Data Cart

Your data extract

0 variables
0 samples
View Cart



sc

Page 1 of 6


2010 NHIS Questionnaire - Sample Child Child Identification
Document Version Date: 12-Apr-11

Question ID: CID.001_00.000
Instrument Variable Name: CURRES
QuestionText:

* Enter the line number of the person to whom you are speaking.
01-25 Person number of the respondent for Sample Child
UniverseText: Sample child section not started or not completed
SkipInstructions:
if CSTAT ne empty and CSTAT ne '2' THEN
if ASTAT = empty or ASTAT = '2' THEN
goto adult.aid.SADULT
elseif recontact.RCIFLAG ne '1' THEN
goto recontact.RCI_BEGIN procedure
else
goto back.OUTCOMEB1 procedure
endif
goto back.OUTCOMEB1 procedure
endif
(01-25)if this is NOT an allowable line number
goto ERR_CURRES
elseif CURRES = a line number entered in KNOWSC2
store CURRES in CSPAVAIL and CSRESP
goto CSRELTIV
elseif KNOWSC2 = 'Don't know' or 'Refused' or empty (no line numbers in KNOWSC2)
goto KNOAVAIL
else
goto CSPAVAIL
endif

Page 2 of 6

Question ID: CID.010_00.000

Instrument Variable Name: CSPAVAIL
QuestionText:
The next questions are about [fill1: ALIAS of Sample Child].
Is [fill2:KNOWSC2 names] available to answer some questions about [fill3: HISHER] health?
* Enter line number of available respondent from list or enter '96 ' if no one is available.
* If refused enter CTRL_R.
01-25 Person # of person available to answer questions about Sample Child
96 No person available
UniverseText: Someone identified as knowledgeable about child's health and knowledgeable person(s) not entered in CURRES
SkipInstructions:
(01-25)if line number not equal one of the line numbers in KNOWSC2
goto child.cid.ERR_CSPAVAIL
else
store child.cid.CSPAVAIL in child.cid.CSRESP
goto child.cid.CSRELTIV
endif
(96) store child.cid.CSPAVAIL in child.cid.CSRESP
goto cbk.CCALLBK1
(R) store '4' in CSTAT(FAMINT)
if ASTAT = empty or ASTAT = '2' THEN
goto adult.aid.SADULT
elseif recontact.RCIFLAG ne '1' THEN
goto recontact.RCI_BEGIN procedure
else
goto back.OUTCOMEB1 procedure
endif

Question ID: CID.030_00.000

Instrument Variable Name: CSRELTIV
QuestionText: (book) C1
[fill1: The next questions are about [fill2: ALIAS of Sample Child].]
What is your relationship to [fill2: ALIAS of Sample Child]?
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
UniverseText: Someone identified as knowledgeable about child's health
SkipInstructions:
(1-8,R,D) If CSRESP = demographics.hhc.RELRESP_A
goto child.chs.BWGT_LB
elseif CSRESP = demographics.hhc.HHRESP
goto child.chs.BWGT_LB
else]
goto CSPVERF_S
endif]

Page 3 of 6

Question ID: CID.040_00.000

Instrument Variable Name: CSPVERF_S
QuestionText:
* Please verify the following information about the sample child before proceeding:
I have recorded [fill1: ALIAS of Sample Child]' s sex as [fill2: Sex of Sample Child]. Is this correct?
* If respondent "refuses" or says "don't know", enter "1" for "yes".
1 Yes
2 No
UniverseText: Respondent is not the person entered in HHRESP or RELRESP_A.
Sample Child
SkipInstructions:
(1) goto CSPVERF_A
(2) goto NEWSEX

Question ID: CID.041_00.000

Instrument Variable Name: NEWSEX
QuestionText:
* Ask if appropriate; otherwise, enter your best guess of the person's sex.
Is [fill: ALIAS of Sample Child] Male or Female?
1 Male
2 Female
UniverseText: Respondent said child's sex is not correct.
Sample Child
SkipInstructions:
(1,2) store NEWSEX in SEX
goto ERR_NEWSEX
reset CSPVERF_S
goto CSPVERF_S

Question ID: CID.042_00.000

Instrument Variable Name: CSPVERF_A
QuestionText:
* Please verify the following information about the sample child before proceeding: I have recorded [fill1: ALIAS of Sample Child]' s age as [fill2: Age of Sample Child] old. Is this correct? If respondent "refuses" or says "don't know", enter "1" for "yes".
1 Yes
2 No
UniverseText: Respondent verified child's sex Sample Child?
SkipInstructions:
(1) goto CSPVERF_D
(2) goto NEWAGE

Question ID: CID.043_00.000

Instrument Variable Name: NEWAGE
QuestionText:
How old is [fill1: ALIAS of Sample Child]?
* If age given in months, weeks, or days, convert age to appropriate year. If less than one year old, enter "0".
000-120 Age in years
UniverseText: Respondent said child's age is not correct
SkipInstructions:
(0-120, Refused, Don't know)
if NEWAGE = 'Refused' or NEWAGE = 'Don't know' or NEWAGE = AGE
reset CSPVERF_A
goto ERR_NEWAGE
else
store NEWAGE in AGE
goto NEWDOB_M

Question ID: CID.044_00.000

Instrument Variable Name: CSPVERF_D
QuestionText:
* Please verify the following information about the sample child before proceeding:
I have recorded [fill1: ALIAS of Sample Child]'s birthday as [fill2: Birthday of Sample Child]. Is this correct?
* If respondent "refuses" or says "don't know", enter "1" for "yes".
1 Yes
2 No
UniverseText: Respondent verified child's sex
SkipInstructions:
(1) if AGE of Sample Child ge '18'
goto CNO_MORE
else
goto child.chs.BWGT_LB
endif
(2) goto NEWDOB_M

Page 5 of 6

Question ID: CID.046_01.000

Instrument Variable Name: NEWDOB_M
QuestionText:
1 of3
What is [fill: ALIAS of Sample Child]'s birthday?
*Enter month of birth.
1 January
2 February
3 March
4 April
5 May
6 June
7 July
8 August
9 September
10 October
11 November
12 December
UniverseText: Respondent said child's date of birth is not correct or child' s age is not correct
SkipInstructions:
(01-12, Refused, Don't know) goto NEWDOB_D

Question ID: CID.046_02.000

Instrument Variable Name: NEWDOB_D
QuestionText:
2 of 3
* Enter day of birth.
01-31 Day of the month
UniverseText: Respondent said child's date of birth is not correct or child' s age is not correct
SkipInstructions:
(01-31,Refused,Don't know) goto NEWDOB_Y
If days not valid, goto ERR_NEWDOB_D

Question ID: CID.046_03.000

Instrument Variable Name: NEWDOB_Y
QuestionText:
3 of 3
* Enter year of birth.
1880-2020 Year of birth
UniverseText: Respondent said child's date of birth is not correct or child's age is not correct
SkipInstructions:
(1880-2020, Refused, Don't know) if CSPVERF_A = '2' (No) then reset CSPVERF_A to empty
goto CSPVERF_A
elseif CSPVERF_D = '2' (No) then reset CSPVERF_D to empty
goto CSPVERF_D
endif
(if year GT current year) or (if year = current year and month GT current month) or (if year = current year and
month = current month and day GT current day)
goto ERR1_NEWDOB_Y
endif
(if birth month = '02' and birth day = '29' and this is not a leap year)
goto ERR2_NEWDOB_Y
endif
(if NEWDOB_M = 'Ref' or 'DK') or (if NEWDOB_D = 'Ref' or 'DK') or (if NEWDOB_Y = 'Ref' or 'DK')
goto ERR3_NEWDOB_Y
else
store NEWDOB_M in DOBM
store NEWDOB_D in DOBD
store NEWDOB_Y in DOBY
if CSPVERF_A = '2' (No) then reset CSPVERF_A to empty
goto CSPVERF_A
elseif CSPVERF_D = '2' (No) then reset CSPVERF_D to empty
goto CSPVERF_D
endif
endif
Calculate age from NEWDOB_M, NEWDOB_D, and NEWDOB_Y.
if age from NEWDOB items is ne AGE and age from NEWDOB items is valid
reset CSPVERF_A or CSPVERF_D
goto ERR4_NEWDOB_Y
endif


Child Health Status and Limitations 2010
NHIS Questionnaire - Sample Child


Question ID: CHS.010_01.000

Instrument Variable Name: BWGT_LB
QuestionText:
What was [fill: S.C. name]'s birth weight?
* Enter 'M' to record metric measurements.


01-15 1-15 pounds
97 Refused
99 Don't know
M Metric
UniverseText: Sample children LT18
SkipInstructions:
(1-12) [goto BWGT_OZ]
(13-15) [goto ERR1_BWGT_LB]
(R,D) [goto CHGT_FT]
(M) [goto BWGT_GR]
[If NE (1-15, M, R, D) goto ERR2_BWGT_LB]


Question ID: CHS.010_02.000

Instrument Variable Name: BWGT_OZ
QuestionText:
* Enter ounces.
00-15 ounces 0-15
97 Refused
99 Don't know
Blank Blank
UniverseText: Sample children LT18 who have a value entered for weight in pounds.
SkipInstructions:
(0-15,R,D) [goto CHGT_FT]
[if BWGT_LB = (0-15, R, D) and BWGT_OZ = (empty) go to CHGT_FT]


Question ID: CHS.011_00.000

Instrument Variable Name: BWGT_GR
QuestionText:
* Enter weight in grams.
0500-5485 grams 500-5485
9997 Refused
9999 Don't know
UniverseText: Sample children LT18 whose birth weight will be entered in metric.
SkipInstructions:
(500-5485,R,D) [goto CHGT_FT]
(5486-6900) [goto ERR_BWGT_GR]


Question ID: CHS.020_01.000

Instrument Variable Name: CHGT_FT
QuestionText:
How tall is [fill: S.C. name] now (without shoes)?
* If the child's height is given in inches, press 'ENTER' at feet and enter the measure in inches (36 inches maximum).
* Enter 'M' to record metric measurements.
00-07 0-7 feet
97 Refused
99 Don't know
M Metric
UniverseText: Sample children 12+
SkipInstructions:
(empty) [goto CHGT_IN]
(0-7) [goto CHGT_IN]
(R,D) [goto CWGT_LB]
(M) [goto CHGT_M]
[If NE (0-7, M, R, D) go to ERR_CHGT_FT]
Question ID: CHS.020_02.000

Instrument Variable Name: CHGT_IN
QuestionText:
* Enter inches.
00-36 0-36 inches
97 Refused
99 Don't know
UniverseText: Sample children 12+ whose height in feet is 0-7 or is left empty.
SkipInstructions:
(0-36) [goto CWGT_LB]
[If both CHGT_FT and CHGT_IN are either (empty) or (0), display ERR1_CHGT_IN]
[If CHGT_FT = (0-7) and CHGT_IN is GE (12) display ERR2_CHGT_IN]
Question ID: CHS.021_01.000

Instrument Variable Name: CHGT_M
QuestionText:
* Enter height in metric.
* If the child's height is given in centimeters, press 'ENTER' at meters and enter the measure in centimeters (241
centimeters maximum).
0-2 0-2 meters
7 Refused
9 Don't know
Blank Blank
UniverseText: Sample children 12+ whose current height will be entered in metric.
SkipInstructions:
(0-2) [goto CHGT_CM]
(R,D) [goto CWGT_LB]
(empty) [go to CHGT_CM]
Question ID: CHS.021_02.000

