [ YER73a ] CH stayed in car/truck/oth vehicle - last 12 months

Have you stayed in a car, truck, or some other type of vehicle (in the last 12 months)?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Logic before:

IF Y_ER73a = 1, CONTINUE. ELSE GOTO Y_ER75a

Y_ER74a [ YER74a ] Time CH stayed in car/truck/oth vehicle - last 12 months

Altogether, in the last 12 months, how much time did you spend staying in a car, truck, or some

other type of vehicle?

Question Type: TER68a

a1 1 Less than 2 weeks

a2 2 At least two weeks, but less than one month

a3 3 At least a month, but less than six months

a4 4 At least six months, but less than 12 months

a5 5 Twelve months

---------------------------------------------------------------------------------

Y_ER75a [ YER75a ] CH stayed in abdoned bldg/outside - last 12 months

Have you stayed in an abandoned building, on the street, or outside somewhere (in the last 12

months)?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Logic before:

IF Y_ER75a = 1, CONTINUE. ELSE GOTO Y_ER77a

Y_ER76a [ YER76a ] Time CH stayed in abdoned bldg/outside - last 12 months

Altogether, in the last 12 months, how long did you stay in an abandoned building, on the street,

or outside somewhere?

Question Type: TER68a

a1 1 Less than 2 weeks

a2 2 At least two weeks, but less than one month

a3 3 At least a month, but less than six months

a4 4 At least six months, but less than 12 months

a5 5 Twelve months

---------------------------------------------------------------------------------

Logic before:

IF RESPONDENT IS MALE, GOTO Y_ER79a. ELSE CONTINUE

Y_ER77a [ YER77a ] CH stayed in battered womens shelter - last 12 months

Have you stayed in a shelter for battered women (in the last 12 months)?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Logic before:

IF Y_ER77a = 1, CONTINUE. ELSE GOTO Y_ER79a

Y_ER78a [ YER78a ] Time CH in battered womens shelter - last 12 months

Altogether, in the last 12 months, how long did you stay in a battered women's shelter?

Question Type: TER68a

a1 1 Less than 2 weeks

a2 2 At least two weeks, but less than one month

a3 3 At least a month, but less than six months

a4 4 At least six months, but less than 12 months

a5 5 Twelve months


Y_ER78b [ YYD21 ] How much R needed domestic violence svcs - past 12M

In the last 12 months, how much have you needed domestic violence services or help to deal with

an abusive partner? Would you say...

Question Type: TYYV13a

alot 1 a lot,

somewhat 2 somewhat,

alittle 3 a little, or

notatall 4 not at all?



---------------------------------------------------------------------------------

Y_ER79a [ YER79a ] CH stayed in homeless shelter - last 12 months

Have you stayed in a shelter for the homeless (in the last 12 months)?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Logic before:

IF Y_ER79a = 1, CONTINUE. ELSE GOTO Y_ER81a

Y_ER80a [ YER80a ] Time CH stayed in homeless shelter - last 12 months

Altogether, in the last 12 months, how much time did you spend in a homeless shelter?

Question Type: TER68a

a1 1 Less than 2 weeks

a2 2 At least two weeks, but less than one month

a3 3 At least a month, but less than six months

a4 4 At least six months, but less than 12 months

a5 5 Twelve months

---------------------------------------------------------------------------------

Y_ER81a [ YER81a ] CH get food or money from friend/rel - last 12 months

In the last 12 months, did you ever get food or borrow money from friends or relatives?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_ER81a = 2 GOTO Y_ER83a

---------------------------------------------------------------------------------

Y_ER82a [ YER82a ] Freq CH get food or money from friend/rel - last 12 months

How often did this happen? Would you say...

Question Type: TER82a

a1 1 Almost every month

a2 2 Some months but not every month

a3 3 In only 1 or 2 months

---------------------------------------------------------------------------------

Y_ER83a [ YER83a ] CH get food from church/pantry - last 12 months

In the last 12 months, did you ever get emergency food from a church, a food pantry, or food bank?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_ER83a = 2 GOTO Y_ER85a

---------------------------------------------------------------------------------

Y_ER84a [ YER84a ] Freq CH get food from church/pantry - last 12 months

How often did this happen? Would you say...

Question Type: TER82a

a1 1 Almost every month

a2 2 Some months but not every month

a3 3 In only 1 or 2 months

---------------------------------------------------------------------------------

Y_ER85a [ YER85a ] CH eat meals at soup kitchen - last 12 months

In the last 12 months, did you ever eat any meals at a soup kitchen?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_ER85a = 2 GOTO Y_ER87a

---------------------------------------------------------------------------------

Y_ER86a [ YER86a ] Freq CH eat meals at soup kitchen - last 12 months

How often did this happen? Would you say...

Question Type: TER82a

a1 1 Almost every month

a2 2 Some months but not every month

a3 3 In only 1 or 2 months

---------------------------------------------------------------------------------

Y_ER87a [ YER87a ] CH hungry but couldnt buy food - last 12 months

In the last 12 months, were you ever hungry but didn't eat because you couldn't afford enough food?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_ER87a = 2 GOTO Y_ER89a

---------------------------------------------------------------------------------

Y_ER88a [ YER88a ] Freq CH hungry but couldnt buy food - last 12 months

How often did this happen? Would you say...

Question Type: TER82a

a1 1 Almost every month

a2 2 Some months but not every month

a3 3 In only 1 or 2 months


ADMINISTER Y_ER89 – Y_ER110 TO EMANCIPATED YOUTH AND TO YOUNG ADULTS FROM STATES WITH EXTENDED FOSTER CARE PROGRAMS


Y_ER89 [ YER89 ] NO LABEL

In the last 12 months, has a caseworker or agency helped you to find a job, prepare for your

education, find a place to live, or help with day-to-day activities such as managing finances?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_ER90 [ YER90 ] NO LABEL

In the past 12 months, has a caseworker or agency helped you find services to help you handle

stress or cope with things that come up in your life?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF WAVE >= 2, ASK.

IF Y_YH36ab = yes or Y_YH36a = yes or Y_YH43a = yes or Y_YH45a = yes or Y_YH50k1a = yes

or (Y_ER7=yes and Y_ER8="Caseworkrer") or Y_ER47=yes or Y_YH52=yes or Y_ER89=yes or

Y_ER90=yes ASK

ELSE IF none of above =yes, GOTO Y_ER108a

Y_ER108 [ YER108 ] NO LABEL

Were any of the services you just reported receiving @bprovided or paid for@b by the child welfare

agency?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

if Y_ER108 = yes then GOTO Y_ER109

if Y_ER108 = NO then GOTO Y_ER108a

---------------------------------------------------------------------------------

Y_ER108a [ YER108a ] Services paid for by agency

USE CARD 19. Please look at the list of services on Card 19. Since ^lstintdate, have you received

any of these services from the child welfare agency? The agency may have provided the services

directly or paid for you to receive the services somewhere else.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

CARD 30 CONTENTS:

Foster care or kinship care services

Individualized Education Plan (IEP)

Individualized Family Service Plan (IFSP)

Special Education Services

In-home counseling or in-home crisis services

Family counseling

Therapeutic nursery care

Mental health services or treatment

Job-related services

Organized support groups: Alcoholics Anonymous, Parents Anonymous, etc.

Child care services

Services for alcohol or drug problems

Parenting skills training

Training on ways to discipline child

Home management training (e.g., budgeting or planning meals)

Respite care for a child

Transportation help

Case manager visits or other types of contacts with case manager

---------------------------------------------------------------------------------

Logic before:

IF Y_ER108=yes or Y_ER108a = yes then ASK Y_ER109

ELSE SKIP TO Y_ER_END

Y_ER109 [ YER109 ] NO LABEL

What is the name of the caseworker who is most knowledgeable about the services you have

received?


NAME:

Question Type: string[50]

---------------------------------------------------------------------------------

Y_ER110 [ YER110 ] NO LABEL

What is the caseworker's telephone number?


PHONE

Question Type: TPHONE

---------------------------------------------------------------------------------

Y_ER_END [ YER_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

YI - YOUNG ADULT AND EMANCIPATED YOUTH INCOME MODULE

---------------------------------------------------------------------------------

Logic before:

IF CHILD IS EMANCIPATED OR YOUNG ADULT (18+) YEARS OLD, CONTINUE. ELSE GO TO

Y_YIEND

Y_YI1an [ YYI1an ] Available income and income assitance to HH during past 12M

The next questions are about income or income assistance available to your household during the

past 12 months. By household, I mean all of the people who live here. Please remember that all

information you provide will be kept private.


First, I need to know the @Btotal combined income of your family@B from all sources @Bin the

past 12 months@B. Please include your own income and the income of everyone living with you.

This includes money from jobs, net income from business or rent, pensions, dividends, interest,

social security, public assistance programs, welfare, food stamps, child support and income from

any other source such as family or friends and activities such as work "off the books" or "under

the table." If you don't know exactly, your best guess is okay.

Question Type: TCont

Continue 1 Continue

---------------------------------------------------------------------------------

Y_YI2n [ YYI2n ] Best estimate of total family income before taxes past 12M

In the past twelve months, what was the total income of your household from all sources before taxes and other deductions? Please include your own income and the income of everyone living with you


Question Type: 0..999997

Logic after:

IF Y_YI2n = DK or REF, GO TO Y_YI3aa. ELSE GO TO Y_YI2an

---------------------------------------------------------------------------------

Y_YI2r


I just need to have a range. Can you tell me if it was . . .


Less than $5,000, ............................................................. 1

$5,001 to $10,000, ............................................................ 2

$10,001 to $15,000, .......................................................... 3

$15,001 to $20,000, .......................................................... 4

$20,001 to $25,000, .......................................................... 5

$25,001 to $30,000, .......................................................... 6

$30,001 to $40,000, .......................................................... 7

$40,001 to $50,000, or ...................................................... 8

More than $50,000? .......................................................... 9


---------------------------------------------------------------------------------

Y_YI2an [ YYI2an ] How many people contributed to total combined family income

How many people contributed to this total combined family income?

Question Type: 1..30

---------------------------------------------------------------------------------

Y_YI3_1n [ YYI3_1n ] How many adults including yourself depend on this income

How many adults, including yourself, depend on this income?


NOTE: QUESTION REFERS TO ALL ADULTS, INCLUDING THOSE WHO MAY LIVE IN A

DIFFERENT HOUSEHOLD.


NUMBER OF ADULTS:

Question Type: 1..30

---------------------------------------------------------------------------------

Logic before:

IF CH35a = 1, CONTINUE. ELSE, GOTO Y_YI5

Y_YI3_2n [ YYI3_2n ] How many children depend on this income

How many children depend on this income?


NOTE: QUESTION REFERS TO ALL CHILDREN, INCLUDING THOSE WHO MAY LIVE IN A

DIFFERENT HOUSEHOLD.


NUMBER OF CHILDREN:

Question Type: 0..30

---------------------------------------------------------------------------------

Y_YI5 [ YYI5 ] Labels are in Logic After

In the last 12 months, did anyone in this household receive...


CODE ALL THAT APPLY.

Question Type: TYI5S



1 = WIC (Women Infants, and Children),

2 = [NAME OF STATE SNAP PROGRAM], [NAME OF STATE EBT CARD] Electronic Bank Transfer (EBT) card, or Food Stamps,

3 = Welfare or TANF (PROBE: By welfare or TANF, we mean temporary assistance to needy families, AFDC, or cash welfare) or other public assistance

4 = Housing Support, such as public housing, a voucher or assistance from Section 8),

5 = A disability check (SSI)?

6 = Child care assistance

7 = NONE OF THE ABOVE.


IF Y_YI5 = 2, ASK Y_YI6 – Y_YI7.


Y_YI6

How many months did you receive help from [NAME OF STATE SNAP PROGRAM] in the last twelve months?


Y_YI7

Approximately how much did you receive the last month you received [NAME OF STATE SNAP PROGRAM]?



IF Y_YI5 = 3, ASK Y_YI8 – Y_YI10.


Y_YI8

How many months did you receive help from welfare or TANF in the last twelve months?


Y_YI9

Approximately how much did you receive the last month you received welfare or TANF?


Y_YI10

Do the TANF benefits provide for ...

1 = you and other household members,

2 = you only, or

3 = other household members only and not you?



IF Y_YI5 = 5, ASK Y_YI11.


Y_YI11

Is the disability check (SSI) to provide for ...

1 = you and other household members,

2 = you only, or

3 = other household members only and not you?


Y_YI12.

Did you receive the Earned Income Tax Credit, or EITC, or any tax refund within the last 12 months?

PROBE IF DON’T KNOW WHAT EITC IS: The federal government has a special rule that allows working people who make less than about $29,000 a year to get a tax refund. It’s called the Earned Income Credit or EIC. Sometimes, if the IRS thinks that someone is eligible for the EIC they send out a letter asking that person to fill out a special form so that they can claim the EIC.


YES ....................................................................... 1

NO ........................................................................ 2


Y_YI13

How difficult is it for you to pay your bills each month? Would you say you have a…

1 Great deal of difficulty

2 Quite a bit of difficulty

3 Some difficulty

4 A little difficulty

5 No difficulty at all


Y_YI14

Generally, at the end of each month do you end up with…

1 Not enough to make ends meet

2 Almost enough to make ends meet

3 Just enough to make ends meet

4 Some money left over

5 More than enough money left over


Y_YI15

[I/My family and I] [have/has] enough money to afford the kind of home [I/we] need. Do you…

1 Strongly disagree

2 Disagree

3 Agree

4 Strongly agree


Y_YI16

[I/My family and I] [have/has] enough money to afford the kind of clothing [I/we] need. Do you…

1 Strongly disagree

2 Disagree

3 Agree

4 Strongly agree


Y_YI17

[I/My family and I] [have/has] enough money to afford the kind of food [I/we] need. Do you…

1 Strongly disagree

2 Disagree

3 Agree

4 Strongly agree


Y_YI18

[I/My family and I] [have/has] enough money to afford the kind of medical care [I/we] need. Do you…

1 Strongly disagree

2 Disagree

3 Agree

4 Strongly agree



AC - CHILD ACASI INTRODUCTION MODULE

---------------------------------------------------------------------------------

Logic before:

IF AGE 11 OR OLDER, CONTINUE. IF CHILD IS YOUNG ADULT (18+) OR EMANCIPATED,

CONTINUE. ELSE, GOTO Y_ACEND.

Y_AC0 [ YAC0 ] NO LABEL

Now I'd like you to use the headphones to listen to some questions and enter your answers into

the computer yourself. This will allow you to answer the questions in complete privacy. I will not

be able to hear the questions or see the answers you type into the computer. I'll help you do the

first few, and I'd like you to finish the rest on your own. Let me explain how to use the computer.



MOVE COMPUTER SO RESPONDENT CAN USE IT AND POINT OUT THE FOLLOWING:


- NUMBER KEYS

- ENTER KEY (TO ACCEPT AND STORE THE RESPONSE)

- FUNCTION KEYS


CAUTION RESPONDENT ABOUT ON/OFF SWITCH.


ADJUST HEADPHONES FOR RESPONDENT AND DEMONSTRATE VOLUME CONTROL.


WHEN RESPONDENT IS READY, PRESS "1" AND [ENTER] TO CONTINUE.

Question Type: TCont

Continue 1 Continue

---------------------------------------------------------------------------------

Y_AC1 [ YAC1 ] NO LABEL

The next questions are for practice. The interviewer is going to help you do this. Press "1" and

the large [Enter] key on the right side of the keyboard to see the first question.


The [Enter] key is the one with the <-- symbol on it.

Question Type: TCont

Continue 1 Continue

---------------------------------------------------------------------------------

Y_AC2a [ YAC2a ] Month CH was born

In what month were you born?

Question Type: TMonth

jan 1 January

feb 2 February

mar 3 March

apr 4 April

may 5 May

jun 6 June

jul 7 July

aug 8 August

sep 9 September

oct 10 October

nov 11 November

dec 12 December

---------------------------------------------------------------------------------

Y_AC3a [ YAC3a ] Birth month entered correctly(YN2T)

The computer has recorded that you were born in ^Fills.Y_AC3a. Is this correct?

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_AC3a

jan January

feb February

mar March

apr April

may May

jun June

jul July

aug August

sep September

oct October

nov November

dec December

Logic after:

IF Y_AC3a = 2 GOTO Y_AC2a ("PLEASE RE-ENTER YOUR ANSWER TO QUESTION Y_AC2a.")

---------------------------------------------------------------------------------

Y_AC4 [ YAC4 ] NO LABEL

The next practice questions will show you some of the different types of answers you can choose

during this part of the interview. Please pay close attention to the answer choices that are given

for each question.


Press "1" and the [Enter] key to continue.

Question Type: TCont

Continue 1 Continue

---------------------------------------------------------------------------------

Y_AC5a [ YAC5a ] # days ate ice cream past 30 days(DAY1T)

In the @Blast 30 days@B, on how many days did you eat ice cream?

Question Type: TAC5a

one 1 1 day

two 2 2 days

threetofive 3 3 to 5 days (about 1 day a week)

sixtoeleven 4 6 to 11 days (about 2 days a week)

tentonineteen 5 10 to 19 days (about 3 or 4 days a week)

twentymore 6 20 days or more (5 days a week or more)

notdone 8 I have not done this in the past 30 days

---------------------------------------------------------------------------------

Y_AC6a [ YAC6a ] # times to movies past 6 months(TIME2T)

How many times in the @Bpast 6 months@B did you go to the movies?

Question Type: TAC6a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourxs 4 4 times

fivemore 5 5 or more times

notdone 8 I have not done this in the past 6 months

---------------------------------------------------------------------------------

Y_AC7a [ YAC7a ] # times to museum past 12 months(TIME3T)

In the @Bpast 12 months@B, how many times have you watched TV?

Question Type: TAC7a

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notin6mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_AC8 [ YAC8 ] NO LABEL

Thank you. If you have any questions about how to use the computer, please ask your interviewer

now.


These last questions are about things that may have happened to you, and are personal

questions that may make you feel uncomfortable or a little sad. Please remember that your

honest answers to our questions are important and will help us understand what different children

experience and how it affects their lives. This will allow us to help others get as good as possible

at helping children like you in the future.


Press "1" and [Enter] to continue.

Question Type: TCont

Continue 1 Continue

---------------------------------------------------------------------------------

Y_AC10 [ YAC10 ] NO LABEL

In past studies, some people have told us that they did not feel comfortable talking to an

interviewer about personal topics, so we have developed the recorded interview procedure that you

are using now to finish the interview. You can listen to the questions and put your answers into

the computer in complete privacy. You can also skip any question you don't want to answer.

Your interviewer will not know how you answer and will not ask you any questions about your

answers. However, as your interviewer told you at the beginning of the interview, if your answers

to these questions indicate that your life or health is in danger, we will have to tell someone

whose job it is to see that you and others are safe and protected.


Thank you for helping us with our effort to understand your experiences.


Please press "1" and [Enter] now to hear and see the questions.

Question Type: TCont

Continue 1 Continue

Logic after:

GOTO Y_ACEND

RC - CHILD RELATIONSHIP WITH CAREGIVER(S) MODULE

---------------------------------------------------------------------------------

Y_RC_BGN [ YRC_BGN ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

---------------------------------------------------------------------------------

Logic before:

IF AGE < 11, GOTO Y_RCEND. IF CHILD IS YOUNG ADULT (18+) OR EMANCIPATED, GOTO

Y_RCEND. ELSE, CONTINUE.

Y_RC1a [ YRC1a ] CH feels good w/CG-A

Now I want to ask you about your relationship with your ^CAREGIVER_A. I am going to read a list

of different statements and for each one I want you to tell me how true the statement is about

you. Remember that your answers are private. Please tell me what you really feel or think.


When I'm with my ^CAREGIVER_A, I feel good. How true is this?

Question Type: THowTrue

nottrue 1 not at all true

notvtrue 2 not very true

sorttrue 3 sort of true, or

verytrue 4 very true?

---------------------------------------------------------------------------------

Y_RC2a [ YRC2a ] CH feels mad w/CG-A

When I'm with my ^CAREGIVER_A, I feel mad. How true is this?

Question Type: THowTrue

nottrue 1 not at all true

notvtrue 2 not very true

sorttrue 3 sort of true, or

verytrue 4 very true?

---------------------------------------------------------------------------------

Y_RC3a [ YRC3a ] CH feels unhappy w/CG-A

When I'm with my ^CAREGIVER_A, I feel unhappy. How true is this?

Question Type: THowTrue

nottrue 1 not at all true

notvtrue 2 not very true

sorttrue 3 sort of true, or

verytrue 4 very true?

---------------------------------------------------------------------------------

Y_RC4a [ YRC4a ] CG-A enjoys time w/CH

My ^CAREGIVER_A enjoys spending time with me. How true is this?

Question Type: THowTrue

nottrue 1 not at all true

notvtrue 2 not very true

sorttrue 3 sort of true, or

verytrue 4 very true?

---------------------------------------------------------------------------------

Y_RC5a [ YRC5a ] CG-A does a lot to help CH

My ^CAREGIVER_A does a lot to help me. How true is this?

Question Type: THowTrue

nottrue 1 not at all true

notvtrue 2 not very true

sorttrue 3 sort of true, or

verytrue 4 very true?

---------------------------------------------------------------------------------

Y_RC6a [ YRC6a ] CG-A doesn't have time for CH

My ^CAREGIVER_A doesn't seem to have enough time for me. How true is this?

Question Type: THowTrue

nottrue 1 not at all true

notvtrue 2 not very true

sorttrue 3 sort of true, or

verytrue 4 very true?

---------------------------------------------------------------------------------

Y_RC7a [ YRC7a ] CG-A DK how CH feels

My ^CAREGIVER_A doesn't seem to know how I feel about things. How true is this?

Question Type: THowTrue

nottrue 1 not at all true

notvtrue 2 not very true

sorttrue 3 sort of true, or

verytrue 4 very true?

---------------------------------------------------------------------------------

Y_RC8a [ YRC8a ] CG-A trusts CH

My ^CAREGIVER_A trusts me. How true is this?

Question Type: THowTrue

nottrue 1 not at all true

notvtrue 2 not very true

sorttrue 3 sort of true, or

verytrue 4 very true?

---------------------------------------------------------------------------------

Y_RC9a [ YRC9a ] CG-A doesn't let CH make decisions

My ^CAREGIVER_A doesn't let me make any of my own decisions. How true is this?

Question Type: THowTrue

nottrue 1 not at all true

notvtrue 2 not very true

sorttrue 3 sort of true, or

verytrue 4 very true?

---------------------------------------------------------------------------------

Y_RC10a [ YRC10a ] CG-A is fair w/ CH

My ^CAREGIVER_A is fair with me. How true is this?

Question Type: THowTrue

nottrue 1 not at all true

notvtrue 2 not very true

sorttrue 3 sort of true, or

verytrue 4 very true?

---------------------------------------------------------------------------------

Y_RC11a [ YRC11a ] CG-A thinks CH can't do much

My ^CAREGIVER_A doesn't think I can do very much. How true is this?

Question Type: THowTrue

nottrue 1 not at all true

notvtrue 2 not very true

sorttrue 3 sort of true, or

verytrue 4 very true?

---------------------------------------------------------------------------------

Y_RC12a [ YRC12a ] CH DK what CG-A wants

I don't know what my ^CAREGIVER_A wants from me. How true is this?

Question Type: THowTrue

nottrue 1 not at all true

notvtrue 2 not very true

sorttrue 3 sort of true, or

verytrue 4 very true?

---------------------------------------------------------------------------------

Logic before:

IF CAREGIVER_B IS BLANK, GOTO RCEND

Y_RC13a [ YRC13a ] CH feels good w/CG-B

Now I want to ask you about your relationship with your ^CAREGIVER_B. I am going to read a list

of different statements and for each one I want you to tell me how true the statement is about

you. Remember that your answers are private. Please tell me what you really feel or think.


When I'm with my ^CAREGIVER_B, I feel good. How true is this?

Question Type: THowTrue

nottrue 1 not at all true

notvtrue 2 not very true

sorttrue 3 sort of true, or

verytrue 4 very true?

---------------------------------------------------------------------------------

Y_RC14a [ YRC14a ] CH feels mad w/CG-B

When I'm with my ^CAREGIVER_B, I feel mad. How true is this?

Question Type: THowTrue

nottrue 1 not at all true

notvtrue 2 not very true

sorttrue 3 sort of true, or

verytrue 4 very true?

---------------------------------------------------------------------------------

Y_RC15a [ YRC15a ] CH feels unhappy w/CG-B

When I'm with my ^CAREGIVER_B, I feel unhappy. How true is this?

