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[p. 173]

Section D -- Child Health

Item D1
Refer to household composition.

[] Child under 18 in family (D2)
[] No child under 18 in family (Section E)
Item D2
Enter person number, first name, and age of sample child under 18.

Person number ____
First name ____
Age ____

Enter person number of respondent.

Person number ____
Item D3
Refer to age.

1[] Under 6 (Intro above D4)
2[] 6-17 (D5)

These questions refer to (read name), and are about various health topics, including immunizations that -- may have received. It would be helpful if we could refer to -- shot record.

Item D4
Refer to shot record

1[] Available (1)
2[] Not available (7)


1. Transcribe from shot record


Immunization: DTP/DT (shot)


1st Shot:
Months ____
Day ____
Year 19 ____


2nd Shot:
Months ____
Day ____
Year 19 ____


3rd Shot:
Months ____
Day ____
Year 19 ____


4th Shot:
Months ____
Day ____
Year 19 ____


5th Shot:
Months ____
Day ____
Year 19 ____


6th Shot:
Months ____
Day ____
Year 19 ____


7th Shot:
Months ____
Day ____
Year 19 ____


8th Shot:
Months ____
Day ____
Year 19 ____


Immunization: Polio (Drops of shots)


1st Shot:
Months ____
Day ____
Year 19 ____


2nd Shot:
Months ____
Day ____
Year 19 ____


3rd Shot:
Months ____
Day ____
Year 19 ____


4th Shot:
Months ____
Day ____
Year 19 ____


5th Shot:
Months ____
Day ____
Year 19 ____


6th Shot:
Months ____
Day ____
Year 19 ____


7th Shot:
Months ____
Day ____
Year 19 ____


8th Shot:
Months ____
Day ____
Year 19 ____


Immunization: Measles/MMR (shots)


1st shot:
1[] Measles
2[] MMR
Month ____
Day ____
Year 19____


2nd shot:
1[] Measles
2[] MMR
Month ____
Day ____
Year 19____


3rd shot:
1[] Measles
2[] MMR
Month ____
Day ____
Year 19____


Immunization: HIB (shot)


1st Shot:
Months ____
Day ____
Year 19 ____


2nd Shot:
Months ____
Day ____
Year 19 ____


3rd Shot:
Months ____
Day ____
Year 19 ____


4th Shot:
Months ____
Day ____
Year 19 ____


2. Are all the immunizations that -- ever received included on this shot record?

1[] Yes (9)
2[] No (3)
9[] DK (3)


3a. Has -- ever received an additional DTP shot (sometimes called a DPT shot, diphtheria-tetanus-pertussis shot, baby shot, or three-in-one-shot)?

1[] Yes (3b)
2[] No (4)
9[] DK (4)


b. How many additional DTP shots has -- received?

Shots ____ (Number)
9[] DK


4a. Has -- ever received an additional polio vaccine by mouth (pink drops) or a polio shot?

1[] Yes (4b)
2[] No (5)
9[] DK (5)


b. How many additional polio vaccines has -- received?

Vaccines ____ (Number)
9[] DK


5a. Has -- ever received an additional measles or MMR (Measles - Mumps - Rubella) shot?

1[] Yes (5b)
2[] No (6)
9[] DK (6)


b. How many additional measles or MMR shots has -- received?

Shots ____ (Number)
9[] DK

[p. 174]

Section D -- CHILD HEALTH -- Continued


6a. Has -- ever received an additional HIB shot? This shot is for meningitis and called Haemophilus Influenzae (HA-MA-FI-LUS IN-FLU-EN-ZI), HIB vaccine or H. flu vaccine.

1[] Yes (6b)
2[] No (9)
9[] DK (9)


b. How many additional HIB shots has -- received?

