Appendix D_2022 NSCH Screener and Topical Questionnaire Drafts

Appendix D_2022 NSCH Screener and Topical Questionnaires (1).pdf

National Survey of Children's Health

Appendix D_2022 NSCH Screener and Topical Questionnaire Drafts

OMB: 0607-0990

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0607-0990 can be found here:

Document [pdf]

Download: pdf | pdf

Appendix D

2022 National Survey of Children’s Health
Screener and Topical Questionnaires

26002089

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The Census Bureau is required by law to protect your information. We are not permitted to publicly release your responses in a way that
could identify your household. The Census Bureau is conducting this survey under the authority of Title 13, United States Code (U.S.C.),
Section 8(b) (13 U.S.C. § 8(b)) and Section 501(a)(2) of the Social Security Act (42 U.S.C. § 701). Federal law protects your privacy and
keeps your answers confidential under Title 13, U.S.C., Section 9 (13 U.S.C. § 9). Per the Federal Cybersecurity Enhancement Act of 2015,
your data are protected from cybersecurity risks through screening of the systems that transmit your data.
Access to records maintained in the system is restricted to Census Bureau employees and certain individuals authorized by Title 13, U.S.
Code (designated as Special Sworn Status individuals). These individuals are subject to the same confidentiality requirements as regular
Census Bureau employees identified above and as permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a) and SORN
COMMERCE/CENSUS-3, Demographic Survey Collection (Census Bureau Sampling Frame).
Participation in this survey is voluntary and there are no penalties for refusing to answer questions. However, your cooperation in obtaining
this much needed information is extremely important in order to ensure complete and accurate results.

NSCH-S1
(01/21/2022)

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26002071

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26022111

G. This Child’s Schooling
and Activities

Yes

did this child miss school because of illness or injury?
Include days missed from any formal home schooling.

b. Any clubs or organizations after
school or on weekends?

No missed school days

c. Any other organized activities or
lessons, such as music, dance,
language, or other arts?

1-3 days
4-6 days

d. Any type of community service or
volunteer work at school, place of
worship, or in the community?

7-10 days

e. Any paid work, including regular
jobs as well as babysitting, cutting
grass, or other occasional work?

11 or more days
This child was not enrolled in school
G6

DURING THE PAST 12 MONTHS, how many times has
this child’s school contacted you or another adult in
your household about any problems they are having
with school?

DURING THE PAST 12 MONTHS, how often did you
attend events or activities that this child participated in?
Always
Usually

None
Sometimes
1 time
Rarely
2 or more times
Never
G3 Across all subjects, what grades did this child get

during the 2021-2022 school year?

Mostly A’s

DURING THE PAST WEEK, on how many days did
this child exercise, play a sport, or participate in
physical activity for at least 60 minutes?

Mostly A’s and B’s

0 days

Mostly B’s and C’s

1-3 days

Mostly C’s and D’s

4-6 days

Mostly D’s or lower

Every day

This child’s school does not give these grades

a. A sports team or did they take
sports lessons after school or
on weekends?

G1 DURING THE PAST 12 MONTHS, about how many days

DURING THE PAST 12 MONTHS, did this child
participate in...

G4 SINCE STARTING KINDERGARTEN, has this child

repeated any grades?

Compared to other children their age, how much
difficulty does this child have making or keeping
friends?
No difficulty

Yes

A little difficulty

A lot of difficulty

NSCH-T2

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26022103

H. About You and This
Child

G9 DURING THE PAST 12 MONTHS, how often was this

child bullied, picked on, or excluded by other children?
Do not include siblings. If the frequency changed
throughout the year, report the highest frequency.
H1

Never (in the past 12 months)

Was this child born in the United States?

1-2 times (in the past 12 months)

Yes ➔ SKIP to question H3

1-2 times per month

1-2 times per week

If no, how long has this child been living in the United
States?

Almost every day
years AND

G10 DURING THE PAST 12 MONTHS, how often did this

child bully others, pick on them, or exclude them?
Do not include siblings. If the frequency changed
throughout the year, report the highest frequency.

Never (in the past 12 months)

months

How many times has this child moved to a new address
since they were born?
Number of times

1-2 times (in the past 12 months)
H4

1-2 times per month

How often does this child go to bed at about the same
time on weeknights?

