4c MCH-JS Survey_2024_Guam_Chuukese

MCH Jurisdictional Survey Instrument

Guam-Chukkese
OMB Control number: 0906-0042; Uma le aoga: xx/xx/2028

1. ^Screener

1. Mi wor semirit seni 0-17 ierir rekan nom lon ei imw?

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

   2. ☐ UII

2. Fitemon semirt seni 0-17 ierir re nom ikkei lon ei imw?

AKAFITEMON SEMIRIT RA KAN NONOM IKA WILIPOS LON EI ADDRESS

3. Met sokkun fossun fonu ouwa kan ani lon imwemi ei?

1. ☐ KAPASAN MERIKA

2. ☐ KAPASAN SPANISH

3. ☐ Chon CHUUK

4. ☐ Chon KOSRAE

5. ☐ Chon POHNPEI

6. ☐ Chon YAP

7. ☐ IKA PWAL EU SOKKUN FWOS, KOSE MOCHEN AFATA:

Polueni ekkena lusun kapas eis fan iten emon me emon ekkewe semirit seni 0-17 ierir ra kan nonom lon ei leni.

Poputa won ewe kukunulo sipwe aiten ngeni “Semirit 1” iwe sopwelo won ewe aruemenun kukkun semirit tori om ka polueni meinisin ekkewe kapas eis ren unusen ekkewe semirit re kan nom ika wilipos lon ewe leni.

4. SEMIRIT 1

Ifa wesetan itan ewe semirit, lepoputan makan itan (initials), ika fer itan a chok forieta?

5. Chon ian ei semirit me/ika mwirimwirin chochon ia? FINI MEINISIN MEI PWUNGU NGENI

Ei semirit nge…

Chon Hispanic ika Latino?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon Hispanic ika Latino. Ei semirit nge…?

☐ Chon Mexico

☐ Chon Puerto Rico

☐ Chon El Salvador

☐ Chon Cuba

☐ Chon Dominican

☐ Chon Guatemala

☐ Pwan ew sokkun Hispanic ika Latino. Kose mochen awewei, ren ei semirit, ika mwirimwirin pwan tefen ia ren chon Hispanic ika Latino. Ren awewe, chon Colombia, Honduras, Spain, me pwan met.

Chon Native Hawaiian ika Pacific Islander?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon Native Hawaiian ika Pacific Islander. Ei semirit nge…?

☐ Chon Native Hawaiian

☐ Chon Tonga

☐ Chon Samoa

☐ Chon Fiji

☐ Chon Guam ika Chamorro

☐ Chon Marshall

☐ Chon Saipan

☐ Chon Mortlock

☐ Chon Kosrae

☐ Chon Carolinian

☐ Chon Palau

☐ Chon Pohnpei

☐ Chon Yap

☐ Chon Chuuk

☐ Pwan ew sokkun Native Hawaiian ika Pacific Islander. Kose mochen awewei, ren ei semirit, ika mwirimwirin pwan tefen ia ren chon Native Hawaiian ika Pacific Islander. Ren awewe, Tahiti, me pwan met.

Chon American Indian ika Alaska Native?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon American Indian ika Alaska Native. Ren awewe, chon Navajo Nation, chochon ewe Blackfeet Einang ren ewe Blackfeet Indian Reservation seni

Montana, chon ewe Native Village ren chon Barrow lnupiat Traditional Kafomon, chon Nome Eskimo

Community, chon Aztec, chon Maya, me pwan met.

Cjon Asia?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon Asia. Ei semirit nge…?

☐ Chon China

☐ Chon Asian Indian

☐ Chon Filipin

☐ Chon Vietnam

☐ Chon Korea

☐ Chon Japan

☐ Pwan ew sokkun chon Asia. Kose mochen awewei, ren ei semirit, ika mwirimwirin pwan tefen ia ren chon Asia. Ren awewe, chon Pakistan, chon Hmong, chon Aghan, me pwan met.

Chon Mei Chonochon ika African American?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon mei chonochon ika African American. Ei semirit nge…?

☐ Chon African American

☐ Chon Jamaica

☐ Chon Haiti

☐ Chon Nigeria

☐ Chon Ethiopia

☐ Chon Somalia

☐ Pwan ew sokkun mei Chonochon ika African American. Kose mochen awewei, ren ei semirit, ika mwirimwirin pwan tefen ia ren chon Mei Chonochon ika African American. Ren awewe, chon Trinidad me Tobago, chon Ghana, chon Congo, me pwan met.

Chon Middle East ika North Afrika?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon Middle East ika North Afrika. Ei semirit nge…?

☐ Chon Lebanon

☐ Chon Iran

☐ Chon Egypt

☐ Chon Syria

☐ Chon Iraq

☐ Chon Israel

☐ Pwan ew sokkun chon Middle East ika North Afrika. Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon Middle East ika North Afrika. Ren awewe, chon Morocco, chon Yemen, chon Kurdistan, me pwan met.

Chon Mei Pwechepwech?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon Mei Pwechepwech. Ei semirit nge…?

☐ Chon England

☐ Chon German

☐ Chon Ireland

☐ Chon Italy

☐ Chon Poland

☐ Chon Scotland

☐ Pwan ew sokkun chon Mei Pwechepwech. Kose mochen awewei, ren ei semirit, ika mwirimwirin pwan tefen ia ren chon Mei Pwechepwech. Ren awewe, chon France, chon Switzerland, chon Norway, me pwan met.

6. Emon met ei semirit?

1. ☐ AT

1. ☐ NENGIN

1. Ier fite ei semirit? Ika pwe ei semirit ekukkun seni eu maram, ka tongeni ara 1 maram pwe kopwe akena ngeni ewe maram a fetal ngeni.

IER (IKA) MARAM

IKA PWE EI SEMIRIT MI KUKKUN SENI IER 4, FEILO NGENI A10.

8. Ifa ukkukun an ei semirit sile fossun Merika?

1. ☐ Fokkun murine

1. ☐ Murine

2. ☐ Ese murine

3. ☐ Fokkun ese murine

1. Ei semirit mi nom won ekkoch safei epwe lamot ngeni seni noun we tokter, me
   nukun vitamins?

1. ☐ UII

2. ☐ APW [GO TO A11]

[IF YES] An ei semirit nom won safei pokiten sokkun osukosuk ren nonomun an samau, lapalapan esap pwung, me pwal ekkewe ekkoch apwangapwangen inis?

1. ☐ UII

1. ☐ APW [GO TO A11]

[IF YES] An ei samau a fen tam ika om ekieki epwe tam seni 12 maram
ika lapeseni?

1. ☐ UII

1. ☐ APW

10. Epwe fich ngeni ei semirit ekkei pekin alilis ren tumunun pochokulen inisin, ika an tupu, pwal alilisin an epwe sile a kan pwal fis ngeni ekkoch taperan?

1. ☐ UII

2. ☐ APW [GO TO A12]

[IF YES] Ei alilis ren pekin pioing, tupu, ika asukul epwe lamot ngeni ewe semirit pokiten sokkun osukosuk ren nonomun an samau, lapalapan esap pwung, me pwal ekkewe ekkoch apwangapwangen inis?

1. ☐ UII

1. ☐ APW [GO TO A12]

[IF YES] An ei samau a fen tam ika om ekieki epwe tam seni 12 maram
ika lapeseni?

1. ☐ UII

1. ☐ APW

11. Om ekieki nge an ewe semirit sile ika tongeni mi eukuk alolo ngeni ekkoch semirit taperan ren met ra kan tongeni me sile?

1. ☐ UII

2. ☐ APW [GO TO A13]

[IF YES] An ei semirit sile ika ton geni mi eukuk pokiten sokkun osukosuk ren nonomun an samau, lapalapan esap pwung, me pwal ekkoch
apwangapwangen inisin?

1. ☐ UII

1. ☐ APW [GO TO A13]

[IF YES] An ei samau a fen tam ika om ekieki epwe tam seni 12 maram
ika lapeseni?

1. ☐ UII

1. ☐ APW

12. Ei semirit epwe eaea ekkewe auchean alilis ren an epwe tongeni mwokutukut ren pekin, amokutu eksersais, riap ren epwe tongeni liwiniti pochokulen me lom me mwirin ewe feiengaw, iwe pwal alilis ren an epwe pwal sile sefal kapas?

1. ☐ UII

2. ☐ APW [GO TO A14]

[IF YES] Ei osukosuk pokiten sokkun osukosuk ren nonomun an samau, lapalapan esap pwung, me pwal ekkewe ekkoch apwangapwangen inis?

1. ☐ UII

1. ☐ APW [GO TO A14]

[IF YES] An ei samau a fen tam ika om ekieki epwe tam seni 12 maram
ika lapeseni?

1. ☐ UII

1. ☐ APW

13. Ei semirit mi wor an osukosuk pun a pwal tongeni safei ren an epwe churi ekkewe konselor ren echichinin letipan, ren mwokutukutun mi osukousk, ika pwan ekkoch?

1. ☐ UII

2. ☐ APW [GO TO A15]

[IF YES] An osukosuk lon mokuran, ika letipan, ika lon an mwokutukut a tam a fen tori 12 maram ika epwe lapaseni?

1. ☐ UII

1. ☐ APW

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

14. SEMIRIT 2

Ifa wesetan itan ewe semirit, lepoputan makan itan (initials), ika fer itan a chok forieta?

16. Chon ian ei semirit me/ika mwirimwirin chochon ia? FINI MEINISIN MEI PWUNGU NGENI

Ei semirit nge…

Chon Hispanic ika Latino?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon Hispanic ika Latino. Ei semirit nge…?

☐ Chon Mexico

☐ Chon Puerto Rico

☐ Chon El Salvador

☐ Chon Cuba

☐ Chon Dominican

☐ Chon Guatemala

☐ Pwan ew sokkun Hispanic ika Latino. Kose mochen awewei, ren ei semirit, ika mwirimwirin pwan tefen ia ren chon Hispanic ika Latino. Ren awewe, chon Colombia, Honduras, Spain, me pwan met.

Chon Native Hawaiian ika Pacific Islander?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon Native Hawaiian ika Pacific Islander. Ei semirit nge…?

☐ Chon Native Hawaiian

☐ Chon Tonga

☐ Chon Samoa

☐ Chon Fiji

☐ Chon Guam ika Chamorro

☐ Chon Marshall

☐ Chon Saipan

☐ Chon Mortlock

☐ Chon Kosrae

☐ Chon Carolinian

☐ Chon Palau

☐ Chon Pohnpei

☐ Chon Yap

☐ Chon Chuuk

☐ Pwan ew sokkun Native Hawaiian ika Pacific Islander. Kose mochen awewei, ren ei semirit, ika mwirimwirin pwan tefen ia ren chon Native Hawaiian ika Pacific Islander. Ren awewe, Tahiti, me pwan met.

Chon American Indian ika Alaska Native?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon American Indian ika Alaska Native. Ren awewe, chon Navajo Nation, chochon ewe Blackfeet Einang ren ewe Blackfeet Indian Reservation seni

Montana, chon ewe Native Village ren chon Barrow lnupiat Traditional Kafomon, chon Nome Eskimo

Community, chon Aztec, chon Maya, me pwan met.

Cjon Asia?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon Asia. Ei semirit nge…?

☐ Chon China

☐ Chon Asian Indian

☐ Chon Filipin

☐ Chon Vietnam

☐ Chon Korea

☐ Chon Japan

☐ Pwan ew sokkun chon Asia. Kose mochen awewei, ren ei semirit, ika mwirimwirin pwan tefen ia ren chon Asia. Ren awewe, chon Pakistan, chon Hmong, chon Aghan, me pwan met.

Chon Mei Chonochon ika African American?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon mei chonochon ika African American. Ei semirit nge…?

☐ Chon African American

☐ Chon Jamaica

☐ Chon Haiti

☐ Chon Nigeria

☐ Chon Ethiopia

☐ Chon Somalia

☐ Pwan ew sokkun mei Chonochon ika African American. Kose mochen awewei, ren ei semirit, ika mwirimwirin pwan tefen ia ren chon Mei Chonochon ika African American. Ren awewe, chon Trinidad me Tobago, chon Ghana, chon Congo, me pwan met.

Chon Middle East ika North Afrika?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon Middle East ika North Afrika. Ei semirit nge…?

☐ Chon Lebanon

☐ Chon Iran

☐ Chon Egypt

☐ Chon Syria

☐ Chon Iraq

☐ Chon Israel

☐ Pwan ew sokkun chon Middle East ika North Afrika. Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon Middle East ika North Afrika. Ren awewe, chon Morocco, chon Yemen, chon Kurdistan, me pwan met.

Chon Mei Pwechepwech?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon Mei Pwechepwech. Ei semirit nge…?

☐ Chon England

☐ Chon German

☐ Chon Ireland

☐ Chon Italy

☐ Chon Poland

☐ Chon Scotland

☐ Pwan ew sokkun chon Mei Pwechepwech. Kose mochen awewei, ren ei semirit, ika mwirimwirin pwan tefen ia ren chon Mei Pwechepwech. Ren awewe, chon France, chon Switzerland, chon Norway, me pwan met.

17. Emon met ei semirit?

1 ☐ AT

2 ☐ NENGIN

18. Ier fite ei semirit? Ika pwe ei semirit ekukkun seni eu maram, ka tongeni ara 1 maram pwe kopwe akena ngeni ewe maram a fetal ngeni.

IER (IKA) MARAM

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

19. Ifa ukkukun an ei semirit sile fossun Merika?

1 ☐ Fokkun murine

2 ☐ Murine

3 ☐ Ese murine

4 ☐ Fokkun ese murine

20. Ei semirit mi nom won ekkoch safei epwe lamot ngeni seni noun we tokter, me
    nukun vitamins?

1 ☐ UII

2 ☐ APW [GO TO A22]

[IF YES] An ei semirit nom won safei pokiten sokkun osukosuk ren nonomun an samau, lapalapan esap pwung, me pwal ekkewe ekkoch apwangapwangen inis?

1. ☐ UII

1. ☐ APW [GO TO A22]

[IF YES] An ei samau a fen tam ika om ekieki epwe tam seni 12 maram
ika lapeseni?

1. ☐ UII

1. ☐ APW

21. Epwe fich ngeni ei semirit ekkei pekin alilis ren tumunun pochokulen inisin, ika an tupu, pwal alilisin an epwe sile a kan pwal fis ngeni ekkoch taperan?

1. ☐ UII

2. ☐ APW [GO TO A23]

[IF YES] Ei alilis ren pekin pioing, tupu, ika asukul epwe lamot ngeni ewe semirit pokiten sokkun osukosuk ren nonomun an samau, lapalapan esap pwung, me pwal ekkewe ekkoch apwangapwangen inis?

1. ☐ UII

1. ☐ APW [GO TO A23]

[IF YES] An ei samau a fen tam ika om ekieki epwe tam seni 12 maram
ika lapeseni?

1. ☐ UII

1. ☐ APW

22. Om ekieki nge an ewe semirit sile ika tongeni mi eukuk alolo ngeni ekkoch semirit taperan ren met ra kan tongeni me sile?

1. ☐ UII

2. ☐ APW [GO TO A24]

[IF YES] An ei semirit sile ika ton geni mi eukuk pokiten sokkun osukosuk ren nonomun an samau, lapalapan esap pwung, me pwal ekkoch
apwangapwangen inisin?

1. ☐ UII

1. ☐ APW [GO TO A24]

[IF YES] An ei samau a fen tam ika om ekieki epwe tam seni 12 maram
ika lapeseni?

1. ☐ UII

1. ☐ APW

23. Ei semirit epwe eaea ekkewe auchean alilis ren an epwe tongeni mwokutukut ren pekin, amokutu eksersais, riap ren epwe tongeni liwiniti pochokulen me lom me mwirin ewe feiengaw, iwe pwal alilis ren an epwe pwal sile sefal kapas?

1. ☐ UII

2. ☐ APW [GO TO A25]

[IF YES] Ei osukosuk pokiten sokkun osukosuk ren nonomun an samau, lapalapan esap pwung, me pwal ekkewe ekkoch apwangapwangen inis?

1. ☐ UII

1. ☐ APW [GO TO A25]

[IF YES] An ei samau a fen tam ika om ekieki epwe tam seni 12 maram
ika lapeseni?