Shots (Number) ____ (9)
9[] DK (9)


7. Has -- ever received an immunization (that is a shot or drops)?

1[] Yes (8)
2[] No (9)
9[] DK (9)


8a. Has -- ever received:


A DTP/DT shot (sometimes called a DPT shot, diptheria-tetanus-pertussis-shot, baby shot, or three-in-one shot)?
1[] Yes (8b)
2[] No (Next vaccine)
9[] DK (Next vaccine)


A polio vaccine by mouth (pink drops) or a polio shot?
1[] Yes (8b)
2[] No (Next vaccine)
9[] DK (Next vaccine)


[] A measles or MMR (Measles - Mumps - Rubella) shot?
1[] Yes (8b)
2[] No (Next vaccine)
9[] DK (Next vaccine)


An HIB shot? (This is for meningitis and called Haemaphilus influenzae (HA-MA-FI-LUS IN-FLU-EN-ZI) HIB vaccine or H. flu vaccine)
1[] Yes (8b)
2[] No (9)
9[] DK (9)


b. At what age(s) did -- receive (additional) -- vaccine(s)?


A DTP/DT shot (sometimes called a DPT shot, diptheria-tetanus-pertussis-shot, baby shot, or three-in-one shot)


1st

Age ____
1[] Months
2[] Years


2nd

Age ____
1[] Months
2[] Years


3rd

Age ____
1[] Months
2[] Years


4th

Age ____
1[] Months
2[] Years


5th

Age ____
1[] Months
2[] Years


6th

Age ____
1[] Months
2[] Years


7th

Age ____
1[] Months
2[] Years


8th

Age ____
1[] Months
2[] Years


A polio vaccine by mouth (pink drops) or a polio shot?


1st

Age ____
1[] Months
2[] Years


2nd

Age ____
1[] Months
2[] Years


3rd

Age ____
1[] Months
2[] Years


4th

Age ____
1[] Months
2[] Years


5th

Age ____
1[] Months
2[] Years


6th

Age ____
1[] Months
2[] Years


7th

Age ____
1[] Months
2[] Years


8th

Age ____
1[] Months
2[] Years


A measles or MMR (Measles-Mumps- Rubella) shot?


1st

1[] Measles
2[] MMR
Age ____
1[] Months
2[] Years


2nd

1[] Measles
2[] MMR
Age ____
1[] Months
2[] Years


3rd

1[] Measles
2[] MMR
Age ____
1[] Months
2[] Years


An HIB shot? (This is for meningitis and called Haemophilus influenzae (HA-MA-FI-LUS IN-FLU-EN-ZI) HIB vaccine or H. Flu vaccine)


1st

Age ____
1[] Months
2[] Years


2nd

Age ____
1[] Months
2[] Years


3rd

Age ____
1[] Months
2[] Years


4th

Age ____
1[] Months
2[] Years


c. Has -- ever received any additional:


DTP/DT shots?
1[] Yes (Reask 8b and c)
2[] No (Next vaccine)
9[] DK (Next vaccine)


Polio drops or shots?
1[] Yes (Reask 8b and c)
2[] No (Next vaccine)
9[] DK (Next vaccine)


Measles/MMR shots?
1[] Yes (Reask 8b and c)
2[] No (Next vaccine)
9[] DK (Next vaccine)


HIB shots?
1[] Yes (Reask 8b and c)
2[] No (9)
9[] DK (9)

[p. 175]

Section D -- CHILD HEALTH -- Continued


9a. During the past 12 months, how many times has -- had diarrhea severe enough that -- had to cut down for more than half of the day on things -- usually does?

00[] None
Times (Number) ____
99[] DK


b. During the past 12 months, how many times has -- had a middle ear infection?

00[] None
Times (Number) ____
99[] DK


c. During the past 12 months, did -- ever receive child care in a place that cares for MORE THAN 6 CHILDREN? This includes day care centers, preschool, nursery school, religious school, kindergarten, but does not include child care provided in this home.

1[] Yes (9d)
2[] No (D5)
9[] DK (D5)


d. In how many of the past 12 months did -- receive such child care?

Months (Number) ____
99[] DK


e. DURING THE PAST 2 WEEKS, did -- receive such child care?

1[] Yes
2[] No
9[] DK


Item D5
Refer to age.

1[] Under 5 (10)
2[] 5-15 (11)
3[] 16-17 (12)


These next questions are about child safety.

10a. Does -- now have a child safety seat?

