sc
[p. 1]

CHILD CORE
Section I -- IDENTIFICATION AND VERIFICATION

Check item CHILD_BEGIN: If not a sample child or the sample child section (not including immunization section) of the family has been completed, goto CIDCCI2 (beginning of immunization section); otherwise, (including sample child call back and new sample child interview) if no person has "x" in KNOWSC (x=person who knows the child), goto KNOAVAIL (CID.015), otherwise goto CURRES (CID.001).

CID.001

ENTER THE NUMBER OF THE PERSON TO WHOM YOU ARE SPEAKING.

CURRES

(01-30) 1-30 Person number

CID.005

The next questions are about (Sample Child name). Are you able to answer questions about (his/her) health at this time?

CSRESP

(1) Yes (CID.030)
(2) No (Check item CSPEDIT)
(7) Refused (Check item CSPEDIT)
(9) Don't know (Check item CSPEDIT)

Check item CSPEDIT: Check those in the family with KNOWSC marked 'x'. If the person number equals CURRES, set counter X2=(0); elseif no one has KNOWSC marked 'x', set counter X equal to (4); else set counter X2 equals the person with KNOWSC='x'. Goto CSPEDIT2.

Check item CSPEDIT2: If counter X equals (4), set KNOAVAIL equal to (2) and goto CALLMORE (arrange callback). If counter X2 equals (0), then go back to CSPEDIT for next KNOWSC. If these conditions are not satisfied, goto CSPAVAIL.

CID.010

Is (KNOWSC name) available to answer some questions about (sample child name)'s health?

CSPAVAIL

(1) Available (CID.030)
(2) Not available (Check item CSPEDIT)
(7) Refused (Check item CSPEDIT)
(9) Don't know (Check item CSPEDIT)

CID.015

Is there any family member available who can answer questions about (sample child name)'s health?

KNOAVAIL

(1) Yes (CID.020)
(2) No (CALLMORE)

CID.020

Enter the person number of the respondent.

CSRESPNO

(01-30) 1-30 Person number

CID.030

FR: SHOW FLASHCARD C1. ENTER ONLY 1.

What is (CSRESPNO name)'s relationship to (sample child name)?

CARD C1

1. Parent (Biological, Adoptive or Step)
2. Grandparent
3. Aunt/Uncle
4. Brother/Sister
5. Other relative
6. Legal guardian
7. Foster parent
8. Other non-relative

CSRELTIV

(01) Parent (Biological, adoptive, or step)
(02) Grandparent
(03) Aunt/Uncle
(04) Brother/Sister
(05) Other relative
(06) Legal guardian
(07) Foster parent
(08) Other non-relative
(97) Refused
(99) Don't know

[p. 2]

Check item CIDCCI1: If CSRESPNO is the household respondent, goto beginning of CHS section, otherwise goto CSPVERF.

CID.040

PLEASE VERIFY THE FOLLOWING INFORMATION ABOUT THE SAMPLE CHILD BEFORE PROCEEDING:

(1) Yes
(2) No

CSPVERF1 Gender = (male/female) Is it correct?
CSPVERF2 Age = (3 digit format) Is it correct?
CSPVERF3 Birthday = (spoken word format) Is it correct?

Check item CIDCCI1A: If CSPVERF1 equals 2 then go to CID.042; If CSPVERF2 equals 2 then go to CID.044; If CSPVERF3 equals 2 then go to CID.046; If any changes in age or birthdate have been made in CID.040, goto CAGECHK; If age is 18+, goto CNO_MORE; else go to beginning of CHS section (conditions, limitation, health status).

CID.042

FR: ASK IF APPROPRIATE; OTHERWISE, ENTER YOUR BEST GUESS OF THE PERSON'S SEX.

Is (sample child name) Male or Female?

NEWSEX

(1) Male
(2) Female

(Go to Check item CIDCCI1A)

[Update revised sex - NEWSEX in SEX]

CID.044

How old is (sample child name)?

NEWAGE

(00-96) 0-96 years old
(97) Refused
(99) Don't know

(Go to Check item CIDCCI1A)

[p. 3]

[Update revised age - NEWAGE in AGE]

CID.046

What is (sample child name) birthday?

