3c MCH-JS Survey_2024_FSM_Pohnpeian

MCH Jurisdictional Survey Instrument

FSM-Pohnpeian

OMB Control number: 0906-0042; Expiration date: XX/XX/2028

1. ^{[Screener (PROGRAMMER: Add Timestamp)]}

1. Mie seri nanpwungen sounpahr 0-17 me kin iahng koausoahn wasaht?

1. ☐ SOH [IF NO, STOP HERE. THIS IS THE END OF THE SURVEY]

2. ☐ EHI

2. Seri depeh nan pwungen sounpwar 0-17 kin iahng koahusoahn meh?

TOHTOAN SERI ME KIN KOHUSOAN WASAHT

3. Kumwail kin mahsen en iah?

1. ☐ LOKAIAN WAI

2. ☐ LOKAIAN SIPEIN

3. ☐ MEHN CHUUK

4. ☐ MEHN KUSAI (KOSRAE)

5. ☐ MEHN POHNPEI

6. ☐ MEHN YAP

7. ☐ LOKAIAN EHU WASA, MENLAU KASELEIONG KIHT:

Sapeng kalelepak pwukat pid seri nan pwungen 0-17 me kin kousahn wasaht.

Tehpikida seri me kehieu tihkitik, me se pahn kadahniki "Seri 1", oh pouhsehlateh sahpehngalah kahlelehpehk kan en seri me kin iahng mih nan ihmwet.

4. SERI 1

Iah ehden seri et, ia ah initals, de ahd kahmwan?

5. Serieh men iah? PILADA KOAROS ME PWUNG

Seri menet...

Mehn Hispanic de Latino?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet mehn Hispanic de Latino. Seri menet...?

☐ MEHN MEXICO

☐ MEHN PUERTO RICO

☐ MEHN SALVADOR

☐ MEHN CUBA

☐ MEHN DOMINICAN

☐ MEHN GUATEMALA

☐ Mehn Pil Ehu Hispanic de Latino. Menlau kaselehda ia mwomwen seri menet mehn pil ehu Hispanic de Latino. Ni karasepe, mehn Colombia, mehn Hondura, mehn Spaniard, wasa teikan.

PWILIDAK EN HAWAII DE DEKEHN PACIFIC KAN?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet mehn Hawaii de deken Pacific. Seri menet...?

☐ PWILIDAK EN HAWAII

☐ MEHN TONGA

☐ MEHN SAMOA

☐ MEHN FIJI

☐ MEHN GUAM

☐ MEHN CHAMORRO

☐ MEHN MWASEL (MARSHALLESE)

☐ [DO NOT DISPLAY IN NP] MEHN SAIPAN

☐ MEHN MWOATLOAK

☐ MEHN KUSAI (KOSRAE)

☐ MEHN CAROLINA

☐ MEHN PALAU

☐ MEHN POHNPEI

☐ MEHN YAP

☐ MEHN CHUUK

☐ PWILIDAK EN HAWAII DE DEKEHN PACIFIC KAN. Menlau kaselehda ia mwomwen seri menet mehn Hawaii de deken Pacific. Ni karasepe, mehn Tahiti, wasa teikan.

MEHN AMERICAN INDIAN DE PWILIDAK EN ALASKA?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet MEHN AMERICAN INDIAN DE PWILIDAK EN ALASKA. Ni karasepe, mehn Navajo Nation, keinek en Blackfeet Tribe of the Blackfeet Indian Reservation en

Montana, Pwilidak en Barrow Inupiat Traditional Government, pwihn en Nome Eskiko Coummunity, mehn Aztec, mehn Maya, wasa teikan.

Community, Aztec, Maya, etc.

Mehn Asia?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet Asia. Serieh men iah?

☐ MEHN CHINA

☐ ASIAN INDIAN

☐ MEHN PILIPIHN

☐ MEHN VIETNAM

☐ MEHN KOREA

☐ MEHN SAPAN

☐ MEHN ASIAN TEIKAN. Menlau kaselehda ia mwomwen seri menet mehn Asia. Ni karasepe, mehn Pakistani, mehn Hmong, mehn Aghan, wasa teikan.

ARAMAS TOANTOAL DE MEHN AFRICAN AMERICAN?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet TOHNTOAL DE MEHN AFRICAN AMERICAN. Serieh men iah?

☐ MEHN AFRICAN AMERICAN

☐ MEHN JAMAICA

☐ MEHN HAITI

☐ MEHN NIGERIA

☐ MEHN ETHIOPIA

☐ Mehn Somali

☐ ARAMAS TOANTOAL DE MEHN AFRICAN AMERICAN. Menlau kaselehda ia mwomwen seri menet TOHNTOAL DE MEHN AFRICAN AMERICAN. Ni karasepe, mehn Trinidad oh mehn Tobagonia, Ghana, Congo, wasa teikan.

MEHN MIDDLE EAST DE NORTH APERIKA?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet MEHN MIDDLE EAST DE NORTH APERIKA. Seri menet...?

☐ MEHN LEBANON

☐ MEHN IRAN

☐ MEHN ISIP

☐ MEHN SYRIA

☐ MEHN IRAQ

☐ MEHN ISRAEL

☐ MEHN MIDDLE EAST DE NORTH APERIKA? Menlau kaselehda ia mwomwen seri menet MEHN MIDDLE EAST DE NORTH APERIKA. Ni karasepe, mehn Moroccan, mehn Yemeni, mehn Kurdish, wasa teikan.

Aramas pwetepwet?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet aramas pwetepwet. Seri menet...?

☐ MEHN ENGLAND

☐ MEHN SEMEN

☐ MEHN IRELAND

☐ MEHN ITALI

☐ MEHN POLAND

☐ MEHN SCOTLAND

☐ Aramas Pwetepwet Teikan. Menlau kaselehda ia mwomwen seri menet aramas pwetepwet. Ni karasepe, mehn French, mehn Sweden, mehn Norweig, wasa teikan.

6. Seri dah?

1. ☐ PWUTAK

2. ☐ SEREPEIN

7. Sounpar depe seri et? Ma seri et tihkitik sang sounpohng ehu 1, pilada sounpar 1.

SOUNPAR (DE) SOUNPWOHNG

MA SERI ET TIKITIK SANG SOUNPAR 4, DOULA KALELEPAK A10.

8. Uwen koaiehk en seri et ah lokaian Sipein?

1. ☐ Uhdahn mwahu

2. ☐ Mwahu

3. ☐ Sohte mwahu

4. ☐ Uhdahn sohte mwahu

9. Seri et kin kohwa de anahne kahng wini en sohumwau sahng rehn ah toahkteh me koasoandih, likin pihdamihn?

1. ☐ EHI

2. ☐ SOH [GO TO A11]

[IF YES] seri et kin kang wini kat pwehki eh kin soumwahu en paliwar de sahliel?

1. ☐ EHI

2. ☐ SOH [GO TO A11]

[IF YES] soumwahu wet lelehr de pahn doulahng sounpwong 12?

1. ☐ EHI

2. ☐ SOH

10. Seri menet anane pil ekei sawas, duehte sawas en me soumwahu, de soumwau en nan moang, de kasikul en sawasakan laudsahng iehnge kan?

1. ☐ EHI

2. ☐ SOH [GO TO A12]

[IF YES]Seri menet anane sawas en me soumwahu, soumwahu en nan moahng, de kasikul en sawasakan pweki mie soangen kapwal pwukat?

1. ☐ EHI

2. ☐ SOH [GO TO A12]

[IF YES] soumwahu wet lelehr de pahn doulahng sounpwong 12?

1. ☐ EHI

2. ☐ SOH

11. Mie en seri et ah ihrahirdi de sohkoaihek en wia soangkan me iehnge kan wiewiah?

1. ☐ EHI

2. ☐ SOH [GO TO A13]

[IF YES] Ihrair sohkoaiek en seri menet, pweki kohwah sohmwau, de sohkoaiek en mohkid, de mie ihre toroar teikan?

1. ☐ EHI

2. ☐ SOH [GO TO A13]

[IF YES] soumwahu wet lelehr de pahn doulahng sounpwong 12?

1. ☐ EHI

2. ☐ SOH

12. Seri menet anane sawas toroar me pid, sawas en paliwahr duhete, ehlihel, de kasuhkuhl en lokaiah?

1. ☐ EHI

2. ☐ SOH [GO TO A14]

[IF YES] Met pweki mie soumwahu, de tihahk me wehkilah, de oahnoapwek tehikan?

1. ☐ EHI

2. ☐ SOH [GO TO A14]

[IF YES] soumwahu wet lelehr de pahn doulahng sounpwong 12?

1. ☐ EHI

2. ☐ SOH

13. Mie en seri wet ah apwal en madamadau de wiewia me kahrehda e anahne sawas en wini de kahweid.

1. ☐ EHI

2. ☐ SOH [GO TO A15]

[IF YES] apwal en paliwar de madamadau wet pahn doulahng sounpwong 12 de laud sang?

1. ☐ EHI

2. ☐ SOH

MA MIE PIL EMEN NAH SERI, DOULAHNG A15. DOULAHNG PALI B

14. Seri 2

Iah ehden seri et, ia ah initals, de ahd kahmwan?

15. Serieh men iah? PILADA KOAROS ME PWUNG

Seri menet...

Mehn Hispanic de Latino?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet mehn Hispanic de Latino. Seri menet...?

☐ MEHN MEXICO

☐ MEHN PUERTO RICO

☐ MEHN SALVADOR

☐ MEHN CUBA

☐ MEHN DOMINICAN

☐ MEHN GUATEMALA

☐ Mehn Pil Ehu Hispanic de Latino. Menlau kaselehda ia mwomwen seri menet mehn pil ehu Hispanic de Latino. Ni karasepe, mehn Colombia, mehn Hondura, mehn Spaniard, wasa teikan.

PWILIDAK EN HAWAII DE DEKEHN PACIFIC KAN?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet mehn Hawaii de deken Pacific. Seri menet...?

☐ PWILIDAK EN HAWAII

☐ MEHN TONGA

☐ MEHN SAMOA

☐ MEHN FIJI

☐ MEHN GUAM

☐ MEHN CHAMORRO

☐ MEHN MWASEL (MARSHALLESE)

☐ [DO NOT DISPLAY IN NP] MEHN SAIPAN

☐ MEHN MWOATLOAK

☐ MEHN KUSAI (KOSRAE)

☐ MEHN CAROLINA

☐ MEHN PALAU

☐ MEHN POHNPEI

☐ MEHN YAP

☐ MEHN CHUUK

☐ PWILIDAK EN HAWAII DE DEKEHN PACIFIC KAN. Menlau kaselehda ia mwomwen seri menet mehn Hawaii de deken Pacific. Ni karasepe, mehn Tahiti, wasa teikan.

MEHN AMERICAN INDIAN DE PWILIDAK EN ALASKA?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet MEHN AMERICAN INDIAN DE PWILIDAK EN ALASKA. Ni karasepe, mehn Navajo Nation, keinek en Blackfeet Tribe of the Blackfeet Indian Reservation en

Montana, Pwilidak en Barrow Inupiat Traditional Government, pwihn en Nome Eskiko Coummunity, mehn Aztec, mehn Maya, wasa teikan.

Community, Aztec, Maya, etc.

Mehn Asia?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet Asia. Serieh men iah?

☐ MEHN CHINA

☐ ASIAN INDIAN

☐ MEHN PILIPIHN

☐ MEHN VIETNAM

☐ MEHN KOREA

☐ MEHN SAPAN

☐ MEHN ASIAN TEIKAN. Menlau kaselehda ia mwomwen seri menet mehn Asia. Ni karasepe, mehn Pakistani, mehn Hmong, mehn Aghan, wasa teikan.

ARAMAS TOANTOAL DE MEHN AFRICAN AMERICAN?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet TOHNTOAL DE MEHN AFRICAN AMERICAN. Serieh men iah?

☐ MEHN AFRICAN AMERICAN

☐ MEHN JAMAICA

☐ MEHN HAITI

☐ MEHN NIGERIA

☐ MEHN ETHIOPIA

☐ Mehn Somali

☐ ARAMAS TOANTOAL DE MEHN AFRICAN AMERICAN. Menlau kaselehda ia mwomwen seri menet TOHNTOAL DE MEHN AFRICAN AMERICAN. Ni karasepe, mehn Trinidad oh mehn Tobagonia, Ghana, Congo, wasa teikan.

MEHN MIDDLE EAST DE NORTH APERIKA?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet MEHN MIDDLE EAST DE NORTH APERIKA. Seri menet...?

☐ MEHN LEBANON

☐ MEHN IRAN

☐ MEHN ISIP

☐ MEHN SYRIA

☐ MEHN IRAQ

☐ MEHN ISRAEL

☐ MEHN MIDDLE EAST DE NORTH APERIKA? Menlau kaselehda ia mwomwen seri menet MEHN MIDDLE EAST DE NORTH APERIKA. Ni karasepe, mehn Moroccan, mehn Yemeni, mehn Kurdish, wasa teikan.

Aramas pwetepwet?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet aramas pwetepwet. Seri menet...?

☐ MEHN ENGLAND

☐ MEHN SEMEN

☐ MEHN IRELAND

☐ MEHN ITALI

☐ MEHN POLAND

☐ MEHN SCOTLAND

☐ Aramas Pwetepwet Teikan. Menlau kaselehda ia mwomwen seri menet aramas pwetepwet. Ni karasepe, mehn French, mehn Sweden, mehn Norweig, wasa teikan.