Question Type: THowTrue

nottrue 1 not at all true

notvtrue 2 not very true

sorttrue 3 sort of true, or

verytrue 4 very true?

---------------------------------------------------------------------------------

Y_RC16a [ YRC16a ] CG-B enjoys time w/CH

My ^CAREGIVER_B enjoys spending time with me. How true is this?

Question Type: THowTrue

nottrue 1 not at all true

notvtrue 2 not very true

sorttrue 3 sort of true, or

verytrue 4 very true?

---------------------------------------------------------------------------------

Y_RC17a [ YRC17a ] CG-B does a lot to help CH

My ^CAREGIVER_B does a lot to help me. How true is this?

Question Type: THowTrue

nottrue 1 not at all true

notvtrue 2 not very true

sorttrue 3 sort of true, or

verytrue 4 very true?

---------------------------------------------------------------------------------

Y_RC18a [ YRC18a ] CG-B doesn't have time for CH

My ^CAREGIVER_B doesn't seem to have enough time for me. How true is this?

Question Type: THowTrue

nottrue 1 not at all true

notvtrue 2 not very true

sorttrue 3 sort of true, or

verytrue 4 very true?

---------------------------------------------------------------------------------

Y_RC19a [ YRC19a ] CG-B DK how CH feels

My ^CAREGIVER_B doesn't seem to know how I feel about things. How true is this?

Question Type: THowTrue

nottrue 1 not at all true

notvtrue 2 not very true

sorttrue 3 sort of true, or

verytrue 4 very true?

---------------------------------------------------------------------------------

Y_RC20a [ YRC20a ] CG-B trusts CH

My ^CAREGIVER_B trusts me. How true is this?

Question Type: THowTrue

nottrue 1 not at all true

notvtrue 2 not very true

sorttrue 3 sort of true, or

verytrue 4 very true?

---------------------------------------------------------------------------------

Y_RC21a [ YRC21a ] CG-B doesn't let CH make decisions

My ^CAREGIVER_B doesn't let me make any of my own decisions. How true is this?

Question Type: THowTrue

nottrue 1 not at all true

notvtrue 2 not very true

sorttrue 3 sort of true, or

verytrue 4 very true?

---------------------------------------------------------------------------------

Y_RC22a [ YRC22a ] CG-B is fair w/ CH

My ^CAREGIVER_B is fair with me. How true is this?

Question Type: THowTrue

nottrue 1 not at all true

notvtrue 2 not very true

sorttrue 3 sort of true, or

verytrue 4 very true?

---------------------------------------------------------------------------------

Y_RC23a [ YRC23a ] CG-B thinks CH can't do much

My ^CAREGIVER_B doesn't think I can do very much. How true is this?

Question Type: THowTrue

nottrue 1 not at all true

notvtrue 2 not very true

sorttrue 3 sort of true, or

verytrue 4 very true?

---------------------------------------------------------------------------------

Y_RC24a [ YRC24a ] CH DK what CG-B wants

I don't know what my ^CAREGIVER_B wants from me. How true is this?

Question Type: THowTrue

nottrue 1 not at all true

notvtrue 2 not very true

sorttrue 3 sort of true, or

verytrue 4 very true?

Logic after:

GOTO Y_RCEND

---------------------------------------------------------------------------------

Y_RC_END [ YRC_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

Logic after:

Y_RCEND



CL - CHILD CLOSENESS TO CAREGIVER(S) MODULE

---------------------------------------------------------------------------------

Logic before:

IF CHILD IS EMANCIPATED OR YOUNG ADULT (18+), GOTO Y_CLEND

Y_CL_BGN [ YCL_BGN ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

---------------------------------------------------------------------------------

Logic before:

IF AGE < 11, GOTO Y_CLEND. IF CAREGIVER_A IS BLANK, GOTO Y_CL3a

Y_CL1a [ YCL1a ] How close CH feels to CG-A

How close do you feel to your ^CAREGIVER_A? Would you say...

Question Type: TCL1a

notatall 1 not at all

littlebit 2 a little bit

somewhat 3 somewhat

quiteabit 4 quite a bit, or

vclose 5 very close?

---------------------------------------------------------------------------------

Y_CL2a [ YCL2a ] How much CG-A cares about CH

How much do you think ^Fills.HeShe cares about you? Would you say...

Question Type: TCL2a

notatall 1 not at all

vlittle 2 very little

somewhat 3 somewhat

quiteabit 4 quite a bit, or

vmuch 5 very much?

Question Fill: ^fillheshe

he he

she she

---------------------------------------------------------------------------------

Logic before:

IF CAREGIVER_B IS BLANK, GOTO Y_CL5aa

Y_CL3a [ YCL3a ] How close CH feels to CG-B

How close do you feel to your ^CAREGIVER_B? Would you say...

Question Type: TCL1a

notatall 1 not at all

littlebit 2 a little bit

somewhat 3 somewhat

quiteabit 4 quite a bit, or

vclose 5 very close?

---------------------------------------------------------------------------------

Y_CL4a [ YCL4a ] How much CG-B cares about CH

How much do you think ^Fills.HeShe cares about you? Would you say...

Question Type: TCL2a

notatall 1 not at all

vlittle 2 very little

somewhat 3 somewhat

quiteabit 4 quite a bit, or

vmuch 5 very much?

Question Fill: ^fillheshe

he he

she she

---------------------------------------------------------------------------------

Logic before:

IF CAREGIVER_A IS BLANK, GOTO Y_CL6aa

Y_CL5aa [ YCL5aa ] CH went shopping w/CG-A past 4 wks

Next, I'm going to read a list of things you may have done with your ^CAREGIVER_A. For each

one, please tell me if you have done it with your ^CAREGIVER_A @Bin the past 4 weeks@B.


In the past 4 weeks, have you gone shopping with your ^CAREGIVER_A?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_CL5ba [ YCL5ba ] CH played sport w/CG-A past 4 wks

In the past 4 weeks, have you played a sport with your ^CAREGIVER_A?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_CL5ca [ YCL5ca ] CH gone to religious service w/CG-A past 4 wks

In the past 4 weeks, have you gone to a religious service or church-related event with your

^CAREGIVER_A?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_CL5da [ YCL5da ] CH talked to CG-A re: dating past 4 wks

In the past 4 weeks, have you talked with your ^CAREGIVER_A about someone you're dating or a

party you went to?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_CL5ea [ YCL5ea ] CH gone to events w/CG-A past 4 wks

In the past 4 weeks, have you gone to a movie, play, museum, concert, or sports event with your

^CAREGIVER_A?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_CL5fa [ YCL5fa ] CH talked w/CG-A re: problem past 4 wks

In the past 4 weeks, have you had a talk with your ^CAREGIVER_A about a personal problem you

were having?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_CL5ga [ YCL5ga ] CH argued w/CG-A re: behavior past 4 wks

In the past 4 weeks, have you had a serious argument with your ^CAREGIVER_A about your

behavior?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_CL5ha [ YCL5ha ] CH talked about school work/grades w/CG-A past 4 wks

In the past 4 weeks, have you talked about your school work or grades with your ^CAREGIVER_A?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_CL5ia [ YCL5ia ] CH worked on school proj w/CG-A past 4 wks

In the past 4 weeks, have you worked on a project for school with your ^CAREGIVER_A?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_CL5ja [ YCL5ja ] CH talked w/CG-A re:othr school things past 4 wks

In the past 4 weeks, have you talked with your ^CAREGIVER_A about other things you're doing in

school?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Logic before:

IF CAREGIVER_B = IS BLANK, GOTO Y_CLEND

Y_CL6aa [ YCL6aa ] CH went shopping w/CG-B past 4 wks

Next, I'm going to read a list of things you may have done with your ^CAREGIVER_B. For each

one, please tell me if you have done it with your ^CAREGIVER_B @Bin the past 4 weeks@B.


In the past 4 weeks, have you gone shopping with your ^CAREGIVER_B?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_CL6ba [ YCL6ba ] CH played sport w/CG-B past 4 wks

In the past 4 weeks, have you played a sport with your ^CAREGIVER_B?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_CL6ca [ YCL6ca ] CH gone to religious service w/CG-B past 4 wks

In the past 4 weeks, have you gone to a religious service or church-related event with your

^CAREGIVER_B?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_CL6da [ YCL6da ] CH talked to CG-B re: dating past 4 wks

In the past 4 weeks, have you talked with your ^CAREGIVER_B about someone you're dating or a

party you went to?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_CL6ea [ YCL6ea ] CH gone to events w/CG-B past 4 wks

In the past 4 weeks, have you gone to a movie, play, museum, concert, or sports event with your

^CAREGIVER_B?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_CL6fa [ YCL6fa ] CH talked w/CG-B re: problem past 4 wks

In the past 4 weeks, have you had a talk with your ^CAREGIVER_B about a personal problem you

were having?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_CL6ga [ YCL6ga ] Ch argued w/CG-B re: behavior past 4 wks

In the past 4 weeks, have you had a serious argument with your ^CAREGIVER_B about your

behavior?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_CL6ha [ YCL6ha ] CH talked about school work/grades w/CG-B past 4 wks

In the past 4 weeks, have you talked about your school work or grades with your ^CAREGIVER_B?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_CL6ia [ YCL6ia ] CH worked on school proj w/CG-B past 4 wks

In the past 4 weeks, have you worked on a project for school with your ^CAREGIVER_B?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_CL6ja [ YCL6ja ] CH talked w/CG-B re:othr school things past 4 wks

In the past 4 weeks, have you talked with your ^CAREGIVER_B about other things you're doing in

school?

Question Type: TYesNoC

Yes 1 YES

No 2 NO



---------------------------------------------------------------------------------

Y_CL_END [ YCL_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

EV - CHILD EXPOSURE TO VIOLENCE MODULE

Skip Logic:

IN THIS SECTION, CERTAIN SENTENCES IN THE QUESTIONS ARE SHOWN ONLY TO KIDS

UNDER 11 (AND OVER 8). THE REMAINDER OF THE QUESTION TEXT IS SHOWN TO ALL

KIDS IN THE SECTION -- I.E., KIDS AGE 8 AND UP.

---------------------------------------------------------------------------------

Logic before:

IF AGE < 8 OR CHILD IS YOUNG ADULT (18+) OR EMANCIPATED, GOTO Y_EVEND. ELSE,

CONTINUE.

Y_EV1a [ YEV1a ] #Xs CH eats ice cream during Summer

^Fills.Y_EV1


Let's try answering an easy question using these different answers. During the summer, how

many times do you eat ice cream?


If you never eat ice cream during the summer, you would say "never."

If you eat ice cream once during the summer, you would say "one time."

If you eat ice cream a few times during the summer, you would say "a few times."

If you eat ice cream lots of times during the summer, you would say "lots of times."


So, during the summer how many times do you eat ice cream?

Question Type: THO3F

nvr 1 Never

once 2 One time

fewtms 3 A few times

lots 4 Lots of times

Question Fill: ^FillY_EV1

lessthan11 USE CARD 19. I am going to show you some pictures that tell about a

child whose name is Chris. I will show you one picture at a time and tell

you what is happening in that picture. Afterwards, I will ask you how

often you may have seen things that are like what Chris saw or things

that may have happened to you that are like what happened to Chris. For

each question, I want you to pick one of the following answers: never,

one time, a few times, or lots of times.

elevenmore I am going to ask you how often you may have seen things or how often

things may have happened to you. For each question, I want you to pick

one of the following answers: never, one time, a few times, or lots of

---------------------------------------------------------------------------------

Logic before:

IF AGE < 11

Y_EV2 [ YEV2 ] NO LABEL

I am going to show you some pictures of things that Chris really saw or that really happened to

Chris. They are not things that Chris imagined or made up. They are not stories that Chris heard

or things that Chris saw on TV or in the movies or on video. The pictures show things that Chris

really saw or that really happened to Chris.


INTERVIEWER: EMPHASIZE WITH THE FIRST FEW PICTURES THAT CHRIS REALLY SAW

THESE THINGS HAPPEN AND THEY ARE NOT THINGS CHRIS WATCHED IN A MOVIE OR

ON VIDEO OR TV.


USE CARD 20: This is Chris.


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

---------------------------------------------------------------------------------

Logic before:

IF AGE < 11

Y_EV3a [ YEV3a ] #Xs CH saw kid on Santas lap

USE CARD 21. Chris sees a kid sitting on Santa's lap. How many times have you seen a kid

sitting on Santa's lap? Would you say. . .

Question Type: THO3F

nvr 1 Never

once 2 One time

fewtms 3 A few times

lots 4 Lots of times

---------------------------------------------------------------------------------

Logic before:

IF AGE < 11

Y_EV4a0 NO LABEL

Now, I'd like you to put on these headphones and listen to the rest of the questions about Chris.

By wearing the headphones, no one else will be able to hear the questions that you are asked. I

will show you the pictures of Chris while you listen to the questions. After you hear each

question, please point to your answer on the card I will be holding. Do not say your answer out

loud. Just point to your answer on the card and I will type it into the computer. When answering

these questions, please remember that if I learn that your life or health is in danger, I will have to

tell someone whose job it is to see that you are safe and protected.


Let's get started.


INTERVIEWER: PUT HEADPHONES ON CHILD


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, empty

Continue 1 Continue

---------------------------------------------------------------------------------

Y_EV4a [ YEV4a ] #Xs CH saw adult yell at others

^Fills.Y_EV4a2 How many times have you seen an adult yell at another person in a home you've

lived in? (Would you say never, one time, a few times, or lots of times?)

Question Type: THO3F

nvr 1 Never

once 2 One time

fewtms 3 A few times

lots 4 Lots of times

Question Fill: ^FillY_EV4a2

lessthan11 USE CARD 22. Chris is at home. Chris sees an adult yell at another

person at home.

elevenmore Let's get started.@/@/@/

Logic after:

IF RESPONSE = 1, DK, RE, GOTO Y_EV5a

---------------------------------------------------------------------------------

Y_EV4aa [ YEV4aa ] CH saw adult yelling at others in past M

Have you seen this happen in the last month?


^Fills.Y_EV4

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV4

lessthan11 USE CARD 22A.

---------------------------------------------------------------------------------

Y_EV4xa [ YEV4xa ] CH saw yelling w/curr residents

Have you seen this happen with the people you live with now?


^Fills.Y_EV4

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV4

lessthan11 USE CARD 22A.

---------------------------------------------------------------------------------

Y_EV5a [ YEV5a ] #Xs CH yelled at by adult

^Fills.Y_EV5a How many times has an adult yelled at you in a home you've lived in? (Would you

say never, one time, a few times, or lots of times?)

Question Type: THO3F

nvr 1 Never

once 2 One time

fewtms 3 A few times

lots 4 Lots of times

Question Fill: ^FillY_EV5a

lessthan11 USE CARD 23. At home, an adult yells at Chris.

elevenmore

Logic after:

IF RESPONSE = 1, DK, RE, GOTO Y_EV6a

---------------------------------------------------------------------------------

Y_EV5aa [ YEV5aa ] CH yelled at by adult in past M

Has this happened in the last month?


^Fills.Y_EV5

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV5

lessthan11 USE CARD 23A.

---------------------------------------------------------------------------------

Y_EV5xa [ YEV5xa ] CH yelled at by curr res

Has this happened with the people you live with now?


^Fills.Y_EV5

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV5

lessthan11 USE CARD 23A.

---------------------------------------------------------------------------------

Y_EV6a [ YEV6a ] #Xs CH saw adult throw at others

^Fills.Y_EV6a How many times have you seen an adult throw something at another person in a

home you've lived in? (Would you say never, one time, a few times, or lots of times?)

Question Type: THO3F

nvr 1 Never

once 2 One time

fewtms 3 A few times

lots 4 Lots of times

Question Fill: ^FillY_EV6a

lessthan11 USE CARD 24. Chris sees an adult throw something at another person

at home.

elevenmore

Logic after:

IF RESPONSE = 1, DK, RE, GOTO Y_EV7a

---------------------------------------------------------------------------------

Y_EV6aa [ YEV6aa ] CH saw adult throw at others in past M

Have you seen this happen in the last month?


^Fills.Y_EV6

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV6

lessthan11 USE CARD 24A.

---------------------------------------------------------------------------------

Y_EV6xa [ YEV6xa ] CH saw adult throw w/curr residents

Have you seen this happen with the people you live with now?


^Fills.Y_EV6

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV6

lessthan11 USE CARD 24A.

---------------------------------------------------------------------------------

Y_EV7a [ YEV7a ] #Xs adult thrown something at CH

^Fills.Y_EV7a How many times has an adult thrown something at you in a home you've lived in?

(Would you say never, one time, a few times, or lots of times?)

Question Type: THO3F

nvr 1 Never

once 2 One time

fewtms 3 A few times

lots 4 Lots of times

Question Fill: ^FillY_EV7a

lessthan11 USE CARD 25. At home, an adult throws something at Chris.

elevenmore

Logic after:

IF RESPONSE = 1, DK, RE, GOTO Y_EV8a

---------------------------------------------------------------------------------

Y_EV7aa [ YEV7aa ] Adult threw at CH in past M

Has this happened in the last month?


^Fills.Y_EV7

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV7

lessthan11 USE CARD 25A.

---------------------------------------------------------------------------------

Y_EV7xa [ YEV7xa ] Adult threw at CH w/curr residents

Has this happened with the people you live with now?


^Fills.Y_EV7

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV7

lessthan11 USE CARD 25A.

---------------------------------------------------------------------------------

Y_EV8a [ YEV8a ] #Xs CH saw adult shove others

^Fills.Y_EV8a How many times have you seen an adult push or shove another person really hard

in a home you've lived in? (Would you say never, one time, a few times, or lots of times?)

Question Type: THO3F

nvr 1 Never

once 2 One time

fewtms 3 A few times

lots 4 Lots of times

Question Fill: ^FillY_EV8a

lessthan11 USE CARD 26. Chris is at home. Chris sees an adult push or shove

another person really hard.

elevenmore

Logic after:

IF RESPONSE = 1, DK, RE, GOTO Y_EV9a

---------------------------------------------------------------------------------

Y_EV8aa [ YEV8aa ] CH saw adult shove others in past M

Have you seen this happen in the last month?


^Fills.Y_EV8

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV8

lessthan11 USE CARD 26A.

---------------------------------------------------------------------------------

Y_EV8xa [ YEV8xa ] CH saw adult shove others w/curr residents

Have you seen this happen with the people you live with now?


^Fills.Y_EV8

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV8

lessthan11 USE CARD 26A.

---------------------------------------------------------------------------------

Y_EV9a [ YEV9a ] #Xs adult shoved CH

^Fills.Y_EV9a How many times has an adult pushed or shoved you really hard in a home you've

lived in? (Would you say never, one time, a few times, or lots of times?)

Question Type: THO3F

nvr 1 Never

once 2 One time

fewtms 3 A few times

lots 4 Lots of times

Question Fill: ^FillY_EV9a

lessthan11 USE CARD 27. Chris is at home. An adult pushes or shoves Chris really

hard.

elevenmore

Logic after:

IF RESPONSE = 1, DK, RE, GOTO Y_EV10a

---------------------------------------------------------------------------------

Y_EV9aa [ YEV9aa ] Adult shoved CH in past M

Has this happened in the last month?


^Fills.Y_EV9

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV9

lessthan11 USE CARD 27A.

---------------------------------------------------------------------------------

Y_EV9xa [ YEV9xa ] Adult shoved CH w/curr residents

Has this happened with the people you live with now?


^Fills.Y_EV9

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV9

lessthan11 USE CARD 27A.

---------------------------------------------------------------------------------

Logic before:

IF AGE >=11, GOTO Y_EV11a

Y_EV10a [ YEV10a ] #Xs CH watched cartoons

USE CARD 28. Chris watches cartoons on TV. How many times have you watched cartoons on

TV? (Would you say never, one time, a few times, or lots of times?)

Question Type: THO3F

nvr 1 Never

once 2 One time

fewtms 3 A few times

lots 4 Lots of times

---------------------------------------------------------------------------------

Y_EV11a [ YEV11a ] #Xs CH saw adult slap other adult

^Fills.Y_EV11a How many times have you seen an adult slap another person really hard in a

home you've lived in? (Would you say never, one time, a few times, or lots of times?)

Question Type: THO3F

nvr 1 Never

once 2 One time

fewtms 3 A few times

lots 4 Lots of times

Question Fill: ^FillY_EV11a

lessthan11 USE CARD 29. Chris is at home. Chris sees an adult slap another

person really hard at home.

elevenmore

Logic after:

IF RESPONSE = 1, DK, RE, GOTO Y_EV12a

---------------------------------------------------------------------------------

Y_EV11aa [ YEV11aa ] CH saw adult slap other in past M

Have you seen this happen in the last month?


^Fills.Y_EV11

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV11

lessthan11 USE CARD 29A.

---------------------------------------------------------------------------------

Y_EV11xa [ YEV11xa ] CH saw adult slap other w/curr residents

Have you seen this happen with the people you live with now?


^Fills.Y_EV11

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV11

lessthan11 USE CARD 29A.

---------------------------------------------------------------------------------

Y_EV12a [ YEV12a ] #Xs adult slapped CH

^Fills.Y_EV12a How many times has an adult slapped you really hard in a home you've lived in?

(Would you say never, one time, a few times, or lots of times?)

Question Type: THO3F

nvr 1 Never

once 2 One time

fewtms 3 A few times

lots 4 Lots of times

Question Fill: ^FillY_EV12a

lessthan11 USE CARD 30. At home, an adult slaps Chris really hard.

elevenmore

Logic after:

IF RESPONSE = 1, DK, RE, GOTO Y_EV13a

---------------------------------------------------------------------------------

Y_EV12aa [ YEV12aa ] Adult slap CH in past M

Has this happened in the last month?


^Fills.Y_EV12

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV12

lessthan11 USE CARD 30A.

---------------------------------------------------------------------------------

Y_EV12xa [ YEV12xa ] Adult slap CH w/curr residents

Has this happened with the people you live with now?


^Fills.Y_EV12

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV12

lessthan11 USE CARD 30A.

---------------------------------------------------------------------------------

Y_EV13a [ YEV13a ] #Xs CH saw adult beat up other

^Fills.Y_EV13a How many times have you seen an adult beat-up another person in a home you've

lived in? (Would you say never, one time, a few times, or lots of times?)

Question Type: THO3F

nvr 1 Never

once 2 One time

fewtms 3 A few times

lots 4 Lots of times

Question Fill: ^FillY_EV13a

lessthan11 USE CARD 31. Chris is at home. Chris sees an adult beat-up another

person at home.

elevenmore

Logic after:

IF RESPONSE = 1, DK, RE, GOTO Y_EV14a

---------------------------------------------------------------------------------

Y_EV13aa [ YEV13aa ] CH saw adult beat other in past M

Have you seen this happen in the last month?


^Fills.Y_EV13

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV13

lessthan11 USE CARD 31A.

---------------------------------------------------------------------------------

Y_EV13xa [ YEV13xa ] CH saw adlt beat other w/curr occup

Have you seen this happen with the people you live with now?


^Fills.Y_EV13

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV13

lessthan11 USE CARD 31A.

---------------------------------------------------------------------------------

Y_EV14a [ YEV14a ] #Xs adult beat up CH

^Fills.Y_EV14a How many times has an adult beaten you up in a home you've lived in? (Would

you say never, one time, a few times, or lots of times?)

Question Type: THO3F

nvr 1 Never

once 2 One time

fewtms 3 A few times

lots 4 Lots of times

Question Fill: ^FillY_EV14a

lessthan11 USE CARD 32. At home, an adult beats Chris up.

elevenmore

Logic after:

IF RESPONSE = 1, DK, RE, GOTO Y_EV15a

---------------------------------------------------------------------------------

Y_EV14aa [ YEV14aa ] Adult who beat up CH responsible for CH care

Was that someone who was responsible for taking care of you?


^Fills.Y_EV14

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV14

lessthan11 USE CARD 32A.

---------------------------------------------------------------------------------

Y_EV14ba [ YEV14ba ] CH beat up by responsible adult in last W

Has this happened in the last week?


^Fills.Y_EV14

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV14

lessthan11 USE CARD 32A.

Logic after:

IF RESPONSE = 1, GOTO Y_EV14xa

---------------------------------------------------------------------------------

Y_EV14ca [ YEV14ca ] CH beat up by responsible adult in last M

Has this happened in the last month?


^Fills.Y_EV14

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV14

lessthan11 USE CARD 32A.

Logic after:

IF RESPONSE = 1, GOTO Y_EV14xa

---------------------------------------------------------------------------------

Y_EV14da [ YEV14da ] CH beat up by responsible adult in last 3M

Has this happened in the last 3 months?


