8 B questionnaire Palau palauan

Maternal and Child Health Jurisdictional Survey Instrument for the Title V MCH Block Grant Program

questionnaire Palau palauan

MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program

OMB: 0906-0042

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0906-0042 can be found here:

2024-04-10 - No material or nonsubstantive change to a currently approved collection

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MCH Jurisdictional Survey Instrument

Palau-Palauan
OMB Control number: 0906-0042; Expiration date: XX/XX/202X

^{CASE ID:}

Screener
1. Ngarngii a rengalk el kiei ra tial delengchokl el 0-17 a rekrir?
  1. ☐ DIAK [IF NO, STOP HERE. THIS IS THE END OF THE SURVEY]
  2. ☐ CHOI
2. Te telang el ngalek el 0-17 a rekrir a oumesind el kiei er tial delengchokl?

Shape9 Shape10 ILDISIR A RENGALEK EL KIEI ER TIAL BASIO.

Ngeral tekoi a omousbech el chadecheduch ra elsel tial delengchokl?
1. ☐ MERIKEL
2. ☐ BELAU
3. ☐ NGODECH EL TEKOI, MOUTEKANGEL EL CHOUCHAIS, MLECHESII

Shape11

Aikal ker a mora dertang er tirkel ngalk el 0-17 el belechoel el kiei ra elsel tial delengchokl.

Omuchel er ngkel kot el kekerei el ngalek el debo domekedong er ngii el “Ngalek 1” e melemolem el mora ongerung el di merekong sel bomerek el onger a ikel rokui el ker el kirir tirkel ngalek el rokui el blechoel el kiei ma lechub e tekiei er tial basio.

NGALEK 1

Techa ngklel a ngalek (first name, initials, or nickname)?

Shape12

Ngkal ngalek ng Hispanic, Latino, ma lechub eng chad ra Spain?
1. ☐ Diak, diak el Hispanic, Latino, ma lechub eng kmal chad ra Spain
2. ☐ Choi, Mexican, Mexican American, Chicano
3. ☐ Choi, Puerto Rican
4. ☐ Choi, Cuban
5. ☐ Choi, ngkuk tara Hispanic, Latino, ma lechub eng kmal chad ra Spain, mlechesii

Shape13

Ngkal ngalek ng kmal ulechell er ker el beluu? AL IMONG MALECHUB NG BETOK E NGDI UNGIL.

☐ CHAD RA NGEBARD
☐ NGEDUCH
☐ MERA EL CHAD RA MERIKEL EL INDIAN MA LECHUB ENG MERA EL CHAD RA ALASKA, NG NGARA RA IKAL TEBLONG:

Shape14

☐ CHAD RA INDIA
☐ CHAD RA SINA
☐ CHAD RA HURIPIN
☐ CHAD RA SIABAL
☐ CHAD RA KOREA
☐ CHAD RA VIETNAM
☐ CHAD RA TA RA BELUU RA ASIA, KER EL BELUU:

Shape15

☐ CHAD RA HAWAII
☐ CHAD RA GUAM EL CHAMORRO
☐ CHAD RA SAMOAN
☐ CHAD RA TONGA
☐ CHAD RA SAIBAL
☐ CHAD RA MOTOLOK
☐ CHAD RA KOSRAE
☐ CAROLINIAN
☐ CHAD RA BELAU
☐ CHAD RA BULABEI
☐ CHAD RA BELUU EL CHAB
☐ CHAD RA RUK
☐ CHAD RA MARSIAR
☐ CHAD RA IUNGS, KER EL BELUU:

Shape16

Ngkal ngalek ng sechal, ng redil?
1. ☐ SECHAL
2. ☐ REDIL
Tela rekil ngkal ngalek? A lsekum a ngalek a ngesonges a rekil ra tal buil, e ke luchesii a rekil el tal buil.

Shape17 Shape18 RAK (OR) Shape19 Shape20 BUIL

IF THIS CHILD IS YOUNGER THAN 4 YEARS OLD, GO TO A10.

PUERTO RICO: Ng uangerang a dechal ngkal ngalek el melekoi a tekoi ra Spain?

ALL OTHER JURISDICTIONS: Ng uangerang a dechal ngkal ngalek el melekoi a tekoi ra Merikel?

☐ Kmal Ungil
☐ Ungil
☐ Diak el sal ungill
☐ Diak el ungil

Ngkal ngalek ngousbech ma lechub eng melai a kar er chelechal taem el bilsang a toktang ngdi diak el vitamins?
1. ☐ CHOI
2. ☐ DIAK [GO TO A11]

[IF YES] e ngkal ngalek ngousbech a ikal kar ele ngii el ngarngii a rektel a bedengel, secherel a uldesuel, ma lechub eng tara bedengel a secher?

☐ CHOI

☐ DIAK [GO TO A11]

[IF YES] tial teletael ma lechub eng secher, ng meketekaetang ral secher malechub eng secherel el meketeket el taem?

☐ CHOI

☐ DIAK

Ngkal ngalek a omomekesiu er ngii el mora re osisiu a rekrir el ngalek, e ngelmuut el ousbech a klou el ngesou ra ukeruul ra bedengel, ukeruull ra uldesuel, ma lechub eng ngesou ra skuul?
1. ☐ CHOI
2. ☐ DIAK [GO TO A12]

[IF YES] ngkal ngalek ngmelai a ngesou ra ukeruul ra bedengel, ukeruull ra uldesuel, ma lechub eng ngesou ra skuul ele ngii el ousbech a ngesou ra ukeruul ra bedengel, ukeruull ra uldesuel, ma lechub eng ngesou ra skuul?

☐ CHOI

☐ DIAK [GO TO A12]

[IF YES] tial teletael ma lechub eng secher, ng meketekaetang ral secher malechub eng secherel el meketeket el taem?

☐ CHOI

☐ DIAK

Sel teletelel a ngkal ngalek el sebechel remuul a tekoi, e ngolngesonges a omomekesiu er ngii el mora re osisiu a rekrir el ngalek?
1. ☐ CHOI
2. ☐ DIAK [GO TO A13]

[IF YES] e ngkal ngalek ngolngesonges ra omeruul tekoi ele ngii el ngarngii a secherel a bedengel, uldesuel, ma lechub eng tara bedengel a secher?

☐ CHOI

☐ DIAK [GO TO A13]

[IF YES] tial teletael ma lechub eng secher, ng meketekaetang ral secher malechub eng secherel el meketeket el taem?

☐ CHOI

☐ DIAK

Ngkal ngalek ngousbech a tokubets el ngesou ra rolel a klisichel a bedengel, ureor el loruul, ma lechub eng omengedecheduch?
1. ☐ CHOI
2. ☐ DIAK [GO TO A14]

[IF YES] e ngkal ngalek ngarngii a secherel a bedengel, uldesuel, ma lechub eng tara bedengel a secher?

☐ CHOI

☐ DIAK [GO TO A14]

[IF YES] tial teletael ma lechub eng secher, ng meketekaetang ral secher malechub eng secherel el meketeket el taem?

☐ CHOI

☐ DIAK

Ngkal ngalek ngarngii a kora secherel a uldesuel, ulekurulel a bedengel, ma lechub e ngodech el blekerdelel el mo uaia luchul e ngousbech a ngesou ra cheldecheduch (counseling)?
1. ☐ CHOI
2. ☐ DIAK [GO TO A15]

[IF YES] tial secherel a uldesuel, ulekurulel a bedengel, ma lechub e ngodech el blekerdelel ng mla mo ungil a lechub eng locha mo ungil ra chelsel a tal rak ma lechub eng kemanget rat al rak?

☐ Choi

☐ Diak

[IF RESPONDENT HAS ANOTHER CHILD, CONTINUE WITH A15. ELSE CONTINUE WITH SECTION B.]

NGALEK 2

Techa ngklel a ngalek (first name, initials, or nickname)?

Shape32

Ngkal ngalek ng Hispanic, Latino, ma lechub eng kmal chad ra Spain?
1. ☐ Diak, diak el Hispanic, Latino, ma lechub eng kmal chad ra Spain
2. ☐ Choi, Mexican, Mexican American, Chicano
3. ☐ Choi, Puerto Rican
4. ☐ Choi, Cuban
5. ☐ Choi, ngkuk tara Hispanic, Latino, ma lechub eng kmal chad ra Spain mlechesii

Shape33

Ngkal ngalek ng kmal ulechell er ker el beluu? AL IMONG MALECHUB NG BETOK E NGDI UNGIL.

☐ CHAD RA NGEBARD
☐ NGEDUCH
☐ MERA EL CHAD RA MERIKEL EL INDIAN MA LECHUB ENG MERA EL CHAD RA ALASKA, NG NGARA RA IKAL TEBLONG:

Shape34

☐ CHAD RA INDIA
☐ CHAD RA SINA
☐ CHAD RA HURIPIN
☐ CHAD RA SIABAL
☐ CHAD RA KOREA
☐ CHAD RA VIETNAM
☐ CHAD RA TA RA BELUU RA ASIA, KER EL BELUU:

Shape35

☐ CHAD RA HAWAII
☐ CHAD RA GUAM EL CHAMORRO
☐ CHAD RA SAMOAN
☐ CHAD RA TONGA
☐ CHAD RA SAIBAL
☐ CHAD RA MOTOLOK
☐ CHAD RA KOSRAE
☐ CAROLINIAN
☐ CHAD RA BELAU
☐ CHAD RA BULABEI
☐ CHAD RA BELUU EL CHAB
☐ CHAD RA RUK
☐ CHAD RA MARSIAR
☐ CHAD RA IUNGS, KER EL BELUU:

Shape36

Ngjak ngalek ng sechal, ng redil?
1. ☐ SECHAL
2. ☐ REDIL
Tela rekil ngkal ngalek? A lsekum a ngalek a ngesonges a rekil rat al buil, e ke luchesii a rekil el tal buil.

Shape37 Shape38 RAK (OR) Shape39 Shape40 BUIL

IF THIS CHILD IS YOUNGER THAN 4 YEARS OLD, GO TO A21.

PUERTO RICO: Ng uangerang a dechal ngkal ngalek el melekoi a tekoi ra Sebangiol?

ALL OTHER JURISDICTIONS: Ng uangerang a dechal ngkal ngalek el melekoi a tekoi ra Merikel?

☐ Kmal Ungil
☐ Ungil
☐ Diak el sal ungill
☐ Diak el ungil

Ngkal ngalek ngousbech ma lechub eng melai a kar er chelechal taem el bilsang a toktang ngdi diak el vitamins?
1. ☐ CHOI
2. ☐ DIAK [GO TO A22]

[IF YES] ngkal ngalek ngousbech a ikal kar ele ngii el ngarngii a rektel a bedengel, secherel a uldesuel, ma lechub eng tara bedengel a secher?

☐ CHOI

☐ DIAK [GO TO A22]

[IF YES] tial teletael ma lechub eng secher, ng meketekaetang ral secher malechub eng secherel el meketeket el taem?

☐ CHOI

☐ DIAK

Ngkal ngalek a omomekesiu er ngii el mora re osisiu a rekrir el ngalek, e ngelmuut el ousbech a klou el ngesou ra ukeruul ra bedengel, ukeruull ra uldesuel, ma lechub eng ngesou ra skuul?
1. ☐ CHOI
2. ☐ DIAK [GO TO A23]

☐ CHOI

☐ DIAK [GO TO A23]

[IF YES] tial teletael ma lechub eng secher, ng meketekaetang ral secher malechub eng secherel el meketeket el taem?

☐ CHOI

☐ DIAK

Ngkal ngalek ngousbech a tokubets el ngesou ra rolel a klisichel a bedengel, ureor el loruul, ma lechub eng omengedecheduch?
1. ☐ CHOI
2. ☐ DIAK [GO TO A24]

[IF YES] e ngkal ngalek ngarngii a secherel a bedengel, uldesuel, ma lechub eng tara bedengel a secher?

☐ CHOI

☐ DIAK [GO TO A24]

[IF YES] tial teletael ma lechub eng secher, ng meketekaetang ral secher malechub eng secherel el meketeket el taem?

☐ CHOI

☐ DIAK

Ngkal ngalek ngousbech a tokubets el ngesou ra rolel a klisichel a bedengel, ureor el loruul, ma lechub eng omengedecheduch?
1. ☐ CHOI
2. ☐ DIAK [GO TO A25]

[IF YES] e ngkal ngalek ngarngii a secherel a bedengel, uldesuel, ma lechub eng tara bedengel a secher?

☐ CHOI

☐ DIAK [GO TO A25]

[IF YES] tial teletael ma lechub eng secher, ng meketekaetang ral secher malechub eng secherel el meketeket el taem?

☐ CHOI

☐ DIAK

Ngkal ngalek ngarngii a kora secherel a uldesuel, ulekurulel a bedengel, ma lechub e ngodech el blekerdelel el mo uaia luchul e ngousbech a ngesou ra cheldecheduch (counseling)?
1. ☐ CHOI
2. ☐ DIAK [GO TO A26]

[IF YES] tial secherel a uldesuel, ulekurulel a bedengel, ma lechub e ngodech el blekerdelel ng meketekaetang ral secher malechub eng secherel el meketeket el taem?