1-2 times per week

Always

Almost every day

Usually

G11 How often does this child...
Always

Sometimes
Usually Sometimes

Never

Rarely

a. Show interest and
curiosity in learning
new things?
b. Work to finish tasks
they start?

Never
H5

c. Stay calm and in
control when faced
with a challenge?

DURING THE PAST WEEK, how many hours of sleep
did this child get on most weeknights?
Less than 6 hours

d. Care about doing
well in school?

6 hours

e. Do all required
homework?

7 hours
8 hours

f. Argue too much?

9 hours
10 hours
11 or more hours

NSCH-T2

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26022095
H6 ON MOST WEEKDAYS, about how much time did this

child spend in front of a TV, computer, cellphone or
other electronic device watching programs, playing
games, accessing the internet or using social media?
Do not include time spent doing schoolwork.

H10 DURING THE PAST 12 MONTHS, was there someone

that you could turn to for day-to-day emotional support
with parenting or raising children?
Yes

Less than 1 hour

No ➔ SKIP to question I1 on page 17

1 hour
H11 If yes, did you receive emotional support from...

2 hours

Yes

3 hours

a. Spouse or domestic partner?

4 or more hours

b. Other family member or close friend?
c. Health care provider?

H7 How well can you and this child share ideas or talk

about things that really matter?

d. Place of worship or religious leader?

Very well

e. Support or advocacy group related
to specific health condition?

Somewhat well

f. Peer support group?

Not very well

g. Counselor or other mental health
professional?

Not well at all

h. Other person, specify:

H8 How well do you think you are handling the day-to-day

demands of raising children?
Very well
Somewhat well
Not very well
Not well at all

H9 DURING THE PAST MONTH, how often have you felt...
Never

Rarely Sometimes Usually Always

a. That this child
is much
harder to care
for than most
children
their age?
b. That this child
does things
that really
bother you
a lot?
c. Angry with
this child?

NSCH-T2

§;#5¢¤

26022087

I. About Your Family and
Household
I1

Yes

DURING THE PAST WEEK, on how many days did all the
family members who live in the household eat a meal
together?

b. Food Stamps or Supplemental Nutrition
Assistance Program (SNAP) benefits?
c. Free or reduced-cost breakfasts or
lunches at school?

1-3 days

d. School meal debit/Electronic Benefits
Transfer (EBT) cards?

4-6 days

e. Benefits from the Women, Infants,
and Children (WIC) Program?

Every day

Does anyone living in your household use cigarettes,
cigars, or pipe tobacco?

Yes

No ➔ SKIP to question I4

If yes, is this for a disability they have?

DURING THE PAST 12 MONTHS, was there a time when
you were not able to pay the mortgage or rent on time?

Yes

Don’t know
I10 DURING THE PAST 12 MONTHS, how often were you

worried or stressed about being evicted, foreclosed on,
or having your housing condemned?

SINCE THIS CHILD WAS BORN, how often has it been
very hard to cover the basics, like food or housing,
on your family’s income?

Always

Never

Usually

Rarely

Sometimes

Somewhat often

Rarely

Very often

Never

Which of these statements best describes your
household’s ability to afford the food you need
DURING THE PAST 12 MONTHS?

I11 DURING THE PAST 12 MONTHS, how many places has

this child lived?

Number of places

We could always afford to eat good nutritious meals.
We could always afford enough to eat but not always
the kinds of food we should eat.

Yes

Does anyone vape or use e-cigarettes inside your home?

Yes

If yes, does anyone smoke inside your home?

No
I4

Does this child receive SSI, that is, Supplemental
Security Income?
SSI is different from Social Security.

Yes

a. Cash assistance from a government
welfare program?

0 days

At any time DURING THE PAST 12 MONTHS, even for
one month, did anyone in your family receive...

I12 SINCE THIS CHILD WAS BORN, have they ever been

homeless or lived in a shelter? Include living in a shelter,
motel, temporary or transitional living situation, scattered site
housing, or having no steady place to sleep at night.

Sometimes we could not afford enough to eat.

Yes

Often we could not afford enough to eat.

No
Don’t know

NSCH-T2

§;#5x¤

26022079
I13 In your neighborhood, is/are there...

I16 The next questions are about events that may have

Yes

happened during this child’s life. These things can
happen in any family, but some people may feel
uncomfortable with these questions. You may skip
any questions you do not want to answer.

a. Sidewalks or walking paths?
b. A park or playground?

