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2011 NHIS Questionnaire - Sample Child
Child Identification
Document Version Date: 30-May-12


Question ID: CID.001_00.000

Instrument Variable Name: CURRES : Sample Child
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 CUR RES = 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
Hard Edit: ERR_CURRES
* You have selected a non-selectable person.
* Please correct.


Question ID: CID.010_00.000

Instrument Variable Name: CSPAVAIL : Sample Child
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
ERR_CSPAVAIL
Hard Edit:
* You have selected a non-selectable person.
* Please correct.


Question ID: CID.030_00.000

Instrument Variable Name: CSRELTIV : Sample Child
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]

Question ID: CID.040_00.000

Instrument Variable Name: CSPVERF_S : Sample Child
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.
SkipInstructions:
(1) goto CSPVERF_A
(2) goto NEWSEX

Question ID: CID.041_00.000

Instrument Variable Name: NEWSEX : Sample Child
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.
SkipInstructions:
(1,2) store NEWSEX in SEX
goto ERR_NEWSEX
reset CSPVERF_S
goto CSPVERF_S
ERR_NEWSEX
Hard Edit:
* The gender will now be changed to [fill: NEWSEX].
goto CSPVERF_S (as the default goto)

Question ID: CID.042_00.000

Instrument Variable Name: CSPVERF_A : Sample Child
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
SkipInstructions:
(1) goto CSPVERF_D
(2) goto NEWAGE

Question ID: CID.043_00.000

Instrument Variable Name: NEWAGE : Sample Child
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
ERR_NEWAGE
Hard Edit:
*Age of [fill1: ALIAS of Sample Child] remains [fill2: Age of Sample Child] years old.
goto CSPVERF_A (whether suppressed or not)

Question ID: CID.044_00.000

Instrument Variable Name: CSPVERF_D : Sample Child
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

Question ID: CID.046_01.000

Instrument Variable Name: NEWDOB_M : Sample Child
QuestionText:
1 of 3
What is [fill: ALIAS of Sample Child]'s birthday?
*Enter month of birth.
1 January
10 October
11 November
12 December
2 February
3 March
4 April
5 May
6 June
7 July
8 August
9 September
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 : Sample Child
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
ERR_NEWDOB_D
Hard Edit:
* [fill2: NEWDOB_D] is not a valid day for [fill3: NEWDOB_M].
* Please correct.

Question ID: CID.046_03.000

Instrument Variable Name: NEWDOB_Y : Sample Child
QuestionText:
3 of 3
1880-2020
* Enter year of birth.
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
ERR1_NEWDOB_Y
Hard Edit:
*Future date invalid: [fill2: (NEWDOB_M) (NEWDOB_D), (NEWDOB_Y)]
*Please correct.
goto NEWDOB_M (whether suppressed or not)
ERR2_NEWDOB_Y
*Not a valid day: [fill2: (NEWDOB_M) (NEWDOB_D), (NEWDOB_Y)]
*Please correct.
goto NEWDOB_M (whether suppressed or not)
ERR3_NEWDOB_Y
*DOB of [fill1: ALIAS of Sample Child] remains [fill3: (DOBM) (DOBD), (DOBY)]
goto CSPVERF_A
ERR4_NEWDOB_Y
*Data mismatched. Please fix Age or Birthday.
goto CSPVERF_A (whether suppressed or not)

Child Health Status and Limitations


Question ID: CHS.010_01.000

Instrument Variable Name: BWGT_LB : Sample Child
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]
ERR2_BWGT_LB
Hard Edit:
* Only "1-15" or "M" or "Don't know/Refused" allowed in this field.
* Please correct.
ERR1_BWGT_LB
Soft Edit:
* [fill: BWGT_LB] is an unusually high number.
* Please verify.
Question ID: CHS.010_02.000

Instrument Variable Name: BWGT_OZ : Sample Child
QuestionText:
* Enter ounces.
00-15 0-15 ounces
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]
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1) [goto CONDL1] (2,R,D) [goto CPOX]
Question ID: CHS.011_00.000

Instrument Variable Name: BWGT_GR : Sample Child
QuestionText:
* Enter weight in grams.
0500 500 grams or less
0501-6899 501-6899 grams
6900 6900+ grams
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]
ERR_BWGT_GR
Soft Edit:
* [fill1: BWGT_GR] is an unusually high number (equal to [fill2] pounds, [fill3] ounces).
* Please verify.


