Form 0920-25-0027 SEED Follow-up Core Survey

DURING THE PAST 12 MONTHS, has this child had FREQUENT or CHRONIC difficulty with any of the following? Please provide a response for each item listed below. If your child does not have any of the conditions listed below, please select 'No'.

	Yes	No	Don’t Know
Toothaches	☐	☐	☐
Bleeding gums	☐	☐	☐
Decayed teeth or cavities	☐	☐	☐

Sleep Health

The next set of questions will ask you about your child’s typical sleep schedule during the week and on weekends.

SLEEP SCHEDULE ON WEEKDAYS
What is their typical bedtime on WEEKDAYS? (Sunday night – Thursday night)	Bedtime: _____:______ ☐AM/☐PM
When do they usually wake up on WEEKDAYS? (Monday morning – Friday morning)	Wake-up time: _____:______ ☐AM/☐PM
SLEEP SCHEDULE ON WEEKENDS
What is their typical bedtime on WEEKENDS? (Friday night and Saturday night)	Bedtime: _____:______ ☐AM/☐PM
When do they usually wake up on WEEKENDS? (Saturday morning and Sunday mornings)	Wake-up time: _____:______ ☐AM/☐PM

DURING A TYPICAL WEEK, does this child have FREQUENT or CHRONIC difficulty with any of the following?

	Yes	No	Don’t Know
Falling asleep at night	☐	☐	☐
Staying asleep at night	☐	☐	☐
Sleeping too much (day or night)	☐	☐	☐
Waking up feeling well rested	☐	☐	☐
Unintentionally falling asleep during the day	☐	☐	☐
Snoring loudly during sleep	☐	☐	☐
Stop breathing during sleep	☐	☐	☐
Is restless and moves a lot during sleep	☐	☐	☐
Wets the bed at night	☐	☐	☐

How confident do you feel in your ability to assess your child's sleep habits and/or sleep problems?

☐Not confident at all

☐Slightly confident

☐Fairly confident

☐Completely confident

Gastrointestinal Health

DURING THE PAST 12 MONTHS, has this child had FREQUENT or CHRONIC difficulty with any of the following… (Please provide a response for each item listed below. If your child does not have any of the conditions listed below, please select 'No'.)

	Yes	No	Don’t Know
Abdominal pain	☐	☐	☐
Constipation	☐	☐	☐
Diarrhea	☐	☐	☐
Gaseousness or bloating	☐	☐	☐
Incontinence (loss of bladder control)	☐	☐	☐
Soilage (accidental bowel movements)	☐	☐	☐
Nausea or vomiting	☐	☐	☐
Reflux	☐	☐	☐
Swallowing	☐	☐	☐

How confident do you feel in your ability to assess your child's gastrointestinal symptoms?

☐Not confident at all

☐Slightly confident

☐Fairly confident

☐Completely confident

Diagnosed Conditions

Next please tell us whether this child has any of the health conditions listed below.

Please answer question A for all conditions in the table below even if this child does not have any of the conditions. Please answer questions B and C for only the conditions this child ever had.

Medical Conditions

			If Question A is YES, please answer Questions B & C
Question A: Has a doctor or other health care provider ever told you that this child has any of the following medical or genetic conditions? Please provide a response for each condition listed below. If your child does not have any of the conditions listed below, please select ‘No’.			Question B: How old was this child when you were first told he or she had the condition? (Write in 0 if less than 1 year)	Question C: Does this child currently have the condition?
Allergy	☐Yes ☐ No ☐ Don’t Know (If yes, check all that apply)		____ Years	☐ Yes ☐ No ☐ Don’t Know
	☐	Food allergy	____ Years	☐ Yes ☐ No ☐ Don’t Know
	☐	Skin allergy or eczema	____ Years	☐ Yes ☐ No ☐ Don’t Know
	☐	Seasonal allergy or hay fever	____ Years	☐ Yes ☐ No ☐ Don’t Know
	☐	Drug allergy, specify: ________	____ Years	☐ Yes ☐ No ☐ Don’t Know
	☐	Other allergy, specify: _______________	____ Years	☐ Yes ☐ No ☐ Don’t Know
Arthritis	☐ Yes ☐ No ☐ Don’t Know		____ Years	☐ Yes ☐ No ☐ Don’t Know
Asthma	☐ Yes ☐ No ☐ Don’t Know		____ Years	☐ Yes ☐ No ☐ Don’t Know
Brain injury, concussion, or head injury	☐ Yes ☐ No ☐ Don’t Know		____ Years	☐ Yes ☐ No ☐ Don’t Know
Cancer	☐ Yes ☐ No ☐ Don’t Know		____ Years	☐ Yes ☐ No ☐ Don’t Know
Celiac disease	☐ Yes ☐ No ☐ Don’t Know		____ Years	☐ Yes ☐ No ☐ Don’t Know
Crohn’s disease	☐ Yes ☐ No ☐ Don’t Know		____ Years	☐ Yes ☐ No ☐ Don’t Know
Cystic fibrosis	☐ Yes ☐ No ☐ Don’t Know		____ Years	☐ Yes ☐ No ☐ Don’t Know
Diabetes (uses insulin)	☐ Yes ☐ No ☐ Don’t Know		____ Years	☐ Yes ☐ No ☐ Don’t Know
Diabetes (does not use insulin)	☐ Yes ☐ No ☐ Don’t Know		____ Years	☐ Yes ☐ No ☐ Don’t Know
Epilepsy or seizure disorder	☐ Yes ☐ No ☐ Don’t Know		____ Years	☐ Yes ☐ No ☐ Don’t Know
Fragile X Syndrome	☐ Yes ☐ No ☐ Don’t Know		____ Years	☐ Yes ☐ No ☐ Don’t Know
Frequent or severe headaches, including migraine	☐ Yes ☐ No ☐ Don’t Know		____ Years	☐ Yes ☐ No ☐ Don’t Know
Heart condition	☐ Yes ☐ No ☐ Don’t Know		____ Years	☐ Yes ☐ No ☐ Don’t Know
High cholesterol	☐ Yes ☐ No ☐ Don’t Know		____ Years	☐ Yes ☐ No ☐ Don’t Know
Hypertension or high blood pressure	☐ Yes ☐ No ☐ Don’t Know		____ Years	☐ Yes ☐ No ☐ Don’t Know
Irritable bowel syndrome	☐ Yes ☐ No ☐ Don’t Know		____ Years	☐ Yes ☐ No ☐ Don’t Know
Sickle cell anemia/thalassemia/other hereditary anemias	☐ Yes ☐ No ☐ Don’t Know		____ Years	☐ Yes ☐ No ☐ Don’t Know
Sleep-Wake disorder	☐Yes ☐No ☐Don’t Know (If yes, check all that apply)
	☐	Sleep Apnea	____ Years	☐ Yes ☐ No ☐ Don’t Know
	☐	Insomnia	____ Years	☐ Yes ☐ No ☐ Don’t Know
	☐	Restless Leg Syndrome	____ Years	☐ Yes ☐ No ☐ Don’t Know
	☐	Narcolepsy	____ Years	☐ Yes ☐ No ☐ Don’t Know
	☐	Other sleep-wake disorder, specify: ______________	____ Years	☐ Yes ☐ No ☐ Don’t Know
Ulcerative colitis	☐ Yes ☐ No ☐ Don’t Know		____ Years	☐ Yes ☐ No ☐ Don’t Know
Other medical or genetic condition, specify:_________	☐ Yes ☐ No ☐ Don’t Know		____ Years	☐ Yes ☐ No ☐ Don’t Know