Instrument Variable Name: CHGT_CM
QuestionText:
* Enter centimeters.
Child
000-241
Blank
0-241 centimeters
Blank
UniverseText: Sample children 12+ whose weight will be entered in metric, and who entered "0-2" for height in meters or left it
empty.
SkipInstructions:
(0-241) [goto CWGT_LB]
[if CHGT_M = (empty, 0) and CHGT_CM = (empty, 0) go to ERR1_CHGT_CM]
[if CHGT_M = 2 and CHGT_CM GT 41 goto ERR2_CHGT_CM]
[if CHGT_M = 1 and CHGT_CM GT141 goto ERR2_CHGT_CM]


Question ID: CHS.022_00.000

Instrument Variable Name: CWGT_LB
QuestionText:
How much does [fill: S.C. name] weigh now (without shoes)?
* Enter 'M' to record metric measurements.
* Enter '500' if 500 pounds or more.
001-500 1-500 pounds
997 Refused
999 Don't know
M Metric
UniverseText: Sample children 12+
SkipInstructions:
(1-500,R,D) [if age ge (2) goto ADD_1, else, goto ADD1_2]
(M) [goto CWGT_KG]
[if = (501-999) goto ERR1_CWGT_LB]
[if NE (1-999, M, R, D) goto ERR2_CWGT_KG]
Question ID: CHS.023_00.000

Instrument Variable Name: CWGT_KG
QuestionText:
* Enter weight in kilograms.
002-226 2-226 kilograms
UniverseText: Sample children 12+ whose weight will be entered in metric.
SkipInstructions:
(2-226) [if AGE ge (2) goto ADD_1; else goto ADD1_2]
[if CWGT_KG ) 226 goto ERR_CWGT_KG]


Question ID: CHS.031_02.000

Instrument Variable Name: ADD1_2
QuestionText:
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Mental Retardation?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT2
SkipInstructions:
(1,2,R,D) [goto ADD1_3]


Question ID: CHS.031_03.000

Instrument Variable Name: ADD1_3
QuestionText:
* Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Any other developmental delay?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT2
SkipInstructions:
(1,2,R,D) [goto CONDL]


Question ID: CHS.032_01.000

Instrument Variable Name: ADD_1
QuestionText:
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 2-17
SkipInstructions:
(1,2,R,D) [go to ADD_2]


Question ID: CHS.032_02.000

Instrument Variable Name: ADD_2
QuestionText:
* Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Mental Retardation?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 2-17
SkipInstructions:
(1,2,R,D) [go to ADD_3]


Question ID: CHS.032_03.000

Instrument Variable Name: ADD_3
QuestionText:
* Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Any other developmental delay?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 2-17
SkipInstructions:
(1,2,R,D) [go to CONDL]


Question ID: CHS.060_00.000

Instrument Variable Name: CONDL
QuestionText:
(book) C2 ?[F1]
Looking at this list, has a doctor or health professional ever told you that [fill: SC name] had any of these conditions?
*Read if necessary.
Down syndrome
Cerebral palsy
Muscular dystrophy
Cystic fibrosis
Sickle cell anemia
Autism
Diabetes
Arthritis
Congenital heart disease
Other heart condition
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1) [goto CONDL1] (2,R,D) [goto CPOX]
Question ID: CHS.061_00.000

Instrument Variable Name: CONDL1
QuestionText:
(book) C2 ?[F1]
Which ones?
* Enter all that apply, separate with commas.
01 Down syndrome
02 Cerebral palsy
03 Muscular dystrophy
04 Cystic fibrosis
05 Sickle cell anemia
06 Autism
07 Diabetes
08 Arthritis
09 Congenital heart disease
10 Other heart condition
UniverseText: Sample children LT18 and CONDL=1
SkipInstructions:
(1-10,R,D) [go to CPOX]
[If (0) and (1-10) go to ERR_CONDL]


Question ID: CHS.070_00.000

Instrument Variable Name: CPOX
QuestionText:
Has [fill: S.C. Name] EVER had chickenpox?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1) [go to CPOX12MO]
(2,R,D) [go to CASHMEV]


Question ID: CHS.072_00.000

Instrument Variable Name: CPOX12MO
QuestionText:
Has [fill: S.C. name] had chickenpox DURING THE PAST 12 MONTHS?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18 who have had chickenpox
SkipInstructions:
(1,2,R,D) [goto CASHMEV]


Question ID: CHS.080_00.000

Instrument Variable Name: CASHMEV
QuestionText:
Has a doctor or other health professional EVER told you that [fill: S.C. name] had asthma?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1) [go to CASSTILL]
(2,R,D) [if AGE LE 2 go to CCONDT1_1; if AGE GT2 go to CCONDT_1]


Question ID: CHS.085_00.000

Instrument Variable Name: CASSTILL
QuestionText:
Does [fill: S.C. name] still have asthma?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18 and doctor has informed that child had asthma
SkipInstructions:
(1,2,R,D) [go to CASHYR]


Question ID: CHS.090_00.000

Instrument Variable Name: CASHYR
QuestionText:
The following questions are about [fill: S.C. name]'s asthma DURING THE PAST 12 MONTHS.
DURING THE PAST 12 MONTHS, has [fill: SC name] had an episode of asthma or an asthma attack?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18 and doctor has informed that child had asthma
SkipInstructions:
(1,2,R,D) [goto CASMERYR]


Question ID: CHS.100_00.000

Instrument Variable Name: CASMERYR
QuestionText:
DURING THE PAST 12 MONTHS, did [fill1: S.C. name] have to visit an emergency room or urgent care center because
of [fill2: his/her] asthma?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18 and doctor has informed that child had asthma
SkipInstructions:
(1,2,R,D) [if AGE LE 2 go to CCONDT1_1,
else go to CCONDT_1]


Question ID: CHS.111_01.000

Instrument Variable Name: CCONDT1_1
QuestionText:
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Hay fever?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions:
(1,2,R,D) [go to CCONDT1_2]


Question ID: CHS.111_02.000

Instrument Variable Name: CCONDT1_2
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Any kind of respiratory allergy?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions:
(1,2,R,D) [go to CCONDT1_3]


Question ID: CHS.111_03.000

Instrument Variable Name: CCONDT1_3
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Any kind of food or digestive allergy?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions:
(1,2,R,D) [go to CCONDT1_4]


Question ID: CHS.111_04.000

Instrument Variable Name: CCONDT1_4
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Eczema or any kind of skin allergy?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions:
(1,2,R,D) [go to CCONDT1_5]


Question ID: CHS.111_05.000

Instrument Variable Name: CCONDT1_5
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Frequent or repeated diarrhea or colitis?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions:
(1,2,R,D) [go to CCONDT1_6]


Question ID: CHS.111_06.000

Instrument Variable Name: CCONDT1_6
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Anemia?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions:
(1,2,R,D) [go to CCONDT1_8]


Question ID: CHS.111_08.000

Instrument Variable Name: CCONDT1_8
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Three or more ear infections?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions:
(1,2,R,D) [go to CCONDT1_9]

Page 11 of 22


Question ID: CHS.111_09.000

Instrument Variable Name: CCONDT1_9
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Seizures?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions:
(1,2,R,D) [go to CHSTATYR]


Question ID: CHS.115_01.000

Instrument Variable Name: CCONDT_1
QuestionText:
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Hay fever?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions:
(1,2,R,D) [go to CCONDT_2]


Question ID: CHS.115_02.000

Instrument Variable Name: CCONDT_2
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Any kind of respiratory allergy?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions:
(1,2,R,D) [go to CCONDT_3]

Page 12 of 22


Question ID: CHS.115_03.000

Instrument Variable Name: CCONDT_3
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Any kind of food or digestive allergy?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions:
(1,2,R,D) [go to CCONDT_4]


Question ID: CHS.115_04.000

Instrument Variable Name: CCONDT_4
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Eczema or any kind of skin allergy?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions:
(1,2,R,D) [go to CCONDT_5]


Question ID: CHS.115_05.000

Instrument Variable Name: CCONDT_5
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Frequent or repeated diarrhea or colitis?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions:
(1,2,R,D) [go to CCONDT_6]

Page 13 of 22


Question ID: CHS.115_06.000

Instrument Variable Name: CCONDT_6
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Anemia?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions:
(1,2,R,D) [go to CCONDT_7]


Question ID: CHS.115_07.000

Instrument Variable Name: CCONDT_7
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Frequent or severe headaches, including migraines?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions:
(1,2,R,D) [go to CCONDT_8]


Question ID: CHS.115_08.000

Instrument Variable Name: CCONDT_8
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Three or more ear infections?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions:
(1,2,R,D) [go to CCONDT_9]

Page 14 of 22


Question ID: CHS.115_09.000

Instrument Variable Name: CCONDT_9
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Seizures?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions:
(1,2,R,D) [go to CCONDT_10]


Question ID: CHS.115_10.000

Instrument Variable Name: CCONDT_10
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Stuttering or stammering?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions:
(1,2,R,D) [go to CHSTATYR]


Question ID: CHS.210_00.000

Instrument Variable Name: CHSTATYR
QuestionText:
Compared with 12 months ago, would you say [fill: S.C. name]' s health is now better, worse, or about the same?
1 Better
2 Worse
3 About the same
7 Refused
9 Don't know
UniverseText: Sample children LT 18
SkipInstructions:
(1-3,R,D) [if AGE le (4) goto CCOLD2W; else goto SCHDAYR]


Question ID: CHS.220_00.000

Instrument Variable Name: SCHDAYR
QuestionText:
DURING THE PAST 12 MONTHS, that is, since [fill1: 12-month ref. date], about how many days did [fill2: S.C. name]
miss school because of illness or injury?
* Enter '996' if child did not go to school in the past 12 months.
000 None
001-240 1-240 days
996 Did not go to school
997 Refused
999 Don't know
UniverseText: Sample children 5-17
SkipInstructions:
(0-99,996,R,D) [goto CCOLD2W]
(100-240) [go to ERR1_SCHDAYR]
(241-995) [goto ERR2_SCHDAYR]


Question ID: CHS.230_00.000

Instrument Variable Name: CCOLD2W
QuestionText:


* Hand calendar card.
These next questions are about [fill: S.C name]'s recent health during the 2 weeks outlined on that calendar.


Did [fill: SC name] have a head cold or chest cold that started during those two weeks?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1,2,R,D) [goto CINTIL2W]


Question ID: CHS.240_00.000

Instrument Variable Name: CINTIL2W
QuestionText:
Did [fill: S.C. name] have a stomach or intestinal illness with vomiting or diarrhea that started during those two weeks?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1,2,R,D) [goto CHEARST1]


Question ID: CHS.250_00.000

Instrument Variable Name: CHEARST1
QuestionText:
Which statement best describes [fill: SC name]'s hearing without a hearing aid: Excellent, good, a little trouble hearing,
moderate trouble, a lot of trouble, or is [fill: SC's name] deaf?
1 Excellent
2 Good
3 A little trouble hearing
4 Moderate trouble
5 A lot of trouble
6 Deaf
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1-6,R,D) [go to CVISION]


Question ID: CHS.260_00.000

Instrument Variable Name: CVISION
QuestionText:
Does [fill1: S.C. name] have any trouble seeing [fill2: , even when wearing glasses or contact lenses]?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1) [goto CBLIND]
(2,R,D) [goto IHSPEQ]


Question ID: CHS.270_00.000

Instrument Variable Name: CBLIND
QuestionText:
Is [fill: S.C. name] blind or unable to see at all?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18 having trouble seeing
SkipInstructions:
(1,2,R,D) [goto IHSPEQ]


Question ID: CHS.290_00.000

Instrument Variable Name: IHSPEQ
QuestionText:
Does [fill1: S.C. name] have any impairment or health problem that requires [fill2: him/her] to use special equipment,
such as a brace, a wheelchair, or a hearing aid (excluding ordinary eyeglasses or corrective shoes)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1,2,R,D) [goto IHMOB]


