Form Appendix A_NSCH-LC Appendix A_NSCH-LC Appendix A_NSCH-LC Questionnaire

Appendix A

National Survey of Children’s Health
Longitudinal Cohort (NSCH-LC)
Questionnaire Drafts

National Survey of Children’s Health
Longitudinal Cohort
A study by the U.S. Department of Health and Human Services to better understand the
health and well-being of children and young adults following the COVID-19 pandemic.

Instructions
Responding to this survey is easy:
1. Go to: https://respond.census.gov/nschlc
2. Enter your Login ID:
OR
Answer the questions on this form and mail it back in the postage-paid envelope provided.
The questions on this form are the first of two parts that make up the NSCH-LC. We will contact you again
if your household is selected for the second part. This survey should be completed by an adult.
For help or questions about completing this form, please call 1-877-749-4943. The telephone call is free.
For Telephone Device for the Deaf (TDD) assistance, please call: 1-800-582-8330. The telephone call is
free.
Para completar el cuestionario en español, llame al 1-877-749-4943. Para recibir ayuda con el Dispositivo
Telefónico para Personas Sordas (TDD, por sus siglas en inglés), llame de forma gratuita al
1-800-582-8330.

Start Here
1

SINCE 2018, have you or another adult in this household lived with a child or young adult?
Please include all children and young adults who:
● are currently ages 3-24
● lived with you or another adult member of your household at another address
● lived with you or another adult member of your household either full-time or part-time.
100
1

Yes ➔ SKIP to question

2

No ➔ You do not need to complete this questionnaire. Please mark "No" and RETURN THIS QUESTIONNAIRE
IN THE ENVELOPE PROVIDED. It is important that we receive a response from every household selected for
this survey.

2

on page 2

NSCH-LCS
(07/24/2023) D13

About You and Your Household
2

What is your first and last name?
First Name

Last Name

101
1

3

2

SINCE 2018, how many children or young adults live or have lived with you or another adult in this household?
Please include all children and young adults who:
● are currently ages 3-24
● lived with you or another adult member of your household at another address
● lived with you or another adult member of your household either full-time or part-time
102
Number of children or young adults

1

4

List all children and/or young adults included in question 3 above. Please list the children and/or young adults from
oldest to youngest.
First name, initials, or nickname of child or young adult
103
1

2

104
1

2

105
1

2

106
1

2

107
1

2

108
1

2

109
1

2

110
1

2

111
1

2

NSCH-LCS

2

Sex

Age in Years
3

Male

4

Female

3

Male

4

Female

3

Male

4

Female

3

Male

4

Female

3

Male

4

Female

3

Male

4

Female

3

Male

4

Female

3

Male

4

Female

3

Male

4

Female

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 completing this survey.

➜ Place the completed questionnaire in the postage-paid return envelope. If the envelope has been
misplaced, please 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 first part of the National Survey of Children’s Health-Longitudinal Cohort 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 [email protected]; use "Paperwork Project 0607-####" 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-LCS

3

This page intentionally left blank.

NSCH-LCS

4

26213207

National Survey of Children’s Health
Longitudinal Cohort
A study by the U.S. Department of Health and Human Services to
better understand the health and well-being of children and young
adults following the COVID-19 pandemic.

The U.S. 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.
Under the Privacy Act of 1974 (5 U.S.C. Section 552a), these records are maintained by the Census Bureau under SORN
COMMERCE/CENSUS-3, Demographic Survey Collection (Census Bureau Sampling Frame). 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.
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-LC1

(07/03/2023) D16

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Start Here

5

What is this child’s sex?
Male

Recently, someone in your household completed a
short survey that asked about children and/or young
adults ages 3 to 24.

Female
NOTE: Answer BOTH question 6 about Hispanic origin
and question 7 about race. For this survey, Hispanic
origins are not races.

Thank you for taking the time to respond.
We now have some important follow-up questions to
ask about:

6

Is this child of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

This survey should be completed by a parent or
caregiver. If the child listed above does not correspond
to a child for whom you or another adult in your
household are a parent or caregiver, please call
1-877-749-4943 for assistance.
We have selected only one child for this follow-up
survey in an effort to minimize the amount of time you
will need to complete the questions.

Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin
7

Your participation is important. Thank you.

What is this child’s race?
Mark (X) one or more boxes.
White
Black or African American

1

Are you a parent or caregiver who is CURRENTLY
familiar with this child’s health?

American Indian or Alaska Native

Yes ➔ SKIP to question 3

Asian Indian

No

Chinese

This child is deceased ➔ You do not need to complete
this questionnaire. Please mark this response option
and RETURN THIS QUESTIONNAIRE IN THE
ENVELOPE PROVIDED.