Behavioral, Developmental, or Mental Health Conditions

		If Question A is YES, please answer Questions B & C.
Question A: Has a doctor or other health care provider ever told you that this child has any of the following behavioral, developmental, or mental health conditions? Please provide a response for each condition listed below. If your child does not have any of the conditions listed below, please select ‘No’.		Question B: How old was this child when you were first told he or she had the condition? (Write in 0 if less than 1 year)	Question C: Does this child currently have the condition?
Attention-Deficit/Hyperactivity disorder, combined or hyperactive or inattentive type (ADD or ADHD)	☐Yes ☐No ☐Don’t Know	____ Years	☐Yes ☐No ☐Don’t Know
Anxiety disorder (This includes generalized anxiety disorder, panic disorder, specific phobia, agoraphobia, selective mutism, or social anxiety disorder)	☐Yes ☐No ☐Don’t Know	____ Years	☐Yes ☐No ☐Don’t Know
Autism, Asperger’s disorder, pervasive developmental disorder, or autism spectrum disorder	☐Yes ☐No ☐Don’t Know	____ Years	☐Yes ☐No ☐Don’t Know
Bipolar disorder	☐Yes ☐No ☐Don’t Know	____ Years	☐Yes ☐No ☐Don’t Know
Cerebral palsy	☐Yes ☐No ☐Don’t Know	____ Years	☐Yes ☐No ☐Don’t Know
Depressive disorder	☐Yes ☐No ☐Don’t Know	____ Years	☐Yes ☐No ☐Don’t Know
Developmental coordination disorder, or motor delay	☐Yes ☐No ☐Don’t Know	____ Years	☐Yes ☐No ☐Don’t Know
Feeding or eating disorder	☐Yes ☐No ☐Don’t Know	____ Years	☐Yes ☐No ☐Don’t Know
Global developmental delay	☐Yes ☐No ☐Don’t Know	____ Years	☐Yes ☐No ☐Don’t Know
Intellectual disability	☐Yes ☐No ☐Don’t Know	____ Years	☐Yes ☐No ☐Don’t Know
Learning disability, specify: _________________	☐Yes ☐No ☐Don’t Know	____ Years	☐Yes ☐No ☐Don’t Know
Obsessive-compulsive disorder	☐Yes ☐No ☐Don’t Know	____ Years	☐Yes ☐No ☐Don’t Know
Oppositional defiant or conduct disorder	☐Yes ☐No ☐Don’t Know	____ Years	☐Yes ☐No ☐Don’t Know
Schizophrenia or other psychotic disorder	☐Yes ☐No ☐Don’t Know	____ Years	☐Yes ☐No ☐Don’t Know
Self-injurious behavior (This includes things like self-hitting, scratching, skin picking, or head banging)	☐Yes ☐No ☐Don’t Know	____ Years	☐Yes ☐No ☐Don’t Know
Sensory integration disorder	☐Yes ☐No ☐Don’t Know	____ Years	☐Yes ☐No ☐Don’t Know

			If Question A is YES, please answer Questions B & C.
Question A: Has a doctor or other health care provider ever told you that this child has any of the following behavioral, developmental, or mental health conditions? Please provide a response for each condition listed below. If your child does not have any of the conditions listed below, please select ‘No’.			Question B: How old was this child when you were first told he or she had the condition? (Write in 0 if less than 1 year)	Question C: Does this child currently have the condition?
Speech or other language disorder	☐Yes ☐No ☐ Don’t Know		____ Years	☐Yes ☐No ☐ Don’t Know
Substance-related & addictive disorders	☐Yes ☐No ☐ Don’t Know (If yes, check all that apply)
	☐	Tobacco	____ Years	☐Yes ☐No ☐ Don’t Know
	☐	Alcohol	____ Years	☐Yes ☐No ☐ Don’t Know
	☐	Opioids (e.g., OxyContin, Vicodin, Morphine, Fentanyl)	____ Years	☐Yes ☐No ☐ Don’t Know
	☐	Other substance, specify: ________	____ Years	☐Yes ☐No ☐ Don’t Know
Tourette syndrome	☐Yes ☐No ☐ Don’t Know		____ Years	☐Yes ☐No ☐ Don’t Know
Any other behavioral, developmental, or mental health disorder, specify: ______________________	☐Yes ☐No ☐ Don’t Know		____ Years	☐Yes ☐No ☐ Don’t Know

Food Allergies and Dietary Restrictions

Do you currently avoid any foods or food ingredients for this child because of a known or suspected food allergy or intolerance? (Check only one box)