To the best of your knowledge, has this child EVER
experienced any of the following?
Yes
No
a. Parent or guardian divorced or
separated

c. A recreation center, community
center, or boys’ and girls’ club?
d. A library or bookmobile?

b. Parent or guardian died

e. Litter or garbage on the street
or sidewalk?

c. Parent or guardian served time in
jail or prison

f. Poorly kept or rundown housing?

d. Saw or heard parents or adults slap,
hit, kick, punch one another in the
home

g. Vandalism such as broken
windows or graffiti?

e. Was a victim of violence or
witnessed violence in their
neighborhood

I14 To what extent do you agree with these statements

about your neighborhood or community?

f. Lived with anyone who was mentally
ill, suicidal, or severely depressed

Definitely Somewhat Somewhat Definitely
agree
agree
disagree disagree

g. Lived with anyone who had a problem
with alcohol or drugs

a. People in this
neighborhood help
each other out

h. Treated or judged unfairly because
of their race or ethnic group

b. We watch out for
each other’s
children in this
neighborhood
c. This child is
safe in our
neighborhood
d. When we
encounter
difficulties, we
know where to
go for help in
our community

Treated or judged unfairly because
of their sexual orientation or gender
identity

Treated or judged unfairly because
of a health condition or disability

I17 When your family faces problems, how often are you

likely to do each of the following?
All of
the time

Most of
the time

Some of
the time

None of
the time

a. Talk together
about what to do

e. This child is safe
at school

b. Work together to
solve our problems

I15 Other than you or other adults in your home, is there at

least one other adult in this child’s school, neighborhood,
or community who knows this child well and who they
can rely on for advice or guidance?

c. Know we have
strengths to draw on
d. Stay hopeful even
in difficult times

Yes
No

NSCH-T2

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26022061

J. Child’s Caregivers

I18 DURING THE PAST 12 MONTHS, has this child had

any health care visits by video or phone?
Yes

About You

If yes, were any of this child’s health care visits
by video or phone because of the coronavirus
pandemic?
Yes

How are you related to this child?
Biological or Adoptive Parent

Step-parent

I19 DURING THE PAST 12 MONTHS, did this child miss,

Grandparent

delay or skip any PREVENTIVE check-ups because of
the coronavirus pandemic?

Foster Parent

Yes

Other: Relative

Other: Non-Relative

I20 DURING THE PAST 12 MONTHS, have any of this

child’s regular childcare arrangements been closed
or unavailable at any time because of the coronavirus
pandemic? Please include before school care, after school
care, and all other forms of childcare that were unavailable.
Yes

What is your sex?
Male
Female

What is your age?

No
Age in years
J4

Where were you born?
In the United States ➔ SKIP to question J6
on page 20
Outside of the United States

When did you come to live in the United States?
Indicate the 4-digit year in which you came to live in the
United States.
4-Digit Year

NSCH-T2

§;#5^¤

26022053

What is the highest grade or level of school you have
completed?
Mark (X) ONE box.

Excellent

8th grade or less

Very good

9th-12th grade; No diploma

Good

High School Graduate or GED Completed

Fair

Completed a vocational, trade, or business school
program

Poor

Some College Credit, but no Degree

J10 Which of the following best describes your current

employment status?
Mark (X) ONE box.

Associate Degree (AA, AS)

Bachelor’s Degree (BA, BS, AB)

Employed full-time

Master’s Degree (MA, MS, MSW, MBA)

Employed part-time

Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)

Working WITHOUT pay
Not employed but looking for work

What is your marital status?

Not employed and not looking for work

Married
Not married, but living with a partner

J11 Have you ever served on active duty in the

U.S. Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.

Never Married

In general, how is your mental or emotional health?

Divorced

Never served in the military ➔ SKIP to question J13

Separated

Only on active duty for training in the
Reserves or National Guard ➔ SKIP to question J13

Widowed

Now on active duty
On active duty in the past, but not now

In general, how is your physical health?
Excellent

J12 Were you deployed at any time during this child’s life?

Very good

Yes

Good

Fair

J13 Does this child have another parent or adult caregiver

who lives in this household?

Poor

Yes ➔ Complete questions J14 - J25 for this other
parent or adult caregiver
No ➔ SKIP to question K1 on page 22

NSCH-T2

§;#5V¤

26022046

Other Parent or Caregiver
in the Household

J19 What is the highest grade or level of school this

caregiver has completed?
Mark (X) ONE box.