Question ID: CHS.300_00.000

Instrument Variable Name: IHMOB
QuestionText:
Does [fill1: S.C. name] have an impairment or health problem that limits [fill2: his/her] ability to (crawl), walk, run, or
play?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1) [goto IHMOBYR]
(2,R,D) [goto PROBRX]


Question ID: CHS.310_00.000

Instrument Variable Name: IHMOBYR
QuestionText:
Is this an impairment or health problem that has lasted, or is expected to last, 12 months or longer?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18 that have limited ability to crawl, walk, run, or play
SkipInstructions:
(1,2,R,D) [goto PROBRX]


Question ID: CHS.311_00.000

Instrument Variable Name: PROBRX
QuestionText:
Does [fill1: S.C. name] NOW have a problem for which [fill2: he/she] has regularly taken prescription medication for at
least three months?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1,2,R,D) [if AGE LE (1) go to CUSUALPL;
if AGE GE (3) go to LEARND;
if AGE = (2) and SEX = (1) go to CMHAGM11_1;
if AGE = (2) and SEX = (2) go to CMHAGF11_1]


Question ID: CHS.312_00.000

Instrument Variable Name: LEARND
QuestionText:
Has a representative from a school or a health professional ever told you that [fill: S.C. name] had a learning disability?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 3-17
SkipInstructions:
(1,2,R,D) [if AGE GT 3 go to CUSUALPL;
if AGE = 3 and SEX = 1 go to CMHAGM11_1;
if AGE = 3 and SEX = 2 go to CMHAGF11_1]


Question ID: CHS.321_01.000

Instrument Variable Name: CMHAGM11_1
QuestionText:
(book) C3
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 [fill: S.C. name] DURING THE PAST TWO MONTHS.
HE:
Has been uncooperative?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
UniverseText: Male sample children 2-3
SkipInstructions:
(0-2,R,D) [go to CMHAGM11_2]
Question ID: CHS.321_02.000

Instrument Variable Name: CMHAGM11_2
QuestionText:
(book) C3
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TR UE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
HE:
Has trouble getting to sleep?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
UniverseText: Male sample children 2-3
SkipInstructions:
(0-2,R,D) [go to CMHAGM11_3]
Question ID: CHS.321_03.000

Instrument Variable Name: CMHAGM11_3
QuestionText:
(book) C3
* Read if necessary.
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 [fill: S.C. name] DURING THE PAST TWO MONTHS.
HE:
Has speech problems?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
UniverseText: Male sample children 2-3
SkipInstructions:
(0-2,R,D) [go to CMHAGM11_4]

Page 20 of 22


Question ID: CHS.321_04.000

Instrument Variable Name: CMHAGM11_4
QuestionText:
(book) C3
* Read if necessary.
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 [fill: S.C. name] DURING THE PAST TWO MONTHS.
HE:
Has been unhappy, sad, or depressed?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
UniverseText: Male sample children 2-3
SkipInstructions:
(0-2,R,D) [go to CUSUALPL]


Question ID: CHS.361_01.000

Instrument Variable Name: CMHAGF11_1
QuestionText:
(book) C3
* Read if necessary.
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 [fill: S.C. name] DURING THE PAST TWO MONTHS.
SHE:
Has temper tantrums or a hot temper?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
UniverseText: Female sample children 2-3
SkipInstructions:
(0-2,R,D) [go to CMHAGF11_2]
Question ID: CHS.361_02.000

Instrument Variable Name: CMHAGF11_2
QuestionText:
(book) C3
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TR UE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
SHE:
Has speech problems?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
UniverseText: Female sample children 2-3
SkipInstructions:
(0-2,R,D) [go to CMHAGF11_3]
Question ID: CHS.361_03.000

Instrument Variable Name: CMHAGF11_3
QuestionText:
(book) C3
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TR UE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
SHE:
Has been nervous or high-strung?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
UniverseText: Female sample children 2-3
SkipInstructions:
(0-2,R,D) [go to CMHAGF11_4]

Page 22 of 22


Question ID: CHS.361_04.000

Instrument Variable Name: CMHAGF11_4
QuestionText:
(book) C3
* Read if necessary.
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 [fill: S.C. name] DURING THE PAST TWO MONTHS.
SHE:
Has been unhappy, sad, or depressed?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
UniverseText: Female sample children 2-3
SkipInstructions:
(0-2,R,D) [go to CUSUALPL]


Child Access to Health Care and Utilization


Question ID: CAU.020_00.000

Instrument Variable Name: CUSUALPL
QuestionText:
The next questions are about health care.
Is there a place that [fill1: alias] USUALLY goes when [fill2: he/she] is sick or you need advice
about [fill3: his/her] health?
1 Yes
2 There is NO place
3 There is MORE THAN ONE place
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1,3) [go to CPLKIND]
(2,R,D) [go to CHCPLKND]


Question ID: CAU.030_00.000

Instrument Variable Name: CPLKIND
QuestionText:
[fill1: What kind of place is it / What kind of place does [fill2: alias] go to most often] - a clinic, doctor's office,
emergency room, or some other place?
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
UniverseText: Sample children LT18 with one or more usual places to go when sick or need health advice
SkipInstructions:
(1-5) [go to CHCPLROU]
(6,R,D) [go to CHCPLKND]


Question ID: CAU.035_00.000

Instrument Variable Name: CHCPLROU
QuestionText:
Is that [fill1: CPLKIND/CAU.030] the same place [fill2: alias] USUALLY goes when [fill3: he/she] needs routine or preventive care, such as a physical examination or (well baby/child) check-up?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18 with one or more usual places to go when sick or need health advice who reported that place as a clinic or health center, doctor's office or HMO, hospital emergency room, hospital outpatient department, or some other place
SkipInstructions:
(1) [go to CHCCHGYR]
(2,R,D) [go to CHCPLKND]


Question ID: CAU.037_00.000

Instrument Variable Name: CHCPLKND
QuestionText:
What kind of place does [fill1: alias] USUALLY go to when [fill2: he/she] needs routine or preventive care, such as a physical examination or (well baby/child) check-up?
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
UniverseText: Sample children LT18 who do not have a usual source of sick care; who Ref/NA/DK if have a usual source of sick care; who have a usual source of sick care but does not go to one place most often; who have a usual source of sick care but Ref/NA/DK what kind of place; who have a usual source of sick care, but it is not same place as usual source of routine/preventive care; who have a usual source of sick care but Ref/NA/DK if it is same place as usual source of routine/preventive care.
SkipInstructions:
(0-6,R,D) [ if CUSUALPL=2,R,D goto CHCDLYR_1; else goto CHCCHGYR]


Question ID: CAU.040_00.000

Instrument Variable Name: CHCCHGYR
QuestionText:
At any time IN THE PAST 12 MONTHS did you CHANGE the place(s) to which [fill: alias] USUALLY goes for healthcare?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18 with one or more place to go when sick/need advice [or who reported same place as usual source of routine/preventive care]
SkipInstructions:
(1) [go to CHCCHGHI]
(2,R,D) [goto to CHCDLYR1_1]


Question ID: CAU.050_00.000

Instrument Variable Name: CHCCHGHI
QuestionText:
Was this change for a reason related to health insurance?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18 that have changed their usual place of health care in the past 12 months
SkipInstructions:
(1,2,R,D) [goto CHCDLYR1_1]

Page 3 of 16


Question ID: CAU.080_01.000

Instrument Variable Name: CHCDLYR1_1
QuestionText:
There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the following reasons IN THE PAST 12 MONTHS...
You couldn't get through on the telephone.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1,2,R,D) [goto CHCDLYR1_2]


Question ID: CAU.080_02.000

Instrument Variable Name: CHCDLYR1_2
QuestionText:
* Read if necessary.
There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the
following reasons IN THE PAST 12 MONTHS...
You couldn't get an appointment for [fill: alias] soon enough.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1,2,R,D) [goto CHCDLYR1_3]


Question ID: CAU.080_03.000

Instrument Variable Name: CHCDLYR1_3
QuestionText:
* Read if necessary.
There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the following reasons IN THE PAST 12 MONTHS...
Once you get there, [fill: alias] has to wait too long to see the doctor.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1,2,R,D) [goto CHCDLYR1_4]


Question ID: CAU.080_04.000

Instrument Variable Name: CHCDLYR1_4
QuestionText:
* Read if necessary.
There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the following reasons IN THE PAST 12 MONTHS...
The (clinic/doctor's office) wasn't open when you could get there.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1,2,R,D) [goto CHCDLYR1_5]


Question ID: CAU.080_05.000

Instrument Variable Name: CHCDLYR1_5
QuestionText:
* Read if necessary.
There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the following reasons IN THE PAST 12 MONTHS...
You didn't have transportation.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1,2,R,D) [if AGE GE (2) goto CHCAFYR1_1; else goto CHCAFYR]


Question ID: CAU.130_00.000

Instrument Variable Name: CHCAFYR
QuestionText:
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't get it because you couldn't afford it...
Prescription medicines?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT2
SkipInstructions:
(1,2,R,D) [if AGE LT1 goto CHCSYR1_2; else goto CDENLONG]
Question ID: CAU.135_01.000

Instrument Variable Name: CHCAFYR1_1
QuestionText:
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't get it because you couldn't afford it...
Prescription medicines?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 2
SkipInstructions:
(1,2,R,D) [goto CHCAFYR1_2]


Question ID: CAU.135_02.000

Instrument Variable Name: CHCAFYR1_2
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't get it because you couldn't afford it...
Mental health care or counseling?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 2
SkipInstructions:
(1,2,R,D) [goto CHCAFYR1_3]


Question ID: CAU.135_03.000

Instrument Variable Name: CHCAFYR1_3
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't get it because you couldn't afford it...
Dental care (including check-ups)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 2
SkipInstructions:
(1,2,R,D) [goto CHCAFYR1_4]


Question ID: CAU.135_04.000

Instrument Variable Name: CHCAFYR1_4
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't get it because you couldn't afford it...
Eyeglasses?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 2
SkipInstructions:
(1,2,R,D) [goto CDENLONG]


Question ID: CAU.160_00.000

Instrument Variable Name: CDENLONG
QuestionText:
(book) C4
About how long has it been since [fill: alias] last saw a dentist? Include all types of dentists, such as orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists.
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
9 Don't know
UniverseText: Sample children GE 1
SkipInstructions:
(0-5,R,D) [if AGE GE (2) goto CHCSYR_1; else go to CHCSYR1_2]


Question ID: CAU.170_01.000

Instrument Variable Name: CHCSYR1_2
QuestionText:
DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], has anyone in the family seen or talked to any of the following health care providers about [fill2: alias]'s health?
An optometrist, ophthalmologist, or eye doctor (someone who prescribes eyeglasses)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT2
SkipInstructions:
(1,2,R,D) [goto CHCSYR1_3]


Question ID: CAU.170_02.000

Instrument Variable Name: CHCSYR1_3
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], has anyone in the family seen or talked to any of the following health care providers about [fill2: alias]'s health?
A foot doctor?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT2
SkipInstructions:
(1,2,R,D) [goto CHCSYR1_5]


Question ID: CAU.170_03.000

Instrument Variable Name: CHCSYR1_5
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], has anyone in the family seen or talked to any of the following health care providers about [fill2: alias]'s health?
A physical therapist, speech therapist, respiratory therapist, audiologist, or occupational therapist?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT2
SkipInstructions:
(1,2,R,D) [goto CHCSYR1_6]


Question ID: CAU.170_04.000

Instrument Variable Name: CHCSYR1_6
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], has anyone in the family seen or talked to any of the following health care providers about [fill2: alias]'s health?
A nurse practitioner, physician assistant or midwife?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT2
SkipInstructions:
(1,2,R,D) [goto CHCSYR8_1]

Page 8 of 16


Question ID: CAU.175_01.000

Instrument Variable Name: CHCSYR_1
QuestionText:
DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], have you seen or talked to any of the
following health care providers about [fill2: alias]'s health?
A mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 2
SkipInstructions:
(1,2,R,D) [goto CHCSYR_2]