☐Yes, diagnosed food allergy

☐Yes, suspected food allergy

☐Yes, confirmed or suspected food intolerance

☐No (Skip to question 13)

Which foods or food ingredients do you currently avoid for this child? (Check all that apply)

Cow's milk or other dairy products	☐	Wheat, gluten, or wheat starch	☐
Soy milk or other soy food	☐	Other grain or cereal ( e.g., oats, barley)	☐
Eggs or egg products	☐	Fruit or fruit juice	☐
Peanuts, peanut butter, or peanut oil	☐	Vegetables	☐
Other nuts (e.g., almonds, pecans, walnuts)	☐	Artificial colors or flavors	☐
Sesame seeds or sesame seed oil	☐	Sulfites	☐
Fish (e.g., salmon, codfish, tuna)	☐	Other foods or ingredients, specify________________________	☐
Crustacean shellfish (e.g., shrimp, crab, lobster)	☐	None of these	☐
Beef, pork, chicken, turkey, or another animal meat	☐

Communication Abilities

Does this child use verbal communication, such as words or noises, to communicate with people?

☐Verbally communicates using words easily

☐Verbally communicates using words with a little trouble

☐Verbally communicates using words with a lot of trouble

☐Verbally communicates with noises

☐Does not verbally communicate

Does this child communicate with people using any of the following non-verbal methods of communication? These methods can occur with or without verbal communication.

	Yes	No
Sign language	☐	☐
Lip reading	☐	☐
Simple hand movements	☐	☐
Facial gestures	☐	☐
Eye contact	☐	☐
Picture board	☐	☐
Electronic device (e.g., uses a tablet, laptop, or smartphone to communicate without talking)	☐	☐

Level of Support Needed

Children and adolescents have different levels of support needs. Overall, how much support does your child need to manage these aspects of life?

	No support	A little support	A lot of support
Understanding and communicating	☐	☐	☐
Moving and getting around	☐	☐	☐
Attending to hygiene, dressing, eating, or staying alone	☐	☐	☐
Interacting with other people	☐	☐	☐
Domestic responsibilities, leisure, work, and school	☐	☐	☐
Joining in community activities or participating in society	☐	☐	☐

B. Service Needs and Utilization

Health Services

Is there a place that this child usually goes when he or she is sick, or you need advice about his or her health?

☐Yes

☐No (Skip to question 3)

If yes, where does this child USUALLY go first? (Check one box only)

☐Doctor’s Office

☐Hospital Emergency Department

☐Hospital Outpatient Department

☐Clinic or Health Center

☐Retail Store or “minute clinic”

☐School (Nurse’s Office, Athletic Trainer’s Office, etc.)

☐Some other place, specify: ________________________

DURING THE PAST 12 MONTHS, did this child see a doctor, nurse, or other health care professional for routine preventative care (such as well-child visits or check-ups) or sick-child care?

☐Yes

☐No (Skip to question 4)

Question A

Question B

Question C

Type of provider

Number of visits in past 12 months

Complete each blank.

(Write in 0 if no visits)

If your child received routine preventative care, how much of a problem was it to get service from this type of provider?

If your child received sick-child care, how much of a problem was it to get service from this type of provider?

Dentist or oral health provider

# of visits for routine

preventative care: _______

# of visits for

sick-child care: _______

☐Not a problem

☐Small problem

☐Big problem

☐Did not receive this type of care in the last 12 months

☐Not a problem

☐Small problem

☐Big problem

☐Did not receive this type of care in the last 12 months

Hearing care provider

# of visits for routine

preventative care: _______

# of visits for

sick-child care: _______

☐Not a problem

☐Small problem

☐Big problem

☐Did not receive this type of care in the last 12 months

☐Not a problem

☐Small problem

☐Big problem

☐Did not receive this type of care in the last 12 months

Vision care provider

# of visits for routine

preventative care: _______

# of visits for

sick-child care: _______

☐Not a problem

☐Small problem

☐Big problem

☐Did not receive this type of care in the last 12 months

☐Not a problem

☐Small problem

☐Big problem

☐Did not receive this type of care in the last 12 months

General Physician or Medical care provider

# of visits for routine

preventative care: _______

# of visits for

sick-child care: _______

☐Not a problem

☐Small problem

☐Big problem

☐Did not receive this type of care in the last 12 months

☐Not a problem

☐Small problem

☐Big problem

☐Did not receive this type of care in the last 12 months

Medical specialist care provider, specify: ________________

# of visits for routine

preventative care: _______

# of visits for

sick-child care: _______

☐Not a problem

☐Small problem

☐Big problem

☐Did not receive this type of care in the last 12 months

☐Not a problem

☐Small problem

☐Big problem

☐Did not receive this type of care in the last 12 months

Psychologist, psychiatrist, counselor, therapist, or mental health care provider (circle type)

# of visits for routine

preventative care: _______

# of visits for

sick-child care: _______

☐Not a problem

☐Small problem

☐Big problem

☐Did not receive this type of care in the last 12 months

☐Not a problem

☐Small problem

☐Big problem

☐Did not receive this type of care in the last 12 months

DURING THE PAST 12 MONTHS, how many times did this child visit a hospital emergency department?

☐No visits

☐1 visit

☐2 or more visits

DURING THE PAST 12 MONTHS, how many times was this child hospitalized for any reason?

☐No hospitalizations

☐1 visit

☐2 or more hospitalizations

DURING THE PAST 12 MONTHS, was there any time when this child needed healthcare, but it was not received? By health care, we mean medical care as well as other kinds of care like dental care, vision care, and mental health services.