16. Seri dah?

1. ☐ PWUTAK

1. ☐ SEREPEIN

17. Sounpar depe seri et? Ma seri et tihkitik sang sounpohng ehu 1, pilada sounpar 1.

SOUNPAR (DE) SOUNPWOHNG

MA SERI ET TIKITIK SANG SOUNPAR 4, DOULA KALELEPAK A21.

18. Uwen koaiehk en seri et ah lokaian Wai?

1. ☐ Uhdahn mwahu

1. ☐ Mwahu

2. ☐ Sohte mwahu

3. ☐ Uhdahn sohte mwahu

19. Seri et kin kang wini me tohnwini men kihong ansou wet, mehnda paidamin kan?

1. ☐ EHI

2. ☐ SOH [GO TO A22]

[IF YES] seri et kin kang wini kat pwehki eh kin soumwahu en paliwar de sahliel?

1. ☐ EHI

2. ☐ SOH [GO TO A22]

[IF YES] soumwahu wet lelehr de pahn doulahng sounpwong 12?

1. ☐ EHI

2. ☐ SOH

20. Seri menet anane sawas en me soumwahu, soumwahu en nan moang, de kasikul en sawasakan sang iehngekan?

1. ☐ EHI

2. ☐ SOH [GO TO A23]

[IF YES]Seri menet anane sawas en me soumwahu, soumwahu en nan moahng, de kasikul en sawasakan pweki mie soangen kapwal pwukat?

1. ☐ EHI

2. ☐ SOH [GO TO A23]

[IF YES] soumwahu wet lelehr de pahn doulahng sounpwong 12?

1. ☐ EHI

2. ☐ SOH

21. Ehn seriet eh ihrahrihdi de sohkoaiek en mwoakid kin kahreiong en apwaliki wia soangkan me iehnge kan wiewia?

1. ☐ EHI

2. ☐ SOH [GO TO A24]

[IF YES] Ihrair sohkoaiek en seri menet, pweki kohwah sohmwau, de sohkoaiek en mohkid, de mie ihre toroar teikan?

1. ☐ EHI

2. ☐ SOH [GO TO A24]

[IF YES] soumwahu wet lelehr de pahn doulahng sounpwong 12?

1. ☐ EHI

2. ☐ SOH

22. Seri wet anahne sawas tohrohr pid paliwere, uwen koaiehk kan, de kasikul en mwomwen eh koasoia?

1. ☐ EHI

2. ☐ SOH [GO TO A25]

[IF YES] pwehki mie soang en somwahu de apwal en paliwar, wiewia, de madamadau?

1. ☐ EHI

2. ☐ SOH [GO TO A25]

[IF YES] soumwahu wet lelehr de pahn doulahng sounpwong 12?

1. ☐ EHI

1. ☐ SOH

23. Mie en seri wet ah apwal en madamadau de wiewia me kahrehda eh ale sawas sang tohnwini?

1. ☐ EHI

2. ☐ SOH [GO TO A26]

[IF YES] apwal en paliwar de madamadau wet pahn doulahng sounpwong 12 de laud sang?

1. ☐ EHI

2. ☐ SOH

Ma mie pil emen nah seri, doulahng A26. DOULAHNG PALI B

24. Seri 3

Iah ehden seri et, ia ah initals, de ahd kahmwan?

25. Serieh men iah? PILADA KOAROS ME PWUNG

Seri menet...

Mehn Hispanic de Latino?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet mehn Hispanic de Latino. Seri menet...?

☐ MEHN MEXICO

☐ MEHN PUERTO RICO

☐ MEHN SALVADOR

☐ MEHN CUBA

☐ MEHN DOMINICAN

☐ MEHN GUATEMALA

☐ Mehn Pil Ehu Hispanic de Latino. Menlau kaselehda ia mwomwen seri menet mehn pil ehu Hispanic de Latino. Ni karasepe, mehn Colombia, mehn Hondura, mehn Spaniard, wasa teikan.

PWILIDAK EN HAWAII DE DEKEHN PACIFIC KAN?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet mehn Hawaii de deken Pacific. Seri menet...?

☐ PWILIDAK EN HAWAII

☐ MEHN TONGA

☐ MEHN SAMOA

☐ MEHN FIJI

☐ MEHN GUAM

☐ MEHN CHAMORRO

☐ MEHN MWASEL (MARSHALLESE)

☐ [DO NOT DISPLAY IN NP] MEHN SAIPAN

☐ MEHN MWOATLOAK

☐ MEHN KUSAI (KOSRAE)

☐ MEHN CAROLINA

☐ MEHN PALAU

☐ MEHN POHNPEI

☐ MEHN YAP

☐ MEHN CHUUK

☐ PWILIDAK EN HAWAII DE DEKEHN PACIFIC KAN. Menlau kaselehda ia mwomwen seri menet mehn Hawaii de deken Pacific. Ni karasepe, mehn Tahiti, wasa teikan.

MEHN AMERICAN INDIAN DE PWILIDAK EN ALASKA?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet MEHN AMERICAN INDIAN DE PWILIDAK EN ALASKA. Ni karasepe, mehn Navajo Nation, keinek en Blackfeet Tribe of the Blackfeet Indian Reservation en

Montana, Pwilidak en Barrow Inupiat Traditional Government, pwihn en Nome Eskiko Coummunity, mehn Aztec, mehn Maya, wasa teikan.

Community, Aztec, Maya, etc.

Mehn Asia?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet Asia. Serieh men iah?

☐ MEHN CHINA

☐ ASIAN INDIAN

☐ MEHN PILIPIHN

☐ MEHN VIETNAM

☐ MEHN KOREA

☐ MEHN SAPAN

☐ MEHN ASIAN TEIKAN. Menlau kaselehda ia mwomwen seri menet mehn Asia. Ni karasepe, mehn Pakistani, mehn Hmong, mehn Aghan, wasa teikan.

ARAMAS TOANTOAL DE MEHN AFRICAN AMERICAN?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet TOHNTOAL DE MEHN AFRICAN AMERICAN. Serieh men iah?

☐ MEHN AFRICAN AMERICAN

☐ MEHN JAMAICA

☐ MEHN HAITI

☐ MEHN NIGERIA

☐ MEHN ETHIOPIA

☐ Mehn Somali

☐ ARAMAS TOANTOAL DE MEHN AFRICAN AMERICAN. Menlau kaselehda ia mwomwen seri menet TOHNTOAL DE MEHN AFRICAN AMERICAN. Ni karasepe, mehn Trinidad oh mehn Tobagonia, Ghana, Congo, wasa teikan.

MEHN MIDDLE EAST DE NORTH APERIKA?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet MEHN MIDDLE EAST DE NORTH APERIKA. Seri menet...?

☐ MEHN LEBANON

☐ MEHN IRAN

☐ MEHN ISIP

☐ MEHN SYRIA

☐ MEHN IRAQ

☐ MEHN ISRAEL

☐ MEHN MIDDLE EAST DE NORTH APERIKA? Menlau kaselehda ia mwomwen seri menet MEHN MIDDLE EAST DE NORTH APERIKA. Ni karasepe, mehn Moroccan, mehn Yemeni, mehn Kurdish, wasa teikan.

Aramas pwetepwet?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet aramas pwetepwet. Seri menet...?

☐ MEHN ENGLAND

☐ MEHN SEMEN

☐ MEHN IRELAND

☐ MEHN ITALI

☐ MEHN POLAND

☐ MEHN SCOTLAND

☐ Aramas Pwetepwet Teikan. Menlau kaselehda ia mwomwen seri menet aramas pwetepwet. Ni karasepe, mehn French, mehn Sweden, mehn Norweig, wasa teikan.

26. Seri dah?

1. ☐ PWUTAK

2. ☐ SEREPEIN

27. Sounpar depe seri et? Ma seri et tihkitik sang sounpohng ehu, pilada sounpar 1.

SOUNPAR (DE) SOUNPWOHNG

MA SERI ET TIKITIK SANG SOUNPAR 4, DOULA KALELEPAK A32.

28. Uwen koaiehk en seri et ah lokaian Wai?

1. ☐ Uhdahn mwahu

2. ☐ Mwahu

3. ☐ Sohte mwahu

4. ☐ Uhdahn sohte mwahu

29. Seri menet kin mi pahn ehpwelpehn toahkte oh kin kahngkan wini ansou koarous, apw kaiden paidamin?

1. ☐ EHI

2. ☐ SOH [GO TO A33]

[IF YES] seri et kin kang wini kat pwehki eh kin soumwahu en paliwar de sahliel?

1. ☐ EHI

2. ☐ SOH [GO TO A33]

[IF YES] soumwahu wet lelehr de pahn doulahng sounpwong 12?

1. ☐ EHI

1. ☐ SOH

30. Seri menet anane de kin doadoangki laudsahng iehngekan soang duehte, sawas en soumwahu, sawas en moang, de kasikul en sawasakan?

1. ☐ EHI

2. ☐ SOH [GO TO A34]

[IF YES]Seri menet anane sawas en me soumwahu, soumwahu en nan moahng, de kasikul en sawasakan pweki mie soangen kapwal pwukat?

1. ☐ EHI

2. ☐ SOH [GO TO A34]

[IF YES] soumwahu wet lelehr de pahn doulahng sounpwong 12?

1. ☐ EHI

1. ☐ SOH

31. Seri menet ah ihrahir en soakoihek de somwokid kareiong en sohte kakong wia de werekiong iehnge kan?

1. ☐ EHI

2. ☐ SOH [GO TO A35]

[IF YES] Ihrair sohkoaiek en seri menet, pweki kohwah sohmwau, de sohkoaiek en mohkid, de mie ihre toroar teikan?

1. ☐ EHI

2. ☐ SOH [GO TO A35]

[IF YES] soumwahu wet lelehr de pahn doulahng sounpwong 12?

1. ☐ EHI

1. ☐ SOH

32. Seri wet anahne sawas tohrohr pid paliwere, uwen koaiehk kan, de mwomwen eh koasoia?

1. ☐ EHI

2. ☐ SOH [GO TO A36]

[IF YES] Met pweki mie soumwahu, de tihahk me wehkilah, de oahnoapwek tehikan?

1. ☐ EHI

2. ☐ SOH [GO TO A36]

[IF YES] soumwahu wet lelehr de pahn doulahng sounpwong 12?

1. ☐ EHI

1. ☐ SOH

33. Mie en seri wet ah apwal en madamadau de wiewia me kahrehda eh ale sawas sang tohnwini?

1. ☐ EHI

2. ☐ SOH [GO TO A37]

[IF YES] apwal en paliwar de madamadau wet pahn doulahng sounpwong 12 de laud sang?

1. ☐ EHI

1. ☐ SOH

Ma mie pil emen nah seri, doulahng A37. DOULAHNG PALI B

34. Seri 4

Iah ehden seri et, ia ah initals, de ahd kahmwan?

35. Serieh men iah? PILADA KOAROS ME PWUNG

Seri menet...

Mehn Hispanic de Latino?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet mehn Hispanic de Latino. Seri menet...?

☐ MEHN MEXICO

☐ MEHN PUERTO RICO

☐ MEHN SALVADOR

☐ MEHN CUBA

☐ MEHN DOMINICAN

☐ MEHN GUATEMALA

☐ Mehn Pil Ehu Hispanic de Latino. Menlau kaselehda ia mwomwen seri menet mehn pil ehu Hispanic de Latino. Ni karasepe, mehn Colombia, mehn Hondura, mehn Spaniard, wasa teikan.

PWILIDAK EN HAWAII DE DEKEHN PACIFIC KAN?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet mehn Hawaii de deken Pacific. Seri menet...?

☐ PWILIDAK EN HAWAII

☐ MEHN TONGA

☐ MEHN SAMOA

☐ MEHN FIJI

☐ MEHN GUAM

☐ MEHN CHAMORRO

☐ MEHN MWASEL (MARSHALLESE)

☐ [DO NOT DISPLAY IN NP] MEHN SAIPAN

☐ MEHN MWOATLOAK

☐ MEHN KUSAI (KOSRAE)

☐ MEHN CAROLINA

☐ MEHN PALAU

☐ MEHN POHNPEI

☐ MEHN YAP

☐ MEHN CHUUK

☐ PWILIDAK EN HAWAII DE DEKEHN PACIFIC KAN. Menlau kaselehda ia mwomwen seri menet mehn Hawaii de deken Pacific. Ni karasepe, mehn Tahiti, wasa teikan.

MEHN AMERICAN INDIAN DE PWILIDAK EN ALASKA?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet MEHN AMERICAN INDIAN DE PWILIDAK EN ALASKA. Ni karasepe, mehn Navajo Nation, keinek en Blackfeet Tribe of the Blackfeet Indian Reservation en

Montana, Pwilidak en Barrow Inupiat Traditional Government, pwihn en Nome Eskiko Coummunity, mehn Aztec, mehn Maya, wasa teikan.

Community, Aztec, Maya, etc.

Mehn Asia?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet Asia. Serieh men iah?

☐ MEHN CHINA

☐ ASIAN INDIAN

☐ MEHN PILIPIHN

☐ MEHN VIETNAM

☐ MEHN KOREA

☐ MEHN SAPAN

☐ MEHN ASIAN TEIKAN. Menlau kaselehda ia mwomwen seri menet mehn Asia. Ni karasepe, mehn Pakistani, mehn Hmong, mehn Aghan, wasa teikan.

ARAMAS TOANTOAL DE MEHN AFRICAN AMERICAN?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet TOHNTOAL DE MEHN AFRICAN AMERICAN. Serieh men iah?