☐ CHOI

☐ DIAK

[IF RESPONDENT HAS ANOTHER CHILD, CONTINUE WITH A26. ELSE CONTINUE WITH SECTION B.]

NGALEK 3

Techa ngklel a ngalek (first name, initials, or nickname)?

Shape64

Ngkal ngalek ng Hispanic, Latino, ma lechub eng kmal chad ra Spain?
1. ☐ Diak, diak el Hispanic, Latino, ma lechub eng kmal chad ra Spain
2. ☐ Choi, Mexican, Mexican American, Chicano
3. ☐ Choi, Puerto Rican
4. ☐ Choi, Cuban
5. ☐ Choi, ngkuk tara Hispanic, Latino, ma lechub eng kmal chad ra Spain mlechesii

Shape65

Ngkal ngalek ng kmal ulechell er ker el beluu? AL IMONG MALECHUB NG BETOK E NGDI UNGIL.

☐ CHAD RA NGEBARD
☐ NGEDUCH
☐ MERA EL CHAD RA MERIKEL EL INDIAN MA LECHUB ENG MERA EL CHAD RA ALASKA, NG NGARA RA IKAL TEBLONG:

Shape66

☐ CHAD RA INDIA
☐ CHAD RA SINA
☐ CHAD RA HURIPIN
☐ CHAD RA SIABAL
☐ CHAD RA KOREA
☐ CHAD RA VIETNAM
☐ CHAD RA TA RA BELUU RA ASIA, KER EL BELUU:

Shape67

☐ CHAD RA HAWAII
☐ CHAD RA GUAM EL CHAMORRO
☐ CHAD RA SAMOAN
☐ CHAD RA TONGA
☐ CHAD RA SAIBAL
☐ CHAD RA MOTOLOK
☐ CHAD RA KOSRAE
☐ CAROLINIAN
☐ CHAD RA BELAU
☐ CHAD RA BULABEI
☐ CHAD RA BELUU EL CHAB
☐ CHAD RA RUK
☐ CHAD RA MARSIAR
☐ CHAD RA IUNGS, KER EL BELUU:

Shape68

Ngjak ngalek ng sechal, ng redil?
1. ☐ SECHAL
2. ☐ REDIL
Tela rekil ngkal ngalek? A lsekum a ngalek a ngesonges a rekil rat al buil, e ke luchesii a rekil el tal buil.

Shape69 Shape70 RAK (OR) Shape71 Shape72 BUIL

A LSEKUM A REKIL A NGALEK A NGESONGES RA EUAL RAK, E GO TO KER EL A32.

PUERTO RICO: Ng uangerang a dechal ngkal ngalek el melekoi a tekoi ra Sebangiol?

ALL OTHER JURISDICTIONS: Ng uangerang a dechal ngkal ngalek el melekoi a tekoi ra Merikel?

☐ Kmal Ungil
☐ Ungil
☐ Diak el sal ungill
☐ Diak el ungil

Ngkal ngalek ngousbech ma lechub eng melai a kar er chelechal taem el bilsang a toktang ngdi diak el vitamins?
1. ☐ CHOI
2. ☐ DIAK [GO TO A33]

[IF YES] ngkal ngalek ngousbech a ikal kar ele ngii el ngarngii a rektel a bedengel, secherel a uldesuel, ma lechub eng tara bedengel a secher?

☐ CHOI

☐ DIAK [GO TO A33]

[IF YES] tial teletael ma lechub eng secher, ng meketekaetang ral secher malechub eng secherel el meketeket el taem?

☐ CHOI

☐ DIAK

Ngkal ngalek a omomekesiu er ngii el mora re osisiu a rekrir el ngalek, e ngelmuut el ousbech a klou el ngesou ra ukeruul ra bedengel, ukeruull ra uldesuel, ma lechub eng ngesou ra skuul?
1. ☐ CHOI
2. ☐ DIAK [GO TO A34]

☐ CHOI

☐ DIAK [GO TO A34]

[IF YES] tial teletael ma lechub eng secher, ng mla mo ungil a lechub eng locha mo ungil ra chelsel a tal rak ma lechub eng kemanget rat al rak?

☐ CHOI

☐ DIAK

Ngkal ngalek ngousbech a tokubets el ngesou ra rolel a klisichel a bedengel, ureor el loruul, ma lechub eng omengedecheduch?
1. ☐ CHOI
2. ☐ DIAK [GO TO A35]

[IF YES] e ngkal ngalek ngarngii a secherel a bedengel, uldesuel, ma lechub eng tara bedengel a secher?

☐ CHOI

☐ DIAK [GO TO A35]

[IF YES] tial teletael ma lechub eng secher, ng meketekaetang ral secher malechub eng secherel el meketeket el taem?

☐ CHOI

☐ DIAK

Ngkal ngalek ngousbech a tokubets el ngesou ra rolel a klisichel a bedengel, ureor el loruul, ma lechub eng omengedecheduch?
1. ☐ CHOI
2. ☐ DIAK [GO TO A36]

[IF YES] e ngkal ngalek ngarngii a secherel a bedengel, uldesuel, ma lechub eng tara bedengel a secher?

☐ CHOI

☐ DIAK [GO TO A36]

[IF YES] tial teletael ma lechub eng secher, ng meketekaetang ral secher malechub eng secherel el meketeket el taem?

☐ CHOI

☐ DIAK

Ngkal ngalek ngarngii a kora secherel a uldesuel, ulekurulel a bedengel, ma lechub e ngodech el blekerdelel el mo uaia luchul e ngousbech a ngesou ra cheldecheduch (counseling)?
1. ☐ CHOI
2. ☐ DIAK [GO TO A37]

[IF YES] tial secherel a uldesuel, ulekurulel a bedengel, ma lechub e ngodech el blekerdelel ng meketekaetang ral secher malechub eng secherel el meketeket el taem?

☐ CHOI

☐ DIAK

[IF RESPONDENT HAS ANOTHER CHILD, CONTINUE WITH A37. ELSE CONTINUE WITH SECTION B.]

NGALEK 4

Techa ngklel a ngalek (first name, initials, or nickname)?

Shape82

Ngkal ngalek ng Hispanic, Latino, ma lechub eng kmal chad ra Spain?
1. ☐ Diak, diak el Hispanic, Latino, ma lechub eng kmal chad ra Spain
2. ☐ Choi, Mexican, Mexican American, Chicano
3. ☐ Choi, Puerto Rican
4. ☐ Choi, Cuban
5. ☐ Choi, ngkuk tara Hispanic, Latino, ma lechub eng kmal chad ra Spain mlechesii

Shape83

Ngkal ngalek ng kmal ulechell er ker el beluu? AL IMONG MALECHUB NG BETOK E NGDI UNGIL.

☐ CHAD RA NGEBARD
☐ NGEDUCH
☐ MERA EL CHAD RA MERIKEL EL INDIAN MA LECHUB ENG MERA EL CHAD RA ALASKA, NG NGARA RA IKAL TEBLONG:

Shape84

☐ CHAD RA INDIA
☐ CHAD RA SINA
☐ CHAD RA HURIPIN
☐ CHAD RA SIABAL
☐ CHAD RA KOREA
☐ CHAD RA VIETNAM
☐ CHAD RA TA RA BELUU RA ASIA, KER EL BELUU:

Shape85

☐ CHAD RA HAWAII
☐ CHAD RA GUAM EL CHAMORRO
☐ CHAD RA SAMOAN
☐ CHAD RA TONGA
☐ CHAD RA SAIBAL
☐ CHAD RA MOTOLOK
☐ CHAD RA KOSRAE
☐ CAROLINIAN
☐ CHAD RA BELAU
☐ CHAD RA BULABEI
☐ CHAD RA BELUU EL CHAB
☐ CHAD RA RUK
☐ CHAD RA MARSIAR
☐ CHAD RA IUNGS, KER EL BELUU:

Shape86

Ngjak ngalek ng sechal, ng redil?
1. ☐ SECHAL
2. ☐ REDIL
Tela rekil ngkal ngalek? A lsekum a ngalek a ngesonges a rekil rat al buil, e ke luchesii a rekil el tal buil.

Shape87 Shape88 RAK (OR) Shape89 Shape90 BUIL

IF THIS CHILD IS YOUNGER THAN 4 YEARS OLD, GO TO A43.

PUERTO RICO: Ng uangerang a dechal ngkal ngalek el melekoi a tekoi ra Sebangiol?

ALL OTHER JURISDICTIONS: Ng uangerang a dechal ngkal ngalek el melekoi a tekoi ra Merikel?

☐ Kmal Ungil
☐ Ungil
☐ Diak el sal ungill
☐ Diak el ungil

Ngkal ngalek ngousbech ma lechub eng melai a kar er chelechal taem el bilsang a toktang ngdi diak el vitamins?
1. ☐ CHOI
2. ☐ DIIAK [GO TO A44]

[IF YES] ngkal ngalek ngousbech a ikal kar ele ngii el ngarngii a rektel a bedengel, secherel a uldesuel, ma lechub eng tara bedengel a secher?

☐ CHOI

☐ DIAK [GO TO A44]

[IF YES] tial teletael ma lechub eng secher, ng meketekaetang ral secher malechub eng secherel el meketeket el taem?

☐ CHOI

☐ DIAK

Ngkal ngalek a omomekesiu er ngii el mora re osisiu a rekrir el ngalek, e ngelmuut el ousbech a klou el ngesou ra ukeruul ra bedengel, ukeruull ra uldesuel, ma lechub eng ngesou ra skuul?
1. ☐ CHOI
2. ☐ DIAK [GO TO A45]

☐ CHOI

☐ DIAK [GO TO A45]

[IF YES] tial teletael ma lechub eng secher, ng meketekaetang ral secher malechub eng secherel el meketeket el taem?

☐ CHOI

☐ DIAK

Ngkal ngalek ngousbech a tokubets el ngesou ra rolel a klisichel a bedengel, ureor el loruul, ma lechub eng omengedecheduch?

☐ CHOI

☐ DIAK [GO TO A46]

[IF YES] e ngkal ngalek ngarngii a secherel a bedengel, uldesuel, ma lechub eng tara bedengel a secher?

☐ CHOI

☐ DIAK [GO TO TO A46]

[IF YES] tial teletael ma lechub eng secher, ng meketekaetang ral secher malechub eng secherel el meketeket el taem?

☐ CHOI

☐ DIAK

Ngkal ngalek ngousbech a tokubets el ngesou ra rolel a klisichel a bedengel, ureor el loruul, ma lechub eng omengedecheduch?
1. ☐ CHOI
2. ☐ DIAK [GO TO A47]

[IF YES] e ngkal ngalek ngarngii a secherel a bedengel, uldesuel, ma lechub eng tara bedengel a secher?

☐ CHOI

☐ DIAK [GO TO A47]

[IF YES] tial teletael ma lechub eng secher, ng meketekaetang ral secher malechub eng secherel el meketeket el taem?

☐ CHOI

☐ DIAK

Ngkal ngalek ngarngii a kora secherel a uldesuel, ulekurulel a bedengel, ma lechub e ngodech el blekerdelel el mo uaia luchul e ngousbech a ngesou ra cheldecheduch (counseling)?
1. ☐ CHOI
2. ☐ DIAK [GO TO A48]

[IF YES] tial secherel a uldesuel, ulekurulel a bedengel, ma lechub e ngodech el blekerdelel ng meketekaetang ral secher malechub eng secherel el meketeket el taem?

☐ CHOI

☐ DIAK

[IF THERE ARE NO OTHER CHILDREN, CONTINUE TO SECTION B.]

IF THERE ARE MORE THAN FOUR CHILDREN 0-17 YEARS OLD WHO USUALLY LIVE OR STAY AT THIS ADDRESS, LIST THE AGE AND SEX FOR EACH. DO NOT REPEAT INFORMATION FOR CHILDREN ALREADY INCLUDED FOR CHILD 1 THROUGH CHILD 4.

NGALEK 5

Techa ngklel a ngalek, initials, or nickname?

Shape100

Tela rekil a ngalek?

Shape101 Shape102 RAK (OR) Shape103 Shape104 BUIL

Ngkal ngalek ng sechal, ng redil?
1. ☐ SECHAL
2. ☐ REDIL
NGALEK 6

Techa ngklel a ngalek, initials, or nickname?

Shape105

Tela rekil a ngalek?

Shape106 Shape107 RAK (OR) Shape108 Shape109 BUIL

Ngkal ngalek ng sechal, ng redil?
1. ☐ SECHAL
2. ☐ REDIL
NGALEK 7

Techa ngklel a ngalek, initials, or nickname?

Shape110

Tela rekil a ngalek?