^Fills.Y_EV14

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV14

lessthan11 USE CARD 32A.

---------------------------------------------------------------------------------

Y_EV14xa [ YEV14xa ] CH beat up by responsible adult w/curr residents

Has this happened with the people you live with now?


^Fills.Y_EV14

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV14

lessthan11 USE CARD 32A.

---------------------------------------------------------------------------------

Y_EV15a [ YEV15a ] #Xs CH saw persib steal in home where lived

^Fills.Y_EV15 How many times have you seen a person steal stuff from another person in a home

you've lived in? (Would you say never, one time, a few times, or lots of times?)

Question Type: THO3F

nvr 1 Never

once 2 One time

fewtms 3 A few times

lots 4 Lots of times

Question Fill: ^FillY_EV15

lessthan11 USE CARD 33. Chris is at home. Chris sees a person steal stuff from

another person at home.

elevenmore

Logic after:

IF RESPONSE = 1, DK, RE, GOTO Y_EV16a

---------------------------------------------------------------------------------

Y_EV15aa [ YEV15aa ] CH saw adult steal in home where live in last M

Have you seen this happen in the last month?


^Fills.Y_EV15a

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV15a

lessthan11 USE CARD 33A.

---------------------------------------------------------------------------------

Y_EV15xa [ YEV15xa ] CH saw adult steal in home where lived w/current residents

Have you seen this happen with the people you live with now?


^Fills.Y_EV15a

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV15a

lessthan11 USE CARD 33A.

---------------------------------------------------------------------------------

Y_EV16a [ YEV16a ] #Xs CH saw adult point gun/knife at other

^Fills.Y_EV16a How many times have you seen a person point a knife or a real gun at another

person in a home you've lived in? (Would you say never, one time, a few times, or lots of times?)

Question Type: THO3F

nvr 1 Never

once 2 One time

fewtms 3 A few times

lots 4 Lots of times

Question Fill: ^FillY_EV16a

lessthan11 USE CARD 34. Chris is at home. Chris sees an adult point a knife or a

real gun at another person at home.

elevenmore

Logic after:

IF RESPONSE = 1, DK, RE, GOTO Y_EV17a

---------------------------------------------------------------------------------

Y_EV16aa [ YEV16aa ] CH saw adult point gun/knife at other in last M

Have you seen this happen in the last month?


^Fills.Y_EV16

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV16

lessthan11 USE CARD 34A.

---------------------------------------------------------------------------------

Y_EV16xa [ YEV16xa ] CH saw adult point gun/knife at other w/curr residents

Have you seen this happen with the people you live with now?


^Fills.Y_EV16

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV16

lessthan11 USE CARD 34A.

---------------------------------------------------------------------------------

Y_EV17a [ YEV17a ] #Xs adult pointed gun/knife at CH

^Fills.Y_EV17a How many times has an adult pointed a knife or a real gun at you in a home

you've lived in? (Would you say never, one time, a few times, or lots of times?)

Question Type: THO3F

nvr 1 Never

once 2 One time

fewtms 3 A few times

lots 4 Lots of times

Question Fill: ^FillY_EV17a

lessthan11 USE CARD 35. At home, an adult points a knife or a real gun at Chris.

elevenmore

Logic after:

IF RESPONSE = 1, DK, RE, GOTO Y_EV18a

---------------------------------------------------------------------------------

Y_EV17aa [ YEV17aa ] Adlt who pointed gun/knife responsible for CH care

Was that someone who was responsible for taking care of you?


^Fills.Y_EV17

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV17

lessthan11 USE CARD 35A.

---------------------------------------------------------------------------------

Y_EV17ba [ YEV17ba ] Adult point gun/knife at CH this W

Has this happened in the last week?


^Fills.Y_EV17

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV17

lessthan11 USE CARD 35A.

Logic after:

IF RESPONSE = 1, GOTO Y_EV17xa

---------------------------------------------------------------------------------

Y_EV17ca [ YEV17ca ] Adult point gun/knife at CH in last M

Has this happened in the last month?


^Fills.Y_EV17

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV17

lessthan11 USE CARD 35A.

Logic after:

IF RESPONSE = 1, GOTO Y_EV17xa

---------------------------------------------------------------------------------

Y_EV17da [ YEV17da ] Adult point gun/knife at CH in past 3M

Has this happened in the last 3 months?


^Fills.Y_EV17

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV17

lessthan11 USE CARD 35A.

---------------------------------------------------------------------------------

Y_EV17xa [ YEV17xa ] Adult point gun/knife at CH w/curr residents

Has this happened with the people you live with now?


^Fills.Y_EV17

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV17

lessthan11 USE CARD 35A.

---------------------------------------------------------------------------------

Logic before:

IF AGE >=11, GOTO Y_EV19a

Y_EV18a [ YEV18a ] #Xs CH went shopping

USE CARD 36. Chris goes shopping. How many times have you gone shopping? (Would you

say never, one time, a few times, or lots of times?)

Question Type: THO3F

nvr 1 Never

once 2 One time

fewtms 3 A few times

lots 4 Lots of times

---------------------------------------------------------------------------------

Y_EV19a [ YEV19a ] #Xs CH saw adult stab other adult

^Fills.Y_EV19 How many times have you seen a person stab another person with a knife in a

home you've lived in? (Would you say never, one time, a few times, or lots of times?)

Question Type: THO3F

nvr 1 Never

once 2 One time

fewtms 3 A few times

lots 4 Lots of times

Question Fill: ^FillY_EV19

lessthan11 USE CARD 37. Chris is at home. Chris sees an adult stab another

person with a knife at home.

elevenmore

Logic after:

IF RESPONSE = 1, DK, RE, GOTO Y_EV20a

---------------------------------------------------------------------------------

Y_EV19aa [ YEV19aa ] CH saw adult stab other in last M

Have you seen this happen in the last month?


^Fills.Y_EV19a

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV19a

lessthan11 USE CARD 37A.

---------------------------------------------------------------------------------

Y_EV19xa [ YEV19xa ] CH saw adult stab other w/curr residents

Have you seen this happen with the people you live with now?


^Fills.Y_EV19a

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV19a

lessthan11 USE CARD 37A.

---------------------------------------------------------------------------------

Y_EV20a [ YEV20a ] #Xs CH saw adult shoot another person

^Fills.Y_EV20a How many times have you seen a person shoot another person with a real gun in

a home you've lived in? (Would you say never, one time, a few times, or lots of times?)

Question Type: THO3F

nvr 1 Never

once 2 One time

fewtms 3 A few times

lots 4 Lots of times

Question Fill: ^FillY_EV20a

lessthan11 USE CARD 38. Chris is at home. Chris sees an adult shoot another

person with a real gun at home.

elevenmore

Logic after:

IF RESPONSE = 1, DK, RE, GOTO Y_EV21a

---------------------------------------------------------------------------------

Y_EV20aa [ YEV20aa ] CH saw adult shoot other in last M

Have you seen this happen in the last month?


^Fills.Y_EV20

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV20

lessthan11 USE CARD 38A.

---------------------------------------------------------------------------------

Y_EV20xa [ YEV20xa ] CH saw adult shoot other w/curr residents

Have you seen this happen with the people you live with now?


^Fills.Y_EV20

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV20

lessthan11 USE CARD 38A.

---------------------------------------------------------------------------------

Y_EV21a [ YEV21a ] #Xs CH saw person arrested at home

^Fills.Y_EV21 How many times have you seen a person being arrested in a home you've lived in?

(Would you say never, one time, a few times, or lots of times?)

Question Type: THO3F

nvr 1 Never

once 2 One time

fewtms 3 A few times

lots 4 Lots of times

Question Fill: ^FillY_EV21

lessthan11 USE CARD 39. Chris is at home. Chris sees a person being arrested at

home.

elevenmore

Logic after:

IF RESPONSE = 1, DK, RE, GOTO Y_EV22a

---------------------------------------------------------------------------------

Y_EV21aa [ YEV21aa ] CH saw person arrested in last M

Have you seen this happen in the last month?


^Fills.Y_EV21a

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV21a

lessthan11 USE CARD 39A.

---------------------------------------------------------------------------------

Y_EV21xa [ YEV21xa ] CH saw person arrested w/curr residents

Have you seen this happen with the people you live with now?


^Fills.Y_EV21a

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV21a

lessthan11 USE CARD 39A.

---------------------------------------------------------------------------------

Y_EV22a [ YEV22a ] #Xs saw persn deal drugs at home

^Fills.Y_EV22a How many times have you seen a person dealing drugs in a home you've lived in?

(Would you say never, one time, a few times, or lots of times?)

Question Type: THO3F

nvr 1 Never

once 2 One time

fewtms 3 A few times

lots 4 Lots of times

Question Fill: ^FillY_EV22a

lessthan11 USE CARD 40. Chris is at home. Chris sees a person dealing drugs at

home.

elevenmore

Logic after:

IF RESPONSE = 1, DK, RE, GOTO Y_EV23a

---------------------------------------------------------------------------------

Y_EV22aa [ YEV22aa ] CH saw person deal drugs in last M

Have you seen this happen in the last month?


^Fills.Y_EV22

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV22

lessthan11 USE CARD 40A.

---------------------------------------------------------------------------------

Y_EV22xa [ YEV22xa ] CH saw person deal drugs w/curr residents

Have you seen this happen with the people you live with now?


^Fills.Y_EV22

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV22

lessthan11 USE CARD 40A.

---------------------------------------------------------------------------------

Y_EV23a [ YEV23a ] #Xs CH saw kid getting spanked

^Fills.Y_EV23a How many times have you seen a kid getting spanked? (Would you say never,

one time, a few times, or lots of times?)

Question Type: THO3F

nvr 1 Never

once 2 One time

fewtms 3 A few times

lots 4 Lots of times

Question Fill: ^FillY_EV23a

lessthan11 USE CARD 41. Chris sees a kid getting spanked.

elevenmore

Logic after:

IF RESPONSE = 1, DK, RE, GOTO Y_EV24a

---------------------------------------------------------------------------------

Y_EV23aa [ YEV23aa ] CH saw kid getting spanked in last M

Have you seen this happen in the last month?


^Fills.Y_EV23

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV23

lessthan11 USE CARD 41A.

---------------------------------------------------------------------------------

Y_EV23xa [ YEV23xa ] CH saw kid getting spanked w/curr residents

Have you seen this happen with the people you live with now?


^Fills.Y_EV23

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV23

lessthan11 USE CARD 41A.

---------------------------------------------------------------------------------

Y_EV24a [ YEV24a ] #Xs CH was spanked

^Fills.Y_EV24a How many times has a person spanked you? (Would you say never, one time, a

few times, or lots of times?)

Question Type: THO3F

nvr 1 Never

once 2 One time

fewtms 3 A few times

lots 4 Lots of times

Question Fill: ^FillY_EV24a

lessthan11 USE CARD 42. A person spanks Chris.

elevenmore

Logic after:

IF RESPONSE = 1, DK, RE, GOTO Y_EVEND

---------------------------------------------------------------------------------

Y_EV24aa [ YEV24aa ] CH was spanked in last M

Has this happened in the last month?


^Fills.Y_EV24

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV24

lessthan11 USE CARD 42A.

---------------------------------------------------------------------------------

Y_EV24xa [ YEV24xa ] CH was spanked w/curr residents

Has this happened with the people you live with now?


^Fills.Y_EV24

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_EV24

lessthan11 USE CARD 42A.

Logic after:

Y_EVEND

---------------------------------------------------------------------------------

Y_EV_END [ YEV_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

Logic after:

Y_IPEND



SV - CHILD SERVICES RECEIVED MODULE

---------------------------------------------------------------------------------

Logic before:

IF AGE < 11 OR CHILD IS YOUNG ADULT (18+) OR EMANCIPATED, GOTO Y_SVEND. ELSE,

CONTINUE.

Y_SV0 [ YSV0 ] NO LABEL

The following questions ask about services you may have received from different places in the

past 6 months.


Press "1" and the [Enter] key to continue.

Question Type: TCont

Continue 1 Continue

---------------------------------------------------------------------------------

Y_SV1a [ YSV1a ] CH went to peer support groups

A peer support group is a group of young people who meet to talk about things that are important

to them. Usually an adult leads the group, and they might meet at school or a community center.

In the @Bpast 6 months@B have you gone to any peer support groups?

FR NOTE: ONLINE OR VIRTUAL MEETINGS SHOULD BE INCLUDED.


NOTE: PEER SUPPORT GROUPS (LIKE ALATEEN) ARE COMPRISED OF CHILDREN WITH

SIMILAR MEDICAL, EMOTIONAL, PHYSICAL, OR MENTAL HEALTH PROBLEMS (E.G.,

CHILDREN WHO HAVE BEEN ADOPTED, ABUSED, ETC.).

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_SV2a [ YSV2a ] CH went to comm youth ctr

In the @Bpast 6 months@B have you gone to a "drop-in" or community youth center? (These

include community recreation centers, Boys/Girls Clubs, YMCA/YWCA, kids clubs, etc.)

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_SV3a [ YSV3a ] CH recd family plan services

In the @Bpast 6 months@B, have you received any family planning services - like birth control

pills, condoms, or information on making decisions about having sex?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_SV4a [ YSV4a ] CH recd trtmnt for drug/alc probs

In the @Bpast 6 months@B, did you get any kind of professional treatment for an alcohol or drug

problem?


NOTE: TREATMENT SHOULD HAVE BEEN PROVIDED BY A MENTAL HEALTH, MEDICAL, OR

OTHER ALCOHOL/DRUG TREATMENT PROFESSIONAL, NOT BY A CASEWORKER.

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_SV5a [ YSV5a ] CH went to hosp ER

In the @Bpast 6 months@B, did you go to the hospital emergency room for any reason?


NOTE: DO NOT INCLUDE VISITS TO URGENT CARE CENTERS.

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_SV5a = No GOTO Y_SV9a

---------------------------------------------------------------------------------

Y_SV6a [ YSV6a ] CH went to hosp ER for drug/alc prbs

In the @Bpast 6 months@B, did you go to the hospital emergency room because of a problem

with drugs or alcohol?


NOTE: DO NOT INCLUDE VISITS TO URGENT CARE CENTERS.

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_SV6a = No GOTO Y_SV7a

---------------------------------------------------------------------------------

Y_SV6aa [ YSV6aa ] #Xs CH went to ER for DA probs

How many times in the past 6 months have you gone to the hospital emergency room because of

a problem with drugs or alcohol?


NOTE: DO NOT INCLUDE VISITS TO URGENT CARE CENTERS.

Question Type: TSV6aa

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourxs 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't gone to the emergency room for this in the past 6 months

---------------------------------------------------------------------------------

Y_SV7a [ YSV7a ] Did CH go to ER for illness

In the @Bpast 6 months@B, did you go to the hospital emergency room for an illness or an

injury?


Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_SV7a = No GOTO Y_SV8a

---------------------------------------------------------------------------------

Y_SV7aa [ YSV7aa ] #Xs CH went to ER for illness

How many times in the past 6 months have you gone to the hospital emergency room for an

illness or injury?


NOTE: DO NOT INCLUDE VISITS TO URGENT CARE CENTERS.

Question Type: TSV6aa

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourxs 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't gone to the emergency room for this in the past 6 months

---------------------------------------------------------------------------------

Y_SV8a [ YSV8a ] Did CH go to ER for depression

In the @Bpast 6 months@B, did you go to the hospital emergency room because you felt

depressed or blue?


NOTE: DO NOT INCLUDE VISITS TO URGENT CARE CENTERS.

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_SV8a = No GOTO Y_SV9a

---------------------------------------------------------------------------------

Y_SV8aa [ YSV8aa ] #Xs CH went to ER for depression

How many times in the past 6 months have you gone to the hospital emergency room because

you felt depressed or blue?


NOTE: DO NOT INCLUDE VISITS TO URGENT CARE CENTERS.

Question Type: TSV6aa

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourxs 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't gone to the emergency room for this in the past 6 months

---------------------------------------------------------------------------------

Y_SV9a [ YSV9a ] CH got counsel to deal w/depress

In the @Bpast 6 months@B, did you get any kind of counseling from a school counselor, doctor,

or therapist to help you deal with feeling depressed or blue?


NOTE: DO NOT INCLUDE COUNSELING FROM A CASEWORKER.

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

GOTO Y_SVEND



SA - CHILD SUBSTANCE ABUSE MODULE

---------------------------------------------------------------------------------

Logic before:

IF AGE >= 11, OR CHILD IS EMACIPATED OR YOUNG ADULT (18+), GOTO Y_SA0. ELSE, GO

TO Y_SAEND.

Y_SA0 [ YSA0 ] NO LABEL

The following questions ask about alcohol, different drugs, and tobacco.


Please remember that all your answers are private.


Press "1" and the [Enter] key to continue.

Question Type: TCont

Continue 1 Continue


Y_SA1

During the past 12 months, have you used any alcohol, marijuana, cocaine, heroin, or other substances?

1=YES

2=NO [GO TO Y_SA5]


Y_SA1a

[During the past 12 months,]

Have you tried to hide that you were using alcohol, marijuana, or other drugs?

1=YES

2=NO


Y_SA1b

[During the past 12 months,]

Have your parents, family, partner, co-workers, classmates, or friends complained about your alcohol, marijuana, or other drug use?

1=YES

2=NO


Y_SA1c

[During the past 12 months,]

Have you used alcohol, marijuana, or other drugs weekly?

1=YES

2=NO


Y_SA1d

[During the past 12 months,]

Has alcohol, marijuana, or other drug use caused you to feel depressed, nervous, suspicious, uninterested in things, reduced your sexual desire or caused other psychological problems?

1=YES

2=NO


Y_SA1e

[During the past 12 months,]

Has alcohol, marijuana, or other drug use caused you to have numbness, tingling, shakes, blackouts, hepatitis, TB, sexually transmitted disease or any other health problems?

1=YES

2=NO


Y_SA2a

[During the past 12 months,]

Have you kept using alcohol, marijuana, or other drugs even though you knew it was keeping you from meeting your responsibilities at work, school, or home?

1=YES

2=NO


Y_SA2b

[During the past 12 months,]

Have you used alcohol, marijuana, or other drugs where it made the situation unsafe or dangerous for you, such as when you were driving a car, using a machine, or where you might have been forced into sex or hurt?

1=YES

2=NO


Y_SA2c

[During the past 12 months,]

Has alcohol, marijuana, or other drug use caused you to have repeated problems with the law?

1=YES

2=NO


Y_SA2d

[During the past 12 months,]

Have you kept using alcohol, marijuana, or other drugs even after you knew it could get you into fights or other kinds of legal trouble?

1=YES

2=NO


Y_SA3a

[During the past 12 months,]

Have you needed more alcohol, marijuana, or other drugs to get the same high or found that the same amount did not get you as high as it used to?

1=YES

2=NO


Y_SA3b

[During the past 12 months,]

Have you had withdrawal problems from alcohol, marijuana, or other drugs like shaking hands, throwing up, having trouble sitting still or sleeping, or have you used any alcohol, marijuana, or other drugs to stop being sick or avoid withdrawal problems?

1=YES

2=NO


Y_SA3c

[During the past 12 months,]

Have you used alcohol, marijuana, or other drugs in larger amounts more often or for a longer time than you meant to?

1=YES

2=NO


Y_SA3d

[During the past 12 months,]

Have you been unable to cut down or stop using alcohol, marijuana, or other drugs?

1=YES

2=NO


Y_SA3e

[During the past 12 months,]

Have you spent a lot of time either getting alcohol, marijuana, or other drugs, using them, or feeling the effects of them (high, sick)?

1=YES

2=NO


Y_SA3f

[During the past 12 months,]

Has alcohol, marijuana, or other drugs caused you to give up, reduce or have problems at important activities as work, school, home or social events?

1=YES

2=NO


Y_SA3g

[During the past 12 months,] Have you kept using alcohol, marijuana, or other drugs even after you knew it was causing or adding to medical, psychological or emotional problems you were having?

1=YES

2=NO


For the next set of questions, please answer for the last 90 days that you lived in the community. Do not count days when you were living in a jail, hospital, or other place where you could not use alcohol, marijuana, or other drugs.


Y_SA4b

During the last 90 days that you lived in the community, how many days did you drink beer, wine, or any kind of alcohol?


NUMBER OF DAYS _______


Y_SA4c

[During the last 90 days that you lived in the community, how many days did you]

Get drunk or have 5 or more drinks at one time?


NUMBER OF DAYS _______


Y_SA4d

[During the last 90 days that you lived in the community, how many days did you]

Smoke or use any kind of marijuana, blunts, or hashish?


NUMBER OF DAYS _______


Y_SA4e

[During the last 90 days that you lived in the community, how many days did you]

Use LSD, cocaine, heroin, ecstasy, inhalants, or any other kind of drug?


NUMBER OF DAYS _______ IF NUMBER OF DAYS > 0 THEN ASK Y_SA4EA


Y_SA4ea

What did you use? CODE ALL THA APPLY

1=Cocaine

2=Heroin

3=Ecstasy

4=Inhalants

5=Other kind of drug


Y_SA4f

[During the last 90 days that you lived in the community, how many days did you]

Go without using any alcohol, marijuana, or other drug?


NUMBER OF DAYS _______


Y_SA5

[During the last 90 days that you lived in the community, how many days did you]

On how many days did you smoke any kind of tobacco?


NUMBER OF DAYS _______

SX - CHILD SEXUAL ACTIVITY MODULE

---------------------------------------------------------------------------------

IF AGE < 11, GOTO Y_SXEND. IF CHILD IS YOUNG ADULT (18+) OR EMANCIPATED, CONTINUE.

The next questions are about sexual activity.  Please remember that your answers are private.


---------------------------------------------------------------------------------

Y_SX1a

During your life, with whom, if anyone, have you had sexual contact?

1=I have never had sexual contact

2=Females

3=Males

4=Females and males

---------------------------------------------------------------------------------

Logic before:

Y_SX10a [ YSX20a ] Have you ever had sex or sexual intercourse?


Have you ever had sex or sexual intercourse?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_SX10a = 2 GO TO Y_SXEND

---------------------------------------------------------------------------------

Y_SX11a [ YSX21a ] Frst time u had sex, was it frcd or not frcd?

Think about the first time you had sex, would you say it was forced or not forced? "Forced"

means that the sex was against your will, and "not forced" means it was something that you

wanted to happen or that it was okay with you.

Question Type: TYSX11a

forced 1 Forced (it was against my will)

notforced 2 Not forced (I wanted it to happen, or it was okay with me)

---------------------------------------------------------------------------------

Y_SX12a [ YSX22a ] How old were you this first time you had sex?

How old were you this @Bfirst@B time you had sex?

Question Type: TYSX12a

eight 8 8 years old or younger

nine 9 9 years old

ten 10 10 years old

eleven 11 11 years old

twelve 12 12 years old

thirteen 13 13 years old

fourteen 14 14 years old

fifteen 15 15 years old

sixteen 16 16 years old

seventeen 17 17 years old

eighteen 18 18 years old or older

---------------------------------------------------------------------------------

Logic before:

IF Y_SX11a = DK/REF, FOLLOW SAME SKIP PATTERN AS IF SX11a = NO.

Y_SX13a [ YSX23a ] Had sex you wntd to hpn/was forced?

^Fills.Y_SX13a

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_SX13a

forced Have you ever had sex that you wanted to happen or that was okay with

you?

notforced Have you ever had sex that was forced -- that is, that was against your

Logic after:

IF Y_SX13a = 2 GO TO Y_SX15a

---------------------------------------------------------------------------------

Logic before:

IF Y_SX11a = 1 fill: sex that you wanted to happen or that was okay with you; IF Y_SX11a = 2 OR

DK/REF fill: sex that was forced or against your will

Y_SX14a [ YSX24a ] How old were you the frst time you had sex you wntd/was frcd

How old were you the first time you had ^Fills.Y_SX14a?

Question Type: TYSX12a

eight 8 8 years old or younger

nine 9 9 years old

ten 10 10 years old

eleven 11 11 years old

twelve 12 12 years old

thirteen 13 13 years old

fourteen 14 14 years old

fifteen 15 15 years old

sixteen 16 16 years old

seventeen 17 17 years old

eighteen 18 18 years old or older

Question Fill: ^FillY_SX14a

forced sex that you wanted to happen or that was okay with you

notforced sex that was forced or against your will

---------------------------------------------------------------------------------

Logic before:

IF R IS MALE fill: Counting all your female partners, even those you had sex with only once, how

many females have you had sex with @Bin your life@B?; IF R IS FEMALE fill: Counting all your

male partners, even those you had sex with only once, how many males have you had sex with

@Bin your life@B?