☐ MEHN AFRICAN AMERICAN

☐ MEHN JAMAICA

☐ MEHN HAITI

☐ MEHN NIGERIA

☐ MEHN ETHIOPIA

☐ Mehn Somali

☐ ARAMAS TOANTOAL DE MEHN AFRICAN AMERICAN. Menlau kaselehda ia mwomwen seri menet TOHNTOAL DE MEHN AFRICAN AMERICAN. Ni karasepe, mehn Trinidad oh mehn Tobagonia, Ghana, Congo, wasa teikan.

MEHN MIDDLE EAST DE NORTH APERIKA?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet MEHN MIDDLE EAST DE NORTH APERIKA. Seri menet...?

☐ MEHN LEBANON

☐ MEHN IRAN

☐ MEHN ISIP

☐ MEHN SYRIA

☐ MEHN IRAQ

☐ MEHN ISRAEL

☐ MEHN MIDDLE EAST DE NORTH APERIKA? Menlau kaselehda ia mwomwen seri menet MEHN MIDDLE EAST DE NORTH APERIKA. Ni karasepe, mehn Moroccan, mehn Yemeni, mehn Kurdish, wasa teikan.

Aramas pwetepwet?

☐ Ei

☐ Soh

[IF YES] Menlau kaselehda ia mwomwen seri menet aramas pwetepwet. Seri menet...?

☐ MEHN ENGLAND

☐ MEHN SEMEN

☐ MEHN IRELAND

☐ MEHN ITALI

☐ MEHN POLAND

☐ MEHN SCOTLAND

☐ Aramas Pwetepwet Teikan. Menlau kaselehda ia mwomwen seri menet aramas pwetepwet. Ni karasepe, mehn French, mehn Sweden, mehn Norweig, wasa teikan.

36. Seri dah?

1. ☐ PWUTAK

2. ☐ SEREPEIN

37. Sounpar depe seri et? Ma seri et tihkitik sang sounpohng ehu, pilada sounpar 1.

SOUNPAR (DE) SOUNPWOHNG

MA SERI ET TIKITIK SANG SOUNPAR 4, DOULA KALELEPAK A43

38. Uwen koaiehk en seri et ah lokaian Wai?

1. ☐ Uhdahn mwahu

2. ☐ Mwahu

3. ☐ Sohte mwahu

4. ☐ Uhdahn sohte mwahu

39. Seri et kin kang wini me tohnwini men kihong ansou wet, mehnda paidamin kan?

1. ☐ EHI

2. ☐ SOH [GO TO A44]

[IF YES] seri et kin kang wini kat pwehki eh kin soumwahu en paliwar de sahliel?

1. ☐ EHI

2. ☐ SOH [GO TO A44]

[IF YES] soumwahu wet lelehr de pahn doulahng sounpwong 12?

1. ☐ EHI

1. ☐ SOH

40. Seri wet anahne de kin touwehng tohnwini en paliwar de sahliel me seri kan tohrohr sohte kin anahne tuhweng?

1. ☐ EHI

2. ☐ SOH [GO TO A45]

[IF YES] seri et anahn en sawas en wini, madamadau de sahliel, de sawas ohng sukuhl kohsang eh soumwahu en paliwere, madamadau, de wiewia kan?

1. ☐ EHI

2. ☐ SOH [GO TO A45]

[IF YES] soumwahu wet lelehr de pahn doulahng sounpwong 12?

1. ☐ EHI

1. ☐ SOH

41. Seri wet sohte kak wia mehkan me seri teikan kak wia?

1. ☐ EHI

1. ☐ SOH [GO TO A46]

[IF YES] pwehki mie soang en somwahu de apwal en paliwar, wiewia, de madamadau?

1. ☐ EHI

1. ☐ SOH [GO TO A46]

[IF YES] soumwahu wet lelehr de pahn doulahng sounpwong 12?

1. ☐ EHI

2. ☐ SOH

42. Seri wet anahne sawas tohrohr pid paliwere, uwen koaiehk kan, de mwomwen eh koasoia?

1. ☐ EHI

2. ☐ SOH [GO TO A47]

[IF YES] Met pweki mie soumwahu, de tihahk me wehkilah, de oahnoapwek tehikan?

1. ☐ EHI

2. ☐ SOH [GO TO A47]

[IF YES] soumwahu wet lelehr de pahn doulahng sounpwong 12?

1. ☐ EHI

1. ☐ SOH

43. Mie en seri wet ah apwal en madamadau de wiewia me kahrehda eh ale sawas sang tohnwini?

1. ☐ EHI

2. ☐ SOH [GO TO A48]

[IF YES] apwal en paliwar de madamadau wet pahn doulahng sounpwong 12 de laud sang?

1. ☐ EHI

1. ☐ SOH

MA SOHTE MIE SERI TEIKAN, MENLAU DOULA PALI B.

MA MIE LAUD SANG SERI PAHIEU ME SOUNPAR NAN PWUNGEN 0-17 ME KIN MIHMI WASAHT, NTINGIDI ARAIL SOUNPAR DEPE OR SOANG EN ARAMAS (PWUTAK DE SEREPEIN). DEHR PWURENG KIHDA IREN SERI 1 LEL SERI 4.

44. Seri 5

Iah ehden seri et, ia ah initals, de ahd kahmwan?

45. Sounpar depe seri et?

SOUNPAR (DE) SOUNPWOHNG

46. Seri dah?

1. ☐ PWUTAK

2. ☐ SEREPEIN

A51. Seri 6

Iah ehden seri et, ia ah initals, de ahd kahmwan?

47. Sounpar depe seri et?

SOUNPAR (DE) SOUNPWOHNG

48. Seri dah?

1. ☐ PWUTAK

2. ☐ SEREPEIN

49. Seri 7 Iah ehden seri et, ia ah initals, de ahd kahmwan?

50. Sounpar depe seri et?

SOUNPAR (DE) SOUNPWOHNG

51. Seri dah?

1. ☐ PWUTAK

2. ☐ SEREPEIN

52. Seri 8

Iah ehden seri et, ia ah initals, de ahd kahmwan?

53. Sounpar depe seri et?

SOUNPAR (DE) SOUNPWOHNG

54. Seri dah?

1. ☐ PWUTAK

2. ☐ SEREPEIN

55. Seri 9

Iah ehden seri et, ia ah initals, de ahd kahmwan?

56. Sounpar depe seri et?

SOUNPAR (DE) SOUNPWOHNG

57. Seri dah?

1. ☐ PWUTAK

2. ☐ SEREPEIN

A63. Seri 10

Iah ehden seri et, ia ah initals, de ahd kahmwan?

58. Sounpar depe seri et?

SOUNPAR (DE) SOUNPWOHNG

59. Seri dah?

1. ☐ PWUTAK

2. ☐ SEREPEIN

2. [This Child’s Health (PROGRAMMER: Add Timestamp)]

Mie aht kalelepak kan pid [SPECIFY CHILD]. Kalelepak pwukat pahn idek rehmwi ia iren nomw seri ah roson, ah tuhweng tohnwini kan, oh uwen pweinen ah sawas en wini. Se pilada seri emente nan imwomwi pwehn katikitikla ansou me komw pahn anahne pwehn sapeng kalelepak pwukat.

1. Ni oaralap, ia mwomwen ahmw madamadau pid en seri wet ah roson?

1. ☐ Mwahu douluhl

2. ☐ Uhdahn mwahu

3. ☐ Mwahu

4. ☐ Sais

5. ☐ Sohte mwahu

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

2. Ia iren ngihen seri wet?

1. ☐ Mwahu douluhl

2. ☐ Uhdahn mwahu

3. ☐ Mwahu

4. ☐ Sais

5. ☐ Sohte mwahu

6. ☐ SOHTE NGIH KAN

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

3. Nan sounpwong 12 me samwolahro, seri wet kin sohte kak wia mehpwukat?

   	EHI	SOH	I SEHSE	KAHNG SAPENG
   B3a. Apwal en esingek	1 ☐	2 ☐	77 ☐	99 ☐
   B3B. Mwenge de kadal pwehki apwal en roson suwed	1 ☐	2 ☐	77 ☐	99 ☐
   B3c. Kang mwenge, iangahki medek en kapehde, iheteng, de mehnteng	1 ☐	2 ☐	77 ☐	99 ☐
   B3d. Medek ansou koaros, iangahki medek en moange, tihnsewe, de paliwere	1 ☐	2 ☐	77 ☐	99 ☐
   B3e. Doadoahngki peh kan	1 ☐	2 ☐	77 ☐	99 ☐
   B3f. Mwemwekidseli	1 ☐	2 ☐	77 ☐	99 ☐
   B3g. Medek en ngih kan	1 ☐	2 ☐	77 ☐	99 ☐
   B3h. Nta en utun ngih	1 ☐	2 ☐	77 ☐	99 ☐
   B3i. Ngihpwoar kan	1 ☐	2 ☐	77 ☐	99 ☐
   B3j. Medek en koaronge	1 ☐	2 ☐	77 ☐	99 ☐

4. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

Seri wet soumwahukilahr mehpwukat?

	EHI	SOH	I SEHSE	KAHNG SAPENG
B4a. Salengopon	1 ☐	2 ☐	77 ☐	99 ☐
B4b. Masukun de apwal en kilang, mehnda ma eh doadoangki kilahs	1 ☐	2 ☐	77 ☐	99 ☐

5. Tohnwini men ndaiongkomwiehr me nomw seri soumwahukilahr mehpwukat? Ma ehi, seri wet soumwahukihla ansou wet?

   	Pak ehu de laud sang?	Ansou wet?	I SEHSE	KAHNG SAPENG
   B5a. Asima	1 ☐ EHI 2 ☐ SOH	1 ☐ EHI 2 ☐ SOH	77 ☐	99 ☐
   B5b. Soumwahu en suke	1 ☐ EHI 2 ☐ SOH	1 ☐ EHI 2 ☐ SOH	77 ☐	99 ☐
   B5c. Soumwahu en Down Syndrome	1 ☐ EHI 2 ☐ SOH	1 ☐ EHI 2 ☐ SOH	77 ☐	99 ☐
   B5d. Medek en moange kan	1 ☐ EHI 2 ☐ SOH	1 ☐ EHI 2 ☐ SOH	77 ☐	99 ☐
   B5e. Mwahliel	1 ☐ EHI 2 ☐ SOH	1 ☐ EHI 2 ☐ SOH	77 ☐	99 ☐
   B5f. Pwunod	1 ☐ EHI 2 ☐ SOH	1 ☐ EHI 2 ☐ SOH	77 ☐	99 ☐
   B5g. Soumwahu en nsensuwed	1 ☐ EHI 2 ☐ SOH	1 ☐ EHI 2 ☐ SOH	77 ☐	99 ☐
   B5h. Soumwahu en Autism, ASD, Asperger's Disorder, de Pervasive Developmental Disorder (PDD)	1 ☐ EHI 2 ☐ SOH	1 ☐ EHI 2 ☐ SOH	77 ☐	99 ☐
   B5i. Soumwahu en Attention Deficit Disorder (ADD) de Attention Deficit/Hyperactivity Disorder (ADHD)	1 ☐ EHI 2 ☐ SOH	1 ☐ EHI 2 ☐ SOH	77 ☐	99 ☐
   B5j. Kerempwa en ah koaiehk kan	1 ☐ EHI 2 ☐ SOH	1 ☐ EHI 2 ☐ SOH	77 ☐	99 ☐
   B5k. Mwersuwed	1 ☐ EHI 2 ☐ SOH	1 ☐ EHI 2 ☐ SOH	77 ☐	99 ☐
   B5l. Sahliel	1 ☐ EHI 2 ☐ SOH	1 ☐ EHI 2 ☐ SOH	77 ☐	99 ☐
   B5m. Apwal en Koasoia de Lokaia	1 ☐ EHI 2 ☐ SOH	1 ☐ EHI 2 ☐ SOH	77 ☐	99 ☐
   B5n. Pakolong en esehla	1 ☐ EHI 2 ☐ SOH	1 ☐ EHI 2 ☐ SOH	77 ☐	99 ☐
   B5o. Pil ehu soumwahu en madamadau de moange.	1 ☐ EHI 2 ☐ SOH	1 ☐ EHI 2 ☐ SOH	77 ☐	☐

6. Nan sounpwong 12 me samwolahro, pak depe me soumwahu de apwal kan karehda en seri wet ah koaiehk en wia mehkan me seri tohrohr kak wia?

1. ☐ SOHTE MIE EN SERI WET AH SOUMWAHU KAN [GO TO B8]

2. ☐ Sohte pak ehu [GO TO B8]

3. ☐ Ekei pak

4. ☐ Ansou kidalap

5. ☐ Ansou Koaros

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

7. En seri ah soumwahu kan karehda sakoaiehk kan?

1. Ekiste

2. ☐ Ekis

3. ☐ Pak tohto

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

8. [ONLY ASK THIS QUESTION IF CHILD IS 6-17 YEARS OLD]

Tohnwini men ndaiongkomwiehr me nomw seri soumwahukilahr Substance Abuse Disorder? Soumwahu en Substance Abuse Disorder wiawi ni emen kin kang sakau en wai de mehn sahliel, me karehda somwahu kan, sakoaiehk kan, oh karehda emen en sohte wia mehkan me eh pwukoahki nan ah doadoahk, sukuhl, de imwe.

1. ☐ EHI

2. ☐ SOH [GO TO B9]

1. ☐ I SEHSE [GO TO B9]

1. ☐ KAHNG SAPENG [GO TO B9]

[IF YES] seri soumwahukihlahr?