Shape111 Shape112 RAK (OR) Shape113 Shape114 BUIL

Ngkal ngalek ng sechal, ng redil?
1. ☐ SECHAL
2. ☐ REDIL
NGAKEJ 8

Techa ngklel a ngalek, initials, or nickname?

Shape115

Tela rekil a ngalek?

Shape116 Shape117 RAK (OR) Shape118 Shape119 BUIL

Ngkal ngalek ng sechal, ng redil?
1. ☐ SECHAL
2. ☐ REDIL
NGALEK 9

Techa ngklel a ngalek, initials, or nickname?

Shape120

Tela rekil a ngalek?

Shape121 Shape122 RAK (OR) Shape123 Shape124 BUIL

Ngkal ngalek ng sechal, ng redil?
1. ☐ SECHAL
2. ☐ REDIL
NGALEK 10

Techa ngklel a ngalek, initials, or nickname?

Shape125

Tela rekil a ngalek?

Shape126 Shape127 RAK (OR) Shape128 Shape129 BUIL

Ngkal ngalek ng sechal, ng redil?
1. ☐ SECHAL
2. ☐ REDIL

Health ra Ngalk

A ker el kibo moker a kmal di Kirel a [NGALEK __] A ikal ker a mo odektak a mui el omesodel a kekerous el telengtengil a health ngkal ngalek el uldimukel er ngii a klisichel a bedengel, osongel er ngii lobenterir a rechad ospitar malechub eng clinic, cheral a ukeruul er ngii, ma ngesou ra udoud el mo harau ra ukeruul er ngii. A kidi mo ngiltii a tal ngalek ra telungalek meng mo kekerie a taem el rukui a ikal ker.

Daitai, e msodii a health er ngkal ngalek?
1. ☐ Kmal ungil el diak a secherel
2. ☐ Kmal Ungil
3. ☐ Ungil
4. ☐ Oikab
5. ☐ Mekngit

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Kam sodii a teletelel a ungelel ngkal ngalek?
1. ☐ Kmal ungil el diak a secherel
2. ☐ Kmal Ungil
3. ☐ Ungil
4. ☐ Oikab
5. ☐ Mekngit
6. ☐ NGALEK A DIAK A UNGELEL

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Chelsel a ikal mla mo merek el teruich ma erul buil, ngkal ngalek ngmle mekudem ma lechub eng mle blechoel el ngarngii a mondai er ngii ra ikal beldukl er riou?

	CHOI	DIAK	NGDIAK UDENGEI	NGDIAK EL SOAK EL ONGER
B3a. Outeliil ma lechub eng mondai ra louteliil ma telil (kora kora kesengliils)	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
B3b. Omengur ma lechub e ngomerkakl el secherel a uchul	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
B3c. Omiich ra kall ra elsel a chii rengii, mekngit el tuong malechub eng omachediil	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
B3d. Blechoel el ringel ra bedengel ma bdelul, malechub eng meringel a btelul	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
B3e. Ousbech a chimal	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
B3f. Ungil merael e ousbech chimal	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
B3g. Meringel a ungelel	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
B3h. Merael a rasech ra techel a ungelel	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
B3i. Merael mo mechitechut a ungelel ma lechub eng musiba	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
B3j. Rektel a Ding	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐

[ONLY ASK THIS QUESTION IF CHILD IS 0‑5 YEARS OLD]

Ngkal ngalek ngarngii er ngii a ikal beldukl e riou?

	CHOI	DIAK	NGDIAK UDENGEI	NGDIAK EL SOAK EL ONGER
B4a. Mechad ma lechub eng mekngit a oderngesel	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
B4b. Meuikeu ma lechub eng mekngit a osengel ma lou klas mengdi mekngit	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐

A toktang ma lechub eng chad ra ospitar ngmla tang el sbedaau el uase ngkal ngalek a ngarngii er ngii a tara ikal beldukel er iou? IF YES] , ngkal ngalek ng ngarngii er chelechal taem?

	Mla tang?	Elechang?	NGDIAK UDENGEI	NGDIAK EL SOAK EL ONGER
B5a. Ngul	₁ ☐ CHOI ₂ ☐ DIAK	₁ ☐ CHOI ₂ ☐ DIAK	₇₇ ☐	₉₉ ☐
B5b. Sukal	₁ ☐ CHOI ₂ ☐ DIAK	₁ ☐ CHOI ₂ ☐ DIAK	₇₇ ☐	₉₉ ☐
B5c. Down Syndrome	₁ ☐ CHOI ₂ ☐ DIAK	₁ ☐ CHOI ₂ ☐ DIAK	₇₇ ☐	₉₉ ☐
B5d. Blechoel meringel a btelul	₁ ☐ CHOI ₂ ☐ DIAK	₁ ☐ CHOI ₂ ☐ DIAK	₇₇ ☐	₉₉ ☐
B5e. Telmellel a no ra btelul, ma lechub eng miltemall abtelul	₁ ☐ CHOI ₂ ☐ DIAK	₁ ☐ CHOI ₂ ☐ DIAK	₇₇ ☐	₉₉ ☐
B5f. Sebekreng	₁ ☐ CHOI ₂ ☐ DIAK	₁ ☐ CHOI ₂ ☐ DIAK	₇₇ ☐	₉₉ ☐
B5g. Secherel a uldasou	₁ ☐ CHOI ₂ ☐ DIAK	₁ ☐ CHOI ₂ ☐ DIAK	₇₇ ☐	₉₉ ☐
B5h. Autism, ASD, Autism Spectrum Disorder (ASD), Asperger’s Disorder, malechub eng Pervasive Developmental Disorder	₁ ☐ CHOI ₂ ☐ DIAK	₁ ☐ CHOI ₂ ☐ DIAK	₇₇ ☐	₉₉ ☐
B5i. Attention Deficit Disorder (ADD ) or Attention Deficit/Hyperactivity Disorder(ADHD)	₁ ☐ CHOI ₂ ☐ DIAK	₁ ☐ CHOI ₂ ☐ DIAK	₇₇ ☐	₉₉ ☐
B5j. Developmental Delay	₁ ☐ CHOI ₂ ☐ DIAK	₁ ☐ CHOI ₂ ☐ DIAK	₇₇ ☐	₉₉ ☐
B5k. Behavior or Conduct Problems	₁ ☐ CHOI ₂ ☐ DIAK	₁ ☐ CHOI ₂ ☐ DIAK	₇₇ ☐	₉₉ ☐
B5l. Intellectual Disability (also known as mental retardation)	₁ ☐ CHOI ₂ ☐ DIAK	₁ ☐ CHOI ₂ ☐ DIAK	₇₇ ☐	₉₉ ☐
B5m. Meoud el mo ungil a ngerel el mengedecheduch ma lechub eng bebil a uchul eng diak lungil melekoi	₁ ☐ CHOI ₂ ☐ DIAK	₁ ☐ CHOI ₂ ☐ DIAK	₇₇ ☐	₉₉ ☐
B5n. Meoud el mo medengelii a tekoi	₁ ☐ CHOI ₂ ☐ DIAK	₁ ☐ CHOI ₂ ☐ DIAK	₇₇ ☐	₉₉ ☐
B5o. Bebil ra rektel a btelud	₁ ☐ CHOI ₂ ☐ DIAK	₁ ☐ CHOI ₂ ☐ DIAK	₇₇ ☐	₉₉ ☐

A chelsel a ikal mla mo merek el teruich a erung el buil, aikal secherel ng mla tomer er ngii el meruul a tekoi el uaia re besechel?
1. ☐ NGKAL NGALEK A DIAK A SECHEREL [GO TO B8]
2. ☐ Dirkak a tang [GO TO B8]
3. ☐ Al bebil
4. ☐ Mekudem
5. ☐ Blechoel

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Aikal rektel, ng ngarngii a techall el torbengii el meruul a tekoi?
1. ☐ Kmal Kekerei
2. ☐ Kora Ngarngii
3. ☐ Kmal Klou

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

[ONLY ASK THIS QUESTION IF CHILD IS 6‑17 YEARS OLD]

A toktang ma lechub eng chad ra ospitar ngmla tang el sbedaau el uase ngkal ngalek a ngarngii a secherel ra mekngit el kar? Tial secher (Substance Abuse Disorder) a duubech ra rechad el blechoel e melemolem el ousbech ra rrom ma lechub eng mekngit el kar meng mla morngii a telmellel ra bedengel, mla rullii meng dikeal sebechel remuul a mle sebechel, dikeal sebechel el remuul a ngerchelel ra ureor, skuul, ma lechub eng blai.

☐ CHOI
☐ DIAK [GO TO B9]

☐ NGDIAK UDENGEI [GO TO B9]

☐ NGDIAK EL SOAK EL ONGER [GO TO B9]

[IF YES] e ngkal ngalek ng ngarngii a ikaikid el teletelel er chelechang?

☐ CHOI

☐ DIAK [GO TO B9]

☐ NGDIAK UDENGEI [GO TO B9]

☐ NGDIAK EL SOAK EL ONGER [GO TO B9]

[IF YES] eng:

☐ Kekerei

☐ Oikab
☐ Hidoi

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

[ONLY ASK THIS QUESTION IF CHILD IS 6‑17 YEARS OLD]

Ngkal ngalek ng ngarngii er ngii a tara ikal beldukel er riou?

	CHOI	DIAK	NGDIAK UDENGEI	NGDIAK EL SOAK EL ONGER
B9a. Meringel er ngii a mo bellemakl (erellakl a uldesuel), lmatk a tekoi, ma lechub eng melillt eleng ngii el ngarngii secherel a bedengel, uldesuel ma lechub eng omelatk	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
B9b. Meringel er ngii a lorael ma lechub eng melemiakl a terebel	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
B9c. Meringel er ngii a omail er ngii ma lechub eng melechong	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
B9d. Meringel er ngii a meruul a urerel el dingii el tang (mora osongel ra toktang, mo oureor malechub eng shopping leng secherel a bedengel, uldesuel ma omeletkel a uchul	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
B9e. Mechad ma lechub eng mekngit a oderngesel	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
B9f. Meuikeu ma lechub eng mekngit a osengel ma lou klas mengdi mekngit	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐

A toktang ma lechub eng chad ra ospitar ngmla tang el sbedaau el uase ngkal ngalek a ngarngii er ngii a…

	CHOI	DIAK	NGDIAK UDENGEI	NGDIAK EL SOAK EL ONGER
B10a. Rheumatic heart disease	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
B10b. Rheumatic fever	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
B10c. Impetigo (or other skin infections)	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐

[A lsekum eng rheumatic heart disease malechub eng fever] Ngarngii a kar el lolim el kirel?

☐ CHOI
☐ DIAK

☐ NGDIAK UDENGEI

☐ Ngdiak el soak el onger

[IF YES] Te melim a kar ma lechub eng orus?

☐ KAR EL LOLIM (PILLS) [GO TO B11]

☐ ORUS [GO TO B11]

[IF NO] E ngerang meng diak? Mluches a ikel rokui el merang.

☐ Kmal takai.

☐ Diak a olidiuul.
☐ Diak a sebechel el nguu a ngelkek el mora ospitar.
☐ Diak a ultutelel
☐ Ngodech a uchul:

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

A toktang ma lechub eng chad ra ospitar ngmla tang el sbedaau el uase ngkal ngalek a ngarngii er ngii a mekngit ra rsechel el ua rakt el kasinoma ra rasech ra chelsel a chiuis, ngesonges a malechub eng sickle cell disease? Diak moldak ra Sickle Cell Trait.

[READ IF NECESSARY]: A rengalek el ngarngii a anemia er tir a ngarngii a mekngit ra rsechir el rulleterir mete mo mesaul a bedengir.

☐ CHOI
☐ DIAK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Elechang ea kmo oker a ker el injury prevention ra ngelkem…

Kau me a lechub eng ta ra klou el chad era blai, ko mla smaod a tekoi era telmellel ma omekerrelel a bedenged el mora ngelekem? Oketa tekoi el ua ng kengaol a doilil era belngel a rael, ma lechub e ng ruebet a lolemiakl a kerrekar ma lechub eng remos al ongedub el le mengai era berius
1. ☐ Choi kengaol el tekoi
2. ☐ Omekerrenglel a bedenged
3. ☐ Ngii el teblo el tekoi
4. ☐ Ngdiak

☐ Ngdiak udengei

☐ Ngdiak el soak el onger

Kobengkel a ngelekem sel loilil e rrikl, mengedub, ma lechub engdi milil?
1. ☐ CHOI
2. ☐ DIAK

☐ DIAK KUDENGEI

☐ DIAK A NGER

[ONLY ASK THIS QUESTION IF CHILD IS 6‑17 YEARS OLD]

A ngelekem sel lengara rrat, e ngousbech ma lechub eng diak lousbech a helmet?