Y_SX15a [ YSX25a ] How mny females/males hve you had sex with in ur life?

^Fills.Y_SX15a

Question Type: TYSX15a

one 1 1 partner

two 2 2 partners

threefive 3 3 - 5 partners

sixnine 4 6 - 9 partners

tenormore 5 More than 10 partners

Question Fill: ^FillY_SX15a

male Counting all your female partners, even those you had sex with only

once, how many females have you had sex with @Bin your life@B?

female Counting all your male partners, even those you had sex with only once,

how many males have you had sex with @Bin your life@B?

---------------------------------------------------------------------------------

Y_SX15b

The last time you had sexual intercourse, did you or your partner use a condom?

1 YES

2 NO

---------------------------------------------------------------------------------

Y_SX15c

Did you drink alcohol or use drugs before you had sexual intercourse the last time?

1 YES

2 NO

---------------------------------------------------------------------------------

Y_SX16a [ YSX26a ] Have you had sex anytime in the past 12 months?

Have you had sex anytime in the past 12 months?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_SX16a = 2 GO TO Y_SX18a


---------------------------------------------------------------------------------

Logic before:

IF R IS MALE: In the past 12 months, how many females have you had sex with? Please count

every female sexual partner, even those you had sex with only once, or if you did not know her

well.; IF R IS FEMALE fill: In the past 12 months, how many males have you had sex with?

Please count every male sexual partner, even those you had sex with only once, or if you did not

Y_SX17a [ YSX27a ] Pst 12 mnths, how mny F/M have you had sex with?

^Fills.Y_SX17a

Question Type: TYSX15a

one 1 1 partner

two 2 2 partners

threefive 3 3 - 5 partners

sixnine 4 6 - 9 partners

tenormore 5 More than 10 partners

Question Fill: ^FillY_SX17a

male In the past 12 months, how many females have you had sex with? Please

count every female sexual partner, even those you had sex with only

once, or if you did not know her well.

female In the past 12 months, how many males have you had sex with? Please

count every male sexual partner, even those you had sex with only once,

or if you did not know him well.

---------------------------------------------------------------------------------

Y_SX18a [ YSX28a ] Labels are in Logic After

The most recent time you had sex, what method or methods did you or your partner use to

prevent a pregnancy? Please check all methods you or your partner used that time.


TO CHOOSE MORE THAN ONE OPTION, PRESS THE SPACE BAR BETWEEN YOUR

ANSWERS OR USE THE MOUSE TO CHOOSE YOUR OPTIONS.

Question Type: TYSX18aS

none 1 We did not use any method

condom 2 Condom

withdrwl 3 Withdrawal ("pulling out")

bcp 4 Birth control pill

shot_ring_patch 5 A shot (such as Depo-Provera), patch (such as Ortho Evra), or birth control ring (such as NuvaRing) patch

iud 6 An IUD (such as Mirena or ParaGard) or implant (such as Implanon or Nexplanon)

other 7 Other methods

Logic after:

YSX18a_1 --Birth control used last time had sex - None; YSX18a_2 --Birth control used last time

had sex - Male condom; YSX18a_3 --Birth control used last time had sex - Withdrawal; YSX18a_4 --Birth control used last time had sex - Birth control pill; YSX18a_5 --Birth control used last time

had sex - Birth control injectn; YSX18a_6 --Birth control used last time had sex - Birth control

patch; YSX18a_7 --Birth control used last time had sex - Other methods; YSX18a_8--Birth control used last time had sex - DK; YSX18a_9--Birth control used last time had sex - RF

---------------------------------------------------------------------------------

Logic before:

IF R IS MALE fill: gotten someone pregnant; IF R IS FEMALE fill: been pregnant

Y_SX19a [ YSX29a ] How many times have you ever been/gttn someone prgnt?

How many times have you ever ^Fills.Y_SX19a?

Question Type: TYSX19a

never 0 I have never (gotten anyone pregnant/gotten pregnant)

once 1 once

twice 2 two times

thrice 3 three times

fourmore 4 four or more times

Question Fill: ^FillY_SX19a

male gotten someone pregnant

female been pregnant

Logic after:

IF Y_SX19a = 0 GO TO Y_SX22a

---------------------------------------------------------------------------------

Logic before:

IF R IS FEMALE fill: you got pregnant?; IF R IS MALE fill: you got someone pregnant?

Y_SX20a [ YSX30a ] How old wre u the time/frst time you got/got someone prgnt?

How old were you the^Fills.Y_SX20a1 time ^Fills.Y_SX20a2?

Question Type: TYSX20a

ten 10 10 years old

eleven 11 11 years old

twelve 12 12 years old

thirteen 13 13 years old

fourteen 14 14 years old

fifteen 15 15 years old

sixteen 16 16 years old

seventeen 17 17 years old

eighteen 18 18 years old or older

Question Fill: ^FillY_SX20a1

once

moreonce ·first

Question Fill: ^FillY_SX20a2

male you got someone pregnant

female you got pregnant

---------------------------------------------------------------------------------

Y_SX21a [ YSX31a ] How mny chldrn have you had (lvng with you or not)?

How many children have you had, including all children living with you or not?

Question Type: TYSX21a

none 0 I have never had a child

one 1 1 child

two 2 2 children

threemore 3 3 or more children

---------------------------------------------------------------------------------

IF AGE11-18+, ASK Y_SX32a. ELSE, SKIP TO Y_SX_END.


Y_SX32a [ YSX32a ] NO LABEL

Which of the following best represents how you think of yourself?

Question Type: Tsexor

_1 1 Lesbian or gay

_2 2 Straight, that is, not gay or lesbian

_3 3 Bisexual

_4 4 [IF Y_CH8a = 1] Two-Spirit 5 5 I use a different term

6) DON’T KNOW

7) PREFER NOT TO ANSWER



IF Y_SX32a = 5, ASK Y_SX3OTH

Y_SX3OTH

What is the term that you use?

[TEXT BOX]

DON’T KNOW

PREFER NOT TO ANSWER



Y_SX_END [ YSX_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue



DE - CHILD DELINQUENCY MODULE

---------------------------------------------------------------------------------

Y_DE_BGN [ YDE_BGN ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

---------------------------------------------------------------------------------

Logic before:

IF AGE <11, GOTO Y_DEEND. IF CHILD IS YOUNG ADULT (18+) OR EMANCIPATED, GOTO

Y_DE7. ELSE, CONTINUE.

Y_DE1a [ YDE1a ] CH run away from home - past 6M

The next questions are about your behavior. Please tell me the number of times you've done each

of these things during the past @B6 months@B. Your best guess will do. No one will tell your

family or teachers anything about your answers. Your answers are private.


In the @Bpast 6 months@B, have you run away from home?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE1a = 2 GOTO Y_DE3a

---------------------------------------------------------------------------------

Y_DE2a [ YDE2a ] # Xs CH ran away from home - past 6M

How many times in the past 6 months have you run away from home?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

Logic after:

IF ANSWER OPTION 8 = HAVE NOT RUN AWAY, GOTO Y_DE3a.

---------------------------------------------------------------------------------

Y_DE2aa [ YDE2aa ] Labels are in Logic After

Why did you run away from home?


CODE ALL THAT APPLY. TO CHOOSE MORE THAN ONE OPTION, PRESS THE SPACE BAR

BETWEEN YOUR ANSWERS OR USE THE MOUSE TO CHOOSE YOUR OPTIONS.

Question Type: TDE2aaS

getaway 1 To get away from parents

forfun 2 For fun and adventure

hadfight 3 Had fight with parents

other 4 Other

Logic after:

YDE2aa_1 --Why did you run away from home? - To get away from parents; YDE2aa_2 --Why did

you run away from home? - For fun and adventure; YDE2aa_3 --Why did you run away from home?

- Had fight with parents; YDE2aa_4 --Why did you run away from home? - Other; YDE2aa_5--Why

did you run away from home? - DK; YDE2aa_6--Why did you run away from home? - RF

---------------------------------------------------------------------------------

Y_DE2bn [ YDE2bn ] How long were you gone from home (number)?

How long were you gone from home?


NUMBER:

Question Type: 0..500

---------------------------------------------------------------------------------

Y_DE2ba [ YDE2ba ] How long were you gone from home (hrs/days/wks/yrs)?

(Is that the number of hours, days, weeks, or months?)

Question Type: THDWMY

hours 1 Hours

days 2 Days

weeks 3 Weeks

months 4 Months

years 5 Years

---------------------------------------------------------------------------------

Y_DE2ca [ YDE2ca ] Were you gone overnight?

Were you gone overnight?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_DE2da [ YDE2da ] Where did you run to?

Where did you run to?

Question Type: TDE2da

relatives 1 Relative's

friends 2 Friend's place

other 3 Other

---------------------------------------------------------------------------------

Y_DE2fa [ YDE2fa ] Were you alone or with others?

Were you alone or with others?

Question Type: TDE2fa

alone 1 Alone

wothers 2 With others

---------------------------------------------------------------------------------

Y_DE3a [ YDE3a ] Past 6M CH skipped classes/sch.

In the @Bpast 6 months@B, have you skipped classes or school without an excuse?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE3a = 2 GOTO Y_DE5a

---------------------------------------------------------------------------------

Y_DE4a [ YDE4a ] # Xs CH skipped classes/sch past 6M

How many times in the past 6 months have you skipped classes or school without an excuse?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE5a [ YDE5a ] Past 6M CH lied about age for movie

In the @Bpast 6 months@B, have you lied about your age to get into some place or to buy

something, for example lying about your age to get into a movie or to buy alcohol?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE5a = 2 GOTO Y_DE7a

---------------------------------------------------------------------------------

Y_DE6a [ YDE6a ] # Xs CH lied about age for movie past 6M

How many times in the past 6 months have you lied about your age to get into some place or to

buy something, for example lying about your age to get into a movie or to buy alcohol?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Logic before:

[READ INTRO ONLY IF AGE IS >=18 OR EMANCIPATED.]

Y_DE7a [ YDE7a ] Past 6M CH hitchhiked

^Fills.Y_DE7a In the @Bpast 6 months@B, have you hitchhiked where it was illegal to do so?

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_DE7a

forya_ey The next questions are about your behavior. Please tell me the number of

times you’ve done each of these things during the past @B6 months@B.

Your best guess will do. No one will tell anyone about your answers.

Your answers are private.

·

notya_ey

Logic after:

IF Y_DE7a = 2 GOTO Y_DE9a

---------------------------------------------------------------------------------

Y_DE8a [ YDE8a ] # Xs CH hitchicked past 6M

How many times in the past 6 months have you hitchhiked where it was illegal to do so?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE9a [ YDE9a ] Past 6M CH carried hidden weapon

In the @Bpast 6 months@B, have you carried a hidden weapon?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE9a = 2 GOTO Y_DE11a

---------------------------------------------------------------------------------

Y_DE10a [ YDE10a ] # Xs CH carried hidden weapon past 6M

How many times in the past 6 months have you carried a hidden weapon?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE11a [ YDE11a ] Past 6M CH unruly in public

In the @Bpast 6 months@B, have you been loud, rowdy, or unruly in a public place so that

people complained about it or you got in trouble?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE11a = 2 GOTO Y_DE13a

---------------------------------------------------------------------------------

Y_DE12a [ YDE12a ] # Xs CH unruly in public past 6M

How many times in the past 6 months have you been loud, rowdy, or unruly in a public place so

that people complained about it or you got in trouble?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE13a [ YDE13a ] Past 6M CH begged $/things

In the @Bpast 6 months@B, have you begged for money or things from strangers?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE13a = 2 GOTO Y_DE15a

---------------------------------------------------------------------------------

Y_DE14a [ YDE14a ] # Xs CH begged $/things past 6M

How many times in the past 6 months have you begged for money or things from strangers?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE15a [ YDE15a ] Past 6M CH was drunk in pub

In the @Bpast 6 months@B, have you been drunk in a public place?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE15a = 2 GOTO Y_DE16aa

---------------------------------------------------------------------------------

Y_DE16a [ YDE16a ] # Xs CH drunk in public past 6M

How many times in the past 6 months have you been drunk in a public place?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE16aa [ YDE16aa ] Past 6MC CH painted graffiti or signs

In the @Bpast 6 months@B, have you painted graffiti or signs on someone else's property or in a

public place?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE16aa = 2 GOTO Y_DE17a

---------------------------------------------------------------------------------

Y_DE16ba [ YDE16ba ] # Xs CH painted graffit past 6M

How many times in the past 6 months have you painted graffiti or signs on someone else's

property or in a public place?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE17a [ YDE17a ] Past 6M CH damaged property

In the @Bpast 6 months@B, have you purposely damaged or destroyed property that did not

belong to you, for example, painting, breaking, cutting, or marking up something?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE17a = 2 GOTO Y_DE19a

---------------------------------------------------------------------------------

Y_DE18a [ YDE18a ] # Xs CH damaged property past 6M

How many times in the past 6 months have you purposely damaged or destroyed property that

did not belong to you, for example, painting, breaking, cutting, or marking up something?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE19a [ YDE19a ] Past 6M CH set fire to house/prop

In the @Bpast 6 months@B, have you purposely set fire to a house, building, car, or other

property or tried to do so?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE19a = 2 GOTO Y_DE21a

---------------------------------------------------------------------------------

Y_DE20a [ YDE20a ] # Xs CH set fire to house/prop past 6M

How many times in the past 6 months have you purposely set fire to a house, building, car, or

other property or tried to do so?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE21a [ YDE21a ] Past 6M CH avoided paying

In the @Bpast 6 months@B, have you avoided paying for things such as movies, bus or subway

rides, food, or clothing?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE21a = 2 GOTO Y_DE23a

---------------------------------------------------------------------------------

Y_DE22a [ YDE22a ] # Xs CH avoided paying past 6M

How many times in the past 6 months have you avoided paying for things such as movies, bus, or

subway rides, food, or computer services?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE23a [ YDE23a ] Past 6M CH went in bldg to steal

In the @Bpast 6 months@B, have you gone into or tried to go into a building to steal something?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE23a = 2 GOTO Y_DE25a

---------------------------------------------------------------------------------

Y_DE24a [ YDE24a ] # Xs CH went in bldg to steal past 6M

How many times in the past 6 months have you gone into or tried to go into a building to steal

something?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE25a [ YDE25a ] Past 6M CH stole things < $5

In the @Bpast 6 months@B, have you stolen or tried to steal things worth $5 or less?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE25a = 2 GOTO Y_DE27a

---------------------------------------------------------------------------------

Y_DE26a [ YDE26a ] # Xs CH stole things < $5 past 6M

How many times in the past 6 months have you stolen or tried to steal things worth $5 or less?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE27a [ YDE27a ] Past 6M CH stole items < $5+ > $50

In the @Bpast 6 months@B, have you stolen or tried to steal things worth between $5 and $50?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE27a = 2 GOTO Y_DE29a

---------------------------------------------------------------------------------

Y_DE28a [ YDE28a ] # Xs CH stole items < $5+ > $50 past 6M

How many times in the past 6 months have you stolen or tried to steal things worth between $5

and $50?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE29a [ YDE29a ] Past 6M CH stole items < $50+ > $100

In the @Bpast 6 months@B, have you stolen or tried to steal things worth between $50 and

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE29a = 2 GOTO Y_DE31a

---------------------------------------------------------------------------------

Y_DE30a [ YDE30a ] # Xs CH stole items < $50+ > $100 past 6M

How many times in the past 6 months have you stolen or tried to steal things worth between $50

and $100?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE31a [ YDE31a ] Past 6M CH stole items > $100

In the @Bpast 6 months@B, have you stolen or tried to steal something worth $100 or more?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE31a = 2 GOTO Y_DE33a

---------------------------------------------------------------------------------

Y_DE32a [ YDE32a ] # Xs CH stole items worth > $100 past 6M

How many times in the past 6 months have you stolen or tried to steal something worth $100 or

more?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE33a [ YDE33a ] Past 6M CH took fr store w/o pay

In the @Bpast 6 months@B, have you taken something from a store without paying for it? This

includes times that you have already told about for other questions.

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE33a = 2 GOTO Y_DE35a

---------------------------------------------------------------------------------

Y_DE34a [ YDE34a ] # Xs CH took fr store w/o pay past 6M

How many times in the past 6 months have you taken something from a store without paying for

it? This includes times that you have already told about for other questions.

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE35a [ YDE35a ] Past 6M CH snatched wallet/purse

In the @Bpast 6 months@B, have you snatched someone's purse or wallet or picked someone's

pocket?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE35a = 2 GOTO Y_DE37a

---------------------------------------------------------------------------------

Y_DE36a [ YDE36a ] # Xs CH snatched wallet/purse past 6M

How many times in the past 6 months have you snatched someone's purse or wallet or picked

someone's pocket?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE37a [ YDE37a ] Past 6M CH took item fr car

In the @Bpast 6 months@B, have you taken something from a car that did not belong to you?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE37a = 2 GOTO Y_DE39a

---------------------------------------------------------------------------------

Y_DE38a [ YDE38a ] # Xs CH took item fr car past 6M

How many times in the past 6 months have you taken something from a car that did not belong to

you?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE39a [ YDE39a ] Past 6M CH bought/sld stolen goods

In the @Bpast 6 months@B, have you knowingly bought, sold or held stolen goods or tried to do

any of these things?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE39a = 2 GOTO Y_DE41a

---------------------------------------------------------------------------------

Y_DE40a [ YDE40a ] # Xs CH bought/sld stolen goods past 6M

How many times in the past 6 months have you knowingly bought, sold or held stolen goods or

tried to do any of these things?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE41a [ YDE41a ] Past 6M CH went joyriding

In the @Bpast 6 months@B, have you gone joyriding, that is, taken a motor vehicle, such as a

car or motorcycle, for a ride or drive without the owner's permission?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE41a = 2 GOTO Y_DE43a

---------------------------------------------------------------------------------

Y_DE42a [ YDE42a ] # Xs CH went joyriding past 6M

How many times in the past 6 months have you gone joyriding, that is, taken a motor vehicle,

such as a car or motorcycle, for a ride or drive without the owner's permission?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE43a [ YDE43a ] Past 6M CH stole vehicle

In the @Bpast 6 months@B, have you stolen or tried to steal a motor vehicle such as a car or

motorcycle?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE43a = 2 GOTO Y_DE45a

---------------------------------------------------------------------------------

Y_DE44a [ YDE44a ] # Xs CH stole vehicle past 6M

How many times in the past 6 months have you stolen or tried to steal a motor vehicle such as a

car or motorcycle?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE45a [ YDE45a ] Past 6 M CH used false checks/$

In the @Bpast 6 months@B, have you used checks illegally or used a slug or fake money to pay

for something?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE45a = 2 GOTO Y_DE47a

---------------------------------------------------------------------------------

Y_DE46a [ YDE46a ] # Xs CH used false checks/$ past 6M

How many times in the past 6 months have you used checks illegally or used a slug or fake

money to pay for something?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE47a [ YDE47a ] Past 6M CH used cr cards w/o perm

In the @Bpast 6 months@B, have you used or tried to use credit cards or bank cards without the

owner's permission?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE47a = 2 GOTO Y_DE49a

---------------------------------------------------------------------------------

Y_DE48a [ YDE48a ] # Xs CH used cr cards w/o perm past 6M

How many times in the past 6 months have you used or tried to use credit cards or bank cards

without the owner's permission?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE49a [ YDE49a ] Past 6M CH sell item above value

In the @Bpast 6 months@B, have you tried to cheat someone by selling them something that

was worthless or not what you said it was?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE49a = 2 GOTO Y_DE51a

---------------------------------------------------------------------------------

Y_DE50a [ YDE50a ] # Xs CH sold item above value past 6M

How many times in the past 6 months have you tried to cheat someone by selling them

something that was worthless or not what you said it was?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE51a [ YDE51a ] Past 6M CH attacked w/intent to hurt

In the @Bpast 6 months@B, have you attacked someone with a weapon or with the idea of

seriously hurting or killing them?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE51a = 2 GOTO Y_DE53a

---------------------------------------------------------------------------------

Y_DE52a [ YDE52a ] # Xs CH attacked w/intent to hurt past 6M

How many times in the past 6 months have you attacked someone with a weapon or with the idea

of seriously hurting or killing them?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE53a [ YDE53a ] Past 6M CH hit to hurt

In the @Bpast 6 months@B, have you hit someone with the idea of hurting them^Fills.Y_DE53a?

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_DE53a

donebefore ·other than the events you just mentioned

notbefore

Logic after:

IF Y_DE53a = 2 GOTO Y_DE55a

---------------------------------------------------------------------------------

Y_DE54a [ YDE54a ] # Xs CH hit to hurt past 6M

How many times in the past 6 months have you hit someone with the idea of hurting

them^Fills.Y_DE53a?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

Question Fill: ^FillY_DE53a

donebefore ·other than the events you just mentioned

notbefore

---------------------------------------------------------------------------------

Y_DE55a [ YDE55a ] Pst6M CH usdd threat/weapon to take $

In the @Bpast 6 months@B, have you used a weapon, force, or strong-arm methods like threats

to get money or things from people?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE55a = 2 GOTO Y_DE57a

---------------------------------------------------------------------------------

Y_DE56a [ YDE56a ] # Xs CH usdd threat/weapon to take $ past 6M

How many times in the past 6 months have you used a weapon, force, or strong-arm methods like

threats to get money or things from people?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE57a [ YDE57a ] Past 6M CH threw rocks/bottles

In the @Bpast 6 months@B, have you thrown objects such as rocks or bottles at people other

than the events that you already mentioned?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE57a = 2 GOTO Y_DE59a

---------------------------------------------------------------------------------

Y_DE58a [ YDE58a ] # Xs CH threw rocks/bottles past 6M

How many times in the past 6 months have you thrown objects such as rocks or bottles at people

other than the events that you already mentioned?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE59a [ YDE59a ] Past 6M CH involved in gang fight

In the @Bpast 6 months@B, have you been involved in a gang fight?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE59a = 2 GOTO Y_DE61a

---------------------------------------------------------------------------------

Y_DE60a [ YDE60a ] # Xs CH involved in gang fight past 6M

How many times in the past 6 months have you been involved in a gang fight?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE61a [ YDE61a ] Past 6M CH paid for having sex

In the @Bpast 6 months@B, have you been paid for having sexual relations with someone?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE61a = 2 GOTO Y_DE63a

---------------------------------------------------------------------------------

Y_DE62a [ YDE62a ] # Xs CH paid for having sex past 6M

How many times in the past 6 months have you been paid for having sexual relations with

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE63a [ YDE63a ] Past 6M CH threat other to have sex

In the @Bpast 6 months@B, have you physically hurt or threatened to hurt someone to get them

to have sex with you?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE63a = 2 GOTO Y_DE65a

---------------------------------------------------------------------------------

Y_DE64a [ YDE64a ] # Xs CH threat other to have sex past 6M

How many times in the past 6 months have you physically hurt or threatened to hurt someone to

get them to have sex with you?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE65a [ YDE65a ] Past 6M CH tried sex against will

In the @Bpast 6 months@B, have you had or tried to have sexual relations with someone against

their will? ^Fills.Y_DE65a

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_DE65a

donebefore Do not include the times you just mentioned in the last question.

notbefore

Logic after:

IF Y_DE65a = 2 GOTO Y_DE67a

---------------------------------------------------------------------------------

Y_DE66a [ YDE66a ] # Xs CH tried sex against will past 6M

How many times in the past 6 months have you had or tried to have sexual relations with

someone against their will? ^Fills.Y_DE65a

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

Question Fill: ^FillY_DE65a

donebefore Do not include the times you just mentioned in the last question.

notbefore

---------------------------------------------------------------------------------

Y_DE67a [ YDE67a ] Past 6M CH sold pot/hash

In the @Bpast 6 months@B, have you sold marijuana or hashish (pot, grass, hash)?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE67a = 2 GOTO Y_DE69a

---------------------------------------------------------------------------------

Y_DE68a [ YDE68a ] # Xs CH sold pot/hash past 6M

How many times in the past 6 months have you sold marijuana or hashish (pot, grass, hash)?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE69a [ YDE69a ] Past 6M CH sold hard drugs

In the @Bpast 6 months@B, have you sold hard drugs such as heroin, cocaine, or crack?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE69a = 2 GOTO Y_DE71a

---------------------------------------------------------------------------------

Y_DE70a [ YDE70a ] # Xs CH sold hard drugs past 6M

How many times in the past 6 months have you sold hard drugs such as heroin, cocaine, or crack?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Y_DE71a [ YDE71a ] Past 6M CH arrested

In the @Bpast 6 months@B, have you been arrested or picked up by the police for something

other than a minor traffic offense?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE71a = 2 GOTO Y_DEEND

---------------------------------------------------------------------------------

Y_DE72a [ YDE72a ] # Xs CH arrested past 6M

How many times in the past 6 months have you been arrested or picked up by the police for

something other than a minor traffic offense?