☐Yes

☐No (Skip to question 9)

If yes, which types of care were NOT received? (Check all that apply)

☐Dental Care

☐Hearing Care

☐Medical care, routine preventative

☐Medical care, sick or urgent care

☐Medical care, hospital emergency

☐Medical care, specialist

☐Mental Health Services

☐Vision Care

☐Other healthcare needed, specify: _______________________

Which of the following contributed to this child not receiving needed healthcare services? “Yes” means it was a factor in not receiving services and “no” means it was not a factor. (Check one in each row)

	Yes	No
This child did not have health insurance that covered the services needed	☐	☐
This child was not eligible for the services	☐	☐
The services this child needed were not available in this child’s area	☐	☐
There were problems getting an appointment when this child needed one	☐	☐
There were problems with getting transportation or childcare	☐	☐
The (clinic/doctor’s) office wasn’t open when this child needed care	☐	☐
There were issues related to cost	☐	☐
There were issues related to COVID-19 (e.g., concerned about being around others at doctor’s office who may have been exposed to COVID-19)	☐	☐
The child’s behaviors limited ability to attend or complete a visit	☐	☐
Other reasons, specify:________________________________	☐	☐

Experience with Child’s Health Care Providers

Do you have one or more persons you think of as this child’s personal doctor or nurse? A personal doctor or nurse is a health professional who knows this child well and is familiar with this child’s health history. This can be a general doctor, a pediatrician, a specialist doctor, a nurse practitioner, or a physician’s assistant.

☐Yes, one person

☐Yes, more than one person

☐No

Answer the following questions only if this child had a health care visit IN THE PAST 12 MONTHS. If this child has NOT had a health care visit in the past 12 months, skip to question 17 in this section.

DURING THE PAST 12 MONTHS, how often did this child’s doctors or other health care providers:

	Never	Sometimes	Usually	Always	Don’t know
Spend enough time with this child?	☐	☐	☐	☐	☐
Listen carefully to you?	☐	☐	☐	☐	☐
Show sensitivity to your family’s values and customs?	☐	☐	☐	☐	☐
Provide the specific information you needed concerning this child’s health?	☐	☐	☐	☐	☐
Help you feel like a partner in this child’s care?	☐	☐	☐	☐	☐

DURING THE PAST 12 MONTHS, were any decisions needed about this child’s health care services or treatment, such as whether to start or stop a prescription or therapy services, get a referral to a specialist, or have a medical procedure?

☐Yes

☐No (Skip to question 13)

DURING THE PAST 12 MONTHS, how often did this child’s doctors or other healthcare providers:

(Check one in each row)

	Never	Sometimes	Usually	Always	Don’t Know
Discuss with you the range of options to consider for his or her health care or treatment?	☐	☐	☐	☐	☐
Make it easy for you to raise concerns or disagree with recommendations for this child’s health care?	☐	☐	☐	☐	☐
Work with you to decide together which health care and treatment choices would be best for this child?	☐	☐	☐	☐	☐

Does anyone help you arrange or coordinate this child’s care among the different doctors or services that this child uses?

☐Yes

☐No

☐Did not see more than one health care provider in past 12 months (Skip to question 15)

DURING THE PAST 12 MONTHS, have you felt that you could have used extra help arranging or coordinating this child’s care among the different health care providers or services?

☐Yes

☐No

DURING THE PAST 12 MONTHS, did this child’s health care provider communicate with this child’s school, childcare provider, or special education program?

☐Yes

☐No (Skip to question 17)

☐Did not need health care provider to communicate with these providers (Skip to question 17)

If yes, overall, how satisfied are you with the health care provider’s communication with the school, childcare provider, or special education program?

☐Very satisfied

☐Somewhat satisfied

☐Somewhat dissatisfied

☐Very dissatisfied

Health Insurance

Is your child currently covered by ANY kind of health insurance or health coverage plan?

☐Yes

☐No (Skip to question 20)

If yes, please tell us which types of health insurance plans your child is CURRENTLY covered under.

	Yes	No
a. Insurance through a current or former employer or union	☐	☐
b. Insurance purchased directly from an insurance company	☐	☐
c. Medicaid, Medical Assistance, or any kind of government-assistance plan	☐	☐
d. TRICARE or other military health care	☐	☐
e. Indian Health Service	☐	☐
f. Any other type of health insurance or health coverage plan, specify: ______________________________	☐	☐

Thinking specifically about your child’s mental or behavioral health needs, how often does this child’s health insurance offer benefits or cover services that meet these needs?

☐Always

☐Usually

☐Sometimes

☐Never

☐This child does not use mental or behavioral health services

Education Services

DURING THE PAST 12 MONTHS, has this child attended school?

☐Yes (Skip to question 22)

☐No

If no, is this child not in school now because they… (Check one then skip to question 28)

☐Graduated with regular high school diploma (e.g., the standard high school diploma awarded to students after completing standard high school curriculum & exit exams)

☐Graduated with certificate of completion (e.g., certificate or alternative diploma awarded to high school students in special education)

☐Took a test for a diploma without taking all of their high school classes (e.g., GED)

☐Dropped out or stopped going

☐Was suspended

☐Was expelled

☐Is older than the school age limit

☐Some other reason, specify: _______________________________

If yes, which of the following best describes the school this child currently attends (or most recently attended)? If this child currently attends 2 schools, describe the school where he or she spends the most time. If this child only attends a school that offers instruction on a specific topic rather than general education check “Other school, specify.”

☐A regular public school that serves a wide variety of students

☐A regular private school that serves a wide variety of students

☐A school that serves only children with disabilities

☐A charter school or alternative school

☐An online school

☐Home instruction by a professional

☐Home schooling by a parent

☐A vocational/technical school (voc-tech)

☐2-year community college

☐4-year college or university

☐Medical or mental health facility, convalescent hospital, institution for people with disabilities, correctional or juvenile justice facility

☐Other school, specify: ____________________________

Which of the following best describes this child’s classroom setting?

☐ Regular classroom with a wide variety of students (this includes both in-person and remote/virtual classrooms). If Regular (typical) classroom, please specify type below:

Regular (typical) classroom with classroom support (for example, pull out or in class; one-to-one (1-to-1) aide; Collaborative Team Teaching (CTT) or Integrated Co-teaching (ICT) classroom)
Regularly (typical) classroom without support

☐ Special education classroom for students with disabilities or special needs

☐ Mix of regular and special education classrooms

☐ Does not apply because this child is home-schooled or not attending school

What grade is this child currently in? (If summer, what is the highest grade level this child has already completed)?