Filipino
Japanese
Korean

2

If no, is there another parent or caregiver in this household
who is CURRENTLY familiar with this child’s health?

Vietnamese

Yes ➔ Please have this other parent or caregiver
complete the rest of the survey.

Other Asian
Native Hawaiian

No ➔ You do not need to complete this questionnaire.
Please mark "No" and RETURN THIS
QUESTIONNAIRE IN THE ENVELOPE PROVIDED.
3

Chamorro
Samoan

What is this child’s full name?
First

Other Pacific Islander
8

Last

Where does this child live AT LEAST HALF OF THE TIME?
Mark (X) ALL that apply.
With me
With another parent or caregiver at another address

4

In what month and year was this child born?
Birth Month / 4-Digit Birth Year

/

Institutional setting (such as congregate care,
residential treatment, group home, penal facility)
Other, specify:

2 0

NSCH-LC1

2

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A. This Child’s Health
A1

In general, how would you describe this child’s
health?

Has a doctor, other health care provider, or educator
EVER told you that this child has...
Examples of educators are teachers and school nurses.
A6 Behavioral or Conduct Problems?

Excellent

Yes

Very good

No

If yes, does this child CURRENTLY have the
condition?

Good

Yes

No

Fair
A7

Poor

Developmental Delay?
Yes

A2

How would you describe the condition of this child’s
teeth?

If yes, does this child CURRENTLY have the
condition?

Excellent

Yes

Very good
A8

Good

No

Intellectual Disability (formerly known as Mental
Retardation)?

Fair

Yes

Poor

If yes, does this child CURRENTLY have the
condition?

A9

Permanent hearing loss?
Yes

No

Yes

Has a doctor or other health care provider EVER told
you that this child has…
A3

No

Speech or other language disorder?
Yes

No

No

No

If yes, does this child CURRENTLY have the
condition?

If yes, is the hearing loss:
Mark (X) ALL that apply.

Yes

Mild
Moderate

No

A10 Learning Disability?

Severe

Yes

Profound

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

A4 Anxiety Problems?

Yes

No

No

A11 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).

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

No

Yes
A5 Depression?

Yes

No ➔ SKIP to question A16 on page 4

If yes, does this child CURRENTLY have the
condition?

No

Yes

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

No

No

No

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A12 SINCE MARCH 2020, has this child received

medication or 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?

A18 SINCE MARCH 2020, has this child experienced any gaps

or delays in receiving medication or behavioral treatment
for ADD or ADHD?
Yes

Yes, this child received all needed medication or
behavioral treatment
Yes, this child received some needed medication or
behavioral treatment

No
A19 Is this child CURRENTLY taking medication for ADD

or ADHD?

No, this child needed but did not receive any medication
or behavioral treatment ➔ SKIP to question A16

Yes
No

No, this child did not need either medication or
behavioral treatment ➔ SKIP to question A16

A20 At any time DURING THE PAST 12 MONTHS, did this
child receive behavioral treatment for ADD or ADHD,
A13 SINCE MARCH 2020, has this child experienced any gaps

such as training or an intervention that you or this
child received to help with their behavior?

or delays in receiving medication or behavioral treatment
for Autism, ASD, Asperger’s Disorder, or PDD?
Yes

Yes

No

No

A14 Is this child CURRENTLY taking medication for Autism,

A21 Thinking of this child today, how often would you say

each of the following describes this child?

ASD, Asperger’s Disorder, or PDD?

Never Sometimes Often

Yes

a. Feels sad, unhappy

No

b. Feels hopeless

A15 At any time DURING THE PAST 12 MONTHS, did this

c. Is down on self

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?

d. Worries a lot
e. Seems to be having less fun

Yes
f. Fidgety, unable to sit still
No
g. Daydreams too much
A16 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

h. Distracted easily

No ➔ SKIP to question A21

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

i.

Has trouble concentrating

j.

Acts as if driven by a motor

A22 Thinking of this child today, how often would you say

each of the following describes this child?

No

Never Sometimes Often

A17 SINCE MARCH 2020, has this child received medication

a. Fights with other children

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

b. Does not listen to rules

Yes, this child received all needed medication or
behavioral treatment

c. Does not understand other
people’s feelings

Yes, this child received some needed medication or
behavioral treatment

d. Teases others
e. Blames others for their
troubles

No, this child needed but did not receive any medication
or behavioral treatment ➔ SKIP to question A21

f. Refuses to share
g. Takes things that do not
belong to them

No, this child did not need either medication or
behavioral treatment ➔ SKIP to question A21
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A23 Does this child CURRENTLY need or use medicine

prescribed by a doctor, other than vitamins?
Yes

A27 Does this child have any kind of emotional,

developmental, or behavioral problem for which
they need treatment or counseling?