1. ☐ EHI

2. ☐ SOH [GO TO B9]

1. ☐ I SEHSE [GO TO B9]

1. ☐ KAHNG SAPENG [GO TO B9]

[IF YES] eh:

1. ☐ Ekis

1. ☐ Sais

2. ☐ Doar

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

9. [ONLY ASK THIS QUESTION IF CHILD IS 6-17 YEARS OLD]

Seri wet soumwahukilahr mehpwukat?

	EHI	SOH	I SEHSE	KAHNG SAPENG
B9a. Apwal laud en madamadau, tamataman, de pilada pwehki soumwahu en paliwere de madamadau kan	1 ☐	2 ☐	77 ☐	99 ☐
B9b. Apwal en alialuseli de kohdahla poweo	1 ☐	2 ☐	77 ☐	99 ☐
B9c. Apwal en likouda de duhdu	1 ☐	2 ☐	77 ☐	99 ☐
B9d. Apwal en kohkohseli ni kelehpw pwehki ah soumwahu en paliwere de madamadau	1 ☐	2 ☐	77 ☐	99 ☐
B9e. Salengopon	1 ☐	2 ☐	77 ☐	99 ☐
B9f. Masukun de apwal en kilang, mehnda ma eh doadoangki kilahs	1 ☐	2 ☐	77 ☐	99 ☐

10. T ohnwini men ndaiongkomwiehr me nomw seri soumwahukilahr...

	EHI	SOH	I SEHSE	KAHNG SAPENG
B10a. Soumwahu en mongiong Rheumatic	1 ☐	2 ☐	77 ☐	99 ☐
B10b. Soumwahu en karakar Rheumatic	1 ☐	2 ☐	77 ☐	99 ☐
B10c. Soumwahu en kihl (Impetigo ape)	1 ☐	2 ☐	77 ☐	99 ☐

[IF YES TO RHEUMATIC HEART DISEASE OR FEVER] Re kin kang wini en kamwahuiala soumwahu wet?

1. ☐ EHI

1. ☐ SOH

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

[IF YES] Re kin kang weren wini kan de ale koahr en wini?

1. ☐ SOANGEN WINI ME ARAMAS KANG (WEREN WINI KAN) [GO TO B11]

1. ☐ KOAHREN WINI [GO TO B11]

[IF NO] Pwehkida? PILADA KOAROS ME PWUNG

1. ☐ Sohte kak pwainda

1. ☐ Sohte mwomwehn kohkohseli

2. ☐ Sohte me kak iang nei seri kohlahng imwen wini

3. ☐ Sohte kesempwal

4. ☐ KAHREPE TOHROHR, MENLAU KAWEWEDA:

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

11. Tohnwini men ndaiongkomwiehr me nomw seri soumwahukihlahr soumwahu en nta, iangahki leukemia, anemia, de sickle cell disease? Menalu dehr iang wadek soumwahu en Sickle Cell Trait.

[READ IF NECESSARY]: Seri me soumwahukihla anemia anahki apwal en ntarail me kak kahrehda arail men meir.

1. ☐ EHI

2. ☐ SOH

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

Ansou wet I pahn peki rehmwi pasapeng kan pid dahme komw kak wia en kalikedi nomw seri en ohla.

12. Komwi de pil emen aramas nan ahmw mour koaskoasoia duwen dehr peii de kalikehdi ohla kan? Ni kahrasepe, mehn keper kan ni ahmw mwadmwadong nan ahl, paleke tuhke, de pampap nan sehd.

1. ☐ Ehi, dehr peii

2. ☐ Ehi, kalikedi ohla en paliwar

3. ☐ Koaros

4. ☐ Sohte

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

13. Komw iang nomw seri ni pampap de mwadmwadohngseli?

1. ☐ EHI

2. ☐ SOH

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

14. [ONLY ASK THIS QUESTION IF CHILD IS 6-17 YEARS OLD]

Ni nomw seri doahke pwaisikel, e kin likawih erimeddo?

1. ☐ Nei seri sohte doahke pwaisikel

2. ☐ Sohte kin likawih erimeddo

3. ☐ Sohte kin likawih erimeddo

4. ☐ Likawih erimeddo ekei pak

5. ☐ E kin likawih erimeddo

6. ☐ E kin likawih erimeddo ansou koaros

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

15. [ONLY ASK THIS QUESTION IF CHILD IS 0-11 YEARS OLD]

Nomw seri kin mwohndi nan sehr en seri nan sidohsa?

1. ☐ Ansou Koaros

2. ☐ Ansou koaros

3. ☐ Ekei pak

4. ☐ Pak malaulau

5. ☐ Sohte pak ehu [IF CHILD 0-5 YEARS OLD, GO TO B17; IF CHILD 6-11 YEARS OLD, GO TO C1]

6. ☐ NEI SERI SOHTE IANG IDAN SIDOHSA [IF CHILD 0-5 YEARS OLD, GO TO B17; IF CHILD 6-11 YEARS OLD, GO TO C1]

1. ☐ I SEHSE

99. ☐ KAHNG SAPENG

16. [ONLY ASK THIS QUESTION IF CHILD IS 0-11 YEARS OLD]

En nomw seri nah sehr mihmi ia nan wereomw sidohsa?

1. ☐ Mwowe ni palikoaiehk

2. ☐ Mwhur ni palikoaiehk

3. ☐ Mwhur ni palisakoaiehk

4. ☐ Nan pwungen sehr kan nan wasahn mwhur

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

3. [This Child as an Infant (PROGRAMMER: Add Timestamp)]

1. Nomw seri ipwidi wihk 3 de mwuhr mwohn ansou me re madamadau e pahn ipwidi?

1. ☐ EHI

2. ☐ SOH

77. ☐ I SEHSE

99. ☐ KAHNG SAPENG

2. Uwen toutou ni eh ipwidi? Menlau sapeng ni paun kan oh paun tikitik kan de kilogram kan oh gram kan. Kihda uwen ahmw madamadau mwahu [IF NEEDED, READ: YOUR BEST GUESS IS FINE. IT DOES NOT HAVE TO BE EXACT]

PAUN KAN OH PAUN TIKITIK KAN

KILOGRAM KAN OH GRAM KAN

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

3. Komw soupar depe ni nomw seri ah iwpwidi?

SOUNPAR

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

Seri et kedihdi ni ah tikitik?

1. ☐ EHI

2. ☐ SOH [GO TO C6]

1. ☐ I SEHSE [GO TO C6]

1. ☐ KAHNG SAPENG [GO TO C6]

[IF YES] sounpar depe ni seri et sohlahr kedihdi?

RAHN (DE)

WIHK (DE)

SOUNPWONG (DE)

SOUNPAR

SERI KIN KEDIHDI ANSOU WET

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

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

Sounpar depe seri menet ni eh TEPIN ale de nim formula?

RAHN (DE)

WIHK (DE)

SOUNPWONG (DE)

NI IPWIDI

SOHTE PAK EHU SERI MENET ALE DE NIM FORMULA

☐ I SEHSE

☐ SOHTE MEN SAPENG

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

Sounpar depe ni seri et sohlahr kedihdi oh kang mwenge tohrohr? Iangahki pilen wahntuhke, pil en suke, mwenge en seri pwelel, de mwenge teikan me nomw seri mwein kang, iangahki pil.

RAHN (DE) WIHK (DE) MONTHS

NI IPWIDI

PILADA KOHPWA WET MA SERI ET SAIK MWENGE

MEHNDA DIHDI

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

1. [Health Care Services (PROGRAMMER: Add Timestamp)]

1. Nan sounpwong 12 me samwolahro, seri wet tuhweng tohnwini pwehki e soumwahu, anahne tehk en roson, tuhweng imwen wini, de soang en sawas en wini tohrohr?

1. ☐ EHI

2. ☐ SOH [GO TO D2]

77. ☐ I SEHSE [GO TO D2]

99. ☐ KAHNG SAPENG [GO TO D2]

[IF YES] Nan sounpwong 12 me samwolahro, pak depe seri wet tuhweng tohnwini pwehn ale sawas mwohn e soumwahu? Soang en sawas pwukat (mwohn seri soumwahulahr) iangahki des en mwadong kan, ansou en tuhweng tohnwini nan ehu ehu par, ape.

1. ☐ PAK 0

1. ☐ PAK 1

2. ☐ PAK 2 DE LAUD SANG

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

2. Komw pwunodki toutowi en nomw seri?

1. ☐ Ehi, toutowi toutou

2. ☐ Ehi, toutowi tikitik

3. ☐ Soh, I sohte pwunodki

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

3. Uwen reirei en seri wet? Kihda uwen ahmw madamadau mwahu [IF NEEDED, READ: YOUR BEST GUESS IS FINE. IT DOES NOT HAVE TO BE EXACT]

NEH KAN OH INS KAN

MIHTER KAN OH MIHTER TIKITIK KAN

77. ☐ I SEHSE

99. ☐ KAHNG SAPENG

4. Uwen toutawi en seri et ansou wet? Kihda uwen ahmw madamadau mwahu [IF NEEDED, READ: YOUR BEST GUESS IS FINE. IT DOES NOT HAVE TO BE EXACT]

PAUN KAN OH PAUN TIKITIK KAN

KILOGRAM KAN OH GRAM KAN

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

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

Nan sounpwong 12 me samwolahro, en nomw seri ah tohnwini peki rehmwi ma mie ahmw pwunod kan pid en nomw seri ah roson, uwen esehda, de wiewia kan?

1. ☐ EHI

2. ☐ SOH

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

6. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

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

Nan sounpwong 12 me samwolahro, en nomw seri ah tohnwini kihong komwi douloal ieu pid ahmw pwunod kan pid en nomw seri ah roson, uwen koasoia, de wiewia kan? Tohnwini men mwein pahn peki rehmwi en wia soang wet ni ah tuhweng imwomwi de ni komw tuhweng ah ohpihs.

1. ☐ EHI

2. ☐ SOH [GO TO D7]

77. ☐ I SEHSE [GO TO D7]

1. ☐ KAHNG SAPENG [GO TO D7]

[IF THIS CHILD IS 9-23 MONTHS]

Douloal wet idek pid ahmw pwunod de madamadau kan pid duwen: PILADA KOAROS ME PWUNG

1. ☐ Ia mwomwen seri wet kin koasoia de lal?

1. ☐ Ia mwomwen seri wet kin wiewia nan rehmwi?

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

[IF THIS CHILD IS 2-5 YEARS]

Douloal wet idek pid ahmw pwunod de madamadau kan pid duwen: PILADA KOAROS ME PWUNG

1. ☐ Lepen lokaia kan me nomw seri doadoangki oh wehwehki?

1. ☐ Ia mwomwen seri wet kin wiewia nan rehmwi?

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

7. Mie wasa me nomw seri kin tuhweng ni ah soumwahu de komw anahne sawas pid ah roson?

1. ☐ EHI

2. ☐ SOH [GO TO D8]

77. ☐ I SEHSE [GO TO D8]

1. ☐ KAHNG SAPENG [GO TO D8]

[IF YES] e kin kohla ia?

1. ☐ Ohpihs en sounwini men

1. ☐ Imwen wini

2. ☐ Imwen wini

3. ☐ Ohpihs en wini nan ahmw sahpw

4. ☐ Sukuhl

5. ☐ Sidohwa en wini nan ahmw sahpw

6. ☐ Pil ehu wasa, MENLAU KAWEWEHDA

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

8. Mie wasa me nomw seri kin tuhweng ni ah soumwahu de komw anahne sawas pid ah roson?

1. ☐ EHI

2. ☐ SOH [GO TO D9]

1. ☐ I SEHSE [GO TO D9]

1. ☐ KAHNG SAPENG [GO TO D9]

[IF YES] wasaht duwehte wasa me e kin kohla ia ni ah soumwahu?

1. ☐ EHI

1. ☐ SOH

9. Nan sounpwong 12 me samwolahro, seri wet ale soang en sawas en wini pwukat? PILADA KOAROS ME PWUNG Sawas en wini tohrohr iangahki acupuncture, sawas en tihnwere, wini en nansahpw, oh teikan. Ekei sawas kan anahne komw tuhweng tohnwini, ah ekei komw kak wia ni kelehpw.

1. ☐ Sawas en wini

1. ☐ Sawas en kairoir

1. ☐ Sawas en karonge

2. ☐ Sawas en ngih kan

3. ☐ Sawas en madamadau

4. ☐ Soang en sawas tohrohr

7. ☐ Sohte [GO TO D10]

1. ☐ I SEHSE [GO TO D10]

1. ☐ KAHNG SAPENG [GO TO D10]

[IF VISION CARE] Soang en wasa dah me nomw seri ale des en kairoir? PILADA KOAROS ME PWUNG

1. ☐ Ohpihs en tohnwini en pwoaren mese

1. ☐ Ohpihs en tohnwini en peneinei

1. ☐ Ohpihs en wini nan ahmw sahpw

2. ☐ Sukuhl

3. ☐ PIL EHU WASA, MENLAU KAWEHWEHDA

10. Nan sounpwong 12 me samwolahro, mie ansou me nomw seri anahne sawas ah sohte mie? Sawas wet iangahki sawas en kairoir, ngih kan, oh madamadau.