Question ID: CHS.020_01.000

Instrument Variable Name: CHGT_FT : Sample Child
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]
ERR_CHGT_FT
Hard Edit:
* Only "0-7" or "M" or "Don't know/Refused" allowed in this field.
* Please correct.
Question ID: CHS.020_02.000

Instrument Variable Name: CHGT_IN : Sample Child
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]
ERR1_CHGT_IN
Hard Edit:
* Must enter an answer in at least the inches item.
* Please correct.
ERR2_CHGT_IN
* Number of inches exceeds maximum allowed.
* Please correct.
ERR3_CHGT_IN
Soft Edit:
* Please verify that the height was entered correctly. Probe only if necessary.
Question ID: CHS.021_01.000

Instrument Variable Name: CHGT_M : Sample Child
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
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 : Sample Child
QuestionText:
* Enter centimeters.
000-241 0-241 centimeters
Blank 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 )141 goto ERR2_CHGT_CM]
ERR1_CHGT_CM
Hard Edit:
* Must enter an answer at least in the centimeters item.
* Please correct.
ERR2_CHGT_CM
* Total height exceeds maximum allowed.
* Please correct.
ERR3_CHGT_CM
Soft Edit:
* Please verify that the height was entered correctly. Probe only if necessary.


Question ID: CHS.022_00.000

Instrument Variable Name: CWGT_LB : Sample Child
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]
ERR1_CWGT_LB
Hard Edit:
* Weight is out of range (1-500).
* Please correct.
ERR2_CWGT_LB
Soft Edit:
* Please verify that the weight was entered correctly. Probe only if necessary.
Question ID: CHS.023_00.000

Instrument Variable Name: CWGT_KG : Sample Child
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 GT 226 goto ERR_CWGT_KG]
ERR1_CWGT_KG
Hard Edit:
* Weight is out of range (2-226).
* Please correct.
ERR2_CWGT_KG
Soft Edit:
* Please verify that the weight was entered correctly. Probe only if necessary.


Question ID: CHS.031_02.000

Instrument Variable Name: ADD1_2 : Sample Child
QuestionText:
Has a doctor or health professional ever told you that [fill: S.C. name] had...
an intellectual disability, also known as 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 : Sample Child
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 : Sample Child
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 : Sample Child
QuestionText:
* Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had...
an intellectual disability, also known as 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 : Sample Child
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 : Sample Child
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/Autism spectrum disorder
Diabetes
Arthritis
Congenital heart disease
Other heart condition
1 Yes
2 No
Question ID: CHS.061_00.000

Instrument Variable Name: CONDL1 : Sample Child
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/Autism spectrum disorder
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 : Sample Child
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 : Sample Child
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 : Sample Child
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 )2 go to CCONDT_1]


Question ID: CHS.085_00.000

Instrument Variable Name: CASSTILL : Sample Child
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 : Sample Child
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 : Sample Child
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 : Sample Child
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 : Sample Child
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 : Sample Child
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 : Sample Child
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 : Sample Child
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 : Sample Child
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 : Sample Child
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]


Question ID: CHS.111_09.000

Instrument Variable Name: CCONDT1_9 : Sample Child
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 : Sample Child
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 : Sample Child
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]


Question ID: CHS.115_03.000

Instrument Variable Name: CCONDT_3 : Sample Child
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 : Sample Child
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 : Sample Child
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]


Question ID: CHS.115_06.000

Instrument Variable Name: CCONDT_6 : Sample Child
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 : Sample Child
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 : Sample Child
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]


Question ID: CHS.115_09.000

Instrument Variable Name: CCONDT_9 : Sample Child
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 : Sample Child
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 : Sample Child
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 : Sample Child
QuestionText:
DURING THE PAST 12 MONTHS, 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]
ERR2_SCHDAYR
Hard Edit:
* "241-995" days not allowed in this field.
* Please correct.
ERR1_SCHDAYR
Soft Edit:
[fill4: SCHDAYR] is an unusually large number. Did [fill2: SC name] miss [fill: SCHDAYR] days of school
because of illness or injury?
* Please verify.