NEWDOB_M

MONTH:
(01) January
(02) February
(03) March
(04) April
(05) May
(06) June
(07) July
(08) August
(09) September
(10) October
(11) November
(12) December
(97) Refused
(99) Don't know

NEWDOB_D

DAY:
(01-31) 1-31
(97) Refused
(99) Don't Know

NEWDOB_Y

YEAR:
(1900-2001) 1900-2001
(9997) Refused
(9999) DK

[Update Birthdates in DOB_M, DOB_D, and DOB_Y_P]

Check item CAGECHK: Verify that the age and birthdate are consistent. If not, goto CID.040, re-enter age or birthdate. If there is no change of age or birthday in CID.040, and the age calculated form CID.046 agrees with CID.040, then goto CHS.010. If either age or birthday has been changed in CID.040 and the age calculated in CID.046 agrees with AGE, display (Please confirm data again) and goto CID.040 (gender). If ages do not agree, display (Data inconsistency) and goto CID.040 (age). If there is no change of age or birthday in CID.040, and the age calculated form CID.046 disagrees with AGE, then display (Data mismatched, please fix age or birthday) and go to CID.040 (age).

CID.047

FR:(SC name) IS NO LONGER THE SAMPLE CHILD FOR THIS FAMILY

CNO_MORE

@ Enter (P) to proceed (goto end of sample child)

(Go to next section--Conditions, Limitations, Health Status)

[p. 4]

Section II - CONDITIONS, LIMITATION, HEALTH STATUS

Part A -- Conditions, Limitation of Activity and Health Status

CHS.010

What was (S.C.name)'s birth weight?

FR: ALLOW THE RESPONSES IN METRIC IF VOLUNTEERED.

BWGTLB

(1-15) 1-15 pounds
(97) Refused
(99) Don't know

BWGTOZ

(0-15) 0-15 ounces
(97) Refused
(99) Don't know

BWGTMGR

(500) 500 grams or less
(501-5484) 501-5484 grams
(5485) 5485+ grams
(9997) Refused
(9999) DK

CHS.020

How tall is (S.C.name) now?

FR: ALLOW ALL RESPONSES TO BE IN METRIC IF VOLUNTEERED.

CHGHTF

(0-7) 0-7 Feet
(97) Refused
(99) Don't know

CHGHTI

(0-36) 0-36 Inches
(97) Refused
(99) Don't know

CHEIGHTN

(12-95) 12-95 inches
(97) Refused
(99) Don't know

CHEIGHTC

(30-241) 30-241 Centimeters
(997) Refused
(999) Don't know

CHS.021

How much does (S.C.name) weigh now? (without shoes)

FR: ALLOW RESPONSES IN METRIC IF VOLUNTEERED.

CWT_LB

(1-500) 1-500 pounds
(997) Refused
(999) Don't know

CWT_KG

(20) 2.0 kilograms or less
(21-2268) 2.1-226.8 kilograms
(9997) Refused
(9999) Don't know

[p. 5]

Check item CHSCCI1: If age is greater than or equal to 2 go to CHS.032; If the age is less than or equal to 1 then go to CHS.031.

CHS.031

Has a doctor or health professional ever told you that (S.C. name) had:

(1) Yes
(2) No
(7) Refused
(9) Don't know

(Go to CHS.060)

AMR1...Mental Retardation?
AODD1...Any other developmental delay?

CHS.032

Has a doctor or health professional ever told you that (S.C. name) had:

(1) Yes
(2) No
(7) Refused
(9) Don't know

ADD2...Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD)
AMR2...Mental Retardation?
AODD2...Any other developmental delay?

CHS.060

Looking at this list, has a doctor or other health professional ever told you that (S.C. name) had any of these conditions?

FR: SHOW FLASHCARD C2.

CARD C2

You may choose more than one.
1. Down's Syndrome
2. Cerebral Palsy
3. Muscular Dystrophy
4. Cystic Fibrosis
5. Sickle Cell Anemia
6. Autism
7. Diabetes
8. Arthritis
9. Congenital Heart Disease
10 .Other heart condition

CONDL

(0) None
(1) Down's syndrome
(2) Cerebral Palsy
(3) Muscular Dystrophy
(4) Cystic Fibrosis
(5) Sickle cell anemia
(6) Autism
(7) Diabetes
(8) Arthritis
(9) Congenital heart disease
(10) Other heart condition
(97) Refused
(99) Don't know

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

CHS.070

Has (S.C. name) EVER had chickenpox?

CPOX

(1) Yes (CHS.072)
(2) No (CHS.080)
(7) Refused (CHS.080)
(9) Don't know (CHS.080)

CHS.072

Has (S.C. name) had chickenpox DURING THE PAST 12 MONTHS?