1. ☐ UII

1. ☐ APW

24. Ei semirit mi wor an osukosuk pun a pwal tongeni safei ren an epwe churi ekkewe konselor ren echichinin letipan, ren mwokutukutun mi osukousk, ika pwan ekkoch?

1. ☐ UII

2. ☐ APW [GO TO A26]

[IF YES] An osukosuk lon mokuran, ika letipan, ika lon an mwokutukut a tam a fen tori 12 maram ika epwe lapaseni?

1. ☐ UII

1. ☐ APW

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

25. SEMIRIT 3

Ifa wesetan itan ewe semirit, lepoputan makan itan (initials), ika fer itan a chok forieta?

26. Chon ian ei semirit me/ika mwirimwirin chochon ia? FINI MEINISIN MEI PWUNGU NGENI

Ei semirit nge…

Chon Hispanic ika Latino?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon Hispanic ika Latino. Ei semirit nge…?

☐ Chon Mexico

☐ Chon Puerto Rico

☐ Chon El Salvador

☐ Chon Cuba

☐ Chon Dominican

☐ Chon Guatemala

☐ Pwan ew sokkun Hispanic ika Latino. Kose mochen awewei, ren ei semirit, ika mwirimwirin pwan tefen ia ren chon Hispanic ika Latino. Ren awewe, chon Colombia, Honduras, Spain, me pwan met.

Chon Native Hawaiian ika Pacific Islander?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon Native Hawaiian ika Pacific Islander. Ei semirit nge…?

☐ Chon Native Hawaiian

☐ Chon Tonga

☐ Chon Samoa

☐ Chon Fiji

☐ Chon Guam ika Chamorro

☐ Chon Marshall

☐ Chon Saipan

☐ Chon Mortlock

☐ Chon Kosrae

☐ Chon Carolinian

☐ Chon Palau

☐ Chon Pohnpei

☐ Chon Yap

☐ Chon Chuuk

☐ Pwan ew sokkun Native Hawaiian ika Pacific Islander. Kose mochen awewei, ren ei semirit, ika mwirimwirin pwan tefen ia ren chon Native Hawaiian ika Pacific Islander. Ren awewe, Tahiti, me pwan met.

Chon American Indian ika Alaska Native?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon American Indian ika Alaska Native. Ren awewe, chon Navajo Nation, chochon ewe Blackfeet Einang ren ewe Blackfeet Indian Reservation seni

Montana, chon ewe Native Village ren chon Barrow lnupiat Traditional Kafomon, chon Nome Eskimo

Community, chon Aztec, chon Maya, me pwan met.

Cjon Asia?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon Asia. Ei semirit nge…?

☐ Chon China

☐ Chon Asian Indian

☐ Chon Filipin

☐ Chon Vietnam

☐ Chon Korea

☐ Chon Japan

☐ Pwan ew sokkun chon Asia. Kose mochen awewei, ren ei semirit, ika mwirimwirin pwan tefen ia ren chon Asia. Ren awewe, chon Pakistan, chon Hmong, chon Aghan, me pwan met.

Chon Mei Chonochon ika African American?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon mei chonochon ika African American. Ei semirit nge…?

☐ Chon African American

☐ Chon Jamaica

☐ Chon Haiti

☐ Chon Nigeria

☐ Chon Ethiopia

☐ Chon Somalia

☐ Pwan ew sokkun mei Chonochon ika African American. Kose mochen awewei, ren ei semirit, ika mwirimwirin pwan tefen ia ren chon Mei Chonochon ika African American. Ren awewe, chon Trinidad me Tobago, chon Ghana, chon Congo, me pwan met.

Chon Middle East ika North Afrika?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon Middle East ika North Afrika. Ei semirit nge…?

☐ Chon Lebanon

☐ Chon Iran

☐ Chon Egypt

☐ Chon Syria

☐ Chon Iraq

☐ Chon Israel

☐ Pwan ew sokkun chon Middle East ika North Afrika. Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon Middle East ika North Afrika. Ren awewe, chon Morocco, chon Yemen, chon Kurdistan, me pwan met.

Chon Mei Pwechepwech?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon Mei Pwechepwech. Ei semirit nge…?

☐ Chon England

☐ Chon German

☐ Chon Ireland

☐ Chon Italy

☐ Chon Poland

☐ Chon Scotland

☐ Pwan ew sokkun chon Mei Pwechepwech. Kose mochen awewei, ren ei semirit, ika mwirimwirin pwan tefen ia ren chon Mei Pwechepwech. Ren awewe, chon France, chon Switzerland, chon Norway, me pwan met.

27. Emon met ei semirit?

1. ☐ AT

1. ☐ NENGIN

28. Ier fite ei semirit? Ika pwe ei semirit ekukkun seni eu maram, ka tongeni ara 1 maram pwe kopwe akena ngeni ewe maram a fetal ngeni.

IER (IKA) MARAM

IF THIS CHILD IS YOUNGER THAN 4 YEARS OLD, GO TO A32.

29. Ifa ukkukun an ei semirit sile fossun Merika?

1. ☐ Fokkun murine

1. ☐ Murine

2. ☐ Ese murine

3. ☐ Fokkun ese murine

30. Ei semirit mi nom won ekkoch safei epwe lamot ngeni seni noun we tokter, me
    nukun vitamins?

1. ☐ UII

2. ☐ APW [GO TO A33]

[IF YES] An ei semirit nom won safei pokiten sokkun osukosuk ren nonomun an samau, lapalapan esap pwung, me pwal ekkewe ekkoch apwangapwangen inis?

1. ☐ UII

1. ☐ APW [GO TO A33]

[IF YES] An ei samau a fen tam ika om ekieki epwe tam seni 12 maram
ika lapeseni?

1. ☐ UII

1. ☐ APW

31. Epwe fich ngeni ei semirit ekkei pekin alilis ren tumunun pochokulen inisin, ika an tupu, pwal alilisin an epwe sile a kan pwal fis ngeni ekkoch taperan?

1. ☐ UII

2. ☐ APW [GO TO A34]

[IF YES] Ei alilis ren pekin pioing, tupu, ika asukul epwe lamot ngeni ewe semirit pokiten sokkun osukosuk ren nonomun an samau, lapalapan esap pwung, me pwal ekkewe ekkoch apwangapwangen inis?

1. ☐ UII

1. ☐ APW [GO TO A34]

[IF YES] An ei samau a fen tam ika om ekieki epwe tam seni 12 maram
ika lapeseni?

1. ☐ UII

1. ☐ APW

32. Om ekieki nge an ewe semirit sile ika tongeni mi eukuk alolo ngeni ekkoch semirit taperan ren met ra kan tongeni me sile?

1. ☐ UII

2. ☐ APW [GO TO A35]

[IF YES] An ei semirit sile ika ton geni mi eukuk pokiten sokkun osukosuk ren nonomun an samau, lapalapan esap pwung, me pwal ekkoch
apwangapwangen inisin?

1. ☐ UII

1. ☐ APW [GO TO A35]

[IF YES] An ei samau a fen tam ika om ekieki epwe tam seni 12 maram
ika lapeseni?

1. ☐ UII

1. ☐ APW

33. Ei semirit epwe eaea ekkewe auchean alilis ren an epwe tongeni mwokutukut ren pekin, amokutu eksersais, riap ren epwe tongeni liwiniti pochokulen me lom me mwirin ewe feiengaw, iwe pwal alilis ren an epwe pwal sile sefal kapas?

1. ☐ UII

2. ☐ APW [GO TO A36]

[IF YES] Ei osukosuk pokiten sokkun osukosuk ren nonomun an samau, lapalapan esap pwung, me pwal ekkewe ekkoch apwangapwangen inis?

1. ☐ UII

1. ☐ APW [GO TO A36]

[IF YES] An ei samau a fen tam ika om ekieki epwe tam seni 12 maram
ika lapeseni?

1. ☐ UII

1. ☐ APW

34. Ei semirit mi wor an osukosuk pun a pwal tongeni safei ren an epwe churi ekkewe konselor ren echichinin letipan, ren mwokutukutun mi osukousk, ika pwan ekkoch?

1. ☐ UII

2. ☐ APW [GO TO A37]

[IF YES] An osukosuk lon mokuran, ika letipan, ika lon an mwokutukut a tam a fen tori 12 maram ika epwe lapaseni?

1. ☐ UII

1. ☐ APW

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

35. SEMIRIT 4

Ifa wesetan itan ewe semirit, lepoputan makan itan (initials), ika fer itan a chok forieta?

36. Chon ian ei semirit me/ika mwirimwirin chochon ia? FINI MEINISIN MEI PWUNGU NGENI

Ei semirit nge…

Chon Hispanic ika Latino?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon Hispanic ika Latino. Ei semirit nge…?

☐ Chon Mexico

☐ Chon Puerto Rico

☐ Chon El Salvador

☐ Chon Cuba

☐ Chon Dominican

☐ Chon Guatemala

☐ Pwan ew sokkun Hispanic ika Latino. Kose mochen awewei, ren ei semirit, ika mwirimwirin pwan tefen ia ren chon Hispanic ika Latino. Ren awewe, chon Colombia, Honduras, Spain, me pwan met.

Chon Native Hawaiian ika Pacific Islander?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon Native Hawaiian ika Pacific Islander. Ei semirit nge…?

☐ Chon Native Hawaiian

☐ Chon Tonga

☐ Chon Samoa

☐ Chon Fiji

☐ Chon Guam ika Chamorro

☐ Chon Marshall

☐ Chon Saipan

☐ Chon Mortlock

☐ Chon Kosrae

☐ Chon Carolinian

☐ Chon Palau

☐ Chon Pohnpei

☐ Chon Yap

☐ Chon Chuuk

☐ Pwan ew sokkun Native Hawaiian ika Pacific Islander. Kose mochen awewei, ren ei semirit, ika mwirimwirin pwan tefen ia ren chon Native Hawaiian ika Pacific Islander. Ren awewe, Tahiti, me pwan met.

Chon American Indian ika Alaska Native?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon American Indian ika Alaska Native. Ren awewe, chon Navajo Nation, chochon ewe Blackfeet Einang ren ewe Blackfeet Indian Reservation seni

Montana, chon ewe Native Village ren chon Barrow lnupiat Traditional Kafomon, chon Nome Eskimo

Community, chon Aztec, chon Maya, me pwan met.

Cjon Asia?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon Asia. Ei semirit nge…?

☐ Chon China

☐ Chon Asian Indian

☐ Chon Filipin

☐ Chon Vietnam

☐ Chon Korea

☐ Chon Japan

☐ Pwan ew sokkun chon Asia. Kose mochen awewei, ren ei semirit, ika mwirimwirin pwan tefen ia ren chon Asia. Ren awewe, chon Pakistan, chon Hmong, chon Aghan, me pwan met.

Chon Mei Chonochon ika African American?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon mei chonochon ika African American. Ei semirit nge…?

☐ Chon African American

☐ Chon Jamaica

☐ Chon Haiti

☐ Chon Nigeria

☐ Chon Ethiopia

☐ Chon Somalia

☐ Pwan ew sokkun mei Chonochon ika African American. Kose mochen awewei, ren ei semirit, ika mwirimwirin pwan tefen ia ren chon Mei Chonochon ika African American. Ren awewe, chon Trinidad me Tobago, chon Ghana, chon Congo, me pwan met.

Chon Middle East ika North Afrika?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon Middle East ika North Afrika. Ei semirit nge…?

☐ Chon Lebanon

☐ Chon Iran

☐ Chon Egypt

☐ Chon Syria

☐ Chon Iraq

☐ Chon Israel

☐ Pwan ew sokkun chon Middle East ika North Afrika. Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon Middle East ika North Afrika. Ren awewe, chon Morocco, chon Yemen, chon Kurdistan, me pwan met.

Chon Mei Pwechepwech?

☐ Ewer

☐ Apw

[IF YES] Kose mochen awewei, ren ei semirit, ika mwirimwirin tefen chon Mei Pwechepwech. Ei semirit nge…?

☐ Chon England

☐ Chon German

☐ Chon Ireland

☐ Chon Italy

☐ Chon Poland

☐ Chon Scotland

☐ Pwan ew sokkun chon Mei Pwechepwech. Kose mochen awewei, ren ei semirit, ika mwirimwirin pwan tefen ia ren chon Mei Pwechepwech. Ren awewe, chon France, chon Switzerland, chon Norway, me pwan met.

37. Emon met ei semirit?

1. ☐ AT

1. ☐ NENGIN

38. Ier fite ei semirit? Ika pwe ei semirit ekukkun seni eu maram, ka tongeni ara 1 maram pwe kopwe akena ngeni ewe maram a fetal ngeni.

IER (IKA) MARAM

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

39. Ifa ukkukun an ei semirit sile fossun Merika?

1. ☐ Fokkun murine

1. ☐ Murine

2. ☐ Ese murine

3. ☐ Fokkun ese murine

40. Ei semirit mi nom won ekkoch safei epwe lamot ngeni seni noun we tokter, me
    nukun vitamins?

1. ☐ UII

2. ☐ APW [GO TO A44]

[IF YES] An ei semirit nom won safei pokiten sokkun osukosuk ren nonomun an samau, lapalapan esap pwung, me pwal ekkewe ekkoch apwangapwangen inis?

1. ☐ UII

1. ☐ APW [GO TO A44]

[IF YES] An ei samau a fen tam ika om ekieki epwe tam seni 12 maram
ika lapeseni?

1. ☐ UII

1. ☐ APW

41. Epwe fich ngeni ei semirit ekkei pekin alilis ren tumunun pochokulen inisin, ika an tupu, pwal alilisin an epwe sile a kan pwal fis ngeni ekkoch taperan?

1. ☐ UII

2. ☐ APW [GO TO A45]

[IF YES] Ei alilis ren pekin pioing, tupu, ika asukul epwe lamot ngeni ewe semirit pokiten sokkun osukosuk ren nonomun an samau, lapalapan esap pwung, me pwal ekkewe ekkoch apwangapwangen inis?

1. ☐ UII

1. ☐ APW [GO TO A45]

[IF YES] An ei samau a fen tam ika om ekieki epwe tam seni 12 maram
ika lapeseni?

1. ☐ UII

1. ☐ APW

42. Om ekieki nge an ewe semirit sile ika tongeni mi eukuk alolo ngeni ekkoch semirit taperan ren met ra kan tongeni me sile?

1. ☐ UII

2. ☐ APW [GO TO A46]

[IF YES] An ei semirit sile ika ton geni mi eukuk pokiten sokkun osukosuk ren nonomun an samau, lapalapan esap pwung, me pwal ekkoch
apwangapwangen inisin?

1. ☐ UII

1. ☐ APW [GO TO A46]

[IF YES] An ei samau a fen tam ika om ekieki epwe tam seni 12 maram
ika lapeseni?

1. ☐ UII

1. ☐ APW

43. Ei semirit epwe eaea ekkewe auchean alilis ren an epwe tongeni mwokutukut ren pekin, amokutu eksersais, riap ren epwe tongeni liwiniti pochokulen me lom me mwirin ewe feiengaw, iwe pwal alilis ren an epwe pwal sile sefal kapas?

1. ☐ UII

2. ☐ APW [GO TO A47]

[IF YES] Ei osukosuk pokiten sokkun osukosuk ren nonomun an samau, lapalapan esap pwung, me pwal ekkewe ekkoch apwangapwangen inis?

1. ☐ UII

1. ☐ APW [GO TO A47]

[IF YES] An ei samau a fen tam ika om ekieki epwe tam seni 12 maram
ika lapeseni?

1. ☐ UII

1. ☐ APW

44. Ei semirit mi wor an osukosuk pun a pwal tongeni safei ren an epwe churi ekkewe konselor ren echichinin letipan, ren mwokutukutun mi osukousk, ika pwan ekkoch?

1. ☐ UII

2. ☐ APW [GO TO A48]

[IF YES] An osukosuk lon mokuran, ika letipan, ika lon an mwokutukut a tam a fen tori 12 maram ika epwe lapaseni?

1. ☐ UII

1. ☐ APW

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

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

45. SEMIRIT 5

Ifa wesetan itan ewe semirit, lepoputan makan itan (initials), ika fer itan a chok forieta?