Question ID: CAU.175_02.000

Instrument Variable Name: CHCSYR_2
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], have you seen or talked to any of the
following health care providers about [fill2: alias]'s health?
An optometrist, ophthalmologist, or eye doctor (someone who prescribes eyeglasses)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 2
SkipInstructions:
(1,2,R,D) [goto CHCSYR_3]


Question ID: CAU.175_03.000

Instrument Variable Name: CHCSYR_3
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], have you seen or talked to any of the following health care providers about [fill2: alias]'s health?
A foot doctor?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 2
SkipInstructions:
(1,2,R,D) [goto CHCSYR_4]

Page 9 of 16


Question ID: CAU.175_04.000

Instrument Variable Name: CHCSYR_4
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], have you seen or talked to any of the following health care providers about [fill2: alias]'s health?
A chiropractor?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 2
SkipInstructions:
(1,2,R,D) [goto CHCSYR_5]


Question ID: CAU.175_05.000

Instrument Variable Name: CHCSYR_5
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], have you seen or talked to any of the
following health care providers about [fill2: alias]'s health?
A physical therapist, speech therapist, respiratory therapist, audiologist, or occupational therapist?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 2
SkipInstructions:
(1,2,R,D) [goto CHCSYR_6]


Question ID: CAU.175_06.000

Instrument Variable Name: CHCSYR_6
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], have you seen or talked to any of the
following health care providers about [fill2: alias]'s health?
A nurse practitioner, physician assistant or midwife?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 2
SkipInstructions:
(1,2,R,D) [if SEX eq (2) and AGE GE 15 goto CHCSYR7; else goto CHCSYR8_1]


Question ID: CAU.230_00.000

Instrument Variable Name: CHCSYR7
QuestionText:
DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], have you seen or talked to a doctor who specializes in women's health (an obstetrician/gynecologist) about [fill2: alias]'s health?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 15 who are female
SkipInstructions:
(1,2,R,D) [goto CHCSYR8_1]


Question ID: CAU.240_01.000

Instrument Variable Name: CHCSYR8_1
QuestionText:
DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], have you seen or talked to the following about [fill2: alias]'s health?
A medical doctor who specializes in a particular medical disease or problem (fill3:other than obstetrician/ gynecologist, psychiatrist or ophthalmologist? /fill4: other than psychiatrist or ophthalmologist)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1,2,R,D) [goto CHCSYR8_2]


Question ID: CAU.240_02.000

Instrument Variable Name: CHCSYR8_2
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], have you seen or talked to the following about [fill2: alias]'s health?
A general doctor who treats a variety of illnesses (a doctor in general practice, pediatrics, family medicine, or internal medicine)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1) [goto CHCSYR10]
(2,R,D) [goto CHPEXYR]


Question ID: CAU.260_00.000

Instrument Variable Name: CHCSYR10
QuestionText:
Does that doctor treat children and adults (a doctor in general practice or family medicine)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18 who have seen or talked to a general doctor during the past 12 months
SkipInstructions:
(1,2,R,D) [goto CHCSYREM]


Question ID: CAU.265_00.000

Instrument Variable Name: CHCSYREM
QuestionText:
Did you see or talk to this general doctor because of an emotional or behavioral problem that [fill1: alias] may have?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18 who have seen a general doctor in the past 12 months
SkipInstructions:
(1,2,R,D) [goto CHPEXYR]


Question ID: CAU.270_00.000

Instrument Variable Name: CHPEXYR
QuestionText:
DURING THE PAST 12 MONTHS, did [fill1: alias] receive a well-child check-up, that is a general check-up, when [fill2: he/she] was not sick or injured?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1,2,R,D) [goto CHERNOYR]

Page 12 of 16


Question ID: CAU.280_00.000

Instrument Variable Name: CHERNOYR
QuestionText:
DURING THE PAST 12 MONTHS, HOW MANY TIMES has [fill1: alias] gone to a HOSPITAL EMERGENCY ROOM about [fill2: his/her] health? (This includes emergency room visits that resulted in a hospital admission.)
00 None
01 1
02 2-3
03 4-5
04 6-7
05 8-9
06 10-12
07 13-15
08 16 or more
97 Refused
99 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(0-8,R,D) [goto CHCHYR]


Question ID: CAU.290_00.000

Instrument Variable Name: CHCHYR
QuestionText:
DURING THE PAST 12 MONTHS, did [fill1: alias] receive care AT HOME from a nurse or other health care professional?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1) [goto CHCHMOYR]
(2,R,D) [goto CHCNOYR]


Question ID: CAU.300_00.000

Instrument Variable Name: CHCHMOYR
QuestionText:
DURING THE PAST 12 MONTHS, how many months did [fill: alias] receive care AT HOME from a health care professional?
01-12 1-12 months
97 Refused
99 Don't know
UniverseText: Sample children LT18 that have received home care from health professional during the past 12 months
SkipInstructions:
(01-12,R,D) [goto CHCHNOYR]

Page 13 of 16


Question ID: CAU.310_00.000

Instrument Variable Name: CHCHNOYR
QuestionText:
What was the total number of home visits received for [fill1: alias] during [fill2: that month/those months]?
01 1
02 2-3
03 4-5
04 6-7
05 8-9
06 10-12
07 13-15
08 16 or more
97 Refused
99 Don't know
UniverseText: Sample children LT18 that have received home care from health professional during the past 12 months
SkipInstructions:
(1-8,R,D) [goto CHCNOYR]


Question ID: CAU.320_00.000

Instrument Variable Name: CHCNOYR
QuestionText:
DURING THE PAST 12 MONTHS, HOW MANY TIMES has [fill1: alias] seen a doctor or other health care professional about [fill2: his/her] health at A DOCTOR'S OFFICE, A CLINIC, OR SOME OTHER PLACE? Do not include times [fill1: alias] was hospitalized overnight, visits to hospital emergency rooms, home visits, dental visits or telephone calls.
00 None
01 1
02 2-3
03 4-5
04 6-7
05 8-9
06 10-12
07 13-15
08 16 or more
97 Refused
99 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1-8,R,D) [goto CSRGYR]


Question ID: CAU.330_00.000

Instrument Variable Name: CSRGYR
QuestionText:
DURING THE PAST 12 MONTHS has [fill1: alias] had SURGERY or other surgical procedures either as an inpatient or outpatient?
* Read if necessary.
This includes both major surgery and minor procedures such as setting bones or removing growths.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1) [goto CSRGNOYR]
(2,R,D) [goto CMDLONG]


Question ID: CAU.340_00.000

Instrument Variable Name: CSRGNOYR
QuestionText:
Including any times you may have already told me about, HOW MANY DIFFERENT TIMES has [fill1: alias] had surgery DURING THE PAST 12 MONTHS?
* Enter '95' for 95 or more times.
01-94 1-94 times
95 95+ times
97 Refused
99 Don't know
UniverseText: Sample children LT18 that have undergone surgery during the past 12 months
SkipInstructions:
(1-10,R,D) [goto CMDLONG]
(11-95) [goto ERR_CMDLONG]


Question ID: CAU.345_00.000

Instrument Variable Name: CMDLONG
QuestionText:
(book) C4
About how long has it been since anyone in the family last saw or talked to a doctor or other health care professional about [fill1: alias]'s health? Include doctors seen while [fill2: he/she] was a patient in a hospital.
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
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(0-5, D, R) [if AGE 14-17 goto CSUN1HR;
else if AGE=4-13 goto CMHCOPY;
else goto CH1N1_1]

Page 15 of 16


Question ID: CAU.347_00.010

Instrument Variable Name: CSUN1HR
QuestionText:
Now, we are going to ask you about [fill1: SC name]'s skin's reaction to the sun. After several months of not being in the sun very much, if [fill1: SC name] went out in the sun for an hour without sunscreen, a hat, or protective clothing, which one of these best describes what would happen to [fill1: SC name]'s skin? (*Read choices 1-5 only.)
*Read if necessary: Even if [fill1: SC name] did not go out in the sun, what would happen if [fill1: SC name] did? Use the most recent experience. If none, then think about the past.
*By "sunburn" we mean even a small part of [fill1: SC name]'s skin turns red or hurts for 12 hours or more.
01 Get a severe sunburn with blisters
02 Have a moderate sunburn with peeling
03 Burn mildly with some or no darkening/tanning
04 Turn darker without sunburn
05 Nothing would happen to skin
06 Do not go out in the sun
07 Other
97 Refused
99 Don't know
UniverseText: Sample children age 14-17
SkipInstructions:
(1-7,R,D) [goto CSUNTAN]


Question ID: CAU.347_00.020

Instrument Variable Name: CSUNTAN
QuestionText:
Next, consider that [fill1: SC name] was out in the sun repeatedly, such as every day for two weeks, without sunscreen, a hat, or protective clothing. Which one of these best describes what [fill1: SC name]'s skin would LOOK like? (*Read choices 1-5 only.)
*Read if necessary: Even if [fill1: SC name] did not go out in the sun, what would happen if [fill1: SC name] did? Use the most recent experience. If none, then think about the past.
*By "sunburn" we mean even a small part of [fill1: SC name]'s skin turns red or hurts for 12 hours or more.
01 Very dark or deeply tanned
02 Dark/moderately tanned
03 A little dark/mildly tanned
04 Freckled but still light skinned
05 Burned repeatedly with little or no darkening or tanning--still light skinned
06 Don't go out in the sun
07 Other
97 Refused
99 Don't know
UniverseText: Sample children age 14-17
SkipInstructions:
(1-7,R,D) [goto CNBURN]


Question ID: CAU.347_00.030

Instrument Variable Name: CNBURN
QuestionText:
DURING THE PAST 12 MONTHS, has [fill1: S.C. name] had a sunburn?
*Read if necessary: By "sunburn" we mean even a small part of [fill1: S.C. name]'s skin turns red or hurts for 12 hours or more. Also include burns from sunlamps and other indoor tanning devices.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children age 14-17
SkipInstructions:
(1,2,R,D) [goto CSNLAMP]


Question ID: CAU.350_00.010

Instrument Variable Name: CSNLAMP
QuestionText:
During the PAST 12 MONTHS, has [fill1: SC name] used any of the following indoor tanning devices - a sunlamp, sunbed, or tanning booth EVEN ONE TIME? Do NOT include a spray-on tan.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children age 14-17
SkipInstructions:
(1) [goto CSNNUM] (2,R,D) [goto CMHCOPY]


Question ID: CAU.350_00.020

Instrument Variable Name: CSNNUM
QuestionText:
During the PAST 12 MONTHS, how many times has [fill1: SC name] used the following indoor tanning devices - a sunlamp, sunbed, or tanning booth? Do NOT include times [fill1: SC name] has gotten a spray-on tan.
001-365 001-365 times
997 Refused
999 Don't know
UniverseText: Sample children 14-17 who have used an indoor tanning device in the past 12 months
SkipInstructions:
(1-99,R,D) [goto CMHCOPY]
(100-365) [goto ERR1_CSNNUM]

Page 1 of 4


Child Mental Health Brief Questionnaire

Question ID: CMB.010_00.000

Instrument Variable Name: CMHCOPY
QuestionText:
* The following statements are not to be read to the respondent. They are displayed and included here for legal reasons.
* The next 6 items contained in CMHMF_1 through CMHDIFF are included in this survey with permission as indicated below.
* 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.
* Enter 1 to Continue.
1 Enter 1 to continue
UniverseText: Sample children GE 4
SkipInstructions:
(1) [goto CMHMF_1]