☐ A NGELKEK A DIAK EL NGARA RRAT
☐ Dirkak a tang e lou helmet
☐ Dertang e lou helmet
☐ A lebebil ra taem e ngou helmet
☐ Oumesind el taem a ngou helmet
☐ Ng blechoel e lou helmet

☐ DIAK KUDENGEI

☐ DIAK A NGER

[ONLY ASK THIS QUESTION IF CHILD IS 0‑11 YEARS OLD]

A ngelkem sel ngara rrat eng ngara car seat malechub eng booster seat?

☐ Blechoel
☐ Oumesind el taem
☐ Bebil ra taem
☐ Dertang
☐ Dirkak a tang [IF CHILD 0-5 YEARS OLD, GO TO B17; IF CHILD 6-11 YEARS OLD, GO TO C1]
☐ A NGELEKEK A DIAK EL DIAK EL NGARA MLAI [[IF CHILD 0-5 YEARS OLD, GO TO B17; IF CHILD 6-11 YEARS OLD, GO TO C1]

☐ DIAK KUDENGEI

☐ DIAK A NGER

[ONLY ASK THIS QUESTION IF CHILD IS 0‑11 YEARS OLD]

A car seat ra ngelkem ng ngara keskelel a mlai?

☐ Ngara utendai
☐ Ngara ullel auttendai
☐ Ngara ullel a omekall
☐ Belngel a kingall era uriul

☐ DIAK KUDENGEI

☐ DIAK A NGER

[ONLY ASK THIS QUESTION IF CHILD IS 0‑5 YEARS OLD]

A yobo ra ngelekem ng up to date?

☐ CHOI
☐ DIAK

☐ DIAK KUDENGEI

☐ DIAK A NGER

Ngkal Ngalek ral Tolechoi
1. Ngkal ngalek ng milechell ra edei el sandei ra uchei er sel temel el mechell?
  1. ☐ CHOI
  2. ☐ DIAK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Ng mle tela bengdel a ngelekem ra lemechell Telal bond ma ons Obla mobes e di molangch el kmo eng mle bekord el telang [IF NEEDED, READ]: A DI MOLANGCH E NGDI UNGIL MA LAK EL SAL NGII ENG DIRREK EL DI UNGIL.

Shape136 Shape137 POUNDS MA Shape138 Shape139 OUNCES

Shape140 Shape141 KILOGRAMS MA Shape142 Shape143 GRAMS

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Ng mle telang a rekim e mechellii ngkal ngalek?

Shape144 Shape145 RAK

[ONLY ASK THIS QUESTION IF CHILD IS 0‑1 YEAR OLD]

Ng uangerang a teletelel ngkal ngalek sel momechiuaiu er ngii?

☐ Ulitech
☐ Dengarch
☐ Terrob

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

[ONLY ASK THIS QUESTION IF CHILD IS 0‑5 YEARS OLD. ELSE GO TO SECTION D]

Mle tal omultut er ngkal ngalek ra tum?

☐ Choi
☐ Diak [GO TO C6]

☐ NGDIAK UDENGEI [GO TO C6]

☐ NGDIAK EL SOAK EL ONGER [GO TO C6]

[IF YES] ng mle tela rekil seral stob el tmut a tut?

Shape147 Shape148 SILS (LECHUB)

Shape149 Shape150 SANDEI (LECHUB)

Shape151 Shape152 BUIL (LECHUB)

Shape153 Shape154 RAK

Shape155 A NGALEK A DIRK TMUT A TUK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Ngmle tela rekil ngkal ngalek seral kot el mo menga a kall e diak e dil tut era tut ma lechub eng formula uldimukel erngii a kall ma ilumel el ua juice, milk, ralm ma sukal, baby food , ma cereal, ma ngiidil ngarang el mo lmuut er a ralm, ngii dil lak el tut ma lechub eng ouabech a formula.

Shape156 Shape157 SILS (LECHUB)

Shape158 Shape159 SANDEI (LECHUB)

Shape160 Shape161 BUIL

Shape162 SERA LEMECHELL

Shape163 MLIA OLANGCH RA BOX A LSEKUM NGARNGII A NGODECH KALL/ILUMEL EL MLORA NGALEK EL DIAK EL OSECHEL A TUM MA LECHUB ENG DETERIR A RENGALEK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Ulekerruio a Ukeruul
1. Chelsel tial mlo merek teruich ma erul buil, ngkal ngalk mla tal lesa chad ra ospitar leng mle smecher, temel a osongel, physical exam, ng nyuing malechub eng tara tekoi ra ukeruul?
  1. ☐ CHOI
  2. ☐ DIAK [GO TO D2]

☐ NGDIAK UDENGEI [GO TO D2]

☐ DUAK A NGER [GO TO D2]

[IF YES] Chelsel aikal mla mo merek el teruich ma erul buil, Ngkal ngalek ngmlo omes ra toktang, nurse ma lechub eng kuk tara ellimosk el chad ra ukeruul el ikel ukeruul el merrob a secher ra uchei ra leborngii (preventive check‑up)? A preventive check‑up a ukeruul el ngalek a diak el secher ma lechub eng telemall, ngua osengelir a rechad ra undo malechub eng osengelir ar tolechoi el kirel a ulekerulir.

☐ DIRKAK A TANG

☐ TANG EL BLAL BONG
☐ ERUNG MA LECHUB ENG BETOK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Kau ke bekikl ra berredel ngkal ngalek?
1. ☐ Choi, kmal oberaod
2. ☐ Choi, Kmal mekesai
3. ☐ Diak, Diak bekikl

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Ng ngara telongeklel a ngalekem era ngelechang? Ng bekord el telang [IF NEEDED, READ]: A DI MOLANGCH E NGDI UNGIL MA LAK EL SAL NGII ENG DIRREK EL DI UNGIL.

Shape165 Shape166 FEET AND Shape167 Shape168 INCHES

Shape169 Shape170 METERS AND Shape171 Shape172 CENTIMETERS

☐ DIAK A KUDENGEI

☐ NGDIAK EL SOAK EL ONGER

[DO NOT READ TO RESPONDENT] How was the measurement taken?

☐ RESPONDENT ESTIMATE
☐ MEASURED ON SITE

Ng tela bengdel a ngelekem era chelechang Ng bekord el telang [IF NEEDED, READ]: A DI MOLANGCH E NGDI UNGIL MA LAK EL SAL NGII ENG DIRREK EL DI UNGIL.

Shape173 Shape174 POUNDS MA Shape175 Shape176 OUNCES

Shape177 Shape178 KILOGRAMS MA Shape179 Shape180 GRAMS

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

[DO NOT READ TO RESPONDENT] How was the measurement taken?

☐ RESPONDENT ESTIMATE
☐ MEASURED ON SITE

[ONLY ASK THIS QUESTION IF CHILD IS 0‑5 YEARS OLD]

Chelsel aikal mla mo merek el teruich ma erung el buil, ma lechub eng ellimosk el chad ra ukeruul ngmla oker er kau el uase kekora suebek a regnum el kirel a omesubel, ulekerulel a bedengel ma uldesuel, ma lechub eng blekerdelel ngkal el ngalek?

☐ CHOI
☐ DIAK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

[ONLY ASK THIS QUESTION IF CHILD IS 0‑5 YEARS OLD]

[IF THIS CHILD IS YOUNGER THAN 9 MONTHS, GO TO D7].

Aikal mla mo merek el teruich ma erul buil, eng ngarngii a toktang malechub eng tal chad loureor ra tekoi ra ukeruul (Health) el milskau malechub eng tara obeteterir ar ngalek, a uai tial ker mengonger rengii el kirel a ulekurulel, omengedechedal, malechub a blekerdelel a ngalek? A le bebil ra tae mea toktang malechub eng chad ra ureor ra health a msa chedam ma chedil a uai tial ker mete meruul a le mera chosongel malechub eteme oldingel ra blai e meskid.

☐ CHOI
☐ NG DIAK [GO TO D7]

☐ NGDIAK UDENGEI [GO TO D7]

☐ NGDIAK EL SOAK EL ONGER [GO TO D7]

[IF THIS CHILD IS 9‑23 MONTHS]

A ker el mulnger ng kirel aikel momdasu, ma osengem raikal beldukl er riou: Ka mlia olangch el kongei.

☐ A ngalek ng melekoi el uangerang malechub sel oto ra tekingel?

☐ Ngera blekerdelel lobengkem malechub ar bebil ra rechad?

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

[IF THIS CHILD IS 2‑5 YEARS]

Tial ker mlo ungil kmer aikel mle kirem el mo medengei ma osengem ma uldesuem: Ka mlia olangch raikal beldukl er riou.

☐ Aikel tekoi ma delecherul, a ngalek ng medengei?

☐ Ngkal ngalek ng delodau a lobengkem ma lobengterir ar bebil ra rechad?

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Ngarker al blechoel el ngara ukeruul er ngii ngkal ngalek al secher? Kau malechub a tara obeteterir ar ngalek ng ungil bo modengei a kirel a secherel ma ukeruul ra ngalek?
1. ☐ CHOI
2. ☐ NG DIAK [GO TO D8]

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

[IF YES] Koba ngalk el mora ukeruul er ker?

☐ A obis ra toktang

☐ emergency room ra osbitar ER
☐ A osbitar
☐ Mekekerei el osbitar ra beluu ma public health
☐ Nurse ra skuul, obis ra sensei ra klekoul ma obis ra skuul
☐ A dispensary ra beluu
☐ A ngodech al basio, NG KER EL BASIO

Shape183

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Ngar ngii a ulterekokl (blechoel) el labor chosongel er ngii a ngalek, el diak el secher eng di kirel a kmong uangera health er ngii?
1. ☐ CHOI
2. ☐ NG DIAK [GO TO D9]

☐ NGDIAK UDENGEI [GO TO D9]

☐ NGDIAK EL SOAK EL ONGER [GO TO D9]

[IF YES] a ngalek ng mo rtial osisiu basio sel le bol secher?

☐ CHOI
☐ NG DIAK

A chelsel tial mla mo merek el teruich ma cherul buil e ngkal ngalek eng mla ngara Mdangch a ikel merang Ukeruul ra ikrel a osbitar el ua omesumech, ousbechelel a kar ra Belau ma kuk bebil Al tang eng mlara chad era omesumech ma lechub eng di mla ra blai?
1. ☐ Ukeruul
2. ☐ Toktang ra Mad
3. ☐ Toktang ra ding
4. ☐ Haisia
5. ☐ Counselor ra skuu
6. ☐ Kuk bebil ra bedegel a ukeruul
7. ☐ Ngdimlak el GO TO ngii dil ta ra ikang [GO TO D10]

☐ NGDIAK UDENGEI [GO TO D10]

☐ NGDIAK EL SOAK EL ONGER [GO TO D10]

[IF YES] eng mlo ra skeng er chosengel er ker? Mlia olangch ra ikel le mleues er ngii.

☐ Toktang ra mad

☐ Toktang ra rengalek malechub eng ngidil toktang
☐ Ileakel ospitar ra al chad (Private Clinic‑ Health Center)
☐ Skuul
☐ Kuk tara basio, er ker:

Shape186

Aikal mla mo merek el teruich ma erul buil, mlarngii a taem el ngkal ngalek a kmal uluusbech ra ukeruul e dimlak el nguu ma lechub eng dimlak lengarngii a ukeruul? A ukeruul a belkul a kmo, ukeruul ra bedenged ma lechub e ngiidil bedengel a ukeruul el ua ukeruul r angered, osenged ma uldesued.
1. ☐ CHOI
2. ☐ DIAK [GO TO D12]

☐ DIAK KUDENGEI [GO TO D12]

☐ DIAK A NGER [GO TO D12]

[A LSEKUM ENG CHOI] e ngeral bedengel a ukeruul a mlo diak? Mluches a ikel merang.

☐ Ukeruul ra Bedenged

☐ Ukeruul ra Ungeled
☐ Ukeruul ra Osenged
☐ Ukeruul ra Orrenges
☐ Ukeruul ra Uldasou
☐ Kuk tang ra Bedengel, mlechesii:

Shape188

Ngerang ra ikang el beldukel er iou e a mle uchul me ngkal ngalek a mlo diak el nguu sel mle kirel ukeruul:

	CHOI	DIAK	DIAK KUDENGEI	DIAK A NGER
D14a. Ngkal ngalek a dimlak el sebechel melai er tiang el ukeruul?	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
D14b. Tial ukeruul el uluusbech er ngii ngkal ngalek a dimlak er sel basio el kiei er ngii?	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
D14c. Mlarngii a mondai meng mlo diak el meruul a temel el mong er sera lousbech er ngii?	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
D14d. Mlarngii a mondai ra olidiuul ra ngalek el mora ukeruul?	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
D14e. Tial ukeruul ma obis ra toktang a mle chelsimer?	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
D14f. Mlarngii a mondai ra cheral a ukeruul?	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐

Ngkal ngalk mla tal lebol niuing ra osbitar ra elsel a ikal teruich ma erul buil (12 months)? Kedirek el odak a temel el mora emergency room ma mechiuaiu ra osbitar el mo tutau.
1. ☐ Choi
2. ☐ Ngdiak

☐ DIAK KUDENGEI

☐ NGDIAK EL SOAK EL ONGER

[IF YES] A chelsel a ikal mla momerek el truich ma eru el buil, 12 months, ngtelal taem el blal bol niuing ra osbitar ngkal ngalk el kirel a telemellel a bedengel? A 'injury', a belkul a kmo, telemellel a bedenged malechub telemall lokiu a accident malechub eng odechelakl. A telemall, a sebechel uldimukel engdi ngdiak el dil rua chelemcham el iuis, elreuakl, delobech, delul ra ngau, blangch/beltuut, malechub eng chellebed ra kmungerang.