46. Ier fite ei semirit?

IER (IKA) MARAM

47. Emon met ei semirit?

1. ☐ AT

1. ☐ NENGIN

48. SEMIRIT 6

Ifa wesetan itan ewe semirit, lepoputan makan itan (initials), ika fer itan a chok forieta?

49. Ier fite ei semirit?

IER (IKA) MARAM

50. Emon met ei semirit?

1. ☐ AT

1. ☐ NENGIN

51. SEMIRIT 7

Ifa wesetan itan ewe semirit, lepoputan makan itan (initials), ika fer itan a chok forieta?

52. Ier fite ei semirit?

IER (IKA) MARAM

53. Emon met ei semirit?

1. ☐ AT

1. ☐ NENGIN

54. SEMIRIT 8

Ifa wesetan itan ewe semirit, lepoputan makan itan (initials), ika fer itan a chok forieta?

55. Ier fite ei semirit?

IER (IKA) MARAM

56. Emon met ei semirit?

1. ☐ AT

1. ☐ NENGIN

57. SEMIRIT 9

Ifa wesetan itan ewe semirit, lepoputan makan itan (initials), ika fer itan a chok forieta?

58. Ier fite ei semirit?

IER (IKA) MARAM

59. Emon met ei semirit?

1. ☐ AT

1. ☐ NENGIN

60. SEMIRIT 10

Ifa wesetan itan ewe semirit, lepoputan makan itan (initials), ika fer itan a chok forieta?

61. Ier fite ei semirit?

IER (IKA) MARAM

62. Emon met ei semirit?

1. ☐ AT

2. ☐ NENGIN

2. Nonomun Pochokulen Inisin Ei Semirit

Mi wor pwal ekkoch kapas eis sipwe liwin sefal le eis ren [AFATA MENI LEIN EKKEWE SEMIRIT]. Ekkei kapas eis epwe aworato tichikikin porausen me nonomun pochokulen inisin, me tumunun ewe semirit fan iten an churi pioing, pwal momon an churi pioing, fengen me noun momon lon pioing ren met noun insurance mi moni. Sia filata emon chok semirit seni eu imw ren ach achocho ngeni ekukunalo ewe aukukun fansoun mi auchea ach sipwe awesalo ika liwiniti ekkewe kapas eis sipwe eis.

1. Om kopwe menlapei, ifa usun kopwe awewei nonomun pochokulen inisin ei semirit?

1. ☐ Unuseoch

1. ☐ Fokkun Murine

2. ☐ Murine

3. ☐ Eoch

4. ☐ Ngaw

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

2. ifa usun kopwe awewei nonomun pochokulen ngin ei semirit?

1. ☐ Unuseoch

1. ☐ Fokkun Murine

2. ☐ Murine

3. ☐ Eoch

4. ☐ Ngaw

5. ☐ EWE SEMIRIT ESE MO WOR NGIN

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

3. Lon ekkewe 12 maram a lo, ei semirit mi soun ika fis ngeni weiresin epwe fori
   ekkei metoch?

   	UII	APW	USE SILEI	UWA FILATA USAP POLUENI
   B3a. Osukosuken non ngasangas ika sokkun weires an lenien ngas (awewe ren ngungun an mwi ika mochen weires an ngasengas)	1 ☐	2 ☐	77 ☐	99 ☐
   B3b. Mwongo ika oromi pokiten an samau	1 ☐	2 ☐	77 ☐	99 ☐
   B3c. Ekkewe mongo si walong lon upwach/a aworato ach osukosuk, ren mwech kiten mwong, ika fen pwal feilseni	1 ☐	2 ☐	77 ☐	99 ☐
   B3d. Metekitek ese eukuk, mi pachelong metek mokur, sokur ika metekitek inis	1 ☐	2 ☐	77 ☐	99 ☐
   B3e. Eaean poun	1 ☐	2 ☐	77 ☐	99 ☐
   B3f. Emekutu fengeni ika mwokutukut	1 ☐	2 ☐	77 ☐	99 ☐
   B3g. Metekin ngi	1 ☐	2 ☐	77 ☐	99 ☐
   B3h. Chaan ochan ngi	1 ☐	2 ☐	77 ☐	99 ☐
   B3i. Ngawelon ngi	1 ☐	2 ☐	77 ☐	99 ☐
   B3j. Paikin lon seling	1 ☐	2 ☐	77 ☐	99 ☐

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

Mi uri ei semirit ekkei ekkoch osukosuk?

	UII	APW	USE SILEI	UWA FILATA USAP POLUENI
B4a. Seling mi pwa ika osukosuken esap rong	1 ☐	2 ☐	77 ☐	99 ☐
B4b. Chuun ika osukosuken esap kuna mwan, inamo ika mi nounou kilasin mesechun	1 ☐	2 ☐	77 ☐	99 ☐

5. Tokter ika pekin pioing ra fen erenuk pun ewe semirit mi wor ren ekkei sokkun samau? Ika pwe uii, ewe semirit mi wor chiwen an osukosuk?

   	Fan Ekkoch?	Iei?	USE SILEI	UWA FILATA USAP POLUENI
   B5a. Mwi	1 ☐ Uii 2 ☐ Apw	1 ☐ Uii 2 ☐ Apw	77 ☐	99 ☐
   B5b. Man Suke	1 ☐ Uii 2 ☐ Apw	1 ☐ Uii 2 ☐ Apw	77 ☐	99 ☐
   B5c. Down Syndrome (Terin Inis Mangen Ekiek)	1 ☐ Uii 2 ☐ Apw	1 ☐ Uii 2 ☐ Apw	77 ☐	99 ☐
   B5d. Soun Metek Mokur mi Fiti Elingaw, pwal Toputopun Lon Mas	1 ☐ Uii 2 ☐ Apw	1 ☐ Uii 2 ☐ Apw	77 ☐	99 ☐
   B5e. Feiengawen en Tupu, Chaa Lon Ewe Mokur Mi Feiengaw, pwan Feiengawen Mokur	1 ☐ Uii 2 ☐ Apw	1 ☐ Uii 2 ☐ Apw	77 ☐	99 ☐
   B5f. Riafou Mi Fiti Lolilen	1 ☐ Uii 2 ☐ Apw	1 ☐ Uii 2 ☐ Apw	77 ☐	99 ☐
   B5g. Letipechou	1 ☐ Uii 2 ☐ Apw	1 ☐ Uii 2 ☐ Apw	77 ☐	99 ☐
   B5h. Autism, ASD, Autism Spectrum Disorder (ASD), Asperger’s Disorder, ika Pervasive Developmental Disorder (PDD) (awewe, semirit mi apwangapwang inisir me ar ekiek)	1 ☐ Uii 2 ☐ Apw	1 ☐ Uii 2 ☐ Apw	77 ☐	99 ☐
   B5i. Attention Deficit Disorder (ADD) or Attention Deficit/Hyperactivity Disorder (ADHD) (awewe, semirit mi osukosuk ar ekiek, rese pwal tongeni mesonoson)	1 ☐ Uii 2 ☐ Apw	1 ☐ Uii 2 ☐ Apw	77 ☐	99 ☐
   B5j. Mi Mang Marir Pokiten En Tupu	1 ☐ Uii 2 ☐ Apw	1 ☐ Uii 2 ☐ Apw	77 ☐	99 ☐
   B5k. Lapelaper me Mwokutukutur Esap Pwung	1 ☐ Uii 2 ☐ Apw	1 ☐ Uii 2 ☐ Apw	77 ☐	99 ☐
   B5l. Ese Wor Ar Wewe (pwal wewen mang me tiparoch)	1 ☐ Uii 2 ☐ Apw	1 ☐ Uii 2 ☐ Apw	77 ☐	99 ☐
   B5m. Kumwechumoch Foos	1 ☐ Uii 2 ☐ Apw	1 ☐ Uii 2 ☐ Apw	77 ☐	99 ☐
   B5n. Weiresin Kaio	1 ☐ Uii 2 ☐ Apw	1 ☐ Uii 2 ☐ Apw	77 ☐	99 ☐
   B5o. Pwal Eu Sokkun Samaun Tupu	1 ☐ Uii 2 ☐ Apw	1 ☐ Uii 2 ☐ Apw	77 ☐	☐

6. Lon ekkewe 12 maram a lononomun ei semirit ren an samau a kan aosukosuka an epwe tongeni fori ekkewe ekkoch metoch ekkewe semirit mi lolo ngeni ierir ra kan fori?

1. ☐ EI SEMIRIT ESAP PWAL URI EKKOCH SAMAU [GO TO B8]

2. ☐ Ese mo [GO TO B8]

1. ☐ Fan ekkoch

2. ☐ Iteitan

3. ☐ Fansoun meinisin

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

7. Ifa ukukun an ei semirit a tongeni angawalo an tongeni pokiten an samau?

1. ☐ Fokkun ekis chok

1. ☐ Pwal ianan

2. ☐ Unusan lon eu waten pwungun

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

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

Ewe tokter ika chon angang lon pekin tumwunun inis a fen esile ngonuk pwe noumw we semirit men wor ren ewe semwen pun inan men angei ewe safean opuchopuch (drugs) nupwen an pwopwo? Ewe semwenin sakau ika safeian opuchopuch (drugs) a kan fis lupwen a kon wate met ka angei nge ekkei metoch mi afeiengawa inisich, pun sia pwal tongeni mwek ren pwal osukosuka wisach lon angang, sukun, me lon imw.

1. ☐ UII

2. ☐ APW [GO TO B9]

1. ☐ USE SILEI [GO TO B9]

1. ☐ UWA FILATA USAP POLUENI [GO TO B9]

[IF YES] A fen wor ei samau ren ei semirit?

1. ☐ UII

1. ☐ APW [GO TO B9]

1. ☐ USE SILEI [GO TO B9]

1. ☐ UWA FILATA USAP POLUENI [GO TO B9]

[IF YES] A fen:

1. ☐ Ekisi chok

1. ☐ Ekis wate

1. ☐ Ngawelo

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

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

Mi uri ei semirit ekkei ekkoch osukosuk?

	UII	APW	USE SILEI	UWA FILATA USAP POLUENI
B9a. Fokkun weires an epwe auselingifich, chemeni, ika fori och filata pokiten met mi fis ngeni ren samaun lukun inisin, lon mekuran, ika fen lon an ekiek	1 ☐	2 ☐	77 ☐	99 ☐
B9b. Waten osukosuken fetaleta won nato	1 ☐	2 ☐	77 ☐	99 ☐
B9c. Weiresin ufouf me pwisin tutu	1 ☐	2 ☐	77 ☐	99 ☐
B9d. Weiresin an fetal le fori an angang nge alaemon, awewe ren feilo ngeni tokter ika shopping, pokiten feingaw, ika osukosuken lon mekuran, me meefian	1 ☐	2 ☐	77 ☐	99 ☐
B9e. Seling mi pwa ika osukosuken esap rong	1 ☐	2 ☐	77 ☐	99 ☐
B9f. Chuun ika osukosuken esap kuna mwan, inamo ika mi nounou kilasin mesechun	1 ☐	2 ☐	77 ☐	99 ☐

10. Mi wor tokter ika chon pioing mi pin erenuk pun ei semirit mi uri….

	UII	APW	USE SILEI	UWA FILATA USAP POLUENI
B10a. Rheumatic heart disease (osukosuken ekkewe paip mi sa ngeni en ngasengas)	1 ☐	2 ☐	77 ☐	99 ☐
B10b. Rheumatic fever (eu semwen e fisita ika pwe kose kon chikar seni ewe paiking lon chiorom iwe a efisata rheumatic fever mi fiti pwichikar, metekin kupukupun chum)	1 ☐	2 ☐	77 ☐	99 ☐
B10c. Impetigo (kilingaw mi tongeni tori ekkoch ika ke nom unukur)	1 ☐	2 ☐	77 ☐	99 ☐

[IF YES TO RHEUMATIC HEART DISEASE OR FEVER] A fen nom won safei ren
ei samau?

1. ☐ UII

2 ☐ APW

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

[IF YES] A fen nom won foun safei ika appos?

1. ☐ FOUN SAFEI [GO TO B11]

1. ☐ APPOS [GO TO B11]

[IF NO] Pwata ese nom won ena safei? CHEKI MEINISIN MI WENEITI.

1. ☐ Ese ukkukun momon ewe.

1. ☐ Ese wor wa epwe atoura kich.

3 ☐ Ese wor epwe tongeni uwei nei we semirit ngeni pioing.

4 ☐ Ese auchea

5 ☐ PWAL EKKOCH POPUN, KOSE MOCHEN AFATA

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

11. Mi wor tokter ika chon pioing re erenuk pun ei semirit mi osukosuk chaan ren ewe samaun lon chaa (leukemia), ika esap naf ewe chaa mi foukukumos parepar (anemia), ika pwal ewe samaun lon chaa a fis ika pwe ekkew chaa mi kukumos parapar a momokutiw (sickle cell disease)? Kosapw pachenong Sickle Cell Trait.

[READ IF NECESSARY]: Semirit mi wor rer ei semwau “anemia” are osukosuk non chaar a kan efisi ar repwe fokkun melulu.

1. ☐ UII

2. ☐ APW

1. ☐ USAP SILEI

1. ☐ UWA FILATA USAP POLUENI

Iei upwele eisinuk kapas eis usun om epeti feiengaw seni noum we semirit.

12. Eni ka emon menumuk lon imwomw we ka kan poputa ne poporaus ngeni ewe semirit ren ifa usun ach sipwe epetir ika tumunu ir seni feiengawan fifiou ika kawet tumunu an ewe semirit esap feiengaw? Awewe chok, feiengawan urumot won alen toraku, toki ira, pwal tuken lon ewe saat.

1. ☐ Uii, epeti seni feiengawen osukosuken fifiu

1. ☐ Uii, ren tumunu kich seni feiengaw

2. ☐ Me ruu

3. ☐ Use mo

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

13. Ka kan fifiti noum we semirit atun kukunou lukun awewe ren kunou lon ach kewe pool ren eaea ika ukurumot lukun?

1. ☐ UII

1. ☐ APW

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

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

Lupwen noum we a kan wawa wan we pasikel, fan fite an kan akau ekkewe elmet?

1. ☐ Nei we semirit ese kan wawa pasikel

1. ☐ Esap fan eu epwe akau ekkewe elmet

2. ☐ Esap iteitan fansoun meinisin

3. ☐ Fan ekkoch a akau ekkewe elmet

4. ☐ Lapengeni mi chok akakau ekkewe elmet

5. ☐ Iteitan mi chok akakau ekkewe elmet

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

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

Fan fite noum we semirit mi chok nonom lon lenien lenien semirit (car seat ika booster) lupwen ra fiti en toraku pwe resap feiengaw.

1. ☐ Fansoun meinisin

1. ☐ Lapengeni iteitan

2. ☐ Fan ekkoch

3. ☐ Fan ekkoch chok

4. ☐ Ese mo [GO TO C1]

5. ☐ NEI WE SEMIRIT ESE NONOM LON LENIEN LENIEN SEMIRIT LUPWEN A FITI TORAKU [GO TO C1]

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

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

Tefan womw we toraku a kan nom ia lenien ewe semirit we?

1. ☐ Nenian memot mwan unukun ewe chon unteng

2. ☐ Nenian memot nukunu sokurun ewe chon memot mwan

3. ☐ Nenian memot nukun sokurun ewe chon unteng

4. ☐ Nenian memot nukanapan mwirin ewe pasin me chon unteng

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

3. Ren Ei Semirit Lupwen An Chiwen Menukon

1. Ei semirit e uputiw lapeseni 3 wik me mwan ewe fansoun ururun epwe uputiw?

1. ☐ UII

1. ☐ APW

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

2. Fitu pounen ewe semirit lupwen an uputiw? Polueni lon poun me ounes ika kilo me krams. Wato chok ena nampa e kan ngeni ena eukukun. [IF NEEDED, READ]: ASISILETA CHOK UKKUKUN OM TONGENI. ESAP ITA EPWE WESEWESEN WON ENA
   WESEN NAMPA.