1[] Yes
2[] No
9[] DK


b. When riding in a car, is -- buckled in (a child safety seat or) a seat belt all or most of the time, some of the time, once in awhile, or never?

1[] All or most of the time (D7)
2[] Some of the time (D7)
3[] Once in awhile (D7)
4[] Never (D7)
5[] Doesn't ride in car (D7)
9[] DK (D7)


These next questions are about child safety.

11. When riding in a car, does -- wear a seat belt all or most of the time, some of the time, once in awhile, or never?

1[] All or most of the time (D6)
2[] Some of the time (D6)
3[] Once in awhile (D6)
4[] Never (D6)
5[] Doesn't ride in car (D6)
9[] DK (D6)


These next questions are about child safety.
12. When driving or riding in a car, does -- wear a seat belt all or most of the time, some of the time, once in awhile, or never?

1[] All or most of the time (13)
2[] Some of the time (13)
3[] Once in awhile (13)
4[] Never (13)
5[] Doesn't ride in car (13)
9[] DK (13)

[p. 176]

Section D -- CHILD HEALTH -- Continued

Item D6
Refer to age.

1[] 7-15 (13)
2[] Under 7 (D7)

Hand Card D1. Read list if telephone interview.
CARD D1
1. Football
2. Baseball or softball
3. Soccer
4. Rugby
5. Field or ice hockey
6. Lacrosse
7. Wrestling
8. Boxing
9. Karate or Judo


13a. During the past 12 months, did -- play any of these ORGANIZED sports?

1[] Yes (13b)
2[] No (D7)
9[] DK (D7)


b. Which ones did -- play?
Mark "Yes" or "No" for each activity.


(1) Football
1[] Yes
2[] No


(2) Baseball or softball
1[] Yes
2[] No


(3) Soccer
1[] Yes
2[] No


(4) Rugby
1[] Yes
2[] No


(5) Field or ice hockey
1[] Yes
2[] No


(6) Lacrosse
1[] Yes
2[] No


(7) Wrestling
1[] Yes
2[] No


(8) Boxing
1[] Yes
2[] No


(9) Karate or Judo
1[] Yes
2[] No


NOTE: Ask 13c and d for each activity marked "Yes" in 13b.
c. During the past 12 months, when (playing) (sport in 13b), how often did -- wear a mouth guard to protect -- mouth and teeth -- all or most of the time, some of the time, once in awhile or never?


(1) Football
1[] All or most of the time
2[] Some of the time
3[] Once in awhile
4[] Never
9[] DK


(2) Baseball or softball
1[] All or most of the time
2[] Some of the time
3[] Once in awhile
4[] Never
9[] DK


(3) Soccer
1[] All or most of the time
2[] Some of the time
3[] Once in awhile
4[] Never
9[] DK


(4) Rugby
1[] All or most of the time
2[] Some of the time
3[] Once in awhile
4[] Never
9[] DK


(5) Field or ice hockey
1[] All or most of the time
2[] Some of the time
3[] Once in awhile
4[] Never
9[] DK


(6) Lacrosse
1[] All or most of the time
2[] Some of the time
3[] Once in awhile
4[] Never
9[] DK


(7) Wrestling
1[] All or most of the time
2[] Some of the time
3[] Once in awhile
4[] Never
9[] DK


(8) Boxing
1[] All or most of the time
2[] Some of the time
3[] Once in awhile
4[] Never
9[] DK


(9) Karate or Judo
1[] All or most of the time
2[] Some of the time
3[] Once in awhile
4[] Never
9[] DK


d. During the past 12 months, when (playing) (sport in 13b), how often did -- wear protective headgear -- all or most of the time, some of the time, once in awhile or never?