CPOX12MO

(1) Yes
(2) No
(7) Refused
(9) Don't know

CHS.080

Has a doctor or other health professional EVER told you that (S.C. name) had asthma?

CASHMEV

(1) Yes (CHS.085)
(2) No (Check item CHSCCI2)
(7) Refused (Check item CHSCCI2)
(9) Don't know (Check item CHSCCI2)

[p. 6]

[ The following questions are about (S.C. name) asthma DURING THE PAST 12 MONTHS. ]

CHS.085

Does (S.C. name) still have asthma?

CASSTILL

(1) Yes
(2) No
(7) Refused
(9) Don't know

CHS.090

DURING THE PAST 12 MONTHS, has (S.C. name) had an episode of asthma or an asthma attack?

CASHYR

(1) Yes (CHS.100)
(2) No (CHSCCI2)
(7) Refused (CHSCCI2)
(9) Don't know (CHSCCI2)

CHS.100

DURING THE PAST 12 MONTHS, did (S.C. name) have to visit an emergency room or urgent care center because of (his/her) asthma?

CASMERYR

(1) Yes
(2) No
(7) Refused
(9) Don't know

Check item CHSCCI2: If the age is greater than or equal to 3 then go to CHS.115; If the age is less than or equal to 2 then goto CHS.111.

CHS.111

DURING THE PAST 12 MONTHS, has (S.C. name) had any of the following conditions?

(1) Yes
(2) No
(7) Refused
(9) Don't know

HAYF1... Hay fever?
RALLG1... Any kind of respiratory allergy?
DALLG1... Any kind of food or digestive allergy?
SALLG1... Eczema or any kind of skin allergy?
DIARH1... Frequent or repeated diarrhea or colitis?
ANEMIA1... Anemia?
EARINF1... Three or more ear infections?
SEIZE1... Seizures?

(Go to CHS.210)

CHS.115

During the past 12 months, has (S.C.name) had any of the following conditions?

(1) Yes
(2) No
(7) Refused
(9) Don't know

HAYF2... Hay fever?
RALLG2... Any kind of respiratory allergy?
DALLG2... Any kind of food or digestive allergy?
SALLG2... Eczema or any kind of skin allergy?
DIARH2... Frequent or repeated diarrhea or colitis?
ANEMIA2... Anemia?
FHEAD... Frequent or severe headaches, including migraines?
EARINF2... Three or more ear infections?
SEIZE2... Seizures?
STUTTER... Stuttering or stammering?

[p. 7]

CHS.210

Compared with 12 months ago, would you say (S.C. name)'s health is now better, worse, or about the same?

CHSTATYR

(1) Better
(2) Worse
(3) About the same
(7) Refused
(9) Don't know

Check item CHSCCI3: If the age is greater than or equal to 5 go to CHS.220; If age is less than or equal to 4 go to CHS.230.

CHS.220

DURING THE PAST 12 MONTHS, that is, since (12-month ref. date), about how many days did (S.C. name) miss school because of illness or injury?

FR: ENTER 996 IF CHILD DID NOT GO TO SCHOOL IN THE PAST 12 MONTHS.

SCHDAYR1

(0) None
(1-240) 1-240 Days
(996) Did not go to school
(997) Refused
(999) Don't know

[ These next questions are about (S.C. name)'s recent health during the 2 weeks outlined on that calendar. ]

CHS.230

Did (S.C.name) have a head cold or chest cold that started during those two weeks?

CCOLD2W

(1) Yes
(2) No
(7) Refused
(9) Don't know

CHS.240

Did (S.C.name) have a stomach or intestinal illness with vomiting or diarrhea that started during those two weeks?

CINTIL2W

(1) Yes
(2) No
(7) Refused
(9) Don't know

CHS.250

Which statement best describes (S.C. name)'s hearing without a hearing aid: Good, a little trouble, a lot of trouble, or deaf?

CHEARST

(1) Good
(2) Little trouble
(3) Lot of trouble
(4) Deaf
(7) Refused
(9) Don't know

CHS.260

Does (S.C. name) have any trouble seeing?

[If child's age is 2 or more add:]
Even when wearing glasses or contact lenses?

CVISION

(1) Yes (CHS.270)
(2) No (CHS.290)
(7) Refused (CHS.290)
(9) Don't know (CHS.290)

CHS.270

Is (S.C. name) blind or unable to see at all?