Shape192 Shape193 MLIA OCHUR

☐ DIAK KUDENGEI

☐ NGDIAK EL SOAK EL ONGER

Experience Lobengterir a Rechad ra Ukeruul Ra Ngalek
1. Ngarngii a tang malechub te betook el molatk el kmo te toktang ma nurse rengkal ngalek? A toktang ma nurse ra ngalek a blekul a kmo te kmal mui el medengelii a ngalek, rekltel ma ukeruul rengii, ma rekisi ra ukeruul er ngii. Ng sebechel di toktang, toktang ra rengalek, nurse lou babier el lomkar, malechub eng kldemel a toktang.
  1. ☐ CHOI, NGDI TA EL CHAD
  2. ☐ CHOI, TE BETOOK RA TA EL CHAD
  3. ☐ NG DIAK
2. Aikal mla mo teruich ma erul buil, eng mla tal lomes ra toktang malechub eng mlara ukeruul ngkal ngalek?
  1. ☐ CHOI
  2. ☐ NG DIAK [GO TO E3]

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

[IF yes] eng mle uangera klungel a mondai meng mlo meues ra toktang?

☐ Dimlak a mondai

☐ Dimle kekerei
☐ Ng kmal mle klou

[Answer the following questions only if this child had a health care visit IN THE PAST 12 MONTHS. Otherwise, go to E4.]

Tial mla mo merek el teruich ma erul buil, mle uangera temel a ngalek el meues ra toktang malechub a ngidil chad ra ukeruul:

	Blechoel	Beblechoel	Bebil ra taem	Kmal diak	NGDIAK UDENGEI	NGDIAK EL SOAK EL ONGER
E3a. Mle ungil a idisel a taem lobengkel a ngalek?	₁ ☐	₂ ☐	₃ ☐	₄ ☐	₇₇ ☐	₉₉ ☐
E3b. Ungil lorrenges er kau?	₁ ☐	₂ ☐	₃ ☐	₄ ☐	₇₇ ☐	₉₉ ☐
E3c. Ochotii a kerkikl reng rengii raikel siukang ma loumerang a telungalek?	₁ ☐	₂ ☐	₃ ☐	₄ ☐	₇₇ ☐	₉₉ ☐
E3d. Milskau a ulterekokl el tekoi el mle soam el mo medengei el kirel a ngalek?	₁ ☐	₂ ☐	₃ ☐	₄ ☐	₇₇ ☐	₉₉ ☐
E3e. Ngilsukau meke mlo melchesuar a kmo kusbechall el kirel ongetmeklel ma ulekerreuil a ngalk?	₁ ☐	₂ ☐	₃ ☐	₄ ☐	₇₇ ☐	₉₉ ☐

Ngarngii a tara chad lolengeseu rekau ra oketmeklel rokui el ukeruul rengkal ngalek ra delongelel a blil a ukeruul mar kakerous el toktang?
1. ☐ CHOI
2. ☐ NG DIAK
3. ☐ A LEMLAK LEMEUES RA BETOOK RA TANG EL CHAD RA UKERUUL RETIAL MERKOL TAL RAK [GO TO E7]
Aikal mla mo merek el teruich ma erul buil, ekekora mlo melchesuar a kmo kuluusbech ra tang ma lechub e te bebil ra rechad, malechub a ngesou el sumchokl e orael a teletelel a ukeruul rengkal ngalek?
1. ☐ CHOI
2. ☐ NG DIAK [GO TO E6]

[IF YES] Aikal mla mo merek el teruich ma erul buil, eng mle uangera klungel a ngesou el mngiluu el kirel a orretel ma ongetmeklel a ukeruul rengkal ngalek?

☐ Mle blechoel

☐ Bebil ra taem
☐ Kmal dimlak

Ma uldekial rokui, eng kmal uangera klungiolel a regnum el kirel a mle ungil klaodengei ma cheldecheduch ra delongelir tirkel rokui lulmes e meruul ra ukeruul rengkal ngalek?
1. ☐ Ng kmal mle ungil
2. ☐ Kora mle ungil
3. ☐ Dimlak el sal ungil
4. ☐ Kmal mle mekngit

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

[ONLY ASK THIS QUESTION IF CHILD IS 12‑17 YEARS OLD]

Ngarngii er tirkal toktang rengkal ngalek a kmal diulterkokl el diomes rar ngalek?

☐ CHOI
☐ NG DIAK [GO TO E8]

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

[IF yes] eng mla tal longedecheduch rekau, el kmo ngarngii a taem engkal ngalek a kuk mo mesa toktang rar meklou el chad?

☐ CHOI

☐ NG DIAK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

[ONLY ASK THIS QUESTION IF CHILD IS 12‑17 YEARS OLD]

A toktang malechub eng chad loungerachel rengkal ngalek, ng blechoel el:

	CHOI	NG DIAK	NGDIAK UDENGEI	NGDIAK EL SOAK EL ONGER
E8a. Rullii a ngalek el momdasu el kirel a klengar rengii re ngar medadel taem. Kora kirel, skulel, ureor, deleuill, ma duch er ngii ra ureor el kirel a ileakl el delengchokl?	₁ ☐	₂ ☐	₇₇ ☐	₉₉☐
E8b. Ungil luldasu el kirel a mesisiich el bedengel ma uldesuel (health) uaia tabesul blengur, ungil undo, diak lousbech a dekool, rrom ma mesisiich el mekngit el kar, ma tekoi ra cheliuaiu ra redil ma sechal?	₁ ☐	₂ ☐	₇₇ ☐	₉₉☐
E8c. Duch er ongetmeklel a ungil e mesisiich el klechad er ngii el uaia, duch ma klemedengei ra rakt ma orrebengel a rakt, al dubech a bkais emrungel el tekoi eng mekerang, a usbechellel a kar el kirel lomkar a rakt?	₁ ☐	₂ ☐	₇₇ ☐	₉₉☐
E8d. Medengei aikel kuk mengodech ra tekoi ra ukeruul er ngii sel bol teruich ma eai a rekil el uaia, a llemeltel el di ngii, kengei er ngii, llemeltel di ngii el merritel e melilt?	₁ ☐	₂ ☐	₇₇ ☐	₉₉☐

[ONLY ASK THIS QUESTION IF CHILD IS 12‑17 YEARS OLD]

A toktang metirkel chad ra ukeruul rengkal mlatal loureor lobengkem el kutmeklii a llechukl el moktek ra teletelel a osengelel ma ukeruul rengkal ngalek lotireklii sel kmal usbechellel ra ukeruul ma klisichel a bedengel?

☐ CHOI
☐ NG DIAK [GO TO E10]

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

[IF yes] etial plan (moktek) ngocholt e mades e rokui aikel rektel ma usbechellel ra tekoi ra ukeruul ma klisichel a bedengel ma uldesuel luldimukl ra ngesou el kmo sebchel ngmai rker?

☐ CHOI

☐ NG DIAK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Mekau mengkal ngalek ngarngii a otsusi (copy) er tial plan (moktek) el mobang?

☐ CHOI

☐ NG DIAK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Me tial plan (moktek) ng atter ra usbechellel ngkal ngalek ma klungel ma rektel er chelechal taem?

☐ CHOI

☐ NG DIAK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Sel rullii a ngalek mengdi sebechel ngmai a ngesou ra insurance a blechoel mengodech sel le kekerei ma kuk bol klou lechad, ke medengei el kmo ngmo uangera teletelel a ngelsuir a insurance rengkal ngalek a bole klou lechad?
1. ☐ CHOI [GO TO F]
2. ☐ NG DIAK

[IF NO] ngarngii a chad el mla subedau ra kmo ngera kuk mo teletelel a ngesou el mora ngalek e sebechel ngmai rker sel bol klou lechad?

☐ CHOI

☐ NG DIAK

Udoud (insurance) el Harau a Ukeruul ra Ngalek

A ngiidil taem ra chelsel tial mla mo merek el teruich ma cherul buil e ngkal ngalek ng mlarngii a ngiidil bedengel a insurance er ngii? Uldimukl er a ngii dil teletelel a insurance el mo lmuut ra NHI ma MSA
1. ☐ Choi, ngmle cherrungel tal rak, alsekum ngesonges ra tal rak, disera lemechell [GO TO F4]
2. ☐ Choi, engdi mlarngii a dimlak el sebechel, ua blel teleu
3. ☐ Ng diak

Ngera ra ikal beldukl er iou a uchul meng ngkal ngalk a dimlak el ngara insurance ra chelsel a ikal lmla momerek el teruich ma cherul buil:

	CHOI	DIAK
F2a. Ngmlo ngodech a kombalii ma lechub eng ureor	₁ ☐	₂ ☐
F2b. Ngmil terob a insurance leng mlo diak a udoud el harau	₁ ☐	₂ ☐
F2c. Ngmlo diak kuu insurance le leng kmal meringel a cheral	₁ ☐	₂ ☐
F2d. Ngmlo diak kuu insurance leng dimlak el omdoud a kuusbech el uukeruul	₁ ☐	₂ ☐
F2e. Ngmlo diak kuu insurance leng ngesonges ar toktang el kongei er ngii	₁ ☐	₂ ☐
F2f. Mle meringel a omerellel a babier ra ngii	₁ ☐	₂ ☐
F2g. Kuk tara uchul ea ngalek a dimlak el ou insurance	₁ ☐	₂ ☐

Ngkal ngalek er chelechang, ngarngii a insurance malechub eng ngidil bedengel a health coverage plan a lengar ngii?
1. ☐ CHOI
2. ☐ NG DIAK [GO TO SECTION G]

☐ NGDIAK UDENGEI [GO TO SECTION G]

☐ NGDIAK EL SOAK EL ONGER [GO TO SECTION G]

Ngkal ngalek ngulsiseb ra ngii dil tang ra ikal insurance? [Interviewer Note: Only read jurisdiction-specific insurance types for your jurisdiction].

	CHOI	DIAK
F4a. Private health insurance	₁ ☐	₂ ☐
F4b. Insurance ra urerem ma lechub eng urerel a bechim	₁ ☐	₂ ☐
F4c. Medicaid ma lechub eng ngesu ra kabelment Palau NHI	₁ ☐	₂ ☐
F4d. tara bedengel a insurance ra kabelment (el ua Micronesia MiCare or Chuuk State, Marshall Islands Public Insurance, and Marshall Islands Supplemental Health Fund)	₁ ☐	₂ ☐
F4e. MSA	₁ ☐	₂ ☐
F4f. CHIP (Children’s Health Insurance Program)	₁ ☐	₂ ☐
F4g. TRICARE ma lechub eng insurance ra resoldau	₁ ☐	₂ ☐
F4h. HIS Indian Health Service	₁ ☐	₂ ☐
F4i. Kuk tara bedengel a ukeruul, Ng ngara ngklel	₁ ☐	₂ ☐

A insurance ra ngkal ngalek eng blechoel harau ra ukeruulel? Al bora haisia, ma tokta ra mad, osbitar, ER, ma di osongel
1. ☐ Ng kmal blechoel
2. ☐ Blechoel
3. ☐ Bebil ra taem
4. ☐ Ng kmal diak

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Ngkmal telal taem etial health insurance ra ngalek a msa kengei meng mo meues er tirkal meral toktang mar chad ra ukeruul el meral kirel usbechellel?
1. ☐ Ng kmal blechoel
2. ☐ Blechoel
3. ☐ Bebil ra taem
4. ☐ Ng kmal diak

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Harau a Ukeruul ra Ngalek
1. A chelsel tial mla mo merek el teruich ma cherul buil eng telal udoud a mla mechoit el harau a rokui el ukeruulel ma osongelel ngkal ngalek, el mo uldimukl ra udoud ra MSA, ma sel ngerchelem el basent el cheral a ukeruul.Ngdiak e moldak er sel cheral a HCI.
  1. ☐ $0 (A LSEKUM ENG DIMLAK A OMCHITII EL UDOUD [GO TO G4]
  2. ☐ $1‑$249
  3. ☐ $250‑$499
  4. ☐ $500‑$999
  5. ☐ $1,000‑$5,000
  6. ☐ BETOK RA $5,000

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Ng blechoel el ungil e melemalt e atter?
1. ☐ Kmal Blechoel
2. ☐ Blechoel
3. ☐ Bebil ra Taem
4. ☐ Diak