CHOUN ME OUNUS

KILO ME KRAM

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

3. Ke ier fite lupwen a uputiw ei semirit?

IER

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

Ei semirit ekkan oup ika un titi?

1. ☐ UII

2. ☐ APW [GO TO C6]

1. ☐ USE SILEI [GO TO C6]

1. ☐ UWA FILATA USAP POLUENI [GO TO C6]

[IF YES] Ier fite ei semirit lupwen an wesewesen keuno me un chonun oup ika ar chiwen ounu chonun oup?

RAN (IKA)

WIK (IKA)

MARAM (IKA)

IER

EI SEMIRIT MI CHIWEN OUP

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

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

Fitu ierin ena semirit an ewe AKKOMWEN wuun unumen monukon minik?

FITU RAN (IKA)

WIIK (IKA)

MARAM (IKA)

AN UPWUTIW

ESE MWO WUUN UNUMEN MONUKON MINIK

☐ ESE FFAT

☐ USE MOCHEN EPPONUWA

6. Ier fite ei semirit lupwen ka keran poputa amongoni mongo me lukun chonun oupu me aunu milik? Pachelong juice, milik seni kow, konik mi suke, anan menukon mongo ika siriel, ika ese pwal lifilifil sokkun mongo ka pin amongonui noum na semirit, pwal pachelong konik.

RAN (IKA) WIK (IKA) MARAM

LUPWEN AN UPUTIW

CHEKI EI POR IKA PWE NOUM EI SEMIRIT ESE MEN PIN MONGO IKA
UN METOCH

ME LUKUN CHONUN OUP ME MILIK

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

4. Health Care Services (Pekin Alilis Ren Tumunun Inis)

1. Lon ekkewe fansoun 12 maram a lo, Ei semirit mi pin churi tokter, kangof, ika ese pwal lifilifil chon pioing ren an samau ika an chok chekin-semirit, kensa ika check-up, ika mi pin nuuing pioing ika pwal ese lifilifil chekin tumunun inis?

1. ☐ UII

2. ☐ APW [GO TO D2]

1. ☐ USE SILEI [GO TO D2]

1. ☐ UWA FILATA USAP POLUENI [GO TO D2]

[IF YES] Lon ekkewe fansoun 12 maram a lo, Fan fite an ei semirit churi tokter, kangof, ika ekkoch chon angangen pioing ren om tumunu an epwe angei eu “PREVENTIVE” check-up ika akomwen chekin inisin pwe epwe tongeni epeti seni feiengaw? Eu “preventive check-up” a wewe ngeni om wato noum we semirit pioing ren met sia aita ngeni epet wewen ei semirit ese samau ika feiengaw, ka feito pokiten a tori ewe ierin epwe etto angei an safeian epet, ika ren pekin sports ika urumot lon sukul epwe fiti, ika fen pwal an churi tokter fan itan a pwal tori atun epwe chek ren pekin tumunun ewe semirit lon an mamarita pun epwe pochokul.

1. ☐ ESE MO CHURI

1. ☐ 1 AN CHURI

1. ☐ 2 IKA LAPESENI AN CHURI

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

2. En mi lolilen ren choun noum ei?

1. ☐ Uii, pun a kon kineta

1. ☐ Uii, pun a kon kinetiw

2. ☐ Apw, use lolilen

1. ☐ USAP SILEI

1. ☐ UWA FILATA USAP POLUENI

3. Ren iei ifa ukkukun taman (ika chochon)? Kose mochen apasa met chok ka ekieki mi kan ngeni om oukuk. [IF NEEDED, READ]: ASISILETA CHOK UKKUKUN OM TONGENI. ESAP ITA EPWE WESEWESEN WON ENA WESEN NAMPA.

TAMAN ME INIS

MITER ME SENTIMITER

1. ☐ USAP SILEI

1. ☐ UWA FILATA USAP POLUENI

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

1. ☐ RESPONDENT ESTIMATE

2. ☐ MEASURED ON SITE

4. Fitu pounen ei semirit iei? Kose mochen apasa met chok ka ekieki mi kan ngeni om oukuk. [IF NEEDED, READ]: ASISILETA CHOK UKKUKUN OM TONGENI. ESAP ITA EPWE WESEWESEN WON ENA WESEN NAMPA.

CHOUN ME OUNUS

KILO ME KRAM

1. ☐ USAP SILEI

1. ☐ UWA FILATA USAP POLUENI

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

1. ☐ RESPONDENT ESTIMATE

1. ☐ MEASURED ON SITE

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

Lon ekkewe fansoun 12 maram a lo, Noun ei semirit we tokter ika chon tumunun lon pioing mi eis ika en mi eani lolilien ren an ei semirit pekin kaio, ika mamarin,
pwal mwokutukutun?

1. ☐ UII

1. ☐ APW

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

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

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

Lon ekkewe fansoun 12 maram a lo, Ewe tokter ika ekkewe chon tumunu ei semirit me pioing, rese mo erenuk kopwe amasoua ekkewe taropwen kapas eis fan itan ei semirit ren tichikin met ka eani osukosuk ren noum om ourusacha mamarin lapalapan, lon an fofos ika lapalapan lon an chiechi ngeni pwal ekkewe ekkoch? Fan ekkoch noun ewe semirit tokter ika ekkewe chon angangan pioing repwe erenuk kopwe amosoua ei taropwe lupwen ka feito pioing.

1. ☐ UII

2. ☐ APW [GO TO D7]

1. ☐ USE SILEI [GO TO D7]

1. ☐ UWA FILATA USAP POLUENI [GO TO D7]

[IF THIS CHILD IS 9-23 MONTHS]

Ewe taropwe mi fiti kapas eis ka amosoua mi pachelong om kewe lolilen ren noum we om okotolo mwokutukutun: CHEKI METOCH MEINISIN MI WENEITI

1. ☐ Ifa usun an we semirit poporaus mi fiti mengungu?

1. ☐ Ifa usun an noum we semiriti chiechi ngonuk me ekkewe ekkoch?

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

[IF THIS CHILD IS 2-5 YEARS]

Ewe taropwe mi fiti kapas eis ka amosoua mi pachelong om kewe lolilen ren noum we om okotolo mwokutukutun: CHEKI MEINISIN MI WENEITI.

1. ☐ Kapas me foufoun kapas ewe semirit mi weweiti?

2 ☐ Lapalapan ewe semirit me usun an tipeu ngonuk me chiechian kewe?

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

7. Mi wor ia ei semirit ekkan soun feilo ngeni lupwen a mefi samau, ika en me ewe chon tumun uwa tipeu ach sipwe ereni kemi ekkoch leni ren tumunun pochokulen?

1. ☐ UII

2. ☐ APW [GO TO D8]

1. ☐ USE SILEI [GO TO D8]

1. ☐ UWA FILATA USAP POLUENI [GO TO D8]

[IF YES] Ifa ewe semirit ekkan soun feilo ia?

1. ☐ Imulo tokter an ofes

1. ☐ Pioing emergency room

1. ☐ Pioing outpatient department

2. ☐ Community health clinic, community clinic, ika public health clinic (pekin safei ren ese wor nouch insurance ika esap naf)

3. ☐ Ofesin kangof non sukun, ika ofesin pekin urumot

4. ☐ Village dispensary (kukkun pioing ra kan awora safei)

5. ☐ Pwal ekkoch leni, KOSE MOCHEN AFATA

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

8. Mi wor pioing ka kan soun walo noum we semirit ika a tori fansoun an chekin semirit ren epetin samau, awewe ren chekin unusen inisin?

1. ☐ UII

2. ☐ APW [GO TO D9]

1. ☐ USE SILEI [GO TO D9]

1. ☐ UWA FILATA USAP POLUENI [GO TO D9]

[IF YES] Ei pioing iei ei leni ei semirit ekkan soun feito ia ika pwe a samau?

1. ☐ UII

1. ☐ APW

9. Lon ekkewe 12 maram a lo, ei semirit mi eaea ei sokkun alilis seni ach kewe pioingin alilis? Cheki meinisin mi weneiti. Ekkewe pwal ekkoch lenien alilis ren tumunuch chowen an pekin acupuncture (leni ra kan aposu ifa ikkewe mi samau ia), chiropractic care (lenien chon awena chuuch ika rawani kich), relaxation therapies (ekkewe leni ra kan ekinamwei ach kei foucho mi pekus ika osukosuk), traditional herbal medicine (ekkewe leni ra kan safeieni kich won safei seni ach eoreni safei seni ira), pwal ekkoch. Ekkoch alilis (ika therapy) ren om samau mi pachelong churi noum tokter, pwal ekkoch tumunum kopwe pusin fori won om.

1. ☐ Medical Care (Tumun Seni Pioing)

2. ☐ Vision Care (Tumunun Mas)

3. ☐ Hearing Care (Tumunun Lenien Rongorongo)

4. ☐ Dental (tumunun ngi) ika Oral Care (tumunun non awomw)

5. ☐ Mental Health Services (Tumunun Ekiek me Tupu)

6. ☐ Alternative Health Care ika Treatment (pwal ekkoch alilis ren pekin pioing ika safei)

7. ☐ Ese wor lein ekkei [GO TO D10]

1. ☐ USE SILEI [GO TO D10]

1. ☐ UWA FILATA USAP POLUENI [GO TO D10]

[IF VISION CARE] Met sokkun leni ei semirit mi pin churi le cheki mesan? Cheki meinisin mi weneiti.

1. ☐ Tokterin mas ika korman mi mwelo lon pekin tumunun ewe mas ar we ofes

1. ☐ Ofesin tokterin semirit ika ekkoch tokter pusin ar ewe pisness ika pioing ar we ofes

1. ☐ Community health clinic, community clinic, ika public health clinic (pekin safei ren ese wor nouch insurance ika esap naf)

2. ☐ Sukul

3. ☐ Pwal eu leni, KOSE MOCHEN AFATA

10. Lon ekkewe 12 maram a lo mi wor eu fansoun a auchea an ewe semirit epwe churi ekkewe lenien tumun nge ese tikelong ika ese ponueta? Seni pekin tumun, uwa auchean tumunun inisin emon me emon pwal ekkewe sokopaten tumun ren tumunun lon awach ika ngich, tumunun mas, ika tumunun ach ekiek me tupu.

1. ☐ UII

2. ☐ APW [GO TO D12]

1. ☐ USE SILEI [GO TO D12]

1. ☐ UWA FILATA USAP POLUENI [GO TO D12]

[IF YES] Met sokkun alilis ese toruk ese pwal ponueta? Cheki meinisin mi weneiti.

1. ☐ Medical Care (Tumun Seni Pioing)

1. ☐ Dental (tumunun ngi) ika Oral Care (tumunun non awomw)

1. ☐ Vision Care (Tumunun Mas)

2. ☐ Hearing Care (Tumunun Lenien Rongorongo)

3. ☐ Mental Health Services (Tumunun Ekiek me Tupu)

4. ☐ Ika pwal eu sokkun, KOSE MOCHEN AFATA

11. Meni lein ekkei a efisata an ewe semirit esap tori ekkewe health services ika alilis ren pekin tumunun inisin:

    	UII	APW	USE SILEI	UWA FILATA USAP POLUENI
    D11a. Ei semirit ese tongeni epwe tori ekkewe alilis?	1 ☐	2 ☐	77 ☐	99 ☐
    D11b. Ei sokkun alilis a auchea fan itan ewe semirit ese wor lon ei kinikin?	1 ☐	2 ☐	77 ☐	99 ☐
    D11c. A fokkun weires ach tikelong ese wor mi suk lupwen ewe semirit a auchea epwe churi tokter.	1 ☐	2 ☐	77 ☐	99 ☐
    D11d. Mi pwal weires kutan wa ngeni ekkewe fansoun a auchea sipwe uwalo nouch kewe ngeni ekkewe lenien safei pwal weires pekin tumun (child care) fan iten nouch kewe?	1 ☐	2 ☐	77 ☐	99 ☐
    D11e. Ewe (pioing/ika an tokter) ofes ese fokkun suk lupwen a auchea me lamot nouch semirit epwe churir?	1 ☐	2 ☐	77 ☐	99 ☐
    D11f. A wor osukosuken liwin pokiten mi kamo?	1 ☐	2 ☐	77 ☐	☐

12. Lon ekkewe 12 maram a lo, noum ei semirit ese mo pin tolong lon pioing? Kose mochen pwal pachelong an tolong lon ewe pioingin atepwalepwal.

1. ☐ Uii

2. ☐ Apw

1. ☐ USE SILEI

1. ☐ USE TIPEU

[IF YES] Lon ekkewe 12 maram a lo, fan fite ei semirt mi tolong lon pioing ren an feiengaw? Ren 'feiengaw' wewen feiengawan inisich ren emon an efeiengawa kich ika fen ach tup lon serengaw. Feiengaw mi pachelong, sisap etiwau feiengawan chuuch, meienon kifetin inisch ren feiengaw, pekun inisich, kaar, kuuk/arotong, ika feiengaw ren an emon efeiengawa kich.

WALONG ENA NAMPA

1. ☐ USE SILEI

1. ☐ USE TIPEU

5. Om memeief fan iten Ekkewe Tokter ika Chon Tumunu Noum We Lon Pioing

1. Mi wor tokter ika kangof ke ekieki epwe murine an noum we epwe chuchuri? Emon tokter ika kangof ir seni pekin tumunun inisich ra fen awesi ar sukul ika kaio iwe ra silelap lon pekin tumun a wor io a fen silei nonomun me tumunu noum we semirit ren an samau me metekan nge ka tipeu ngeni epwele wisan tumunu noum we. Ekkei chon pioing mi tongeni epwe emon tokter epwe churuk lupwen ka samau, ika tokterin semirit, ika emon mi mwelo lon eu pekin, ika fer pwal ewe kangof mi mwelo a kan pwal tongeni chekuk, usun chok angangen emon korman nge esap emon wesewesen tokter.

1. ☐ UII, EMON

1. ☐ UII, LAP SENI EMON

2. ☐ APW

2. Non ekkei 12 maram sia tou seni, en, ika pwan emon chon tumwun, ika emon chon tumwun mei semwen, mei finata met epwe fis fan iten an ei semirit epwe tumwun, awewe ren an epwe wuun safei, no ngeni tokter, ika an epwe reirei?​

1. ☐ Ewer

2. ☐ Apw

☐ ESE FFAT

☐ USE MOCHEN EPPONUWA

3. [IF YES] Non ekkei 12 maram sia tou seni, fan fite an noun ei semirit tokter ika chon tumwun mei semwen…

	Iteitan	Napengeni	Fan ekkoch	Ese mwo	ESE FFAT	USE MOCHEN EPPONUWA
E2a. kapas ngonuk ren met aninnis mei kawor an ena semirit epwe tumwun ika safei fan iten an epwe pochokkun?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
E2b. mecheres ngonuk omw kopwe kapas eis ren omw noniinen ika ren omw kese tipeew ngeni met re pesei epwe fis fan iten an ena semirit epwe pochokkun?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
E2c. fituk me anisuk ne finata met epwe fis fan iten tumwunun noumw me an safei pwe epwe pochokkun?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐

4. Lon ekkewe fansoun 12 maram a lo, Epwe auchea an ei semirit epwe angei taropwen mumuta an epwe churi tokter ika angei ekkewe sokkun alilis?

1. ☐ UII

2. ☐ APW [GO TO E3]

1. ☐ USE SILEI [GO TO E3]

1. ☐ UWA FILATA USAP POLUENI [GO TO E3]

[IF YES] Mi wate osukosuken an epwe mumuta ika wor ewe taropwen
mumuta (referrals)?

1. ☐ Ese wor osukosuk

1. ☐ Ekis osukosuk

1. ☐ Fokkun wate osukosuken

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

Lon ekkewe 12 maram a lo, ifa echichinin an noun ei semirit tokter ika ekkewe chon tumun lon pioing:

	Fansoun meinisin	Iteitan	Fan ekkoch	Ese mo	USE SILEI	UWA FILATA USAP POLUENI
E4a. Ar ekis atamalo ar fansoun ngeni ei semirit?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
E4b. Euseling fich lupwen ka poraus?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
E4c. Ar aucheani me asufelu met ka aucheani me om eoreni?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
E4d. Ar awora ngonuk ewe tichikin poraus mi auchea ren tumunun fan iten noum we semirit?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
E43e. Ka mefi nge ra pachelong pwe chiener le tumunu noum we semirit?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	☐

6. Mi wor chon alisuk ren ar fori angangen tumunun an ewe semirit epwe churi ekkewe sokopaten tokter pwal ren an epwe lo ngeni ekkewe pekin alilis ewe semirit a kan eaea?