Question ID: CMB.020_01.000

Instrument Variable Name: CMHMF_1
QuestionText:
(book) C7
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, or CERTAINLY TRUE for [fill1: SC name] DURING THE PAST SIX MONTHS... [fill2: He/She]
...is generally well behaved, usually does what adults request.
0 Not true
1 Somewhat true
2 Certainly true
7 Refused
9 Don't know
UniverseText: Sample children GE 4
SkipInstructions:
(1-3,D,R) [goto CMHMF_2]

Page 2 of 4


Question ID: CMB.020_02.000

Instrument Variable Name: CMHMF_2
QuestionText:
(book) C7
* Read if necessary.
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, or CERTAINLY TRUE for [fill1: SC name] DURING THE PAST SIX MONTHS...
[fill2: He/She]
...has many worries, or often seems worried.
0 Not true
1 Somewhat true
2 Certainly true
7 Refused
9 Don't know
UniverseText: Sample children GE 4
SkipInstructions:
(1-3,D,R) [goto CMHMF_3]


Question ID: CMB.020_03.000

Instrument Variable Name: CMHMF_3
QuestionText:
(book) C7
* Read if necessary.
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, or CERTAINLY TRUE for [fill1: SC name] DURING THE PAST SIX MONTHS...
[fill2: He/She]
...is often unhappy, depressed or tearful.
0 Not true
1 Somewhat true
2 Certainly true
7 Refused
9 Don't know
UniverseText: Sample children GE 4
SkipInstructions:
(1-3,D,R) [goto CMHMF_4]

Page 3 of 4


Question ID: CMB.020_04.000

Instrument Variable Name: CMHMF_4
QuestionText:
(book) C7
* Read if necessary.
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, or CERTAINLY TRUE for [fill1: SC name] DURING THE PAST SIX MONTHS...
[fill2: He/She]
...gets along better with adults than with other [fill3: children/youth].
0 Not true
1 Somewhat true
2 Certainly true
7 Refused
9 Don't know
UniverseText: Sample children GE 4
SkipInstructions:
(1-3,D,R) [goto CMHMF_5]


Question ID: CMB.020_05.000

Instrument Variable Name: CMHMF_5
QuestionText:
(book) C7
* Read if necessary.
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, or CERTAINLY TRUE for [fill1: SC name] DURING THE PAST SIX MONTHS...
[fill2: He/She]
...has good attention span, sees chores or homework through to the end.
0 Not true
1 Somewhat true
2 Certainly true
7 Refused
9 Don't know
UniverseText: Sample children GE 4
SkipInstructions:
(1-3,D,R) [goto CMHDIFF]

Page 4 of 4


Question ID: CMB.030_00.000

Instrument Variable Name: CMHDIFF
QuestionText:
(book) C8
Overall, do you think that [fill1: SC name] 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
7 Refused
9 Don't know
UniverseText: Sample children GE 4
SkipInstructions:
(1-4,R,D) [goto next section]

Page 1 of 22


Child Mental Health Services


Question ID: CMS.001_00.000

Instrument Variable Name: DIFF6M
QuestionText:
Has [fill: SC name] had any difficulties with emotions, concentration, behavior, or getting along with others DURING
THE PAST 6 MONTHS, that is since [fill month and year of 6 month reference period]?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 4-17
SkipInstructions:
(1) [goto DIFFINTF] (2,R,D) [if CMHDIFF IN('2','3','4')[goto DIFFINTF]; else [goto PRESCP6M]


Question ID: CMS.005_00.000

Instrument Variable Name: DIFFINTF
QuestionText:
DURING THE PAST 6 MONTHS, did the difficulties interfere with or limit [fill1: SC name] being able to get along in your family, in school, or in daily activities?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who have at least minor difficulties with emotions, concentration, behavior, or being able to get along with others
SkipInstructions:
(1) [goto DIFFDEG] (2,R,D) [goto PRESCP6M]


Question ID: CMS.007_00.000

Instrument Variable Name: DIFFDEG
QuestionText:
How much did these difficulties interfere with [fill: S.C. name] being able to get along in your family, in school, or in daily activities? Would you say...
*Read categories below.
1 A lot
2 Some
3 A little
4 None
7 Refused
9 Don't know
UniverseText:Sample children 4-17 whose difficulties interfere with child being able to get along in the family, school, or daily
Activities
SkipInstructions:
(1-4,R,D) [goto PRESCP6M]

Page 2 of 22


Question ID: CMS.010_00.000

Instrument Variable Name:PRESCP6M
QuestionText:
DURING THE PAST 6 MONTHS, was [fill1: S.C. name] prescribed medication or taking prescription medication for difficulties with emotions, concentration, behavior, or being able to get along with others?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 4-17
SkipInstructions:
(1) [goto PMEDPED] (2,R,D) if CMHDIFF=1,R,D and DIFF6M=2,R,D then [goto next section]; else [goto NSDUH1]


Question ID: CMS.012_01.000

Instrument Variable Name: PMEDPED
QuestionText:
Who FIRST prescribed the medication? Was it...A pediatrician or other family doctor?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who have been prescribed or have taken prescription medication in the past 6 months
SkipInstructions:
(1) if CMHDIFF=1,R,D and DIFF6M=2,R,D then [goto next section]; else [goto NSDUH1]; (2,R,D) [goto
PMEDPSY]


Question ID: CMS.012_02.000

Instrument Variable Name:PMEDPSY
QuestionText:
*Read if necessary.
Who FIRST prescribed the medication? Was it...A psychiatrist, psychologist or other mental health professional?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who were prescribed medication in the past 6 months by someone other than a pediatrician
or other family doctor
SkipInstructions:
(1) if CMHDIFF=1,R,D and DIFF6M=2,R,D then [goto next section]; else [goto NSDUH1]; (2,R,D) [goto
PMEDOTH]

Page 3 of 22


Question ID:CMS.012_03.000

Instrument Variable Name:PMEDOTH
QuestionText:
*Read if necessary.
Who FIRST prescribed the medication? Was it...Someone else?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who were prescribed medication in the past 6 months by someone other than a pediatrician, family doctor, or mental health professional
SkipInstructions:
(1) [goto PMEDSP]; (2,R,D) if CMHDIFF=1,R,D and DIFF6M=2,R,D then [goto next section]; else [goto NSDUH1]

Question ID:CMS.012_04.000

Instrument Variable Name:PMEDSP
QuestionText:
*Enter the person who prescribed the medication.
7 Refused
9 Don't know
Verbatim Verbatim
UniverseText:Sample children 4-17 who were prescribed medication in the past 6 months by someone other than a pediatrician, family doctor, or mental health professional
SkipInstructions:
(allow 20,R,D) if CMHDIFF=1,R,D and DIFF6M=2,R,D then [goto next section]; else [goto NSDUH1]


Question ID:CMS.013_00.000

Instrument Variable Name:NSDUH1
QuestionText:
Sometimes students get treatment or counseling through the school system for DIFFICULTIES WITH emotions, concentration, behavior, or being able to get along with others. This counseling is often provided by school social
workers, school psychologists, school nurses, school counselors, or school speech, occupational or physical therapists.
1 Continue
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration, behavior, or being able to get along in the past 6 months
SkipInstructions:
(1) [goto NSDUH2]
Question ID:CMS.014_00.000

Instrument Variable Name:NSDUH2
QuestionText:
DURING THE PAST 6 MONTHS, did [fill: S.C. name] receive any treatment or counseling FROM A SCHOOL SOCIAL WORKER, PSYCHOLOGIST, NURSE, COUNSELOR, OR SPEECH, OCCUPATIONAL OR PHYSICAL THERAPIST?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration, behavior, or being able to get along in the past 6 months
SkipInstructions:
(1,2,R,D) [goto NSDUH3]


Question ID:CMS.015_00.000

Instrument Variable Name:NSDUH3
QuestionText:
At any time DURING THE PAST 6 MONTHS did [fill1: S.C. name] attend a school for students with difficulties with emotions, concentration, behavior, or being able to get along with others?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration, behavior, or being able to get along in the past 6 months
SkipInstructions:
(1,2,R,D) [goto NSDUH4]


Question ID:CMS.016_00.000

Instrument Variable Name:NSDUH4
QuestionText:
Regular schools sometimes provide programs for students with difficulties with emotions, concentration, behavior, or being able to get along with others.
DURING THE PAST 6 MONTHS, did [fill1: S.C. name] participate in a school program that was just for students with these kinds of difficulties?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration, behavior, or being able to get along in the past 6 months
SkipInstructions:
(1) [goto NSDUH5] (2,R,D) if age 4-6 [goto TRETWHR1]; else [goto TRETWHR2]

Page 5 of 22


Question ID:CMS.017_00.000

Instrument Variable Name:NSDUH5
QuestionText:
Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
1 School teacher
2 Special Ed teacher
3 School counselor, psychologist, nurse or social worker
4 School speech, occupational or physical therapist
5 Other school official
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who participated in a special school program for these difficulties
SkipInstructions:
(1-5,R,D) age 4-6 [goto TRETWHR1]; else [goto TRETWHR2]


Question ID:CMS.020_01.000

Instrument Variable Name:TRETWHR1
QuestionText:
Now I'd like to ask about places where children and adolescents receive treatment or counseling for difficulties with emotions, concentration, behavior, or being able to get along with others.
DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
At daycare, child care, or play group?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-6 who had at least minor difficulties
SkipInstructions:
(1) [goto TRETWHO1] (2,R,D) [goto TRETWHR2]

Page 6 of 22


Question ID:CMS.020_02.000

Instrument Variable Name:TRETWHO1
QuestionText:
(book) C9
Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
01 School counselor, school nurse or school social worker
02 Speech, occupational or physical therapist
03 Psychiatrist, psychologist, social worker, psychiatric nurse
04 Pediatrician or family doctor
05 Acupuncturist, massage therapist, chiropractor
06 Religious or spiritual counselor
07 Probation or juvenile corrections officer or court counselor
08 Other
97 Refused
99 Don't know
UniverseText:Sample children 4-6 who received counseling at daycare, child care, or play group
SkipInstructions:
(1-7,R,D) [goto TRETWHR2] (8) [goto TRTWHRS1]

Question ID:CMS.020_03.000

Instrument Variable Name:TRTWHRS1
QuestionText:
*Specify the other source of treatment or counseling at daycare, child care, or play group.
97 Refused
99 Don't know
Verbatim Verbatim
UniverseText:Sample children 4-6 who received counseling or treatment from other source
SkipInstructions:
(allow 20,R,D) [goto TRETWHR2]


Question ID:CMS.021_01.000

Instrument Variable Name:TRETWHR2
QuestionText:
[fill2: Now I'd like to ask about places where children and adolescents receive treatment or counseling for difficulties
with emotions, concentration, behavior, or being able to get along with others.]
DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
In an office, clinic or center in your community?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who had at least minor difficulties
SkipInstructions:
(1) [goto TRETWHO2] (2,R,D) [goto TRETWHR3]

Page 7 of 22


Question ID:CMS.021_02.000

Instrument Variable Name:TRETWHO2
QuestionText:
(book) C9Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
01 School counselor, school nurse or school social worker
02 Speech, occupational or physical therapist
03 Psychiatrist, psychologist, social worker, psychiatric nurse
04 Pediatrician or family doctor
05 Acupuncturist, massage therapist, chiropractor
06 Religious or spiritual counselor
07 Probation or juvenile corrections officer or court counselor
08 Other
UniverseText:Sample children 4-17 who received counseling at an office, clinic or community center
SkipInstructions:
(1-7,R,D) [goto TRETWHR3] (8) [goto TRTWHRS2]

Question ID:CMS.021_03.000

Instrument Variable Name:TRTWHRS2
QuestionText:
*Specify the other source of treatment or counseling provided at an office, clinic or community center.
97 Refused
99 Don't know
Verbatim Verbatim
UniverseText:Sample children 4-17 who received counseling or treatment from other source
SkipInstructions:
(allow 20,R,D) [goto TRETWHR3]