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Kau ma telungalek er kau er tial merekong el rak, ngmlarngii a mondai ra ukeruul ra ngalek?
1. ☐ CHOI
2. ☐ DIAK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Tial mlo merek el tal rak, kau ma lechub tara rechad ra telungalek er kau:

	CHOI	DIAK	NGDIAK UDENGEI	NGDIAK EL SOAK EL ONGER
G4a. Mlo diak moureor eleng rektel ngkal ngalek a uchul?	1 ☐	2 ☐	77 ☐	99 ☐
G4b. Mlo ngosonges atemel a ureriu eleng rektel a ngalek a uchul ?	1 ☐	2 ☐	77 ☐	99 ☐
G4c. Mlo diak el somiu el melodech a ureriu eleng mle suebek a rengmiu a llemengodech ma lechub eng mo diak a insurance ra ngalek?	1 ☐	2 ☐	77 ☐	99 ☐
G4d. Ngarngii a ngesou el mngilai ra rechedemiu el kirel a rekter a ngalek?	1 ☐	2 ☐	77 ☐	99 ☐

Elsel a tal sandei, eng locha uaia klungel a ngeral taem a omchitii el ngara blai el olengeseu er ngkal ngalek? Tiang a uldimukel er ngii ra omtechei a hotai ra telemall ra bedengel, omsang a kerul, e omsang a ikel rokui el bedengel a ukeruul el ousbech.
1. ☐ NGKAL NGALEK A DIAK EL OUSBECH A NGESOU EL MENGETMOKEL ER NGII
2. ☐ NGDIAK, NGARA BLAI E NGAK MAR BEBIL RA RECHAD RA BLAI A MENGETMOKEL ER NGII
3. ☐ NGESONGES ERA TAL ZIKANG RA AL SANDEI
4. ☐ TANG EL MORA EUANG EL ZIKANG RA AL SANDEI
5. ☐ EIIM EL MO TERUICH EL ZIKANG RA TAL SANDEI
6. ☐ TERUICH MA TAL ZIKANG MA LECHUB ENG BETOK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Chelsel a tal sandei eng kmal telal zikang er kau ma lechub eng chad ra telungalek er kau a omchoit el mesmechokl e merech ra ukeruul er ngkal ngalek el kirel a appointment er ngii ma basio el GO TO ukeruul er ngii.
1. ☐ NGKAL NGALEK A DIAK EL OUSBECH A NGESOU EL MENGETMOKEL ER NGII
2. ☐ NGDIAK, NGARA BLAI E NGAK MAR BEBIL RA RECHAD RA BLAI A MENGETMOKEL ER NGII
3. ☐ NGESONGES ERA TAL ZIKANG RA AL SANDEI
4. ☐ TANG EL MORA EUANG EL ZIKANG RA AL SANDEI
5. ☐ EIIM EL MO TERUICH EL ZIKANG RA TAL SANDEI
6. ☐ TERUICH MA TAL ZIKANG MA LECHUB ENG BETOK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Omesubel a Ngalek
1. Chelsel a tal sandei eng kmal uangera klungel taem a lechitii a ngalek el omes a TV, omes a video, ma lechub e ngousekool a video game?
  1. ☐ DIAK
  2. ☐ NGESONGES RA AL ZIKANG
  3. ☐ TAL ZIKANG
  4. ☐ ERUNG EL ZIKANG
  5. ☐ EDEI EL ZIKANG
  6. ☐ EUANG EL MO BETOOK EL ZIKANG

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Chelsel a tal sandei eng kmal uangera klungel taem a lechitii a ngalek el ngara computer, cell phone, games, ma bebil ra klalou el ousbech a dengki el diak el ngii a subelel ra skuul?
1. ☐ DIAK
2. ☐ NGESONGES RA AL ZIKANG
3. ☐ TAL ZIKANG
4. ☐ ERUNG EL ZIKANG
5. ☐ EDEI EL ZIKANG
6. ☐ EUANG EL MO BETOOK EL ZIKANG

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

[ONLY ASK THIS QUESTION IF CHILD IS 0‑5 YEARS OLD]

Ngkal ngalek ng uangerang a duch er ngii el di ngii el mengetmokel er ngii?

☐ Kmal Meduch
☐ Kora Sebechel
☐ Metitur
☐ Diak el Sebechel

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

[ONLY ASK THIS QUESTION IF CHILD IS 0‑5 YEARS OLD]

Kau ke kmal lulterekokl el medengei el kmo ngkmal sebechel ngkal ngalek el mo ungil ra elementary ma high school?

☐ A Kmal Ulterekokl el Medengei
☐ A Kumdasou el kmo Ngsebechel
☐ Kora Locha Sebechel
☐ Diak sal Medengeiv

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

[ONLY ASK THIS QUESTION IF CHILD IS 6‑17 YEARS OLD]

Aikal mla mo merek el teruich ma erul buil, eng kmal mle telal sils el dimlak el GO TO skuul a ngalek leng rektel ma lechub eng telmellel a bedengel a uchul?

☐ DIMLAK EL CHITII A SKUUL
☐ TANG EL MO EDEI EL KLEBESEI
☐ EUANG EL MORA ELOLEM EL KLEBESEI
☐ EUID EL MORA TERUICH EL KLEBESEI
☐ TERUICH MA TANG MA LECHUB ENG BETOK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

[ONLY ASK THIS QUESTION IF CHILD IS 6‑17 YEARS OLD]

Aikal mla mo merek el teruich ma erul buil eng kmal telal taem el skuul a subedau ma lechub e ngii diltang el chad ra blai el kirel a mondai el ngarngii er ngkal ngaled ra skuul?

☐ DIMLAK A TAL TAEM
☐ TAL TAEM
☐ ERUNG MA LECHUB ENG BETOK EL TAEM

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

A ikang el teblong ra ker a oker er kirel a bullying. A bullying sel sekum ea tang ma lechub e te terung el ngalek a melemolem el omekakou, orrouk, omerk a telulchoid,mengelebed, oldubech, ma lechub e tomekringel ra tara ngalek. Ngdiak el bullying a lsekum ar terung el ngalek ra skuul el kmeed el osisiu a klisichir a kau mondai, kautoktok, ma lechub e te kaiukakou el teletelir ar terung el kausechelei el ngalek

[ONLY ASK THIS QUESTION IF CHILD IS 12‑17 YEARS OLD]

A ngelekem ng mla tang el le bully er ngii ra kerensel a skuul?

☐ CHOI
☐ DIAK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

[ONLY ASK THIS QUESTION IF CHILD IS 12‑17 YEARS OLD]

A ngelekem ng mla tang el bully er ngii lokiu a, text, ma facebook (electronic)? (Ko mechur a ikel blel bully er ngii lokiu a texting, Instagram, Facebook, ma lechub eng kuk bebil ra bedengenel).

☐ CHOI
☐ DIAK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

[ONLY ASK THIS QUESTION IF CHILD IS 6‑17 YEARS OLD]

Sera lomuchel ra yotsiyeng, eng mle tal lomelekl ra osisiu el dauch (grade) ra skuul?

☐ CHOI
☐ DIAK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

[ONLY ASK THIS QUESTION IF CHILD IS 6‑17 YEARS OLD]

Chelsel tial merekong el tal sandei, ng telal sils el luluu undo ngkal ngalek, uluu sekool a ouedikel el klekool, ma lechub engdi uluuedikel a bedengel al tal zikang?

☐ DIMLAK A TAL SILS
☐ TANG EL MO EDEI EL KLEBESEI
☐ EUANG EL MO ELOLEM EL KLEBESEI
☐ BEKEL SILS

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Kirem Kau ma Ngalek
1. Ngkmal telal taem el bla lolukl ngkal ngalek el mo kiei ra beches el basio er sera lemechell el mei er elengang?

Shape201 Shape202 ILDISEL A TAEM

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

[ONLY ASK THIS QUESTION IF CHILD IS 0‑5 YEARS OLD]

Chelsel tial merekong el tal sandei e kau ma lechub eng tara chad ra telungalek a mlenguiu el mora ngalek?

☐ DIMLAK A TAL SILS
☐ TANG EL MO EDEI EL KLEBESEI
☐ EUANG EL MO ELOLEM EL KLEBESEI
☐ BEKEL SILS

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

[ONLY ASK THIS QUESTION IF CHILD IS 0‑5 YEARS OLD]

Chelsel tial mlo merek el tal sandei e kau ma lechub eng tara chad ra telungalek a mlengedecheduch el chelid ma lechub eng milngitakl el mora ngalek?

☐ DIMLAK A TAL SILS
☐ TANG EL MO EDEI EL KLEBESEI
☐ EUANG EL MO ELOLEM EL KLEBESEI
☐ BEKEL SILS

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

[ONLY ASK THIS QUESTION IF CHILD IS 0‑5 YEARS OLD]

Ngkal ngalek ng dirrek el ngilai a ulekerreu ma lechub eng omengedmokl el kesengil eng teruich el zikang el mlara ngodech el chad el diak el delal ma demal ma lechub eng chad el oungerachel er ngii? Tial ulekerreu a sebechel el mlara basio el obetriri a rengalek, (day care center), yotsiyeng (preschool, Head Start program), ileakel ngesou ra telungalek (family child care home, nanny, au pair, or relative) ma lechub eng udeudel el chad el obang a ngalek (babysitter).

☐ CHOI
☐ DIAK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

A chelsel tial mla mo merek el teruich ma erul buil, e ngkal ngalek ng mlar ngii a temel lomes ra toktang ma lechub eng chad er a osbitar lokiu a video malechub eng dengua?
1. ☐ CHOI
2. ☐ DIAK

[IF YES] Ra ikakid el temel a ngalek lomes ra chad er a osbitar lokiu a video malechub eng dengua, tial klou el secher el corona virus ng mle uchul okedong?

☐ CHOI

☐ DIAK

A chelsel tial mla mo merek el teruich ma cherul buil e ngkal ngalek ng mlarngii a temel mora ospitar el kirel olekebai a rakt el dimlak lsebechel mor ngii malechub e te mlo mengodech ra temel el tial klou el secher el coronavirus a uchul?

☐ CHOI

☐ DIAK

A chelsel tial mla mo merek el teruich ma cherul buil eng ngarngii a mla mengodech el temel a chesmerel a headstart malechub eng ngodech siobai el omes e omkerreu er ngkal ngalek, el tial klou el secher el coronavirus a uchul?

☐ CHOI

☐ DIAK

Kirel A Telungalek Ma Delengchokl
1. Ng ngarngii a ngii dil chad era blim e melokoa a dekoul, a baeb, melamech a cheliud ma lechub eng melamech a buuch? [READ IF NECESSARY:] A lak mungil medengei and dim delii sel modengelii. A buuch a redechel a buuch. Ngdirrek el areca nut. A chemelamech el buuch a siukang era betok el iungs me a meklou el beluu el ua Taiwan ma Vietnam. A chemachel a buuch el chelaus e beliull ra kebuu e dirrek e morngii a dekool
  1. ☐ CHOI
  2. ☐ DIAK [GO TO J3]

☐ NGDIAK UDENGEI [GO TO J3]

☐ NGDIAK EL SOAK EL ONGER [GO TO J3]

Ngarngii a ngiidil chad el melokoo a dekool ra chelsel a blai?
1. ☐ CHOI
2. ☐ DIAK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Ngkal ngelekem ng mla tal lolamech a chemachel buuch? [READ IF NECESSARY]: A buuch a redechel a buuch. Ngdirrek el areca nut. A chemelamech el buuch a siukang era betok el iungs me a meklou el beluu el ua Taiwan ma Vietnam. A chemachel a buuch el chelaus e beliull ra kebuu e dirrek e morngii a dekool.
1. ☐ CHOI
2. ☐ DIAK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Ke medengei a telmellel a omelamech el buuch?
1. ☐ CHOI
2. ☐ DIAK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

A ikal keldei el ker a kirel a udoud.