Question Type: TDE2a

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourx 4 4 times

fivemore 5 5 or more times

notin6mos 8 I haven't done this in the past 6 months

---------------------------------------------------------------------------------

Logic before:

IF Y_DE72a = 8, GOTO Y_DEEND. ELSE, CONTINUE.

Y_DE73a [ YDE73a ] CH arrested/picked up for assault

^Fills.Y_DE73a


Were you arrested or picked up for assault, that is, battery, rape, aggravated assault, or

manslaughter?

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_DE73a

onetime Next, we’d like to know why you were arrested or picked up by the police

in the past 6 months.

moreonetime Next, we’d like to know all of the reasons you have been arrested or

picked up by the police in the past 6 months.

notonce

---------------------------------------------------------------------------------

Y_DE74a [ YDE74a ] CH arrested/picked up for robbery

Were you arrested or picked up for robbery, that is, taking something using a weapon or physical

force?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_DE75a [ YDE75a ] CH arrested/picked up for theft

Still thinking about the last 6 months, were you arrested or picked up for theft or taking something

without using force, such as burglary, larceny or shoplifting?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_DE76a [ YDE76a ] CH arrested/picked up stolen prop

Were you arrested or picked up for receiving, possessing, or selling stolen property?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_DE77a [ YDE77a ] CH arrested destroy prop

Were you arrested or picked up for destroying property, such as vandalism or arson, or another

property offense, such as trespassing or breaking and entering?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_DE78a [ YDE78a ] CH arrested/picked up for drugs

Still thinking about the last 6 months, were you arrested or picked up for a drug related offense,

such as possessing or selling drugs?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_DE78a = 2 GOTO Y_DE79a

---------------------------------------------------------------------------------

Y_DE78aa [ YDE78aa ] CH arrested possessing marijuana

Were you arrested or picked up for possessing or using marijuana or hashish?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_DE78ba [ YDE78ba ] CH arrested for selling marijuana

Were you arrested or picked up for selling marijuana or hashish?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_DE78ca [ YDE78ca ] CH arrested for illegal drugs

Were you arrested or picked up for possessing or using other illegal drugs?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_DE78da [ YDE78da ] CH arrested selling illegal drugs

Were you arrested or picked up for selling or manufacturing other illegal drugs?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_DE79a [ YDE79a ] CH arrested major traffic offense

Were you arrested or picked up for a major traffic offense, such as driving while impaired, reckless

driving, or driving without a license?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_DE80a [ YDE80a ] CH arrested underage drinking

Still thinking about the last 6 months, were you arrested or picked up for drinking or purchasing

alcohol while under the legal age?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_DE81a [ YDE81a ] CH arrested animal abuse/neglect

Were you arrested or picked up for animal abuse or neglect?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_DE82a [ YDE82a ] CH arrested for illegal firearm

Were you arrested or picked up for possessing or selling an illegal firearm?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_DE83a [ YDE83a ] CH arrested for prostitution

Were you arrested or picked up for solicitation or prostitution?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_DE84a [ YDE84a ] Past year, were you a member of a youth or street gang?

In the past year, were you a member of a youth or street gang?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

GOTO Y_DEEND

---------------------------------------------------------------------------------

Y_DE_END [ YDE_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue





VC - VICTIMIZATION AND ADVERSE CHILD EXPERIENCES MODULE

---------------------------------------------------------------------------------

Logic before:

IF CHILD IS YOUNG ADULT (18+), CONTINUE. ELSE, GOTO Y_VCEND.

Y_VC7a [ YVC7a ] NO LABEL

Now I would like to ask you some questions about events that may have happened during your childhood. All questions refere to the time before you were 18 years of age. I would like you to remember that your answers to these questions will be completely private.


Press ""1"" and the [Enter] key to continue.

Question Type: TCont

Continue 1 Continue

---------------------------------------------------------------------------------

Y_VC8a [ YVC8a ] CH have illness/inj ignored by CG

Did you ever have a serious illness or injury or physical disability, but your caregivers ignored it or

failed to obtain necessary medical or remedial treatment for it? For example, pneumonia that

became serious because it was not treated soon enough, untreated broken bones, or hearing or

vision problems that were not treated with glasses or hearing aids?

Question Type: TYN

yes 1 YES

no 2 NO


Y_VC8aa

What about for less serious illnesses like the flu or an ear infection. Was there someone to take you to the doctor if you needed it?


1 YES

2 NO

---------------------------------------------------------------------------------

Y_VC9a [ YVC9a ] CG not help with washing/grooming CH

Did your caregivers fail to help you with washing and grooming so that you were often dirty, had

uncombed hair, or wore dirty clothes?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_VC10a [ YVC10a ] CG fail to provide regular meals for CH

Did your caregivers often fail to provide regular meals for you so that you had to go hungry or ask

other people for food?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_VC11a [ YVC11a ] Go w/o needed things b/c CG got other things

Did you ever have to go without things that you needed, for example clothes, shoes, school

supplies, food, etc., because your family's paycheck was spent on the adult's interests? For

example, a parent spending money on alcohol, gambling, drugs, fancy cars or clothes, so that

there was little money left over for the children?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_VC12a [ YVC12a ] CH does chores that were difficult/dangerous

Were you ever required to do chores that were too difficult or dangerous for you? For example,

cooking at the stove when you were too small to do it safely, or operating farm machinery that

could have been dangerous?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_VC13a [ YVC13a ] CH ever abandoned by CG

Were you ever abandoned by a caregiver?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_VC13b

Were your parents or caregivers ever separated or divorced?

Question Type: TYN

yes 1 YES

no 2 NO

3 NOT APPLICABLE - DID NOT HAVE MARRIED PARENTS/CAREGIVERS

---------------------------------------------------------------------------------


Y_VC13c

Were any of your caregivers or other adults in your home ever depressed, mentally ill, or suidical?

Question Type: TYN

yes 1 YES

no 2 NO


---------------------------------------------------------------------------------

Y_VC13d

Were any of your caregivers or other adults in your home problem drinkers or alcoholics, users of illegal drugs, or abusers of prescription medications?

Question Type: TYN

yes 1 YES

no 2 NO


---------------------------------------------------------------------------------

Y_VC13e

Did any of your caregivers or other adults in your home ever serve time or were sentenced to serve time in a prison, jail, or other correctional facility?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------


Y_VC13f

How often did your caregivers or other adults in your home ever slap, hit, kick, punch, or beat each other up? Would you say…

0 Never

1 Once or twice

2 Sometimes

3 Often

4 Very often


Y_VC13g

Before age 18, how often did a caregiver or other adult in your home ever hit, beat, kick, or physically hurt you in any way? Do not include spanking. Would you say…


0 Never

1 Once or twice

2 Sometimes

3 Often

4 Very often


Y_VC13h

How often did a caregiver or adult in your home ever swear at you, insult you, or put you down? Would you say…

0 Never

1 Once or twice

2 Sometimes

3 Often

4 Very often


---------------------------------------------------------------------------------

Y_VC15a [ YVC15a ] CH miss sch to take care of CG/do chores

Did you ever miss school because you had to stay home to take care of a parent, grandparent,

brother or sister, or to do chores?

Question Type: TYN

yes 1 YES

---------------------------------------------------------------------------------

Y_VC16a [ YVC16a ] CG fail to protect CH from being harmed

Did any of your caregivers ever fail to protect you from being physically harmed by someone else?

For example, one parent watching while the other parent or a brother or sister beat you?


THIS QUESTION DOES NOT APPLY TO A PARENT'S OR CAREGIVER'S FAILURE TO

PROTECT FROM SEXUAL MALTREATMENT.

Question Type: TYN

yes 1 YES

no 2 NO


Y_VC16b

Would you say the following statement is true before you were 18 years old: Someone in your family helped you feel important or special, you felt loved, people in your family looked out for each other and felt close to each other, and your family was a source of strength and support?

1 YES, TRUE

2 NO, NOT TRUE


---------------------------------------------------------------------------------

---------------------------------------------------------------------------------

---------------------------------------------------------------------------------

Y_VC24a [ YVC24a ] Anyone ever touch/kiss CH against will

Now we're going to move on to another topic. We'd like to ask you some questions about sexual

abuse. Once again I'd like to remind you that your answers will be private.


First, did anyone at least five years older than you or an adult ever touch or kiss you against your will?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_VC24a = 2 GOTO Y_VC28a

---------------------------------------------------------------------------------

Y_VC25a [ YVC25a ] Who touched/kissed CH against will

Who did this? Was it a parent, another adult relative, a brother or sister, a non-relative adult, or

other youths?

Question Type: TVC25a

parent 1 Parent

adultrel 2 Another adult relative

sibling 3 Brother or sister

stepparent 4 Step-parent

liveinboygrlfrnd 5 Live-in boyfriend/girlfriend

boygrlfrnd 6 Non-live-in boyfriend/girlfriend

otheradult 7 Other non-relative adult

otheryouth 8 Other youths


Y_VC25b

How often did this happen? Would you say…


1 Once or twice

2 Sometimes

3 Often

4 Very often

---------------------------------------------------------------------------------

Y_VC26a [ YVC26a ] Anyone else touch/kiss CH against will

Did anyone @Belse@B at least five years older than you or an adult ever touch or kiss you against your will?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_VC26a = 2, DK, OR REF, GOTO Y_VC28a

---------------------------------------------------------------------------------

Y_VC27a [ YVC27a ] Who else touched/kissed CH against will

Who did this?

Question Type: TVC25a

parent 1 Parent

adultrel 2 Another adult relative

sibling 3 Brother or sister

stepparent 4 Step-parent

liveinboygrlfrnd 5 Live-in boyfriend/girlfriend

boygrlfrnd 6 Non-live-in boyfriend/girlfriend

otheradult 7 Other non-relative adult

otheryouth 8 Other youths

---------------------------------------------------------------------------------


Y_VC27b

How often did this happen? Would you say…


1 Once or twice

2 Sometimes

3 Often

4 Very often

---------------------------------------------------------------------------------

Logic before:

ASK ONLY IF Y_VC24a = 2 OR VC26a = 2. ELSE, GOTO Y_VC30a.

Y_VC28a [ YVC28a ] Anyone ever try touch/kiss CH against will

Did anyone ever @Btry@B to touch or kiss you against your will?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_VC28a = 2 GOTO Y_VC30a

---------------------------------------------------------------------------------

Y_VC29a [ YVC29a ] Who tried to touch/kiss CH against will

Who did this? Was it a parent, another adult relative, a brother or sister, a non-relative adult, or

other youths?

Question Type: TVC25a

parent 1 Parent

adultrel 2 Another adult relative

sibling 3 Brother or sister

stepparent 4 Step-parent

liveinboygrlfrnd 5 Live-in boyfriend/girlfriend

boygrlfrnd 6 Non-live-in boyfriend/girlfriend

otheradult 7 Other non-relative adult

otheryouth 8 Other youths---------------------------------------------------------------------------------

Y_VC29aa [ YVC29aa ] Anyone else try touch/kiss CH against will

Did anyone @Belse@B ever @Btry@B to touch or kiss you against your will?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_VC29aa = 2 GOTO Y_VC30a

---------------------------------------------------------------------------------

Y_VC29ba [ YVC29ba ] Who else tried to touch/kiss CH against will

Who did this?

Question Type: TVC25a

parent 1 Parent

adultrel 2 Another adult relative

sibling 3 Brother or sister

stepparent 4 Step-parent

liveinboygrlfrnd 5 Live-in boyfriend/girlfriend

boygrlfrnd 6 Non-live-in boyfriend/girlfriend

otheradult 7 Other non-relative adult

otheryouth 8 Other youths

---------------------------------------------------------------------------------

Y_VC30a [ YVC30a ] Anyone ever have sex w/ CH against will

Did anyone at least five years older than you or an adult ever have intercourse, oral sex, or anal sex with you against your will?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_VC30a = 2 GOTO Y_VC32a

---------------------------------------------------------------------------------

Y_VC31a [ YVC31a ] Who had sex w/ CH against will

Who did this? Was it a parent, another adult relative, a brother or sister, a non-relative adult, or

other youths?

Question Type: TVC25a

parent 1 Parent

adultrel 2 Another adult relative

sibling 3 Brother or sister

stepparent 4 Step-parent

liveinboygrlfrnd 5 Live-in boyfriend/girlfriend

boygrlfrnd 6 Non-live-in boyfriend/girlfriend

otheradult 7 Other non-relative adult

otheryouth 8 Other youths

---------------------------------------------------------------------------------

Y_VC31b

How often did this happen? Would you say…


1 Once or twice

2 Sometimes

3 Often

4 Very often

---------------------------------------------------------------------------------

Y_VC31aa [ YVC31aa ] Anyone else ever have sex w/ CH against will

Did anyone @Belse@B at least five years older than you or an adult ever have intercourse, oral sex, or anal sex with you against your will?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_VC31aa = 2, DK, OR REF, GOTO Y_VC32a

---------------------------------------------------------------------------------

Y_VC31ba [ YVC31ba ] Who else had sex w/ CH against will

Who did this?

Question Type: TVC25a

parent 1 Parent

adultrel 2 Another adult relative

sibling 3 Brother or sister

stepparent 4 Step-parent

liveinboygrlfrnd 5 Live-in boyfriend/girlfriend

boygrlfrnd 6 Non-live-in boyfriend/girlfriend

otheradult 7 Other non-relative adult

otheryouth 8 Other youths


---------------------------------------------------------------------------------


Y_VC31ca

How often did this happen? Would you say…


1 Once or twice

2 Sometimes

3 Often

4 Very often


---------------------------------------------------------------------------------

Logic before:

ASK IF Y_VC30a = 2 OR VC31aa = 2. ELSE, GOTO Y_VC34a.

Y_VC32a [ YVC32a ] Anyone ever try to have sex w/ CH against will

Did anyone ever @Btry@B to have intercourse, oral sex, or anal sex with you against your will?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_VC32a = 2 GOTO Y_VC34a

---------------------------------------------------------------------------------

Y_VC33a [ YVC33a ] Who tried to have sex w/ CH against will

Who did this? Was it a parent, another adult relative, a brother or sister, a non-relative adult, or

other youths?

Question Type: TVC25a

parent 1 Parent

adultrel 2 Another adult relative

sibling 3 Brother or sister

stepparent 4 Step-parent

liveinboygrlfrnd 5 Live-in boyfriend/girlfriend

boygrlfrnd 6 Non-live-in boyfriend/girlfriend

otheradult 7 Other non-relative adult

otheryouth 8 Other youths

---------------------------------------------------------------------------------

Y_VC33aa [ YVC33aa ] Anyone else try to have sex w/ CH against will

Did anyone @Belse@B ever @Btry@B to have intercourse, oral sex, or anal sex with you against

your will?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_VC33aa = 2 GOTO Y_VC34a

---------------------------------------------------------------------------------

Y_VC33ba [ YVC33ba ] Who else tried to have sex w/ CH against will

Who did this?

Question Type: TVC25a

parent 1 Parent

adultrel 2 Another adult relative

sibling 3 Brother or sister

stepparent 4 Step-parent

liveinboygrlfrnd 5 Live-in boyfriend/girlfriend

boygrlfrnd 6 Non-live-in boyfriend/girlfriend

otheradult 7 Other non-relative adult

otheryouth 8 Other youths

---------------------------------------------------------------------------------

Y_VC34a [ YVC34a ] CH Robbed past 12 months

The next questions are about things that may have happened to you in the past 12 months.


In the past 12 months, has someone robbed you?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_VC35a [ YVC35a ] CH Attacked or beaten up past 12 months

In the past 12 months, has someone attacked or beaten you up?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_VC36a [ YVC36a ] CH Victimized sexually past 12 months

In the past 12 months, has someone victimized you sexually?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

Y_VCEND



HT - HUMAN TRAFFICKING EXPOSURE


IF CHILD AGE IS 13 OR OLDER OR CHILD IS A YOUNG ADULT (18+) OR EMANCIPATED YOUTH, CONTINUE. ELSE, GOTO Y_HTEND.


Some people experience difficult situations at work or in other places. I’d like to know if you have ever had any of these experiences.


Y_HT1

Have you ever been unable to leave a place you worked or talk to people you wanted to talk to, even when you weren’t working, because the person you worked for threatened or controlled you?

1=YES

2=NO


Y_HT2

Did someone you work for ever refuse to pay what they promised and keep all or most of the money you made?

1=YES

2=NO


Y_HT3

Were you ever physically beaten, slapped, hit, kicked, punched, burned or harmed in any way by someone you work for?

1=YES

2=NO


Y_HT4

Did you ever feel emotionally abused by someone you worked for?

1=YES

2=NO


Y_HT5

Did someone you work for ever ask, pressure, or force you to do something sexually that you did not feel comfortable doing?

1=YES

2=NO


Y_HT6

Were you ever forced to engage in sexual acts with family, friends, clients, or business associates for money or favors, by someone you work for?

1=YES

2=NO


Y_HT7

Did you ever trade sexual acts for food, clothing, money, shelter, favors, or other necessities for survival before you reached the age of 18?

1=YES

2=NO



Y_HTEND






IJ - CHILD INJURIES MODULE

---------------------------------------------------------------------------------

Logic before:

IF AGE < 11, GOTO Y_IJEND. ELSE, CONTINUE. IF CHILD IS EMANCIPATED OR YOUNG

ADULT (18+), CONTINUE

Y_IJ1a [ YIJ1a ] Past 12M CH had bad scrape

The next questions ask about some injuries that you might have had in the past @B12

months@B.


Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_IJ1a = No GOTO Y_IJ3a

---------------------------------------------------------------------------------

Y_IJ2a [ YIJ2a ] CH saw doc/RN for scrape - past 12M

Did you see a doctor or nurse for this injury?

Please consider online or telehealth visits.

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_IJ3a [ YIJ3a ] Past 12M CH had sprain

In the past @B12 months@B, have you had a bad sprain or torn ligament?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_IJ3a = No GOTO Y_IJ5a

---------------------------------------------------------------------------------

Y_IJ4a [ YIJ4a ] CH saw doc/RN for sprain - past 12M

Did you see a doctor or nurse for this injury?

Please consider online or telehealth visits.

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_IJ5a [ YIJ5a ] Past 12M CH had broken bone/nose

In the past @B12 months@B, have you had a broken bone, dislocated joint, or broken nose?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_IJ5a = No GOTO Y_IJ7a

---------------------------------------------------------------------------------

Y_IJ6a [ YIJ6a ] CH saw doc/RN for broken bone/nose - past 12M

Did you see a doctor or nurse for this injury?

Please consider online or telehealth visits.


Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_IJ7a [ YIJ7a ] Past 12M CH had head inj/concuss

In the past @B12 months@B, have you had a bad head injury or concussion?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_IJ7a = No GOTO Y_IJ9a

---------------------------------------------------------------------------------

Y_IJ8a [ YIJ8a ] CH saw doc/RN fr head inj/concuss - past 12M

Did you see a doctor or nurse for this injury?

Please consider online or telehealth visits.

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_IJ9a [ YIJ9a ] Past 12M CH had gun/stab wound

In the past @B12 months@B, have you had a gun shot wound or stab wound?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_IJ9a = No GOTO Y_IJ11a

---------------------------------------------------------------------------------

Y_IJ10a [ YIJ10a ] CH saw doc/RN fr gun/stab wound - past 12M

Did you see a doctor or nurse for this injury?

Please consider online or telehealth visits.


Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_IJ11a [ YIJ11a ] Past 12M CH got bitten

In the past @B12 months@B, have you had a bite from another person or animal?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_IJ11a = No GOTO Y_IJ13a

---------------------------------------------------------------------------------

Y_IJ12a [ YIJ12a ] CH saw doc/RN for bite - past 12M

Did you see a doctor or nurse for this injury?

Please consider online or telehealth visits.


Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_IJ13a [ YIJ13a ] Past 12M CH was burned

In the past @B12 months@B, have you had a bad burn?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_IJ13a = No GOTO Y_IJ15a

---------------------------------------------------------------------------------

Y_IJ14a [ YIJ14a ] CH saw doc/RN for burn - past 12M

Did you see a doctor or nurse for this injury?

Please consider online or telehealth visits.


Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_IJ15a [ YIJ15a ] # Xs CH was hurt phys

In the past @B12 months@B, how many times has someone physically hurt you on purpose?

Question Type: TIJ15a

none 0 0 times

once 1 1 time

twice 2 2 times

thrice 3 3 times

fourmore 4 4 or more times

Logic after:

IF Y_IJ15a = none GOTO Y_IJEND

---------------------------------------------------------------------------------

Y_IJ15aa [ YIJ15aa ] Physically hurt you in the last week?

Has this happened in the last week?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_IJ15aa = Yes GOTO Y_IJ15da

---------------------------------------------------------------------------------

Y_IJ15ba [ YIJ15ba ] Physically hurt you in the last month?

Has this happened in the last month?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_IJ15ba = Yes GOTO Y_IJ15da

---------------------------------------------------------------------------------

Y_IJ15ca [ YIJ15ca ] Physically hurt you in the last 3 months?

Has this happened in the last 3 months?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Logic before:

IF Y_IJ15ca = 2, FILL: Thinking of the most recent time that someone physically hurt you on

Y_IJ15da [ YIJ15da ] Where did this happen (physically hurt you)?

^Fills.IJ15da did this happen?

Question Type: TIJ15da

school 1 At school

neighborhood 2 In my neighborhood

mall 3 At a mall or other place where I was hanging out with friends

home 4 At home

friends 5 At a friend's or relative's home

other 6 Somewhere else

Question Fill: ^FillIJ15da

recent Thinking of the most recent time that someone physically hurt you on

purpose, where

notrecent Where

---------------------------------------------------------------------------------

Y_IJ16a [ YIJ16a ] CH knew person who hurt them

Did you know any of the people who hurt you?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_IJ16a = No GOTO Y_IJ17a

---------------------------------------------------------------------------------

Y_IJ16ba [ YIJ16ba ] Who was involved?

Who was involved?

Question Type: TIJ16ba

friend 1 A friend

schoolkid 2 A kid from school

neighborkid 3 A kid in the neighborhood

sibling 4 My brother or sister

respadult 5 Someone responsible for taking care of me

other 6 Someone else

unknown 7 Someone I don't know

---------------------------------------------------------------------------------

Y_IJ17a [ YIJ17a ] CH had phys inj

Did you have a physical injury?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_IJ17a = No GOTO Y_IJ18a

---------------------------------------------------------------------------------

Y_IJ17aa [ YIJ17aa ] Labels are in Logic After

What kind of injuries occurred?


CODE ALL THAT APPLY.

Question Type: TIJ17aaS

brokenbone 1 BROKEN BONES OR DISLOCATED JOINTS

sprain 2 SPRAIN, STRAIN OR PULLED MUSCLE

cuts 3 WOUND: CUTS, SCRAPES, PUNCTURE

headinj 4 HEAD INJURY, CONCUSSION

bruise 5 BRUISE, CONTUSION, INTERNAL BLEEDING

burn 6 BURN, SCALD

unconscious 7 LOST CONSCIOUSNESS (FOR MORE THAN 30 SECONDS)

dental 8 INJURY TO TEETH

eyeinj 9 INJURY TO EYES

internalinj 10 INTERNAL ORGAN INJURY

othinjury 11 SOME OTHER INJURY

Logic after:

YIJ17aa_1 --Type of physical injuries - BROKEN BONES, DISLOCATED JOINTS; YIJ17aa_2 --Type

of physical injuries - SPRAIN, STRAIN OR PULLED MUSCLE; YIJ17aa_3 --Type of physical

injuries - WOUND: CUTS, SCRAPES, PUNCTURE; YIJ17aa_4 --Type of physical injuries - HEAD

INJURY, CONCUSSION; YIJ17aa_5 --Type of physical injuries - BRUISE, CONTUSION, INTERNL

BLDNG; YIJ17aa_6 --Type of physical injuries - BURN, SCALD; YIJ17aa_7 --Type of physical

injuries - LOST CONSCIOUSNESS(GT30 SECONDS); YIJ17aa_8 --Type of physical injuries -

INJURY TO TEETH; YIJ17aa_9 --Type of physical injuries - INJURY TO EYES; YIJ17aa_10 --Type

of physical injuries - INTERNAL ORGAN INJURY; YIJ17aa_11 --Type of physical injuries - SOME

OTHER INJURY; YIJ17aa_12--Type of physical injuries - DK; YIJ17aa_13--Type of physical injuries

---------------------------------------------------------------------------------

Y_IJ18a [ YIJ18a ] CH got trtmnt by doc/RN for hurt

Did you get medical treatment from a doctor or nurse because you were hurt by someone on

purpose?