Question ID:CMS.022_01.000

Instrument Variable Name:TRETWHR3
QuestionText:
DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
In your home, for example, from a visiting teacher or counselor?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who had at least minor difficulties
SkipInstructions:
(1) [goto TRETWHO3] (2,R,D) [goto TRETWHR4]

Page 8 of 22


Question ID:CMS.022_02.000

Instrument Variable Name:TRETWHO3
QuestionText:
(book) C9
Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
01 School counselor, school nurse or school social worker
02 Speech, occupational or physical therapist
03 Psychiatrist, psychologist, social worker, psychiatric nurse
04 Pediatrician or family doctor
05 Acupuncturist, massage therapist, chiropractor
06 Religious or spiritual counselor
07 Probation or juvenile corrections officer or court counselor
08 Other
UniverseText:Sample children 4-17 who received counseling at home from visiting teacher or counselor
SkipInstructions:
(1-7,R,D) [goto TRETWHR4] (8) [goto TRTWHRS3]

Question ID:CMS.022_03.000

Instrument Variable Name:TRTWHRS3
QuestionText:
*Specify the other source of treatment or counseling provided in the home.
7 Refused
9 Don't know
Verbatim Verbatim
UniverseText:Sample children 4-17 who received counseling or treatment from other source
SkipInstructions:
(allow 20,R,D) [goto TRETWHR4]


Question ID:CMS.023_01.000

Instrument Variable Name:TRETWHR4
QuestionText:
DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
In a hospital emergency room, crisis center, or emergency shelter?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who had at least minor difficulties
SkipInstructions:
(1) [goto TRETWHO4] (2,R,D) [goto TRETWHR5]

Page 9 of 22


Question ID:CMS.023_02.000

Instrument Variable Name:TRETWHO4
QuestionText:
(book) C9 Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
01 School counselor, school nurse or school social worker
02 Speech, occupational or physical therapist
03 Psychiatrist, psychologist, social worker, psychiatric nurse
04 Pediatrician or family doctor
05 Acupuncturist, massage therapist, chiropractor
06 Religious or spiritual counselor
07 Probation or juvenile corrections officer or court counselor
08 Other
UniverseText:Sample children 4-17 who received counseling at hospital/ER/crisis center/shelter
SkipInstructions:
(1-7,R,D) [goto TRETWHR5] (8) [goto TRTWHRS4]

Question ID:CMS.023_03.000

Instrument Variable Name:TRTWHRS4
QuestionText:
*Specify the other source of treatment or counseling provided in in hospital/ER/shelter.
7 Refused
9 Don't know
Verbatim Verbatim
UniverseText:Sample children 4-17 who received counseling or treatment from other source
SkipInstructions:
(allow 20,R,D) [goto TRETWHR5]


Question ID:CMS.024_01.000

Instrument Variable Name:TRETWHR5
QuestionText:
DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
At a day treatment program in a hospital or community?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who had at least minor difficulties
SkipInstructions:
(1) [goto TRETWHO5] (2,R,D) [goto TRETWHR6]


Question ID:CMS.024_02.000

Instrument Variable Name:TRETWHO5
QuestionText:
(book) C9Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
01 School counselor, school nurse or school social worker
02 Speech, occupational or physical therapist
03 Psychiatrist, psychologist, social worker, psychiatric nurse
04 Pediatrician or family doctor
05 Acupuncturist, massage therapist, chiropractor
06 Religious or spiritual counselor
07 Probation or juvenile corrections officer or court counselor
08 Other
UniverseText:Sample children 4-17 who received counseling at day treatment program in a hospital or community
SkipInstructions:
(1-7,R,D) [goto TRETWHR6] (8) [goto TRTWHRS5]

Question ID:CMS.024_03.000

Instrument Variable Name:TRTWHRS5
QuestionText:
*Specify the other source of treatment or counseling provided at day treatment program.
7 Refused
9 Don't know
Verbatim Verbatim
UniverseText:Sample children 4-17 who received counseling or treatment from other source
SkipInstructions:
(allow 20,R,D) [goto TRETWHR6]


Question ID:CMS.025_01.000

Instrument Variable Name:TRETWHR6
QuestionText:
DURING THE PAST 6 MONTHS, did [fill1: SC name] receive treatment or counseling for these difficulties...
Any other place?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who had at least minor difficulties
SkipInstructions:
(1) [goto TRETWHO6] (2,R,D) [goto OVERNT6M]

Page 11 of 22


Question ID:CMS.025_02.000

Instrument Variable Name:TRETWHO6
QuestionText:
(book) C9Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
01 School counselor, school nurse or school social worker
02 Speech, occupational or physical therapist
03 Psychiatrist, psychologist, social worker, psychiatric nurse
04 Pediatrician or family doctor
05 Acupuncturist, massage therapist, chiropractor
06 Religious or spiritual counselor
07 Probation or juvenile corrections officer or court counselor
08 Other
UniverseText:Sample children 4-17 who received counseling at another place
SkipInstructions:
(1-7,R,D) [goto OVERNT6M] (8) [goto TRTWHRS6]

Question ID:CMS.025_03.000

Instrument Variable Name:TRTWHRS6
QuestionText:
*Specify the other source of treatment or counseling provided at other place.
7 Refused
9 Don't know
Verbatim Verbatim
UniverseText:Sample children 4-17 who received counseling or treatment from other source
SkipInstructions:
(allow 20,R,D) [goto OVERNT6M]


Question ID:CMS.050_00.000

Instrument Variable Name:OVERNT6M
QuestionText:
DURING THE PAST 6 MONTHS, did [fill: S.C. name] stay overnight or longer in a hospital, any type of group home, any type of juvenile detention center, sometimes called juvie, or juvenile hall, youth prisons, training school or jail, foster care home, or another special type of school to receive counseling or treatment for these difficulties?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration, behavior, or being able to get along in the past 6 months
SkipInstructions:
(1) [goto OVERWHCH] (2,R,D) [goto SH1]

Page 12 of 22


Question ID:CMS.060_00.000

Instrument Variable Name:OVERWHCH
QuestionText:
Which one?
*Read list if necessary.
*Enter all that apply, separate with commas.
01 Hospital
02 Residential treatment center
03 Foster care or therapeutic foster care home
04 In any type of juvenile detention center, sometimes called "juvie", prison or jail
05 Group home
06 Homeless Shelter
07 In another place
97 Refused
99 Don't know
UniverseText:Sample children 4-17 who stayed overnight in a hospital or other overnight location for difficulties
SkipInstructions:
(1-7,R,D) [goto SH1]


Question ID:CMS.070_00.000

Instrument Variable Name:SH1
QuestionText:
DURING THE PAST 6 MONTHS, did [fill1: S.C. name] take part in a self-help group for children and youth with these difficulties?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration, behavior, or being able to get along in the past 6 months
SkipInstructions:
(1,2,R,D) [goto SH2]


Question ID:CMS.080_00.000

Instrument Variable Name:SH2
QuestionText:
DURING THE PAST 6 MONTHS, did [fill1: S.C. name] use the Internet to seek treatment or counseling for these difficulties?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration,behavior, or being able to get along in the past 6 months
SkipInstructions:
(1,2,R,D) [goto CASEM6M]

Page 13 of 22


Question ID:CMS.100_00.000

Instrument Variable Name:CASEM6M
QuestionText:
Parents and caregivers sometimes get help from people sometimes called case managers or care coordinators who help to find or organize treatment for children's difficulties with emotions, concentration, behavior, or being able to get along with others.
*Read if necessary: This type of help is sometimes called care coordination or case management. People or agencies that do this work might also help you develop a service plan, contact providers for you, and provide support to you in getting the help your child or adolescent needs.
DURING THE PAST 6 MONTHS, did you or [fill1: S.C. name] receive this type of help from any individual or agency?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration, behavior, or being able to get along in the past 6 months
SkipInstructions:
(1) [goto CASEMWHO] (2,R,D) [goto TRPAYPHI]


Question ID:CMS.110_00.000

Instrument Variable Name:CASEMWHO
QuestionText:
Who provides help arranging or coordinating [fill1: S.C. name]'s care?
*Enter the MAIN answer.
01 Child welfare/social services/family and child services agency
02 School or educational system
03 Mental health agency
04 Private mental health professional
05 Juvenile justice agency or court system
06 Private insurance service
07 Family or friend08Pediatrician or other family doctor
09 Family or youth advocacy groups
10 Other
97 Refused
99 Don't know
UniverseText:Sample children 4-17 who received help from case managers/care coordinators in the past 6 months
SkipInstructions:
(1-10,R,D) [goto TRPAYPHI]

Page 14 of 22


Question ID:CMS.120_01.000

Instrument Variable Name:TRPAYPHI
QuestionText:
I'm going to read a list of ways that treatment and counseling get paid for. Please tell me who pays for [fill1: S.C. name]'s treatment or counseling.
Private health insurance, such as insurance that comes with a job?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration, behavior, or being able to get along in the past 6 months and had some type of treatment or counseling
SkipInstructions:
(1,2,R,D) [goto TRPAYSCH]


Question ID:CMS.120_02.000

Instrument Variable Name:TRPAYSCH
QuestionText:
*Read if necessary: Please tell me who pays for [fill1: S.C. name]'s treatment or counseling.
School system?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration, behavior, or being able to get along in the past 6 months and had some type of treatment or counseling
SkipInstructions:
(1,2,R,D) [goto TRPAYSLF]


Question ID:CMS.120_03.000

Instrument Variable Name:TRPAYSLF
QuestionText:
*Read if necessary: Please tell me who pays for [fill1: S.C. name]'s treatment or counseling.
You or your family (sometimes called out of pocket or co-payment)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration, behavior, or being able to get along in the past 6 months and had some type of treatment or counseling
SkipInstructions:
(1,2,R,D) [goto TRPAYMED]

Page 15 of 22


Question ID:CMS.120_04.000

Instrument Variable Name:TRPAYMED
QuestionText:
(Book) F14*Read if necessary: Please tell me who pays for [fill1: S.C. name]'s treatment or counseling.
Medicaid?
*Read if necessary: In this State it is also called *(Refer to flashcard F14 for state Medicaid names).
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration, behavior, or being able to get along in the past 6 months and had some type of treatment or counseling
SkipInstructions:
(1,2,R,D) [goto TRPAYCHP]


Question ID:CMS.120_05.000

Instrument Variable Name:TRPAYCHP
QuestionText:
*Read if necessary: Please tell me who pays for [fill1: S.C. name]'s treatment or counseling.
[fill2: A state SCHIP/CHIP program?/ [STNAME1]]?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration, behavior, or being able to get along in the past 6 months and had some type of treatment or counseling
SkipInstructions:
(1,2,R,D) [goto TRPAYMIL]


Question ID:CMS.120_06.000

Instrument Variable Name:TRPAYMIL
QuestionText:
*Read if necessary: Please tell me who pays for [fill1: S.C. name]'s treatment or counseling.
Military health care?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration, behavior, or being able to get along in the past 6 months and had some type of treatment or counseling
SkipInstructions:
(1,2,R,D) [goto TRPAYSHP]

Page 16 of 22


Question ID:CMS.120_07.000

Instrument Variable Name:TRPAYSHP
QuestionText:
*Read if necessary: Please tell me who pays for [fill1: S.C. name]'s treatment or counseling.
Some other state or county sponsored health plan, Medicare or other government program?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration, behavior, or being able to get along in the past 6 months and had some type of treatment or counseling
SkipInstructions:
(1) [goto TRPAYSP] (2,R,D) [goto TRPAYIHS]

Question ID:CMS.120_08.000

Instrument Variable Name:TRPAYSP
QuestionText:
*Enter the name of the state sponsored health plan, Medicare, or other government program.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who paid for treatment with a state sponsored health plan, etc.
SkipInstructions:
(allow 20) [goto TRPAYIHS]