No
Yes

If yes, is this child’s need for prescription
medicine because of ANY medical, behavioral, or
other health condition?
Yes

No

If yes, has their emotional, developmental, or
behavioral problem lasted or is it expected to last
12 months or longer?

No
Yes

No

If yes, is this a condition that has lasted or is
expected to last 12 months or longer?
Yes

No

B. Health Care Services

A24 Does this child need or use more medical care,

mental health, or educational services than is usual
for most children of the same age?
Yes

B1

No

If yes, is this child’s need for medical care, mental
health, or educational services because of ANY
medical, behavioral, or other health condition?
Yes

Yes
No ➔ SKIP to question B3

No

If yes, is this a condition that has lasted or is
expected to last 12 months or longer?
Yes

B2

No

A25 Is this child limited or prevented in any way in their

1 visit

No

2 or more visits

If yes, is this child’s limitation in abilities because
of ANY medical, behavioral, or other health
condition?
Yes

B3

No

If yes, is this a condition that has lasted or is
expected to last 12 months or longer?
Yes

No

No ➔ SKIP to question B6 on page 6

physical, occupational, or speech therapy?

B4

No

If yes, is this because of ANY medical, behavioral,
or other health condition?
Yes

If yes, did the questionnaire ask about your concerns
or observations about:
Mark (X) Yes or No for EACH item.
Yes

a. Words and phrases this child uses
and understands?

No

b. How this child behaves and gets
along with you and others?

If yes, is this a condition that has lasted or is
expected to last 12 months or longer?
Yes

SINCE MARCH 2020, has a doctor or other health care
provider had you or another caregiver fill out a
questionnaire about observations or concerns you may
have about this child’s development, communication,
or social behaviors?
Sometimes a child’s doctor or other health care provider
will ask a parent to do this at home or during a child’s visit.
Yes

A26 Does this child need or get special therapy, such as

Yes

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.
0 visits

ability to do the things most children of the same age
can do?
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

NSCH-LC1

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No

26213157

B5

What happened after you filled out the questionnaire?
Mark (X) Yes or No for EACH item.
Yes

B10 Has this child EVER had a special education or early

intervention plan?
Children receiving these services often have an Individualized
Family Service Plan (IFSP), Individualized Education Plan
(IEP), or 504 Plan.

No

a. The provider discussed the
questionnaire results with me
b. This child was referred for
evaluation for services to help with
concerns

Yes
No, but this child needed
a plan ➔ SKIP to question B13

c. The provider discussed ways to
support this child’s development
with me
B6

B7

No, this child did not need
a plan ➔ SKIP to question B13

Is there a place you or another caregiver USUALLY take B11 The COVID-19 pandemic began in March 2020. Did
this child when they are sick or you need advice about
this child have a special education or early
their health?
intervention plan DURING THE PANDEMIC?
Yes

Yes

No

No, but this child needed
a plan ➔ SKIP to question B13

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, this child did not need
a plan ➔ SKIP to question B13
B12 Did the pandemic affect this child’s special education

or early intervention services?

No preventive visits in the past 12 months

B8

Yes, 1 visit

Yes, this child received limited or inconsistent
services during the pandemic

Yes, 2 or more visits

Yes, this child did not receive any services during
the pandemic

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.

No
B13 SINCE MARCH 2020, has this child received speech

therapy?
Yes

Yes

No, but this child needed
speech therapy ➔ SKIP to question B15

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

No, this child did not need
speech therapy ➔ SKIP to question B15

No, this child did not need to see a mental health
professional ➔ SKIP to question B10

B14 SINCE MARCH 2020, has this child experienced any
B9

gaps or delays in receiving speech therapy?

How difficult was it to get the mental health treatment
or counseling that this child needed?

Yes

Not difficult

No

Somewhat difficult
Very difficult

B15 SINCE MARCH 2020, has this child received health

care related to the use of hearing devices such as
hearing aids or cochlear implants?

It was not possible to obtain care

Yes
No, but this child needed health care related to the use
of hearing devices ➔ SKIP to question B17 on page 7
No, this child did not need health care related to the use
of hearing devices ➔ SKIP to question B17 on page 7
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C. This Child’s Schooling
and Activities

B16 SINCE MARCH 2020, has this child experienced any

gaps or delays in receiving health care related to the
use of hearing devices?
Yes
C1

No
B17 SINCE MARCH 2020, has this child received

language instruction including sign language and/or
cued speech?