☐ Pre-school	☐ 10^th grade
☐ Kindergarten	☐ 11^th grade
☐ 1^st grade	☐ 12^th grade
☐ 2^nd grade	☐ College Freshman
☐ 3^rd grade	☐ College Sophomore
☐ 4^th grade	☐ College Junior
☐ 5^th grade	☐ College Senior
☐ 6^th grade	☐ Does not apply, my child did not attend a typical public or private school
☐ 7^th grade	☐ Don’t know
☐ 8^th grade	☐ Other education, specify: _____________________________ (e.g., 18-21-year-old program for eligible high school students)
☐ 9^th grade

DURING THE PAST 12 MONTHS, about how many days did this child miss school because of illness or injury?

☐No missed school days

☐1-3 days

☐4-6 days

☐7-10 days

☐11 or more days

DURING THE PAST 12 MONTHS, how many times has this child’s school contacted you or another adult in your household about any problems he or she is having with school?

☐No calls

☐1 time

☐2 or more times

DURING THE PAST 12 MONTHS, how many times has this child been suspended or expelled from school?

☐None

☐1 time

☐2 or more times

Since starting kindergarten, has this child repeated any grades?

☐Yes

☐No

Has this child ever changed schools or educational setting because his or her education needs were not being met?

☐Yes

☐No

Have you ever been involved in mediation, a due process hearing, or litigation concerning the child’s education services?

☐Yes

☐No

Has this child EVER received special education or an Individualized Education Plan (IEP), 504 plan, tutoring, classroom aide, reader/interpreter, communication device, enrichment program, pull-out program, or accelerated curriculum??

☐Yes

☐No, my child has never had a plan or services for special education (Skip to question 34)

If yes, please indicate below which of the following plans or services your child has received.

Question A: Has your child ever received one of these plans or services? Please provide a response for each plan or service listed below. If your child did not receive a plan or service listed below, please select ‘No’		If YES to Question A, please answer Questions B & C
		Question B: If yes, at what age in years did your child first receive the plan or service? (Write in 0 if less than 1 year)	Question C: Does the child currently have this plan or received this service IN THE PAST 12 MONTHS?
Individualized Education Plan or IEP (used for special education services in children 3 or older)	☐Yes ☐No ☐Don’t Know	______Years	☐Yes ☐No
504 Plan (sometimes used for special education services instead of or in addition to an IEP)	☐Yes ☐No ☐Don’t Know	______Years	☐Yes ☐No
Gifted and talented services, such as enrichment, pull-out program, or accelerated curriculum	☐Yes ☐No ☐Don’t Know	______Years	☐Yes ☐No
Tutoring	☐Yes ☐No ☐Don’t Know	______Years	☐Yes ☐No
Classroom aide	☐Yes ☐No ☐Don’t Know	______Years	☐Yes ☐No
Reader/interpreter	☐Yes ☐No ☐Don’t Know	______Years	☐Yes ☐No
Communication device or other electronic device (e.g., tablet, laptop, smartphone) to assist with classwork or to communicate without talking	☐Yes ☐No ☐Don’t Know	______Years	☐Yes ☐No
Other plan or service, specify: _________________________________	☐Yes ☐No ☐Don’t Know	______Years	☐Yes ☐No

Overall, how satisfied are you with the educational plans or services your child has received?

☐Very satisfied

☐Somewhat satisfied

☐Somewhat dissatisfied

☐Very dissatisfied

Developmental Services

Please tell us whether this child has ever used any of the developmental services or supports listed below. These types of services might be received through the school, a healthcare provider, or some other person or place such as an independent therapist.

Please answer question A for all services and supports in the table below, even if the child does not use the service or support. Please answer questions B, C, and D for only services and supports the child ever received.

		If Question A is YES, please answer Questions B to D.
			If yes, has this child received the service or support DURING THE PAST 12 MONTHS?
Question A: Has this child EVER received …		Question B: If yes, at what age in years did your child first receive this service? (Write in 0 if less than 1 year)	Question C: Received THROUGH SCHOOL DURING PAST 12 MONTHS?	Question D: Received OUTSIDE OF SCHOOL DURING PAST 12 MONTHS?
Audiology or hearing services?	☐Yes ☐No ☐Don’t Know	______Years	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know
Behavioral therapy, such as applied behavior analysis?	☐Yes ☐No ☐Don’t Know	______Years	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know
Occupational therapy or sensory therapy?	☐Yes ☐No ☐Don’t Know	______Years	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know
Physical therapy?	☐Yes ☐No ☐Don’t Know	______Years	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know
Psychological or mental health services or counseling?	☐Yes ☐No ☐Don’t Know	______Years	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know
Social skills therapy or training?	☐Yes ☐No ☐Don’t Know	______Years	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know
Speech or language therapy?	☐Yes ☐No ☐Don’t Know	______Years	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know
Other services? Specify:_______________	☐Yes ☐No ☐Don’t Know	______Years	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know

Overall, how satisfied are you with the developmental services or supports your child has received?

☐Very satisfied

☐Somewhat satisfied

☐Somewhat dissatisfied

☐Very dissatisfied

☐My child did not receive any developmental services or supports

Medications

Please tell us whether this child has taken medication because of the difficulties noted below. The medication can be prescription or over the counter.

Please answer question A for all conditions that may be treated with medication, even if the child does not take medication. Please answer questions B and C for only those conditions that are treated with medication.

Question A: DURING THE PAST 12 MONTHS, has this child taken any medication because of difficulties noted below at least once per month for at least 3 months?		Question B: If yes to Question A, did the child take a medication prescribed by a doctor or other healthcare provider?	Question C: If yes to Question A, did the child take an over-the-counter medication?
Aggression	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know
Anxiety	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know
Asthma	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know
Attention, concentration, or hyperactivity	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know
Autism	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know
Depression	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know
Gastrointestinal problems	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know
Repetitive behaviors	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know
Restricted interests	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know
Obsessive Compulsive Disorder	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know
Seizures	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know
Self-injurious behaviors (This includes things like self-hitting, scratching, skin picking, or head banging)	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know
Sleep problems	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know	☐Yes ☐No ☐Don’t Know

Complementary and Alternative Treatments

DURING THE PAST 12 MONTHS, did your child use any type of complementary or alternative health care or treatment to help improve or manage their behavior or development? This could be acupuncture, animal therapy, art or music therapy, relaxation or mindfulness therapy, special diets or supplements, or other alternative treatments.