1. ☐ EHI

2. ☐ SOH [GO TO D12]

1. ☐ I SEHSE [GO TO D12]

1. ☐ KAHNG SAPENG [GO TO D12]

[IF YES] soang en sawas dah me sohte mie ni ansou me nomw seri anahne? PILADA KOAROS ME PWUNG

1. ☐ Sawas en wini

1. ☐ Sawas en ngih kan

1. ☐ Sawas en kairoir

2. ☐ Sawas en karonge

3. ☐ Sawas en madamadau

4. ☐ PIL EHU SOANG, MENLAU KAWEHWEHDA

11. Menia soang pwukat karehda nomw seri en sohte ale sawas:

    	EHI	SOH	I SEHSE	KAHNG SAPENG
    D11a. Seri et sohte mweidohng ale sawas?	1 ☐	2 ☐	77 ☐	99 ☐
    D11b. Sohte mie soang en sawas me seri et anahne nan sahpwe?	1 ☐	2 ☐	77 ☐	99 ☐
    D11c. Apwal en koasoane ansou en ale sawas ni ansou mwahu ni ah anahne?	1 ☐	2 ☐	77 ☐	99 ☐
    D11d. Apwal en diarada mwomwen kohkohseli de apwalih seri?	1 ☐	2 ☐	77 ☐	99 ☐
    D11e. Ohpihs en tohnwini saik ritda?	1 ☐	2 ☐	77 ☐	99 ☐
    D11f. Apwal en pwainda?	1 ☐	2 ☐	77 ☐	☐

12. Nan sounpwong 12 me samwolahro, seri wet tuhweng imwen wini? Menlau iangahki ansou ni ahmw tuhweng imwen wini.

1. E hi

1. Soh

1. I SEHSE

1. KAHNG

[IF YES] Nan sounpwong 12 me samwolahro, seri wet tuhweng imwen wini pwehki ohla? 'Ohla' wehwehki tiahksuwed en paliwar pwehki depweila de paker.
Ohla kak iangahki tih ohla kan, medek en uduk, selipat kan, mwasik kan, de medek pwehki paker.

PAK

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

5. [Experience with This Child’s Health Care Providers (PROGRAMMER: Add Timestamp)]

1. Mie en nomw seri ah tohnwini men? Tohnwini men iei emen me ese mwahu nomw seri oh pid duwen ah roson. Tohnwini men kak iangahki tohnwini oaralap men, tohnwini tohrohr men, de sounsawas tohnwini men.

1. ☐ EHI, ARAMAS EMEN

2. ☐ EHI, LAUD SANG ARAMAS EMEN

3. ☐ SOH

2. Erein sounpar 12 samwalahro, ia duwe, kowe, de emen sounepwel tohroh, de emen toahkte anahne wiahda sohte pilipil duwen epwelpen roson en serien, duwehte ma toahkte en ntignihdi kene wini, alehdi referral kan, de koasoandi en pwal ape?​

77. ☐ Ei

78. ☐ Soh

☐ I SEHSE

☐ SOHTE MEN SAPENG

3. [IF YES] Erein sounpwong 12 samwalahro, pahn pak depe en seri menet eh toahkte de soun sawas teikan…​

	Ansou Koaros	Kalapw	Ekei pak	Sohte pak ehu	I SEHSE	SOHTE MEN SAPENG
E3a. kawehwehiong uhk duwen omw pilipil kan me kak ale ong epwelpen eh roson de ale sawas en wini?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
E3b. wia en mengei ong uhk en ken kak kasalehda omw madamadau de sohte pwungki soahng kan me re nda me mwahu ong epwelpen en seri menet eh roson?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
E3c. iang uhk doadoahk pwe ken kak pilada mehnia epwelpen roson oh sawas en wini kan me pahn keieu mwahu ong seri menet?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐

4. Nan soupwong 12 me samwolahro, mie ansou me seri et anahne tuhweng tohnwini oh ale sawas?

1. ☐ EHI

2. ☐ SOH [GO TO E3]

77. ☐ I SEHSE [GO TO E3]

99. ☐ KAHNG SAPENG [GO TO E3]

[IF YES] uwen apwal en ale mehn katuhpene?

1. ☐ Sohte apwal

1. ☐ Apwal tikitik

1. ☐ Apwal lapala

5. [ANSWER THE FOLLOWING QUESTIONS ONLY IF THIS CHILD HAD A HEALTH CARE VISIT IN THE PAST 12 MONTHS. OTHERWISE, GO TO E4.]

Nan sounpwong 12 me samwolahro, pak depe me en nomw seri ah tohnwini kan:

	Ansou Koaros	Ansou kidalap	Ekei pak	Sohte pak ehu	I SEHSE	KAHNG SAPENG
E5a. Mih rehn seri menet ansou itar?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
E5b. Karonge komwi mwahu?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
E5c. Waunehki ahmw tiahk kan?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
E5d. Kihong komwi ire kan pid duwen seri et?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
E5e. Sewese komwi en pehm me kuwail koaros iang nsenohki en nomw seri ah sawas en wini?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	☐

6. Mie emen me kin sewese komwi en koasoane en nomw seri ah sawas en wini nan pwungen tohnwini?

1. ☐ EHI

2. ☐ SOH

3. ☐ SOHTE TUHWENG LAUD SANG EMEN TOHNWINI NAN SOUNPWONG 12 ME SAMWOLAHRO [GO TO E7]

7. Nan sounpwong 12 me samwolahro, komw pehm me komw anahne sawas laud en koasoane en nomw seri ah tuhweng tohnwini kan?

1. ☐ EHI

2. ☐ SOH [GO TO E6]

[IF YES] Nan sounpwong 12 me samwolahro, pak depe me komw ale sawas itar en koasoane en seri menet ah sawas en wini?

1. ☐ Ansou kidalap

1. ☐ Ekei pak

1. ☐ Sohte pak ehu

8. Ni oaralap, uwen ahmw mwahuki mehn kapese sang en nomw seri ah tohnwini kan?

1. ☐ Uhdahn mwahuki

2. ☐ Ekis mwahuki

3. ☐ Ekis sohte mwahuki

4. ☐ Uhdahn sohte mwahuki

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

9. [ONLY ASK THIS QUESTION IF CHILD IS 12-17 YEARS OLD]

Tohnwini kin sewese nomw seri sewese seri kan tohr?

1. ☐ EHI

2. ☐ SOH [GO TO E8]

1. ☐ I SEHSE [GO TO E8]

1. ☐ KAHNG SAPENG [GO TO E8]

[IF YES] irail peki rehmwi pid duwen nomw seri tuhweng tohnwini me kin sewese aramas lalauehr?

1. ☐ EHI

1. ☐ SOH

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

10. [ONLY ASK THIS QUESTION IF CHILD IS 12-17 YEARS OLD]

En seri menet ah tohnwini kin sewese seri et en:

	EHI	SOH	I SEHSE	KAHNG SAPENG
E10a. Pilahn duwen ansou me kohkohdo. Ni karasape, ni ahmw koasoi duwen ah sukuhl, doadoahk, peneinei, oh koaiehk en mih ni kalehpw?	1 ☐	2 ☐	77 ☐	99 ☐
E10b. Pilada pilapil mwahu duwen ah roson. Ni karasepe, ni ah kang mwenge mwahu, kaiahn ansou tohto, dehr kang sika, sakau en wai, de mehn kahsaliel, oh awi en tuhpenen pwopwoud?	1 ☐	2 ☐	77 ☐	99 ☐
E10c. Esehla ia mwomwen ah kak pein apwalih ah roson. Ni karasepe, ni a wehwehki anahn en rosonmwahu kan, dahme ah anahne wia ma mie ansou suwed, oh soang en wini kan me e pahn anahne?	1 ☐	2 ☐	77 ☐	99 ☐
E10d. Wehwehki wehkid en sawas en wini ni ah lel sounpar 18. Ni karasepe, ni ah wehwehki wehkid en iren rir kan, pwung, oh ale ire kesempwal kan?	1 ☐	2 ☐	77 ☐	99 ☐

11. Ihs me warong wekwekila ni ah lalaudala. Komw ese ia mwomwen nomw seri pahn ale sawas en pwain sawas en wini ni eh lalaudla?

1. ☐ EHI [GO TO F]

2. ☐ SOH

[IF NO] mie emen me koasoionguhk duwen ia mwomwen nomw seri kak ale sawas en pwain sawas en wini ni eh lalaudla?

1. ☐ EHI

1. ☐ SOH

5. [This Child’s Health Insurance Coverage (PROGRAMMER: Add Timestamp)]

1. Nan sounpwong 12 me samwolahro, seri et anahki sawas en pwain sawas en wini? Iangahki pirohkiram en nek mwoni pwehn pwain sawas en wini, sawas en wini tohrohr, oh sawas en pwain wini me kohsang koapwoarment.

1. ☐ Ehi, seri et ahneki soang en sawas wet nan sounpwong 12 koaros, oh ma tikitik sang sounpar 1, sang ni ah ipwidi [GO TO F4]

2. ☐ Ehi, ahpw mie ansou ieu me eh sohte ahneki

3. ☐ Soh

2. Seri et ahneki soang en sawas en pwain wini ansou kiset?

1. ☐ EHI

2. ☐ SOH [GO TO SECTION G]

77. ☐ I SEHSE [GO TO SECTION G]

99. ☐ KAHNG SAPENG [GO TO SECTION G]

3. Seri et ahneki soang en sawas en pwain wini ansou kiset nan pilapil me mih pah? [Interviewer Note: Only read jurisdiction-specific insurance types for your jurisdiction]

   	EHI	SOH
   F3a. Sawas en pwain wini sang kompani ieu	1 ☐	2 ☐
   F3b. Sawas en pwain wini me eh ale sang ahmw doadoahk de doadoahk en ahmw pwoud	1 ☐	2 ☐
   F3c. Sawas en pwain wini me kohsang koapwoarment (iangahki Guam Medical Indigent Program, Palau National Health Insurance Program, oh Puerto Rico Government Health Plan)	1 ☐	2 ☐
   F3d. Sang en sawas en pwain wini sang koapwoarment tohrohr (iangahki Micronesia MiCare de Chuuk State, Marshall Islands Public Insurance, oh Marshall Islands Supplemental Health Fund)	1 ☐	2 ☐
   F3e. Nahken Sent Pid Wini	1 ☐	2 ☐
   F3f. CHIP (Children's Health Insurance Program)	1 ☐	2 ☐
   F3g. TRICARE de sawas en wini sang military tohrohr	1 ☐	2 ☐
   F3h. Indian Health Service	1 ☐	2 ☐
   F3i. Pil ehu, Menlau kawehwehda	1 ☐	☐

4. Uwen depe en seri et ah sawas en wini pwainda pweinen wini koaros? Ni karasepe, iangahki sawas en ngih or pwoaren mese kan, wini, tuhweng imwen wini, sawas en naitik, sawas en madamadau, oh tuhweng tonwini oaralap ni ehu ehu pahr.

1. ☐ Ansou Koaros

2. ☐ Ansou kidalap

3. ☐ Ekei pak

4. ☐ Sohte pak ehu

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

5. Uwen depe en seri et ah sawas en wini mweidong seri et en tuweng tohnwini kan me eh anahne?

1. ☐ Ansou Koaros

2. ☐ Ansou kidalap

3. ☐ Ekei pak

4. ☐ Sohte pak ehu

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

1. [Providing for This Child’s Health (PROGRAMMER: Add Timestamp)]

1. Iangahki pweinen wini me komw pwukoahki nan ahmw naken sent pid wini, uwen pweinen en seri et ah sawas en wini, ngih, oh pwoaren mese kan nan sounpwong 12 me samwolahro? Sohte iangahki pweinen wini me ah sawas en wini pahn pwainda.

1. ☐ $0 (SOHTE PWEINEN WINI DE ROSON SUWED) [GO TO G4]

2. ☐ $1-$249

3. ☐ $250-$499

4. ☐ $500-$999

5. ☐ $1,000-$5,000

6. ☐ Laud sang $5,000

77. ☐ I SEHSE

99. ☐ KAHNG SAPENG

2. Komw kamelele me pweinen wini kan inen?

1. ☐ Ansou Koaros

2. ☐ Ansou kidalap

3. ☐ Ekei pak

4. ☐ Sohte pak ehu

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

3. Nan sounpwong 12 me samwolahro, mie apwal en ahmw peneinei arail koaiehk en pwainda en nomw seri ah sawas en wini?

1. ☐ EHI

2. ☐ SOH

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

4. Nan sounpwong 12 me samwolahro, komwi de emen nan ahmw peneinei:

	EHI	SOH	I SEHSE	KAHNG SAPENG
G4a. Sohlahr doadoahk pwehki en seri ah roson suwed?	1 ☐	2 ☐	77 ☐	99 ☐
G4b. Katikitikla awa en doadoahk pwehki en seri ah roson suwed?	1 ☐	2 ☐	77 ☐	99 ☐
G4c. Dehr kawekila wasahn doadoahk pwehn nekid sawas en pwainda wini?	1 ☐	2 ☐	77 ☐	99 ☐
G4d. Ale sawas sang peneinei?	1 ☐	2 ☐	77 ☐	99 ☐

8. [This Child’s Learning (PROGRAMMER: Add Timestamp)]

1. Nan ehu ehu rahn, awa depe me nomw seri kilang kasdo de dihpih?

1. ☐ Sohte

2. ☐ Awa 1 de malaulau sang

3. ☐ AWA 1

4. ☐ AWA 2

5. ☐ AWA 3

6. ☐ AWA 4 de laud sang

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

2. Nan ehu ehu rahn, awa depe me nomw seri kin doadoangki kampiuder, dengwa, mehn mwadong en kapiuter tohrohr, de soang teikan mehnda doadoahk en sukuhl?