Question ID: CHS.230_00.000

Instrument Variable Name: CCOLD2W : Sample Child
QuestionText:
These next questions are about [fill: SC name]'s recent health DURING THE LAST 2 WEEKS.
Did [fill: SC name] have a head cold or chest cold that started DURING THE LAST 2 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 : Sample Child
QuestionText:
Did [fill: SC name] have a stomach or intestinal illness with vomiting or diarrhea that started DURING THE LAST 2 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 : Sample Child

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 : Sample Child
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 : Sample Child
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 : Sample Child
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 : Sample Child
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 : Sample Child
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 : Sample Child
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 : Sample Child
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 : Sample Child
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 : Sample Child
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 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 : Sample Child
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]


Question ID: CHS.321_04.000

Instrument Variable Name: CMHAGM11_4 : Sample Child
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 : Sample Child
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.
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 : Sample Child
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 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 : Sample Child
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 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]


Question ID: CHS.361_04.000

Instrument Variable Name: CMHAGF11_4 : Sample Child
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]


Question ID: CAU.020_00.000

Instrument Variable Name: CUSUALPL : Sample Child
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 : Sample Child
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 : Sample Child
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 : Sample Child
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 [goto CNOUSLPL]; else if CUSUALPL=,R,D [goto CPRVTRYR]; else [goto
CHCCHGYR]


Question ID: CAU.040_00.000

Instrument Variable Name: CHCCHGYR : Sample Child
QuestionText:
At any time IN THE PAST 12 MONTHS did you CHANGE the place(s) to which [fill: alias] USUALLY goes for health care?
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 CPRVTRYR]


Question ID: CAU.050_00.000

Instrument Variable Name: CHCCHGHI : Sample Child
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 CPRVTRYR]


Question ID: CAU.050_00.010

Instrument Variable Name: CNOUSLPL : Sample Child
QuestionText:
Why doesn't [fill: alias] have a usual source of medical care?
*Enter all that apply, separate with commas.
01 Doesn't need a doctor/Haven't had any problems
02 Doesn't like/trust/believe in doctors
03 Doesn't know where to go
04 Previous doctor is not available/moved
05 Too expensive/no insurance/cost
06 Speak a different language
07 No care available/Care too far away, not convenient
08 Put it off/Didn't get around to it
09 Other
97 Refused
99 Don't know
UniverseText: Sample children LT18 who don't have a usual place of care
SkipInstructions:
(1-9,R,D)[goto CPRVTRYR]


Question ID: CAU.052_00.010

Instrument Variable Name: CPRVTRYR QuestionnaireFileName: Sample Child
QuestionText:
DURING THE PAST 12 MONTHS, did you have any trouble finding a general doctor or provider who would see [fill:alias]?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1) [goto CPRVTRFD ] (2,R,D) [goto CDRNANP]


Question ID: CAU.053_00.010

Instrument Variable Name: CPRVTRFD : Sample Child
QuestionText:
Were you able to find a general doctor or provider who could see [fill: alias]?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18 who had trouble finding a provider in the last year
SkipInstructions:
(1,2,R,D) [goto CDRNANP]


Question ID: CAU.055_00.010

Instrument Variable Name: CDRNANP : Sample Child
QuestionText:
DURING THE PAST 12 MONTHS, were you told by a doctor's office or clinic that they would not accept [fill: alias] as a new patient?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1,2,R,D)[goto CDRNAI]