Question ID:CMS.120_09.000

Instrument Variable Name:TRPAYIHS
QuestionText:
*Read if necessary: Please tell me who pays for [fill1: S.C. name]'s treatment or counseling.
Indian Health Service?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration, behavior, or being able to get along in the past 6 months and had some type of treatment or counseling
SkipInstructions:
(1,2,R,D) [goto TRPAYOTH]

Page 17 of 22


Question ID:CMS.120_10.000

Instrument Variable Name:TRPAYOTH
QuestionText:
*Read if necessary: Please tell me who pays for [fill1: S.C. name]'s treatment or counseling.
Some other source?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration, behavior, or being able to get along in the past 6 months and had some type of treatment or counseling
SkipInstructions:
(1) [goto TRPAYOTS];
(2,R,D) if TRPAYPHI=2,R,D and TRPAYSCH=2,R,D and TRPAYSLF=2,R,D and TRPAYMED=2,R,D and
TRPAYCHP=2,R,D and TRPAYMIL=2,R,D and TRPAYSHP=2,R,D and TRPAYIHS=2,R,D and
TRPAYOTH=2,R,D [goto TRETFREE]; else [goto TRETNEED]

Question ID:CMS.120_11.000

Instrument Variable Name:TRPAYOTS
QuestionText:
*Enter the name of the other source.
7 Refused
9 Don't know
Verbatim Verbatim
UniverseText:Sample children 4-17 who paid for treatment with some other source
SkipInstructions:
(allow 20) [goto TRETNEED]


Question ID:CMS.120_12.000

Instrument Variable Name:TRETFREE
QuestionText:
Was ALL OF THE treatment or counseling [fill1: S.C. name] RECEIVED free?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who did not pay for treatment
SkipInstructions:
(1,2,R,D)[goto TRETNEED]

Page 18 of 22


Question ID:CMS.150_00.000
Instrument Variable Name:TRETNEED
QuestionText:

DURING THE PAST 6 MONTHS, has [fill1: S.C. name] needed treatment or counseling for difficulties with emotions, concentration, behavior or being able to get along WITH OTHERS but didn't get it?
1 Not true
2 Somewhat true
3 Certainly true
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties with emotions, concentration, behavior, or being able to get along in the past 6 months
SkipInstructions:
(1) [goto NTRTCOST] (2,R,D) [goto next section]


Question ID:CMS.150_01.000

Instrument Variable Name:NTRTCOST
QuestionText:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
Help was too expensive?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but
didn't get it in the past 6 months
SkipInstructions:
(1,2,R,D) [goto NTRTLOC]


Question ID:CMS.150_02.000

Instrument Variable Name:NTRTLOC
QuestionText:
*Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You didn't know where to go?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but didn't get it in the past 6 months
SkipInstructions:
(1,2,R,D) [goto NTRTNEXP]

Page 19 of 22


Question ID:CMS.150_03.000

Instrument Variable Name:NTRTNEXP
QuestionText:
*Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You had a negative experience with professionals?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but didn't get it in the past 6 months
SkipInstructions:
(1,2,R,D) [goto NTRTFEAR]


Question ID:CMS.150_04.000

Instrument Variable Name:NTRTFEAR
QuestionText:
*Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You are afraid or you don't like professionals?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but didn't get it in the past 6 months
SkipInstructions:
(1,2,R,D) [goto NTRTLOSE]


Question ID:CMS.150_05.000

Instrument Variable Name:NTRTLOSE
QuestionText:
*Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You were afraid [fill1: S.C. name] would be taken from your home or that you would lose your parental rights or custody?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but didn't get it in the past 6 months
SkipInstructions:
(1,2,R,D) [goto NTRTSAY]

Page 20 of 22


Question ID:CMS.150_06.000

Instrument Variable Name:NTRTSAY
QuestionText:
*Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You were afraid of what your family or friends would say?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but didn't get it in the past 6 months
SkipInstructions:
(1,2,R,D) [goto NTRTWAIT]


Question ID:CMS.150_07.000

Instrument Variable Name:NTRTWAIT
QuestionText:
*Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You had to wait a long time for an appointment?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but didn't get it in the past 6 months
SkipInstructions:
(1,2,R,D) [goto NTRTTRAN]


Question ID:CMS.150_08.000

Instrument Variable Name:NTRTTRAN
QuestionText:
*Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
You had no way to get there?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but didn't get it in the past 6 months
SkipInstructions:
(1,2,R,D) [goto NTRTINCV]

Page 21 of 22


Question ID:CMS.150_09.000

Instrument Variable Name:NTRTINCV
QuestionText:
*Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
Services were too inconvenient to use?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but didn't get it in the past 6 months
SkipInstructions:
(1,2,R,D) [goto NTRTFAR]


Question ID:CMS.150_10.000

Instrument Variable Name:NTRTFAR
QuestionText:
*Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
Services were too far away?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but didn't get it in the past 6 months
SkipInstructions:
(1,2,R,D) [goto NTRTCHNO]


Question ID:CMS.150_11.000

Instrument Variable Name:NTRTCHNO
QuestionText:
*Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
[fill1: S.C. name] did not want to go?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but didn't get it in the past 6 months
SkipInstructions:
(1,2,R,D) [goto NTRTOTH]

Page 22 of 22


Question ID:CMS.150_12.000

Instrument Variable Name:NTRTOTH
QuestionText:
*Read lead-in if necessary:
Please tell me if any of these reasons kept [fill1: S.C. name] from getting treatment or counseling.
Some other reason?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but didn't get it in the past 6 months
SkipInstructions:
(1) [goto NTRTSPEC] (2,R,D) [goto next section]

Question ID:CMS.150_13.000

Instrument Variable Name:NTRTSPEC
QuestionText:
*Enter other reason for not getting treatment or counseling.
7 Refused
9 Don't know
Verbatim Verbatim
UniverseText:Sample children 4-17 who currently have or have had at least minor difficulties and who needed treatment but didn't get it in the past 6 months
SkipInstructions:
(allow 20,R,D) [goto next section]


Child Influenza Immunization


Question ID: CFI.005_00.010

Instrument Variable Name: CH1N1_1
QuestionText:
This question was removed from the instrument in August 2010.
There are currently two kinds of flu vaccines available, the seasonal flu vaccine, and the 2009 H1N1 flu vaccine. I will first ask you questions about the vaccine for H1N1 flu, which is sometimes called swine flu or pandemic flu, and then ask you questions about the seasonal flu.
Since October 2009, has {SC name} had a H1N1 flu vaccination? There are two types of H1N1 flu vaccinations. One is
a shot and the other is a spray, mist, or drop in the nose.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample Child LE 17 years
SkipInstructions:
(1) [goto CH1N1_2] (2,R,D) [goto CSHFLUYR]


Question ID: CFI.005_00.010.

Instrument Variable Name: CH1N1_1
QuestionText:
This question was added to the instrument in August 2010.
During the past 12 months, several kinds of flu vaccines have been available. I will ask you about {S.C. name's} most recent flu vaccinations.
DURING THE PAST 12 MONTHS, has {SC name} had a flu vaccination? A flu vaccination is usually given in the fall and protects against influenza for the flu season.
*Read if necessary: {fill: SC name}'s most recent flu vaccination could have been the new 2010-2011 flu vaccine
available starting this fall, or either of the two types available last season, one called "seasonal" and the other called
"H1N1" or "swine" flu vaccine.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample Child LE 17 years
SkipInstructions:
(1) [goto CH1N1_2]
(2,R,D) IF AGE='8-17' [goto CHP.CHPVHRD];
else [goto SCSSN4]


Question ID: CFI.005_00.020

Instrument Variable Name: CH1N1_2
QuestionText:
This question was removed from the instrument in August 2010.
How many of these H1N1 vaccinations has {S.C. name} received?
1 1 vaccination or dose
2 2 or more vaccination doses
7 Refused
9 Don't know
UniverseText: Sample Child LE 17 years who have had an H1N1 vaccine dose
SkipInstructions:
(1,2) [goto CH1N1_3M] (R,D) [goto CSHFLUYR]


Question ID: CFI.005_00.020.

Instrument Variable Name: CH1N1_2
QuestionText:
This question was added to the instrument in August 2010.
How many vaccinations has {S.C. name} received?
1 1 vaccination or dose
2 2 or more vaccination doses
7 Refused
9 Don't know
UniverseText: Sample Child LE 17 years who have had a flu vaccine dose
SkipInstructions:
(1,2) [goto CH1N1_3M]
(R,D) IF AGE='8-17' [goto CHP.CHPVHRD];
else [goto SCSSN4]

Page 3 of 10


Question ID: CFI.005_00.030

Instrument Variable Name: CH1N1_3M
QuestionText:
This question was removed from the instrument in August 2010.
1 of 2
During what month and year did {S.C. name} receive {fill: his/her/his first/her first} H1N1 flu vaccine?
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
UniverseText: Sample Child LE 17 who have had one or more H1N1 vaccine doses
SkipInstructions:
(1-12,D) [ goto CH1N1_4Y] (R) [goto CH1N1_5]


Question ID: CFI.005_00.030.

Instrument Variable Name: CH1N1_3M
QuestionText:
This question was added to the instrument in August 2010.
1 of2
During what month and year did {S.C. name} receive {fill: his/her} most recent flu vaccine?
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
UniverseText: Sample Child LE 17 who have had one or more vaccine doses
SkipInstructions:
(1-12,D) [ goto CH1N1_4Y] (R) [goto CH1N1_5]

Page 4 of 10


Question ID: CFI.005_00.040

Instrument Variable Name: CH1N1_4Y
QuestionText:
This question was removed from the instrument in August 2010.
2 of 2
Sample Child
*Enter year of {fill: H1N1 flu vaccine/first H1N1 flu vaccine}.
Year Year
9997 Refused
9999 Don't know
UniverseText: Sample Child LE 17 years who have had one or more H1N1 vaccine doses and gave month/ don't know month of vaccine dose
SkipInstructions:
(valid year,R,D) [goto CH1N1_5]
[If CH1N1_3M and CH1N1_4Y = a future date] goto ERR1_ CH1N1_4Y]
[If CH1N1_3M and CH1N1_4Y = a date prior to birth] goto ERR2_ CH1N1_4Y]
[If CH1N1_3M and CH1N1_4Y = a date prior to October 2009] goto ERR3_ CH1N1_4Y]


Question ID: CFI.005_00.040.

Instrument Variable Name: CH1N1_4Y
QuestionText:
This question was added to the instrument in August 2010.
2 of 2
Sample Child
*Enter year of most recent flu vaccine.
Year Year
9997 Refused
9999 Don't know
UniverseText: Sample Child LE 17 years who have had one or more vaccine doses and gave month/don't know month of vaccine dose
SkipInstructions:
(valid year,R,D) [goto CH1N1_5]
[If CH1N1_3M and CH1N1_4Y = a future date] goto ERR1_ CH1N1_4Y]
[If CH1N1_3M and CH1N1_4Y = a date prior to birth] goto ERR2_ CH1N1_4Y]
[If CH1N1_3M and CH1N1_4Y = a date prior to 12 months ago] goto ERR3_ CH1N1_4Y]


Question ID: CFI.005_00.050

Instrument Variable Name: CH1N1_5
QuestionText:
This question was removed from the instrument in August 2010.
Was this a shot, or was it a vaccine sprayed in the nose?
1 Flu shot
2 Flu nasal spray (spray, mist or drop in nose)
7 Refused
9 Don't know
UniverseText: Sample Child LE 17 years who have had one or more H1N1 vaccine doses
SkipInstructions:
(1-2,R,D) if CH1N1_2=1 [goto CSHFLUYR]; else if CH1N1_2=2 [goto CH1N1_6M]


Question ID: CFI.005_00.050.