CBLIND

(1) Yes
(2) No
(7) Refused
(9) Don't know

[p. 8]

CHS.290

Does (S.C. name) have any impairment or health problem that requires (him/her) to use special equipment, such as a brace, a wheelchair, or a hearing aid (excluding ordinary eyeglasses or corrective shoes)?

IHSPEQ

(1) Yes
(2) No
(7) Refused
(9) Don't know

CHS.300

Does (S.C. name) have an impairment or health problem that limits (his/her) ability to (crawl), walk, run, or play?

IHMOB

(1) Yes (CHS.310)
(2) No (CHS.311)
(7) Refused (CHS.311)
(9) Don't know (CHS.311)

CHS.310

Is this an impairment or health problem that has lasted, or is expected to last 12 months or longer?

IHMOBYR

(1) Yes
(2) No
(7) Refused
(9) Don't know

CHS.311

Does (S.C. name) NOW have a problem for which (he/she) has regularly taken prescription medication for at least three months?

PROBRX

(1) Yes
(2) No
(7) Refused
(9) Don't know

Check item CHSCCI4: If age is less than or equal to 1 go to next section--Health Care Access and Utilization, CAU.020; If the age is equal to 2 go to CHSCCI5; If the age is greater than or equal to 3 go to CHS.312

CHS.312

Has a representative from a school or a health professional EVER told you that (S.C. name) had a learning disability?

LEARND

(1) Yes
(2) No
(7) Refused
(9) Don't know

[p. 9]

Part B - Mental Health

Check item CHSCCI5: If AGE = 2-3 and SEX is male, then goto CHS.321;
If AGE = 2-3 and SEX is female, then, goto CHS.361;

CHS.321

I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES TRUE, or OFTEN TRUE, of (S.C. name) DURING THE PAST 2 MONTHS.

FR: SHOW FLASHCARD C3

(0) Not True
(1) Sometimes True
(2) Often True
(7) Refused
(9) Don't know

HE:

CARD C3

0. Not true
1. Sometimes true
2. Often true

CMHAGM12... Has been uncooperative?
CMHAGM13... Has trouble getting to sleep?
CMHAGM14... Has speech problems?
CMHAGM15... Has been unhappy, sad, or depressed?

(Go to CAU.020)

CHS.361

I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES TRUE, or OFTEN TRUE, of (C.S. name) DURING THE 2 PAST MONTHS.

FR: SHOW FLASHCARD C3

(0) Not True
(1) Sometimes True
(2) Often True
(7) Refused
(9) Don't know

SHE:

CARD C3

0. Not true
1. Sometimes true
2. Often true

CMHAGF12... Has temper tantrums or a hot temper?
CMHAGF13... Has speech problems?
CMHAGF14... Has been nervous or high-strung?
CMHAGF15... Has been unhappy, sad, or depressed?

(Go to CAU.020)

(Go to next section-Health Care Access and Utilization)

[p. 10]

Section III -- HEALTH CARE ACCESS AND UTILIZATION

Part A -- Access To Care

[ The next questions are about Health Care. ]

CAU.020

Is there a place that (S.C. name) USUALLY goes when (he/she) is sick or you need advice about (his/her) health?

CUSUALPL

(1) Yes (CAU.030)
(2) There is NO place (CAU.037)
(3) There is MORE THAN ONE place (CAU.030)
(7) Refused (CAU.037)
(9) Don't know (CAU.037)

CAU.030

[If CAU.020 equal to 1, then read:]
What kind of place is it ...

[ If CAU.020 equal 3, then read:]
What kind of place does (S.C. name) go to most often ...
... A clinic, doctor's office, emergency room, or some other place?

CPLKIND

(1) Clinic or health center (CAU.035)
(2) Doctor's office or HMO (CAU.035)
(3) Hospital emergency room (CAU.035)
(4) Hospital outpatient department (CAU.035)
(5) Some other place (CAU.035)
(6) Doesn't go to one place most often (CAU.037)
(7) Refused (CAU.037)
(9) Don't know (CAU.037)

CAU.035

Is that (place selected in CAU.030) the same place (S.C. name) usually goes when (he/she) needs routine or preventive care, such as a physical examination or well baby/child check-up?

