[p.279]
A
Begin interview by asking: When we conducted the interview several months ago, we recorded (sample child's) age as (age from label). Is this still correct?
1[] Yes (Go to Section A on page 5)
2[] No (Correct age on label, then go to Section A on page 5)
[p.281]
Section A - Home Care Services
Read to respondent: Because of earlier participation by your family in the
National Health Interview Survey, (child) has been selected for a special followup study on children's health. In order to get a complete picture of the health needs of U.S. children, we have included a wide range of children in this survey. For this reason, some of the questions may not seem relevant to (child), but your honest responses will help us get an accurate description of the health status and health care needs of U.S. children.
Now I am going to ask you about any SPECIAL HELP AND SUPERVISION that (child) NOW receives at home. By this I mean help BEYOND what is needed by most children [his/her] age.
ITEM A1
Refer to child's age
2[] Other (Skip to 2)
2[] No (Skip to 3)
9[] DK (Skip to 3)
b. During the past 12 months, did (child) receive, as part of [his/her] care, training to increase [his/her] independence in daily living skills, such as bathing, dressing, eating, and toileting?
2[] No (Skip to 3)
9[] DK (Skip to 3)
2. Because of any significant delays in development, does (child) need special help at home?
2[] No
9[] DK
3. Because of a physical, mental, or emotional problem, does (child) need constant supervision or need to be watched more closely than other children [his/her] age?
2[] No
9[] DK
ITEM A2
Refer to questions 1a, 2, and 3. (Special help or supervision)
2[] All other (Skip to 10 on page 10)
Anyone else?
or
0[] None in past 2 weeks (Skip to 9 on page 8)
9[] DK (Skip to 9 on page 8)
Ask 4b only if 4 names in Table H; otherwise
b. Besides helpers you just mentioned, has anyone else helped (child) AT HOME with personal care or supervision in the past two weeks?
2[] No (Skip to 5a on page 6)
9[] DK (Skip to 5a on page 6)
c. How many other people have helped?
(Number)
00[] None
99[] DK
d. How many of these additional helpers were paid?
(Number)
00[] None
99[] DK
[p.282]
Section A - Home Care Services - Continued
Table H
Ask 5-8 separately for each helper listed.
5a. Does (helper) help with (child's) personal care, supervision or both?
Mark (X) only one.
2[] Supervision
3[] Both
9[] DK
Verify and mark (X) if known or hand card C1 and ask. Read categories if telephone interview.
(Emily's note: Although the survey says card C1, it appears to actually require card DG1. Card C1 lists activities SC might have difficulty with.)
CARD DG1
1. Other relative who lives here
2. Other relative who does not live
3. Non-relative who lives here
4. Friend/Neighbor
5. Unpaid volunteer from an organization or business
6. Paid employee if an organization or business
7. Paid employee of yours
8. Other
b. What is (helper's) relationship to (child)?
Mark (X) only one.
1[] Other relative in HH (Go to 6a)
2[] Other relative not in HH (Go to 6a)
3[] Non-relative in HH (Go to 6a)
4[] Friend/Neighbor (Go to 6a)
5[] Unpaid volunteer from an organization or business (Skip to 6f)
6[] Paid employee if an organization or business (Skip to 6b)
7[] Paid employee of yours (Skip to 6b)
8[] Other (Go to 6a)
9[] DK (Go to 6a)
2[] No (Skip to 6f)
9[] DK (Skip to 6f)
Hand card C2. Read categories if telephone interview.
card C2 does not list these categories. Card G2 seems to be the correct one.
CARD DG2
1. Other relative who lives here
2. Other relative who does not live here
3. Private insurance
4. Rehabilitation program
5. Medicaid
6. Public school system
7. Other public source
8. Other private source
9. Other
b. Who pays for this help?
(Anyone else?)
Mark (X) all that apply.
01[] Family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicaid
05[] Rehabilitation program
06[] Parent's employer
07[] School system
08[] VA program
09[] Other military
10[] Other private source
11[] Other public source
12[] No one/ Free
99[] DK
Ask if more than one box marked in 6b; if only one, transcribe the number of the box without asking.
c. Who pays for most of this help? Record box number from 6b.
(Number)
99[] DK
Ask 6d and e only if box 00 or 01 marked in 6b; otherwise, skip to 6f.
d. DURING THE PAST 12 MONTHS, about how much did the family pay for this help? Do not count any money that will be reimbursed by insurance or any other source.
$_____ . [ 00 ]
99999[] DK
e. DURING THE PAST 2 WEEKS, about how much did the family pay for this help? Do not count any money that will be reimbursed by insurance or any other source.
$_____ . [ 00 ]
99999[] DK
f. How satisfied or dissatisfied are you with this help? Are you very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied?
Mark (X) only one.
2[] Somewhat satisfied
3[] Somewhat dissatisfied
4[] Very dissatisfied
9[] DK
Ask or verify:
g. Is (helper) male or female?
2[] Female
3[] DK
7. How many days in the past 2 weeks did (helper) help?
______ Days
14[] All
99[] DK
8. How many hours per day did (helper) help in the past 2 weeks?
________ Hours (Go to 5a for next helper, or A3 on page 8)
96[] Less than one hour (Go to 5a for next helper, or A3 on page 8)
99[] DK (Go to 5a for next helper, or A3 on page 8)
[p.283]
Section A - Home Care Services - Continued
ITEM A3
Refer to question 5b for ALL HELPERS in Table H.
(Any related household members)
2[] Other (Skip to 10 on page 10)
Respite care for children with special needs is care provided by a person or organization to relieve the parent or family caregivers. It can be provided at your home, someone else's home, a home run by an organization, a facility, or an institution.
9a. During the past 12 months, have you used any respite care for (child) so that you or your family could go out for awhile, take a break, or go on vacation?
2[] No
9[] DK
b. During the past 12 months, have you NEEDED any (additional) respite care for (child)?
2[] No
9[] DK
ITEM A4
Refer to question 9a.
(Respite care in past 12 months)
2[] Other (Skip to 10 on page 10)
Ask 9c(1)-(5) before going to 9d-f.
9c. Was any of this respite care in the past 12 months provided by --
2[] No
9[] DK
(2) An unpaid volunteer from an organization or business?
2[] No
9[] DK
(3) A paid employee of an organization or business?
2[] No
9[] DK
(4) A paid employee of yours?
2[] No
9[] DK
(5) Any other source?
2[] No
9[] DK
Ask 9d-f for each provider marked "Yes" in 9c.
9d. Altogether, how many days in the past 12 months did you use care provided by ("Yes" in 9c)?
(Number)
99[]DK
(2) An unpaid volunteer from an organization or business
(Number)
99[]DK
(3) A paid employee of an organization or business
(Number)
99[]DK
(4) A paid employee of yours
(Number)
99[]DK
(5) Any other source
(Number)
99[]DK
[p.284]
Section A - Home Care Services - Continued
Read categories if necessary.
9e. On the day(s) that you used this care, on the average how many hours did you use it?
Round fractions to the nearest whole hour.
2[] 1-2 hours
3[] 3-11 hours
4[] 12-24 hours
9[] DK
(2) An unpaid volunteer from an organization or business
2[] 1-2 hours
3[] 3-11 hours
4[] 12-24 hours
9[] DK
(3) A paid employee of an organization or business
2[] 1-2 hours
3[] 3-11 hours
4[] 12-24 hours
9[] DK
(4) A paid employee of yours
2[] 1-2 hours
3[] 3-11 hours
4[] 12-24 hours
9[] DK
(5) Any other source
2[] 1-2 hours
3[] 3-11 hours
4[] 12-24 hours
9[] DK
9f. Where was this care provided?
Anywhere else?
Mark (X) all that apply.
2[] Home run by organization
3[] Other private home
4[] Facility or institution
5[] Other
9[] DK
(2) An unpaid volunteer from an organization or business
2[] Home run by organization
3[] Other private home
4[] Facility or institution
5[] Other
9[] DK
(3) A paid employee of an organization or business
2[] Home run by organization
3[] Other private home
4[] Facility or institution
5[] Other
9[] DK
(4) A paid employee of yours
2[] Home run by organization
3[] Other private home
4[] Facility or institution
5[] Other
9[] DK
(5) Any other source
2[] Home run by organization
3[] Other private home
4[] Facility or institution
5[] Other
9[] DK
[p.285]
Section A - Home Care Services - Continued
10. Does (child's) health require that [he/she] be left only with a person trained to handle MEDICAL EMERGENCIES or perform special procedures?
2[] No
9[] DK
11a. Does (child) regularly receive any shots or injections at home?
2[] No (Skip to 12)
9[] DK (Skip to 12)
b. Who gives the shots?
Anyone else?
Mark (X) all that apply.