J14 How is this other caregiver related to this child?

8th grade or less

Biological or Adoptive Parent

9th-12th grade; No diploma

Step-parent

High School Graduate or GED Completed

Grandparent

Completed a vocational, trade, or business school
program

Foster Parent
Some College Credit, but no Degree
Other: Relative
Associate Degree (AA, AS)
Other: Non-Relative
Bachelor’s Degree (BA, BS, AB)
J15 What is this caregiver’s sex?

Master’s Degree (MA, MS, MSW, MBA)

Male

Doctorate (PhD, EdD) or Professional Degree
(MD, DDS, DVM, JD)

Female
J20 What is this caregiver’s marital status?
J16 What is this caregiver’s age?

Married
Age in years

Not married, but living with a partner
Never Married

J17 Where was this caregiver born?

In the United States ➔ SKIP to question J19

Divorced

Outside of the United States

Separated
Widowed

J18 When did this caregiver come to live in the United

States? Indicate the 4-digit year in which this caregiver
came to live in the United States.

J21 In general, how is this caregiver’s physical health?

Excellent

4-Digit Year

Very good
Good
Fair
Poor

NSCH-T2

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26022038

K. Household Information

J22 In general, how is this caregiver’s mental or emotional

health?

Excellent

K1
K4

Very good
Good
Fair

How many people are living or staying at this address?
Include everyone who usually lives or stays at this address.
Do NOT include anyone who is living somewhere else for
more than two months, such as a college student living away
or someone in the Armed Forces on deployment.
Number of people

Poor
K2
J23 Which of the following best describes this caregiver’s

current employment status?
Mark (X) ONE box.

How many of these people in your household are family
members? Family is defined as anyone related to this child
by blood, marriage, adoption, or through foster care.
Number of people

Employed full-time
Employed part-time
Working WITHOUT pay
Not employed but looking for work
Not employed and not looking for work
J24 Has this caregiver ever served on active duty in the

U.S. Armed Forces, Reserves, or the National Guard?
Mark (X) ONE box.
Never served in the
military ➔ SKIP to question K1
Only on active duty for training in the Reserves or
National Guard ➔ SKIP to question K1
Now on active duty
On active duty in the past, but not now

J25 Was this caregiver deployed at any time during this

child’s life?
Yes
No

NSCH-T2

§;#5G¤

26022020

Income in 2021
Mark (X) the "Yes" box for EACH type of income this child’s
family received, and give your best estimate of the TOTAL
AMOUNT IN THE LAST CALENDAR YEAR. Mark (X) the
"No" box to show types of income NOT received.

a. Wages, salary, commissions, bonuses, or tips for
all jobs.
Yes ➔

.00

TOTAL AMOUNT
in the last calendar year

.00

Loss

TOTAL AMOUNT
in the last calendar year

b. Self-employment income from own nonfarm
businesses or farm business, including
proprietorships and partnerships.
Yes ➔

The following question is about your 2021 income.
Think about your total combined family income IN THE
LAST CALENDAR YEAR for all members of the family.
What is that amount before taxes? Include money from
jobs, child support, social security, retirement income,
unemployment payments, public assistance, and so forth.
Also, include income from interest, dividends, net income
from businesses, farm or rent, and any other money income
received.

Loss

TOTAL AMOUNT
in the last calendar year

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Yes ➔

.00

Loss

TOTAL AMOUNT
in the last calendar year

d. Social Security or Railroad Retirement; retirement,
survivor, or disability pensions.
Yes ➔

.00

TOTAL AMOUNT
in the last calendar year

e. Supplemental Security Income (SSI); any public
assistance or welfare payments from the state or
local welfare office.
Yes ➔

.00

TOTAL AMOUNT
in the last calendar year

f. Any other sources of income received regularly
such as Veterans’ (VA) payments, unemployment
compensation, child support, or alimony.
Yes ➔
No

.00

TOTAL AMOUNT
in the last calendar year

NSCH-T2

§;#55¤

26022012

Mailing Instructions
Thank you for your participation.
On behalf of the U.S. Department of Health and Human Services, we would like to thank you for the time
and effort you have spent sharing information about this child and your family.
Your answers are important to us and will help researchers, policymakers, and family advocates to better
understand the health and health care needs of children in our diverse population.
Place the completed questionnaire in the postage-paid return envelope. If the envelope has been
misplaced, mail the questionnaire to:
U.S. Census Bureau
ATTN: DCB 60-A
1201 E. 10th Street
Jeffersonville, IN 47132-0001

