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scpr
[p. 1]


CHILD PREVENTION MODULE

Section A. - CONDITIONS


Check item PCACCI01: If [CHEARST/(CHS.250)] eq (1, D, R) [go to PCACCI03]; Else if [CHEARST/(CHS.250)] eq (2, 3, 4) [go to CKHEAR/(PCA.010)].

PCA.010

These next questions are about health conditions in children.
Earlier you told me that {fill child's name} has a hearing problem.

If CHEARST eq (2) FILL1="began to have trouble hearing";
If CHEARST eq (3,4) FILL1="began to have serious trouble hearing or became deaf"

How old was {child's name} when {he/she} {fill FILL1}?
CKHEAR
(00) At birth (PCA.030)
(01) Less than or equal to 1 year old (PCA.030)
(02-17) 2-17 years of age
(97) Refused (PCACCI02)
(99) Don't know (PCACCI02)
Check item PCACCI02: If AGE lt (3) set BIR03=1 (PCA.020) and go to [DIAG/(PCA.030)]; Else if AGE ge (3) go to [BIR03/(PCA.030)].


PCA.020

Was it before or after {child's name} 3rd birthday?
BIR03
(1) Before
(2) After
(7) Refused
(9) Don't Know


PCA.030

How old was {child's name} when {his/her} (hearing problem/deafness) was diagnosed by a doctor or other health professional?

FR: ENTER NUMBER, PRESS RETURN, AND ENTER TIME PERIOD. (ENTER "96" IF SINCE BIRTH)
DIAG_NUM
[ ] NUMBER

(01-94) 1-94
(95) 95+
(96) Since birth
(97) Refused
(99) Don't know
DIAG_TP
[ ] TIME PERIOD

(1) Day(s)
(2) Week(s)
(3) Month(s)
(4) Year(s)
(6) Since birth
(7) Refused
(9) Don't know

[p. 2]


Check item PCACCI03: If AGE lt (6), [go to DIAR/(PCA.040)]; Else if AGE ge (6) go to END_PCA.


PCA.040

During the past 12 months, how many times has {child's name} had diarrhea severe enough that {he/she} had to cut down for more than a half a day on the things {he/she} usually does?{invalid input message}
DIAR
(00) None
(01-95) 1-95 times
(97) Refused
(99) Don't know


PCA.050

During the past 12 months, did {child's name} 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.
CARE
(1) Yes (PCA.060)
(2) No (END_PCA)
(7) Refused (END_PCA)
(9) Don't know (END_PCA)


PCA.060

In how many of the past 12 months did {child's name} receive such child care?
CCAREMON
(00) Less than one full month
(01-12) 1-12 months
(97) Refused
(99) Don't know

Check item END_PCA: Go to next section--Dental
[p. 3]

Section B. - Dental


LEADPCB The next questions are about dental health in children.

Check item PCBCCI01: If AGE lt (6) [go to BTLFD1/(PCB.010)]; Else if AGE ge (6) [go to DENSL/(PCB.040)].


PCB.010

These next questions are about bottle feeding.
Has {child name} ever been fed with a bottle? Do not include bottles with plain water.
BTLFD1
(1) Yes (PCBCCI02)
(2) No (PCB.040)
(7) Refused (PCB.040)
(9) Don't know (PCB.040)


Check item PCBCCI02: If AGE lt (2) [go to BTLFD2W/(PCB.030)]; Else if AGE ge (2) [go to BTLFD2/(PCB.020)].

PCB.020

Does {child name} still use a bottle? Do not include bottles with plain water.
BTLFD2
(1) Yes (PCB.030)
(2) No (PCB.040)
(7) Refused (PCB.040)
(9) Don't know (PCB.040)


PCB.030

During the past 2 weeks, on how many days was {child name} put to bed with a bottle at bedtime or naptime? Do not include bottles with plain water.
BTLFD2W
(00) None
(01-14) 01-14 days
(97) Refused
(99) Don't know


PCB.040

The next questions are about oral hygiene.
Dental sealants are special plastic coatings that are painted on the tops of the back teeth to prevent tooth decay. They are different from fillings, caps, crowns, and fluoride treatments. Has {child name} had dental sealants painted on {his/her} teeth?
DENSL
(1) Yes
(2) No
(7) Refused
(9) Don't know


PCB.050

In the past two weeks, has {child name} used a mouthwash or mouthrinse at home?
CORW
(1) Yes (PCB.060)
(2) No (PCBCCI03)
(7) Refused (PCBCCI03)
(9) Don't know (PCBCCI03)

[p. 4]


PCB.060

What brand did {child name} use most often during the past two weeks?