CHCPLROU

(1) Yes (CAU.040)
(2) No (CAU.037)
(7) Refused (CAU.037)
(9) Don't know (CAU.037)

CAU.037

What kind of place does (S.C. name) USUALLY go to when (he/she) needs routine preventive care, such as a physical examination or (well baby/child) check-up?

CHCPLKND

(0) Doesn't get preventive care anywhere
(1) Clinic or health center
(2) Doctor's office or HMO
(3) Hospital emergency room
(4) Hospital outpatient department
(5) Some other place
(6) Doesn't go to one place most often
(7) Refused
(9) Don't know

Check item CAUCCI1:If CAU.020 equals (2, 7, 9) go to CAU.080; Else go to CAU.040.

CAU.040

At any time IN THE PAST 12 MONTHS did you CHANGE the place(s) to which (S.C. name) USUALLY goes for health care?

CHCCHGYR

(1) Yes (CAU.050)
(2) No (CAU.080)
(7) Refused (CAU.080)
(9) Don't know (CAU.080)

CAU.050

Was this change for a reason related to health insurance?

CHCCHGHI

(1) Yes
(2) No
(7) Refused
(9) Don't know

CAU.080

There are many reasons people delay getting medical care. Have you delayed getting care for (S.C. name) for any of the following reasons IN THE PAST 12 MONTHS?

(1) Yes
(2) No
(7) Refused
(9) Don't know

CHCDLYR1... You couldn't get through on the telephone.
CHCDLYR2... You couldn't get an appointment for (S.C. name) soon enough.
CHCDLYR3... Once you get there, (S.C. name) has to wait too long to see the doctor.
CHCDLYR4... The (clinic/doctor's office) wasn't open when you could get there.
CHCDLYR5... You didn't have transportation.

Check item CAUCCI2:If the age is greater than or equal to 2 go to CAU.135; Else go to CAU.130.

CAU.130

DURING THE PAST 12 MONTHS, was there any time when (S.C. name) NEEDED any of the following, but didn't get it because you couldn't afford it:

...Prescription medicines?

CHCAFYR

(1) Yes
(2) No
(7) Refused
(9) Don't know

(Go to CAUCCI2A)

CAU.135

DURING THE PAST 12 MONTHS, was there any time when (S.C. name) NEEDED any of the following, but didn't get it because you couldn't afford it:

(1) Yes
(2) No
(7) Refused
(9) Don't know

CHCAFYR1... Prescription medicines?
CHCAFYR2... Mental health care or counseling?
CHCAFYR3... Dental care (including check-ups)?
CHCAFYR4... Eyeglasses?

Check item CAUCCI2A:If age is less than 1 go to CAU.170; Else go to CAU.160.

[p. 12]

Part B -- Dental Care

CAU.160

About how long has it been since (S.C. name) last saw a dentist? Include all types of dentists, such as orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists.

FR: SHOW FLASHCARD C4

CARD C4
You may choose more than one.

1. Not sure needed emergency room care/wanted advice from health care provider/plan first
2. Could not take time off from work
3. Did not have child care
4. Did not have transportation
5. Ambulance did not arrive at home/pick up point quickly enough
6. Did not have health insurance
7. Emergency room costs too much
8. Did not have money for co-payment
9. Health plan requires pre-authorization
10. Concerned that health plan would not pay
11. Long wait
12. Sent to another part of the hospital for care
13. Other -- Specify

CDNLONGR

(0) Never
(1) 6 months or less
(2) More than 6 months, but not more than 1 year ago
(3) More than 1 year, but not more than 2 years ago
(4) More than 2 years, but not more than 5 years ago
(5) More than 5 years ago
(7) Refused (CAUCCI2B)
(9) Don't know (CAUCCI2B)

Check Item CAUCCI2B: If the age is greater than or equal to 2 go to CAU.175; Else go to CAU.170

[p. 13]

Part C -- Health Care Provider Contacts

CAU.170

DURING THE PAST 12 MONTHS, that is since (12-month ref. date), has anyone in the family seen or talked to any of the following health care providers about (S.C. name)'s health?

(1) Yes
(2) No
(7) Refused
(9) Don't know

CHCSYR11 An optometrist, ophthalmologist, or eye doctor (someone who prescribes eyeglasses)?
CHCSYR12 A foot doctor?
CHCSYR13 A physical therapist, speech therapist, respiratory therapist, audiologist, or occupational therapist?
CHCSYR14 A nurse practitioner, physician assistant or midwife?

