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[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 C71.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