1. ☐ UII

1. ☐ APW

2. ☐ ESE MO PIN CHURI TOKTER IKA CHON TUMUN NON PIOING LAPESENI EMON CHOK LON EKKEWE 12 MARAM A LO [GO TO E7]

7. Lon ekkewe 12 maram a lo, en mi mefi om fokkun mochen repwe alisuk ren ar repwe fori ngonuk ika kokori ekkewe leni fan iten noum we epwe churi ekkewe sokopaten doctor ika pwal ekkoch pekin alilis?

1. ☐ UII

2. ☐ APW [GO TO E6]

[IF YES] Lon ekkewe 12 maram a lo, fan fitu an ekkewe chon tumun lon pioing alisuk ren an noum we epwe churi ekkewe pwal ekkoch tokter fengen ren tumunun pochokulen noum we?

1. ☐ Iteitan

1. ☐ Fan ekkoch

1. ☐ Ese mo

8. Ren metoch meinisin, en mi mefi menemenoch ren om wewe fichiti ekkewe chon pioing ren tumunun noum we semirit lon pekin poraus?

1. ☐ Fokkun menemenoch

1. ☐ Pwal ianan menemenoch

2. ☐ Ekis ai use menemenoch

3. ☐ Use men menemenoch

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

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

Mi wor lein noun ei semirit kewe tokter ika chon tumun lon pioing ekan chok
safeieni semirit?

1. ☐ UII

2. ☐ APW [GO TO E8]

1. ☐ USE SILEI [GO TO E8]

1. ☐ UWA FILATA USAP POLUENI [GO TO E8]

[IF YES] Ra fen poraus ngonuk usun an noum we epwe lolo a churi tokterin menumuk ika ekkewe chon tumun lon pioing ra kan churi chok menumuk?

1. ☐ UII

1. ☐ APW

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

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

Noun ei semirit kewe tokter ika chon tumunun lon pioing remen soun chuchuri ei
semirit ren:

	UII	APW	USE SILEI	UWA FILATA USAP POLUENI
E10a. Ar repwe okot fan iten eochun ei semirit lon ekkan ran mwach. Awewe chok ren ar awora ar fansoun ar repwe poporaus fan itan ekkan ran mwach ren pekin an ewe semirit kaio lon sukul, angang, chiechiechun ngeni ekkoch, iwe pwal ren an epwe tongeni pusin alisi ii an epwe silelap lon metoch mi fich ngeni?	1 ☐	2 ☐	77 ☐	99 ☐
E10b. An epwe fori filata mi murine fan iten pochokulen inisin. Awewe chok, ren an epwe mongo, mongo mi eoch ngeni inisin, eksersais iteitan, esap angei ekkewe supwa, ika sakau pwal safeian opuchopuch, ika fen ekis witiwitilo ren pekin lisou?	1 ☐	2 ☐	77 ☐	99 ☐
E10c. Om kopwe silelap ren tumunun inisin noum we semirit pwal lon pekin pioing. Awewe chok, ren an epwe weweiti tumunun pochokulen inisin lon ach ei fansoun, an epwe pwal silei met epwe fori ren tumunun lon fansoun emergency (atepwalepwal), ika inet epwe auchea an epwe angei ewe safei?	1 ☐	2 ☐	77 ☐	99 ☐
E10d. Pwal weweiti ewe ekesiwil epwe fis ngeni lupwen a tori 18 ierin. Awewe chok, ren an epwe weweiti ekesiwil ren met mi monomonolo, met epwe mutata, epwe pwal silei ifa usun an epwe tori ekkoch poraus mi auchea fan itan, ren an epwe pusin fori an filata?	1 ☐	2 ☐	77 ☐	99 ☐

11. Ren soposopolon om kopwe nom won health insurance pun epwe ekesiwil lupwen ka nom lon ierin serafo. En mi silei ifa usun an ei semirit epwe soposopolo manamanen noun we taropwen safei lupwen a tori ierin serafo?

1. ☐ UII [GO TO F]

2. ☐ APW

[IF NO] A fen wor chon poraus ngonuk usun kutan ekkoch pekin taropwen epwe mumuta an safei ren met sokkun insurance epwe nounou lupwen epwe serafo?

1. ☐ UII

1. ☐ APW

6. Noun ei Semirit Health Insurance (insurans an epwe moni lon pioing)

1. Lon ekkewe 12 maram a lo, ei semirit mi pin wor noun taropwen safei seni ekkoch health insurance an epwe moni lon pioing? Ekkei mi pachelong lenien iseis (medical savings account) fan iten chok an churi pioing, ekis alilis (supplemental health) ren tumunun inisin, ika fen pwal alilis seni muuch (government) we a awora ika fen pwal ekkoch pekin insurance mi mwokukun.

1. ☐ Uii, ei semiirt mi nom fan insurance lon ukukun 12 maram, ika fan 1 ier, seni an uputiw [GO TO F4]

1. ☐ Uii, nge ei semirit mi wor noun we gap ika akeunon an we insurance

2. ☐ Apw

2. Kose mochen afata ika iei popun ei semirit ese nom won taropwen safei ika health insurance. lon ekkewe 12 maram a lo:

	UII	APW
F2a. Ekesiwil ren angang ika nonomum lon angang	1 ☐	2 ☐
F2b. Koturulo pokiten kose sopwelo le moni om insurance	1 ☐	2 ☐
F2c. Ka oturalo noum we insurance pokiten ese chiwen mo ngonuk	1 ☐	2 ☐
F2d. Ka oturalo pokiten ese ese fen naf ngonuk	1 ☐	2 ☐
F2e. Ka oturalo pokiten ese kon chommong ekkewe tokter ika chon tumun kopwe kefil seni	1 ☐	2 ☐
F2f. Osukosuk ren forisefali	1 ☐	2 ☐
F2g. Pwal eu popun, kose mochen afata	1 ☐	☐

3. Ei semirit mi nom won eu ekkei sokkun insurance ika prokram an epwe tongeni mo an churi pioing? [Interviewer Note: Only read jurisdiction-specific insurance types for
   your jurisdiction].

   	UII	APW
   F3a. Health insurance mi private (esap seni ach we muu)	1 ☐	2 ☐
   F3b. Insurance seni om angang (ika an puluom we) angang ika seni union	1 ☐	2 ☐
   F3c. Medicaid, Medical Assistance, ika alilis ren om kopwe tongeni safei seni ach ei muu mi pachelong Guam Medical Indigent Program, Palau Health Insurance Programika fen pwal Puerto Rico Government Health Plan)	1 ☐	2 ☐
   F3d. Pwal an ekkoch ekkewe muu awora moni an epwe mwokukun insurance pachelong Microneisa MiCare ika Chuuk State, Marshall Islands Public Insurance, pwal Marshall Islands Supplemental Health Fund	1 ☐	2 ☐
   F3e. Medical savings account	1 ☐	2 ☐
   F3f. CHIP (Children’s Health Insurance Program)	1 ☐	2 ☐
   F3g. TRICARE ika ekkoch pekin tumun ren sounfiu	1 ☐	2 ☐
   F3h. Indian Health Service	1 ☐	2 ☐
   F3i. Ika pwal eu sokkun, Kose mochen afata	1 ☐	☐

4. Fan fite an noun ei semirit ei health insurance awora manemanen an epwe monalo ekkewe sokkun alilis mi lamot fan itan ewe semirit? Awewe chok ren mi pachelong dental ika vision (pioingin tumunun ngiich me tumunun maas), ika mi pwal pachelong om angei unumom safei, emergency room (lenien atepwalepwal) ika pekin tumunun inelap, ika tumunun ekiek, ika pwal om chok chuto iteitan ier ren om chek me ren pekin apeti
   sonuk samau.

1. ☐ Fansoun meinisin

1. ☐ Iteitan

2. ☐ Fan ekkoch

3. ☐ Ese mo

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

5. Pokiten mi auchea an ei semirt epwe churi ekkewe chon safeieni fan fite an noun ei semirit ei health insurance mut ngeni epwe churi ekkewe tokter ika chon pioing?

1. ☐ Fansoun meinisin

2. ☐ Iteitan

3. ☐ Fan ekkoch

4. ☐ Ese mo

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

7. Awora Fan Iten Tumunun Inisin Ei Semirit

1. Pachelong co-pay ika met mi touou me lon pwekitom ewe ukukun ka moni seni om we lenien isois fan iten chok om churi pioing, fite ukkukun moni ka fen moni fan iten tumunun lon pioing, ren tumunun inisin, tumunun ngiin kewe, me tumunun mesan lon 12 maram a lo? Kosap pachelong health insurance premiums (met ka moni iteitan maram fan iten an epwe wor manemanen noum we health insurance) ika fen ewe moni ka fen moni nge ewe insurance epwe moni sefali ngonuk ika fen pwal ekkewe ekkoch pekin.

1. ☐ $0 (ESE WOR MET KOPWE MONI) [GO TO G4]

1. ☐ $1-$249

2. ☐ $250-$499

3. ☐ $500-$999

4. ☐ $1,000-$5,000

5. ☐ LAP SENI $5,000

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

2. Fan fite an mo kukkun ngonuk?

1. ☐ Fansoun meinisin

1. ☐ Iteitan

2. ☐ Fan ekkoch

3. ☐ Ese mo

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

3. Lon ekkewe fansoun 12 maram a lo, Mi weires ngeni om we famili repwe monalo ei ukkukun an noum we liwinimang ren tumunun lon pioing ika ofesin tokter?

1. ☐ UII

1. ☐ APW

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

4. Lon ekkewe 12 maram a lo, en me chochon om famili:

	UII	APW	USE SILEI	UWA FILATA USAP POLUENI
G4a. Keulo le angang pokiten an noum we samau ika nonomun an we samau?	1 ☐	2 ☐	77 ☐	99 ☐
G4b. Eukuku ewe ukkun awa ka kan akanganga iteitan ran pokiten an ei semirit samau ika nonomun an samau?	1 ☐	2 ☐	77 ☐	99 ☐
G4c. Kose tongeni ekesiwili om lenien angang pokiten om lolilen ren noun noum we health insurance?	1 ☐	2 ☐	77 ☐	99 ☐
G4d. Chochon om aramas ra kan alisuk?	1 ☐	2 ☐	77 ☐	99 ☐

8. An Ei Semirit Kakaio

1. Epwe fitu awa lon eu ran eu wik, ewe semirti a kan eaea le katol TV ika ekkewe prokram won TV, ika katol video, ika nounou noun kewe video games?

1. ☐ ESE WOR

1. ☐ FAN 1 AWA

2. ☐ 1 AWA

3. ☐ 2 AWA

4. ☐ 3 AWA

5. ☐ 4 AWA IKA LAP SENI

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

2. Epwe fitu awa lon eu ran lon eu wik, ifa langetamen an ei semirit mot ngeni noun computer, ika cell phones, ika ekkewe video games sia kan komoch ika pwal ekkewe sokopaten minen apwapwa ren elektroniks, ika fen pwal fori ekkoch minen apwapwa lap seni an fori wisan lon imw ren pekin sukul?

1. ☐ ESE WOR

1. ☐ FAN 1 AWA

2. ☐ 1 AWA

3. ☐ 2 AWA

4. ☐ 3 AWA

5. ☐ 4 AWA IKA LAP SENI

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

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

Ifa ukkukun tufichin an ei semirit kaio an epwe fori metoch fan itan?

1. ☐ Fokkun murine

1. ☐ Pwal ianan

2. ☐ Ese tawe

3. ☐ Fokkun ese murine

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

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

Ifa ukkun om luku epwe ponueta ika awesi an sukul lon elementary tori a sochungio me lon 12 mwich?

1. ☐ Uwa fokkun luku o tipeu ngeni

2. ☐ Uwa tipeu

3. ☐ Uwa ekis tipeu

4. ☐ Use luku

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

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

5. Fan fite…​

	Iteitan	Napengeni	Fan ekkoch	Ese mwo	ESE FFAT	USE MOCHEN EPPONUWA
H5a. ei semirit mei fitipach ngonuk?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
H5b. ei semirit mei mwittir ne tipetipeoch sefan mwirin an ese fis met ar mochen?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
H5c. mei pwa me won ei semirit pwe e mochen sinei ika kaeo met mei minafo ngeni?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
H5d. ei semirit mei ekkemenimen me takir?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐

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

Lon ekkewe 12 maram a lo, epwe fitu ran ei semirit ese feilo ngeni sukul pokiten an samau me feiengaw?

1. ☐ ESE MO FAN EU AN ETIWANO SUKUL

1. ☐ 1-3 RAN

2. ☐ 4-6 RAN

3. ☐ 7-10 RAN

4. ☐ 11 IKA FAN LAP SENI

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

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

Fan fite an ei semirit…​

	Iteitan	Napengeni	Fan ekkoch	Ese mwo	ESE FFAT	USE MOCHEN EPPONUWA
H7a. mochen sinei ika kaeo met mei minafo ngeni?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
H7b. awesi met angang re popwutani?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
H7c. tipetipeoch me fanafaneno ika e wor ar osukosuk?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
H7d. ker ren an epwe tipachem non sukuun?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
H7e. fori meinisin an asaimen seni sukuun?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	☐
H7f. soun chok aniini?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	☐

Ekkei 2 kapas eis sipwe eis usun an emon kuta om kopwe osukosuk me feiengaw. Efisata osukosuk wewen lupwen 1 ika ekkoch chon sukul ra urumotei, amangawa, ika chofonata, peeni, tini, ika efeiengawa emon chon sukul iteitan. Esap eu minen aosukosuk lupwen ruemon chon sukul ir taitap lon pochokuler ra chok lolo pochokuler lon ar enini fengen ika fiuu ika amangawa fengenir lon eu lapalap mi ese wor osukosukan.

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

Chienan noum na lon sukul rese mo kan turunufasei?

1. ☐ UII

1. ☐ APW

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

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

Ese mo wor mi pin turunufasa noum we me won ekkei mecha lupwen a tolong won? (Pachelong ar kuna turunufas lon text, Instagram, Facebook, me ekkoch minen lenien kukunou won mecha.)

1. ☐ UII

1. ☐ APW

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

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

Seni ewe fansoun ei a poputa sukul lon kindergarten, ei semirit e fen liwin sefal
lon mwichan?

1. ☐ UII

1. ☐ APW

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

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

Ren ewe wik a lo, fitu ran ei semirit mi fiti ekisersais, ren an fiti ekkewe ika fiti ekkewe pekin mi fokkun amokutu inisin ren ukkukun 60 minich?

1. ☐ 0 RAN

1. ☐ 1-3 RAN

2. ☐ 4-6 RAN

3. ☐ ITEITAN RAN

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

9. Faniten En me Ei Semirit

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

Lon ewe wik a lo, fitu ran en me chochon om we famili ouwa kan akalea ngeni ewe semirit?

1. ☐ 0 RAN

1. ☐ 1-3 RAN

2. ☐ 4-6 RAN

3. ☐ ITEITAN RAN

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

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

Lon ewe wik a lo, fitu ran en me chochon om we famili ouwa kan akalea ika kokol ngeni ewe semirit?

1. ☐ 0 RAN

1. ☐ 1-3 RAN

2. ☐ 4-6 RAN

3. ☐ ITEITAN RAN

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

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

Ei semirit a kan pwal angei an tumun seni pwal ekkoch me lukun inan me seman me a kefilita pwe epwe noun chon tumun? A pwal pachelong ekkewe lenien tumun ren day care center, preschool, Head start prokram, ika chochon famili child care home, ika nanny, ika chon ekkis e feiton epwe alilis ren angangen ewe imw me tumunun ewe semirit pwe epwe wor lenien.

1. ☐ UII

1. ☐ APW

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

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

Me nukun en me ekkan watte non imw, mei pwan wor emon me non an ei semirit sukuun, aramasen winiorun imwemi, ika community mei sissinei ei semirit minne-ka e tongeni no ngeni ren an osukosuk ika ar repwe anisi?