(Go to CAU.240)

CAU.175

DURING THE PAST 12 MONTHS, that is since (12-month ref. date), have you seen or talked to any of the following health care providers about (S.C. name)'s health?

(1) Yes
(2) No
(7) Refused
(9) Don't know

CHCSYR1... A mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker?
CHCSYR2... An optometrist, ophthalmologist, or eye doctor (someone who prescribes eyeglasses)?
CHCSYR3... A foot doctor?
CHCSYR4... A chiropractor?
CHCSYR5... A physical therapist, speech therapist, respiratory therapist, audiologist, or occupational therapist?
CHCSYR6... A nurse practitioner, physician assistant or midwife?

Check item CAUCCI2C:If female and age is greater 14 then go to CAU.230; Else go to CAU.240.

CAU.230

DURING THE PAST 12 MONTHS, that is since (12-month ref. date), have you seen or talked to a doctor who specializes in women's health (an obstetrician/gynecologist) about (S.C. name)'s health?

CHCSYR7

(1) Yes
(2) No
(7) Refused
(9) Don't know

CAU.240

DURING THE PAST 12 MONTHS, that is since (12-month ref. date), have you seen or talked to the following about (S.C. name)'s health?

(1) Yes
(2) No
(7) Refused
(9) Don't know

CHCSYR81 A medical doctor who specializes in a particular medical disease or problem (other than obstetrician/gynecologist, psychiatrist or ophthalmologist)?
CHCSYR82 A general doctor who treats a variety of illnesses (a doctor in general practice, pediatrics, family medicine, or internal medicine)?

Check item CAUCCI2D: If CHCSYR82 equals 1 go to CAU.260; Else go to CAU.270.

CAU.260

Does that doctor treat children and adults (a doctor in general practice or family medicine)?

CHCSYR10

(1) Yes
(2) No
(7) Refused
(9) Don't know

CAU.260.010

Did you see or talk to this general doctor because of an emotional or behavioral problem that (S.C. name) may have?

CHCSYREM

(1) Yes
(2) No
(7) Refused
(9) Don't know

CAU.270

DURING THE PAST 12 MONTHS did (S.C. name) receive a well-child checkup-that is a general checkup when (he/she) was not sick or injured?

CHPEXYR_C

(1) Yes
(2) No
(7) Refused
(9) Don't know

CAU.280

DURING THE PAST 12 MONTHS, HOW MANY TIMES has (S.C. name) gone to a HOSPITAL EMERGENCY ROOM about (his/her) health? (This includes emergency room visits that resulted in a hospital admission.)

FR: SHOW FLASHCARD C5

CARD C5

0. Never
1. 6 months or less
2. More than 6 months, but not more than 1 year ago
3. More than 1 year, but not more than 2 years ago
4. More than 2 years, but not more than 5 years ago
5. More than 5 years ago

CHERNOY2

(0) None
(1) 1
(2) 2-3
(3) 4-5
(4) 6-7
(5) 8-9
(6) 10-12
(7) 13-15
(8) 16 or more
(97) Refused
(99) Don't know

CAU.290

DURING THE PAST 12 MONTHS, did (S.C. name) receive care AT HOME from a nurse or other health care professional?

CHCHYR

(1) Yes (CAU.300)
(2) No (CAU.320)
(7) Refused (CAU.320)
(9) Don't know (CAU.320)

CAU.300

DURING THE PAST 12 MONTHS, how many months did (S.C. name) receive care at home from a health care professional?

CHCHMOYR

(1-12) 1-12 months
(7) Refused
(9) Don't know

CAU.310

What was the total number of home visits received for (S.C. name) during that/those month(s)?

FR: SHOW FLASHCARD C6

CARD C6

0. None
1. 1
2. 2 - 3
3. 4 - 5
4. 6 - 7
5. 8 - 9
6. 10 - 12
7. 13 - 15
8. 16 or more

CHCHNOY2

(1) 1
(2) 2-3
(3) 4-5
(4) 6-7
(5) 8-9
(6) 10-12
(7) 13-15
(8) 16 or more
(97) Refused
(99) Don't know

[p. 15]

CAU.320

During the past 12 months, HOW MANY TIMES has (S.C. name) seen a doctor or other health care professional about (his/her) health at A DOCTOR'S OFFICE, A CLINIC, OR SOME OTHER PLACE?
DO NOT INCLUDE TIMES (S.C. name) WAS HOSPITALIZED OVERNIGHT, VISITS TO HOSPITAL EMERGENCY ROOMS, HOME VISITS, OR TELEPHONE CALLS.