1. ☐ Sohte

2. ☐ Awa 1 de malaulau sang

3. ☐ AWA 1

4. ☐ AWA 2

5. ☐ AWA 3

6. ☐ AWA 4 de laud sang

1. ☐ I SEHSE

99. ☐ KAHNG SAPENG

3. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

Ia uwen koaiehk en seri menet ah wiewia kan ni kelehpw?

1. ☐ Uhdahn mwahu

2. ☐ Ekis

3. ☐ Sohte mwahu

4. ☐ Uhdahn sohte mwahu

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

4. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

Uwen ahmw koapwoaroapwoar me nomw seri pahn pweida nan sukuhl?

1. ☐ Koapwoaroapwoar laud

2. ☐ Koapwoaroapwoar

3. ☐ Koapwoaroapwoar

4. ☐ Sohte koapwoaroapwoar

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

5. [ONLY ASK THIS QUESTION IF CHILD IS 6 MONTHS-5 YEARS OLD]

Pak depe...​

	Ansou Koaros	Kalapw	Ekei pak	Sohte pak ehu	I SEHSE	SOHTE MEN SAPENG
H5a. seri menet kin kasalehda eh poakohng uhk oh men karanih iuk?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
H5b. seri menet kin mwadang en mwakarda ma e sohte alehdi soahng kan me en wia?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
H5c. seri menet kin kasalehda eh men wia de ese duwen soahng kapw kan?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
H5d. seri menet kin poh komwomkomw oh kouruhr?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐

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

Nan sounpwong 12 me samwolahro, rahn depe seri et sohte iang sukuhl pwehki soumwahu de ohla?

1. ☐ SOHTE RAHN ME EH SOHTE IANG SUKUHL

2. ☐ RAHN 1-3

3. ☐ RAHN 4-6

4. ☐ RAHN 7-10

5. ☐ RAHN 11 DE LAUD SANG

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

7. [ONLY ASK THIS QUESTION IF CHILD IS 6-17 YEARS OLD]

Pak depe seri menet kin...​

	Ansou Koaros	Kalapw	Ekei pak	Sohte pak ehu	I SEHSE	SOHTE MEN SAPENG
H7a. kin kasalehda eh men wia de ese duwen soahng kapw kan?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
H7b. nantihong kanekehla doadoahk kan me re tapiada?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
H7c. kin meleilei oh kak kanengamah ni ahnsou me mehkot apwal kin pwarada?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
H7d. nsenohki en pweida ni skuhl?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
H7e. wia eh doadoahk en skuhl kan koaros?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	☐
H7f. kin nohn akamai laud?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	☐

8. [ONLY ASK THIS QUESTION IF CHILD IS 12-17 YEARS OLD]

Kalelepak 2 mwhur pid duwen kamasepwehk en seri. Kamasepwehk en seri wiawi ni emen tohnsukuhl de laud sang kapailok, likamw, de poakih pil emen tohnsukuhl. pak tohto. Kaidehn kamasepwehk en seri ma tohnsukuhl riamen ni soang en paliwar de kehl duwehte kadillap de kapailok ni mwomwen kempoakepah kan.

Aramas kamasepwehk nomw seri nan sukuhl?

1. ☐ EHI

1. ☐ SOH

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

9. [ONLY ASK THIS QUESTION IF CHILD IS 12-17 YEARS OLD]

Aramas kamasepwehk nomw seri nan internet? (Iangahki ansou me met wiawi nan text, Instagram, Facebook, de pil ehu soang en internet.)

1. ☐ EHI

2. ☐ SOH

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

10. H9. [ONLY ASK THIS QUESTION IF CHILD IS 6-17 YEARS OLD]

Sang ni ansou eh tep nan sukuhl, seri et anahne pwurehng iang ehu pwihn nan sukuhl?

1. ☐ EHI

2. ☐ SOH

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

11. [ONLY ASK THIS QUESTION IF CHILD IS 6-17 YEARS OLD]

Nan wihk samwolahro, rahn depe me seri et kaiahn, mwadong, de wia soang en mwadong tohrohr me doulahng minit 60?

1. ☐ RAHN 0

2. ☐ RAHN 1-3

3. ☐ RAHN 4-6

4. ☐ RAHN KOAROS

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

8. [About You and This Child (PROGRAMMER: Add Timestamp)]

1. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

Nan wihk samwolahro, rahn depe me komwi de tohnpeneinei wadawad ong seri menet?

1. ☐ RAHN 0

2. ☐ RAHN 1-3

3. ☐ RAHN 4-6

4. ☐ RAHN KOAROS

77. ☐ I SEHSE

1. ☐ KAHNG SAPENG

2. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

Nan wihk samwolahro, rahn depe me komwi de tohnpeneinei koasoai de koul ong seri menet?

1. ☐ RAHN 0

2. ☐ RAHN 1-3

3. ☐ RAHN 4-6

4. ☐ RAHN KOAROS

77. ☐ I SEHSE

99. ☐ KAHNG SAPENG

3. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

Seri et kin ale sawas sang emen kaidehn ah pahpa de nohno de sounsilasil men awa 10 de laud sang nan ehu ehu wihk? Iangahki wasahn epwelseri, sukuhl en kisin seri, pirokiram en Head Start, epwelseri nan peneinei, sounsilasil men, de emen nan ah peneinei.

1. ☐ EHI

2. ☐ SOH

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

4. [ONLY ASK THIS QUESTION IF CHILD IS 6-17 YEARS OLD]

Likin kowe oh de aramas laud kan nan imwomw, mie emen arama laud nan en seri menet eh skuhl, mehn mpe kan, de ni kousapw wet me uhdahn ese seri menet oh seri o kak liki pwehn kihong ih kaweid mwahu oh sawas?

2. ☐ EI

☐ SOH

3. ☐ I SEHSE

1. ☐ SOHTE MEN SAPENG

5. NAN SOUNPWONG 12 ME SAMWALAHRO, seri wet tuhweng imwen wini ni dengwa de kahsdo?

1. ☐ EHI

2. ☐ SOH

8. [About Your Family and Household (PROGRAMMER: Add Timestamp)]

1. Mie emen me kin mihmi imwomw me kin kang sika, e-cigarettes de vapors, cigars, pipe tobacco, chewing tobacco, de pwuh? [READ IF NECESSARY: Please answer to the best of your ability. Betel nut is the seed of the fruit of the areca palm. It is also known as areca nut. Betel nut chewing is an important cultural practice in some regions in south and south-east Asia and the Asia Pacific. It is often chewed wrapped inside betel leaves (paan) or with tobacco (betel quid)].

1. ☐ EHI

2. ☐ SOH [GO TO J3]

1. ☐ I SEHSE [GO TO J3]

99. ☐ KAHNG SAPENG [GO TO J3]

2. Mie emen me kin kang sika nan imwomw?

1. ☐ EHI

2. ☐ SOH

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

Ma Puerto Rico, doulahng Pali J5

3. Nomw seri kang pwuh? [READ IF NECESSARY: Betel nut is the seed of the fruit of the areca palm. It is also known as areca nut. Betel nut chewing is an important cultural practice in some regions in south and south-east Asia and the Asia Pacific. It is often chewed wrapped inside betel leaves (paan) or with tobacco (betel quid)]

1. ☐ EHI

2. ☐ SOH

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

4. Komw wehwehki kisehn mwahl en kang pwuh?

1. ☐ EHI

2. ☐ SOH

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

Kalelepak siluh mwuhr pid duwen mwoni.

5. Sang ah ipwidi lel ansou wet, pak depe kumwail apwalki pwainda kenomwail mwenge, pweinen imwomwail, ape?

1. ☐ Sohte pak ehu

2. ☐ Ansou sohte mwahl

3. ☐ Ansou ekis mwahl

4. ☐ Pak tohto

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

6. Kalelepak mwuhr pid duwen ahmw koaiehk en pwainda mwenge. Menia pasapeng pah kawehweh kenomwail NAN SOUNPWONG 12 ME SAMWOLAHRO?

1. ☐ Se kak pwainda mwenge paliwaramwahu ansou koaros.

2. ☐ Se kak pwainda mwenge ansou koaros, ah kenomwail sohte nohn paliwaramwahu.

3. ☐ Se sohte kak pwainda mwenge ekei ansou.

4. ☐ Se sohte kak pwainda mwenge ekei ansou.

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

7. Nan sounpwong 12 me samwolahro, mehnda ma sounpwong ehute, emen nan ahmw peneinei ale:

	EHI	SOH	I SEHSE	KAHNG SAPENG
J7a. Sawas en mwohni sang pirokiram en koapwoarment?	1 ☐	2 ☐	77 ☐	99 ☐
J7b. [Programming note: Do not show for Puerto Rico] Food Stamps de Supplemental Nutrition Assistance Program Benefits (SNAP)? [Programming note: For Puerto Rico Show the Following] Nutrition Assistance Program (pil kadahniki PAN)	1 ☐	2 ☐	77 ☐	99 ☐
J7c. Mwenge ni sohte pweipwei nan sukuhl?	1 ☐	2 ☐	77 ☐	99 ☐
J7d. [Programming note: Do not show for RMI, Palau, FSM, Puerto Rico] Kamwahu kan sang Woman, Infants, and Children (WIC) Program?	1 ☐	2 ☐	77 ☐	99 ☐

Peidek kan en mwuri kin dokedoke duwen anahn en ihmw de wasahn kousoan.

8. Erein sounpwong 12 samwalahro, mie pak me ke sohte kak pwain imwomw (mortgage) de rent ni ahnsou me koasoandi ken pwain?

1. ☐ EI

1. ☐ SOH

1. ☐ I SEHSE

1. ☐ SOHTE MEN SAPENG

9. Erein sounpwong 12 samwalahro, pak depe seri menet mwekidla ni ehu address kapw?

1. PAHN PAK

2. ☐ I SEHSE

3. ☐ SOHTE MEN SAPENG

10. Sang ni ahnsou me seri menet eh ipwidi, mie pak sohte ar wasahn kousoan de re mih nan wasahn sawas kan (shelter)? Met kak wehwehki en mih nan shelter, motel, de nan wasa kis ong ahnsou kis, mihseli ni ihmw kan, de sohte eh wasahn kousoan me mwahu oh ong ahnosu reirei pwe en kak meir oh koammoal mwahu.

4. ☐ EI

5. ☐ SOH

1. ☐ I SEHSE

1. ☐ SOHTE MEN SAPENG

Aramas tohto kin lelohng irair kapwunod kan nan mour. Me pwukat kak wiawieng sohte lipilpil peneinei, ahpw ong ekei aramas peidek pwukat sohte pahn soanoamwahu ong irail. Peidek kan en mwuri pahn dokedoke irair kan me ele kakete wiawi nan erein mour en seri menet. Nin duwen ehu iren kataman, omw pasapeng kan sohte pahn sansalda ong meteikan, oh ke kak lus sang sohte lipilipil peidek me ke sohte men sapeng.​

11. Nin duwen soahng koaros me ke ese, mie PAK seri menet lelohng ehu rehn ape pwukat me ntinting pah?​

	EI	SOH	I SEHSE	SOHTE MEN SAPENG
J11a. Pahpa de nohno de aramas me ahneki pwung en apwalih mweipeseng de tohrohpeseng?​	1 ☐	2 ☐	77 ☐	99 ☐
J11b. Pahpa de nohno de aramas me ahneki pwung melahr?​	1 ☐	2 ☐	77 ☐	99 ☐
J11c. Miheier pak pahpa de nohno de aramas me ahneki pwung mih nan imweteng de kalapwus?​	1 ☐	2 ☐	77 ☐	99 ☐
J11d. Kilang de rong pahpa oh nohno de aramas laud kan poahr, poaki, kikimw de pakirih emenemen nan imwe?​	1 ☐	2 ☐	77 ☐	99 ☐
J11e. Wia emen me lelohng tiahk lemei de kilang tiahk lemei wiawi rehn mehn mpe kan?​	1 ☐	2 ☐	77 ☐	99 ☐
J11f. Mih rehn emen me ahneki soumwahu en madamadau, song en kemehla pein ih, de ahneki soumwahu en pahtou laud?​	1 ☐	2 ☐	77 ☐	99 ☐
J11g. Mihier ren emen me ahneki kapwal en kamom sakau laud de doadoahngki wini suwed kan?	1 ☐	2 ☐	77 ☐	99 ☐
J11h. Aramas wia ih suwed de kadeiki pwehki keinek de wasa me e kohsang ie?	1 ☐	2 ☐	77 ☐	99 ☐
J11i. Aramas wia ih suwed de kadeiki pwehki dah men ih (ohl de lih) de dahme eh pilada pwehn ese dahmen ih?	1 ☐	2 ☐	77 ☐	99 ☐
J11j. Aramas wia ih suwed de kadeiki pwehki ehu soangen soumwahu en roson en paliwar de luhmwumw en paliwar?	1 ☐	2 ☐	77 ☐	99 ☐

8. [About You (PROGRAMMER: Add Timestamp)]

SAPENG KALELEPAK PWUKAT PID SOUNSILASIL RIAMEN NAN IMWE ME KIN APWALIH SERI MENET. Ma mie aramas laud emente, kihda pasapeng pid ih.

1. ARAMAS 1

Komw peneineiki seri wet?