1. ☐ EWER

1. ☐ APW

1. ☐ ESE FFAT

1. ☐ USE MOCHEN EPPONUWA

5. Non ekkewe 12 maram a nó, ei semirit mei fen churi noun iwe dokter me non video ika fon?

1. ☐ UII

2. ☐ APW

10. Porausen Chochon Om Famili

1. Mi wor chochon lon imwom we a kan pwal eaea ekkei pekin mitiri re supwa, e-supwa ika vapors, cigars ika supwa mi tukutuk lon lon cheen, ika pwal supwa lon paip, ika pwal mongo ekkewe foun betel nut ika puu? [READ IF NECESSARY]: Kose mochen polueni ren ukkukun om tongeni. Ewe foun betel nut ika puu a feito seni ewe iran areca palm. Sia kan pwal aiten ngeni areca nut. Nguung betel nut ika puu eu foforun eoreni lon ekkoch kinikin lon south me south-east Asia me Asia Pacific. Aremas ra kan nguung ei puu ra tukumi lon cheen betel nut itan (paan) ika nofiti me supwa lon ewe (betel quid).

1. ☐ UII

1. ☐ APW [GO TO J3]

1. ☐ USE SILEI [GO TO J3]

1. ☐ UWA FILATA USAP POLUENI [GO TO J3]

2. Mi wor chon ukkun supwa lon imwom we?

1. ☐ UII

2. ☐ APW

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

IKA PORTERIKO, FEILO NGENI J5

3. Noum we semirit mi kan nguung betel nut ika puu? [READ IF NECESSARY]: Ewe foun betel nut ika puu a feito seni ewe iran areca palm. Sia kan pwal aiten ngeni areca nut. Nguung betel nut ika puu eu foforun eoreni lon ekkoch kinikin lon south me south-east Asia me Asia Pacific. Aremas ra kan nguung ei puu ra tukumi lon cheen betel nut itan (paan) ika nofiti me supwa lon ewe (betel quid).

1. ☐ UII

1. ☐ APW

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

4. En mi silei feiengawan om kopwe nguung betel nut ika puu?

1. ☐ UII

2. ☐ APW

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

Ekkei ekkoch kapas eis a poraus usun moni.

5. Seni lupwen ei semirit a uputiw, fan fitu om mefi weires pokiten ese naf moni tolong lon ami famili – mi weires ami oupwe tori ekkewe mongo mi mecheres ika pwal kuten imw?

1. ☐ Ese mo

1. ☐ Esap iteitan

2. ☐ Fan ekkoch

3. ☐ Fan chommong

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

6. Ekkei ekkoch kapas eis kapasen ika en mi tongeni memeon ekkewe mongo mi auchea ngeni kich. Meni lein ekkei kapas eis a awewei nonomum ren mongon lon imwom we LON EKKEWE 12 MARAM A LO?

1. ☐ Iteitan mi chok mo ngeni kem ekkewe mongo mi auchea ngeni inisich.

2. ☐ Iteitan mi chok mo ngeni kem enem mongo nge esap ekkewe sokkun mongo ururun
   sisap mongo.

3. ☐ Fan ekkoch ese fokkun naf mon enem mongo.

4. ☐ Iteitan use fokkun naf ngeni mon enem mongo.

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

7. Lon ekkoch fansoun atun 12 maram a lo, pwal mo nge eu maram, mi wor chochon lon imwom na ika famili mi angei:

	UII	APW	USE SILEI	UWA FILATA USAP POLUENI
J7a. Moni tolong seni ach ei muu cash assistance ika welfare program?	1 ☐	2 ☐	77 ☐	99 ☐
J7b. [Programming note: Do not show for Puerto Rico] Ren Food Stamp ika Supplemental Nutrition Assistance Program (SNAP) ika ewe pekin auora mongo mi murine ngeni inisich? [Programming note: For Puerto Rico Show the Following] Nutrition Assistance Program (NAP) (a pwan iteni PAN)	1 ☐	2 ☐	77 ☐	99 ☐
J7c. Mongon lesosor me Neanouas ese kamo ika mongo mi kukkun mon fan itan nouch kewe semirit lon sukul?	1 ☐	2 ☐	77 ☐	99 ☐
J7d. [Programming note: Do not show for RMI, Palau, FSM, Puerto Rico] Ika fen mongo seni ewe pekin Woman, Infants, and Children (WIC) Program (Inelap, Menukol, me Semirit)?	1 ☐	2 ☐	77 ☐	99 ☐

Ekkei ekkoch kapas eis, ren fan iten imweimw.

8. Non ekkei 12 maram sia tou seni, mei wor ew fansoun kese naaf omw kopwe meonatiw meon imw ika rent me mwen an epwe mangeno?

☐ EWER

5. ☐ APW

1. ☐ ESE FFAT

1. ☐ USE MOCHEN EPPONUWA

9. Non ekkei 12 maram sia tou seni, fan fite an ei semirit amwet ngeni pwan ew minafo imw ika adress?

8. A FAN CHOMMONG

9. ☐ ESE FFAT

10. ☐ USE MOCHEN EPPONUWA

10. Seni an ei semirit upwutiw, mei wor fansoun an epwe homeless ika nomw non nenien ekkewe ese wor imwar? Epwe pwan pachenong ar nomw non nenien ekkewe ese wor imwar, non motel, neeni non mwochomwochen fansoun ika nenien utiwitin imweimw, nomw non housing, ika ese wor ian epwe mourutiw nepwin non fansoun mei ttam.

☐ EWER

11. ☐ APW

12. ☐ ESE FFAT

13. ☐ USE MOCHEN EPPONUWA

Chommong aramas re sapengeni osukosuk non manawar. Mei tongeni fis ngeni famini ese nifinifin, nge ekkoch aramas ina resapw kinamwei ne epponuwa ekkei kapas eis. Ekkei ekkoch kapas eis, ren fan iten met e fis fansoun non manawen ei semirit. Kopwe chechemeni, omw epponu epwe monomonono, iwe nge en mei pwan tongeni amwet seni met kapas eis kese mochen epponuwa.​

11. Ren met ke tongeni chemeni, ei semirit MEI PIIN nomw non ew ekkei napanap?​

	EWER	APW	ESE FFAT	USE MOCHEN EPPONUWA
J11a. Iin me saam ika chon mwuuti ra divorce ika wes nefiinar?​	1 ☐	2 ☐	77 ☐	99 ☐
J11b. Iin ika saam ika chon mwuuti ra sopwono?​	1 ☐	2 ☐	77 ☐	99 ☐
J11c. Iin ika saam ika chon mwuuti re kanopwuus ika nomw non pureik?​	1 ☐	2 ☐	77 ☐	99 ☐
J11d. Kuna ika rong an iin me saam ika ion ra watte repwe peosap, fiu, faati, ika kofon fengen non imw?​	1 ☐	2 ☐	77 ☐	99 ☐
J11e. Mei feiengaw ika kuna emon e feiengaw winiorun imwar?​	1 ☐	2 ☐	77 ☐	99 ☐
J11f. Nonnomw ren emon mei wor semwenin non ar ekiek, ion e mochen niyeno, ika ion mei soun netipechou?​	1 ☐	2 ☐	77 ☐	99 ☐
J11g. Nonnomw ren emon mei soun sakaw ika soun aea drug?	1 ☐	2 ☐	77 ☐	99 ☐
J11h. Wor chon opwuta ika kirikiringaw ngeni pokiten ir chon ekis ika chochon ew neeni?	1 ☐	2 ☐	77 ☐	99 ☐
J11i. Wor chon opwuta ika kirikiringaw ngeni pokiten ir mei winin ika ir mei winipok?	1 ☐	2 ☐	77 ☐	99 ☐
J11j. Wor chon opwuta ika kirikiringaw ngeni pokiten mei wor terin ika mei mwok?	1 ☐	2 ☐	77 ☐	99 ☐

11. Nge En

KOSE MOCHEN POLUENI EKKEI KAPAS EIS LON EI TAROPWE FAN ITEN EKKEWE RUEMON INELAP ME SEMELAP IR EKKEWE AKAEWIN CHON TUMUN FAN ITEN EWE SEMIRIT. IKA PWE EMON CHOK EWE MENUMUK LON EWE IMW, POLUENI CHOK FAN ITEN EN EMON CHOK.

1. MENUMUK 1

Tefom ewe semirit?

1. ☐ WESETAN NGANG EWE INELAP IKA SEMELAP

1. ☐ NGANG EWE UU MUTI EI SEMIRIT

2. ☐ NOUN PULUWEI WE IWE UWA INELAP NGENI IKA SEMALAP

3. ☐ NGANG EWE INAN INAN, IKA SEMAN SEMAN

4. ☐ CHON TUMUNATIW EWE SEMIRIT LUPWEN A KAIMU SENI INAN ME SEMAN (A
   ITENI “FOSTER”)

5. ☐ TETELIN INOM ME TETELIN SEMOM

6. ☐ PWAL EKKOCH: ARAMASOM

7. ☐ PWAL EKKOCH: ESAP ARAMASOM

2. En at (mwan) ika nengin (fefen)?

1. ☐ AT

1. ☐ NENGIN

3. Fite ierum?

IERUM LON AUKUKUN OM EORENI

4. Ke afituan mwich lupwen ka wes me sukul CHEKI CHOK EU.

1. ☐ 8 MWICH IKA KIS SENI

1. ☐ 9-12 MWICH; KESE MO ANGEI NOUM WE TAROPWEN SOCHUNGIO

2. ☐ EN MI SOCHUNGIO SENI HIGH SCHOOL IKA EN ME AWESI GED

3. ☐ EN MI AWESI SUKUN NON EU/EKKOCH VOCATIONAL, TRADE IKA BUSINESS
   SCHOOL PROGRAM

4. ☐ UWA TORI COLLEGE MI WOR AI CREDIT PUN UWA FEN WES LE FITI EKKOCH CLASS NGE USE TORI NEI DEGREE

5. ☐ ASSOCIATE DEGREE (AA, AS) DEGRIN OM AWESI 2 IERIN COLLEGE

6. ☐ BACHELOR’S DEGREE (BA, BS, AB)

7. ☐ MASTER’S DEGREE (MA, MS, MSW, MBA)

8. ☐ DOCTORATE (PHD, EDD) IKA PROFESSIONAL DEGREE (MD, DDS, DVM, JD)

5. Ifa nonomum en mi pupulu ika kose pupulu?

1. ☐ PUPULU [GO TO K7]

1. ☐ USE MO PUPULU

2. ☐ UWA WES ME PUPULU

3. ☐ UWA KAIMU SENI PULUWEI

4. ☐ NGANG EMON MI MALO PULUAN

1. ☐ UWA FILATA USAP POLUENI [GO TO K7]

6. Ke kan nom ren chiecheom mi echenuk?

1. ☐ UII

1. ☐ APW

1. ☐ UWA FILATA USAP POLUENI

7. Ika kopwe menlapei, ifa usun nonomun pochokulen inisum?

1. ☐ Unuseoch

1. ☐ Fokkun Murine

2. ☐ Murine

3. ☐ Eoch

4. ☐ Ngaw

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

8. Ika kopwe menlapei, ifa usun nonomun pochokulen om ekiek me ifa usun om tumunuk me aukukuk ren ekiek esap murine ngonuk?

1. ☐ Unuseoch

1. ☐ Fokkun Murine

2. ☐ Murine

3. ☐ Eoch

4. ☐ Ngaw

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

9. En mi angang lon ukkukun 50 lon ekkewe 52 wik a lo?

1. ☐ UII

1. ☐ APW

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

10. Mi chiwen wor menumuk lon ena imw chon tumun (caregiver) ika chon pwal tumun mi mumuta me lon taropwen kapung an epwe tumunu ewe semirit (guardian)?

1. ☐ UII

2. ☐ APW [GO TO SECTION L]

1. ☐ UWA FILATA USAP POLUENI [GO TO SECTION L]

Ekkei chon tumun sipwele aiten ngenir Menumuk 2.

11. Ifa lefilan Menumuk 2 ngeni ewe semirit?

1. ☐ WESETAN NOUN INELAP IKA SEMELAP

1. ☐ NGANG EWE UU MUTI EI SEMIRIT

2. ☐ NOUN PULUWEI WE IWE UWA INELAP NGENI IKA SEMALAP

3. ☐ NGANG EWE INAN INAN, IKA SEMAN SEMAN

4. ☐ CHON TUMUNATIW EWE SEMIRIT LUPWEN A KAIMU SENI INAN ME SEMAN (A
   ITENI “FOSTER”)

5. ☐ TETELIN INOM ME TETELIN SEMOM

6. ☐ PWAL EKKOCH: ARAMASOM

7. ☐ PWAL EKKOCH: ESAP ARAMASOM

12. Emon mwan ika fefin ewe Menumuk 2?

1. ☐ AT

1. ☐ NENGIN

13. Ier fite ewe Menumuk 2?

IERUM LON AUKUKUN OM EORENI

14. Menumuk 2 e efituan mwich nge a wes le sukul? CHEKI CHOK EU.

1. ☐ 8 MWICH IKA KIS SENI

1. ☐ 9-12 MWICH; KESE MO ANGEI NOUM WE TAROPWEN SOCHUNGIO

2. ☐ EN MI SOCHUNGIO SENI HIGH SCHOOL IKA EN ME AWESI GED

3. ☐ EN MI AWESI SUKUN NON EU/EKKOCH VOCATIONAL, TRADE IKA BUSINESS
   SCHOOL PROGRAM

4. ☐ UWA TORI COLLEGE MI WOR AI CREDIT PUN UWA FEN WES LE FITI EKKOCH CLASS NGE USE TORI NEI DEGREE

5. ☐ ASSOCIATE DEGREE (AA, AS) DEGRIN OM AWESI 2 IERIN COLLEGE

6. ☐ BACHELOR’S DEGREE (BA, BS, AB)

7. ☐ MASTER’S DEGREE (MA, MS, MSW, MBA)

8. ☐ DOCTORATE (PHD, EDD) IKA PROFESSIONAL DEGREE (MD, DDS, DVM, JD)

15. Menumuk 2 mi pupulu ika ese pupulu?

1. ☐ PUPULU [GO TO K17]

1. ☐ USE MO PUPULU

2. ☐ UWA WES ME PUPULU

3. ☐ UWA KAIMU SENI PULUWEI

4. ☐ NGANG EMON MI MALO PULUAN

1. ☐ UWA FILATA USAP POLUENI [GO TO K17]

16. Menumuk 2 ekkan nom ren chienan we usun ita nge puluan?

1. ☐ UII

1. ☐ APW

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

17. Ika kopwe menlapei, ifa usun nonomun pochokulen inisin Menumuk 2?

1. ☐ Unuseoch

1. ☐ Fokkun Murine

2. ☐ Murine

3. ☐ Eoch

4. ☐ Ngaw

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

18. Ika kopwe pwal menlapei, ifa usun nonomun an Menumuk 2

1. ☐ Unuseoch

1. ☐ Fokkun Murine

2. ☐ Murine

3. ☐ Eoch

4. ☐ Ngaw

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

19. Ewe Menumuk 2 mi angang lon ukkun 50 lon ekkewe 52 wik a lo?

1. ☐ UII

1. ☐ APW

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

12. Nonomun pochokulen Inisin ewe Inelap

1. Eu “routine checkup” a wewe ngeni om wato noum we semirit pwe repwe cheki inisin, nge esap pokiten och sokkun feiengaw, samau, ika apwangapwang non inisin. A ifa taman om kose churi tokter seni ewe fansoun saingon om churi ren om chek iteitan ier?

1. ☐ Lon ewe ier a lo (EU FANSOUN FAN 12 MARAM A LO)

1. ☐ Lon 2 ierr a lo (1 IER NGE NGANG MI SILEI PUN FAN 2 IER A LO)

2. ☐ Lon ekkewe 5 ier a lo (2 IER NGE NGANG MI SILEI PUN FAN 5 IER A LO)

3. ☐ 5 ier a lo ika lapeseni

4. ☐ Ese mo

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

2. Lon ekkewe 12 maram a lo, en mi pin churi ika angei om alilis seni ekkewe chon alisikich ren pekin memeief me ekiek seni pioing? Ekkewe chon alilis lon pioing ren pekin tumunun ach ekiek me memeief ir mi wate ar sile pokiten ar sukul awewe ren psychiatrists, psychologist, psychiatric kangof me nouch kewe chon tumun ren metoch sia kan eani osupwangen me alisi kich pwal ren ekkoch osukosuk iter (social workers).