Question ID: CAU.056_00.010

Instrument Variable Name: CDRNAI : Sample Child
QuestionText:
DURING THE PAST 12 MONTHS, were you told by a doctor's office or clinic that they did not accept [fill: alias]'s health care coverage?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18
SkipInstructions:
(1,2,R,D)[goto CHCDLYR_1]


Question ID: CAU.080_01.000

Instrument Variable Name: CHCDLYR1_1 : Sample Child
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 (18
SkipInstructions:
(1,2,R,D) [goto CHCDLYR1_2]


Question ID: CAU.080_02.000

Instrument Variable Name: CHCDLYR1_2 : Sample Child
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 : Sample Child
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 : Sample Child
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 : Sample Child
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 LT18SkipInstructions:
(1,2,R,D) [if AGE GE (2) goto CHCAFYR1_1; else goto CHCAFYR]


Question ID: CAU.130_00.000

Instrument Variable Name: CHCAFYR : Sample Child
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 (2
SkipInstructions:
(1,2,R,D) [goto CHCAFYRN]


Question ID: CAU.133_00.010

Instrument Variable Name: CHCAFYRN : Sample Child
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...
To see a specialist?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT2
SkipInstructions:
(1,2,R,D) [goto CHCAFYRF]


Question ID: CAU.133_00.020

Instrument Variable Name: CHCAFYRF : Sample Child
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...
Follow-up care?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT2
SkipInstructions:
(1,2,R,D) [if AGE (1 goto CHCSYR1_2; else goto CDENLONG]


Question ID: CAU.135_01.000

Instrument Variable Name: CHCAFYR1_1 : Sample Child
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 : Sample Child
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 : Sample Child
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 : Sample Child
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 CHCAFYR1_5]


Question ID: CAU.135_05.010

Instrument Variable Name: CHCAFYR1_5 : Sample Child
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...
To see a specialist?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 2
SkipInstructions:
(1,2,R,D) [goto CHCAFYR1_6]


Question ID: CAU.135_06.010

Instrument Variable Name: CHCAFYR1_6 : Sample Child
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...
Follow-up care?
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 : Sample Child
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 : Sample Child
QuestionText:
DURING THE PAST 12 MONTHS, 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 : Sample Child
QuestionText:

?[F1]

* Read if necessary.
DURING THE PAST 12 MONTHS, 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 : Sample Child
QuestionText:

?[F1]

* Read if necessary.
DURING THE PAST 12 MONTHS, 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 : Sample Child
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, 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]


Question ID: CAU.175_01.000

Instrument Variable Name: CHCSYR_1 : Sample Child
QuestionText:
DURING THE PAST 12 MONTHS, 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 : Sample Child
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, 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 : Sample Child
QuestionText:

?[F1]

* Read if necessary.
DURING THE PAST 12 MONTHS, 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]


Question ID: CAU.175_04.000

Instrument Variable Name: CHCSYR_4 : Sample Child
QuestionText:

?[F1]

Read if necessary.
DURING THE PAST 12 MONTHS, 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 : Sample Child
QuestionText:

?[F1]

* Read if necessary.
DURING THE PAST 12 MONTHS, 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 : Sample Child
QuestionText:

?[F1]

* Read if necessary.
DURING THE PAST 12 MONTHS, 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 : Sample Child
QuestionText:
?[F1]
DURING THE PAST 12 MONTHS, 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 : Sample Child
QuestionText:
DURING THE PAST 12 MONTHS, 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 : Sample Child
QuestionText:
* Read if necessary.
DURING THE PAST 12 MONTHS, 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 : Sample Child
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 : Sample Child
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 : Sample Child
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]


Question ID: CAU.280_00.000

Instrument Variable Name: CHERNOYR : Sample Child
QuestionText:
(book) C5
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,R,D) [goto CHCHYR] (1-8) [goto CERVISND]


Question ID: CAU.281_00.010

Instrument Variable Name: CERVISND : Sample Child
QuestionText:
Thinking about [fill: S.C. name]'s most recent emergency room visit, did [fill: he/she ] go to the emergency room either at night or on the weekend?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18 who had at least one ER visit in the past year
SkipInstructions:
(1,2,R,D) [go to CERHOS]