We estimate that completing the National Survey of Children’s Health will take 35 minutes on average. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing
this burden, to U.S. Department of Commerce, Paperwork Project 0607-0990, U.S. Census Bureau, 4600 Silver Hill Road,
Room 8H590, Washington, DC 20233. You may e-mail comments to [email protected]; use "Paperwork
Project 0607-0990" as the subject. This collection has been approved by the Ofﬁce of Management and Budget (OMB).
The eight-digit OMB approval number that appears at the upper left of the form conﬁrms this approval. If this number
were not displayed, we could not conduct this survey.

NSCH-T2

§;#5-¤

26032243

National Survey of Children’s Health
A study by the U.S. Department of Health and Human Services
to better understand the health issues faced by children in the
United States today.

The Census Bureau is required by law to protect your information. We are not permitted to publicly release your responses in a way that
could identify your household. The Census Bureau is conducting this survey under the authority of Title 13, United States Code (U.S.C.),
Section 8(b) (13 U.S.C. § 8(b)) and Section 501(a)(2) of the Social Security Act (42 U.S.C. § 701). Federal law protects your privacy and
keeps your answers conﬁdential under Title 13, U.S.C., Section 9 (13 U.S.C. § 9). Per the Federal Cybersecurity Enhancement Act of 2015,
your data are protected from cybersecurity risks through screening of the systems that transmit your data.
Access to records maintained in the system is restricted to Census Bureau employees and certain individuals authorized by Title 13, U.S.
Code (designated as Special Sworn Status individuals). These individuals are subject to the same conﬁdentiality requirements as regular
Census Bureau employees identiﬁed above and as permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a) and SORN
COMMERCE/CENSUS-3, Demographic Survey Collection (Census Bureau Sampling Frame).
Participation in this survey is voluntary and there are no penalties for refusing to answer questions. However, your cooperation in obtaining
this much needed information is extremely important in order to ensure complete and accurate results.

NSCH-T3
(04/04/2022)

§;$7L¤

26032235

Start Here

Recently, you completed a survey that asked about the
children usually living or staying at this address.
Thank you for taking the time to complete that survey.

Yes

a. Breathing or other respiratory
problems (such as wheezing or
shortness of breath)

We now have some follow-up questions to ask about:

b. Eating or swallowing because of
a health condition
c. Digesting food, including
stomach/intestinal problems,
constipation, or diarrhea

If the name listed above is not correct or does not
correspond to a child living in this household, please
call 1-800-845-8241 for assistance.

d. Repeated or chronic physical pain,
including headaches or other back
or body pain

We have selected only one child per household in an
effort to minimize the amount of time you will need to
complete the follow-up questions.

e. Toothaches
f. Bleeding gums

The survey should be completed by a parent or adult
caregiver who lives in this household and who is
familiar with this child’s health and health care.
Your participation is important. Thank you.

DURING THE PAST 12 MONTHS, has this child had
FREQUENT or CHRONIC difficulty with any of the
following?

g. Decayed teeth or cavities
A4

Does this child have any of the following?
a. Serious difficulty concentrating,
remembering, or making decisions
because of a physical, mental, or
emotional condition
b. Serious difficulty walking or climbing
stairs

A. This Child’s Health

c. Difficulty dressing or bathing
A1 In general, how would you describe this child’s health

d. Difficulty doing errands alone, such
as visiting a doctor’s office or
shopping, because of a physical,
mental, or emotional condition

(the one named above)?
Excellent
Very good

e. Deafness or problems with hearing

Good

f. Blindness or problems with seeing,
even when wearing glasses

Fair

Has a doctor or other health care provider EVER told
you that this child has...

Poor
A5
A2 How would you describe the condition of this child’s

Allergies (such as food, drug, insect, seasonal, or other)?
Yes

teeth?

If yes, does this child CURRENTLY have the
condition?

Excellent

Yes

Very good
Good
Fair

If yes, is it:
Mild
A6

Poor

Moderate

Severe

Asthma?
Yes

If yes, does this child CURRENTLY have the
condition?
Yes

If yes, is it:
Mild
NSCH-T3

Moderate

Severe

§;$7D¤

26032227
Has a doctor or other health care provider EVER told
you that this child has...
A7

Autoimmune disease (such as Type 1 Diabetes,
Celiac, or Juvenile Idiopathic Arthritis)?
Yes

Has a doctor or other health care provider EVER told
you that this child has...
A12 Frequent or severe headaches, including migraine?