1. ☐ Uii

1. ☐ Apw, nge uwa aucheani ai upwe churi ekkewe chon pioing ra kan tumunu ach ekiek me memeief

2. ☐ Apw, use mochen churi ekkewe chon pioing ra kan tumunu ach ekiek me memeief [GO TO L4]

1. ☐ USE SILEI [GO TO L4]

1. ☐ UWA FILATA USAP POLUENI [GO TO L4]

3. Ifa ukkukun osukosuken om kopwe tori ekkei chon tumunun pochokulen om ekiek me memeief ren pwapwan insium?

1. ☐ Ese wor osukosuk

1. ☐ Ekis osukosuk

2. ☐ Fokkun wate osukosuken

4. Io ekan wisan filata om kopwe churi pioing ren pekin tumunun inisum?

1. ☐ En

1. ☐ Punuom we

2. ☐ Ika en me punuom/chon imwom

3. ☐ Inom me semom

4. ☐ Ika pwal emon, KOSE MOCHEN AFATA

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

5. Io ekkan filata tumunun noum kewe ren ar repwe churi ekkewe chon pioing?

1. ☐ En

2. ☐ Punuom we

3. ☐ Ika en me punuom/chon imwom

4. ☐ Inom me semom

5. ☐ PWAL EMON, KOSE MOCHEN AFATA

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

Ekkei ekkoch kapas eis a eis usun un supwa, sakau, me safeian opuchopuch (drugs). Kose mochen kopwe chechemeni pwe meinisin met ka pwarata ngeni kich mi monomonolo. Chon chok ewe teaman ra aiten ngeni kuta ir repwe silei. Kose mochen polueni ren ukkukun om tongeni.

6. Lon ekkewe 30 ran a lo, fitu ran ka kan ukkun supwa lon?

1. ☐ 0 RAN

1. ☐ 1 NGENI 2 RAN

2. ☐ 3 NGENI 5 RAN

3. ☐ 6 NGENI 9 RAN

4. ☐ 10 NGENI 19 RAN

5. ☐ 20 RAN NGENI 29 RAN

6. ☐ IKA UNUSEN 30 RAN

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

7. En mi kan ukkun sakau, pachelong sakau mi nelel ika sakau ke for me lon imwom?

1. ☐ UII

1. ☐ APW

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

8. Lon unusen manauom, en mi pin eaea ekkei metoch: [READ IF NECESSARY]: Ewe foun betel nut ika puu a feito seni ewe iran areca palm. Sia kan pwal aiten ngeni areca nut. Nguung betel nut ika puu eu foforun eoreni lon ekkoch kinikin lon south me south-east Asia me Asia Pacific. Aremas ra kan nguung ei puu ra tukumi lon cheen betel nut itan (paan) ika nofiti me supwa lon ewe (betel quid). Ewe chon ira ra kan eaea le tukumi nguter puu lon itan funta ika fronto, mi chonochon ra kan pwal eaea le tukumi unumer pekun supwa.

	UII	APW	USE SILEI	UWA FILATA USAP POLUENI
L8a. Betel nut ika puu	1 ☐	2 ☐	77 ☐	99 ☐
L8b. Vape me e-cigarette (ekkewe sokkun supwa mi wor nenen mi aro ngarangar, pwal supwa lapengeni batiri)	1 ☐	2 ☐	77 ☐	99 ☐
L8c. Funta	1 ☐	2 ☐	77 ☐	99 ☐
L8d. Maruana (a kan pwal iteni cheen fetil, “grass”, “pot”, “weed”, “me reefer”, me pwan ekkoch pekun maruo)	1 ☐	2 ☐	77 ☐	99 ☐
L8e. Koukein (eu sokkun drug/safeian opuchopuch), mi pachelong piepien powter, “crack”, ika “freebase”	1 ☐	2 ☐	77 ☐	99 ☐
L8f. Eroin (pwan eu sokkun drug/safeian opuchopuch a pwal iteni kawetengaw, “smack”, “junk”, me “China White”)	1 ☐	2 ☐	77 ☐	99 ☐
L8g. Methamfetamins (a pwal iteni MDMA, sapwich, me moromor)	1 ☐	2 ☐	77 ☐	99 ☐
L8h. Ekstasi (pwal eu foun drugs/safeian opuchopuch, a pwal iteni MDMA)	1 ☐	2 ☐	77 ☐	99 ☐
L8i. Siwinin maruao ika maruao mi “synthetic” (pwan eu sokkun drugs/safeian opuchopuch mi nofit me sokkun kemikal forian chok aramas, cheen fetil, a pwan iteni “K2”, “Spice”, “fake weed”, “King Kong”, Yucatan Fire”, “Skunk”, me “Moon Rocks”)	1 ☐	2 ☐	77 ☐	99 ☐
L8j. Steroit (foun safei ika oppos tokter rese mo mut ngonuk om kopwe angei)	1 ☐	2 ☐	77 ☐	99 ☐
L8k. Safeian metek mi pochokul tokter rese mo mut ngonuk om kopwe angei ika om asokolo seni met tokter ra erenuk usun ununun ei safei? (Pachanong ekkewe safeian metek mi fokkun pochokul aramas ra kan angei pwe repwe mefi maruon, usun “codeine”, “Vicodin”, “OxyContin”, “Hydrocodone”, me “Percocet”)	1 ☐	2 ☐	77 ☐	99 ☐

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

9. Lon ekkewe 30 ran a lo, fitu ran en mi nguung betel nut ika puu?

1. ☐ 0 RAN

1. ☐ 1 NGENI 2 RAN

2. ☐ 3 NGENI 5 RAN

3. ☐ 6 NGENI 9 RAN

4. ☐ 10 NGENI 19 RAN

5. ☐ 20 RAN NGENI 29 RAN

6. ☐ IKA UNUSEN 30 RAN

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

10. Mi wor chon emenuk ika poraus ngonuk fan iten alilis (kounseling ika treatment), ren om kopwe tongeni keulo seni ekkei/ika porausen eureur ren ekkei minen unumi ika mongo mi ngaw ngeni kich?

1. ☐ UII

1. ☐ APW

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

11. Noum we tokter a fen erenuk pwe a uruk man suke (type 1 ika type 2)?

1. ☐ TYPE 1 MAN SUKE

1. ☐ TYPE 2 MAN SUKE

2. ☐ ESAP EU [GO TO L14]

1. ☐ USE SILEI [GO TO L14]

1. ☐ UWA FILATA USAP POLUENI [GO TO L14]

12. En mi nom won safei ren ei samau?

1. ☐ Aposun insilin

1. ☐ Feun safei

2. ☐ Aposun insilin me foun safei

3. ☐ Use nom won safei

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

13. Mi wor tokter ika chon pioing a fen erenuk pun mi uruk ekkei ekkoch osukosuk…?

    	UII	APW	USE SILEI	UWA FILATA USAP POLUENI
    L13a. Rheumatic heart disease (osukosuken ekkewe paip mi sa ngeni en ngasengas)	1 ☐	2 ☐	77 ☐	99 ☐
    L13b. Rheumatic fever (eu semwen e fisita ika pwe kose kon chikar seni ewe paiking lon chiorom iwe a efisata rheumatic fever mi fiti pwichikar, metekin kupukupun chum)	1 ☐	2 ☐	77 ☐	99 ☐
    L13c. Cancerin fefin lon en tit pelietan en pwang	1 ☐	2 ☐	77 ☐	99 ☐
    L13d. Anemia (eu samau a uri kich nupwen esap naf ekkewe chaa mi foukukumos parapar lon inisich)	1 ☐	2 ☐	77 ☐	99 ☐

14. Aporausa ika awewei choum na?

1. ☐ Fokkun kukkun seni kukkun

1. ☐ Ekis kukkun

2. ☐ Karapan ewe eukukun

3. ☐ Ekis lap seni ewe aukukkun

4. ☐ Fokkun lap seni ewe aukukkun

15. Meni lein ekkei ka sosot om kopwe fori ren pounom ei?

1. ☐ Mochen epwe kotur

1. ☐ Mochen epwe pacheta

2. ☐ Mochen epwe ususun ewe chok

3. ☐ USE SOSOT AI UPWE OTURALO POUNEI

16. Lon ekkewe 7 ran ra lo, fitu ran ka fokkun mwokutukut lon le taiso ren ukkukun 60 minich ika lapelo lon eu ran? Apacha ekkena fansoun ka kan taiso ika mwokutukut mi efisi om ngase lap ika fer ngase chou lon.

1. ☐ 0 RAN

1. ☐ 1 RAN

2. ☐ 2 RAN

3. ☐ 3 RAN

4. ☐ 4 RAN

5. ☐ 5 RAN

6. ☐ 6 RAN

7. ☐ 7 RAN

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

17. En mi pwopwo?

1. ☐ Uii

2. ☐ Apw [GO TO M1]

1. ☐ USE SILEI [GO TO M1]

1. ☐ UWA FILATA USAP POLUENI [GO TO M1]

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

Ekkei ekkoch kapas eis usun ewe samau a iteni “Zika virus”. “Zika virus” eu menun samau seni menukuk a cheu fetal ika pwe ewe menukuk a kuuk nge mi pwal tongeni tori ekkoch ika re mour ren emon mwan mi tori ewe menun ewe Zika virus.

18. Lupwen om we chok pwopwo iei to, ifa ukukkun om lolilen ika e toruk ei menun samau itan “Zika virus”? Cheki chok EU poluen

1. ☐ Fokkun lolilen

1. ☐ Ekis lolilen

2. ☐ Use lolilen

3. ☐ USE MO PIN RONG ITAN EU MENUN SAMAU A ITENI “ZIKA VIRUS” LUPWEN AI WE CHIWEN PWOPWO [GO TO M1]

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

19. Lon ekkewe fansoun ren saingon om we pwopwo, en mi pin fos ngeni tokter, kangof, ika ekkewe chon pioing ren ei zika virus?

1. ☐ Apw

1. ☐ Uii, emon chon pioiing uwa poraus ngeni nge use mo fen eisini

2. ☐ Uii, emon chon angangen pioing mi fos ngeniei, nge ra fos ngeniei murin uwa eis usun

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

20. Lupwen om we saingon pwopwo, en mi angang chaa ren ar repwe kuna ewe menun kuen menukuk ika “zika virus” reom?

1. ☐ UII

1. ☐ APW [GO TO L23]

1. ☐ USE SILEI [GO TO L23]

1. ☐ UWA FILATA USAP POLUENI [GO TO L23]

21. Ese mo pwata lon om chek ren saingon om we pwopwo ika mi uruk Zika?

1. ☐ UII

2. ☐ APW [GO TO M1]

1. ☐ USE SILEI [GO TO M1]

1. ☐ UWA FILATA USAP POLUENI [GO TO M1]

[IF YES] Meni lein noum kewe semirit ke pwopwo ren lon ena fansoun?

IKA PORTERIKO, FEILO NGENI KINIKIN M

Ekkewe ekkoch kapas eis usun saii lupwen om we saingon pwopwo.

22. Lupwen om we saingon pwopwo, en mi sai ngeni ekkoch leni mi wor ewe “Zika virus”?

1. ☐ UII

2. ☐ APW

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

[IF YES] Lupwen om we saingon churi ewe tokter ren om we pwopwo, en mi tepereni ekkoch ekkewe metoch ra eani kapas usun fefin mi pwopwo ar repwe sai ngeni ekkei leni mi wor menun ewe “Zika virus”?

1. ☐ UII

2. ☐ APW

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

[IF NO] Ren saingon om we pwopwo, en mi sotuni kosap feilo ngeni ekkewe leni mi wor menun “Zika virus” ia pokiten mi ngaw ngeni fefin mi pwopwo repwe tori ekkena leni?

1. ☐ UII

2. ☐ APW

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

13. Porausan Chochon Lon Imwom

1. Fitemon aramas ra kan nom lon ei imw ika leni? Pachelong meinisin chon nom lon ei imw ika leni. Kose tongeni pwal pachelong emon chochon om famili mi nom ekkis lap seni ruu maram, awewe nom lon college ika chon sukul mi nom fetal ika fen fiti ekkewe ra kan fiti Armed Forces ika military (maun).

FITEMON ARAMAS

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

2. Fitemon ekkei aramas chochon om famili? Wewen “famili” aramas ir kan fengen pokiten re kan ngeni ewe semirit won chaar, seni ar pupulu, ika mweumweu, ika fen seni pekin tumun seni ach kewe foster.

FITEMON ARAMAS

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

3. Ekkei poraus sia angei senuk a men auchea ngeni kich ach silei fan iten MCH epwe tongeni silei ukkukun alilis epwe tolong pun epwe wor rech ekkewe pekin alilisin tumunun pochokulen inisich ngeni sokopaten aramas. Chon chok ewe teaman ra aiten ngeni kuta ir repwe silei. Asisileta chok ukkukun om tongeni. Esap ita epwe wesewesen won ena wesen nampa. Ekieki ewe ukkukun unuselapan moni tolong ren famili ren ewe ier ren unusen chochon om famili. Fite me mwen takisis epwe touou? Pachelong moni seni angang, alilisin semirit, social security, monien ritair, monien kose chiwen angang, ika fen alilis seni ach ei muu, pwal ekkoch. Pwal pachelong moni mi wor manauan, moni mi kawor seni om angang, ika sokkun moni tolong mi toruk.

, , KAPACHELAPAN ($)

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

4. Pwan ekkoch kinikinin poraus mi teteletiw fan: Kopwe apasa pwe om moni tolong lon imwom we iei…

1. ☐ Fan $10,000

2. ☐ $10,000 ngeni fan $15,000

3. ☐ $15,000 ngeni fan $20,000

4. ☐ $20,000 ngeni fan $25,000

5. ☐ $25,000 ngeni fan $35,000

6. ☐ $35,000 ngeni fan $50,000

7. ☐ $50,000 ngeni fan $75,000

8. ☐ $75,000 ika lap seni

77. ☐ USE SILEI

99. ☐ UWA FILATA USAP POLUENI

14. Guam Nemenemen MuuWon Eu Tichikin Kinikin

Upwe poputa eis ekkoch kapas eis usun nonomun pochokulen inisum.

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

Seni atun ewe noumw a upwutiw, en mei pwan no chek ren noumw tokter ren sowumwar? Chekin sowumwar nge pwan ew pekin tumwun ngeni fefin epwe fis, esapw nuno seni 12 wiik mwirin omw nounou.

☐ EWER

☐ APW

☐ ESE FFAT

☐ USE MOCHEN EPPONUWA

[IF YES] ke no ian ren omw kopwe chek?

