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pdfNational 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.
Dear Parent or Caregiver,
A few weeks ago, a parent or caregiver in your household responded to the National Survey of
Children’s Health. We greatly appreciate your participation.
We recently discovered a printing error in the questionnaire that we sent you. As a result, it was
missing several pages containing important questions. We are providing those questions in this
booklet and asking for your help. We hope you will give us just a few more minutes of your time
to complete these voluntary questions about:
These questions should be completed by a parent or adult caregiver who is familiar with this
child’s health and health care. We estimate that it will take most households less than 5 minutes
to complete this booklet of questions. Please return your completed booklet in the postage-paid
envelope provided.
If you have any questions about this request, please call us at 1-800-845-8241 or email
[email protected].
Thank you once again for your help.
The National Survey of Children’s Health Team
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.
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F. Providing for This
Child’s Health
F1
F5
Including co-pays and amounts reimbursed from
Health Savings Accounts (HSA) and Flexible Spending
Accounts (FSA), how much money did you pay for
this child’s medical, health, dental, and vision care
DURING THE PAST 12 MONTHS? Do not include
health insurance premiums or costs that were or will
be reimbursed by insurance or another source.
IN AN AVERAGE WEEK, how many hours do you or
other family members spend providing health care at
home for this child? Care might include changing bandages,
or giving medication and therapies when needed.
This child does not need health care provided at home
on a weekly basis
Less than 1 hour per week
1-4 hours per week
5-10 hours per week
$0 (No medical or health-related
expenses) ➔ SKIP to question F4
11 or more hours per week
$1-$249
F6
$250-$499
$500-$999
F2
IN AN AVERAGE WEEK, how many hours do you or
other family members spend arranging or coordinating
health or medical care for this child, such as making
appointments or locating services?
$1,000-$5,000
This child does not need health care coordinated
on a weekly basis
More than $5,000
Less than 1 hour per week
1-4 hours per week
How often are these costs reasonable?
Always
5-10 hours per week
Usually
11 or more hours per week
Sometimes
Never
F3
DURING THE PAST 12 MONTHS, did your family have
problems paying for any of this child’s medical or
health care bills?
Yes
No
F4
DURING THE PAST 12 MONTHS, have you or other
family members...
a. Left a job or taken a leave of
absence because of this child’s
health or health conditions?
Yes
No
b. Cut down on the hours you work
because of this child’s health or
health conditions?
c. Avoided changing jobs because of
concerns about maintaining health
insurance for this child?
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G. This Child’s Learning
G2
Is this child 3 years old or older?
Yes
Answer the following question only if this child is at
least 1 year old. Otherwise END questionnaire and return.
No ➔ END questionnaire and return.
G1 Is this child able to do the following...
Mark (X) Yes or No for EACH item.
Yes
No
G3
a. Say at least one word, such as "hi"
or "dog"?
Yes, preschool
b. Use 2 words together, such as
"car go"?
Yes, kindergarten
c. Use 3 words together in a sentence,
such as, "Mommy come now."?
d. Ask questions like "who," "what,"
"when," "where"?
e. Ask questions like "why" and "how"?
Has this child started school? Include any formal
home schooling.
Yes, first grade
No
G4
f. Tell a story with a beginning,
middle, and end?
How often can this child recognize the beginning
sound of a word? For example, can this child tell you
that the word “ball” starts with the “buh” sound?
Always
g. Understand the meaning of the
word "no"?
Most of the time
h. Follow a verbal direction without
hand gestures, such as "Wash your
hands."?
About half the time
i.
Point to things in a book when
asked?
Never
j.
Follow 2-step directions, such as
"Get your shoes and put them in the
basket."?
Sometimes
G5
How often can this child come up with words that
start with the same sound? For example, can this child
come up with "sock" and "sun?"
Always
k. Understand words such as "in,"
"on," and "under"?
Most of the time
About half the time
Sometimes
Never
G6
How often can this child explain things they have seen
or done so that you know what happened?
Always
Most of the time
About half the time
Sometimes
Never
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G7 How often can this child write their first name, even if
some of the letters aren’t quite right or are backwards?
G11 How often can this child tell which group of objects
has more? For example, can this child tell you a group
of seven blocks has more than a group of four blocks?
Always
Always
Most of the time
Most of the time
About half the time
About half the time
Sometimes
Sometimes
Never
G8 How often can this child focus on a task you give them
for at least a few minutes? For example, can this child
focus on simple chores?
Never
G12 If asked to count objects, how high can this child
count correctly?
Always
This child cannot count
Most of the time
Up to five
About half the time
Up to ten
Sometimes
Up to 20
Never
Up to 30 or more
G9 How often can this child read one-digit numbers?
For example, can this child read the numbers 2 or 8?
G13 About how many letters of the alphabet can this child
recognize?
Always
All of them
Most of the time
Most of them
About half the time
About half of them
Sometimes
Some of them
Never
None of them
G10 How often can this child correctly do simple addition?
For example, can this child tell you that two blocks and
three blocks add to a total of five blocks?
G14 How well can this child come up with words that rhyme?
For example, can this child come up with "cat" and "mat?"
Always
This child cannot rhyme
Most of the time
Not well
About half the time
Somewhat well
Sometimes
Very well
Never
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G15 How often can this child recognize and name their
own emotions?
G19 How often does this child get easily distracted?
Always
Always
Most of the time
Most of the time
About half the time
About half the time
Sometimes
Sometimes
Never
Never
G16 How often does this child have difficulty when asked
G20 How often does this child show concern when they see
others who are hurt or unhappy?
to end one activity and start a new activity?
Always
Always
Most of the time
Most of the time
About half the time
About half the time
Sometimes
Sometimes
Never
Never
G21 How often does this child have trouble calming
down?
G17 How often does this child play well with other children?
Always
Always
Most of the time
Most of the time
About half the time
About half the time
Sometimes
Sometimes
Never
Never
G18 How often does this child lose their temper?
G22 How often does this child have difficulty waiting for
their turn?
Always
Always
Most of the time
Most of the time
About half the time
About half the time
Sometimes
Sometimes
Never
Never
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OMB No. 0607-0990 Approval Expires 05/31/2025
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 supplement will take 5 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.
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| File Type | application/pdf |
| Author | OneFormUser |
| File Modified | 2022-09-15 |
| File Created | 2022-09-15 |