Please consider online or telehealth visits.

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_IJ19a [ YIJ19a ] CH had changed feelings after hurt

Did being hurt on purpose by someone cause a change in your feelings -- like making you afraid

or depressed?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_IJ20a [ YIJ20a ] CH had changed actions after hurt

Did being hurt on purpose by someone cause a change in what you do -- like where you go and

how you act?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

GOTO Y_IJEND

---------------------------------------------------------------------------------

Y_IJ_END [ YIJ_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

YL - CHILD INVOLVEMENT WITH LAW MODULE

---------------------------------------------------------------------------------

Logic before:

IF CHILD IS EMANCIPATED OR YOUNG ADULT (18+), CONTINUE. ELSE, GOTO Y_YLEND.

Y_YL1a [ YYL1a ] CH ever been arrested for any offense

The next questions are about your involvement with the ^Fills.Y_YL1a1


^Fills.Y_YL1a2

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_YL1a1

waveone law.

wavetwo law in the last 12 months.

Question Fill: ^FillY_YL1a2

waveone Have you @Bever@B been arrested for any offense?

wavetwo @BIn the last 12 months@B, have you been arrested for any offense?

Logic after:

IF Y_YL1a = 2 GOTO Y_YLEND

---------------------------------------------------------------------------------

Y_YL2a [ YYL2a ] # of times CH arrested

How many ^Fills.Y_YL2n have you been arrested?


TIMES ARRESTED:

Question Type: 0..10

Question Fill: ^FillY_YL2n

waveone times

wavetwo times in the last 12 months

---------------------------------------------------------------------------------

Logic before:

IF WAVE > 1, GOTO Y_YL5a. ELSE, IF WAVE = 1, ASK Y_YL3y THROUGH Y_YL8a FOR

EACH ARREST.

Y_YL3y [ YYL3 ] Labels are in Logic After

In what year were you arrested^Fills.Y_YL3y1^Fills.FirstSecond^Fills.Y_YL3y2?


ENTER 4-DIGIT YEAR

Question Type: 1990..2013

Question Fill: ^FillY_YL3y1

moreonea ·the·

onlyone

Question Fill: ^FillY_YL3y2

moreoneb ·time

onlyone

Logic after:

YYL3_1a--Y CH arrested; YYL3_2a--Y CH arrested - 2; YYL3_3a--Y CH arrested - 3; YYL3_4a--Y

CH arrested - 4; YYL3_5a--Y CH arrested - 5; YYL3_6a--Y CH arrested - 6; YYL3_7a--Y CH

arrested - 7; YYL3_8a--Y CH arrested - 8; YYL3_9a--Y CH arrested - 9; YYL3_10a--Y CH arrested -

---------------------------------------------------------------------------------

Logic before:

IF Y_YL3y = RESPONSE, THEN Y_YL3y_year = response to Y_YL3y; IF Y_YL3y = RF/DK,

THEN Y_YL3y_year = "that year"

Y_YL4m [ YYL4 ] Labels are in Logic After

In what month in ^Y_YL3y_year were you

arrested^Fills.Y_YL3y1^Fills.FirstSecond^Fills.Y_YL3y2?


Question Type: TMonth

jan 1 January

feb 2 February

mar 3 March

apr 4 April

may 5 May

jun 6 June

jul 7 July

aug 8 August

sep 9 September

oct 10 October

nov 11 November

dec 12 December

Question Fill: ^FillY_YL3y1

moreonea ·the·

onlyone

Question Fill: ^FillY_YL3y2

moreoneb ·time

onlyone

Logic after:

YYL4_1a--M CH arrested; YYL4_2a--M CH arrested - 2; YYL4_3a--M CH arrested - 3; YYL4_4a--M

CH arrested - 4; YYL4_5a--M CH arrested - 5; YYL4_6a--M CH arrested - 6; YYL4_7a--M CH

arrested - 7; YYL4_8a--M CH arrested - 8; YYL4_9a--M CH arrested - 9; YYL4_10a--M CH arrested

- 10

---------------------------------------------------------------------------------

Logic before:

IF WAVE > 1, ASK Y_YL5a THROUGH Y_YL8a FOR EACH ARREST.

Y_YL5a [ YYL5 ] Labels are in Logic After

^Fills.Y_YL5a1^Fills.FirstSecond^Fills.Y_YL5a2

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_YL5a1

waveone Were you convicted?

wavetwo Thinking about your·

Question Fill: ^FillY_YL5a2

waveone

wavetwo ·arrest, were you convicted?

Logic after:

IF Y_YL5a = 2 GOTO Y_YL3y; YYL5_1a--CH convicted; YYL5_2a--CH convicted - 2; YYL5_3a--CH

convicted - 3; YYL5_4a--CH convicted - 4; YYL5_5a--CH convicted - 5; YYL5_6a--CH convicted - 6;

YYL5_7a--CH convicted - 7; YYL5_8a--CH convicted - 8; YYL5_9a--CH convicted - 9; YYL5_10a--

CH convicted - 10

---------------------------------------------------------------------------------

Y_YL_Arrest Questions Y_YL3y - Y_YL8a are in Y_YL_Arrest

Question Type: ARRAY[1..10] OF BY_YL_Arrest

---------------------------------------------------------------------------------

Y_YL6a [ YYL6 ] Labels are in Logic After

Were you placed on probation?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_YL6a = 1 GOTO Y_YL3y; YYL6_1a--CH placed on probation; YYL6_2a--CH placed on

probation - 2; YYL6_3a--CH placed on probation - 3; YYL6_4a--CH placed on probation - 4;

YYL6_5a--CH placed on probation - 5; YYL6_6a--CH placed on probation - 6; YYL6_7a--CH placed

on probation - 7; YYL6_8a--CH placed on probation - 8; YYL6_9a--CH placed on probation - 9;

YYL6_10a--CH placed on probation - 10

---------------------------------------------------------------------------------

Y_YL7a [ YYL7 ] Labels are in Logic After

Did you spend time in prison as a result of that ^Fills.FirstSecond^Fills.Y_YL7a

Question Type: TYN

yes 1 YES

no 2 NO

Question Fill: ^FillY_YL7a

waveone ·arrest?

Logic after:

IF Y_YL7a = 2 GOTO Y_YL3y; YYL7_1a--CH spend time in prison as result of arrest; YYL7_2a--

CH spend time in prison as result of arrest - 2; YYL7_3a--CH spend time in prison as result of

arrest - 3; YYL7_4a--CH time in prison as result of arrest - 4; YYL7_5a--CH time in prison as result

of arrest - 5; YYL7_6a--CH time in prison as result of arrest - 6; YYL7_7a--CH time in prison as

result of arrest - 7; YYL7_8a--CH time in prison as result of arrest - 8; YYL7_9a--CH time in prison

as result of arrest - 9; YYL7_10a--CH time in prison as result of arrest - 10

---------------------------------------------------------------------------------

Y_YL8a [ YYL8 ] Labels are in Logic After

How long were you in prison?

Question Type: TYYL8a

less1mo 1 Less than 1 month

onetothree 2 1 to 3 months

fourtosix 3 4 to 6 months

seventoyr 4 7 months to 1 year

moreyr 5 ^Fills.TY_YL8a

Question Fill: ^FillTY_YL8a

waveone More than 1 year

wavetwo

Logic after:

YYL8_1a--Length of time CH in prison; YYL8_2a--Length of time CH in prison - 2; YYL8_3a--Length

of time CH in prison - 3; YYL8_4a--Length of time CH in prison - 4; YYL8_5a--Length of time CH in

prison - 5; YYL8_6a--Length of time CH in prison - 6; YYL8_7a--Length of time CH in prison - 7;

YYL8_8a--Length of time CH in prison - 8; YYL8_9a--Length of time CH in prison - 9; YYL8_10a--

Length of time CH in prison - 10

---------------------------------------------------------------------------------

Logic before:

IF RESPONSE = YES SET ILEXIT FLAG SO THIS SUBMODULE WILL NOT BE INVOKED AGAIN

Y_YL_MORE [ YYLMORE ] Labels are in Logic After

Were there more arrests?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

REPEAT LOOP FOR NEXT ARREST, STARTING AT Y_YL3y IF WAVE = 1 OR Y_YL5a IF

WAVE > 1.

GOTO Y_YLEND; YYLMORE_1 --Were there more CH arrests - 1; YYLMORE_2 --Were there

more CH arrests - 2; YYLMORE_3 --Were there more CH arrests? - 3; YYLMORE_4 --Were there

more CH arrests? - 4; YYLMORE_5 --Were there more CH arrests? - 5; YYLMORE_6 --Were there

more CH arrests? - 6; YYLMORE_7 --Were there more CH arrests? - 7; YYLMORE_8 --Were

there more CH arrests? - 8; YYLMORE_9 --Were there more CH arrests? - 9; YYLMORE_10 --

Were there more CH arrests? - 10

---------------------------------------------------------------------------------

Y_YL_END [ YYL_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

YM - CHILD DISCIPLINE AND CHILD MALTREATMENT MODULE

---------------------------------------------------------------------------------

Logic before:

IF CHILD IS EMANCIPATED OR YOUNG ADULT (18+), AND R HAS CHILDREN LIVING WITH

THEM, CONTINUE.

FOR OREGON CASES ONLY ADD a FILL (if rtiagnid = 948 or uppercase(sj_state) = ‘OR’ )

Y_YM0 [ YYM0 ] NO LABEL

Children sometimes do things that are wrong, disobey, or make their parents angry. For the next

set of questions, we would like to know what you have done when your child or children did

something wrong or made you upset or angry.

^Fills.Y_YM0

For each question pick an answer that says how many times this has happened in the past

@B12 months@B. If it hasn't happened in the past @B12 months@B, but it did happen before

that, pick the answer "not in the past @B12 months@B, but it happened before." If it has never

happened, pick the answer "this has never happened."


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

Question Fill: ^FillY_YM0

OREGON @/Please note that if I learn that your child’s life or health is in danger, I

have to tell someone whose job it is to see that your child is safe and

protected.@/

---------------------------------------------------------------------------------

Y_YM1a [ YYM1a ] # Xs explained to your ch why something was wrong - past 12M

In the past @B12 months@B, how many times have you explained to your child or children why

something was wrong?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM2a [ YYM2a ] Put your ch in time-out/sent to room - past 12M

In the past @B12 months@B, how many times have you put your child or children in "time out" or

sent your child or children to his/her room?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM3a [ YYM3a ] Shaken your ch - past 12M

In the past @B12 months@B, how many times have you shaken your child or children?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM4a [ YYM4a ] Hit your ch on bottom w/hard object - past 12M

In the past @B12 months@B, how many times have you hit your child or children on the bottom

with something like a belt, hairbrush, a stick or some other hard object?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM5a [ YYM5a ] Redirect your ch - past 12M

In the past @B12 months@B, how many times have you given your child or children something

else to do instead of what he/she was doing wrong?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM6a [ YYM6a ] Shouted/yelled/screamed your ch - past 12M

In the past @B12 months@B, how many times have you shouted, yelled, or screamed at your

child or children?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM7a [ YYM7a ] Hit your ch w/ fist/kicked hard - past 12M

In the past @B12 months@B, how many times have you hit your child or children with a fist or

kicked him/her hard?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM8a [ YYM8a ] Spanked your ch on bottomw w/bare hand - past 12M

In the past @B12 months@B, how many times have you spanked your child or children on the

bottom with your bare hand?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM9a [ YYM9a ] Grabbed your ch around neck and choked - past 12M

In the past @B12 months@B, how many times have you grabbed your child or children around

the neck and choked him/her?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

Logic after:

IF ANSWER IS 7, 8, DK, OR REF, GOTO Y_YM10a

---------------------------------------------------------------------------------

Y_YM9aa [ YYM9aa ] Grabbed your ch around neck and choked - reported - past 12M

Was this reported?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_YM9a = 1 GOTO Y_YM10a

---------------------------------------------------------------------------------

Y_YM9ca [ YYM9ca ] Grabbed your ch around neck and choked - reported - past W

Did this happen in the past week?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_YM9ca = 1 GOTO Y_YM10a

---------------------------------------------------------------------------------

Y_YM9da [ YYM9da ] Grabbed your ch around neck and choked - reported - past M

Did this happen in the past month?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_YM9da = 1 GOTO Y_YM10a

---------------------------------------------------------------------------------

Y_YM9ea [ YYM9ea ] Grabbed your ch around neck and choked - reported - past 3M

Did this happen in the last 3 months?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_YM9ea = 1 GOTO Y_YM10a

---------------------------------------------------------------------------------

Y_YM10a [ YYM10a ] Sworn/cursed at ch - past 12M

In the past @B12 months@B, how many times have you sworn or cursed at your child or children?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM11a [ YYM11a ] Beat ch hit hard over and over - past 12M

In the past @B12 months@B, how many times have you beat your child or children up by hitting

him/her over and over as hard as you could?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

Logic after:

IF ANSWER IS 7, 8, DK, REF GOTO Y_YM12a.

---------------------------------------------------------------------------------

Y_YM11aa [ YYM11aa ] Beat ch hit hard over and over - reported - past 12M

Was this reported?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_YM11aa = 1 GOTO Y_YM12a

---------------------------------------------------------------------------------

Y_YM11ca [ YYM11ca ] Beat ch hit hard over and over - reported - past W

Did this happen in the past week?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_YM11ca = 1 GOTO Y_YM12a

---------------------------------------------------------------------------------

Y_YM11da [ YYM11da ] Beat ch hit hard over and over - reported - past M

Did this happen in the past month?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_YM11da = 1 GOTO Y_YM12a

---------------------------------------------------------------------------------

Y_YM11ea [ YYM11ea ] Beat ch hit hard over and over - reported - past 3M

Did this happen in the last 3 months?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_YM11ea = 1 GOTO Y_YM12a

---------------------------------------------------------------------------------

Y_YM12a [ YYM12a ] Said ch will be sent away/kicked out - past 12M

In the past @B12 months@B, how many times have you said your child or children would be sent

away or kicked out of the house?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM13a [ YYM13a ] Burned/scalded ch on purpose - past 12M

In the past @B12 months@B, how many times have you burned or scalded your child or children

on purpose?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

Logic after:

IF ANSWER IS 7, 8, DK, OR REF, GOTO Y_YM14A.

---------------------------------------------------------------------------------

Y_YM13aa [ YYM13aa ] Burned/scalded ch on purpose - reported - past 12M

Was this reported?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_YM13aa = 1 GOTO Y_YM14a

---------------------------------------------------------------------------------

Y_YM13ca [ YYM13ca ] Burned/scalded ch on purpose - reported - past W

Did this happen in the past week?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_YM13ca = 1 GOTO Y_YM14a

---------------------------------------------------------------------------------

Y_YM13da [ YYM13da ] Burned/scalded ch on purpose - reported - past M

Did this happen in the past month?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_YM13da = 1 GOTO Y_YM14a

---------------------------------------------------------------------------------

Y_YM13ea [ YYM13ea ] Burned/scalded ch on purpose - reported - past 3M

Did this happen in the last 3 months?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_YM13ea = 1 GOTO Y_YM14a

---------------------------------------------------------------------------------

Y_YM14a [ YYM14a ] Threaten to spank/hit but not do it - past 12M

In the past @B12 months@B, how many times have you threatened to spank or hit your child or

children but did not actually do it?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM15a [ YYM15a ] Hit on oth prt of bdy w/hrd obj - past 12M

In the past @B12 months@B, how many times have you hit your child or children on some other

part of the body besides the bottom with something like a belt, hairbrush, a stick or some other

hard object?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM16a [ YYM16a ] Slapped ch on hand/arm/leg - past 12M

In the past @B12 months@B, how many times have you slapped your child or children on the

hand, arm, or leg?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM17a [ YYM17a ] Taken away priveleges/grounded - past 12M

In the past @B12 months@B, how many times have you taken away privileges or grounded your

child or children?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM18a [ YYM18a ] Pinched ch - past 12M

In the past @B12 months@B, how many times have you pinched your child or children?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM19a [ YYM19a ] Threatened ch w/knife or gun - past 12M

In the past @B12 months@B, how many times have you threatened your child or children with a

knife or gun?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM20a [ YYM20a ] Thrown/knocked ch down - past 12M

In the past @B12 months@B, how many times have you thrown or knocked your child or children

down?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM21a [ YYM21a ] Called ch dumb/lazy/other name - past 12M

In the past @B12 months@B, how many times have you called your child or children dumb or

lazy or some other name like that?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM22a [ YYM22a ] Slapped ch on face/head/ears - past 12M

In the past @B12 months@B, how many times have you slapped your child or children on the

face or head or ears?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM23 [ YYM23 ] NO LABEL

Sometimes things can get in the way of caring for your child the way you would like to: for

example, money problems, personal problems, or having a lot to do. For the next set of items,

please tell me how many times in the past @B12 months@B this has happened to you in trying

to care for your child.


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

---------------------------------------------------------------------------------

Y_YM24a [ YYM24a ] Leave ch home alone when shouldnt - past 12M

In the past @B12 months@B, how many times have you ever had to leave your child or children

home alone, even when you thought some adult should be with him/her?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM25a [ YYM25a ] Not show/tell ch love him/her - past 12M

In the past @B12 months@B, how many times were you so caught up with problems that you

were not able to show or tell your child or children that you loved him/her?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM26a [ YYM26a ] Unable to ensure ch get food needed - past 12M

In the past @B12 months@B, how many times were you not able to make sure that your child or

children got the food he/she needed?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM27a [ YYM27a ] Unable to get ch to doc as needed - past 12M

In the past @B12 months@B, how many times were you unable to make sure your child or

children got to a doctor or hospital when he/she needed it?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM28a [ YYM28a ] Cdnt take care of ch b/c drunk/high - past 12M

In the past @B12 months@B, how many times were you so drunk or high that you had a problem

taking care of your child or children?

Question Type: TYYMHM

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

twentymore 6 More than 20 times

notinpastyr 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_YM29a [ YYM29a ] Your ch forced sexual contact by adult/oldr ch - past 12M

In the past @B12 months@B, has your child, or children, been touched in a sexual way by an

adult or older child when he/she did not want to be touched that way? Or has he/she been forced

to touch an adult or older child in a sexual way -- including anyone who was a member of your

family, or anyone outside the family?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_YM29a = 2 GOTO Y_YM31a

---------------------------------------------------------------------------------

Y_YM29aa [ YYM29aa ] Your ch forced sexual contact occur w/a person resp for ch

Was the person responsible for taking care of the child when the incident occurred?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_YM29ba [ YYM29ba ] Your ch forced sexual contact reported

Was this reported?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Logic before:

IF Y_YM29a = 1

Y_YM30a [ YYM30a ] Your ch forced sexual contact past 12M > once in past 12M

Has it happened more than once in the past @B12 months@B?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_YM30a = 2 GOTO Y_YM32a

---------------------------------------------------------------------------------

Y_YM30aa [ YYM30aa ] Your ch forced sexual contact past 12M in past W

Did this happen in the past week?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_YM30aa = 1 GOTO Y_YM32a

---------------------------------------------------------------------------------

Y_YM30ca [ YYM30ca ] Your ch forced sexual contact past 12M in past M

Did this happen in the past month?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_YM30ca = 1 GOTO Y_YM32a

---------------------------------------------------------------------------------

Y_YM30da [ YYM30da ] Your ch forced sexual contact past 12M last 3 months

Did this happen in the last 3 months?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_YM30da = 1 OR 2 GOTO Y_YM32a

---------------------------------------------------------------------------------

Logic before:

IF Y_YM29a = 2, DK, RE

Y_YM31a [ YYM31a ] Your ch forced sexual contact ever happened

Has it @Bever@B happened?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_YM32a [ YYM32a ] Your ch forced sex by adult/older ch - past 12M

In the past @B12 months@B, has your child or children been forced to have sex by an adult or an

older child -- including anyone who was a member of the family?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_YM32a = 2 GOTO Y_YM34a

---------------------------------------------------------------------------------

Y_YM32aa [ YYM32aa ] Your ch forced sex occur w/a person resp for ch

Was the person responsible for taking care of the child when the incident occurred?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_YM32ba [ YYM32ba ] Your ch forced sex reported

Was this reported?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_YM32ca [ YYM32ca ] Your ch forced sex past 12M in past W

Did this happen in the past week?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_YM32ca = 1 GOTO Y_YM33a

---------------------------------------------------------------------------------

Y_YM32da [ YYM32da ] Your ch forced sex past 12M in past M

Did this happen in the past month?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_YM32da = 1 GOTO Y_YM33a

---------------------------------------------------------------------------------

Y_YM32ea [ YYM32ea ] Your ch forced sex past 12M in past 3M

Did this happen in the last 3 months?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_YM32ea = 1 GOTO Y_YM33a

---------------------------------------------------------------------------------

Logic before:

IF Y_YM32a = 1

Y_YM33a [ YYM33a ] Your ch forced sex > once in past 12M

Has it happened more than once in the past @B12 months@B?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_YM33a = 1 OR 2 GOTO Y_YMEND

---------------------------------------------------------------------------------

Logic before:

IF Y_YM32 = 2, DK, RE

Y_YM34a [ YYM34a ] Your ch forced sex ever happened

Has it @Bever@B happened?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

GOTO Y_YMEND

---------------------------------------------------------------------------------

Y_YM_END [ YYM_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue



YD - DATING VIOLENCE

---------------------------------------------------------------------------------

Logic before:

IF WAVE > 1 AND CHILD IS YOUNG ADULT (18+), CONTINUE. ELSE, GOTO Y_YDEND.



The next questions ask about your experiences with dating. By dating, we mean spending time with someone you are seeing or going out with. The term date includes both one-time dates and time together as part of longer-term relationships.

Y_YD1

Have you dated someone in the past 12 months?

1 YES

2 NO

Logic after:

If Y_YD1 = NO, GOTO END


Please think about things that may have happened during a conflict or argument with someone you are or were dating in the last 12 months. During a conflict or argument, did the following things happen never, seldom, sometimes or often...


Y_YD2

I spoke to him/her in a hostile or mean tone of voice

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YD3

He/she spoke to me in a hostile or mean tone of voice

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YD4

I insulted him/her with put-downs

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YD5

He/she insulted me with put-downs

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YD6

I said things to his/her friends to try and turn them against him/her

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN


Y_YD7

He/she said things to my friends to try and turn them against me

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YD8

I kicked, hit, or punched him/her

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YD9

He/she kicked, hit, or punched me

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN


Y_YD10

I slapped or pulled his/her hair

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN


Y_YD11

He/she slapped or pulled my hair

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN


Y_YD12

I threatened to hurt him/her

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN


Y_YD13

He/she threatened to hurt me

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN



Y_YD14

I threatened to hit or throw something at him/her

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN


Y_YD15

He/she threatened to hit or throw something at me

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN


Y_YD16

I spread rumors about him/her

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN


Y_YD17

He/she spread rumors about me

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN


Y_YD18

I touched him/her sexually when they didn’t want me to

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN

Y_YD18

He/she touched me sexually when I didn’t want them to

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN


Y_YD19

I forced my partner to have sex when they didn’t want to

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN




Y_YD19

He/she forced me to have sex when I didn’t want to

0 NEVER

1 SELDOM

3 SOMETIMES

4 OFTEN



Y_YDEND



AF - CHILD ACASI FINISH MODULE

---------------------------------------------------------------------------------

Logic before:

IF AGE < 11, GOTO Y_AFEND. ELSE, CONTINUE. IF CHILD IS EMANCIPATED OR YOUNG

ADULT (18+), CONTINUE.

Y_AF1 [ YAF1 ] NO LABEL

Please tell the interviewer you are done.


INTERVIEWER: PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

Logic after:

GOTO Y_AFEND

---------------------------------------------------------------------------------

Y_AF_END [ YAF_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

CM - CHILD MALTREATMENT MODULE

---------------------------------------------------------------------------------

Logic before:

IF AGE < 11 OR CHILD IS EMANCIPATED OR YOUNG ADULT (18+), GOTO Y_CMEND. ELSE,

CONTINUE.

Y_CM1a [ YCM1a ] # Xs parents/adult exp why something was wrng - past 12M

Sometimes parents get angry at their children or lose their tempers. These questions are about

your parents and other adults who have taken care of you and what they did when they got angry

or when you did something they did not like.