SINCE MARCH 2020, has this child EVER received care
for at least 10 hours per week from someone other
than their parent or guardian?
This could be a day care center, preschool, Head Start
program, family child care home, nanny, au pair,
babysitter, or relative.
Yes

Yes

No ➔ SKIP to question

No, but this child needed these types of
language instruction ➔ SKIP to question

B19

No, this child did not need these types of
language instruction ➔ SKIP to question

B19

C2

B18 SINCE MARCH 2020, has this child experienced any

gaps or delays in language instruction?
Yes
No

C5

SINCE MARCH 2020, have you or anyone else in your
family been able to make alternative child care
arrangements for this child when their regular day care
or other child care arrangement was closed or
unavailable?
Alternative arrangements mean that care was provided by a
different day care center, preschool, Head Start program,
family child care home, nanny, au pair, babysitter, or any
relative other than the child’s parent or guardian that is
different from the USUAL care arrangement.
Yes

B19 Is this child CURRENTLY covered by ANY kind of

No

health insurance or health coverage plan?
Yes

Alternative child care was not needed

No ➔ SKIP to question

C1

C3
B20 Is this child CURRENTLY covered by any of the

following types of health insurance or health coverage
plans?
Mark (X) Yes or No for EACH item.
Yes

Yes

No

No

a. Insurance through a current or
former employer or union
b. Insurance purchased directly from
an insurance company

SINCE MARCH 2020, has there ever been a time when
you were concerned about the quality of this child’s
regular or alternative child care arrangements?

C4

c. Medicaid, Medical Assistance, or
any kind of government assistance
plan for those with low incomes or a
disability

Does this child CURRENTLY receive care for at least
10 hours per week from someone other than their
parent or guardian?
This could be a day care center, preschool, Head Start
program, family child care home, nanny, au pair, babysitter
or relative.
Yes

d. TRICARE or other military health care

No

e. Indian Health Service
f. Other, specify:

C

C5

Has this child started school?
Include any formal home schooling.
Yes, preschool
Yes, kindergarten
Yes, first grade
No

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C6

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?

C11 How high can this child count?

This child cannot count
Up to five

Always

Up to ten

Most of the time

Up to 20

About half the time

Up to 50

Sometimes

Up to 100 or more

Never
C7

About how many letters of the alphabet can this child
recognize?

C12 How often can this child identify basic shapes such as

a triangle, circle, or square?
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
C8

C9

Can this child rhyme words?

C13 Can this child identify the colors red, yellow, blue, and

green by name?

Yes

Yes, all of them

No

Yes, some of them

How often can this child explain things they have
seen or done so that you get a very good idea what
happened?

No, none of them
C14 How often is this child easily distracted?

Always

Always

Most of the time

Most of the time

About half the time

About half the time

Sometimes

Sometimes

Never

Never

C10 How often can this child write their first name, even if

some of the letters aren’t quite right or are backwards? C15 How often does this child keep working at something
until they are finished?
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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C16 When this child is paying attention, how often can

they follow instructions to complete a simple task?

C21 When excited or all wound up, how often can this child

calm down quickly?

Always

Always

Most of the time

Most of the time

About half the time

About half the time

Sometimes

Sometimes

Never

Never

C17 How does this child usually hold a pencil?

C22 How often does this child lose control of their temper

when things do not go their way?

Uses fingers to hold the pencil
Always
Grips the pencil in their fist
Most of the time
This child cannot hold a pencil
About half the time
C18 How often does this child play well with others?

Sometimes

Always

Never

Most of the time
About half the time

C23 Compared to other children their age, how much

difficulty does this child have making or keeping friends?

Sometimes

No difficulty

Never

A little difficulty
A lot of difficulty

C19 How often does this child become angry or anxious

when going from one activity to another?
Always

C24 Compared to other children their age, how often is this

child able to sit still?

Most of the time

Always

About half the time

Most of the time

Sometimes

About half the time

Never

Sometimes
Never

C20 How often does this child show concern when others

are hurt or unhappy?
Always

C25 How often…
Always

Usually Sometimes

a. Is this child
affectionate and
tender with you?

Most of the time
About half the time

b. Does this child
bounce back quickly
when things do not
go their way?

Sometimes
Never

c. Does this child
show interest and
curiosity in learning
new things?
d. Does this child
smile and laugh?

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Never

26213116

D. About Your Family
and Household

D5

When your family faces problems, how often are you
likely to do each of the following?
All of
the time

D1 ON MOST WEEKDAYS, about how much time does

Most of
the time

Some of
the time

None of
the time

a. Talk together about
what to do

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

b. Work together to
solve our problems
c. Know we have
strengths to draw
on

1 hour or less
2-3 hours

d. Stay hopeful even
in difficult times

4-6 hours
7-8 hours

D6

More than 8 hours

SINCE MARCH 2020, how many times has this child
moved to a new address?
If none, write 0.