Instrument Variable Name: CH1N1_5
QuestionText:
This question was added to the instrument in August 2010.
Was this a shot, or was it a vaccine sprayed in the nose?
*Read if necessary: The flu nasal spray is called FluMist(trademark).
1 Flu shot
2 Flu nasal spray (spray, mist or drop in nose)
7 Refused
9 Don't know
UniverseText: Sample Child LE 17 years who have had one or more vaccine doses
SkipInstructions:
(1-2,R,D) IF (CH1N1_2=1 and AGE='8-17') [goto CHP.CHPVHRD];
else if (CH1N1_2=1 and AGE LE 7) [go to SCSSN4];
else if CH1N1_2=2 [goto CH1N1_6M]


Question ID: CFI.005_00.060

Instrument Variable Name: CH1N1_6M
QuestionText:
This question was removed from the instrument in August 2010.
1 of2
During what month and year did {S.C. name} receive {fill: his/her} second H1N1 flu vaccine?
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
UniverseText: Sample Child LE 17 years who have had more than one H1N1 vaccine doses
SkipInstructions:
(1-12,D) [ goto CH1N1_7Y] (R) [goto CH1N1_8]

Page 6 of 10


Question ID: CFI.005_00.060.

Instrument Variable Name: CH1N1_6M
QuestionText:
This question was added to the instrument in August 2010.
1 of2
During what month and year did {S.C. name} receive {fill: his/her} next most recent flu vaccine?
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
UniverseText: Sample Child LE 17 years who have had more than one vaccine doses
SkipInstructions:
(1-12,D) [ goto CH1N1_7Y] (R) [goto CH1N1_8]


Question ID: CFI.005_00.070

Instrument Variable Name: CH1N1_7Y
QuestionText:
This question was removed from the instrument in August 2010.
2 of 2
*Enter year of second H1N1 flu vaccine.
Year Year
9997 Refused
9999 Don't know
UniverseText: Sample Child LE 17 years who have had more than one H1N1 vaccine doses and gave month/don't know month of vaccine dose
SkipInstructions:
(valid year,R,D) [goto CH1N1_8]
[If CH1N1_6M and CH1N1_7Y = a future date] goto ERR1_ CH1N1_7Y]
[If CH1N1_6M and CH1N1_7Y = a date prior to birth] goto ERR2_ CH1N1_7Y]
[If CH1N1_6M and CH1N1_7Y = a date prior to October 2009] goto ERR3_ CH1N1_7Y]

Page 7 of 10


Question ID: CFI.005_00.070.

Instrument Variable Name: CH1N1_7Y
QuestionText:
This question was added to the instrument in August 2010.
2 of 2
*Enter year of next most recent flu vaccine.
Year Year
9997 Refused
9999 Don't know
UniverseText: Sample Child LE 17 years who have had more than one vaccine doses and gave month/don't know month of vaccine dose
SkipInstructions:
(valid year,R,D) [goto CH1N1_8]
[If CH1N1_6M and CH1N1_7Y = a future date] goto ERR1_ CH1N1_7Y]
[If CH1N1_6M and CH1N1_7Y = a date prior to birth] goto ERR2_ CH1N1_7Y]
[If CH1N1_6M and CH1N1_7Y = a date prior to 12 months ago] goto ERR3_ CH1N1_7Y]


Question ID: CFI.005_00.080

Instrument Variable Name: CH1N1_8
QuestionText:
This question was removed from the instrument in August 2010.
Was this a shot, or was it a vaccine sprayed in the nose?
1 Flu shot
2 Flu nasal spray (spray, mist or drop in nose)
7 Refused
9 Don't know
UniverseText: Sample Child LE 17 years who have more than one H1N1 vaccine dose
SkipInstructions:
(1-2,R,D) [goto CSHFLUYR]


Question ID: CFI.005_00.080.

Instrument Variable Name: CH1N1_8
QuestionText:
This question was added to the instrument in August 2010.
Was this a shot, or was it a vaccine sprayed in the nose?
*Read if necessary: The flu nasal spray is called FluMist(trademark).
1 Flu shot
2 Flu nasal spray (spray, mist or drop in nose)
7 Refused
9 Don't know
UniverseText: Sample Child LE 17 years who have more than one vaccine dose
SkipInstructions:
(1-2,R,D) IF AGE='8-17' [goto CHP.CHPVHRD];
else IF AGE LE 7 [go to SCSSN4]

Page 8 of 10


Question ID: CFI.010_00.000

Instrument Variable Name: CSHFLUYR
QuestionText:
This question was removed from the instrument in August 2010.
Now I'm going to ask you about the seasonal flu vaccine.
DURING THE PAST 12 MONTHS, has {fill1: SC name} had a seasonal flu shot? A seasonal flu shot is usually given in the fall and protects against influenza for the flu season.
* Read if necessary.
A flu shot is injected in the arm. Do not include an influenza vaccine srayed in the nose.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1) [goto CSHFLU_M] (2,R,D) [ goto CSPFLUYR ]


Question ID: CFI.015_01.000

Instrument Variable Name: CSHFLU_M
QuestionText:
This question was removed from the instrument in August 2010.
1 of 2
During what month and year did {fill1: SC name} receive {fill2: his/her} most recent seasonal flu shot?
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
UniverseText: Sample children LT18 who have had a flu shot
SkipInstructions:
(1-12,D) [ goto CSHFLU_Y] (R) [goto CSPFLUYR]

Page 9 of 10


Question ID: CFI.015_02.000

Instrument Variable Name: CSHFLU_Y
QuestionText:
This question was removed from the instrument in August 2010.
2 of2
*Enter year of most recent seasonal flu shot.
Year Year
9997 Refused
9999 Don't know
UniverseText: Sample children LT18 who gave a month for their last flu shot or who didn't know the month
SkipInstructions:
(valid year,R,D) [goto CSPFLUYR]
[If CSHFLU_M and CSHFLU_Y = a future date] goto ERR1_CSHFLU_Y]
[If CSHFLU_M and CSHFLU_Y = a date prior to birth] goto ERR2_CSHFLU_Y]
[If CSHFLU_M and CSHFLU_Y = a date prior to 12 months ago] goto ERR3_CSHFLU_Y]


Question ID: CFI.020_00.000

Instrument Variable Name: CSPFLUYR
QuestionText:
This question was removed from the instrument in August 2010.
DURING THE PAST 12 MONTHS, has {fill1: SC name} had a seasonal flu vaccine sprayed in {fill2: his/her} nose by a doctor or other health professional? This vaccine is usually given in the fall and protects against influenza for the flu season.
* Read if necessary.
This influenza vaccine is called FluMist (trademark).
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1) [goto CSPFLU_M] (2,R,D) [goto next section]
[if CSHFLUYR =1 and CSPFLUYR=1] goto ERR_CSPFLUYR

Page 10 of 10


Question ID: CFI.025_01.000

Instrument Variable Name: CSPFLU_M
QuestionText:
This question was removed from the instrument in August 2010.
1 of 2
During what month and year did {fill1: SC name} receive [fill: his/her] most recent seasonal flu nasal spray?
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
UniverseText: Sample children LT18 who have had a flu nasal vaccine
SkipInstructions:
(1-12,D) [ goto CSPFLU_Y] (R) [goto next section]


Question ID: CFI.025_02.000

Instrument Variable Name: CSPFLU_Y
QuestionText:
This question was removed from the instrument in August 2010.
2 of 2
*Enter year of most recent seasonal flu nasal spray.
Year Year
9997 Refused
9999 Don't know
UniverseText: Sample children LT18 who gave a month for their flu nasal vaccine or who didn't know the month
SkipInstructions:
(valid year,R,D) [goto next section]
[If CSPFLU_M and CSPFLU_Y = a future date] goto ERR1_CSPFLU_Y]
[If CSPFLU_M and CSPFLU_Y = a date prior to birth] goto ERR2_CSPFLU_Y]
[If CSPFLU_M and CSPFLU_Y = a date prior to 12 months ago] goto ERR3_CSPFLU_Y]

Page 1 of 3


Child HPV


Question ID: CHP.010_00.000

Instrument Variable Name: CHPVHRD
QuestionText:
Two vaccines, or shots, to prevent the human papillomavirus (pap-uh-LOW-muh-vi-rus) or HPV infection are available in the United States. Both vaccines prevent cervical cancer and one also prevents genital warts. The two HPV vaccines are sometimes called CERVARIX® or GARDASIL®. Before this survey, have you ever heard of HPV vaccines or shots?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 8+
SkipInstructions:
(1,2,R,D) goto CSHTHPV


Question ID: CHP.020_00.000

Instrument Variable Name: CSHTHPV
QuestionText:
Did [fill: SC name] ever receive an HPV shot?
1 Yes
2 No
3 Doctor refused when asked
7 Refused
9 Don't know
UniverseText: Sample children 8+
SkipInstructions:
(1) goto CSHHPVDS
(2,R,D) IF SEX=2 goto CHPVREC;
else if SEX=1 goto next section.
(3) goto next section


Question ID: CHP.030_00.000

Instrument Variable Name: CSHHPVDS
QuestionText:
How many HPV shots did [fill: SC name] receive?
* Enter '96' for all shots.
01-50 1-50 shots
96 All shots
97 Refused
99 Don't know
UniverseText: Sample children 8+ who have received the HPV vaccine or shot
SkipInstructions:
(1-50,96,R,D) IF SEX=2 goto HPVAGE;
else if SEX=1 goto next section.
(51-95) goto ERR_CSHHPVDS

Page 2 of 3


Question ID: CHP.035_00.000

Instrument Variable Name: HPVAGE
QuestionText:
How old was [fill1: SC name] when she received her first HPV shot?
08-17 8-17 years
97 Refused
99 Don't know
UniverseText: Female sample children 8+ who have received the HPV vaccine or shot
SkipInstructions:
(1-17,R,D) goto next section


Question ID: CHP.040_00.000

Instrument Variable Name: CHPVREC
QuestionText:
If [fill1: SC name]' s doctor recommended the HPV vaccine, would you have her get it?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Female sample children 8+ who have not received an HPV vaccine or shot or refused to say/sreceived vaccine or shot aid don't know if
SkipInstructions:
(1) goto CHPVCOST
(2,D) goto CHPVNOT
(R) goto next section


Question ID: CHP.050_00.000

Instrument Variable Name: CHPVNOT
QuestionText:
What is the MAIN reason you would NOT want [fill: SC name] to get the vaccine?
01 Does not need vaccine
02 Not sexually active
03 Too expensive
04 Too young for vaccine
05 Doctor didn't recommend it
06 Worried about safety of vaccine
07 Don't know where to get vaccine
08 My spouse/family member is against it
09 Don't know enough about vaccine
10 Already has HPV
11 Other
97 Refused
99 Don't know
UniverseText: Female sample children 8+ who would not get the HPV vaccine if her doctor recommended itknow to this information or who said don't
SkipInstructions:
(1,2,4-11,R,D) goto next section
(3) goto CHPVLOC

Page 3 of 3


Question ID: CHP.060_00.000

Instrument Variable Name: CHPVCOST
QuestionText:
The cost of the vaccine may be about $360-$500. Would you have [fill: SC name] get the vaccine if you had to pay this amount?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Female sample children age 8+ whose respondent would be interested in getting the HPV vaccine for her
SkipInstructions:
(1,R,D) goto next section
(2) goto CHPVLOC


Question ID: CHP.070_00.000

Instrument Variable Name: CHPVLOC
QuestionText:
If [fill1: SC name] could get the vaccine free or at a much lower cost, would you have her get it?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Female sample children age 8+ whose respondent would not pay $360-$500 for the HPV vaccine or for whom the main reason not to get the vaccine was because it was too expensive
SkipInstructions:
(1,2,R,D) goto next section