For each of the following questions pick an answer that says how many times this has happened

in the past @B12 months@B. If it hasn't happened in the past @B12 months@B, but it did

happen before that, pick the answer "Not in the past @B12 months@B, but it happened before."

If it has never happened, pick the answer "This has never happened."


In the past @B12 months@B, how many times have your parents or other adults who lived with

you explained why something was wrong?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM2a [ YCM2a ] # Xs parents/othr put CH in time out - past 12M

In the past @B12 months@B, how many times have your parents or other adults who lived with

you put you in "time out" or sent you to your room?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM3a [ YCM3a ] # Xs parents/othr shook CH

In the past @B12 months@B, how many times have your parents or other adults who lived with

you shaken you?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM4a [ YCM4a ] # Xs parents/othr hit CH on bottom w/ hard object - past 12M

In the past @B12 months@B, how many times have your parents or other adults who lived with

you hit you on the bottom with something like a belt, hairbrush, a stick or some other hard object?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM5a [ YCM5a ] # Xs parents gave CH something else to do - past 12M

In the past @B12 months@B, how many times have your parents or other adults who lived with

you given you something else to do instead of what you were doing wrong?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM6a [ YCM6a ] # Xs parents/othr yelled at CH - past 12M

In the past @B12 months@B, how many times have your parents or other adults who lived with

you shouted, yelled, or screamed at you?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM7a [ YCM7a ] # Xs parents/othr hit/kicked CH - past 12M

In the past @B12 months@B, how many times have your parents or other adults who lived with

you hit you with a fist or kicked you hard?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

Logic after:

IF Y_CM7a = 7 or 8 GOTO Y_CM8a

---------------------------------------------------------------------------------

Y_CM7aa [ YCM7aa ] Parents/othr kicked/hit CH - past W

Did this happen in the last week?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_CM7aa = 1 GOTO Y_CM8a

---------------------------------------------------------------------------------

Y_CM7ba [ YCM7ba ] Parents/othr kicked/hit CH in last M

Did this happen in the last month?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_CM7ba = 1 GOTO Y_CM8a

---------------------------------------------------------------------------------

Y_CM7ca [ YCM7ca ] Parents/othr kicked/hit CH in last 3M

Did this happen in the last 3 months?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_CM8a [ YCM8a ] # Xs parents/othr spanked CH w/hands

In the past @B12 months@B, how many times have your parents or other adults who lived with

you spanked you on the bottom barehanded?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM9a [ YCM9a ] # Xs parents/othr choked CH

In the past @B12 months@B, how many times have your parents or other adults who lived with

you grabbed you around the neck and choked you?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

Logic after:

IF Y_CM9a = 7/8/RF/DK GOTO Y_CM10a

---------------------------------------------------------------------------------

Y_CM9aa [ YCM9aa ] Parents/othr choked CH in last W

Did this happen in the last week?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_CM9aa = 1 GOTO Y_CM10a

---------------------------------------------------------------------------------

Y_CM9ba [ YCM9ba ] Parents/othr choked CH in last M

Did this happen in the last month?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_CM9ba = 1 GOTO Y_CM10a

---------------------------------------------------------------------------------

Y_CM9ca [ YCM9ca ] Parents/othr choked CH in last 3M

Did this happen in the last 3 months?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_CM10a [ YCM10a ] # Xs parents/othr cursed at CH

In the past @B12 months@B, how many times have your parents or other adults who lived with

you sworn or cursed at you?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM11a [ YCM11a ] # Xs parents/othr hit CH repeatedly

In the past @B12 months@B, how many times have your parents or other adults who lived with

you beat you up by hitting you over and over as hard as possible?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

Logic after:

IF Y_CM11a = 7/8/RF/DK GOTO Y_CM12a

---------------------------------------------------------------------------------

Y_CM11aa [ YCM11aa ] Parents/othr hit CH over + overn last W

Did this happen in the last week?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_CM11aa = 1 GOTO Y_CM12a

---------------------------------------------------------------------------------

Y_CM11ba [ YCM11ba ] Parents/othr hit CHover + over last M

Did this happen in the last month?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_CM11ba = 1 GOTO Y_CM12a

---------------------------------------------------------------------------------

Y_CM11ca [ YCM11ca ] Parents/othr hit CH over + over last 3M

Did this happen in the last 3 months?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_CM12a [ YCM12a ] # Xs parents/othr threat to kick CH out

In the past @B12 months@B, how many times have your parents or other adults who lived with

you said you would be sent away or kicked out of the house?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM13a [ YCM13a ] # Xs parents/othr burned CH

In the past @B12 months@B, how many times have your parents or other adults who lived with

you burned or scalded you on purpose?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

Logic after:

IF Y_CM13a = 7/8/RF/DK GOTO Y_CM14a

---------------------------------------------------------------------------------

Y_CM13aa [ YCM13aa ] Parents/othr burned CH last W

Did this happen in the last week?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_CM13aa = 1 GOTO Y_CM14a

---------------------------------------------------------------------------------

Y_CM13ba [ YCM13ba ] Parents/othr burned CH last M

Did this happen in the last month?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_CM13ba = 1 GOTO Y_CM14a

---------------------------------------------------------------------------------

Y_CM13ca [ YCM13ca ] Parents/othr burned CH last 3M

Did this happen in the last 3 months?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_CM14a [ YCM14a ] # Xs parents/othr threat to spank CH

In the past @B12 months@B, how many times have your parents or other adults who lived with

you threatened to spank or hit you but did not actually do it?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM15a [ YCM15a ] # Xs parents/othr hit CH on body

In the past @B12 months@B, how many times have your parents or other adults who lived with

you hit you on some other part of the body besides your bottom with something like a belt,

hairbrush, a stick or some other hard object?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM16a [ YCM16a ] # Xs parents/othr slapped CH on body

In the past @B12 months@B, how many times have your parents or other adults who lived with

you slapped you on the hand, arm, or leg?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM17a [ YCM17a ] # Xs parents/othr grounded CH

In the past @B12 months@B, how many times have your parents or other adults who lived with

you taken away privileges or grounded you?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM18a [ YCM18a ] # Xs parents/othr pinched CH

In the past @B12 months@B, how many times have your parents or other adults who lived with

you pinched you?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM19a [ YCM19a ] # Xs parents/othr threat CH w /gun/knife

In the past @B12 months@B, how many times have your parents or other adults who lived with

you threatened you with a knife or gun?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

Logic after:

IF Y_CM19a = 7/8/RF/DK GOTO Y_CM20a

---------------------------------------------------------------------------------

Y_CM19aa [ YCM19aa ] Parents/othr threat.w/gun/knife in last W

Did this happen in the last week?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_CM19aa = 1 GOTO Y_CM20a

---------------------------------------------------------------------------------

Y_CM19ba [ YCM19ba ] Parents/othr threat.w/gun/knife in last M

Did this happen in the last month?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_CM19ba = 1 GOTO Y_CM20a

---------------------------------------------------------------------------------

Y_CM19ca [ YCM19ca ] Parents/othr threat.w/gun/knife in last 3M

Did this happen in the last 3 months?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_CM20a [ YCM20a ] # Xs parents/othr threw down CH

In the past @B12 months@B, how many times have your parents or other adults who lived with

you thrown or knocked you down?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

Logic after:

IF Y_CM20a = 7/8/RF/DK GOTO Y_CM21a

---------------------------------------------------------------------------------

Y_CM20aa [ YCM20aa ] Parents/othr threw down CH in last W

Did this happen in the last week?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_CM20aa = 1 GOTO Y_CM21a

---------------------------------------------------------------------------------

Y_CM20ba [ YCM20ba ] Parents/othr threw down CH in last M

Did this happen in the last month?

Question Type: TYN

yes 1 YES

no 2 NO

Logic after:

IF Y_CM20ba = 1 GOTO Y_CM21a

---------------------------------------------------------------------------------

Y_CM20ca [ YCM20ca ] Parents/othr threw down CH in last 3M

Did this happen in the last 3 months?

Question Type: TYN

yes 1 YES

no 2 NO

---------------------------------------------------------------------------------

Y_CM21a [ YCM21a ] # Xs parents/othr called CH dumb

In the past @B12 months@B, how many times have your parents or other adults who lived with

you called you dumb or lazy or some other name like that?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

---------------------------------------------------------------------------------

Y_CM22a [ YCM22a ] # Xs parents/othr slapped CH on face

In the past @B12 months@B, how many times have your parents or other adults who lived with

you slapped you on the face or head or ears?

Question Type: THMTimes

once 1 1 time

twice 2 2 times

threetofive 3 3-5 times

sixtoten 4 6-10 times

eleventotwenty 5 11-20 times

moretwenty 6 More than 20 times

notpast12mos 7 Not in the past @B12 months@B, but it happened before

never 8 This has never happened

Logic after:

GOTO Y_CMEND

LO - CHILD LOCATOR FORM MODULE

---------------------------------------------------------------------------------

Logic before:

IF CHILD IS EMANCIPATED OR IS AGE 16+ (INCLUDING YOUNG ADULTS), ASK Y_LO1.

ELSE, GOTO Y_LOEND.

Y_LO1 [ YLO1 ] NO LABEL

To help us understand how the well-being of youth changes over time, we @Bmay@B contact

you in the future to update our information. I'd like to ask a few questions to help us locate you in

case you move.


Please remember that everything you tell me will be kept private in the ways that were

explained to you at the beginning of the interview.


I'd like to verify your full legal name. Is your full legal name...(READ DISPLAYED NAME.

CORRECT AS NEEDED.)


FIRST NAME: @|@B^CHILD_FName@B

MIDDLE NAME:@|@B^CHILD_MName@B

LAST NAME:@|@|@B^CHILD_LName@B

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_LO1 = 1 GOTO Y_LO2a; IF Y_LO1 = 2 GOTO Y_LO1a

---------------------------------------------------------------------------------

Y_LO1a [ YLO1a ] Eman CH legal first name

INTERVIEWER: CORRECT FIRST NAME AS NEEDED.


FIRST NAME:

Question Type: STRING[20]

---------------------------------------------------------------------------------

Y_LO1b [ YLO1b ] Eman CH legal middle name

INTERVIEWER: CORRECT MIDDLE NAME AS NEEDED.


MIDDLE NAME:

Question Type: STRING[20], empty

---------------------------------------------------------------------------------

Y_LO1c [ YLO1c ] Eman CH legal last name

INTERVIEWER: CORRECT LAST NAME AS NEEDED.


LAST NAME:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Logic before:

IF SEX = FEMALE, ASK Y_LO2a. ELSE, GOTO Y_LO3a.

Y_LO2a [ YLO2a ] Eman CH maiden name

What is your maiden name?


MAIDEN NAME:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Y_LO3a [ YLO3a ] Eman CH any other names/nicknames(YN2T)

Do you go by any other names or nicknames?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_LO3a = 2 GOTO Y_LO5a

---------------------------------------------------------------------------------

Y_LO4a [ YLO4a ] Eman CH alias #1

What are they?


ALIAS 1:

Question Type: STRING[40]

---------------------------------------------------------------------------------

Y_LO4b [ YLO4b ] Eman CH alias #2

What are they?


ALIAS 2:

Question Type: STRING[40], EMPTY

---------------------------------------------------------------------------------

Y_LO4c [ YLO4c ] Eman CH alias #3

What are they?


ALIAS 3:

Question Type: STRING[40], EMPTY

---------------------------------------------------------------------------------

Y_LO5 [ YLO5 ] NO LABEL

Let me confirm your street address. (VERIFY INFORMATION DISPLAYED ON SCREEN.)


STREET ADDRESS@|@B^Street@B

CITY:@|@|@|@B^City@B

STATE:@|@|@B^State@B

ZIP:@|@|@|@B^Zip@B


Is this correct?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_LO5 = 1 GOTO Y_LO6a; IF Y_LO5 = 2 GOTO Y_LO5a

---------------------------------------------------------------------------------

Y_LO5a [ YLO5a ] Eman CH address - street

INTERVIEWER: CORRECT STREET ADDRESS IF NEEDED.


STREET ADDRESS:

Question Type: STRING[50]

---------------------------------------------------------------------------------

Y_LO5b [ YLO5b ] Eman CH address - city

INTERVIEWER: CORRECT CITY IF NEEDED.


CITY:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Y_LO5c [ YLO5c ] Eman CH address - state

INTERVIEWER: CORRECT STATE IF NEEDED.


STATE:

Question Type: STRING[2]

---------------------------------------------------------------------------------

Y_LO5d [ YLO5d ] Eman CH address - zip

INTERVIEWER: CORRECT ZIP IF NEEDED.


ZIP:

Question Type: TZip

---------------------------------------------------------------------------------

Y_LO6a [ YLO6a ] EmanCH at same address in 6mo(ADDRES1T)

Do you expect to be living at this same address or at a different address 6 months from now?

Question Type: TLO6a

same 1 SAME ADDRESS

different 2 DIFFERENT ADDRESS

Logic after:

IF Y_LO6a = 1 GOTO Y_LO10an

---------------------------------------------------------------------------------

Logic before:

IF Y_L06a = DK/RE, ASK Y_LO6aa. ELSE, GOTO Y_LO7.

Y_LO6aa [ YLO6aa ] Better address to contact emanCH (YN2T)

Is there a better address we can use to contact you in the future?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_LO6aa = 2 GOTO Y_LO10an

---------------------------------------------------------------------------------

Y_LO7a [ YLO7a ] EmanCH best future address - street

What is the best address for us to use in the future?


STREET ADDRESS:


NOTE: IF R PLANS TO MOVE, COLLECT AS MUCH INFORMATION AS POSSIBLE ABOUT

NEW LOCATION.

Question Type: STRING[50]

---------------------------------------------------------------------------------

Y_LO7b [ YLO7b ] EmanCH best future address - city

What is the best address for us to use in the future?


CITY:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Y_LO7c [ YLO7c ] EmanCH best future address - state

What is the best address for us to use in the future?


STATE:

Question Type: STRING[2]

---------------------------------------------------------------------------------

Y_LO7d [ YLO7d ] EmanCH best future address - zip code

What is the best address for us to use in the future?


ZIP:

Question Type: TZip

---------------------------------------------------------------------------------

Y_LO8a [ YLO8a ] BestFuture addres emanCH/other(ADRES1T)

Is that your address or the address of another person or place?

Question Type: TLO8a

rsadd 1 RESPONDENT'S ADDRESS

othradd 2 ADDRESS OF SOME OTHER PERSON/PLACE

Logic after:

IF Y_LO8a = 1 GOTO Y_LO10an

---------------------------------------------------------------------------------

Y_LO9a [ YLO9a ] Whose best future address

Whose address is it? (ENTER NAME)


NAME:

Question Type: STRING[40]

---------------------------------------------------------------------------------

Y_LO9b [ YLO9b ] Best future address person relationship

Whose address is it? (ENTER RELATIONSHIP TO RESPONDENT)


RELATIONSHIP:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Y_LO10an [ YLO10an ] NO LABEL

What is your home phone number?


PHONE:


NOTE: ENTER R'S CURRENT HOME PHONE NUMBER. IF R DOES NOT HAVE A PHONE

NUMBER, ENTER 000-000-0000.

Question Type: TPhone

---------------------------------------------------------------------------------

Y_LO10ba [ YLO10ba ] Best curr phone#-day/evening(PHONE1T)

Is this your day or evening phone number?

Question Type: TLO10ba

day 1 DAY

evening 2 EVENING

both 3 BOTH

---------------------------------------------------------------------------------

Y_LO10cn [ YLO10cn ] NO LABEL

What is your cell phone number?


PHONE:


NOTE: IF R DOES NOT HAVE A CELL NUMBER, ENTER 000-000-0000.

Question Type: TPhone

---------------------------------------------------------------------------------

Y_LO11a [ YLO11a ] Another phone# for emanCH(YN2T)

Is there another phone number, beeper, or pager number to use to reach you?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_LO11a = 2 GOTO Y_LO12ea

---------------------------------------------------------------------------------

Y_LO12aa [ YLO12aa ] Another phone# for eman CH

What is that number?


PHONE:


NOTE: IF R HAS MORE THAN 1 ALTERNATIVE NUMBER, ENTER THE ONE HE/SHE CAN BE

REACHED AT MOST OFTEN.

Question Type: TPhone

---------------------------------------------------------------------------------

Y_LO12ba [ YLO12ba ] Another phone#-day/evening (PHONE1T)

And is that your day or evening number?

Question Type: TLO10ba

day 1 DAY

evening 2 EVENING

both 3 BOTH

---------------------------------------------------------------------------------

Y_LO12ca [ YLO12ca ] Type another phone# emanCH (PHONE2T)

Is this your home phone number, a work number, or some other number?

Question Type: TLO12ca

home 1 HOME NUMBER

work 2 WORK NUMBER

friend 3 FRIEND/RELATIVE'S NUMBER

beeper 4 BEEPER/PAGER/CELL PHONE NUMBER

other 5 OTHER (SPECIFY)

Logic after:

IF Y_LO12ca = other GOTO Y_LO12cb

---------------------------------------------------------------------------------

Logic before:

IF Y_LO12ca = 5, CONTINUE. ELSE, GOTO Y_LO12ea.

Y_LO12cb [ YLO12cb ] Other-specify type another phone#

Please specify what number this is.


NUMBER IS:

Question Type: STRING[40]

Logic after:

IF Y_LO12ca = 5, CONTINUE. ELSE, GOTO Y_LO12ea

---------------------------------------------------------------------------------

Y_LO12ea [ YLO12ea ] NO LABEL

Do you have an email address?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_LO12ea = 2 GOTO Y_LO13a

---------------------------------------------------------------------------------

Y_LO12f [ YLO12f ] NO LABEL

What is your current email address?


EMAIL:


NOTE: EMAIL ADDRESS MUST CONTAIN 2 @@@@ SIGNS (i.e., janedoe@@@@yahoo.com).

Question Type: STRING[50]

---------------------------------------------------------------------------------

Y_LO13a [ YLO13a ] EmanCH provide 1st contact info (YN2T)

We'd also like the names of three relatives or friends @Bwho do not live with you@B but would

always know how to reach you if you moved.


Can you give me the name, address, and telephone number of a relative or friend who would

always know how to reach you if you moved?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_LO13a = 2 GOTO Y_LO19a

---------------------------------------------------------------------------------

Y_LO14a [ YLO14a ] EmanCH contact #1 name

What is the first person's name?


VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.


@BCONTACT PERSON 1:@B


NAME:

Question Type: STRING[40]

---------------------------------------------------------------------------------

Y_LO14b [ YLO14b ] EmanCH contact #1 relationship

What is the first person's relationship to you?


VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.


@BCONTACT PERSON 1:@B


RELATIONSHIP:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Y_LO14c [ YLO14c ] EmanCH contact #1 address-street/POBox

What is the first person's street address?


VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.


@BCONTACT PERSON 1:@B


STREET ADDRESS:

Question Type: STRING[50]

---------------------------------------------------------------------------------

Y_LO14d [ YLO14d ] EmanCH contact #1 address - city

What is the first person's city?


VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.


@BCONTACT PERSON 1:@B


CITY:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Y_LO14e [ YLO14e ] EmanCH contact #1 address - state

What is the first person's state?


VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.


@BCONTACT PERSON 1:@B


STATE:

Question Type: STRING[2]

---------------------------------------------------------------------------------

Y_LO14f [ YLO14f ] End emanCH contact #1 info

What is the first person's zip code?


VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.


@BCONTACT PERSON 1:@B


ZIP:

Question Type: TZip

---------------------------------------------------------------------------------

Y_LO14g [ YLO14g ] EmanCH contact #1 address - phone

What is the first person's telephone number?


VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.


@BCONTACT PERSON 1:@B


PHONE:


NOTE: IF DOES NOT HAVE A PHONE NUMBER, ENTER 000-000-0000.

Question Type: TPhone

---------------------------------------------------------------------------------

Y_LO15a [ YLO15a ] EmanCH provide 2nd contact info (YN2T)

Is there another relative or friend who would always know how to reach you?


NOTE: THIS INFORMATION IS VERY IMPORTANT! ENCOURAGE R TO PROVIDE ADDITIONAL

CONTACT PERSON.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_LO15a = 2 GOTO Y_LO19a

---------------------------------------------------------------------------------

Y_LO16a [ YLO16a ] EmanCH contact #2 name

What is the second person's name?


VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.


@BCONTACT PERSON 2:@B


NAME:

Question Type: STRING[40]

---------------------------------------------------------------------------------

Y_LO16b [ YLO16b ] EmanCH contact #2 relationship

What is the second person's relationship to you?


VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.


@BCONTACT PERSON 2:@B


RELATIONSHIP:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Y_LO16c [ YLO16c ] EmanCH contact #2 address-street/POBox

What is the second person's street address?


VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.


@BCONTACT PERSON 2:@B


STREET ADDRESS:

Question Type: STRING[50]

---------------------------------------------------------------------------------

Y_LO16d [ YLO16d ] EmanCH contact #2 address - city

What is the second person's city?


VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.


@BCONTACT PERSON 2:@B


CITY:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Y_LO16e [ YLO16e ] EmanCH contact #2 address - state

What is the second person's state?


VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.


@BCONTACT PERSON 2:@B


STATE:

Question Type: STRING[2]

---------------------------------------------------------------------------------

Y_LO16f [ YLO16f ] End emanCH contact #2 info

What is the second person's zip code?


VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.


@BCONTACT PERSON 2:@B


ZIP:

Question Type: TZip

---------------------------------------------------------------------------------

Y_LO16g [ YLO16g ] EmanCH contact #2 address - phone

What is the second person's telephone number?


VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.


@BCONTACT PERSON 2:@B


PHONE:


NOTE: IF DOES NOT HAVE A PHONE NUMBER, ENTER 000-000-0000.

Question Type: TPhone

---------------------------------------------------------------------------------

Y_LO17a [ YLO17a ] EmanCH provide 3rd contact info (YN2T)

Is there another relative or friend who would always know how to reach you?


NOTE: THIS INFORMATION IS VERY IMPORTANT! ENCOURAGE R TO PROVIDE ADDITIONAL

CONTACT PERSON.

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_LO17a = 2 GOTO Y_L019a

---------------------------------------------------------------------------------

Y_LO18a [ YLO18a ] EmanCH contact #3 name

What is the third person's name?


VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.


@BCONTACT PERSON 3:@B


NAME:

Question Type: STRING[40]

---------------------------------------------------------------------------------

Y_LO18b [ YLO18b ] EmanCH contact #3 relationship

What is the third person's relationship to you?


VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.


@BCONTACT PERSON 3:@B


RELATIONSHIP:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Y_LO18c [ YLO18c ] EmanCH contact #3 address-street/POBox

What is the third person's street address?


VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.


@BCONTACT PERSON 3:@B


STREET ADDRESS:

Question Type: STRING[50]

---------------------------------------------------------------------------------

Y_LO18d [ YLO18d ] EmanCH contact #3 address - city

What is the third person's city?


VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.


@BCONTACT PERSON 3:@B


CITY:

Question Type: STRING[30]

---------------------------------------------------------------------------------

Y_LO18e [ YLO18e ] EmanCH contact #3 address - state

What is the third person's state?


VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.


@BCONTACT PERSON 3:@B


STATE:

Question Type: STRING[2]

---------------------------------------------------------------------------------

Y_LO18f [ YLO18f ] End emanCH contact #3 info

What is the third person's zip code?


VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.


@BCONTACT PERSON 3:@B


ZIP:

Question Type: TZip

---------------------------------------------------------------------------------

Y_LO18g [ YLO18g ] EmanCH contact #3 address - phone

What is the third person's telephone number?


VERIFY SPELLING. ENCOURAGE R TO PROVIDE ALL REQUESTED INFORMATION.


@BCONTACT PERSON 3:@B


PHONE:


NOTE: IF DOES NOT HAVE A PHONE NUMBER, ENTER 000-000-0000.

Question Type: TPhone

---------------------------------------------------------------------------------

Logic before:

IF WAVE > 1 AND RESPONDENT IS SAME FROM PREVIOUS INTERVIEW, VERIFY

PRELOADED SSN IN Y_LO19a IF AVAILABLE. ELSE, ASK FOR SSN.

Y_LO19a [ YLO19a ] Eman CH social security number

I'd also like to get your Social Security Number. This information will only be used to help us

locate you if you move. What is your social security number? (PROMPT R TO GET NUMBER

FROM SSN CARD, IF NEEDED.)


SSN:


NOTE: IF R DOES NOT HAVE SSN NUMBER, ENTER 000-00-0000.