2[] Child (him/herself)
3[] Doctor/Nurse
4[] Other
9[] DK
Hand card C4. Read categories if telephone interview.
(Emily's note: CARD C4 in the survey refers to ranges of money. The correct card the question used was not found.)
12. Did you have any of these problems trying to get help at home for (child) during the past 12 months?
(Anything else?)
Mark (X) all that apply.
01[] Service not available
02[] Had trouble finding the right kind of service
03[] Medicaid not accepted
04[] Insurance did not cover
05[] Too expensive/can't afford
06[] Difficulty arranging it
07[] Helpers not reliable
08[] Helpers not properly trained or equipped
09[] Helpers hours not convenient
10[] Could not take off from work to arrange it
11[] Other problem
12[] No problem getting help
99[] DK
[p.286]
Section B - Work/Child Care
1a. Have you worked at a job or business for pay in the past month?
2[] No (Skip to 2)
b. How many hours do you usually work each week?
99[] DK
2a. Did you attend school in the past month?
2[] No (Skip to item B1)
b. How many hours do you usually attend school each week?
99[] DK
ITEM B1
Refer to questions 1a and 2a above.
(Work and/or attend school)
2[] All other (Skip to Section C on page 12)
Refer to child's age on label.
2[] Other (skip to 4)
2[] No
9[] DK
4a. (Not counting (child's) regular school hours) who took care of (child) MOST OFTEN when you were at [work/(or) school] during the past month?
Mark (X) only one.
02[] Mother cares for child (Skip to Section C on page 12)
03[] Father cares for child (Skip to Section C on page 12)
04[] Child cares for self (Go to 4b)
05[] Other relatives care for child (Skip to 4c)
06[] Unrelated babysitter (Skip to 4d)
07[] Care provided at school (Skip to 4e)
08[] Day care center (Skip to 4e)
09[] Day camp (Skip to 4e)
10[] Other (Skip to 4d)
99[] DK (Skip to Section C on page 12)
b. Approximately how many hours did (child) take care of [himself/herself] LAST WEEK?
______ Number of hours (Skip to Section C on page 12)
99[] DK (Skip to Section C on page 12)
c. how is this person related to (child)?
2[] Grandparent
3[] Other
9[] DK
d. Where was (child) cared for most often, at home or somewhere else?
2[] Somewhere else
9[] DK
e. Approximately how many hours was (child) cared for by (answer in 4a) while you [worked/(or) went to school] LAST WEEK?
_______ Number of hours
99[] DK
f. Do you pay for this child care?
2[] No
9[] DK
g. How satisfied are you with this child care? Are you very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied?
2[] Somewhat satisfied
3[] Somewhat dissatisfied
4[] Very dissatisfied
9[] DK
[p.287]
Section C - Medical Services
The following questions concern medical care for (child). Do not count visits for counseling or mental health therapy.
1. During the past 12 months has (child) had any visits to a doctor's office, clinic, hospital, or some other place for health care?
2[] No (Skip to Section D on page 13)
9[] DK (Skip to Section D on page 13)
Hand card C5. Read categories if telephone interview.
(Emily's note: Card C5 or a card relating to the reasons why a child last went to medical appointment was not found)
2. Why did (child) LAST go to a clinic, health center, hospital, doctor's office, or other medical facility?
(Anything else?)
Mark (X) all that apply.
2[] Care for an illness, injury or special condition
3[] Consultation
4[] Other
9[] DK
3. During the past 12 months, how many times has (child) been to a hospital emergency room?
_______ Times
(Number)
99[] DK
4. During the past 12 months, has (child) received any treatments AT A HOSPITAL ON A REGULAR BASIS?
Read if necessary: For example, dialysis, IV treatments, radiation treatments, chemotherapy, transfusions, or physical therapy.
2[] No
9[] DK
[p.288]
Section D - Assistive Devices and Technologies
The next questions are about medical devices and implants.
Ask 1a-o before going to 2.
1. In the past 12 months, did (child) use any of the following medical devices or supplies?
2[] No
9[] DK
b. A respirator?
2[] No
9[] DK
c. An ostomy bag?
2[] No
9[] DK
d. Catheterization equipment?
2[] No
9[] DK
e. A glucose monitor?
2[] No
9[] DK
f. Diabetic equipment or supplies?
2[] No
9[] DK
g. An inhaler?
2[] No
9[] DK
h. A nebulizer?
2[] No
9[] DK
i. A hearing aid?
2[] No
9[] DK
j. A feeding tube?
2[] No
9[] DK
k. A wheelchair?
2[] No
9[] DK
l. A scooter?
2[] No
9[] DK
m. Crutches?
2[] No
9[] DK
n. A cane?
2[] No
9[] DK
o. A walker?
2[] No
9[] DK
Ask for each "Yes" in 1.
2. Did (child) use (device) in the past two weeks?
2[] No
9[] DK
b. A respirator
2[] No
9[] DK
c. An ostomy bag
2[] No
9[] DK
d. Catheterization equipment
2[] No
9[] DK
e. A glucose monitor
2[] No
9[] DK
f. Diabetic equipment or supplies
2[] No
9[] DK
g. An inhaler
2[] No
9[] DK
h. A nebulizer
2[] No
9[] DK
i. A hearing aid
2[] No
9[] DK
j. A feeding tube
2[] No
9[] DK
k. A wheelchair
2[] No
9[] DK
l. A scooter
2[] No
9[] DK
m. Crutches
2[] No
9[] DK
n. A cane
2[] No
9[] DK
o. A walker
2[] No
9[] DK
ITEM D1
Refer to question 1 above
(Devices used in the past 12 months)
2[] Other (Skip to 4)
$_____ . [ 00 ]
99999[] DK
4. Does (child) now have any of the following implants?
2[] No
9[] DK
b. Any shunt that drains away fluid?
2[] No
9[] DK
c. An artificial joint?
2[] No
9[] DK
d. Implanted lens?
2[] No
9[] DK
e. Implanted pin, screw, nail, wire, rod, or plate?
2[] No
9[] DK
f. An artificial heart valve?
2[] No
9[] DK
g. A pacemaker?
2[] No
9[] DK
h. Silicone implant?
2[] No
9[] DK
i. Infusion pump?
2[] No
9[] DK
j. A cochlear (k?k'l?-?r) implant?
2[] No
9[] DK
k. Any other organ implant?
2[] No
9[] DK
[p.289-294]
Section E - Other Services
The next questions are about other services (child) may have received.
1a. During the past 12 months, did (child) receive any services from ______ ?
2[] No (Go to 1b)
9[] DK (Go to 1b)
(B) An occupational therapist
2[] No (Go to 1b)
9[] DK (Go to 1b)
(C) An audiologist
2[] No (Go to 1b)
9[] DK (Go to 1b)
(D) A speech therapist or pathologist
2[] No (Go to 1b)
9[] DK (Go to 1b)
(E) A recreational therapist
2[] No (Go to 1b)
9[] DK (Go to 1b)
(F) A visiting nurse
2[] No (Go to 1b)
9[] DK (Go to 1b)
1a. During the past 12 months, did (child) receive any services from ______ ?
2[] No (Go to 1b)
9[] DK (Go to 1b)
(H) A reader or interpreter
2[] No (Go to 1b)
9[] DK (Go to 1b)
(I) Home visits from a doctor
2[] No (Go to 1b)
9[] DK (Go to 1b)
1a. During the past 12 months, did (child) receive any services from ______ ?
2[] No (Go to 1b)
9[] DK (Go to 1b)
(K) Respiratory therapy services
2[] No (Go to 1b)
9[] DK (Go to 1b)
(L) Social work services
2[] No (Go to 1b)
9[] DK (Go to 1b)
(M) Transportation services
2[] No (Go to 1b)
9[] DK (Go to 1b)
b. Did (child) need the services of ________ in the past 12 months?
2[] No (Go to 1 for next service)
9[] DK (Go to 1 for next service)
(B) An occupational therapist
2[] No (Go to 1 for next service)
9[] DK (Go to 1 for next service)
(C) An audiologist
2[] No (Go to 1 for next service)
9[] DK (Go to 1 for next service)
(D) A speech therapist or pathologist
2[] No (Go to 1 for next service)
9[] DK (Go to 1 for next service)
(E) A recreational therapist
2[] No (Go to 1 for next service)
9[] DK (Go to 1 for next service)
(F)
A visiting nurse
2[] No (Go to 1 for next service on page 16)
9[] DK (Go to 1 for next service on page 16)
b. Did (child) need the services of ________ in the past 12 months?
2[] No (Go to 1 for next service)
9[] DK (Go to 1 for next service)
(H) A reader or interpreter
2[] No (Go to 1 for next service)
9[] DK (Go to 1 for next service)
(I) Home visits from a doctor
2[] No (Go to 1 for next service)
9[] DK (Go to 1 for next service on page 18)
b. Did (child) need the services of ________ in the past 12 months?