Question ID: CAU.282_00.010

Instrument Variable Name: CERHOS : Sample Child
QuestionText:
Did this emergency room visit result in a hospital admission?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18 who had at least one ER visit in the past year
SkipInstructions:
(1,R,D) [goto CHCHYR] ( 2) [go to CERREAS1]


Question ID: CAU.283_01.010

Instrument Variable Name: : Sample Child CERREAS1
QuestionText:
Tell me which of these apply to [fill: alias]'s last emergency room visit?
... [fill: He/She] didn't have another place to go
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18 who had at least one ER visit in the past year which did not result in a hospital admission
SkipInstructions:
(1,2,R,D) [goto CERREAS2]


Question ID: CAU.283_02.020

Instrument Variable Name: CERREAS2 : Sample Child
QuestionText:
*Read if necessary.
Tell me which of these apply to [fill: alias]'s last emergency room visit?
... [fill: alias]'s doctor's office or clinic was not open
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18 who had at least one ER visit in the past year which did not result in a hospital admission
SkipInstructions:
(1,2,R,D) [goto CERREAS3]


Question ID: CAU.283_03.030

Instrument Variable Name: CERREAS3 : Sample Child
QuestionText:
*Read if necessary.
Tell me which of these apply to [fill: alias]'s last emergency room visit?
... [fill: alias]'s health provider advised that [fill: he/she] go
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18 who had at least one ER visit in the past year which did not result in a hospital admission
SkipInstructions:
(1,2,R,D) [goto CERREAS4]


Question ID: CAU.283_04.040

Instrument Variable Name: CERREAS4 : Sample Child
QuestionText:
*Read if necessary.
Tell me which of these apply to [fill: alias]'s last emergency room visit?
... The problem was too serious for the doctor's office or clinic
1 Yes
2 No
7 Refused
9 Don't' know
UniverseText: Sample children LT18 who had at least one ER visit in the past year which did not result in a hospital admission
SkipInstructions:
(1,2,R,D) [goto CERREAS5]


Question ID: CAU.283_05.050

Instrument Variable Name: CERREAS5 : Sample Child
QuestionText:
*Read if necessary.
Tell me which of these apply to [fill: alias]'s last emergency room visit?
... Only a hospital could help [fill: alias]
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18 who had at least one ER visit in the past year which did not result in a hospital admission
SkipInstructions:
(1,2,R,D) [goto CERREAS6]


Question ID: CAU.283_06.060

Instrument Variable Name: : Sample Child CERREAS6
QuestionText:
*Read if necessary.
Tell me which of these apply to [fill: alias]'s last emergency room visit?
... The emergency room is [fill: alias]'s closest provider
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18 who had at least one ER visit in the past year which did not result in a hospital admission
SkipInstructions:
(1,2,R,D) [goto CERREAS7]


Question ID: CAU.283_07.070

Instrument Variable Name: CERREAS7 : Sample Child
QuestionText:
*Read if necessary.
Tell me which of these apply to [fill: alias]'s last emergency room visit?
...[fill: alias] gets most of [fill: his/her] care at the emergency room
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18 who had at least one ER visit in the past year which did not result in a hospital admission
SkipInstructions:
(1,2,R,D) [goto CERREAS8]


Question ID: CAU.283_08.080

Instrument Variable Name: CERREAS8 : Sample Child
QuestionText:
*Read if necessary.
Tell me which of these apply to [fill: alias]'s last emergency room visit?
...[fill: alias] arrived by ambulance or other emergency vehicle
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LT18 who had at least one ER visit in the past year which did not result in a hospital admission
SkipInstructions:
(1,2,R,D) [goto CHCHYR]


Question ID: CAU.290_00.000

Instrument Variable Name: CHCHYR : Sample Child
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 : Sample Child
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]


Question ID: CAU.310_00.000

Instrument Variable Name: CHCHNOYR : Sample Child
QuestionText:

(book)

C6 ?[F1]
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 : Sample Child
QuestionText:
(book) C5 [F1]
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:
(0-8,R,D) [goto CSRGYR]


Question ID: CAU.330_00.000

Instrument Variable Name: CSRGYR : Sample Child
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 : Sample Child
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]
ERR_CMDLONG
Soft Edit:
[fill2: CSRGNOYR] is an unusually large number. Did [fill1: alias] have [fill2: CSRGNOYR] surgical procedures?
*Please verify.