1. ☐ AH PAHPA DE NOHNO MEHLEL

2. ☐ AH PAHPA DE NOHNO KEIRIDA

3. ☐ AH PAHPA DE NOHNO PWEHKI PWOPWOUD

4. ☐ EN AH PAHPA DE NOHNO AH PAHPA DE NOHNO

5. ☐ AH PAHPA DE NOHNO NI ANSOU TIKITIK

6. ☐ PENEINEI EN AH PAHPA DE NOHNO

7. ☐ METEIKAN: PENEINEI

8. ☐ METEIKAN: KAIDEHN PENEINEI

2. Komwi soang dah?

1. ☐ PWUTAK

2. ☐ SEREPEIN

3. Komw sounpar depe?

SOUNPAR

4. Komw kesepwil sang sukuhl dah? PILADA IHTE EHU.

1. ☐ PWIHN 8 DE MALAULAU SANG

2. ☐ PWIHN 9-12, SOHTE DIPLOHMA

3. ☐ KESEPWIL SANG HIGH SUKUHL DE GED

4. ☐ KESEPWIL SANG SUKUHL EN DOADOAHK DE PESNES

5. ☐ KOALET, AH SOHTE DIPLOHMA

6. ☐ DIPLOHMA EN ASSOCIATE (AA, AS)

7. ☐ DIPLOHMA EN BACHELOR'S (BA, BS, AB)

8. ☐ DIPLOHMA EN MASTERS (MA, MS, MSW, MBA)

9. ☐ DIPLOHMA EN DOCTORATE PHD, EDD, MD, DDS, DVM, JD)

5. Komw pwopwoudehr?

1. ☐ PWOPWOUD [GO TO K7]

2. ☐ SAIK PWOPWOUD

3. ☐ MWEIPESENG

4. ☐ KOHPESENG

5. ☐ LIHOHDI

1. ☐ KAHNG SAPENG [GO TO K7]

6. Mie ahmw kahs me kin mihmi rehmwi?

1. ☐ EHI

2. ☐ SOH

1. ☐ KAHNG SAPENG

7. Ia iren ahmw roson?

1. ☐ Mwahu douluhl

2. ☐ Uhdahn mwahu

3. ☐ Mwahu

4. ☐ Sais

5. ☐ Sohte mwahu

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

8. Ia iren ahmw madamadau?

1. ☐ Mwahu douluhl

2. ☐ Uhdahn mwahu

3. ☐ Mwahu

4. ☐ Sais

5. ☐ Sohte mwahu

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

9. Komw doadoahk nan wihk 50 nan wihk 52 mwuren rahnet?

1. ☐ EHI

2. ☐ SOH

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

10. Mie pil emen nan imwet me kin apwalih seri menet?

1. ☐ EHI

2. ☐ SOH [GO TO SECTION L]

1. ☐ KAHNG SAPENG [GO TO SECTION L]

Pil emen aramas menet pahn kadahniki 'Aramas 2'.

11. Aramas 2 peneineiki seri wet?

1. ☐ AH PAHPA DE NOHNO MEHLEL

2. ☐ AH PAHPA DE NOHNO KEIRIDA

3. ☐ AH PAHPA DE NOHNO PWEHKI PWOPWOUD

4. ☐ EN AH PAHPA DE NOHNO AH PAHPA DE NOHNO

5. ☐ AH PAHPA DE NOHNO NI ANSOU TIKITIK

6. ☐ PENEINEI EN AH PAHPA DE NOHNO

7. ☐ METEIKAN: PENEINEI

8. ☐ METEIKAN: KAIDEHN PENEINEI

12. Aramas 2 soang dah?

1. ☐ PWUTAK

2. ☐ SEREPEIN

13. Aramas 2 sounpar depe?

SOUNPAR

14. Aramas 2 kesepwil sang sukuhl dah? PILADA IHTE EHU.

1. ☐ PWIHN 8 DE MALAULAU SANG

2. ☐ PWIHN 9-12, SOHTE DIPLOHMA

3. ☐ KESEPWIL SANG HIGH SUKUHL DE GED

4. ☐ KESEPWIL SANG SUKUHL EN DOADOAHK DE PESNES

5. ☐ KOALET, AH SOHTE DIPLOHMA

6. ☐ DIPLOHMA EN ASSOCIATE (AA, AS)

7. ☐ DIPLOHMA EN BACHELOR'S (BA, BS, AB)

8. ☐ DIPLOHMA EN MASTERS (MA, MS, MSW, MBA)

9. ☐ DIPLOHMA EN DOCTORATE PHD, EDD, MD, DDS, DVM, JD)

15. Aramas 2 pwopwoud?

1. ☐ PWOPWOUD [GO TO K17]

2. ☐ SAIK PWOPWOUD

3. ☐ MWEIPESENG

4. ☐ KOHPESENG

5. ☐ LIHOHDI

1. ☐ KAHNG SAPENG [GO TO K17]

16. Mie en aramas 2 ah kahs me kin mihmi reh?

1. ☐ EHI

2. ☐ SOH

2. ☐ I SEHSE

1. ☐ KAHNG SAPENG

17. Ia iren en aramas 2 ah roson?

1. ☐ Mwahu douluhl

2. ☐ Uhdahn mwahu

3. ☐ Mwahu

4. ☐ Sais

5. ☐ Sohte mwahu

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

18. Ia iren en aramas 2 ah madamadau?

1. ☐ Mwahu douluhl

2. ☐ Uhdahn mwahu

3. ☐ Mwahu

4. ☐ Sais

5. ☐ Sohte mwahu

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

19. Aramas 2 doadoahk nan wihk 50 nan wihk 52 mwuren rahnet?

1. ☐ EHI

2. ☐ SOH

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

8. [Health of Child’s Mother (PROGRAMMER: Add Timestamp)]

1. Soang en tuhweng tohnwini kadahniki "routine" wehwehki sopla rehn tohnwini ni sohte ohla de soumwahu pwehn ale wehwehkin ahmw roson ni oaralap. Uwen wereila sang ahmw tuhweng tohnwini men?

1. ☐ Nan pahr samwolahro (NAN PWUNGEN SOUNPWONG 12 SAMWOLAHRO OH ANSOU WET)

2. ☐ Nan pahr 2 samwolahro (LAUD SANG PAHR 1 AHPW KAIDEHN PAHR 2 SAMWOLAHRO)

3. ☐ Nan pahr 5 samwolahro (LAUD SANG PAHR 2 AHPW KAIDEHN PAHR 5 SAMWOLAHRO)

4. ☐ PAHR 5 DE LAUD SANG SAMWOLAHRO

5. ☐ Sohte pak ehu

77. ☐ I SEHSE

1. ☐ KAHNG SAPENG

2. Nan sounpwong 12 me samwolahro, komw ale sawas en madamadau sang tohnwini en madamadau men? Tohnwini en madamadau men iangahki psychiatrist kan, psychologist kan, psychiatric nurse kan, oh tohndoadoahk en social kan.

1. ☐ Ehi

2. ☐ Soh, ahpw I anahne tuhweng tohnwini en madamadau men

3. ☐ Soh, I sohte anahne tuhweng tohnwini en madamadau men [GO TO L4]

1. ☐ I SEHSE [GO TO L4]

1. ☐ KAHNG SAPENG [GO TO L4]

3. Uwen apwal en ale sawas en madamadau me komw anahne?

1. ☐ Sohte apwal

2. ☐ Apwal tikitik

3. ☐ Apwal lapala

4. Ihs me pilada pilapil kan pid ahmw roson?

1. ☐ EHI

2. ☐ Ahmw pwoud

3. ☐ Komwi oh ahmw pwoud koaros

4. ☐ Ahmw pahpa oh nohno

5. ☐ Pil emen, MENLAU KAWEHWEHDA

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

5. Ihs me pilada pilapil kan pid en nomw seri kan arail roson?

1. ☐ EHI

2. ☐ Ahmw pwoud

3. ☐ Komwi oh ahmw pwoud koaros

4. ☐ Ahmw pahpa oh nohno

5. ☐ PIL EMEN, MENLAU KAWEHWEHDA:

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

Kalelepak kan mwhur pid kang sika, sakau en wai, oh mehn sahliel. Menlau tamataman me ire kan me komw kawehwehda pahn mih ni rir. Ihte aramas me iang wia doadahk en douloal wet pahn kak kilang ire pwukat. Menlau sapeng uwen ahmw koaiehk.

6. Nan rahn 30 me samwolahro, nan rahn depe komw kang sika?

1. ☐ RAHN 0

2. ☐ RAHN 1 DE 2

3. ☐ RAHN 3 LEL 5

4. ☐ RAHN 6 LEL 9

5. ☐ RAHN 10 LEL 19

6. ☐ RAHN 20 LEL 29

7. ☐ RAHN 30 KOAROS

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

7. Komw kang sakau en wai, iangahki sakau en wai me komw kaunopehda nan imwomw?

1. ☐ EHI

2. ☐ SOH

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

8. Nan ahmw mour, komw doadoahngki mehpwukat: [READ IF NECESSARY: Betel nut is the seed of the fruit of the areca palm. It is also known as areca nut. Betel nut chewing is an important cultural practice in some regions in south and south-east Asia and the Asia Pacific.
   It is often chewed wrapped inside betel leaves (paan) or with tobacco (betel quid). Funta, or fronto, is a dark tobacco leaf that can be used for smoking].

	EHI	SOH	I SEHSE	KAHNG SAPENG
L8a. Pwuh	1 ☐	2 ☐	77 ☐	99 ☐
L8b. Vape de e-cigarette	1 ☐	2 ☐	77 ☐	99 ☐
L8c. Funta	1 ☐	2 ☐	77 ☐	99 ☐
L8d. Marijuana (pil kadahniki grass, pot, weed, de reefer)	1 ☐	2 ☐	77 ☐	99 ☐
L8e. Cocaine, iangahki powder, crack de freebase	1 ☐	2 ☐	77 ☐	99 ☐
L8f. Heroin (pil kadahniki smack, junk, de China White)	1 ☐	2 ☐	77 ☐	99 ☐
L8g. Methamphetamines (pil kadahniki speed, crystal, crank, de ice)	1 ☐	2 ☐	77 ☐	99 ☐
L8h. Ecstasy (pil kadahniki MDMA)	1 ☐	2 ☐	77 ☐	99 ☐
L8i. Synthetic marijuana (pil kadahniki K2, spice, face weed, King Kong, Yucatan Fire, Skunk, Moon Rocks)	1 ☐	2 ☐	77 ☐	99 ☐
L8j. Weren wini en steroid de koahr en wini me tohnwini sohte mweidong	1 ☐	2 ☐	77 ☐	99 ☐
L8k. Wini en medek kan me tohnwini men sohte mweidong, de mwomwen doadoahngki tohrohrsang mwomwen tohnwini koasoane? (Iangahki mehn saliel kan codeine, Vicodin, OxyContin, Hydrocodone, oh Percocet)	1 ☐	2 ☐	77 ☐	99 ☐

MA ARAMAS KANG PWUH, DOULAHNG L10. MA ARAMAS MENET DOADOANGKI MEHN SAHLIEL TOHROHR NAN L9, DOULAHNG L11. MA EH SOHTE DOADOANGKI MEHN SAHLIEL, DOULAHNG L12.

9. Nan rahn 30 me samwolahro, nan rahn depe komw kang pwuh?

1. ☐ RAHN 0

2. ☐ RAHN 1 DE 2

3. ☐ RAHN 3 LEL 5

4. ☐ RAHN 6 LEL 9

5. ☐ RAHN 10 LEL 19

6. ☐ RAHN 20 LEL 29

7. ☐ RAHN 30 KOAROS

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

10. Komw ale sawas en mwahula pwehki ahmw doadoadngki mehn sahliel?

1. ☐ EHI

2. ☐ SOH

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

11. Ahmw tohnwini ndaiongkomwi me komw soumwahuki soumwahu en suke pali 1 de 2?

1. ☐ SOAHNG EN SOUMWAHU EN SUKE 1

2. ☐ SOAHNG EN SOUMWAHU EN SUKE 2

3. ☐ SOHTE [GO TO L14]

1. ☐ I SEHSE [GO TO L14]

1. ☐ KAHNG SAPENG [GO TO L14]

12. Komw kang wini pwehn kamwahuiala met?

1. ☐ Wini en soumwahu en suke

2. ☐ Weren wini kan

3. ☐ Wini en soumwahu en suke oh weren wini kan

4. ☐ I sohte kin kang wini

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

13. Tohnwini men ndaiongkomwiehr me nomw seri soumwahukilahr mehpwukat?

    	EHI	SOH	I SEHSE	KAHNG SAPENG
    L13a. Soumwahu en mongiong Rheumatic	1 ☐	2 ☐	77 ☐	99 ☐
    L13b. Soumwahu en karakar Rheumatic	1 ☐	2 ☐	77 ☐	99 ☐
    L13c. Kanser en Cervix	1 ☐	2 ☐	77 ☐	99 ☐
    L13d. Soumwahu en nta	1 ☐	2 ☐	77 ☐	99 ☐

14. Uwen ahmw toutou?

1. ☐ Toutou Tikitik Douluhl

2. ☐ Toutou Tikitik

3. ☐ Toutou Mwahu

4. ☐ Toutou Laud

5. ☐ Toutou Laud Douluhl

15. Dahme komw kin wiewia pid ahmw toutou?

1. ☐ Tihtihla

2. ☐ Mworouroula

3. ☐ Doulahte

4. ☐ I sohte wia mehkot pid ahi toutou

16. Nan rahn 7 me samwolahro, rahn depe me komw kaiahn de mie ahmw wiewia kan laud sang minit 60 nan ehu ehu rahn? Kapatpene ansou koaros me karehda mohngiongomw marahrahla de esingek laud.