Yes

If yes, does this child CURRENTLY have the
condition?

If yes, is it:
Mild

Moderate

Yes

Severe

Mild

No
Mild

Moderate

Yes

Severe

Yes

If yes, does this child CURRENTLY have the
condition?
Yes

Mild

If yes, is it:

Moderate

Severe

A14 Anxiety Problems?

Mild

Moderate

Severe

Yes

If yes, does this child CURRENTLY have the
condition?

A10 Epilepsy or Seizure Disorder?

Yes

If yes, does this child CURRENTLY have the
condition?
Yes

If yes, is it:

If yes, is it:
Mild

If yes, is it:

Moderate

Severe

A15 Depression?

Mild

Moderate

Severe

Yes

If yes, does this child CURRENTLY have the
condition?

A11 Heart Condition?

Yes

Severe

If yes, does this child CURRENTLY have the
condition?

A9 Type 2 Diabetes?

Yes

Moderate

A13 Tourette Syndrome?

If yes, is it:

Yes

If yes, is it:

A8 Cerebral Palsy?

Yes

If yes, was this child born with the condition?
Yes

Mild

Does this child CURRENTLY have the condition?
Yes

If yes, is it:
Moderate

Severe

A16 Down Syndrome?

Yes

If yes, is it:
Mild

Moderate

Severe

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Has a doctor or other health care provider EVER told
you that this child has...
A17 Blood Disorders (such as Sickle Cell Disease,

Thalassemia, or Hemophilia)?
Yes

Has a doctor, other health care provider, or educator
EVER told you that this child has...
Examples of educators are teachers and school nurses.
A21 Behavioral or Conduct Problems?

Yes

If yes, does this child CURRENTLY have the
condition?

If yes, is it:
Mild

Moderate

Severe

Yes

Was this child diagnosed with:
Sickle Cell Disease?

Yes

Thalassemia?

Yes

Hemophilia?

Yes

Other Blood
Disorders?

Yes

If yes, is it:
Mild

Moderate

Severe

A22 Developmental Delay?

Yes

If yes, does this child CURRENTLY have the
condition?

Were any of these blood disorders identified
through a blood test done shortly after birth?
These tests are sometimes called newborn screening.
Yes

Yes

If yes, is it:

Mild

Moderate

Severe

A18 Cystic Fibrosis?

Yes

A23 Intellectual Disability (formerly known as Mental

Retardation)?

If yes, is it:

Yes

Mild

Moderate

Severe

If yes, does this child CURRENTLY have the
disability?

Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.
Yes

Yes
If yes, is it:

Mild

A19 Any other genetic or inherited condition?

Yes

Moderate

Severe

A24 Speech or other language disorder?

If yes, specify: C

Yes

If yes, does this child CURRENTLY have the
condition?

Is it:
Mild

Moderate

Yes

Severe

Yes

If yes, is it:

Was this condition identified through a blood
test done shortly after birth? These tests are
sometimes called newborn screening.

Mild

Moderate

Severe

A25 Learning Disability?

Yes

A20 Fetal Alcohol Spectrum Disorder (FASD)?

Yes

If yes, does this child CURRENTLY have the
disability?

Yes

If yes, is it:
Mild

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Severe

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A26 Has a doctor or other health care provider EVER told

you that this child has Autism or Autism Spectrum
Disorder (ASD)? Include diagnoses of Asperger’s Disorder
or Pervasive Developmental Disorder (PDD).
Yes

A31 Has a doctor or other health care provider EVER told

you that this child has Attention Deficit Disorder or
Attention-Deficit/Hyperactivity Disorder, that is, ADD or
ADHD?
Yes

No ➔ SKIP to question A31

If yes, does this child CURRENTLY have the
condition?

If yes, does this child CURRENTLY have the
condition?
Yes

Yes

Moderate

Mild

Severe

A27 How old was this child when a doctor or other health

Don’t know

Yes

A33 At any time DURING THE PAST 12 MONTHS, did this

child receive behavioral treatment for ADD or ADHD,
such as training or an intervention that you or this
child received to help with their behavior?
Yes

A34 Do you think this child has EVER had a concussion or

brain injury? A concussion or brain injury is when a blow
or jolt to the head causes problems such as headaches,
dizziness, being dazed or confused, difficulty remembering
or concentrating, vomiting, blurred vision, changes in mood
or behavior, or being knocked out.