FR: SHOW FLASHCARD C5

CARD C5

CHCNOYR2

(0) None
(1) 1
(2) 2-3
(3) 4-5
(4) 6-7
(5) 8-9
(6) 10-12
(7) 13-15
(8) 16 or more
(97) Refused
(99) Don't know

CAU.330

During the past 12 months has (S.C. name) had SURGERY or other surgical procedures either as an inpatient or outpatient?

FR: (READ IF NECESSARY) THIS INCLUDES BOTH MAJOR SURGERY AND MINOR PROCEDURES SUCH AS SETTING BONES OR REMOVING GROWTHS.

CSRGYR

(1) Yes (CAU.340))
(2) No (Check item CAUCCI3)
(7) Refused (Check item CAUCCI3)
(9) Don't know (Check item CAUCCI3)

CAU.340

Including any times you may have already told me about, HOW MANY DIFFERENT TIMES has (S.C. name) had surgery done as an outpatient DURING THE PAST 12 MONTHS?

CSRGNOYR

(0) None
(1-94) 1-94 times
(95) 95+ times
(97) Refused
(99) Don't know

Check item CAUCCI3:If sample child had a doctor visit in the last 2 weeks as indicated in the family core, that is: If FAU.180 equals (1) and sample child's person number is in FAU.190, then CAU.345 equals (1) and goto next section; Else goto CAU.345.

CAU.345

About how long has it been since anyone in the family last saw or talked to a doctor or other health care professional about (S.C. name)'s health? Include doctors seen while (he/she) was a patient in a hospital.

FR: SHOW FLASHCARD C4.

CARD C4
You may choose more than one.

CMDLONG

[p. 16]

CAU.345.050

FR: THE FOLLOWING STATEMENTS ARE NOT TO BE READ TO THE RESPONDENT. THEY ARE DISPLAYED AND INCLUDED HERE FOR LEGAL REASONS.

THE NEXT 25 ITEMS CONTAINED IN CSCL1 THROUGH CSCL5 ARE INCLUDED IN THIS SURVEY WITH PERMISSION AS INDICATED.

THE SDQ QUESTIONS ARE COPYRIGHTED BY ROBERT GOODMAN, PH.D., FRCPSYCH, MRCP. STATE AND LOCAL AGENCIES MAY USE THESE QUESTIONS WITHOUT CHARGE AND WITHOUT SEEKING SEPARATE PERMISSION PROVIDED THE WORDING IS NOT MODIFIED, ALL THE QUESTIONS ARE RETAINED, AND DR. GOODMAN'S COPYRIGHT IS ACKNOWLEDGED.

CSCLCOPY ENTER (P) TO PROCEED

CAU.345.010

I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE, SOMEWHAT TRUE, CERTAINLY TRUE for (S.C. name) DURING THE PAST 6 MONTHS:

FR: SHOW FLASHCARD C8

(1) Not True
(2) Somewhat True
(3) Certainly True
(7) Refused (blind)
(9) Don't Know (blind)

(HE/SHE...)

CARD C8

1. Not true
2. Somewhat true
3. Certainly true

CSCL1_S1... is considerate of other people's feelings
CSCL1_H1... is restless, overactive, cannot stay still for long
CSCL1_E1... often COMPLAINS of headaches, stomach-aches or sickness
CSCL1_S2... shares readily with other (children (if AGE less than 12) (treats, toys, pencils)/youths (CD's, games, food))
CSCL1_C1... often loses temper.

[p. 17]

CAU.345.020

FR: SHOW FLASHCARD C8.

(1) Not True
(2) Somewhat True
(3) Certainly True
(7) Refused (blind)
(9) Don't Know (blind)

(HE/SHE...)

CARD C8

1. Not true
2. Somewhat true
3. Certainly true

CSCL2_P1... is rather solitary, prefers to play alone (for ages 4-11);
would rather be alone than with other teenagers (for ages 12-17)
CSCL2_C2... is generally well-behaved, usually does what adults request
CSCL2_E2... has many worries or often seems worried
CSCL2_S3... is helpful if someone is hurt, upset or feeling ill
CSCL2_H2... is constantly fidgeting or squirming

CAU.345.030

I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE, SOMEWHAT TRUE, CERTAINLY TRUE for (S.C. name) DURING THE PAST 6 MONTHS:

FR: SHOW FLASHCARD C8.