☐Yes

☐No (Skip to question 1 in Section C)

If yes, please select all below that apply. Where relevant, please include these regardless of how it was given (e.g., pill, spray, cream, injection, etc.)

☐Acupuncture

☐Animal therapy

☐Arts therapy (includes music, art, dance, or drama/acting therapy)

☐Auditory integration

☐Chiropractic care

☐Wellness or Mindfulness (includes massage therapy, relaxation therapy, meditation, and yoga)

☐Vitamin or mineral supplements (includes supplements of any vitamin, folic acid, omega-3 FA and fish oils, and multi-vitamin and/or multi-mineral)

☐CBD/cannabis (e.g., CBD oil, marijuana, hash, weed, THC edibles)

☐Melatonin

☐Oxytocin

☐Special diet such as gluten-free casein-free (GFCF), gluten-free only, casein-free only, Feingold diet, ketogenic diet)

☐Other complementary or alternative health care or treatment, specify: __________________

C. Community and Social Participation

DURING THE PAST 12 MONTHS, did this child participate in:

(Check one in each row)

	Yes	No
Any sports team or sports lessons after school or on weekends?	☐	☐
Any clubs or organizations after school or on weekends?	☐	☐
Any other organized activities or lessons, such as music, dance, language, or other arts after school or on weekends?	☐	☐
Any type of community service or volunteer work at school, church, or in the community?	☐	☐
Any work, including regular jobs as well as babysitting, cutting grass, or other occasional work?	☐	☐

DURING THE PAST 2 WEEKS, did this child:

(Check one in each row)

	Yes	No
Get together socially with friends or neighbors?	☐	☐
Talk with friends or neighbors on the telephone, video conferencing system, or social media APP (e.g., Snapchat, Facebook, etc.)?	☐	☐
Get together with ANY relatives not including those who live with you?	☐	☐
Go to church, temple, or another place of worship for services or other activities?	☐	☐
Go to a show or movie, sports events, club meeting, after school class or other group event?	☐	☐
Go out to eat at a restaurant?	☐	☐

DURING THE PAST WEEK, on how many days was this child physically active for at least 60 minutes per day? Add all the time that he or she spent in any kind of physical activity that increased his or her heart rate and made him or her breathe hard some of the time.

☐0 days

☐1 day

☐2 days

☐3 days

☐4 days

☐5 days

☐6 days

☐Every day

☐I don’t know

ON AN AVERAGE WEEKDAY, about how much time does this child usually spend watching TV programs or movies, including streaming services such as Netflix, Hulu, Disney+, Apple TV, etc.?

☐None

☐Less than 1 hour

☐1 hour

☐2 hours

☐3 hours

☐4 or more hours

☐I don’t know

ON AN AVERAGE WEEKDAY, about how much time does this child usually spend playing on an electronic device? This does NOT include doing schoolwork, or watching TV shows, movies, or videos on YouTube/TikTok.

☐None

☐Less than 1 hour

☐1 hour

☐2 hours

☐3 hours

☐4 or more hours

☐I don’t know

D. Bullying and Discrimination

DURING THE PAST 12 MONTHS, has this child faced a barrier to community or social participation because of:

	Yes	No
A physical environment that is not accessible?	☐	☐
Lack of assistive or adaptive technology?	☐	☐
Negative attitudes towards people with disability?	☐	☐
A service, system, or policy that prevents equal participation for everyone?	☐	☐

Discrimination occurs when people are unfairly treated because they are perceived as different from others. Disability is any condition of the body or mind that makes it more difficult for the person with the condition to do certain activities and interact with the world around them.

Has this child been discriminated against because of a disability?

☐Yes

☐No, my child has not been discriminated against because a disability (Skip to question 4)

☐Not applicable, my child does not have a disability (Skip to question 4)

☐I don’t know (Skip to question 4)

If so, who discriminated against this child (check all that apply)?

☐Employer

☐Educator

☐Healthcare provider

☐Community worker (e.g., staff in shops)

☐Other person or people, specify:_________________________

DURING THE PAST MONTH (30 days), how often has this child been bullied by someone else?

☐Never (Skip to question 6)

☐1 time

☐2-3 times

☐4 or more times

☐Don’t know (Skip to question 6)

Please check all the ways this child has been bullied.

	Yes	If yes, check if the behavior occurred in the last 30 days	No	Don’t Know
Called bad names	☐	☐	☐	☐
Threatened that they would be hurt or hit	☐	☐	☐	☐
Teased, picked on, or made fun of	☐	☐	☐	☐
Pushed or shoved	☐	☐	☐	☐
Hit, slapped or kicked	☐	☐	☐	☐
Was electronically bullied or experienced cyber-bulling (this includes being bullied through texting, Instagram, Facebook, or other social media)	☐	☐	☐	☐
Ignored or left out of things on purpose	☐	☐	☐	☐
Someone tried to keep others from liking them by saying something bad or mean about them, or spreading rumors or lies	☐	☐	☐	☐
Others stole their things	☐	☐	☐	☐
Other types of bullying, please specify: ________________________________________	☐	☐	☐	☐

DURING THE PAST MONTH (30 days), how often has this child bullied another child?

☐Never (Skip to question 1 in Section E)

☐1 time

☐2-3 times

☐4 or more times

☐Don’t know (Skip to question 1 in Section E)

In what ways has this child bullied others?

Please check all the ways that this child bullied others.