1. ☐ RAHN 0

2. ☐ RAHN 1

3. ☐ RAHN 2

4. ☐ RAHN 3

5. ☐ RAHN 4

6. ☐ RAHN 5

7. ☐ RAHN 6

8. ☐ RAHN 7

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

17. Komw liseian?

1. ☐ Ehi

2. ☐ SOH

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

[IF RESPONDENT IS PREGNANT AND/OR HAS INFANT 12 MONTHS OR YOUNGER,
GO TO L10; ELSE, GO TO M1.]

Kalelepak pwukat pid soumwahu en Zika. Soumwahu en Zika wehwehki soumwahu ieu me mwarahkpeseng pwehki amwise, ahpw pil kak mwarahkpeseng pwehki pwes rehn emen me soumwahukiher Zika.

18. Nan ahmw liseian samwolahro, komw pwunodki soumwahukihla Zika? Pilada pasapeng ehu te.

1. ☐ Pwunodki laud

2. ☐ Ekis pwunodki

3. ☐ Sohte pwunod

4. ☐ I sehse soumwahu en Zika ni ahi liseian samwolahro [GO TO M1]

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

19. Mie ansou ni ahmw liseian samwolahro me komw koasoiong tohnwini men de ah tohndoadoahk kan pid duwen soumwahu en Zika?

1. ☐ Soh

2. ☐ Ehi, tohnwini men koasoiehngie pid duwen soumwahu en Zika mehnda I sohte idek reh

3. ☐ Ehi, tohnwini men koasoiehngie pid duwen soumwahu en Zika mwurin I idek reh

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

20. Nan ahmw liseian samwolahro, komw ale des en nta pwehn esela ma komw soumwahukihla Zika?

1. ☐ EHI

2. ☐ SOH [GO TO L23]

1. ☐ I SEHSE [GO TO L23]

1. ☐ KAHNG SAPENG [GO TO L23]

21. Komw soumwahukihla Zika nan ahmw liseian samwolahro?

1. ☐ EHI

2. ☐ SOH [GO TO M1]

1. ☐ I SEHSE [GO TO M1]

1. ☐ KAHNG SAPENG [GO TO M1]

[IF YES] liseiano pid seri dah?

Ma Puerto Rico, doulahng Pali M

Kalelepak kan mwuhr pid ahmw mwekidseli ni ahmw liseian samwolahro.

22. Nan ahmw liseian samwolahro, komw kohla wasa me mie soumwahu en Zika?

1. ☐ EHI

2. ☐ SOH

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

[IF YES] Nan ahmw liseian samwolahro, komw ese me lih liseian kan sohte kohlang wasa kan me mie soumwahu en Zika?

1. ☐ EHI

1. ☐ SOH

77. ☐ I SEHSE

1. ☐ KAHNG SAPENG

[IF NO] Nan ahmw liseian samwolahro, komw kohla wasa me mie soumwahu en Zika?

1. ☐ EHI

2. ☐ SOH

77. ☐ I SEHSE

1. ☐ KAHNG SAPENG

8. [Household Information (PROGRAMMER: Add Timestamp)]

1. Aramas depe kin mihmi wasaht? Iangahki aramas koaros me kin pweidi ihmwet.
   Sohte iangahki emen me kin mihmi pil ehu wasa laud sang sounpwong riau, mwein mie tohnsukuhl de sounpei men.

DEPEN ARAMAS

1. ☐ I SEHSE

1. ☐ KAHNG SAPENG

2. Aramas pwukat depe me peneinei? Peneinei wehwehki aramas me peneineiki seri menet pwehki nta, pwopwoud, keirada, de pirokiram en apwalih seri.

DEPEN ARAMAS

77. ☐ I SEHSE

99. ☐ KAHNG SAPENG

3. Kahrepen ire kan pah pwehn MCH kak esehla laud duwen sawas en wini nan pwungen pwihn en kapwehpwe tohrohr kan. Ihte aramas me iang wia doadahk en douloal wet pahn kak kilang ire pwukat. Uwen ahme ese mwahu. Sohte anahne sapeng medel. Medemedewe duwen uwen amwail mwohni nan ahmw peneinei nan pahr nekihero. Uwen depe mwohn daks kan? Iangahki mwohni koaros me kumwail ale sang doadoahk, pweinen apwalih seri, soang en ale mwoni koaros me komw ale sang koapwoarment, ape. Pil iangahki soang en mwohni tohrohr me kumwail ale.

, , UWEN DEPE KOAROS ($)

77. ☐ I SEHSE

99. ☐ KAHNG SAPENG

4. Ah ma I kihongkomwi ire kei? Komw wehwehki me amwail mwohni...

1. ☐ Malaulau sang $10,000

2. ☐ Nan pwungen $10,000 oh $15,000

3. ☐ Nan pwungen $15,000 oh $20,000s

4. ☐ Nan pwungen $20,000 oh $25,000

5. ☐ Nan pwungen $25,000 oh $35,000

6. ☐ Nan pwungen $35,000 oh $50,000

7. ☐ Nan pwungen $50,000 oh $75,000

8. ☐ $75,000 de laud sang

77. ☐ I SEHSE

99. ☐ KAHNG SAPENG

8. FSM Jurisdiction Specific Module

I pahn tepkihda kalelepak kan pid duwen en nomw seri ah roson.

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

Ni noumw serien eh sounpwong 0 lel 12, pali laud en ahnsou ia mwomwen omw kawendi pwe en meirla?

1. ☐ Ni keilen paliwere

☐ Ni tihnsewe

☐ Pohn kapehde

2. ☐ I SEHSE

3. ☐ SOHTE MEN SAPENG

[ONLY ASK THIS QUESTION IF CHILD IS 0-5 or 6-11 YEARS OLD]

2. Seri menet soumwahuki pakolong en madamadau?

1. ☐ EHI

2. ☐ SOH [GO TO MC2]

77. ☐ I SEHSE [GO TO MC2]

99. ☐ KAHNG SAPENG [GO TO MC2]

[IF YES] Ah [his/her] soumwahu en madamadau ekiste sakanakan, sakanakan, de sakanakan douluhl?

1. ☐ Ekis

2. ☐ Sais

3. ☐ Doar

77. ☐ I SEHSE

1. ☐ KAHNG SAPENG

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

Met I pahn peki rehmwi pid duwen ahmw roson.

3. Nan ahmw liseian samwolahro, komw soumwahukihla soang en soumwahu kan pah?

   	EHI	SOH	I SEHSE	KAHNG SAPENG
   FM3a. Soumwahu en suke pwehki liseian (me tepida nan duwen liseian)	1 ☐	2 ☐	77 ☐	99 ☐
   FM3b. Nta laud (me tepida nan duwen liseian wet), pre-eclampsia, de eclampsia	1 ☐	2 ☐	77 ☐	99 ☐
   FM3c. Soumwahu en nsensuwed	1 ☐	2 ☐	77 ☐	☐

4. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD AND IF BIOLOGICAL MOTHER]

Mwohn komw naitikidi nomw seri, mepwukat wiawi?

	EHI	SOH	I SEHSE	KAHNG SAPENG
FM4a. Mehmen sapeng ahi kalelepak pid duwen dihdi	1 ☐	2 ☐	77 ☐	99 ☐
FM4b. Re peki rehi en iang kilahs en dihdi	1 ☐	2 ☐	77 ☐	99 ☐
FM4c. Re peki rehi en iang kilahs en dihdi	1 ☐	2 ☐	77 ☐	99 ☐
FM4d. I pilada me nei seri pahn ihte dihdi pwehn mwenge	1 ☐	2 ☐	77 ☐	99 ☐
FM4e. I koasoieng ahi peneinei pid ahi pilapil wet	1 ☐	2 ☐	77 ☐	99 ☐
FM4f. I koasoieng ahi tohndoadoahk en wini men pid ahi pilapil wet	1 ☐	2 ☐	77 ☐	99 ☐
FM4g. I pilada en dehr dihdi	1 ☐	2 ☐	77 ☐	☐

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

Sangete ahnsou me noumw seri kapw en neitikdi, ke tuhwongehr toahkte pwehn tehk ma soahng koaros mwahu mwurin omw neitikla (postpartum checkup)? En tuhwong toahkte en liseian mwurin omw neitikla iei keseu ehu me ke anahne wia wihk 12 mwurin omw neitikla.

☐ EI

☐ SOH

☐ I SEHSE

☐ SOHTE MEN SAPENG

6. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

[IF YES] Erein ahnsou me ke wia omw postpartum checkup, omw toahkte o koasoiehng uhk duwen...?​ ​

	EHI	SOH	I SEHSE	SOHTE MEN SAPENG
FM6a. mwenge ong roson mwahu, eksersais, oh katikala uwen toutou de paun me ke alehdi erein omw liseian o	1 ☐	2 ☐	77 ☐	99 ☐
FM6b. ia uwen reirei en ahnsou me I pahn awihki pwe ien kak pil ehu liseian?	1 ☐	2 ☐	77 ☐	99 ☐
FM6c. doadoahngki mehn katokei liseian (birth control)?	1 ☐	2 ☐	77 ☐	99 ☐
FM6d. kilel kan me kasalehda kapwal kan me ke kakete alehdi pwehki omw liseian o?	1 ☐	2 ☐	77 ☐	99 ☐
FM6e. kaukaule tehk kehl en omw nta?	1 ☐	2 ☐	77 ☐	99 ☐
FM6f. dahme ke anahne wia ma ke pehm pepehm en pahtou de pwunod?	1 ☐	2 ☐	77 ☐	99 ☐

7. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

[IF YES] Erein ahnsou me ke aliale omw postpartum checkup, mie emen toahkte me idek rehmw…?​ ​

	EHI	SOH	I SEHSE	SOHTE MEN SAPENG
FM7a. ma ke kin simoke sika de doadoahngki sika me adaneki e-cigarettes ("vape") de tobacco me ke sohte anahne simoke	1 ☐	2 ☐	77 ☐	99 ☐
FM7a. ma mie emen me kamedeki omw pepehm de paliweremwen	1 ☐	2 ☐	77 ☐	99 ☐

8. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

[IF YES] Erein ahnsoun omw postpartum o, mie emen toahkte me…?​ ​

	EHI	SOH	I SEHSE	SOHTE MEN SAPENG
FM8a. kasawih iuk ma ke soumwahu en suke?	1 ☐	2 ☐	77 ☐	99 ☐
FM8b. kihong uhk konomw wini ong soumwahu en nsesuwed laud de pwunod?	1 ☐	2 ☐	77 ☐	99 ☐

9. Nan soupwong 12 me samwolahro, me komw men ale sawas en wini (ni karasepe ni ahmw men tuhweng tohnwini men), and sohte me sewesekomwi?

1. ☐ EHI

2. ☐ SOH [GO TO END]

1. ☐ I SEHSE [GO TO END]

1. ☐ KAHNG SAPENG [GO TO END]

10. Dahme karehda komw kalehpw sohte kak ale sawas en wini? PILADA KOAROS ME PWUNG

	EHI	SOH	I SEHSE	KAHNG SAPENG
FM10a. I sohte kak pwainda.	1 ☐	2 ☐	77 ☐	99 ☐
FM10b. I sehse ia wasa en kohla ie.	1 ☐	2 ☐	77 ☐	99 ☐
FM10c. E uhdahn doh.	1 ☐	2 ☐	77 ☐	99 ☐
FM10d. I sohte kak kohla ni ansou me re mihmi mwo.	1 ☐	2 ☐	77 ☐	99 ☐
FM10e. I sohte kak koasoane ansou en kohla mwo ni ansou mwahu.	1 ☐	2 ☐	77 ☐	99 ☐
FM10f. Sohte werei sidohsa de mwomwhen kohkohseli.	1 ☐	2 ☐	77 ☐	99 ☐
FM10g. Sohte ahi ansou en iang.	1 ☐	2 ☐	77 ☐	99 ☐
FM10h. I pwunodki me ahi sawas en wini sohte pahn pwainda.	1 ☐	2 ☐	77 ☐	99 ☐
FM10i. Karepe tohrohr, Menlau kawehwehda	1 ☐	2 ☐	77 ☐	99 ☐

Kalahngan en ahmw iang douloal wet.

Kiht nan US Department of Health and Human Services men kihong komwi aht kapingki ahmw ansou oh pasapeng kan pid komwi, nome seri kan, oh ahmw peneinei.

Se kesempwalki ahmw pasapeng kan, oh re pahn sewese aht tohndoadoahk kan, irail me wiahda pwung en wehi kan, oh irail me utung peneinei kan en wehwehki laud duwen roson en irail me kin mihmi nan wehi.

Iren Wisik en Mehn Sahpw Kan: Pwhin de kompani sohte kak kaweid de uhki, oh emen sohte anahne sapeng, ire kan ma sohte mie nembe en OMB me saik tokehdiher. Nembe en OMB me kakohng pirokiram wet iei 0906-0042. Iren wisik kan pwehn alehdi ire pwukat pahn kapatpene mwein awa .71 ni ehu ehu sapeng, me iangahki ansou en dawih iren padahk kan, alehdi ire kan tohrohr, kanehkela douloal oh dawih ire kan koaros me mih loale. Ma mie ahmw lamalam pid duwen iren wisik kan en alehdi ire pwukat, de lamalam teikan pid duwen soang en kamalaulaula wisik pwukat, menlau kadaralahng HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857.