2[] No (Go to 1 for next service)
9[] DK (Go to 1 for next service)
(K) Respiratory therapy services
2[] No (Go to 1 for next service)
9[] DK (Go to 1 for next service)
(L) Social work services
2[] No (Go to 1 for next service)
9[] DK (Go to 1 for next service)
(M) Transportation services
2[] No (Skip to 6 on page 20)
9[] DK (Skip to 6 on page 20)
2a. During the past 12 months, in how many months did (child) receive services from _______ ?
(Number)
99[]DK
(B) An occupational therapist
(Number)
99[]DK
(C) An audiologist
(Number)
99[]DK
(D) A speech therapist or pathologist
(Number)
99[]DK
(E) A recreational therapist
(Number)
99[]DK
(F) A visiting nurse
(Number)
99[]DK
2a. During the past 12 months, in how many months did (child) receive services from _______ ?
(Number)
99[]DK
(H) A reader or interpreter
(Number)
99[]DK
(I) Home visits from a doctor
(Number)
99[]DK
2a. During the past 12 months, in how many months did (child) receive services from _______ ?
(Number)
99[]DK
(K) Respiratory therapy services
(Number)
99[]DK
(L) Social work services
(Number)
99[]DK
(M) Transportation services
(Number)
99[]DK
b. What was the total number of times (child) received services from ________ during [that/those] month(s)?
(Number)
99[]DK
(B) An occupational therapist
(Number)
99[]DK
(C) An audiologist
(Number)
99[]DK
(D) A speech therapist or pathologist
(Number)
99[]DK
(E) A recreational therapist
(Number)
99[]DK
(F) A visiting nurse
(Number)
99[]DK
b. What was the total number of times (child) received services from ________ during [that/those] month(s)?
(Number)
99[]DK
(H) A reader or interpreter
(Number)
99[]DK
(I) Home visits from a doctor
(Number)
99[]DK
b. What was the total number of times (child) received services from ________ during [that/those] month(s)?
(Number)
99[]DK
(K) Respiratory therapy services
(Number)
99[]DK
(L) Social work services
(Number)
99[]DK
(M) Transportation services
(Number)
99[]DK
Hand card C2. Read categories if telephone interview.
card C2 does not list these categories
3a. Who paid or will pay or the services (child) received from ______ in the past 12 months?
(Anyone else?)
Mark (X) all that apply.
01[] Family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicaid
05[] Rehabilitation program
06[] Parent's employer
07[] School system
08[] VA program
09[] Other military
10[] Other private source
11[] Other public source
12[] No one/ Free (Skip to 4)
99[] DK (Skip to 4)
(B) An occupational therapist
01[] Family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicaid
05[] Rehabilitation program
06[] Parent's employer
07[] School system
08[] VA program
09[] Other military
10[] Other private source
11[] Other public source
12[] No one/ Free (Skip to 4)
99[] DK (Skip to 4)
(C) An audiologist
01[] Family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicaid
05[] Rehabilitation program
06[] Parent's employer
07[] School system
08[] VA program
09[] Other military
10[] Other private source
11[] Other public source
12[] No one/ Free (Skip to 4)
99[] DK (Skip to 4)
(D) A speech therapist or pathologist
01[] Family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicaid
05[] Rehabilitation program
06[] Parent's employer
07[] School system
08[] VA program
09[] Other military
10[] Other private source
11[] Other public source
12[] No one/ Free (Skip to 4)
99[] DK (Skip to 4)
(E) A recreational therapist
01[] Family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicaid
05[] Rehabilitation program
06[] Parent's employer
07[] School system
08[] VA program
09[] Other military
10[] Other private source
11[] Other public source
12[] No one/ Free (Skip to 4)
99[] DK (Skip to 4)
(F) A visiting nurse
01[] Family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicaid
05[] Rehabilitation program
06[] Parent's employer
07[] School system
08[] VA program
09[] Other military
10[] Other private source
11[] Other public source
12[] No one/ Free (Skip to 4)
99[] DK (Skip to 4)
Hand card C2. Read categories if telephone interview.
card C2 does not list these categories
3a. Who paid or will pay or the services (child) received from ______ in the past 12 months?
(Anyone else?)
Mark (X) all that apply.
01[] Family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicaid
05[] Rehabilitation program
06[] Parent's employer
07[] School system
08[] VA program
09[] Other military
10[] Other private source
11[] Other public source
12[] No one/ Free (Skip to 4)
99[] DK (Skip to 4)
(H) A reader or interpreter
01[] Family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicaid
05[] Rehabilitation program
06[] Parent's employer
07[] School system
08[] VA program
09[] Other military
10[] Other private source
11[] Other public source
12[] No one/ Free (Skip to 4)
99[] DK (Skip to 4)
(I) Home visits from a doctor
01[] Family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicaid
05[] Rehabilitation program
06[] Parent's employer
07[] School system
08[] VA program
09[] Other military
10[] Other private source
11[] Other public source
12[] No one/ Free (Skip to 4)
99[] DK (Skip to 4)
Hand card C2. Read categories if telephone interview.
card C2 does not list these categories
3a. Who paid or will pay or the services (child) received from ______ in the past 12 months?
(Anyone else?)
Mark (X) all that apply.
01[] Family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicaid
05[] Rehabilitation program
06[] Parent's employer
07[] School system
08[] VA program
09[] Other military
10[] Other private source
11[] Other public source
12[] No one/ Free (Skip to 4)
99[] DK (Skip to 4)
(K) Respiratory therapy services
01[] Family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicaid
05[] Rehabilitation program
06[] Parent's employer
07[] School system
08[] VA program
09[] Other military
10[] Other private source
11[] Other public source
12[] No one/ Free (Skip to 4)
99[] DK (Skip to 4)
(L) Social work services
01[] Family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicaid
05[] Rehabilitation program
06[] Parent's employer
07[] School system
08[] VA program
09[] Other military
10[] Other private source
11[] Other public source
12[] No one/ Free (Skip to 4)
99[] DK (Skip to 4)
(M) Transportation services
01[] Family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicaid
05[] Rehabilitation program
06[] Parent's employer
07[] School system
08[] VA program
09[] Other military
10[] Other private source
11[] Other public source
12[] No one/ Free (Skip to 4)
99[] DK (Skip to 4)
Ask if more than one box marked in 3a. If only one, transcribe number of box marked without asking.
b. Who paid most of the cost for the services received from _______ in the past 12 months? Record number of main source.
(Number)
99[] DK
(B) An occupational therapist
(Number)
99[] DK
(C) An audiologist
(Number)
99[] DK
(D) A speech therapist or pathologist
(Number)
99[] DK
(E) A recreational therapist
(Number)
99[] DK
(F) A visiting nurse
(Number)
99[] DK
Ask if more than one box marked in 3a. If only one, transcribe number of box marked without asking.
b. Who paid most of the cost for the services received from _______ in the past 12 months? Record number of main source.
(Number)
99[] DK
(H) A reader or interpreter
(Number)
99[] DK
(I) Home visits from a doctor
(Number)
99[] DK
Ask if more than one box marked in 3a. If only one, transcribe number of box marked without asking.
b. Who paid most of the cost for the services received from _______ in the past 12 months? Record number of main source.
(Number)
99[] DK
(K) Respiratory therapy services
(Number)
99[] DK
(L) Social work services
(Number)
99[] DK
(M) Transportation services
(Number)
99[] DK
Ask only if box 00 or 01 marked in 3a; otherwise, skip to 4.
c. DURING THE PAST 12 MONTHS, about how much did (child's) family pay for the services received from _______ ? Do not count any money that has been or will be reimbursed by insurance or any other source.
$_____ . [00]
99999[] DK
(B) An occupational therapist
$_____ . [00]
99999[] DK
(C) An audiologist
$_____ . [00]
99999[] DK
(D) A speech therapist or pathologist
$_____ . [00]
99999[] DK
(E) A recreational therapist
$_____ . [00]
99999[] DK
(F) A visiting nurse
$_____ . [00]
99999[] DK
Ask only if box 00 or 01 marked in 3a; otherwise, skip to 4.
c. DURING THE PAST 12 MONTHS, about how much did (child's) family pay for the services received from _______ ? Do not count any money that has been or will be reimbursed by insurance or any other source.
$_____ . [00]
99999[] DK
(H) A reader or interpreter
$_____ . [00]
99999[] DK
(I) Home visits from a doctor
$_____ . [00]
99999[] DK
Ask only if box 00 or 01 marked in 3a; otherwise, skip to 4.
c. DURING THE PAST 12 MONTHS, about how much did (child's) family pay for the services received from _______ ? Do not count any money that has been or will be reimbursed by insurance or any other source.