Don’t know

Number of times

D2 DURING THE PAST WEEK, how many days did you or

other family members read to this child?

D7

Is the house, apartment, or mobile home where you live...
Mark (X) ONE box.

0 days

Owned by you or someone in this household with a
mortgage or loan? Include home equity loans.

1-3 days

Owned by you or someone in this household free and
clear (without a mortgage or loan)?

4-6 days

Rented?

Every day

Occupied without payment of rent?

D3 DURING THE PAST WEEK, how many days did you or

other family members tell stories or sing songs to this
child?

D8

0 days

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

1-3 days

No

4-6 days
D9

Every day
D4 What is the primary language spoken in the

SINCE MARCH 2020, has this child 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.

household?

Yes
English
No
Spanish
Other language, specify:

D10 DURING THE PAST 12 MONTHS, how often has it been

very hard to cover the basics, like food or housing,
on your family’s income?

C

Never
Rarely
Somewhat often
Very often

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E. This Child’s Parents or
Caregivers

D11 Which of these statements best describes your

household’s ability to afford the food you need DURING
THE PAST 12 MONTHS?
We could always afford to eat good nutritious meals

Complete these questions for UP TO TWO ADULTS
who are this child’s parents or caregivers. Please only
include adults who are currently active in this child’s
life.

We could always afford enough to eat but not always
the kinds of food we should eat
Sometimes we could not afford enough to eat

About You

Often we could not afford enough to eat
E1
D12 At any time DURING THE PAST 12 MONTHS, even for

one month, did anyone in your family receive…
Mark (X) Yes or No for EACH item.
Yes

Biological or Adoptive Parent

No

Step-parent

a. Cash assistance from a government
welfare program?

Grandparent

b. Food Stamps or Supplemental
Nutrition Assistance Program
(SNAP) benefits?

Foster Parent
Other: Relative

c. Free or reduced-cost breakfasts or
lunches at school?

Other: Non-Relative

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

E2

What is your sex?
Male

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

Female

f. Unemployment Insurance (UI)?

E3

D13 The next questions are about events that may have

E4

Where were you born?
In the United States

To the best of your knowledge, has this child EVER
experienced any of the following?
Mark (X) Yes or No for EACH item.
Yes

What is your age?
Age in years

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. Parent or guardian divorced or
separated

How are you related to this child?

Outside of the United States
No
E5

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

b. Parent or guardian died
8th grade or less

c. Parent or guardian served time in
jail or prison

9th-12th grade; No diploma

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

High school graduate or GED completed

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

Some college credit, but no degree

Completed a vocational, trade, or business school
program

Associate Degree (AA, AS)

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

Bachelor’s Degree (BA, BS, AB)

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

Master’s Degree (MA, MS, MSW, MBA)
Doctorate (PhD, EdD) or Professional Degree (MD,
DDS, DVM, JD)

NSCH-LC1

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26213090

E6

What is your marital status?

E11 Does this child have another parent or caregiver who

is active in their life?

Married

Yes
Not married, but living with a partner
No ➔ SKIP to question F1 on page 14
Never married

Other Parent or Caregiver

Divorced
Separated

E12 How is this other parent or caregiver currently related

to you?
Mark (X) ONE box.

Widowed
E7

Spouse or partner

Has there been a change in your marital status SINCE
2018?

Ex-spouse or ex-partner
Yes
Parent (include adoptive or foster parent)
No
Grandparent
E8

In general, how is your physical health?

In-law (include parent or grandparent)

Excellent

Other: Relative

Very good

Other: Non-Relative

Good
E13 Does this parent or caregiver live with you?

Fair
Yes
Poor
No
E9

In general, how is your mental or emotional health?
E14 How is this parent or caregiver related to this child?

Excellent
Biological or Adoptive Parent
Very good
Step-parent
Good
Grandparent
Fair
Foster Parent
Poor
Other: Relative
E10 Which of the following best describes your current

Other: Non-Relative

employment status?
Mark (X) ONE box.

Employed full-time

E15 What is this parent or caregiver’s sex?

Male

Employed part-time

Female

Working without pay
Not employed but looking for work

E16 What is this parent or caregiver’s age?

Not employed and not looking for work

Age in years

Don’t know

Retired

NSCH-LC1

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E17 Where was this parent or caregiver born?

E21 In general, how is this parent or caregiver’s mental or

emotional health?

In the United States

Excellent
Outside of the United States
Very good
Don’t know
Good
E18 What is the highest grade or level of school this

Fair

parent or caregiver has completed?
Mark (X) ONE box.

Poor

8th grade or less

Don’t know

9th-12th grade; No diploma
High school graduate or GED completed

E22 Which of the following best describes this parent or

caregiver’s current employment status?
Mark (X) ONE box.