Sera lemechell ngkal ngalek, ng mle uangerang a renglel a okurulel ngkal ngalek el ousbech a ikel mlarngii el ududel a telungalek el omechar a kall ma siungel a delengchokl?
1. ☐ Diak
2. ☐ Kora Dimlak
3. ☐ Kora mle Blechoel
4. ☐ Blechoel

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Tial ker a oker er kau el uase, ngmle sebechem el mechar a ikel kall el muluusbech. Ngera ra ikal beldukl e riou a ungil smodii a mle teletelel a omengeliu ma lechub eng rolel a kall el muluusbech ra blai raikal mla mo merek el teruich ma erul buil?
1. ☐ Ng mle blechoel el sebecham el smiik a ungil ra bedenged el kall.
2. ☐ Mle sebecham el smiik a kall ra blai engdi dimlak el blechoel el ikel kall el ungil ra bedenged.
3. ☐ A lebebil ra taem eng mlo diak el sebecham el smiik/mechar a mle ungil a ildisel el kall
4. ☐ Kmal mlo diak el sebecham el smiik ma lechub a ki mechar a ungil a ildisel el kall

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Ngiidil taem ra chelsel tial mla mo merek el teruich ma cherul buil, ma alta ngdi tal buil, eng ngarngii a chad ra blim el mla ngmai a ngesu er a:

	Choi	Diak	Ngdiak udengei	Ngdiak el soak el onger
J7a. udoud el ngesu ra kabelement	1 ☐	2 ☐	77 ☐	99 ☐
J7b. [Programming note: For Puerto Rico show “Nutrition Assistance Program (NAP) (known as PAN)”] Food Stamps me a SNAP or Supplemental Nutrition Assistance Program	1 ☐	2 ☐	77 ☐	99 ☐
J7c. a kall ra skuul	1 ☐	2 ☐	77 ☐	99 ☐
J7d. [Programming note: Do not show for RMI, Palau, FSM, Puerto Rico] WIC - Woman, Infants, and Children- ngeseu el mora redil, tolechoi me a mekekerei el galk	1 ☐	2 ☐	77 ☐	99 ☐

Kirem
1. [Complete the questions for each of the two adults in the household who are this child’s primary caregivers. If there is just one adult, provide answers for that adult.]

A KLOU EL CHAD 1

Ke mekera e mo chedal ngikal ngalek?

☐ Ak milechellii
☐ Ak rirdelii
☐ Akuu ngalek er ngii
☐ Ak delal/demal a milechellii a ngalk
☐ Ak mengkar ra ngii
☐ Obekul ma lechub eng chudelel
☐ Ng ngodech Ak chedal
☐ Ng ngodech Ngdiak cheda

Ke sechal, ke Redil?
1. ☐ SECHAL
2. ☐ REDIL
Tela Rekim?

Shape204 Shape205 RAK

Ngera kot el ngarbab el skuul el om tilobed er ngii?
1. ☐ ONGEAI EL SKUUL MA LECHUB E NGARIOU
2. ☐ ONGETIU EL MO ONGETERUICH MA ONGERUNG EL SKUUL, DIAK A BABIER EL CHOLECHOTEL A KMO KE TILOBED RA SKUUL
3. ☐ KE TILOBED RA ONGETRUICH MA ONGERUNG EL SKUUL MA LECHUB ENG TARA SKUUL EL MTECHIR A ONGETERUICH MA ONGERUNG EL SKUUL
4. ☐ KE TILOBED RA SKULEL A UREOR RA CHIM MA LECHUB ENG SKULEL A SIOBAI
5. ☐ SESEL DAINGAK ENGDI DIAK A DIKURI
6. ☐ KE NGILUU A ERUNG EL RAK EL DIKURI RA DAINGAK(AA, AS)
7. ☐ KE NGILUU E EUANG EL RAK EL DIKURI RA DAINGAK (BA, BS, AB)
8. ☐ KE NGILUU A MASTER DIKURI ER KAU RA DAINGAK (MA, MS, MSW, MBA)
9. ☐ KE NGILUU A KLTOKTANG ER KAU RA DAINGAK (PHD, EDD) MA LECHUB BEROBESONG DIKURI (MD, DDS, DVM, JD)
Ke bechiil?
1. ☐ BECHIIL [GO TO K7]
2. ☐ DIRKAK A TANG EL BECHIIL
3. ☐ MLA MO DIAK BECHIILL
4. ☐ KORA MOCHA DIAK BECHIIL
5. ☐ MLAD A BECHIM

☐ NGDIAK EL SOAK EL ONGER [GO TO K7]

Ke kiei lobengkel a chad el dirke om kasisiik?
1. ☐ CHOI
2. ☐ DIAK

☐ NGDIAK EL SOAK EL ONGER

A klisichel a bedengem, ng ungil malechub eng mekngit?
1. ☐ Kot Ungil
2. ☐ Kmal Ungil
3. ☐ Ungil
4. ☐ Oikab
5. ☐ Mekngi

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

A mental health er kau, ng ungil malechub eng mekngit?
1. ☐ Kot Ungil
2. ☐ Kmal Ungil
3. ☐ Ungil
4. ☐ Oikab
5. ☐ Mekngi

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Tial merekong el tang el rak ma lechub eng okeim ma erung el sandei, eng mlo sebechem el oureor el kesengil eng okeim el sandei?
1. ☐ CHOI
2. ☐ DIAK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Ngarngii a kuk tara klou el chad ra blai el dirrek el omtebechel e oungerachel er ngkal ngalek?
1. ☐ CHOI
2. ☐ DIAK [GO TO SECTION L]

☐ NGDIAK EL SOAK EL ONGER [GO TO SECTION L]

Ngkaikid el klou el chad oungerachel e omtebechel a mo Klou el Chad 2.

Ngkal tara klou el chad, ng mekera e mo chedal

☐ Ak milechellii
☐ Ak rirdelii
☐ Akuu ngalek er ngii
☐ Ak delal/demal a milechellii a ngalk
☐ Ak mengkar ra ngii
☐ Obekul ma lechub eng chudelel
☐ Ng ngodech Ak chedal
☐ Ng ngodech Ngdiak chedal

Ngkal Klou el Chad 2, Ng sechal, ng redil?
1. ☐ SECHAL
2. ☐ REDIL
Tela rekil ngkal Klou el Chad 2?

Shape206 Shape207 RAK

Ngera kot el ngarbab el skuul el blo tobed er ngii a Klou el Chad 2?
1. ☐ ONGEAI EL SKUUL MA LECHUB E NGARIOU
2. ☐ ONGETIU EL MO ONGETERUICH MA ONGERUNG EL SKUUL, DIAK A BABIER EL CHOLECHOTEL A KMO KE TILOBED RA SKUUL
3. ☐ KE TILOBED RA ONGETRUICH MA ONGERUNG EL SKUUL MA LECHUB ENG TARA SKUUL EL MTECHIR A ONGETERUICH MA ONGERUNG EL SKUUL
4. ☐ KE TILOBED RA SKULEL A UREOR RA CHIM MA LECHUB ENG SKULEL A SIOBAI
5. ☐ SESEL DAINGAK ENGDI DIAK A DIKURI
6. ☐ KE NGILUU A ERUNG EL RAK EL DIKURI RA DAINGAK(AA, AS)
7. ☐ KE NGILUU E EUANG EL RAK EL DIKURI RA DAINGAK (BA, BS, AB)
8. ☐ KE NGILUU A MASTER DIKURI ER KAU RA DAINGAK (MA, MS, MSW, MBA)
9. ☐ KE NGILUU A KLTOKTANG ER KAU RA DAINGAK (PHD, EDD) MA LECHUB BEROBESONG DIKURI (MD, DDS, DVM, JD)
Ngkal Klou el Chad 2, ng bechiil?
1. ☐ BECHIIL [GO TO K17]
2. ☐ DIRKAK A TANG EL BECHIIL
3. ☐ MLA MO DIAK BECHIILL
4. ☐ KORA MOCHA DIAK BECHIIL
5. ☐ MLAD A BECHIM

☐ NGDIAK EL SOAK EL ONGER

Ngkal Klou el Chad 2, ng kiei lobengkel a chad el dirke el kasisiik?
1. ☐ CHOI
2. ☐ DIAK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

A klisichel a bedengel, ng ungil malechub eng mekngit?
1. ☐ Kot Ungil
2. ☐ Kmal Ungil
3. ☐ Ungil
4. ☐ Oikab
5. ☐ Mekngi

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Daitai, a mental health er ngii, ng ungil malechub eng mekngit?
1. ☐ Kot Ungil
2. ☐ Kmal Ungil
3. ☐ Ungil
4. ☐ Oikab
5. ☐ Mekngi

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Tial merekong el tang el rak ma lechub eng okeim ma erung el sandei, eng ngkal Klou el Chad 2, ng mlo sebechel el oureor el kesengil eng okeim el sandei?
1. ☐ Choi
2. ☐ Diak

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Klisichel a Bedengem
1. A hutsu el kensa a daitai eng tirterii a bedengem el rokir el diak el belkul a kmong ngarngii a secher, tellemall, ma lechub eng diak. Ng locha bekord el ua klemengetel a ngerang el taem a mle ulebongel el hutsu el kensa er kau el mlara toktang?
  1. ☐ Chelsel tiang el merekong el rak (Ngiidil taem el ngesonges ra teruich ma erung el buil ra mla memong)
  2. ☐ Chelsel a merekong el erung el rak (tang el rak engdi ngesonges ra erung el rak ra la memong)
  3. ☐ Chelsel a merekong el eim el rak (erung el rak engdi ngesonges ra eim el rak ra la memong)
  4. ☐ Eim ma lechub eng betook el rak ra la memong
  5. ☐ Dirkak a tang

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Chelsel aikal mla mo merek el teruich ma erul buil, e ngkal ngalek mla tal ngara ukeruul a lechub ngesou ra cheldecheduch ra meduch el chad ra ukeruul ra uldesued? A chad ra ukeruul ra uldesued a uldimukel er ngii a toktang ra secherel a uldesued, toktang ra uldasou, nurse ra secherel a uldesued, chad el oureor el olengeseu ra chad el mo di ngii.
1. ☐ Choi
2. ☐ Diak, Ngdi kirek el mesang a semmong ra secherel a uldasou
3. ☐ Diak, Dimlak kuusbech el omes ra semmong ra secherel a uldaous [GO TO L4]

☐ NGDIAK UDENGEI [GO TO L4]

☐ NGDIAK EL SOAK EL ONGER [GO TO L4]

Mle ua klungel a ngerang a mondai er kau meke mlo ousbech ra semmong ra ukeruul ra uldasou?
1. ☐ Diak a Mondai
2. ☐ Kekerei el Mondai
3. ☐ Klou el Mondai
Tial dirke mlo merek el kldiull er kau, a toktang ra uingel ng ngilatech a ungelem?
1. ☐ CHOI
2. ☐ DIAK

☐ NGDIAK UDENGEI

☐ DIAK A KER

Ng techang a oungerachel a rokui el telengtengil ukeruul er kau?
1. ☐ Kau
2. ☐ Bechim
3. ☐ Kau ma Bechim
4. ☐ Delam ma Demam
5. ☐ Kuk di tang ra rechad, mlechesii

Shape208

☐ Ngdiak udengei

☐ Ngdiak el soak el onger

Techa oungerangel a bekel telengtengil a ukeruul ra rengelekem?
1. ☐ Kau
2. ☐ Bechim
3. ☐ Kau ma Bechim ma lechub eng aibo er kau
4. ☐ Dleam ma Demam
5. ☐ Kuk di tang ra rechad, mlechesii

Shape209

☐ Ngdiak udengei

☐ Ngdiak el soak el onger

Ker el kirel a omelouk, chomelim, ma ousbechel a mekngit el kar Aikal tekingem a mo berrotel Tedi rechad er tial ureor a momes a tekingem Mou tekangel el mo ungil onger

Chelsel a ikal mla mo merek el okedei el klebesei, eng telal sils sil el molokoo a dekool?
1. ☐ DIAK A TANG EL SILS
2. ☐ TANG EL MO ERUNG EL SILS
3. ☐ EDEI EL MORA EIM EL SILS
4. ☐ ELOLEM EL MO ETIU EL SILS
5. ☐ TERUICH EL MO TERUICH MA ETIU EL SILS
6. ☐ LLUICH EL MO LLUICH ETIU EL SILS
7. ☐ ROKUI EL OKEDEI EL SILS

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Kau ke melim a rrom, el uldimukl er ngii a ikel di dolengoes ra blai?
1. ☐ CHOI
2. ☐ DIAK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

A chelsel a klengar er kau, eng mla tal mousbec a ikal beldukl er a iou [READ IF NECESSARY]: A buuch a redechel a buuch. Ngdirrek el areca nut. A chemelamech el buuch a siukang era betok el iungs me a meklou el beluu el ua Taiwan ma Vietnam. A chemachel a buuch el chelaus e beliull ra kebuu e dirrek e morngii a dekool. cheliud

	CHOI	DIAK	NGDIAK UDENGEI	NGDIAK EL SOAK EL ONGER
L9a. Buuch	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
L9b. Dekool ma lechub e ngikel okesiul a dekool (vape)	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
L9c. Chemadech el dekool	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
L9d. Mariuana (chudel)	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
L9e. Cocaine, including powder, crack, or freebase	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
L9f. Heroin (also called smack, junk, or China White)	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
L9g. Methamphetamines (also called speed, crystal, crank, or ice)	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
L9h. Ecstasy (also called MDMA)	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
L9i. Synthetic marijuana (also called K2, Spice, fake weed, King Kong, Yucatan Fire, Skunk, or Moon Rocks)	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
L9j. Steroid pills or shots without a doctor's prescription	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
L9k. Prescription pain medicine without a doctor's prescription or differently than how a doctor told you to use it? (Count drugs such as codeine, Vicodin, OxyContin, Hydrocodone, and Percocet)	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐

[IF RESPONDENT CHEWED BETEL NUT, CONTINUE TO L10. ELSE IF RESPONDENT USED ANY OTHER SUBSTANCE IN L9 GO TO L11. ELSE IF NO SUBSTANCES USED, GO TO L12.]