FR: DO NOT READ ANSWER CATEGORIES. CHOOSE ONLY ONE BRAND.
CORWB
(1) ACT, Fluorigard, Kolynos, Listermint, Reach, StanCare (PCB.080)
(2) Prescription fluoride rinse (PCBCCI03)
(3) PLAX (PCB.080)
(4) Scope, Listerine, Lavoris (PCB.080)
(5) Other (PCB.070)
(7) Refused (PCB.080)
(9) Don't know (PCB.080)

PCB.070

FR: SPECIFY THE BRAND NAME OF THE MOUTH WASH OR RINSE
CORWB_1 Name: _____________________________


PCB.080

Does this mouthrinse contain fluoride?
CORWFL
(1) Yes
(2) No
(7) Refused
(9) Don't Know
Check item PCBCCI03: If AGE lt (2) [go to CORVTM/(PCB.100)]; Else if AGE ge (2) [go to CORWPG/(PCB.090)].


PCB.090

FR: READ IF NECESSARY:

Some schools have fluoride mouthrinse programs.
Does {child name} now take part in a fluoride mouthrinse program at school?
CORWPG
(1) Yes
(2) No
(7) Refused
(9) Don't Know


PCB.100

FR: READ IF NECESSARY:
Doctors or dentists may prescribe or provide tablets, drops, or supplements with fluoride in them.(Sometimes these are given at school.)

Does {child name} now take vitamins with FLUORIDE in them or any other kind of FLUORIDE tablets, drops, or supplements?
CORVTM
(1) Yes
(2) No
(7) Refused
(9) Don't know

Check item END_PCB: Go to next section--Injury Prevention
[p. 5]

Section C. - Injury Prevention


Check item CKACI1: If AGE lt (5), [go to PCC.010]; Else if AGE ge (5) and AGE lt (16) [go to PCC.030];
Else if AGE ge (16) and AGE lt (18) [go to PCC.040].


PCC.010

Does {child's name} now have a child safety seat?
SEAT
(1) Yes
(2) No
(7) Refused
(9) Don't know


PCC.020

When riding in a car, is {child's name} buckled in (a child safety seat or) a seat belt all or most of the time, some of the time, once in a while, or never?
BUC1
(1) All or most of the time
(2) Some of the time
(3) Once in a while
(4) Never
(5) Doesn't ride in a car
(7) Refused
(9) Don't know

(Go to END_PCC)

PCC.030

When riding in a car, does {child's name} wear a seatbelt all or most of the time, some of the time, once in a while, or never?
BUC2
(1) All or most of the time
(2) Some of the time
(3) Once in a while
(4) Never
(5) Doesn't ride in a car
(7) Refused
(9) Don't know

(Go to CKACI2)

PCC.040

When driving or riding in a car, does {child's name} wear a seatbelt all or most of the time, some of the time, once in a while, or never?
BUC3
(1) All or most of the time
(2) Some of the time
(3) Once in a while
(4) Never
(5) Doesn't ride in a car
(7) Refused
(9) Don't know


Check item CKACI2: If AGE ge (7) and AGE le (15), [go to PLAY/(PCC.050)]; Else if AGE lt (7) or AGE eq (16) or AGE eq (17), [go to END_PCC].

PCC.050

FR: SHOW CARD C7

During the past 12 months, did {child's name} play any of these ORGANIZED sports?
Card C7
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
PLAY
(1) Yes (PCC.060)
(2) No (END_PCC)
(7) Refused (END_PCC)
(9) Don't know (END_PCC)

PCC.060

Which ones did {child's name} play?
FR: MARK "YES" OR "NO" FOR EACH ACTIVITY.

(1) Yes
(2) No
(7) Refused
(9) Don't know
SPRT_FTB (1) Football (PCC.110)
SPRT_BAS (2) Baseball or softball (PCC.120)
SPRT_SOC (3) Soccer (PCC.130)
SPRT_RUG (4) Rugby (PCC.140)
SPRT_HOC (5) Field or ice hockey (PCC.150)
SPRT_LAC (6) Lacrosse (PCC.160)
SPRT_WRE (7) Wrestling (PCC.170)
SPRT_BOX (8) Boxing (PCC.180)
SPRT_KAR (9) Karate or Judo (PCC.190)

Check item LOOP: After asking SPRT, if any activity had a "1" response, begin LOOP by going to the corresponding follow-up question. When all marked activities have been covered, go to
END_PCC.