Completed a vocational, trade, or business school
program

Employed full-time

Some college credit, but no degree

Employed part-time

Associate Degree (AA, AS)

Working without pay

Bachelor’s Degree (BA, BS, AB)

Not employed but looking for work

Master’s Degree (MA, MS, MSW, MBA)

Not employed and not looking for work

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

Retired

Don’t know

Don’t know

E19 What is this parent or caregiver’s marital status?

Married
Not married, but living with a partner
Never married
Divorced
Separated
Widowed
Don’t know
E20 In general, how is this parent or caregiver’s physical

health?

Excellent
Very good
Good
Fair
Poor
Don’t know

NSCH-LC1

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26213074

F. COVID-19 Pandemic

F6

Yes

The questions in this section ask about this child’s and
your family’s experiences during the COVID-19
pandemic, which began in March 2020.
F1

Has this child ever tested positive for COVID-19 or
been told by a doctor or other health care provider
they had COVID-19?

No ➔ SKIP to question
F7

Yes

F8

Which of the following best describes the vaccine
doses this child received?
A primary vaccine series includes the initial number of
recommended doses, which may differ by vaccine type.
All doses of a primary series and at least one booster

No ➔ SKIP to question
F2

Has this child received a COVID-19 vaccine?

All doses of a primary series but no boosters

F6

If yes, how many times has this child tested positive
for COVID-19 or been told by a doctor or other health
care provider that they had COVID-19?

Some but not all doses of a primary series
F8

Number of times

Have you ever tested positive for COVID-19 or been
told by a doctor or other health care provider you had
COVID-19?
Yes

F3

How long did this child’s COVID-19 symptoms last?
If this child has had multiple COVID-19 infections, report
about the time when the symptoms lasted the longest.
Symptoms can include fever, fatigue, cough, difficulty
breathing, brain fog, headache, problems sleeping, fast
heartbeat, or loss of smell.
This child did not experience
any symptoms ➔ SKIP to question

No ➔ SKIP to question
F9

F6

Less than 1 month

Less than 1 month

3-5 months

1-2 months

6-12 months

3-5 months

More than 12 months

F5

Has a doctor or other health care provider EVER told
you that this child had long COVID?
Long COVID is also referred to as post-COVID conditions,
post-acute COVID-19, or long-term effects of COVID-19.

How long did your COVID-19 symptoms last?
If you have had multiple COVID-19 infections, report about
the time when the symptoms lasted the longest. Symptoms
can include fever, fatigue, cough, difficulty breathing, brain
fog, headache, problems sleeping, fast heartbeat, or loss of
smell.
I did not experience any symptoms

1-2 months

F4

6-12 months
More than 12 months
F10 Have you received a COVID-19 vaccine?

Yes

Yes

No

No ➔ SKIP to question

Has this child EVER been hospitalized for a COVID-19
infection or because of complications from a
COVID-19 infection?

F10

F12

on page 15

F11 Which of the following best describes the vaccine

doses you received?
A primary vaccine series includes the initial number of
recommended doses, which may differ by vaccine type.

Yes
All doses of a primary series and at least one booster
No
All doses of a primary series but no boosters
Some but not all doses of a primary series

NSCH-LC1

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26213066
F12 Answer questions F12 to F15 if this child has

F17

another parent or caregiver who is active in the
child’s life. Otherwise, SKIP to question F16 .

Yes

Has this child’s other parent or caregiver ever tested
positive for COVID-19 or been told by a doctor or
other health care provider they had COVID-19?
Yes
No ➔ SKIP to question

No
F18

F14

Don’t know ➔ SKIP to question

DURING THE PANDEMIC, did this child’s behavior
EVER leave you concerned about their mental or
emotional health?
Yes

F14

No ➔ SKIP to question

F13 How long did this other parent or caregiver’s

symptoms last?
If they have had multiple COVID-19 infections, report about
the time when the symptoms lasted the longest. Symptoms
can include fever, fatigue, cough, difficulty breathing, brain
fog, headache, problems sleeping, fast heartbeat, or loss of
smell

Did any of this child’s parents or caregivers die from
a COVID-19 infection or because of complications from
a COVID-19 infection?

F19

F20

If yes, did this child seem to...
Mark (X) Yes or No for EACH item.

b. Feel depressed?

Less than 1 month

c. Struggle with eating?

1-2 months

d. Struggle to stay focused?

3-5 months

e. Show unusual anger or outbursts?
F20

More than 12 months
Don’t know

DURING THE PANDEMIC, did this child receive any
treatment or counseling from a mental health
professional?
Mental health professionals include psychiatrists,
psychologists, psychiatric nurses, and clinical social workers.
Yes

F14 Has this other parent or caregiver received a COVID-19

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

vaccine?
Yes

No ➔ SKIP to question

No

a. Feel anxious?