Question Type: TSSN

Question Fill: ^FillY_LO19n

donthave I’d also like to get your Social Security Number. This information will only

be used in case we need to contact you again in the future. What is your

social security number? (PROMPT R TO GET NUMBER FROM SSN

CARD, IF NEEDED.)

have I also need to verify your social security number. This information will

only be used to help us locate you if you move. Is it...(READ

DISPLAYED NUMBER. CORRECT AS NEEDED.)

---------------------------------------------------------------------------------

Logic before:

IF VERIFYING PRELOADED SSN

Y_LO19b [ YLO19b ] NO LABEL

I also need to verify your social security number. This information will only be used to help us

locate you if you move. Is it...(READ DISPLAYED NUMBER. CORRECT AS NEEDED.)


PRELOADED SSN ^CHILD_SSN

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF = 1, GOTO P_LO20a

---------------------------------------------------------------------------------

Y_LO19c [ YLO19c ] NO LABEL

What is your correct social security number?


SSN:


NOTE: IF R DOES NOT HAVE SSN NUMBER, ENTER 000-00-0000.

Question Type: TSSN

---------------------------------------------------------------------------------

Logic before:

IF WAVE 1 OR DL# IS NOT AVAILABLE PRELOAD IN LATER WAVES, CONTINUE. IF

PRELOAD FROM PREVIOUS WAVE IS AVAILABLE, GOTO P_LF22na

Y_LO20a [ YLO20a ] Eman CH drivers license number

What is your driver's license number? Again, this will only be used in case we need to contact

you again in the future. (PROMPT R TO GET NUMBER FROM DRIVER'S LICENSE, IF

NEEDED.)


LICENSE:


Question Type: STRING[15]

Logic after:

IF Y_LO20a = 00 GOTO Y_LO21. ELSE, GOTO LO20b.

---------------------------------------------------------------------------------

Logic before:

IF VERIFYING PRELOADED NUMBER

Y_LO20a1 [ YLO20a1 ] NO LABEL

I also need to verify your driver's license number. Is it...(READ DISPLAYED NUMBER AND

STATE. CORRECT AS NEEDED.)


LICENSE#: ^License_no

STATE: ^License_st

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_LO20a2 [ YLO20a2 ] NO LABEL

What is your correct driver's license number?


LICENSE#


NOTE: IF R DOES NOT HAVE DL NUMBER, ENTER 00.

Question Type: STRING[15]

Logic after:

[IF NO DL#, GOTO Y_LO21.]

---------------------------------------------------------------------------------

Y_LO20b [ YLO20b ] Eman CH drivers license state

What state is the driver's license issued in?


STATE:

Question Type: STRING[2]

---------------------------------------------------------------------------------

Y_LO21 [ YLO21 ] NO LABEL

We're almost finished. Remember, this information is voluntary and private and will only be

used in case we need to contact you again in the future.


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

---------------------------------------------------------------------------------

Logic before:

IF R IS MARRIED ASK Y_LO22a. ELSE, GOTO Y_LO23a.

Y_LO22a [ YLO22a ] EmanCH spouse social security #

What is your spouse's social security number? (This will only be used to help us locate your

family if you move.)


SPOUSE SSN:


NOTE: IF SPOUSE DOES NOT HAVE SSN NUMBER, ENTER 000-00-0000.

Question Type: TSSN

---------------------------------------------------------------------------------

Y_LO23a [ YLO23a ] EmanCH name change next 6 months (YN2T)

Do you think your name could change in the next 6 months?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

IF Y_LO23a = 2 GOTO Y_LO25

---------------------------------------------------------------------------------

Y_LO24a [ YLO24a ] EmanCH future first name

What do you think your name would be changed to? Please tell me the first, middle, and last

name. (IF RESPONDENT DOES NOT KNOW, PRESS F3 -- DON'T KNOW -- FOR ALL 3 NAME

FIELDS.)


INTERVIEWER: UPDATE FIRST NAME AS NEEDED.


Question Type: STRING[20]

---------------------------------------------------------------------------------

Y_LO24b [ YLO24b ] EmanCH future middle name

INTERVIEWER: UPDATE MIDDLE NAME AS NEEDED.


MIDDLE NAME:

Question Type: STRING[20]

---------------------------------------------------------------------------------

Y_LO24c [ YLO24c ] EmanCH future last name

INTERVIEWER: UPDATE LAST NAME AS NEEDED.


LAST NAME:

Question Type: STRING[30]


IF (AGE >= 13) ASK Y_LOSM1 OTHERWISE GOTO Y_LO25

Y_LOSM1

The next few questions are about your use of social media. We want to make sure we are able to invite you to participate in the next round. We may use information you provide to help us contact you in the future using the social media platform’s private messaging features. Private messages sent to you through these platforms will only contain information about how you can reach the research team to schedule your next interview. We will never post anything on your profile and your profile will only be viewed if it is necessary to confirm your identity. We will keep your information private but social media websites may, per the terms of use and site policies, be able to access, read, and retain all messages sent through their private messaging platforms.



At some point in the future, a different group of researchers may take over the study. If that happens, with your consent, we will provide this information to the other organization. We would only provide your profile name to other organization. The other organization would only contact you using the social media platform’s private messaging features.



Some people use a name other than their full name on Facebook. What is your profile name on Facebook?

NAME ON FILE: [FILL WITH: name_w1_fn name_w1_lna; IF name_w1_fn OR name_w1_lna=DK OR R, THEN FILL WITH RESPONDENT FIRST AND LAST NAME FROM SAMPLE FILE]



1 R USES NAME ON FILE

2 R USES ANOTHER NAME (SPECIFY)

3 R DOES NOT USE FACEBOOK

F3 DON’T KNOW

F4 REFUSED



Y_LOSM2 [IF Y_LOSM1=2] [TEXT BOX FOR THE NAME]



F3 DON’T KNOW

F4 REFUSED



Y_LOSM3 Some people use a name other than their full name on Instagram. What is your profile name on Instagram?



(IF NEEDED: We want to make sure we are able to invite you to participate in the next round. We may use this to help us contact you in the future using the platform’s private messaging features. We will never post anything on your profile.)



NAME ON FILE: [FILL WITH: name_w1_fn name_w1_lna; IF name_w1_fn OR name_w1_lna=DK OR R, THEN FILL WITH RESPONDENT FIRST AND LAST NAME FROM SAMPLE FILE]



1 R USES NAME ON FILE

2 R USES ANOTHER NAME (SPECIFY)

3 R DOES NOT USE INSTAGRAM

F3 DON’T KNOW

F4 REFUSED



Y_LOSM4 [IF Y_LOSM3=2] [TEXT BOX FOR THE NAME]



F3 DON’T KNOW

F4 REFUSED



Y_LOSM5 Some people use a name other than their full name on Snapchat. What is your profile name on Snapchat?



(IF NEEDED: We want to make sure we are able to invite you to participate in the next round. We may use this to help us contact you in the future using the platform’s private messaging features. We will never post anything on your profile.)



NAME ON FILE: [FILL WITH: name_w1_fn name_w1_lna; IF name_w1_fn OR name_w1_lna=DK OR R, THEN FILL WITH RESPONDENT FIRST AND LAST NAME FROM SAMPLE FILE]



1 R USES NAME ON FILE

2 R USES ANOTHER NAME (SPECIFY)

3 R DOES NOT USE SNAPCHAT

F3 DON’T KNOW

F4 REFUSED



Y_LOSM6 [IF Y_LOSM5=2] [TEXT BOX FOR NAME]



F3 DON’T KNOW

F4 REFUSED



Y_LOSM7 Some people use a name other than their full name on TikTok. What is your profile name on TikTok?



(IF NEEDED: We want to make sure we are able to invite you to participate in the next round. We may use this to help us contact you in the future using the platform’s private messaging features. We will never post anything on your profile.)



NAME ON FILE: [FILL WITH: name_w1_fn name_w1_lna; IF name_w1_fn OR name_w1_lna=DK OR R, THEN FILL WITH RESPONDENT FIRST AND LAST NAME FROM SAMPLE FILE]



1 R USES NAME ON FILE

2 R USES ANOTHER NAME (SPECIFY)

3 R DOES NOT USE TIKTOK

F3 DON’T KNOW

F4 REFUSED



Y_LOSM8 [IF Y_LOSM7=2] [TEXT BOX FOR NAME]

F3 DON’T KNOW

F4 REFUSED



---------------------------------------------------------------------------------

Y_LO25 [ YLO25 ] NO LABEL

Thank you very much for this information.


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

Logic after:

GOTO Y_LOEND

LK - CHILD PERMISSION FOR DATA LINKAGE MODULE

---------------------------------------------------------------------------------

Logic before:

IF (AGE >= 13 AND AGE <= 17) or (Child = YA) or (Child = EA) ask Y_LK1 else goto Y_LK1a

Y_LK1 [ YLK1 ] NO LABEL

In the future, other researchers may want to use your NSCAW data for various types of research.

However, for this to happen, your written permission is required. To help you make an informed

decision about this, there is one more form I need to read to you. After I have read the form to

you, you can decide if you would like other researchers to use your NSCAW data.


INTERVIEWER: PRESS 1 FOR LINKAGE FORMS IN DOCMAN. PLEASE CHOOSE AND READ

THE CORRECT LINKAGE FORM FROM DOCMAN AND OBTAIN SIGNATURE. AFTER

COLLECTING SIGNATURE AND FINALIZING FORM, YOU WILL THEN BE BROUGHT BACK TO

THE INTERVIEW.

Question Type: TCont

Continue 1 Continue

---------------------------------------------------------------------------------

Logic before:

IF (AGE >= 13 AND AGE <= 17) or (Child = YA) or (Child = EA) then fill: "Form needed" Else fill

"Form not Needed"

Y_LK1a [ YLK1a ] NO LABEL

^Fills.Y_LK1a


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

Question Fill: ^FillY_LK1a

need INTERVIEWER: PRESS 1 FOR @bLINKAGE ASSENT@b FORMS IN

DOCMAN. PLEASE CHOOSE AND READ THE CORRECT ASSENT

FORM FROM DOCMAN BASED ON CHILD'S AGE AND OBTAIN

SIGNATURE. AFTER COLLECTING SIGNATURE AND FINALIZING

FORM, YOU WILL THEN BE BROUGHT BACK TO THE INTERVIEW.

no_need INTERVIEWER: THE @bLINKAGE ASSENT@b FORM IS NOT NEEDED

FOR THIS CHILD. SELECT “FORM NOT NEEDED” IN DOCMAN.

---------------------------------------------------------------------------------

Y_LKLA1 Start AS DocMan

@bSTART DOCMAN LINKAGE ASSENT FORM@b


INTERVIEWER: PRESS UP ARROW IF YOU WANT TO GO TO PREVIOUS SCREEN.

Question Type: BDocMan

---------------------------------------------------------------------------------

Logic before:

If status from DocMan=491 OR (Status = 457 AND Form is "Coded Out") then ask ask Y_LKLA2

else ask Y_LKLA3

Y_LKLA2 [ YLKLA2 ] End AS DocMan

@bDOCMAN LINKAGE ASSENT FORM IS COMPLETED@b


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

Logic after:

GOTO Y_LK2a

---------------------------------------------------------------------------------

Y_LKLA3 [ YLKLA3 ] NO LABEL

@bDOCMAN LINKAGE ASSENT FORM IS NOT COMPLETED@b

Question Type: TDMR2F, noDK, noRF

_1 1 REDO THE FORM IN DOCMAN

_2 2 RESPONDENT REFUSED TO COMPLETE ELECTRONIC FORM BUT

SIGNED PAPER FORM

_3 3 A TECHNICAL PROBLEM PREVENTED THE ELECTRONIC FORM

FROM BEING COMPLETED BUT RESPONDENT SIGNED PAPER

FORM

_4 4 RESPONDENT REFUSES SO THERE'S NO FORM

_5 5 A TECHNICAL PROBLEM PREVENTED FROM CODING OUT THE

FORM

Logic after:

If 1 GOTO Y_LKLA1

If 4 GOTO Y_LK_END

IF 3 OR 5 Ask Y_LKLA4

ELSE GOTO Y_LK2a

---------------------------------------------------------------------------------

Y_LKLA4 [ YLKLA4 ] NO LABEL

@bDOCMAN LINKAGE ASSENT FORM IS NOT COMPLETED@b


GIVE DETAILS ABOUT THE TECHNICAL PROBLEM:

Question Type: STRING[60]

---------------------------------------------------------------------------------

Logic before:

IF Y_LKLA1.Status = 491 OR Y_LKLA3 = 2 OR Y_LKLA3 = 3 OR Y_LKLA3 = 5 THEN then ask

Y_LK2a

Y_LK2a [ YLK2a ] Child data linkage permission

Here is a copy of this form for your records.


Do we have permission for your NSCAW data to be combined with other research data?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

Logic after:

GOTO Y_LKEND

---------------------------------------------------------------------------------

Y_LK_END [ YLK_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue

Logic after:

Y_LKEND



VO - CHILD VERIFICATIONS/CHANGE OF ADDRESS/PAYMENT MODULE

---------------------------------------------------------------------------------

Logic before:

IF CHILD IS LEGALLY EMANCIPATED PER CID OR AGE IS 18+, CONTINUE. ELSE, GOTO

Y_VOEND.

Y_VO1 [ YVO1 ] NO LABEL

As part of RTI's quality program, we plan to contact a portion of the persons participating in this

survey to verify that interviewers, including me, have done our work correctly. The questions you

would be asked, if you are selected, are general. This is only to verify my work.


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

---------------------------------------------------------------------------------

Y_VO2a [ YVO2a ] Eman CH agree to verification call

WAS R AGREEABLE TO A VERIFICATION CALL?

Question Type: TYesNoC

Yes 1 YES

No 2 NO

---------------------------------------------------------------------------------

Y_VO3 [ YVO3 ] NO LABEL

We sincerely appreciate your participation in this important research project. To help us

understand how the well-being of children changes over time, we may contact you in the future to

update our information.


Here is a Change of Address Card in case you move. GIVE CARD TO R. It is already stamped

and addressed to RTI. All you have to do is record both your old and new addresses and drop the

card in the mail.


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

---------------------------------------------------------------------------------

Y_VO4 [ YVO4 ] NO LABEL

To show our appreciation for your time and effort, we're offering you cash in the amount of $50.00

for participating in the interview.


Here is an envelope with the cash.


INTERVIEWER: PRESS 1 FOR INCENTIVE RECEIPT IN DOCMAN. PLEASE CHOOSE THE

CORRECT INCENTIVE RECEIPT FROM DOCMAN AND OBTAIN SIGNATURE. AFTER

COLLECTING SIGNATURE AND FINALIZING FORM, YOU WILL THEN BE BROUGHT BACK TO

THE INTERVIEW.


This form states that you have received the money. This copy is for your records.


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

---------------------------------------------------------------------------------

Y_VOIN1 Start IN DocMan

@bSTART DOCMAN INCENTIVE RECEIPT FORM@b


INTERVIEWER: PRESS UP ARROW IF YOU WANT TO GO TO PREVIOUS SCREEN.

Question Type: BDocMan

---------------------------------------------------------------------------------

Logic before:

If status from DocMan=491 ask Y_VOIN2 else ask Y_VOIN3

Y_VOIN2 [ YVOIN2 ] End IN DocMan

@bDOCMAN INCENTIVE RECEIPT FORM IS COMPLETED@b


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

Logic after:

Skip to Y_VO_END

---------------------------------------------------------------------------------

Y_VOIN3 [ YVOIN3 ] NO LABEL

@bDOCMAN INCENTIVE RECEIPT FORM IS NOT COMPLETED@b

Question Type: TDMR4F, noDK, noRF

_1 1 REDO THE FORM IN DOCMAN

_2 2 RESPONDENT REFUSED TO COMPLETE ELECTRONIC FORM BUT

SIGNED PAPER FORM

_3 3 A TECHNICAL PROBLEM PREVENTED THE ELECTRONIC FORM

FROM BEING COMPLETED BUT RESPONDENT SIGNED PAPER

FORM

_4 4 RESPONDENT REFUSES SO THERE'S NO FORM

Logic after:

If 1 GOTO Y_VOIN1

If 4 EXIT form

IF 3 Ask Y_VOIN4

ELSE GOTO Y_VO_END

---------------------------------------------------------------------------------

Y_VOIN4 [ YVOIN4 ] NO LABEL

@bDOCMAN INCENTIVE RECEIPT FORM IS NOT COMPLETED@b


GIVE DETAILS ABOUT THE TECHNICAL PROBLEM:

Question Type: STRING[60]

---------------------------------------------------------------------------------

Y_VO_END [ YVO_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue



EF - Executive Functioning

---------------------------------------------------------------------------------


IF CHILD AGE IS 4 OR OLDER, administer the test of executive functioning: the Shape Go-NoGo Task.

The Shape Go-NoGo task consists of a series of single shapes that “flash” on the laptop screen. The child is instructed to press a button on the laptop as quickly as possible for all shapes except a circle; the child tries not to press the key anytime the circle appears.




CC - CHILD INTERVIEW CLOSE MODULE

---------------------------------------------------------------------------------

Logic before:

IF CHILD AGE < 11 AND NOT EY, FILL: ADDRESS PARENT:

IF YA+EY, SKIP to Y_CC1 Else CONTINUE.

Y_CC03a [ YCC03a ] Incentive accepted by R/parent(YN2T)

^Fills.Y_CC0Fill@a@aHere is a gift certificate as a thank you for your participation.


INTERVIEWER: PRESS 1 FOR INCENTIVE RECEIPTS IN DOCMAN. PLEASE CHOOSE THE

CORRECT INCENTIVE RECEIPT FROM DOCMAN AND OBTAIN SIGNATURE. AFTER

COLLECTING SIGNATURE AND FINALIZING FORM, YOU WILL THEN BE BROUGHT BACK TO

THE INTERVIEW.


This form states that I have given you the gift certificate. This copy is for your records.


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

Question Fill: ^FillY_CC0Fill

under11 ADDRESS PARENT:·

---------------------------------------------------------------------------------

Y_CCIN1 Start IN DocMan

@bSTART DOCMAN INCENTIVE RECEIPT FORM@b


INTERVIEWER: PRESS UP ARROW IF YOU WANT TO GO TO PREVIOUS SCREEN.

Question Type: BDocMan

---------------------------------------------------------------------------------

Logic before:

If status from DocMan=491 ask Y_CCIN2 else ask Y_CCIN3

Y_CCIN2 [ YCCIN2 ] End IN DocMan

@bDOCMAN INCENTIVE RECEIPT FORM IS COMPLETED@b


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

Logic after:

---------------------------------------------------------------------------------

Y_CCIN3 [ YCCIN3 ] NO LABEL

@bDOCMAN INCENTIVE RECEIPT FORM IS NOT COMPLETED@b

Question Type: TDMR4F, noDK, noRF

_1 1 REDO THE FORM IN DOCMAN

_2 2 RESPONDENT REFUSED TO COMPLETE ELECTRONIC FORM BUT

SIGNED PAPER FORM

_3 3 A TECHNICAL PROBLEM PREVENTED THE ELECTRONIC FORM

FROM BEING COMPLETED BUT RESPONDENT SIGNED PAPER

FORM

_4 4 RESPONDENT REFUSES SO THERE'S NO FORM

Logic after:

If 1 GOTO Y_CCIN1

If 4 EXIT form

IF 3 Ask Y_CCIN4

ELSE GOTO Y_CC1/Y_CC2

---------------------------------------------------------------------------------

Y_CCIN4 [ YCCIN4 ] NO LABEL

@bDOCMAN INCENTIVE RECEIPT FORM IS NOT COMPLETED@b


GIVE DETAILS ABOUT THE TECHNICAL PROBLEM:

Question Type: STRING[60]

---------------------------------------------------------------------------------

Y_CC03b [ YCC03b ] NO LABEL

INTERVIEWER: SELECT "FORM NOT NEEDED" IN DOCMAN.


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

---------------------------------------------------------------------------------

Y_CCLG1 Start -L DocMan

@bSTART DOCMAN @b


INTERVIEWER: PRESS UP ARROW IF YOU WANT TO GO TO PREVIOUS SCREEN.

Question Type: BDocMan

---------------------------------------------------------------------------------

Logic before:

If status from DocMan=491 ask Y_QYAS2 else ask Y_QYAS3

Y_CCLG2 [ YCCLG2 ] End -L DocMan

@bDOCMAN IS COMPLETED@b


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

---------------------------------------------------------------------------------

Y_CCLG3 [ YCCLG3 ] NO LABEL

@bDOCMAN IS NOT COMPLETED@b

Question Type: TDMR2F, noDK, noRF

_1 1 REDO THE FORM IN DOCMAN

_2 2 RESPONDENT REFUSED TO COMPLETE ELECTRONIC FORM BUT

SIGNED PAPER FORM

_3 3 A TECHNICAL PROBLEM PREVENTED THE ELECTRONIC FORM

FROM BEING COMPLETED BUT RESPONDENT SIGNED PAPER

FORM

_4 4 RESPONDENT REFUSES SO THERE'S NO FORM

_5 5 A TECHNICAL PROBLEM PREVENTED FROM CODING OUT THE

FORM

Logic after:

If 1 GOTO Y_QYAS1

If 4 EXIT interview

IF 3 Ask Y_QYAS4

ELSE GOTO Y_QY0aa

---------------------------------------------------------------------------------

Y_CCLG4 [ YCCLG4 ] NO LABEL

@bDOCMAN IS NOT COMPLETED@b


GIVE DETAILS ABOUT THE TECHNICAL PROBLEM:

Question Type: STRING[60]

---------------------------------------------------------------------------------

Logic before:

IF AGE < 5, CONTINUE. ELSE, GOTO Y_CC2.

if RTIAGNID = '605' (The digits 2, 3, and 4 of the zrid is the RTIAGNID) then define fill Y_CC605

Y_CC1 [ YCC1 ] NO LABEL

^Fills.Y_CC605@a@aADDRESS PARENT: That is all we need to do involving ^CHILD. Thank you

for helping with these tests. This will help us a great deal in our research.


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

Question Fill: ^FillY_CC605

_605 SAY TO CAREGIVER: I appreciate your help with this important study.

Summit County Children Services Board requires that we get your written

permission before we interview a staff person about your child. Let me go

over the release form with you. READ FORM VERBATIM.@/@/@/

Logic after:

GOTO Y_CCEND

---------------------------------------------------------------------------------

Logic before:

if RTIAGNID = '605' (The digits 2, 3, and 4 of the zrid is the RTIAGNID) then define fill Y_CC605

Y_CC2 [ YCC2 ] NO LABEL

Those are all the questions I have for you. Thank you very much for answering these questions.

This will help us a great deal in our research.


^Fills.Y_CC605@a@aPRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

Question Fill: ^FillY_CC605

_605 SAY TO CAREGIVER: I appreciate your help with this important study.

Summit County Children Services Board requires that we get your written

permission before we interview a staff person about your child. Let me go

over the release form with you. READ FORM VERBATIM.@/@/@/

---------------------------------------------------------------------------------

Logic before:

DISPLAY Y_CC3 NOTICE TO INTERVIEWER IF: Y_CD9aa AND Y_CD9ba = 1, OR Y_YB18aa

AND Y_YB18ba = 1, OR Y_YB91aa AND Y_YB91ba = 1. ELSE, GOTO Y_CCEND.

Y_CC3a [ YCC3a ] Instructions if CH is suicidal

INTERVIEWER: CHILD INDICATED HE/SHE HAS SUICIDE INTENTIONS EARLIER IN

INTERVIEW (CHILD HAD SUICIDE THOUGHTS IN LAST 2 WEEKS AND A PLAN FOR

CARRYING OUT THOUGHTS).


SAY: Earlier, you gave me some answers that caused me to worry about your safety. I need to

talk with someone about my concerns.


FOLLOW REQUIRED STUDY PROCEDURES FOR FOLLOW-UP ACTION. DO NOT LEAVE

CHILD/HOME UNTIL APPROPRIATE ACTIONS HAVE BEEN TAKEN.


AFTER RETURNING HOME, REMEMBER TO COMPLETE AN ADVERSE EVENT REPORT

AND SUBMIT IT TO RTI AS SOON AS POSSIBLE.


PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont

Continue 1 Continue

Logic after:

GOTO Y_CCEND

---------------------------------------------------------------------------------

Y_CC_END [ YCC_END ] NoDeliv

PRESS "1" AND ENTER TO CONTINUE.

Question Type: TCont, NoDK, NoRF

Continue 1 Continue





File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorSmith, Keith R.
File Modified0000-00-00
File Created2022-08-23

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