Example: If @FTB eq (1) [goto PCC.110]. Ask @M and @H questions for PCC.110.
Then begin @M and @H sequence again for next marked activity. If @FTB eq (2,R,D)
[go to @BAS to check whether the activity is marked (1) and so forth]. After all input
fields are checked or if all input fields have (R,D), go to END_PCC.


PCC.110

During the past 12 months when playing football, how often did {child's name}
FOOT_M (a)wear a mouth guard to protect {his/her} mouth and teeth - all or most of the time, some of the time, once in awhile, or never?

FOOT_H
(b) wear protective headgear - all or most of the time, some of the time, once in awhile, or never? (Go to Loop)

(1) All or most of the time
(2) Some of the time
(3) Once in awhile
(4) Never
(7) Refused
(9) Don't know

[p. 7]


PCC.120

During the past 12 months when playing baseball or softball, how often did {child's name}
BASE_M (a)wear a mouth guard to protect {his/her} mouth and teeth - all or most of the time, some of the time, once in awhile, or never?

BASE_H
(b)wear protective headgear - all or most of the time, some of the time, once in awhile, or
never? (Go to LOOP)

(1) All or most of the time
(2) Some of the time
(3) Once in awhile
(4) Never
(7) Refused
(9) Don't know


PCC.130

During the past 12 months when playing soccer, how often did {child's name}
SOCC_M (a)wear a mouth guard to protect {his/her} mouth and teeth - all or most of the time, some of the time, once in awhile, or never?

SOCC_H
(b) wear protective headgear - all or most of the time, some of the time, once in awhile, or never? (Go to LOOP)

(1) All or most of the time
(2) Some of the time
(3) Once in awhile
(4) Never
(7) Refused
(9) Don't know


PCC.140

During the past 12 months when playing rugby, how often did {child's name}
RUGB_M (a)wear a mouth guard to protect {his/her} mouth and teeth - all or most of the time, some of the time, once in awhile, or never?

RUGB_H
(b)wear protective headgear - all or most of the time, some of the time, once in awhile, or never? (Go to LOOP)

(1) All or most of the time
(2) Some of the time
(3) Once in awhile
(4) Never
(7) Refused
(9) Don't know

[p. 8]


PCC.150

During the past 12 months when playing field or ice hockey, how often did {child's name}
HOCK_M (a)wear a mouth guard to protect {his/her} mouth and teeth - all or most of the time, some of the time, once in awhile, or never?

HOCK_H
(b) wear protective headgear - all or most of the time, some of the time, once in awhile, or never? (Go to LOOP)

(1) All or most of the time
(2) Some of the time
(3) Once in awhile
(4) Never
(7) Refused
(9) Don't know


PCC.160

During the past 12 months when playing lacrosse, how often did {child's name}
LACR_M (a)wear a mouth guard to protect {his/her} mouth and teeth - all or most of the time, some of the time, once in awhile, or never?

LACR_H
(b) wear protective headgear - all or most of the time, some of the time, once in awhile, or never? (Go to LOOP)

(1) All or most of the time
(2) Some of the time
(3) Once in awhile
(4) Never
(7) Refused
(9) Don't know


PCC.170

During the past 12 months when wrestling, how often did {child's name}
WRES_M (a)wear a mouth guard to protect {his/her} mouth and teeth - all or most of the time, some of the time, once in awhile, or never?

WRES_H
(b)wear protective headgear - all or most of the time, some of the time, once in awhile, or never? (Go to LOOP)

(1) All or most of the time
(2) Some of the time
(3) Once in awhile
(4) Never
(7) Refused
(9) Don't know

[p. 9]


PCC.180

During the past 12 months when boxing, how often did {child's name}
BOX_M (a)wear a mouth guard to protect {his/her} mouth and teeth - all or most of the time, some of the time, once in awhile, or never?

BOX_H
(b)wear protective headgear - all or most of the time, some of the time, once in awhile, or never? (Go to LOOP)

(1) All or most of the time
(2) Some of the time
(3) Once in awhile
(4) Never
(7) Refused
(9) Don't know


PCC.190

During the past 12 months when practicing Karate or Judo, how often did {child's name}
KAR_M (a)wear a mouth guard to protect {his/her} mouth and teeth - all or most of the time, some of the time, once in awhile, or never?

KAR_H
(b)wear protective headgear - all or most of the time, some of the time, once in awhile, or never? (Go to END_PCC)

(1) All or most of the time
(2) Some of the time
(3) Once in awhile
(4) Never
(7) Refused
(9) Don't know

Check item END_PCC: Go to next section