This other parent or caregiver did not experience any
symptoms

6-12 months

Yes

No, this child did not need to see a mental health
professional ➔ SKIP to question F22
F16

Don’t know ➔ SKIP to question

F21
F16

How difficult was it to get the mental health treatment
or counseling that this child needed?
Not difficult

F15 Which of the following best describes the vaccine

doses this other parent or caregiver received?
A primary vaccine series includes the initial number of
recommended doses, which may differ by vaccine type.

Somewhat difficult
Very difficult

All doses of a primary series and at least one booster
It was not possible to obtain care
All doses of a primary series but no boosters
Some but not all doses of a primary series

F22

Don’t know
F16 Have you or another parent or caregiver EVER been

hospitalized for a COVID-19 infection or because of
complications from a COVID-19 infection?

DURING THE PANDEMIC, was there any time when
health care for this child was not received or was
delayed by at least three months?
By health care, we mean medical care as well as other
kinds of care like dental care, vision care, and mental
health services.
Yes
No ➔ SKIP to question F25 on page 16

Yes
No
NSCH-LC1

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26213058
F23 Did any of the following reasons contribute to this child F28

not receiving or delaying needed health services
DURING THE PANDEMIC?
Mark (X) Yes or No for EACH item.
Yes

No

DURING THE PANDEMIC, was your mental or emotional
health better, worse, or about the same as it was before
the pandemic began?
Better ➔ SKIP to question

a. There were problems getting an
appointment when this child needed
one

F30

About the same ➔ SKIP to question

b. The clinic or doctor’s office wasn’t
open when this child needed care

F30

Worse

c. There were concerns about
exposure to COVID-19 by going to
the clinic or doctor’s office

F29 Please indicate how true the following statements are

about your mental or emotional health DURING THE
PANDEMIC.

d. This child or someone in this child’s
household had COVID-19 or was
exposed to COVID-19

a. I experienced an increase
in feeling nervous, anxious, on
edge, or worried

F24 Which of the following statements best describes how

Not
true

Somewhat Very
true
true

b. I experienced an increase in
feeling down, depressed, or
hopeless

this child’s health was impacted by not receiving or
delaying health care DURING THE PANDEMIC?
There was no impact on this child’s health

F30

There was mild or minimal impact on this child’s health
There was moderate impact on this child’s health

DURING THE PANDEMIC, did you or another parent or
caregiver EVER experience any of the following changes
in employment?
Mark (X) Yes or No for EACH item.
Yes

There was significant or severe impact on this child’s
health

No

a. Shift to remote work/telework
b. Decreased hours

F25 DURING THE PANDEMIC, was this child covered by

ANY kind of health insurance or health coverage plan?

c. Decreased pay

Yes, this child was covered during the entire pandemic

d. Furloughed (temporary job loss)

Yes, but this child had a gap in coverage during the
pandemic

e. Loss of job

No

f. Decreased job security
g. Increased hours

F26 DURING THE PANDEMIC, how well do you think you

handled the day-to-day demands of parenting or raising
children?

h. Left workforce

Very well
F31

Somewhat well
Not very well
Not well at all

DURING THE PANDEMIC, were you or another parent or
caregiver EVER considered an essential worker?
Essential workers are those workers who provide services or
conduct operations deemed essential to the ongoing critical
functions in the community, including work related to health
care, infrastructure, food, and other essential products.
Yes

F27 DURING THE PANDEMIC, how often did the following

happen?

a. Parents or caregivers insulted,
swore, shouted, or yelled at
each other

Not at
all

A few
times
a week

Very
often

No
F32

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

b. Parents or caregivers said mean
things, shouted, yelled, or
screamed at this child

No

c. Parents or caregivers were not
able to pay attention to this
child’s needs
NSCH-LC1

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§;6?[¤

26213041

G. Household Information

F33 DURING THE PANDEMIC, was your family evicted from

your home or was your home foreclosed on?
A landlord not renewing the lease should not be counted as
an eviction.

G1 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.

Yes
No

F34

DURING THE PANDEMIC, how often was it very hard
to cover the basics, like food or housing, on your family’s
income?

Number of people

G2 How many of these people in your household are family

Never

members?
Family is defined as anyone related to this child by blood,
marriage, adoption, or through foster care.

Rarely
Somewhat often

Number of people

Very often
G3 How many children 0-17 years old usually live or stay at

this address?