$_____ . [00]
99999[] DK
(K) Respiratory therapy services
$_____ . [00]
99999[] DK
(L) Social work services
$_____ . [00]
99999[] DK
(M) Transportation services
$_____ . [00]
99999[] DK
d. DURING THE PAST 2 WEEKS, about how much did the family pay or services from ____?
$_____ . [00]
99999[] DK
(B) An occupational therapist
$_____ . [00]
99999[] DK
(C) An audiologist
$_____ . [00]
99999[] DK
(D) A speech therapist or pathologist
$_____ . [00]
99999[] DK
(E) A recreational therapist
$_____ . [00]
99999[] DK
(F) A visiting nurse
$_____ . [00]
99999[] DK
Ask only if box 00 or 01 marked in 3a; otherwise, skip to 4.
c. DURING THE PAST 12 MONTHS, about how much did (child's) family pay for the services received from _______ ? Do not count any money that has been or will be reimbursed by insurance or any other source.
$_____ . [00]
99999[] DK
(H) A reader or interpreter
$_____ . [00]
99999[] DK
(I) Home visits from a doctor
$_____ . [00]
99999[] DK
Ask only if box 00 or 01 marked in 3a; otherwise, skip to 4.
c. DURING THE PAST 12 MONTHS, about how much did (child's) family pay for the services received from _______ ? Do not count any money that has been or will be reimbursed by insurance or any other source.
$_____ . [00]
99999[] DK
(K) Respiratory therapy services
$_____ . [00]
99999[] DK
(L) Social work services
$_____ . [00]
99999[] DK
(M) Transportation services
$_____ . [00]
99999[] DK
4. During (month) did (child) receive services from ______ ?
2[] No (Go to 5)
9[] DK (Skip to 1 for next service)
(B) An occupational therapist
2[] No (Go to 5)
9[] DK (Skip to 1 for next service)
(C) An audiologist
2[] No (Go to 5)
9[] DK (Skip to 1 for next service)
(D) A speech therapist or pathologist
2[] No (Go to 5)
9[] DK (Skip to 1 for next service)
(E) A recreational therapist
2[] No (Go to 5)
9[] DK (Skip to 1 for next service)
(F) A visiting nurse
2[] No (Go to 5)
9[] DK (Skip to 1 for next service on page 16)
4. During (month) did (child) receive services from ______ ?
2[] No (Go to 5)
9[] DK (Skip to 1 for next service)
(H) A reader or interpreter
2[] No (Go to 5)
9[] DK (Skip to 1 for next service)
(I) Home visits from a doctor
2[] No (Go to 5)
9[] DK (Skip to 1 for next service on page 18)
4. During (month) did (child) receive services from ______ ?
2[] No (Go to 5)
9[] DK (Skip to 1 for next service)
(K) Respiratory therapy services
2[] No (Go to 5)
9[] DK (Skip to 1 for next service)
(L) Social work services
2[] No (Go to 5)
9[] DK (Skip to 1 for next service)
(M) Transportation services
2[] No (Go to 5)
9[] DK (Skip to 6 on page 20)
Hand card A7. Read categories if telephone interview.
(Emily's note: The actual card referenced in the following questions could not be found. Card A7 lists possible methods of contracting TB.)
5. Why didn't (child) receive services from _______ [in (month) in the past 12 months]?
(Anything else?)
Mark (X) all that apply.
01[] Provider thinks no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK
(B) An occupational therapist
01[] Provider thinks no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK
(C) An audiologist
01[] Provider thinks no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK
(D) A speech therapist or pathologist
01[] Provider thinks no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK
(E) A recreational therapist
01[] Provider thinks no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK
(F) A visiting nurse
01[] Provider thinks no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK
Hand card A7. Read categories if telephone interview.
(Emily's note: The actual card referenced in the following questions could not be found. Card A7 lists possible methods of contracting TB.)
5. Why didn't (child) receive services from _______ [in (month) in the past 12 months]?
(Anything else?)
Mark (X) all that apply.
01[] Provider thinks no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK
(H) A reader or interpreter
01[] Provider thinks no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK
(I) Home visits from a doctor
01[] Provider thinks no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK
Hand card A7. Read categories if telephone interview.
(Emily's note: The actual card referenced in the following questions could not be found. Card A7 lists possible methods of contracting TB.)
5. Why didn't (child) receive services from _______ [in (month) in the past 12 months]?
(Anything else?)
Mark (X) all that apply.
01[] Provider thinks no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK
(K) Respiratory therapy services
01[] Provider thinks no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK
(L) Social work services
01[] Provider thinks no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK
(M) Transportation services
01[] Provider thinks no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK
[p.295]
Section E - Other Services - Continued
Hand card C6. Read categories in 6b if telephone interview.
Card C6 not found
6a. Is (child) currently on a waiting list for any of these services?
2[] No (Skip to Section F on page 21)
9[] DK (Skip to Section F on page 21)
b. For which ones is (child) on a waiting list?
Anything else?
Mark (X) all that apply.
02[] An occupational therapist
03[] An audiologist
04[] A speech therapist or pathologist
05[] A recreational therapist
06[] A visiting nurse
07[] A personal care attendant, other than family or a friend
08[] A reader or interpreter
09[] Home visits from a doctor
10[] Services from a center for independent living
11[] Respiratory therapy services
12[] Social work services
13[] Transportation services
99[] DK
[p.296]
Section F - Educational Services
ITEM F1
Refer to child's age on label.
2[] Other (Skip to 5 on page 23)
Special education is a program designed to meet the individual needs of children with special needs. It is paid for by the public school system and may take place at a regular school, a special school, a private school, at home, or at a hospital.
1a. DURING THE PAST 12 MONTHS, has (child) received any type of special education services or benefits? Do not include gifted and talented programs.
2[] No (Skip to 3 on page 22)
9[] DK (Skip to 3 on page 22)
Hand card A15. Read categories if telephone interview.
Card A15 not found
b. During the past 12 months, which of these services or benefits did (child) receive through special education programs?
(Anything else?)
Mark (X) all that apply.
02[] Speech/Language therapy
03[] Audiology services for hearing problems (such as testing, evaluation, and training)
04[] Mental health or counseling services
05[] Developmental testing
06[] Physical therapy
07[] Occupational therapy
08[] Recreational therapy
09[] Respiratory therapy
10[] Social work services
11[] Eyeglasses
12[] Hearing aids
13[] Wheelchair
14[] Other assistive devices and training in their use
15[] Medical services for diagnostic and evaluation purposes
16[] Communication services (such as reader, interpreter, or writer)
17[] Nursing services
18[] Other
99[] DK
Hand card A16. Read categories if telephone interview.
Card A16 not found
c. During the past 12 months, has (child) received special education for any of these conditions?
(Anything else?)
Mark (X) all that apply.
02[] Speech or language problems
03[] Mental retardation
04[] Emotional disturbances
05[] Deaf and blind
06[] Hearing, including deafness or hard of hearing
07[] Visual, including blindness and other problems
08[] Orthopedic problems
09[] Autism
10[] Traumatic brain injury
11[] Developmental delay
12[] Multiple disabilities
13[] Other health problem
14[] Not a specific condition
99[] DK
Hand card A17. Read categories if telephone interview.
Card A17 not found
d. During the past 12 months, where did (child) receive these special education services? (Anywhere else?)
Mark (X) all that apply.
02[] Resource room in regular school
03[] Separate class all day or part of a day in regular school
04[] Special school - day school
05[] Special school - residential school
06[] Home
07[] Hospital or institution
08[] Provider's office
09[] Other
99[] DK
e. Has (child) received any special education services during the past month?
2[] No (Go to 1)
9[] DK (Skip to Item F2 on page 22)
f. Why hasn't (child) received any special education services in the past month?
Anything else?
Mark (X) all that apply.
1[] Provider/school thinks services no longer necessary
2[] Child on vacation from school
3[] Provider/service no longer available
4[] Didn't like provider/service
5[] Transportation problems
6[] Could not take time off from work to arrange it
7[] Other reason
9[] DK
[p.297]
Section F - Educational Services - Continued
ITEM F2
Refer to child's age on label.
2[] Other (Skip to 3)
2[] No
9[] DK
3a. During the past 12 months, have you tried to get any (additional) special education services for (child) ?
2[] No (Skip to 4)
9[] DK (Skip to 4)
Hand card A15. Read categories if telephone interview.
Card A15 not found
b. What (additional) special education services did you try to get for (child)?
(Anything else?)
Mark (X) all that apply.