	Yes	If yes, check if the behavior occurred in the last 12 months.	No	Don’t Know
Called someone bad names	☐	☐	☐	☐
Threatened to hurt or hit someone	☐	☐	☐	☐
Teased, picked on, or made fun of someone	☐	☐	☐	☐
Pushed or shoved someone	☐	☐	☐	☐
Hit, slapped or kicked someone	☐	☐	☐	☐
Engaged in electronic or cyber-bulling (this includes being bullied through texting, Instagram, Facebook, or other social media)	☐	☐	☐	☐
Ignored someone or left them out of things on purpose	☐	☐	☐	☐
Tried to keep others from liking someone by saying mean things about them, or spread rumors or lies about someone	☐	☐	☐	☐
Stole others’ things	☐	☐	☐	☐
Other types of bullying, please specify: ________________________________________	☐	☐	☐	☐

E. Child Safety

Some children are likely to wander off and become so lost that it is necessary to search for them.

DURING THE PAST 12 MONTHS, has this child wandered off or became lost from any of these places, even if it occurred just once. (Check one in each row)

	Yes	No
Your home?	☐	☐
Someone else’s home such as a relative, friend, neighbor, or babysitter?	☐	☐
School, day care, or summer camp?	☐	☐
A store, restaurant, playground, campsite, or any other public place?	☐	☐

Do you currently have any of the following to specifically prevent this child from wandering off or to find them if they become lost? (Check one in each row)

	Yes	No
Fences or gates to your home or property (e.g., pool gate)	☐	☐
Locks, alarms, or cameras to your home or property (e.g., motion detectors)	☐	☐
Other barriers to your home or property (e.g., window guards)	☐	☐
A tracking device on this child’s accessories, body, or clothing	☐	☐
An APP, feature, or tracking device on this child’s cell phone	☐	☐

DURING THE PAST 12 MONTHS, has this child had contact with a law enforcement officer for any reason?

☐Yes

☐No (Skip to question 6)

☐I Don’t Know (Skip to question 6)

Did the officer sufficiently explain his or her actions or procedures?

☐Yes

☐No

Are you satisfied with your child’s interaction(s) with your law enforcement agency?

☐Yes

☐No

The next question is about events that may have happened during this child’s life. These things can happen to any family, but some people may feel uncomfortable with these questions. You may skip any questions you do not want to answer.

To the best of your knowledge, has this child ever experienced any of the following?

	Yes	No
Parent/guardian divorced or separated	☐	☐
Parent/guardian died	☐	☐
Parent/guardian served time in jail	☐	☐
Was a victim of violence or witnessed violence in their neighborhood	☐	☐
Lived with anyone who was mentally ill, suicidal, or severely depressed	☐	☐
Lived with anyone who had a problem with alcohol or drugs	☐	☐
Treated or judged unfairly because of their race or ethnic group	☐	☐
Treated or judged unfairly because of their sexual orientation	☐	☐

F. You and Your Family

The next questions are about you and your family

How are you related to this child?

☐Biological or adoptive mother

☐Biological or adoptive father

☐Stepparent

☐Grandparent

☐Aunt or uncle

☐Other relative

☐Other non-relative, specify:___________________________

What is your age?

_____ (Print numbers)

What is the highest grade or year of school you have completed?

☐8th grade or less

☐9^th-12^th grade; No diploma

☐High school graduate or GED completed

☐Completed a vocational, trade, or business school program

☐Some college credit, but no degree

☐Associate Degree (e.g., AA, AS)

☐Bachelor’s Degree (e.g., BA, BS, AB)

☐Master’s Degree (e.g., MA, MS, MSW, MBA)

☐Doctorate (e.g., PhD, EdD) or Professional Degree (e.g., MD, DDS, DVM, JD)

Are you currently…?

If more than one, select the one category which best describes you.

☐Employed for wages

☐Self-employed

☐Out of work for less than 1 year

☐Out of work for 1 year or more

☐A homemaker

☐A student

☐Retired

☐Unable to work

Are you now married, living with a partner together as an unmarried couple, or neither?

☐Married

☐Living with a partner together as unmarried couple

☐Neither (Skip to question 8)

☐Prefer not to answer (Skip to question 8)

What is the highest grade or year of school your spouse or partner has completed?

☐8^th grade or less

☐9^th-12^th grade; No diploma

☐High school graduate or GED completed

☐Completed a vocational, trade, or business school program

☐Some college credit, but no degree

☐Associate Degree (e.g., AA, AS)

☐Bachelor’s Degree (e.g., BA, BS, AB)

☐Master’s Degree (e.g., MA, MS, MSW, MBA)

☐Doctorate (e.g., PhD, EdD) or Professional Degree (e.g., MD, DDS, DVM, JD)

Is your spouse or partner currently…?

If more than one, select the one category which best describes your spouse or partner.

☐Employed for wages

☐Self-employed

☐Out of work for less than 1 year

☐Out of work for 1 year or more

☐A homemaker

☐A student

☐Retired

☐Unable to work

Your Health

The following questions are about your health.

In general, what is your physical health status?

☐Excellent

☐Very Good

☐Good

☐Fair

☐Poor

DURING THE PAST 2 WEEKS, for about how many days have you felt very healthy and full of energy?

☐Nearly every day

☐More than half the days

☐Few days

☐No days

In general, what is your mental or emotional health status?

☐Excellent

☐Very Good

☐Good

☐Fair

☐Poor

Has a doctor or other healthcare provider EVER told you that you had any of the following?

	Yes	No
Attention deficit disorder or Attention deficit hyperactivity disorder (ADD or ADHD)?	☐	☐
Anxiety disorder? (This includes generalized anxiety disorder, panic disorder, specific phobia, agoraphobia, selective mutism, or social anxiety disorder)	☐	☐
Obsessive compulsive disorder?	☐	☐
Autism, Asperger’s, pervasive developmental disorder, or autism spectrum disorder?	☐	☐
Bipolar disorder?	☐	☐
Depression? (This includes Major Depressive Disorder, Disruptive Mood Regulation Disorder, Dysthymia, and Premenstrual dysphoric disorder)	☐	☐
Schizophrenia or other psychotic disorder?	☐	☐
Other developmental or mental health condition, specify ____________________________	☐	☐

How well do you feel that you are coping with the day-to-day demands of raising this child?