F35 Which of these statements best describes your

household’s ability to afford the food you needed
DURING THE PANDEMIC?
We could always afford to eat good
nutritious meals ➔ SKIP to question

Number of children living or staying at this address

G1

We could always afford enough to eat but not always
the kinds of food we should eat
Sometimes we could not afford enough to eat
Often we could not afford enough to eat
F36 How long did your household experience difficulty

affording the food you needed DURING THE PANDEMIC?
Less than 1 month
1 month
2-3 months
4-6 months
More than 6 months

NSCH-LC1

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§;6?J¤

26213033

H. Contact Information

G4 Income in 2022.

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.

You have reached the end of the survey. In case we
have additional follow-up questions about this child in
the future, we would like to get some information to
help us contact you. This information, like your
responses to all questions in the survey, is confidential
and voluntary.

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

$

,

.00

,

H1

TOTAL AMOUNT in 2022

No

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

$

,

.00

,

Please provide your name and contact information.
We will only contact you if needed for official
Census Bureau business.
First Name

Loss

Last Name

TOTAL AMOUNT in 2022

No

Street

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

$

,

.00

,

Loss

Apt.

City

State

ZIP

TOTAL AMOUNT in 2022

No

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

$

,

Phone

–

.00

,

TOTAL AMOUNT in 2022

No

–

Email Address

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

$

,

.00

,

TOTAL AMOUNT in 2022

No

f. Any other sources of income received regularly
such as Veterans’ (VA) payments, unemployment
compensation, child support, or alimony.
Yes ➔

$

,

.00

,

TOTAL AMOUNT in 2022

No

G5 The following question is about your 2022 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 business, farm or rent, and any
other money income received.

$

,

,

.00

Loss

TOTAL AMOUNT in 2022
NSCH-LC1

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26213025
H2 In case we have difficulty getting in touch with you in

the future, what is the name, address, and phone
number of one person who will always know your
whereabouts?
Providing this information is voluntary.

First Name

Last Name

Street

Apt.

City

State

ZIP

Phone

–

–

Email Address

NSCH-LC1

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26213017

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 and young adults 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 second part of the National Survey of Children’s Health-Longitudinal Cohort will take
40 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 [email protected]; use "Paperwork Project
0607-####" as the subject. This collection has been approved by the Office of Management and Budget (OMB). The eightdigit 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-LC1

20

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The U.S. 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.
Under the Privacy Act of 1974 (5 U.S.C. Section 552a), these records are maintained by the Census Bureau under SORN
COMMERCE/CENSUS-3, Demographic Survey Collection (Census Bureau Sampling Frame). 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.
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-LC2_3

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26223198

Start Here
Recently, someone in your household completed a
short survey that asked about children and/or young
adults ages 3 to 24.

NOTE: Answer BOTH question 6 about Hispanic origin
and question 7 about race. For this survey, Hispanic
origins are not races.
6

Is this child of Hispanic, Latino, or Spanish origin?

Thank you for taking the time to respond.

No, not of Hispanic, Latino, or Spanish origin

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

Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban

This survey should be completed by a parent or
caregiver. If the child listed above does not correspond
to a child for whom you or another adult in your
household are a parent or caregiver, please call
1-877-749-4943 for assistance.

Yes, another Hispanic, Latino, or Spanish origin
7

What is this child’s race?
Mark (X) one or more boxes.
White

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

Black or African American
American Indian or Alaska Native

Your participation is important. Thank you.

Asian Indian

1

Chinese

Are you a parent or caregiver who is CURRENTLY
familiar with this child’s health?

Filipino

Yes ➔ SKIP to question 3

Japanese

No

Korean

This child is deceased ➔ You do not need to complete
this questionnaire. Please mark this response option
and RETURN THIS QUESTIONNAIRE IN THE
ENVELOPE PROVIDED.
2

3

Vietnamese
Other Asian

If no, is there another parent or caregiver in this household
who is CURRENTLY familiar with this child’s health?

Native Hawaiian

Yes ➔ Please have this other parent or caregiver
complete the rest of the survey.

Chamorro

No ➔ You do not need to complete this questionnaire.
Please mark "No" and RETURN THIS
QUESTIONNAIRE IN THE ENVELOPE PROVIDED.

Samoan

What is this child’s full name?
First

Other Pacific Islander
8

Where does this child live AT LEAST HALF OF THE TIME?
Mark (X) ALL that apply.
With me

Last

With another parent or caregiver at another address
Campus/dorm room

4

In what month and year was this child born?
Birth Month / 4-Digit Birth Year

/

Institutional setting (such as congregate care,
residential treatment, group home, penal facility)
Somewhere else with roommates

2 0

Somewhere else on their own
5

What is this child’s sex?
Other, specify:

Male

C

Female
NSCH-LC2_3

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