02[] Speech/Language therapy
03[] Audiology services for hearing problems (such as testing, evaluation, and training)
04[] Mental health or counseling services
05[] Developmental testing
06[] Physical therapy
07[] Occupational therapy
08[] Recreational therapy
09[] Respiratory therapy
10[] Social work services
11[] Eyeglasses
12[] Hearing aids
13[] Wheelchair
14[] Other assistive devices and training in their use
15[] Medical services for diagnostic and evaluation purposes
16[] Communication services (such as reader, interpreter, or writer)
17[] Nursing services
18[] Other
99[] DK
c. During the past 12 months, was (child) on a waiting list for any special education services?
2[] No
9[] DK
Hand card C7. Read categories if telephone interview.
Card C7 not found
d. What problems did you have trying to get (additional) special education services for (child) during the past 12 months?
(Anything else?)
Mark (X) all that apply.
01[] Service is not available
02[] Had trouble finding the right kind of service
03[] Services available are inadequate
04[] School did not think child needed the service
05[] School would not test child for disabilities
06[] School would not help in finding services
07[] Could not take time off from work to arrange it
08[] Other problems
99[] DK
4. Overall, how satisfied are you with the educational services that (child) receives? Are you very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied?
1[] Very satisfied (Skip to Section G on page 25)
2[] Somewhat satisfied (Skip to Section G on page 25)
3[] Somewhat dissatisfied (Skip to Section G on page 25)
4[] Very dissatisfied (Skip to Section G on page 25)
9[] DK (Skip to Section G on page 25)
[p.298]
Section F - Educational Services - Continued
Special education is a program designed to meet the individual needs of infants and very young children who have special needs. It is provided free and may include services at home, at a hospital, or somewhere else.
5a. During the past 12 months, has (child) received any type of special education services?
2[] No (Skip to 6 on page 24)
9[] DK (Skip to 6 on page 24)
Hand card C8. Read categories if telephone interview.
(Emily's note: Card C8 not found)
b. During the past 12 months, which of these special education services did (child) receive?
(Anything else?)
Mark (X) all that apply.
02[] Speech/Language therapy
03[] Audiology services for hearing problems (such as testing, evaluation , and training)
04[] Family training, counseling and home visits
05[] Nursing or health services
06[] Physical therapy
07[] Occupational therapy
08[] Nutritional services
09[] Social work services
10[] Psychological services
11[] Service coordination/case management
12[] Special instruction
13[] Vision services, including eye testing and obtaining glasses
14[] Other assistive devices and training in their use
15[] Medical services for diagnostic and evaluation purposes
16[] Other early intervention services
99[] DK
c. During the past 12 months, has (child) received special education for a developmental delay, other health condition, or some other problem?
Mark (X) all that apply.
2[] Other health condition
3[] Other problem
4[] DK
d. During the past 12 months, where did (child) receive these special education services?
Anywhere else?
Mark (X) all that apply.
02[] Family daycare
03[] Regular nursery school/daycare center
04[] Outpatient services facility
05[] Early intervention classroom/center
06[] Hospital as inpatient
07[] Provider's office
08[] Residential facility
09[] Other place
99[] DK
e. Has (child) received any special education services during the past MONTH?
2[] No (Skip to 5f)
9[] DK (Skip to 6 on page 24)
f. Why didn't (child) receive special education services during the past MONTH?
Anything else?
Mark (X) all that apply.
1[] Provider/school thinks service no longer necessary
2[] Child on vacation from school
3[] Provider/service no longer available
4[] Didn't like providers/service
5[] Transportation problems
6[] Could not take time off from work to arrange it
7[] Other reason
9[] DK
[p.299]
Section F - Educational Services - Continued
6a. During the past 12 months, have you tried to get any (additional) special education services for (child)?
2[] No (Skip to 7)
9[] DK (Skip to 7)
Hand card C8. Read categories if telephone interview.
(Emily's note: Card C8 not found)
b. What (additional) special education services did you try to get for (child)?
Anything else?
Mark (X) all that apply.
02[] Speech/Language therapy
03[] Audiology services for hearing problems (such as testing, evaluation , and training)
04[] Family training, counseling and home visits
05[] Nursing or health services
06[] Physical therapy
07[] Occupational therapy
08[] Nutritional services
09[] Social work services
10[] Psychological services
11[] Service coordination/case management
12[] Special instruction
13[] Vision services, including eye testing and obtaining glasses
14[] Other assistive devices and training in their use
15[] Medical services for diagnostic and evaluation purposes
16[] Other early intervention services
99[] DK
c. During the past 12 months, was (child) on a waiting list for any special education services?
2[] No
9[] DK
7. Overall, how satisfied are you with the education services that (child) receives? Are you very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied?
1[] Very satisfied
2[] Somewhat satisfied
3[] Somewhat dissatisfied
4[] Very dissatisfied
9[] DK
[p.300]
Section G - Coordination of Services
1a. Is there any one doctor who you think of as the one who coordinates (child's) overall medical care? By coordinating, I mean one who keeps in touch with the different doctors or therapists who (child) sees, who knows the results of all tests and treatments that (child) has, and who is aware of (child's) different prescription medicines.
2[] No
9[] DK
b. Do (child's) doctors talk to each other about [his/her] health and the care [he/she] gets, including any tests or medications?
2[] No
3[] Only one doctor
9[] DK
2a. Is there anyone who is not a doctor who coordinates (child's) medical care?
2[] No (Skip to 3)
9[] DK (Skip to 3)
b. Who does this for (child)?
Anyone else?
Mark (X) all that apply.
1[] Friend/Family member
2[] Nurse
3[] Therapist
4[] Social worker
5[] Hospital discharge planner
6[] Case manager
7[] Other
9[] DK
3a. Does any physician or someone in a physician's office help with arranging (child's) non-medical care, like social services and personal care services?
2[] No (Skip to 4)
9[] DK (Skip to 4)
b. Is this person, or does this person work for a general care physician or a specialist?
2[] Specialist
3[] Someone else
9[] DK
c. Is this a person a --
Mark (X) all that apply.
2[] Therapist?
3[] Nurse?
4[] Social worker?
5[] Hospital discharge planner?
6[] Case manager?
7[] Something else?
9[] DK
4a. Does anyone NOT in a physician's office help with arranging (child's) non-medical services?
2[] No (Skip to G1)
9[] DK (Skip to G1)
b. Who does this for (child)?
1[] Friend/Family member
2[] Nurse
3[] Therapist
4[] Social worker
5[] Hospital discharge planner
6[] Case manager
7[] Other
9[] DK
ITEM G1
Refer to 1a, 2a, 3a and 4a.
(Coordinates/arranges)
2[] All other (Skip to 9 on page 26)
Section G - Coordination of Services - Continued
Hand card C9. Read categories if telephone interview.
(Emily's note CARD C9 not found)
5. What kinds of medical or non-medical services [does this person/do these persons] provide for (child)?
(Anything else?)
Mark (X) all that apply.
02[] Makes appointments with nurses/therapists/dieticians
03[] Follows up to be sure appointments are kept
04[] Arranges transportation to appointments
05[] Makes referrals to doctors
06[] Makes referrals to nurses/therapists/dieticians
07[] Checks to see if child's needs or conditions have changed
08[] Makes sure that child is doing exercises or following diet
09[] Reviews medications
10[] Explains medical procedures and terms to child and family
11[] Helps with insurance or other benefits
12[] Tries to find volunteers to help child
13[] Tries to find workers or agencies to help child
14[] Arranges home delivered meals for child
15[] Makes sure that friends/family are able to help child
16[] Arranges for care at home
17[] Helps develop a personal care plan
18[] Evaluates need for services
19[] Arranges special education services
20[] Arranges vocational rehabilitation services
21[] Other
99[] DK
ITEM G2
Refer to 4b on page 25.
(Arranges non-medical services)
2[] Other (Go to 6)
2[] No (Skip to 7)
9[] DK (Skip to 7)
Hand card C2. Read categories if telephone interview.
(Emily's note: CARD C2 does not list these categories)
b. Who paid or will pay for this help?
(Anyone else?)
Mark (X) all that apply.
01[] Family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicaid
05[] Rehabilitation program
06[] Parent's employer
07[] School system
08[] VA program
09[] Other military
10[] Other private source
11[] Other public source
12[] No one/free
99[] DK
Ask if more than one box marked in 6b; if only one, transcribe the number of the box without asking.
c. Who paid for the most of the cost of this help?
Record number of main source.
(Number)
99 [] DK
7. In the past 6 months, about how many times did you see or talk to the person(s) who help(s) arrange (child's) non-medical services?
________
(Number)
2[] Per month
3[] Per six months
999[] DK
8. Overall, are you very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied with the job [the person has/these people have] done to help in coordinating (child's) non-medical services?
Mark (X) only one.