☐Very well

☐Somewhat well

☐Not very well

☐Not very well at all

DURING THE PAST 12 MONTHS, was there someone that you could turn to for day-to-day emotional support with parenting or raising this child?

☐Yes

☐No (Skip to question 15)

If yes, did you receive emotional support from (check all that apply):

	Yes	No
Spouse?	☐	☐
Other family member or close friend?	☐	☐
Health care provider?	☐	☐
Place of worship or religious leader?	☐	☐
Support or advocacy group related to specific health condition?	☐	☐
Peer support group?	☐	☐
Counselor or other mental health professional?	☐	☐
Other person, specify: ____________________________	☐	☐

DURING THE PAST 12 MONTHS, have you:

	Yes	No
Delayed getting health care or dental care for yourself because of the time needed to care for this child?	☐	☐
Gotten less physical activity than you wanted because of the time needed to care for this child?	☐	☐
Limited your social life because of the time needed to care for this child?	☐	☐

DURING THE PAST 12 MONTHS, have you needed help with any of the following as a result of parenting this child?

	Yes	No
Finding more time for yourself?	☐	☐
Helping your spouse accept any condition your child might have?	☐	☐
Helping your family discuss problems and reach solutions?	☐	☐
Deciding on and doing recreational activities?	☐	☐
Paying for household expenses, such as food, housing, medical care, clothing, or transportation?	☐	☐
Getting any special equipment your child needs?	☐	☐
Paying for therapy, day care, or other services your child needs?	☐	☐
Job counseling or help in getting a job?	☐	☐

Have you or other family members living in your household EVER stopped working or cut down on the hours you work because of this child’s health or health conditions?

☐Yes

☐No

Have you or other family members living in your household EVER avoided changing jobs because of concerns about maintaining health insurance for this child?

☐Yes

☐No

As a result of parenting this child, do you feel:

	Yes	No
That this child is much harder to care for than most children his or her age?	☐	☐
That this child does things that bother you a lot?	☐	☐
Angry with this child?	☐	☐
An increased sense of personal strength and confidence?	☐	☐
That your priorities have changed?	☐	☐
A greater appreciation of life?	☐	☐
Pleasure in the child’s accomplishments?	☐	☐
Increased faith/spirituality?	☐	☐
That you have more meaningful relationships?	☐	☐
The child has had a positive effect on the wider community?	☐	☐

G. Household Information

Is this child of Hispanic, Latino, or Spanish origin? (Check one)

☐No, not Hispanic, Latino, or Spanish origin

☐Yes, Mexican, Mexican American, Chicano

☐Yes, Puerto Rican

☐Yes, Cuban

☐Yes, another Hispanic, Latino, or Spanish origin

What is this child’s race? (Check all that apply)

☐ White	☐ Korean
☐ Black or African American	☐ Vietnamese
☐ American Indian or Alaska Native	☐ Other Asian
☐ Asian Indian	☐ Native Hawaiian
☐ Chinese	☐ Guamanian or Chamorro
☐ Filipino	☐ Samoan
☐ Japanese	☐ Other Pacific Islander

How many other children under the age of 18 years are now living in the household? Not including this child.

Number of children ____________________________ (If 0, skip to question 5)

Do any of these children have any disability, developmental delay, special need, or condition?

☐Yes

☐No

How many adults 18 years or older are now living in the household? Not including this child.

Number of adults ___________

How many of these adults in your household are family members? Family is defined as anyone related to this child by blood, marriage, adoption, or through foster care.

Number of people _______________

The next questions are about your total income in the last calendar year before taxes.

Income is important in analyzing the health information we collect. For example, with this information, we can learn whether people in one income group use certain types of medical services more or less often than those in another group. Please be assured that, like all other information you have provided, these answers will be kept strictly private.

7. Think about your total combined family income IN THE LAST CALENDAR YEAR for all members of the family. What was your yearly total household income before taxes? Include your income, your spouse’s or partner’s income, and any other income you may have received.

Shape1

If you are unable to provide a specific amount, please indicate an estimated range of total yearly income below.

☐$0 to $16,000

☐$16,001 to $20,000

☐$20,001 to $24,000

☐$24,001 to $28,000

☐$28,001 to $32,000

☐$32,001 to $40,000

☐$40,001 to $48,000

☐$48,001 to $57,000

☐$57,001 to $60,000

☐$60,001 to $73,000

☐$73,001 to $85,000

☐$85,001 or more

8. DURING THE LAST CALENDAR YEAR, how many people, including yourself and this child, depended on this income?

Number of people _______

H. Individual Strengths

The following questions ask about characteristics and abilities you view as individual strengths of your child.

Would you say the following are individual strengths of this child?

	Yes	No
Courage	☐	☐
Empathy	☐	☐
Forgiveness	☐	☐
Kindness	☐	☐
Gratitude	☐	☐
Humor	☐	☐
Optimism	☐	☐
Resilience	☐	☐
Self-control	☐	☐
Self-efficacy, or belief he or she can be successful	☐	☐

Please describe the best things about your child below.

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Powell, Patrick (CDC/DDNID/NCBDDD/DHDD)
File Created	2025:05:22 15:21:07Z

Form 0920-25-0027 SEED Follow-up Core Survey

[NCBDDD] The Study to Explore Early Development (SEED) Follow-up Study

Attachment 2f - SEED Follow-Up Health and Development Core Survey_02-03-25_tracked_changes

SEED Follow-Up Health and Development Core Survey

OMB: 0920-1392

Contents

A. General Health

Height and Weight

Dental Health

Sleep Health

Gastrointestinal Health

Diagnosed Conditions

Medical Conditions

Behavioral, Developmental, or Mental Health Conditions

Food Allergies and Dietary Restrictions

Communication Abilities

Level of Support Needed

B. Service Needs and Utilization

Health Services

Experience with Child’s Health Care Providers

Health Insurance

Education Services

Developmental Services

Medications

Complementary and Alternative Treatments

C. Community and Social Participation

D. Bullying and Discrimination

E. Child Safety

F. You and Your Family

Your Health

G. Household Information

H. Individual Strengths