☐ REN OFESIN NOUN AI FAMINI TOKTER

☐ REN AN NEI WE OB/GYN OFES

☐ REN EWE CLINIC NON PIOING

☐ REN EWE HEALTH DEPARTMENT CLINIC

☐ PWAN EW NEENI, KOSE MOCHEN AFFATA

1. ☐ ESE FFAT

1. ☐ USE MOCHEN EPPONUWA

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

[IF YES] Omw ewe chekin sowumwar, noumw ewe tokter mei kapas ngonuk fan iten…?​ ​

	EWER	APW	ESE FFAT	USE MOCHEN EPPONUWA
GM2a. mwongo eoch, taiso, me omw kopwe ekukkunatiw paunomw ren omw kitinupwuno fansoun omw ewe pwopwo	1 ☐	2 ☐	77 ☐	99 ☐
GM2b. ifa ukuukun tamen omw kopwe utiwitino me mwen omw kopwe pwopwo?	1 ☐	2 ☐	77 ☐	99 ☐
GM2c. safean omw kosapw mwo pwopwo?	1 ☐	2 ☐	77 ☐	99 ☐
GM2d. esisinnen semwen e fis nge mei afeiengaw ngonuk nupwen omw mei pwopwo?	1 ☐	2 ☐	77 ☐	99 ☐
GM2e. soun cheki ifa ukuukun omw feita cha?	1 ☐	2 ☐	77 ☐	99 ☐
GM2f. met kopwe fori nupwen omw mefi netipechou ika ekiekingaw?	1 ☐	2 ☐	77 ☐	99 ☐

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

[IF YES] Omw ewe chekin sowumwar, noumw ewe tokter mei eisinuk ika…?​ ​

	EWER	APW	ESE FFAT	USE MOCHEN EPPONUWA
GM3a. ika en mei wuun suupwa ika e-cigarettes (“vape”) ika pwan aea ew sokkun tamaak ese otuot	1 ☐	2 ☐	77 ☐	99 ☐
GM3b. ika emon mei soun urumemeok ika awatok	1 ☐	2 ☐	77 ☐	99 ☐

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

[IF YES] Omw ewe chekin sowumwar, noumw ewe tokter mei…?​ ​

	EWER	APW	ESE FFAT	USE MOCHEN EPPONUWA
GM4a. tessinuk ika mei uruk maan suke?	1 ☐	2 ☐	77 ☐	99 ☐
GM4b. Ngonuk unumwomw safeian netipechou ika ekiekingaw?	1 ☐	2 ☐	77 ☐	99 ☐

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

Ren ekkewe ekkoch kapas eis, kose mochen fili lein ekkei poluen kapas eis ren met ka mefi seni om we saingon pwopwo. Seni an noumw ena upwutiw, a fan fite omw…

	Iteitan	Fan chommong	Fan ekkoch	Ese konnien	Ese mwo
GM5a. kese mefi pwapwa, netipechou, ika mefi chouchou?	1 ☐	2 ☐	3 ☐	4 ☐	5 ☐
GM5b. kese mochen ika kese konnien pwapwaiti omw kopwe fori och mettoch?	1 ☐	2 ☐	3 ☐	4 ☐	5 ☐
GM5c. mefi nuwokkus, ekiekingaw, ika noniinen?	1 ☐	2 ☐	3 ☐	4 ☐	5 ☐
GM5d. kese tongeni ukuseni ika ekukkunatiw omw noniinen?	1 ☐	2 ☐	3 ☐	4 ☐	5 ☐

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

[IF POSTPARTUM CHECKUP=NO, DK, PNA] Mei wor ew nein ekkei awewe me popwun e eppeti omw kopwe no chek mwirimwirin omw ka nounou?

	UII	APW	USE SILEI	UWA FILATA USAP POLUENI
GM6a. Ese wor health insurance ren an esapw kamo niwinin ai no chek	1 ☐	2 ☐	77 ☐	99 ☐
GM6b. U mefi pochokkun me use ekieki pwe mei auchea ai upwe no chek	1 ☐	2 ☐	77 ☐	99 ☐
GM6c. Use tikelong ren forun kokotun churi tokter lupwen uwa mochen	1 ☐	2 ☐	77 ☐	99 ☐
GM6d. Ese wor wai ren ai upwe feilo ngeni ewe clinic ika ewe ofes an tokter	1 ☐	2 ☐	77 ☐	99 ☐
GM6e. A fokkun chommong met upwe fori mi fis	1 ☐	2 ☐	77 ☐	99 ☐
GM6f. Use tongeni upwe off seni angang	1 ☐	2 ☐	77 ☐	99 ☐
GM6g. Ika pwal ekkoch popun, kose mochen afata	1 ☐	2 ☐	77 ☐	99 ☐

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

[IF POSTPARTUME CHECKUP=YES] Met om ekiek ren om we churi pioing fan iten tumunun pochokulen inisum murin nounou?

	MENEMENEOCH	USE MENEMENEOCH	USE SILEI	UWA FILATA USAP POLUENI
GM7a. Ewe ukkukun fansoun uwa witiwit lon	1 ☐	2 ☐	77 ☐	99 ☐
GM7b. An ekkewe tokter, kangof, me ekkewe chon angangen pioing eaea ar fansoun le poraus ngonuk	1 ☐	2 ☐	77 ☐	99 ☐
GM7c. Ekkewe pesepes re ngonuk ren tumunun pochokulen inisum	1 ☐	2 ☐	77 ☐	99 ☐
GM7d. Ar pwari ngonuk ar weweituk me asamoluk	1 ☐	2 ☐	77 ☐	99 ☐

8. [ONLY ASK THIS QUESTION IF BIOLOGICAL MOTHER]

Ekkei ekkoch kapas eis usun osukosuken samau lon unusen ach kewe kinikin lon fonuach kewe ren ewe menun samau itan HIV, ei samau a kan apwangapwangakichelo pokiten mi nini ekkewe cells mi ngeni kich pochokulach mi pwal fiu ngeni ekkoch samau me paiking. Kopwe chechemeni pwe om polueni ekkei kapas eis mi monomonolo nge ika kose mochen polueni ekkoch me lein ekkei kapas eis ena a letipom chok. Ina mo am upwe eis usun om lo chek ren ei samau, nge am usap pwal eis pungun om chek ren sokkun chek ka fen angei.

Ka fen chek ren HIV? Kosap pwal aleani ekkoch chek ka fen angei ren om fang chaamw ngeni pioing fan iten om fangelo. Pachelong ar cheki chenun awom ika eotufomw.

1. ☐ UII

1. ☐ APW [GO TO GM10]

1. ☐ USE SILEI [GO TO GM10]

1. ☐ UWA FILATA USAP POLUENI [GO TO GM10]

9. [ONLY ASK THIS QUESTION IF BIOLOGICAL MOTHER]

Ka fen chek ren HIV lon ekkewe 12 maram a lo?

1. ☐ UII

1. ☐ APW

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

10. [ONLY ASK THIS QUESTION IF BIOLOGICAL MOTHER]

En mi pin chek ika mi toruk ekkewe samau mi cheu fetal ren an emon lisou fetal (re iteni “STD”) Kosap pwal aleani ekkoch chek ka fen angei ren om fang chaamw ngeni pioing fan iten om fangelo. Pachelong cheki chenun awom ika atufomw.

1. ☐ UII

1. ☐ APW

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

11. [ONLY ASK THIS QUESTION IF BIOLOGICAL MOTHER]

Lupwen om we saingon pwopwo, en mi pin poraus ngeni tokter, kangof ika chon angangen pioing usun ekkewe menun samau itan STD?

1. ☐ UII

1. ☐ APW

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

12. [ONLY ASK THIS QUESTION IF BIOLOGICAL MOTHER]

Non ekkewe 12 maram sia tou seni, mei wor fansoun an mecheresingaw kaworen tumwun ngonuk ren omw semwen? Ren kaworen tumwun, au awewei ren samwau me pwan ekkoch ren tumwunun nii, tumwunun maas, me semwenin non ekiek.

1. ☐ UII

2. ☐ APW [GO TO GM14]

1. ☐ USE SILEI [GO TO GM14]

1. ☐ UWA FILATA USAP POLUENI [GO TO GM14]

[IF YES] met sokkun tumwun e mecheresingaw kaworan ngonuk? CHEKI MEINISIN E PWUNG NGONUK.

1. ☐ Medical Care (Tumun Seni Pioing)

2. ☐ Pekin Aisa (Tumunun lon Auu)

3. ☐ Vision Care (Tumunun Mas)

4. ☐ Hearing Care (Tumunun Lenien Rongorongo)

5. ☐ Mental Health Services (Tumunun Ekiek me Tupu)

6. ☐ Ika pwal ekkoch, kose mochen afata

13. [ONLY ASK THIS QUESTION IF BIOLOGICAL MOTHER]

Pota e mecheresingaw an epwe kawor ngonuk aninnisin tumwun ren omw semwen?

	UII	APW	USE SILEI	UWA FILATA USAP POLUENI
GM13a. Pun ese mo ngeniei.	1 ☐	2 ☐	77 ☐	99 ☐
GM13b. Use silei ie upwe feilo ia.	1 ☐	2 ☐	77 ☐	99 ☐
GM13c. A kon towaw seniei.	1 ☐	2 ☐	77 ☐	99 ☐
GM13d. Use tikeri ikkenan lupwen a chiwen suuk.	1 ☐	2 ☐	77 ☐	99 ☐
GM13e. Ese wor mi suk (appointment) mi mutir ai upwe chuulong.	1 ☐	2 ☐	77 ☐	99 ☐
GM13f. Ese wor wai.	1 ☐	2 ☐	77 ☐	99 ☐
GM13g. Ese wor ai fansoun feilo.	1 ☐	2 ☐	77 ☐	99 ☐
GM13h. U ekis eureka ika esap mo ngeni nei ei taropwen safei ika insurance.	1 ☐	2 ☐	77 ☐	99 ☐
GM13i. Ren pwal ekkoch popun, kose mochen afata	1 ☐	2 ☐	77 ☐	99 ☐

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

Lupwen om we saingon pwopwo, fan fitu om chuchuri tokter, kangof, ika ekkewe chon pioing ren tumunun om pwopwo ika chek chok?

1. ☐ ESE MO CHURI

2. ☐ 1 AN CHURI [GO TO GM15]

3. ☐ 2 CHURI [GO TO GM15]

4. ☐ 3 CHURI [GO TO GM15]

5. ☐ 4 IKA LAP SENI CHURI [GO TO GM15]

1. ☐ USE SILEI [GO TO GM15]

1. ☐ UWA FILATA USAP POLUENI [GO TO GM15]

[IF 0 VISITS] Ekkei metoch mi epetuk seni om kopwe lo chekin tumunuk ren
om ei pwopwo?

	UII	APW	USE SILEI	UWA FILATA USAP POLUENI
GM14a. Use tikelong ren forun kokotun churi tokter lupwen uwa mochen	1 ☐	2 ☐	77 ☐	99 ☐
GM14b. Ese wor wai ren ai upwe feilo ngeni ewe clinic ika ewe ofes an tokter	1 ☐	2 ☐	77 ☐	99 ☐
GM14c. Nei we tokter ika ewe insurance plan mi kaor fan iten epwe moni ai liwinimang lon pioing ese mutir poputa usun met ia aneanei	1 ☐	2 ☐	77 ☐	99 ☐
GM14d. A fokkun chommong met upwe fori mi fis	1 ☐	2 ☐	77 ☐	99 ☐
GM14e. Use fokkun tongeni upwe off seni sukul me/ika angang	1 ☐	2 ☐	77 ☐	99 ☐
GM14f. Ese wor epwe tongeni tumunu nei kewe semirit	1 ☐	2 ☐	77 ☐	99 ☐
GM14g. Use silei nge uwa pwopwo	1 ☐	2 ☐	77 ☐	99 ☐
GM14h. Ese wor nei taropwen safei ika health insurance epwe moni ai kewe churi pioing ika ofesin tokter	1 ☐	2 ☐	77 ☐	99 ☐
GM14i. Uwa mefi pochokul use ekieki nge upwe churi pioing/tokter	1 ☐	2 ☐	77 ☐	99 ☐
GM14j. Use mochen ekkewe pekin tumunun pwopwo seni pioing/tokter	1 ☐	2 ☐	77 ☐	99 ☐
GM14k. Use mochen emon epwe silei nge uwa pwopwo	1 ☐	2 ☐	77 ☐	99 ☐
GM14l. Ren pwal ekkoch popun, kose mochen afata	1 ☐	2 ☐	77 ☐	99 ☐

Ekkei ekkoch kapas eis kapas eisin usun lenien mourn ewe semirit me lenien motun lupwen epwe
fiti chitosan.

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

Atun ewe ena semirit mei 0-12 maraman, ke kan ifa ussun ne akkonaatiw ika a mour?

2. ☐ Mei pereingiing

1. ☐ Mei seneta

2. ☐ Mei chappeno

1. ☐ ESE FFAT

1. UWA FILATA USAP POLUENI

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

Lon ekkewe 2 wik a lo, fan fitu an ewe semirit anut alaemon lon lenien le mour ika lon an we bed?

1. ☐ Fansoun meinisin

1. ☐ Iteitan

2. ☐ Fan ekkoch

3. ☐ Esap iteitan

4. ☐ Ese mo

5. ☐ NEI WE SEMIRIT ESE KAN ANUT LON LENIEN EWE LENIEN MOUR IKA WON BED

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

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

Lupwen an ewe semirit alaemon le mour, mi mour pusin nom lon an lenien mour ika bed lon rumom we ika?

1. ☐ Uii

1. ☐ Apw

2. ☐ ESE WENEITIKICH EI KAPAS EIS, PUN EWE SEMIRIT ESE KAN CHIWEN ANUT LON AN LENIEN MOUR IKA BED

1. ☐ USE SILEI

1. ☐ UWA FILATA USAP POLUENI

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

Ke kaio me ia foforun an noum ei lenien momot lon toraku me ifa usun ka pachelong lon en waa?

	UII	APW	USE SILEI	UWA FILATA USAP POLUENI
GM18a. Chiechiei ika chon ai famili a kan alisiei	1 ☐	2 ☐	77 ☐	99 ☐
GM18b. Emon chon pekin tumunun inis ika emon silelap a aitiei.	1 ☐	2 ☐	77 ☐	99 ☐
GM18c. Uwa pusin for ingang.	1 ☐	2 ☐	77 ☐	99 ☐
GM18d. Uwa fen sile foforun pun mi pwal wor nei kewe ekkoch semirit.	1 ☐	2 ☐	77 ☐	99 ☐
GM18e. Ika pwal ekkoch pekin kaio, kose mochen afata	1 ☐	2 ☐	77 ☐	99 ☐

[ONLY ASK THIS QUESTION IF CHILD IS 6-11 or 12-17 YEARS OLD]

Ekkei saingon kapas eis usun pekin tumunum lon om tukkan lon konik.

19. Kose mochen ereniei noum ei semirit mi tongeni fori ekkei metoch lon konik, ika kose kon silei.

	UII	APW	USE SILEI	UWA FILATA USAP POLUENI
GM19a. Turulong ika tolong lon konik ewe iwe tutua	1 ☐	2 ☐	77 ☐	99 ☐
GM19b. Tolong ika nipapa fetal lon ewe konik ren ukkukun 1 minich nge ese eaea ekkewe metoch mi api kich fetal	1 ☐	2 ☐	77 ☐	99 ☐
GM19c. Kulfetal lon konik pwal liwin sefalaliuou	1 ☐	2 ☐	77 ☐	99 ☐
GM19d. Ekia ukkukun 25 iach (lolo ngeni ach ikia fetal lon lenien tukkan mi aukuk lelon) nge ese kauu	1 ☐	2 ☐	77 ☐	99 ☐
GM19e. Touou seni en lenien tukkan, nge kose eaea nato	1 ☐	2 ☐	77 ☐	99 ☐

Kilisou ren om fiti kich.

Fan itan ewe U.S department of health and Human Services, sia mochen apasa ach kilisou ngonuk ren om fansoun le feito wato porausan om famili me noum we/kewe semirit ngeni kich.

Om polueni ekkei kapas eis a fokkun lamot ngeni kich a pwal alisi ekkewe chon kuta eochun nonomun manauach, fengen me ekkewe chon for alluk, pwal ekkewe chon tumunun famili lon ach kei kinikin (“family advocate”) ren ar repwe weweiti nonoumun pochokulen me tumunun inisin nouch kewe semirit lon ach leniach kei mi nofitifit sokopaten aramas lon.

Public Burden Statement: Esap pwal wor eu leni epwe pwal fori ei angang, an emon aramas polueni ekkei kapas epwe seni om mochen nge sisap aumesuk. Ewe OMB nampa ren ei angangen kaio iei 0906-0042. Ach we pekin repot ren pekin tumunun inisich ra era ei angangen angei poraus ina pwe ukkukun .71 ren eu memeief, mi pachelong fansoun katol sefal foforun, me kuta ekkewe allen poraus, pwal awesalo me katol sefal ekkewe chommongum porausen emon me emon. Ka tongeni uwato mefiom ikkei ika ke mochen silei fite momon ei kaio ika tichikin porausen ei angang pwal pachelong mefiom uwato, HRSA Reports Clearance Officer, 5600 Fisher Lane, Room 14N39, Rockville, Maryland, 20857.