2[] Somewhat satisfied (Skip to 10a on page 27)
3[] Somewhat dissatisfied (Skip to 10a on page 27)
4[] Very dissatisfied (Skip to 10a on page 27)
9[] DK (Skip to 10a on page 27)
9. During the past 12 months have you felt that you NEEDED someone to help arrange or coordinate (child's) personal care or social services?
2[] No
3[] Never thought about it
9[] DK
[p.302]
Section G - Coordination of Services - Continued
10a. Do you need help filling out (child's) insurance forms or benefit applications?
2[] No (Skip to Section H on page 28)
3[] Never filled out forms/applications (Skip to Section H on page 28)
b. Who helps you fill out (child's) insurance forms or applications for public programs or benefits?
Mark (X) all that apply.
1[] Household member
2[] Friend/other relative not in household
3[] Paid caregiver
4[] Volunteer from an organization
5[] Other
9[] DK
[p.303]
Section H - Physical Activity
1. During the past 12 months, has (child) been limited in the kind or amount of physical activity [he/she] can do during play because of a physical, mental, or emotional problem?
2[] No (Skip to 4)
9[] DK (Skip to 4)
Hand card C10. Read categories if telephone interview.
(Emily's note: CARD C10 not found)
Sometimes things other than a person's health limit or prevent participation in physical education or recreational programs.
2. During the past 12 months, was (child's) participation in physical education or recreational programs limited or prevented for any of these reasons?
(Anything else)?
Mark (X) all that apply.
1[] Lack of nearby facilities or programs
2[] Facilities not adapted to child's needs
3[] Inadequate transportation
4[] Cost is too high
5[] Not prevented or limited for any of these reasons
9[] DK
3. During the past 12 months, has (child) participated in any physical education or recreation adapted for children with special needs?
2[] No
9[] DK
4. During the past 12 months, has (child) participated in any ORGANIZED GROUP activities (outside of school) that have adult supervision? Please include any group recreational activities or educational activities such as group lessons, sports teams, scout troops, and clubs.
2[] No
9[] DK
5. During the past 12 months, did (child) go to any kind of summer camp?
2[] No
9[] DK
[p.304]
Section I - Personal Adjustment and Role Skills (PARS)
ITEM I1
Refer to child's age on label.
2[] Other (Skip to Section J on page 31)
In the next questions, I'll ask you about (child's) social behaviors and activities.
Hand card C11.
(Emily's note: CARD C11 not found)
1. During the past 30 days, has (child) --
2[] Sometimes
3[] Often
4[] Always
b. Made friends without difficulty? (Would you say -- (Read all categories)?)
2[] Sometimes
3[] Often
4[] Always
c. Joined others of [his/her] own accord? (Would you say -- (Read all categories)?)
2[] Sometimes
3[] Often
4[] Always
d. Had many different friends? (Would you say -- (Read all categories)?)
2[] Sometimes
3[] Often
4[] Always
e. Wanted help in things [he/she] could have done on own? (Would you say -- (Read all categories)?)
2[] Sometimes
3[] Often
4[] Always
f. Been unable to decide things for [his/her] self? (Would you say -- (Read all categories)?)
2[] Sometimes
3[] Often
4[] Always
g. Asked for help when [he/she] could have figured things out? (Would you say-- (Read all categories)?)
2[] Sometimes
3[] Often
4[] Always
During the past 30 days, has (child) --
2[] Sometimes
3[] Often
4[] Always
i. Does things for attention even though punished for it? (Would you say-- (Read all categories)?)
2[] Sometimes
3[] Often
4[] Always
j. Flared up when [he/she] couldn't have [his/her] own way? (Would you say -- (Read all categories)?)
2[] Sometimes
3[] Often
4[] Always
k. Become upset if others did not agree with [him/her] (Would you say -- (Read all categories)?)
2[] Sometimes
3[] Often
4[] Always
l. Ignored warnings to stop unacceptable behavior? (Would you say -- (Read all categories)?)
2[] Sometimes
3[] Often
4[] Always
m. Told lies? (Would you say -- (Read all categories)?)
2[] Sometimes
3[] Often
4[] Always
n. Not responded to discipline? (Would you say -- (Read all categories)?)
2[] Sometimes
3[] Often
4[] Always
During the past 30 days, has (child) --
2[] Sometimes
3[] Often
4[] Always
p. Made full use of abilities? (Would you say -- (Read all categories)?)
2[] Sometimes
3[] Often
4[] Always
q. Done work without being pushed or punished? (Would you say -- (Read all categories)?
2[] Sometimes
3[] Often
4[] Always
r. Kept on with tasks even when difficult? (Would you say -- (Read all categories)?)
2[] Sometimes
3[] Often
4[] Always
s. Complained about problems? (Would you say -- (Read all categories)?)
2[] Sometimes
3[] Often
4[] Always
t. Seemed restless, tense? (Would you say-- (Read all categories)?)
2[] Sometimes
3[] Often
4[] Always
u. Said people didn't care about [him/her]? (Would you say-- (Read all categories)?)
2[] Sometimes
3[] Often
4[] Always
[p.305]
Section I - Personal Adjustment and Role Skills (PARS) - Continued
During the past 30 days, has (child)--
2[] Sometimes
3[] Often
4[] Always
w. Said [he/she] couldn't do things right? (Would you say -- (Read all categories)?)
2[] Sometimes
3[] Often
4[] Always
x. Acted afraid or apprehensive? (Would you say -- (Read all categories)?)
2[] Sometimes
3[] Often
4[] Always
y. Sat and stared without doing anything? (Would you say -- (Read all categories)?)
2[] Sometimes
3[] Often
4[] Always
z. Appeared listless and apathetic? (Would you say -- (Read all categories)?)
2[] Sometimes
3[] Often
4[] Always
aa. Seemed unaware of things going on around [him/her]? (Would you say-- (Read all categories)?)
2[] Sometimes
3[] Often
4[] Always
bb. Shown little interest in things, had to be pushed into activity? (Would you say-- (Read all categories)?)
2[] Sometimes
3[] Often
4[] Always
[p.306]
Section J - Impact on the Family
1a. For reasons related to (child's) health, has anyone in
the family EVER:
2[] No
9[] DK
(1) Quit working other than normal maternity leave?
2[] No
9[] DK
(2) Changed jobs?
2[] No
9[] DK
(3) Changed work hours to a different time of day?
2[] No
9[] DK
(4) Turned down a better job or promotion?
2[] No
9[] DK
(5) Worked fewer hours?
2[] No (Skip to 2)
9[] DK (Skip to 2)
b. Right BEFORE the family member changed hours the last time, how many hours a week did he or she work?
(Number)
99[] DK
c. AFTER the family member changed hours, how many hours a week did he or she work?
(Number)
99[] DK
2. During the past 12 months, because of (child's) health, has anyone in the family had to change sleeping patterns for more than a few nights at a time?
2[] No
9[] DK
3. During the past 12 months, has the family had severe financial problems because of (child's) health?
2[] No
9[] DK
[p.307]
Section K - Mental Health
ITEM K1
Refer to child's age on label.
2[] Other (Skip to Section L on page 36)
2[] No (Skip to 3 on page 33)
9[] DK (Skip to 3 on page 33)
b. Was this for mental health, substance abuse, or both?
Mark (X) only one.
2[] Substance abuse
3[] Both
9[] DK
Hand card A9. Read categories if telephone interview.
(Emily's note: CARD A9 not found)
c. Where did (child) receive inpatient [mental health/(and) substance abuse] services during the past 12 months?
(Anywhere else?)
Mark (X) all that apply.
2[] Psychiatric service in a general hospital
3[] Other hospital
4[] Residential treatment center
5[] Other place
9[] DK
d. During the past 12 months, altogether how many times was (child) admitted to (place(s) in 1c) for [mental health/(and) substance abuse] services?
(Number)
99[] DK
e. Altogether how many nights did (child) spend in the (place(s) in 1c) during the past 12 months?
(Number)
99[] DK
ITEM K2
Refer to 1d.
(Number of admissions)
2[] 2 or more admissions (Skip to 2b)
0[] DK (Skip to 2c)
2[] No (Skip to 2e)
9[] DK (Skip to 2e)
b. How many of the (number in 1d) admissions were on an emergency basis?
_______ Emergency admissions (Skip to 2e)
(Number)
99[] DK (Skip to 2e)
c. Were any of the admissions in the past 12 months on an emergency basis?
2[] No (Skip to 2e)
9[] DK (Skip to 2e)
d. How many of the admissions were on an emergency basis?
_______ Emergency admissions
(Number)
99[] DK
Hand card C2. Read categories if telephone interview.
(Emily's note: CARD C2 does not list these categories)
e. Who paid, or will pay, for the inpatient [mental health/(and) substance abuse] services (child) received during the past 12 months?
(Anyone else)?
Mark (X) all that apply.