Chelsel aikal mla mo merek elokedei el klebesei, eng mle telal sils el mullamech a buuch?
1. ☐ DIAK A TANG EL SILS
2. ☐ TANG EL MO ERUNG EL SILS
3. ☐ EDEI EL MORA EIM EL SILS
4. ☐ ELOLEM EL MO ETIU EL SILS
5. ☐ TERUICH EL MO TERUICH MA ETIU EL SILS
6. ☐ LLUICH EL MO LLUICH ETIU EL SILS
7. ☐ ROKUI EL OKEDEI EL SILS

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Ng mla tang el modurech el mong ma lechub e kemla ra ukeruul ma lechub e ke millai a ngesou el kirel a terbengel/cheldecheduch/ukeruul ra usbechellel a mekngit el kar?
1. ☐ CHOI
2. ☐ DIAK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

A toktang er kau ma lechub e ngiidil tang el meduch el chad ra ukeruul ngmla subedau el uase ke smecher el sukal (Type 1 ma Type 2)?
1. ☐ TYPE 1 DIABETES
2. ☐ TYPE 2 DIABETES
3. ☐ DIAK [GO TO L14]

☐ NGDIAK UDENGEI [GO TO L14]

☐ NGDIAK EL SOAK EL ONGER [GO TO L14]

Kau ke melim a kerul a sukal?
1. ☐ Orus el Insulin
2. ☐ Melim a Kar
3. ☐ Merus a Insulin e Melim a Kar
4. ☐ Diak Kulai a Kar

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

A toktang ma lechub e ngiidil chad ra ukeruul ngmla subedau el uase ke smecher ra ta raikal rakt?

	CHOI	DIAK	NGDIAK UDENGEI	NGDIAK EL SOAK EL ONGER
L14a. Rheumatic heart disease	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
L14b. Rheumatic fever	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
L14c. Kasinoma ra Medal Omecherelled	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
L14d. Olngesonges a Rsechem	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐

Kam sodii a berredem?
1. ☐ Ke kmal Kebekakl
2. ☐ Oikab el Kebekakl
3. ☐ Ungil a Berredem
4. ☐ Telkib el Oberaod
5. ☐ Kmal Oberaod
Ngerang ra ikang a omolasem el meruul er ngii el kirel a berredem?
1. ☐ Olngesonges a Bendek
2. ☐ Melechel a Bendek
3. ☐ Di uaisei a Berredek
4. ☐ NGDIAK EL SOAK EL ONGERANG EL KURUUL ER NGII EL KIREL A BERREDEK
Chelsel tial mla mo merek el tal sandei, e ngkmal telal sils el muluu chundo ma lechub e kemeringel el oureor el kesengil eng tal zikang ra tal sils? Ka modak a ikel rokui el taem el mchiloit el ouedikl ma lechub e ke chundo meng kmal mlo mesisiich el omomb a heart er kau meng rirellau el mo kora mesel.
1. ☐ DIAK A TANG EL SILS
2. ☐ TANG EL SILS
3. ☐ ERUNG EL SILS
4. ☐ EDEI EL SILS
5. ☐ EUANG EL SILS
6. ☐ EIM EL SILS
7. ☐ ELOLEM EL SILS
8. ☐ EUID EL SILS

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Kau ke dioll?
1. ☐ Choi
2. ☐ Ngdiak [GO TO M1]

☐ Ngdiak udengei [GO TO M1]

☐ Ngdiak el soak el onger [GO TO M1]

IF RESPONDENT IS NOT PREGNANT AND/OR HAS INFANT 12-MONTHS OR YOUNGER, GO TO M1

A ikang el ker a oker el kirel a Zika virus. A Zika virus a bekoiuiuul el rakt el rekas a nguu el oiulii el mora tang ma tang ra rechad. Ngdi dirrek el sebechel el imuul el okiu a sechal el smecher a bolebad (ousechelei) el obengkel a redil. Sel mle ulebongel el kldiull er kau, eng kora mle suebek a rengum el kirel a Zika virus?

Kedi ngiltii a di imong el nger.

☐ Kmal mle suebek a renguk
☐ Kora mle suebek a renguk
☐ Dimlak
☐ DIRKAK A TANG EL KRENGESII A RAKT EL ZIKA VIRUS ER SEL MLE ULEBONGEL EL KLDIULL ER NGAK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Chelsel sel dirke mlo merek el kldiull er kau, eng mle tang el mulngedecheduch ra toktang, nurse, ma lechub e ngiidil chad ra ukeruul el kirel a Zika virus?
1. ☐ Diak
2. ☐ Choi, Ng dimlak kuker engdi chad ra ukeruul a milngedecheduch er ngak el kirel
3. ☐ Choi, A chad ra ukeruul a milngedecheduch er ngak ele ngak a ulker

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Chelsel sel dirke mlo merek el kldiull er kau, eng mlengai a rsechem el mora skeng el kirel a Zika virus?
1. ☐ CHOI
2. ☐ DIAK [GO TO L23]

☐ NGDIAK UDENGEI [GO TO L23]

☐ NGDIAK EL SOAK EL ONGER [GO TO L23]

Ke milteriter el ngarngii a Zika er sel dirke mlo merek el kldiull er kau?
1. ☐ CHOI
2. ☐ DIAK [GO TO M1]

☐ NGDIAK EL SOAK EL ONGER [GO TO M1]

☐ DIAK KUNGER [GO TO M1]

[IF YES] Techang el ngelekem a oblem dioll er ngii?

Shape211

A ikang el ker a kirel a omerollem er sel sel dirke mlo merek el kldiull er kau.

Chelsel tial dirke mlo merek el kldiull er kau, e ke mlora ikel beluu el ngarngii a Zika virus?

☐ CHOI
☐ DIAK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

[IF YES] Tial dirke mlo merek el kldiull er kau, kemle medengei el kmong diak el ungil a oGO TO ikel basio el ngarngii a rakt el Zika virus?

☐ CHOI

☐ DIAK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

[IF NO] Ser om dioll e ke dim mle cheroid ra beluu el ngarngii a Zika lek rirengesii a subed el kmo ng mekngit obong?

☐ CHOI

☐ DIAK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Kirel a Delengchokl
1. Telang el chad a kiei er tiang el basio? Kosisebii a chad el blechoel el kiei ma lechub e te kiei er tiang el basio. Diak molsiseb ra chad el kiei ra tara basio el mo kemangel ra erung el buil ma lechub e ngalek ra daingak el kiei era tara basio ma lechub e ngara klsoldau me ngara tara beluu.

Shape214 Shape215 ILDISIR A RECHAD

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Telang er tirkang el chad er tiang el delengchol a chad er tiang el telungelek? A telungalek a ngiidil chad el ulak el me rengkal ngalek el okiu a rasech, chebehiil, omerodel, ma lechub eng omerodel el okiu a amt.

Shape216 Shape217 ILDISIR A RECHAD

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Aikal ker a osiik el kmo te mekera e mo ungil suub e smisiich a teletelel a ukeruul el mora rebekel chadTedi rechad er tial ureor a momes a tekingem A di molangch e ngdi ungil. Ma lak el sal ngii eng dirrek el di ungil. Sel momes ra klungel a udoud el kau ma rechad ara blim a kirekerngii er a chelsel a tal rak Uchei ra chom harau a tax eng tela a siliseb Modak a ngii dil udoud el siliseb, el mo lmuut era udoud ra ureor, social security, pension, unemployment payments, public assistance, ma kuk bebil Mdirrek el odak a udoud el mlara olengil a siobai, a chutem, ma blai.

Shape218 Shape219 , Shape220 Shape221 Shape222 , Shape223 Shape224 Shape225 ILDISEL A UDOUD ($)

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Ng ua ikakid a bebir ra teletael A bol kau eng uai al.

☐ ngesonges ra teruich el telael
☐ ng klou ra $10,000 e ngesonges ra $15,000
☐ ng klou ra $15,000 e ngesonges ra $20,000
☐ ng klou ra $20,000 e ngesonges ra $25,000
☐ ng klou ra $25,000 e ngesonges ra $35,000
☐ ng klou ra $35,000 e ngesonges ra $50,000
☐ ng klou ra $50,000 e ngesonges ra $75,000
☐ ng klou ra $75,000

☐ Ngdiak udengei

☐ Ngdiak el soak el onger

Jurisdiction Specific Module

PA1. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD] A ngelekem ng mla tal rellii a Ages and Stages Questionnaire (ASQ) ra toktang er ngii ma lechub tara brobesong el chad ra ureor?

☐ CHOI
☐ DIAK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

PA2. Kau ma lechub eng kuk tara klou el chad ra delengchokl a mla tal mosaod oliu a violence malechub eng injury prevention el mora ngelkem?

☐ CHOI

☐ DIAK

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

[ONLY ASK THIS QUESTION IF CHILD IS 0-1 YEAR OLD AND IF BIOLOGICAL MOTHER]

Aikal ker a mo oker a chisel a health er kau er tial dirke mlo merek el kldiull er kau.

PA. 3 [ONLY ASK THIS QUESTION IF CHILD IS 0-1 YEAR OLD AND IF BIOLOGICAL MOTHER] A chelsel tial dirke mlo merek el kldiull er kau, ea toktang, nurse ma lechub eng chad ra ukkeruul ngmal mengedecheduch er kau el kirel a ikang el tekoi el beldukl er iou? Komechur a ikel ngii e milsaod el merkau, ngdiak momechur a ikel mchiluiu, ma lechub e ke miles ra video. Ke loia tengetang ra bekl tekoi el dimlak a chad el smaod lekor kau ma lechub e ke loia tengetang ra Choi a lsekum eng milsaod lekor kau.

	CHOI	DIAK	NGDIAK UDENGEI	NGDIAK EL SOAK EL ONGER
PA3a. Kall el ungil dongang a de dioll	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
PA3b. Undo sel de dioll	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
PA3c. Programs ma lechub eng ngesou el olengeseu er ngak meng di ungil a berredek ra kldiull er ngak	₁ ☐	₂ ☐	₇₇ ☐	₉₉ ☐
PA3d. Programs ma lechub e ngesou el olengeseu er ngak el omeksengaked sel kmechell	₁ ☐	₂ ☐	₇₇ ☐	☐

PA4. [ONLY ASK THIS QUESTION IF CHILD IS 0-1 YEAR OLD AND IF BIOLOGICAL MOTHER] Ng telal bond a ngilasech ra berredem er tial dirke mlo merek el kldiull er kau?

Shape226 Shape227 LBS OR Shape228 Shape229 KILOS

☐ NG DIMLAK A NGMASECK EL BENDEK ER SERAK DIOLL

☐ NGDIAK UDENGEI

☐ NGDIAK EL SOAK EL ONGER

Ke kmal mesulang el ulengeseu er tiang el ureor.

Ak mo omtechei ra U.S. Department of Health and Human Services, e mereng asulem ra taem ma urerem el mchiloit el meskemam a ikang el meklou a belkul el tekoi el kirel ngkal ngalek me kau ma telungalek er kau. A ikang el nger el bla beskemam a mo ngosukemam ra tekoi ra omerritel ma omeuul el llach ma mo kudmokl a bekel telungalek el mo ungil el melchesuar a usbehellel a ngesou ra klisichel a bedenged ma rengalek ra kakerous el bedengir a rechad.

Subed el kirel a babier el omekberaod and mengeuid: A obis a diak el sebechel orrimel a chad, ma chad a diak el morimel, el meruul er tial ureor a lak a bleketakel el control number el lechukl er a babier. A OMB control number re tial babier a 0906-0042. A klemengetel a taem el locha meketmokel tial babier a bekord el tal sikang. Tia ultoi ra omengiuel tial babier, skel a babier el dousbech el henzi a ker, ma omengiuel a nger. Ngidil tekoi malechub ng ker kirel tial chetituokel el tekoi, malechub eng ngidil uldasu el sebechel olngeseu er a tial obis el olngeasek a beraod, a sebechem el uldureklii el moraHRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857.

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	mumford-elizabeth
File Modified	0000-00-00
File Created	2023-08-21

8 B questionnaire Palau palauan

Maternal and Child Health Jurisdictional Survey Instrument for the Title V MCH Block Grant Program

questionnaire Palau palauan

MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program

OMB: 0906-0042

Screener

Health ra Ngalk

Ngkal Ngalek ral Tolechoi

Ulekerruio a Ukeruul

Experience Lobengterir a Rechad ra Ukeruul Ra Ngalek

Udoud (insurance) el Harau a Ukeruul ra Ngalek

Harau a Ukeruul ra Ngalek

Omesubel a Ngalek

Kirem Kau ma Ngalek

Kirel A Telungalek Ma Delengchokl

Kirem

Klisichel a Bedengem

Kirel a Delengchokl

Jurisdiction Specific Module