(1) Not True
(2) Somewhat True
(3) Certainly True
(7) Refused (blind)
(9) Don't Know (blind)

(HE/SHE...)

CARD C8

1. Not true
2. Somewhat true
3. Certainly true

CSCL3_P2... has at least one good friend
CSCL3_C3... often fights with other (children/youth) or bullies them
CSCL3_E3... is often unhappy, depressed or tearful
CSCL3_P3... is generally liked by other (children/youth)
CSCL3_H3... is easily distracted, concentration wanders

[p. 18]

CAU.345.040

I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE, SOMEWHAT TRUE, CERTAINLY TRUE for (S.C. name) DURING THE PAST 6 MONTHS:

FR: SHOW FLASHCARD C8.

(1) Not True
(2) Somewhat True
(3) Certainly True
(7) Refused (blind)
(9) Don't Know (blind)

(HE/SHE...)

CARD C8

1. Not true
2. Somewhat true
3. Certainly true

CSCL4_E4... is nervous or clingy in new situations (age 4-11) is
nervous in new situations, easily loses confidence (age 12-17)
CSCL4_S4... is kind to younger children
CSCL4_C4... often lies OR cheats
CSCL4_P4... is picked on or bullied by other (children/youth)
CSCL4_S5... often offers to help others (parents, teachers, other children)

CAU.345.050

I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE, SOMEWHAT TRUE, CERTAINLY TRUE for (S.C. name) during the past 6 months:

FR: SHOW FLASHCARD C8

(1) Not True
(2) Somewhat True
(3) Certainly True
(7) Refused (blind)
(9) Don't Know (blind)

(HE/SHE...)

CARD C8

1. Not true
2. Somewhat true
3. Certainly true

CSCL5_H4... Thinks things out before acting
CSCL5_C5... Steals from home, school or elsewhere
CSCL5_P5... Gets along better with adults than with other (children/youths)
CSCL5_E5... has many fears, is easily scared
CSCL5_H5... has good attention span, sees chores or homework through to the end

CAU.345.060

Overall, do you think that (sample child) has difficulties in any of the following areas: emotions, concentration, behavior, or being able to get along with other people?

FR: SHOW FLASHCARD C9

CARD C9
Overall, do you think that this child has difficulties in any of the following areas: emotions, concentration, behavior, or being able to get along with other people?

1. No
2. Yes, minor difficulties
3. Yes, definite difficulties
4. Yes, severe difficulties

CSCL6

(1) No (ICAGEM)
(2) Yes, minor difficulties (CAU.345.070)
(3) Yes, definite difficulties (CAU.345.070)
(4) Yes, severe difficulties (CAU.345.070)
(7) Refused (blind) (ICAGEM)
(9) Don't know (blind) (ICAGEM)

CAU.345.070

How long have these difficulties been present?

CSCL7

(1) Less than a month (goto ICAGEM)
(2) 1 - 5 months (CAU.345.080)
(3) 6 - 12 months (CAU.345.080)
(4) Over 12 months (CAU.345.080)
(7) Refused (goto ICAGEM) (blind)
(9) Don't know (goto ICAGEM) (blind)

CAU.345.080

Do the difficulties upset or distress your child?

FR: SHOW FLASHCARD C10

CARD C10

1. Not at all
2. A little
3. A medium amount
4. A great deal

CSCL8

(1) Not at all
(2) A little
(3) A medium amount
(4) A great deal
(7) Refused (blind)
(9) Don't know (blind)

CAU.345.090

Do the difficulties interfere with your child's everyday life in the following areas?

FR: SHOW FLASHCARD C10

(1) Not at all
(2) A little
(3) A medium amount
(4) A great deal
(7) Refused (blind)
(9) Don't know (blind)

CARD C10

1. Not at all
2. A little
3. A medium amount
4. A great deal

CSCL9_HL... Home life
CSCL9_FR... Friendships
CSCL9_CL... Classroom learning
CSCL9_LA... Leisure activities

CAU.345.100

Do the difficulties put a burden on you or the family as a whole?

FR: SHOW FLASHCARD C10

CARD C10

1. Not at all
2. A little
3. A medium amount
4. A great deal

CSCL10

(1) Not at all
(2) A little
(3) A medium amount
(4) A great deal
(7) Refused (blind)
(9) Don't know (blind)

(goto ICAGEM)

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