01[] Family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicaid
05[] Rehabilitation program
06[] Parent's employer
07[] School system
08[] VA program
09[] Other military
10[] Other private source
11[] Other public source
12[] No one/Free (Skip to 3 on page 33)
99[] DK (Skip to 3 on page 33
Ask if more than one box marked in 2e; if only one, transcribe the number of the box marked without asking.
f. Who paid for MOST of the cost of the inpatient [mental health/(and) substance abuse] services?
Record number of main source.
(Number)
99[] DK
Ask if box 00 or 01 marked in 2e; otherwise, skip to 3.
g. During the past 12 months about how much did the family pay for (child's) inpatient [mental health/(and) substance abuse] services? Do not include costs that were or will be reimbursed by insurance or another source.
$________.[ 00 ]
99999 [] DK
[p.308]
Section K - Mental Health - Continued
3a. During the past 12 months, did (child) receive any OUTPATIENT mental health or substance abuse services, including mental health or substance abuse services received from a general practitioner or any other health professional? Do not include treatment for smoking cessation.
2[] No (Skip to 5 on page 34)
9[] DK (Skip to 5 on page 34)
b. Was this for mental health, substance abuse, or both?
Mark (X) only one.
2[] Substance abuse
3[] Both
9[] DK
Hand card A10. Read categories if telephone interview.
(Emily's note: CARD A10 not found.)
c. From whom did (child) receive outpatient [mental/substance abuse] services during the past 12 months?
(Anywhere else?)
Mark (X) all that apply.
2[] Psychologist
3[] Nurse
4[] Social worker
5[] Other mental health counselor or therapist
6[] General practitioner or other medical doctor
7[] Other health professional
9[] DK
Hand card A11. Read categories if telephone interview.
(Emily's note: CARD A11 not found.)
d. Where did (child) receive outpatient [mental health/(and) substance abuse] services during the past 12 months?
(Anywhere else?)
Mark (X) all that apply.
2[] Outpatient mental health clinic, such as a community mental health center
3[] Outpatient medical clinic
4[] HMO
5[] Other place
9[] DK
e. During the past 12 months, in how many months did (child) receive outpatient [mental health/(and) substance abuse] services?
(Number)
99[] DK
f. What was the total number of times (child) received [mental health/(and) substance abuse] services during those months?
(Number)
99[] DK
ITEM K3
Refer to 3f.
(Number of times)
2[] 2 or more times (Skip to 4b)
9[] DK (Skip to 4c)
2[] No (Skip to 4e on page 34)
9[] DK (Skip to 4e on page 34)
b. How many of the (number in 3f) visits were on an emergency basis?
_______ Emergency (Skip to 4e on page 34)
(Number)
99[] DK (Skip to 4e on page 34
)
c. Were any of the visits in the past 12 months on an emergency basis?
2[] No (Skip to 4e on page 34)
9[] DK (Skip to 4e on page 34)
d. How many visits were on an emergency basis?
(Number)
99[] DK (Go to 4e on page 34)
[p.309]
Section K - Mental Health - Continued
Hand card C2. Read categories if telephone interview.
(Emily's note: CARD C2 does not list these categories)
4e. Who paid, or will pay for the outpatient [mental health/(and) substance abuse] services (child) received during the past 12 months?
(Anyone else?)
Mark (X) all that apply.
01[] Family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicaid
05[] Rehabilitation program
06[] Parent's employer
07[] School system
08[] VA program
09[] Other military
10[] Other private source
11[] Other public source
12[] No one/Free (Skip to 5)
99[] DK (Skip to 5)
Ask if more than one box marked in 4e; if only one, transcribe the number of the box marked without asking.
f. Who paid for MOST of the cost of the inpatient [mental health/(and) substance abuse] services?
Record number of main source.
(Number)
99[] DK
Ask if box 00 or 01 marked in 4e; otherwise, skip to 5.
g. During the past 12 months about how much did the family pay for (child's) inpatient [mental health/(and) substance abuse] services? Do not include costs that were or will be reimbursed by insurance or another source.
$________.[ 00 ]
99999[] DK
5. During the past 12 months, did (child) receive any services from a mental health community support program?
Read if necessary: A community support program for clients with mental or emotional problems is a program that makes available mental health, health, social and support services base on individual need.
2[] No
9[] DK
6. During the past 12 months, was (child) on a waiting list for outpatient mental health or substance abuse services?
2[] Yes, substance abuse services
3[] Both
4[] No
9[] DK
ITEM K4
Refer to questions 1a,3a,and 5.
(Received mental health/substance abuse services)
2[] Other (Skip to 8 on page 35)
2[] No (Go to 7b)
9[] DK (Go to 7b)
Hand card A7. Read categories if telephone interview.
Emily's note: CARD A7 not found
b. Why didn't (child) get mental health or substance abuse services during the past month?
Any other reason?
Mark (X) all that apply.
01[] Provider thinks no longer needed
02[] Too expensive/cannot afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK
[p.310]
Section K - Mental Health - Continued
8a. During the past 12 months, has (child) needed any mental health or substance abuse services or counseling that [he/she] HAS NOT RECEIVED?
2[] No (Skip to 9)
9[] DK (Skip to 9)
Hand card A12. Read categories if telephone interview.
(Emily's note: CARD A12 not found)
b. Which of these statements explains why (child) did not receive the mental health or substance abuse services [he/she] needed?
(Anything else?)
Mark (X) all that apply.
01[] Too expensive/can't afford
02[] Didn't know where to go to get services
03[] No mental health services nearby
04[] No nearby provider accepts Medicaid
05[] Private insurance does not cover the services
06[] Did not have insurance
07[] Transportation problems
08[] Trouble finding the right kind of mental health professional
09[] Language barrier
10[] Could not take time off from work
11[] Other reasons
99[] DK
9. Because of a physical, mental or emotional problem, during the past 12 months, did (child) receive any TRAINING in social skills, such as making and keeping friends or how to interact with other people?
2[] No
9[] DK
[p.311]
Section L - Housing and Transportation
Read: These next questions are about the place (child) lives.
1a. Is it NECESSARY to use any stairs to get into this home from outside?
2[] No
9[] DK
Ask or verify:
b. Counting basements and stepdown living areas as separate levels, does this home have more than one floor or level?
2[] No (Go to 2)
9[] DK (Go to 1c)
c. Does this home have a bathroom, bedroom and kitchen ALL on the SAME floor or level?
2[] No
9[] DK
2. Because of a physical impairment or health problem, does (child) have any difficulty:
2[] No
9[] DK
b. Opening or closing any of the doors in your home?
2[] No
9[] DK
c. Reaching or opening cabinets in your home?
2[] No
9[] DK
d. Using the bathroom in your home?
2[] No
9[] DK
3. Does this home have any of these special features:
2[] No
9[] DK
b. Ramps or street level entrances?
2[] No
9[] DK
c. Railings?
2[] No
9[] DK
d. Automatic or easy to open doors?
2[] No
9[] DK
e. Accessible parking or drop off site?
2[] No
9[] DK
f. Bathroom modifications?
2[] No
9[] DK
g. Kitchen modifications?
2[] No
9[] DK
h. Elevator, chair lift, or stair glider?
2[] No
9[] DK
i. Altering devices?
2[] No
9[] DK
j. Any other special features?
2[] No
9[] DK
4. Does (child) NEED any of these special features to get around the home?
2[] No
9[] DK
b. Ramps or street level entrances?
2[] No
9[] DK
c. Railings?
2[] No
9[] DK
d. Automatic or easy to open doors?
2[] No
9[] DK
e. Accessible parking or drop off site?
2[] No
9[] DK
f. Bathroom modifications?
2[] No
9[] DK
g. Kitchen modifications?
2[] No
9[] DK
h. Elevator, chair lift, or stair glider?
2[] No
9[] DK
i. Altering devices?
2[] No
9[] DK
j. Any other special features?
2[] No
9[] DK
5. DURING THE PAST 12 MONTHS, were you ever refused housing or rental accommodations because of any impairment or health problem that (child) has or did you not look for housing in the past 12 months?
1[] Yes
2[] No
9[] DK
[p.312]
Section L - Housing and Transportation
6a. Do you have any special equipment on your car or other motor vehicle because of an impairment or health problem that (child) has?
2[] No (Skip to 6c)
3[] Don't have a car (Skip to 6c)
b. What special equipment do you have because of (child's) impairment or health problem?
Anything else?
Mark (X) all that apply.
2[] Hand rails, straps, specialized handles, ramps, or lifts
3[] Power controls for windows, mirrors, seat, or steering
4[] Automatic transmission
5[] Air conditioning
6[] A button that opens the door
7[] A large trunk or storage area
8[] Other special features
9[] DK
c. Did you NEED any (other) special equipment or feature on a car or other motor vehicle because of any impairment or health problem that (child) has?