Primary Care Provider
Specialist
School Psychologist/Counselor

Yes
Other Psychologist (Non-School)

If yes, did you seek medical care from a doctor or
other health care provider?

Psychiatrist
Other, specify:

Yes
C

Yes

child’s health conditions or problems affected their
ability to do things other children their age do?

This child does not have any
health conditions ➔ SKIP to question B1 on page 6

A30 At any time DURING THE PAST 12 MONTHS, did this

Never

child receive behavioral treatment for Autism, ASD,
Asperger’s Disorder or PDD, such as training or an
intervention that you or this child received to help
with their behavior?
Yes

A35 DURING THE PAST 12 MONTHS, how often have this

ASD, Asperger’s Disorder or PDD?
Yes

If yes, did a doctor or other health care
provider tell you that your child had a
concussion or brain injury?

Don’t know
A29 Is this child CURRENTLY taking medication for Autism,

Severe

ADHD?

A28 What type of doctor or other health care provider was

the FIRST to tell you that this child had Autism, ASD,
Asperger’s Disorder or PDD?
Mark (X) ONE box.

Moderate

A32 Is this child CURRENTLY taking medication for ADD or

care provider FIRST told you that they had Autism, ASD,
Asperger’s Disorder or PDD?
Age in years

If yes, is it:

If yes, is it:
Mild

No ➔ SKIP to question A34

Sometimes
Usually

No
Always
A36 To what extent do this child’s health conditions or

problems affect their ability to do things?
Very little
Somewhat
A great deal

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B. This Child as an Infant
B1

Was this child born more than 3 weeks before their
due date?

C. Health Care Services
C1

Yes

DURING THE PAST 12 MONTHS, did this child see a
doctor, nurse, or other health care professional for
sick-child care, well-child check-ups, physical exams,
hospitalizations or any other kind of medical care?
Include health care visits done by video or phone.

No
B2

Yes

What month and year was this child born?

No ➔ SKIP to question C5

Birth Month / 4-Digit Birth Year
C2

/
B3

2 0

If yes, at their LAST medical care visit, did this child
have a chance to speak with a doctor or other health
care provider privately, without you or another
caregiver in the room?

How much did they weigh when born? Answer in
pounds and ounces OR kilograms and grams. Your best
estimate is fine.

Yes
No

pounds AND

ounces

OR
kilograms AND
B4

grams

If yes, DURING THE PAST 12 MONTHS, how many times
did this child visit a doctor, nurse, or other health care
professional to receive a PREVENTIVE check-up?
A preventive check-up is when this child was not sick
or injured, such as an annual or sports physical, or
well-child visit.

What was the age of the mother when this child was
born? Your best estimate is fine.

0 visits
1 visit

Age in years

2 or more visits
C4

Thinking about the LAST TIME you took this child for
a PREVENTIVE check-up, about how long was the
doctor or health care provider who examined this
child in the room with you? Your best estimate is fine.
Less than 10 minutes
10-20 minutes
More than 20 minutes

What is this child’s CURRENT height?
Your best estimate is fine.
feet AND

inches

OR
meters AND
C6

centimeters

How much does this child CURRENTLY weigh?
Your best estimate is fine.
pounds
OR
kilograms

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Are you concerned about this child’s weight?

C12 Is there a place you or another caregiver USUALLY

take this child when they are sick or you need advice
about their health?

Yes, it’s too high

Yes, it’s too low

Yes

No, I am not concerned

No ➔ SKIP to question C14
C13 If yes, where does this child USUALLY go first?

Has a doctor or other health care provider ever told
you that this child is overweight?

Mark (X) ONE box.

Yes

Doctor’s Office

Hospital Emergency Room

DURING THE PAST 12 MONTHS, did this child engage in
any of the following?
Mark (X) Yes or No for EACH item.