(1) Football
1[] All or most of the time
2[] Some of the time
3[] Once in awhile
4[] Never
9[] DK


(2) Baseball or softball
1[] All or most of the time
2[] Some of the time
3[] Once in awhile
4[] Never
9[] DK


(3) Soccer
1[] All or most of the time
2[] Some of the time
3[] Once in awhile
4[] Never
9[] DK


(4) Rugby
1[] All or most of the time
2[] Some of the time
3[] Once in awhile
4[] Never
9[] DK


(5) Field or ice hockey
1[] All or most of the time
2[] Some of the time
3[] Once in awhile
4[] Never
9[] DK


(6) Lacrosse
1[] All or most of the time
2[] Some of the time
3[] Once in awhile
4[] Never
9[] DK


(7) Wrestling
1[] All or most of the time
2[] Some of the time
3[] Once in awhile
4[] Never
9[] DK


(8) Boxing
1[] All or most of the time
2[] Some of the time
3[] Once in awhile
4[] Never
9[] DK


(9) Karate or Judo
1[] All or most of the time
2[] Some of the time
3[] Once in awhile
4[] Never
9[] DK

[p. 177]

Section D -- CHILD HEALTH -- Continued


Item D7
Refer to age.

1[] Under 6 months (20)
2[] 6 months - 5 years (14)
3[] 6+ years (D9)


These next questions are about bottle feeding.

14. Has -- ever been fed with a bottle? Do not include bottles with plain water.

1[] Yes (D8)
2[] No (D9)
9[] DK (D9)


Item D8
Refer to age.

1[] Less than 2 years (15b)
2[] 2-5 years (15a)


15a. Does -- still use a bottle? Do not include bottles with plain water.

1[] Yes (15b)
2[] No (D9)
9[] DK (D9)


b. During the past 2 weeks, on how many days was -- put to sleep with a bottle at bedtime or naptime? Do not include bottles with plain water.

00[] None
Days (Number) ____
99[] DK


Item D9
Refer to age.

1[] 2-6 years (16)
8[] Other (D10)


16. During the past 12 months, about how many visits did -- make to a dentist?

00[] No visits
Visits (Number) ____
99[] DK


Item D10
Refer to age.

1[] 5-17 years (17)
8[] Other (20)


NOTE: Ask all of 17a before 17b.
The next questions are about how well -- is able to do certain activities.

17a. Because of a physical or mental health condition, does -- have any difficult --
If "Doesn't do," ask before marking a box: Is this because of a physical or mental health condition?
If "Yes," mark "Yes."
If "No," mark "Doesn't do"


(1) Getting around inside the home?
1[] Yes
2[] No
3[] Doesn't do


(2) Walking?
1[] Yes
2[] No
3[] Doesn't do


(3) Getting in or out of bed or chairs?
1[] Yes
2[] No
3[] Doesn't do


(4) Eating?
1[] Yes
2[] No
3[] Doesn't do


(5) Using the toilet, including getting to and from the toilet?
1[] Yes
2[] No
3[] Doesn't do


(6) Bathing or showering?
1[] Yes
2[] No
3[] Doesn't do


(7) Dressing?
1[] Yes
2[] No
3[] Doesn't do


Ask 17b for each activity marked "Yes" in 17a.
b. Does -- need help from another person (activity in 17a)?


(1) Getting around inside the home?
1[] Yes
2[] No
3[] Doesn't do


(2) Walking?
1[] Yes
2[] No
3[] Doesn't do


(3) Getting in or out of bed or chairs?
1[] Yes
2[] No
3[] Doesn't do


(4) Eating?
1[] Yes
2[] No
3[] Doesn't do


(5) Using the toilet, including getting to and from the toilet?
1[] Yes
2[] No
3[] Doesn't do


(6) Bathing or showering?
1[] Yes
2[] No
3[] Doesn't do


(7) Dressing?
1[] Yes
2[] No
3[] Doesn't do


18a. Because of a physical or mental health condition, is -- speech difficult to understand?

1[] Yes (18b)
2[] No (19)
9[] DK (19)


b. Can -- speech be understood AT ALL?

1[] Yes
2[] No
9[] DK


19. Does -- have trouble seeing with one or both eyes EVEN when wearing glasses or contact lenses?

1[] Yes
2[] No
9[] DK


20. Are you -- biological, adoptive, step, or foster (mother/father) or are you some other relative?

01[] Biological mother
02[] Adoptive mother
03[] Step mother
04[] Foster mother
05[] Biological father
06[] Adoptive father
07[] Step father
08[] Foster father
88[] Other relative (Specify) ____
98[] Non-relative (Specify) ____