2[] No (Skip to Section M on page 38)
d. What (other) equipment or feature do you need?
Anything else?
Mark (X) all that apply.
2[] Hand rails, straps, specialized handles, ramps, or lifts
3[] Power controls for windows, mirrors, seat, or steering
4[] Automatic transmission
5[] Air conditioning
6[] A button that opens the door
7[] A large trunk or storage area
8[] Other special features
9[] DK
[p.313]
Section M - Health Insurance
The next questions are about health insurance coverage.
There is a program called Medicaid that pays for health care for persons in need. In this state, it is also called (state name).
1a. In (month), (child) covered by Medicaid or (state name)?
2[] No (Skip to 2)
9[] DK (Skip to 2)
b. How long has (child) been covered by Medicaid or (state name)?
Read categories if necessary.
Mark (X) only one.
2[] 6 months, but less than 1 year
3[] 1 year, but less than 2 years
4[] 2 years, but less than 5 years
5[] 5 years or more
6[] On an off for less than 2 years
7[] On and off for 2 years, but less than 5 years
8[] On and off for 5 years or more
9[] DK
2. In (month), was (child) covered by any OTHER public assistance program (other than Medicaid) that pays for health care? Do not include use of public or free clinics of that is (child's) only source of care.
2[] No
9[] DK
3a. In (month), was (child) covered by military care, including armed forces retirement benefits, or the VA (Department of Veterans' Affairs)?
2[] No
9[] DK
b. Was this CHAMPUS or CHAMP-VA?
Read if necessary: CHAMPUS is a program of medical care for dependents of active
duty or retired military personnel. CHAMP-VA is medical insurance for dependents or survivors of disabled veterans.
2[] No
9[] DK
c. In (month), was (child) covered by any other military health care, including armed forces retirement benefits, or the VA (Department of Veterans' Affairs)?
2[] No
9[] DK
4. In (month), was (child) covered by the Indian Health Service?
2[] No
9[] DK
5a. (Not counting the Government health programs we just mentioned), in (month), was (child) covered by a private health insurance plan?
Read if necessary: Besides government programs. people also get health insurance
through their jobs or union, through other private groups, or directly from an insurance company. A variety of types of plans are available, including Health Maintenance Organizations or HMOs.
1[] Yes (Go to 5b)
2[] No (Skip to Section N on page 39)
9[] DK (Skip to Section N on page 39)
b. Was any of this private insurance obtained originally through a workplace, that is through a parent's employer or union?
2[] Union
3[] Through workplace, DK which
4[] No
9[] DK
[p.314]
Section N - Respondent Information
READ TO RESPONDENT: These next questions are about your relationship to (sample child).
Mark if known or ask:
1a. How are you related to (child)?
1[] Father (Go to 1b)
2[] Brother/sister (Skip to 1d)
3[] Grandparent (Skip to Contact Information Intro)
4[] Other relative (Skip to Contact Information Intro)
5[] Nonrelative (Skip to Contact Information Intro)
9[] DK (Skip to Contact Information Intro)
b. Are you the biological (natural), adoptive, step, or foster parent of (child)?
2[] Adoptive (Go to 1c)
3[] Step (Go to 1c)
4[] Foster (Go to 1c)
c. How old was (child) when [he/she] first started living with you?
(Age)
2[] Years
000[] Since birth (Skip to Contact Information Intro)
999[] DK (Skip to Contact Information Intro)
d. Is (child) a full, half, step, adoptive, or foster [brother/sister] to you?
2[] Half (Go to Contact Information Intro)
3[] Step (Go to Contact Information Intro)
4[] Adoptive (Go to Contact Information Intro)
5[] Foster (Go to Contact Information Intro)
Contact Person Information
Intro: The national Center for Health Statistics may wish to contact you again to obtain additional health related information.
ITEM N1
Refer to CP on label.
2[] No CP on label (Ask 2b)
2[] No (Go to 2b)
b. The National Center for Health Statistics would like the name, address, and telephone number of a relative or friend who would know where you could be reached in case we need additional health information in the future but cannot reach you. Please give me the name of someone who is not currently living in the household.
3. Contact Person current information
First name
MI
Number and street
City
State
ZIP Code
Telephone
Number
1[] None
7[] Refused
9[] DK
[p.315]
Bureau of the Census
Acting as Collecting Agent for the
U.S. Department of Health and Human Services
Public Health Service
Adult Questionnaire)
P
Date
Day
Beginning time
[] a.m.
[] p.m.
Results
Ending time
[] a.m.
[] p.m.
Comments
Part II - Status
02[] Partial (Explain in Notes)
Noninterview
04[] Proxy Refused (Explain in Notes)
05[] Unable to contact (Explain in Notes)
06[] Unable to locate (Explain in Notes)
07[] Deceased (Explain in Notes)
10[] Moved o/s PSU, unable to phone (Explain in Notes)
11[] Other noninterview (Explain in Notes)
B. Mode
2[] Personal visit
C. Respondent
2[] Proxy
Reason for proxy
2[] SP institutionalized
3[] SP unavailable (Fill II.D)
4[] Other - Specify (Fill II.D)
_________
_________
D. Proxy
E. Field representative's name ______ Code ____
Part III- New Address
A. Address (Different from label)
City
State
ZIP Code
B. Telephone (Different from label)
Number
1[] None
7[] Refused
9[] DK number
[p.316]
Initial Screening
1. May I speak with (sample person)?
2[] Not available (Go to 2)
2. Why is (sample person) not available to be interviewed?
2[] SP moved (Skip to 4)
3[] SP temporarily absent/unavailable (Go to 3)
4[] SP incapable (Skip to 5)
5[] Other (Skip to 5)
3. Will (sample person) [return/be available] before (closeout date)?
2[] No (Go to 4)
4a. Has (sample person) moved to a new residence or is [he/she] in a health facility, group home, or some other place?
2[] SP in health facility/group home (Go to 4b)
3[] SP in jail (Skip to 5)
4[] SP in prison (End interview-noninterview)
5[] SP on vacation/visiting/temporarily absent (Skip to 4d)
b. What type of facility or group home is this?
Mark (X) first appropriate box.
02[] Nursing/convalescent home (Go to 4c)
03[] Retirement home (Record new address and telephone no.)
04[] Group home (Record new address and telephone no.)
05[] Supervised apartment
06[] Halfway house (Record new address and telephone no.)
07[] Board and Care home
08[] Developmental Center
09[] Other supervised group residence or facility
10[] Other
c. Refer to age on label.
2[] 69+ (Go to 4d
d. Is it possible to interview (sample person) at the [facility/present location]?
2[] No (Go to 5)
5. Since I won't be able to interview (sample person), I need to talk to the person who knows the most about (sample person's) health. Who would that be?
2[] Other person (Record person's name, address, and telephone no.)
3[] No one (End interview - non interview)
9[] DK/Ref (End interview - non interview)
6. On what date did (sample person) die?
999999[] DK (Go to 7)
7. Did (sample person) die at home, in a hospital, in a nursing or convalescent home, or some other place?
2[] In a hospital (End interview- noninterview)
3[] In nursing/convalescent home (End interview- noninterview)
4[] Other place (End interview- noninterview)
9[] DK(End interview- noninterview)
[p.317]
Initial Screening - Continued
Number and street
City
State
ZIP Code
Telephone
Number
1[] None
7[] Refused
9[] DK number
Number and street
City
State
ZIP Code
Telephone
Number
1[] None
7[] Refused
9[] DK number
Proxy Respondent
1[] Mark box if same address/phone as SP (Skip to A1 on page 4)
Number and street
State
ZIP Code
Telephone
Number
1[] None
7[] Refused
9[] DK number
GENERAL INSTRUCTIONS
1. Conduct all interviews by personal visit unless the only way to get an interview is by telephone.
2. After appropriate introductions, begin all interviews with A on page 2.
3. If the sample person (or proxy) is not within your normal assignment area, call your office for instructions.
4. Make minor corrections to the sample person's address or phone number on the label. Record new addresses and/or phone numbers above.
5. If a question is refused, enter "REF" in the answer space. If the respondent does not know the answer to a question, mark the "DK" box if there is one, or enter "DK" in the answer space.
6. The following symbols and print types are used throughout the questionnaire to standardize the asking of the questions:
* Long dash (--) - Insert the appropriate words or names from the list
* Underlined italics in parentheses - Insert the specified words, name, date, etc.
* Regular type in parentheses - Either read or do not read the parenthetical, depending
on the situation and the context of the question.
*Brackets with a slash ( [ / ] ) - Choose the appropriate words or phrase for the
particular interview.
* Bold capitals - Emphasize the word(s) when reading the question
7. If interviewing a proxy, substitute the sample person's name (or appropriate pronoun) for the word "You" in the questions.