Hospital Outpatient Department

a. Skipping meals or fasting (Do NOT
include skipping meals or fasting for
religious reasons)

Clinic or Health Center

Yes

Urgent Care Center

Retail Store Clinic or “Minute Clinic”

b. Having low interest in food

School (Nurse’s Office, Athletic Trainer’s Office)

c. Extremely picky eating

Some other place

d. Binge eating
C14 Is there a place that this child USUALLY goes when

they need routine preventive care, such as a physical
examination or well-child check-up?

e. Purging or vomiting after eating
f. Using diet pills, laxatives, or diuretics
(water pills) to lose or maintain weight
without a doctor’s orders

Yes
No ➔ SKIP to question C16

g. Over-exercising
h. Not eating due to fear of vomiting
or choking

C15

C10 Answer question C10 only if you marked "Yes" for at

least one item in question
question C11 .

If yes, is this the same place this child goes when they
are sick?
Yes

. Otherwise skip to

C10 ,

For question
consider only the behaviors you
marked "Yes" to in question C9 .

No
C16 DURING THE PAST 2 YEARS, has this child received a

vision screening from a care provider other than an eye
doctor? The screening could have occurred at a
pediatrician’s office, in a school, preschool/child care center,
or a community setting, using pictures, shapes, letters, or a
camera like tool.

DURING THE PAST 12 MONTHS, how concerned were
you about this child engaging in these behaviors?
Very much

Yes

Somewhat

If yes, was it recommended that this child see an
eye doctor or other eye care provider for an eye
examination or additional vision services as a
result of the vision screening? An eye doctor may
be referred to as an optometrist or ophthalmologist.

Not at all
C11 DURING THE PAST 12 MONTHS, how concerned was

this child about their weight, body shape, or body size?

Yes

Very much

Somewhat
Not at all

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C17 DURING THE PAST 2 YEARS, has this child seen an

eye doctor? An eye doctor may be referred to as an
optometrist or ophthalmologist.
Yes

C21 DURING THE PAST 12 MONTHS, has this child

received any treatment or counseling from a mental
health professional? Mental health professionals include
psychiatrists, psychologists, psychiatric nurses, and clinical
social workers.

If yes, what care has this child received from the
eye doctor?
Mark (X) ALL that apply.

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

Received eye examination

No, this child did not need to see a
mental health professional ➔ SKIP to question C23

Prescribed eyeglasses or contact lenses
Diagnosis of a vision disorder other than
nearsighted, farsighted, or astigmatism

C22 How difficult was it to get the mental health treatment

or counseling that this child needed?
Not difficult

Some other care

Somewhat difficult

C18 DURING THE PAST 12 MONTHS, did this child see a

dentist or other oral health care provider for any kind
of dental or oral health care?
Mark (X) ALL that apply.
Yes, saw a dentist

Very difficult
It was not possible to obtain care
C23 DURING THE PAST 12 MONTHS, has this child taken

any medication because of difficulties with their
emotions, concentration, or behavior?

Yes, saw other oral health care provider
No ➔ SKIP to question C21

Yes

C19 If yes, DURING THE PAST 12 MONTHS, did this child

see a dentist or other oral health care provider for
PREVENTIVE dental care, such as check-ups, dental
cleanings, dental sealants, or fluoride treatments?

No
C24 DURING THE PAST 12 MONTHS, did this child see a

specialist other than a mental health professional?
Specialists are doctors like surgeons, heart doctors, allergy
doctors, skin doctors, and others who specialize in one
area of health care.

No preventive visits in the
past 12 months ➔ SKIP to question C21
Yes, 1 visit

Yes

Yes, 2 or more visits

No, but this child needed to see a specialist
C20 If yes, DURING THE PAST 12 MONTHS, what

No, this child did not need to see
a specialist ➔ SKIP to question C26

PREVENTIVE dental service(s) did this child receive?
Mark (X) ALL that apply.
Check-up

C25 How difficult was it to get the specialist care that this

child needed?

Cleaning

Not difficult

Instruction on tooth brushing and oral health care

Somewhat difficult

X-Rays

Very difficult

Fluoride treatment

It was not possible to obtain care

Sealant (plastic coatings on back teeth)
C26 DURING THE PAST 12 MONTHS, did this child use any

type of alternative health care or treatment? Alternative
health care can include acupuncture, chiropractic care,
relaxation therapies, herbal supplements, and others.
Some therapies involve seeing a health care provider,
while others can be done on your own.

Don’t know

Yes
No
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File Type	application/pdf
Author	Leah Meyer (CENSUS/ADDP FED)
File Modified	2022-04-04
File Created	2020-01-17