Question ID: CAU.345_00.000

Instrument Variable Name: CMDLONG : Sample Child
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=4-17 goto CMHCOPY; else goto CH1N1_1]

Child Mental Health Brief Questionnaire

Question ID: CMB.010_00.000

Instrument Variable Name: CMHCOPY : Sample Child
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 : Sample Child
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]


Question ID: CMB.020_02.000

Instrument Variable Name: CMHMF_2 : Sample Child
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 : Sample Child
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]


Question ID: CMB.020_04.000

Instrument Variable Name: CMHMF_4 : Sample Child
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 : Sample Child
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 4SkipInstructions:
(1-3,D,R) [goto CMHDIFF]


Question ID: CMB.030_00.000

Instrument Variable Name: CMHDIFF : Sample Child
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]

Child Mental Health Services


Question ID: CMS.001_00.000

Instrument Variable Name: DIFF6M : Sample Child
QuestionText:
Has [fill: SC name] had any difficulties with emotions, concentration, behavior, or getting along with others DURING THE PAST 6 MONTHS?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 4-17
SkipInstructions:
(1) [goto DIFFINTF] (2,R,D) [if CMHDIFF (variable name in layouts is RSCL6) IN ('2',3','4') [goto DIFFINTF]; else [goto PRESCP6M]


Question ID: CMS.005_00.000

Instrument Variable Name: DIFFINTF : Sample Child
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 DIFFLNG]


Question ID: CMS.007_00.000

Instrument Variable Name: DIFFDEG : Sample Child
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
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:
(1-3,R,D) [goto DIFFLNG]


Question ID: CMS.008_00.000

Instrument Variable Name: DIFFLNG : Sample Child
QuestionText:
How long have these difficulties been present?
1 Less than a month
2 1-5 months
3 6 to 12 months
4 Over a year
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:
(1-4,R,D) [goto PRESCP6M]


Question ID: CMS.010_00.000

Instrument Variable Name: PRESCP6M : Sample Child
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 PRESHELP] (2,R,D) if CMHDIFF=1,R,D and DIFF6M=2,R,D then [end]; else [goto NSDUH21]


Question ID: CMS.011_00.000

Instrument Variable Name: PRESHELP : Sample Child
QuestionText:
During the past 6 months, how much has this prescription medication helped [fill: S.C. name]? Would you say...
*Read categories below.
1 Not at all
2 A little
3 Some
4 A lot
7 Refused
9 Don't know
UniverseText: Sample children 4-17 have taken prescription medicine in the past 6 mos
SkipInstructions:
(1-4,R,D) [goto PMEDPED]


Question ID: CMS.012_01.000

Instrument Variable Name: PMEDPED : Sample Child
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 TRETHELP]; else [goto NSDUH21]; (2,R,D) [goto
PMEDPSY]


Question ID: CMS.012_02.000

Instrument Variable Name: PMEDPSY : Sample Child
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 TRETHELP]; else [goto NSDUH21]; (2,R,D) [goto
PMEDNEU]


Question ID: CMS.012_03.000

Instrument Variable Name: PMEDNEU : Sample Child
QuestionText:
*Read if necessary.
Who FIRST prescribed the medication? Was it
...A neurologist?
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, psychiatrist/ or other family doctor
SkipInstructions:
(1) if CMHDIFF=1,R,D and DIFF6M=2,R,D then [goto TRETHELP]; else [goto NSDUH21]; (2,R,D) [goto
PMEDOTH]


Question ID: CMS.012_04.000

Instrument Variable Name: PMEDOTH : Sample Child
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, psychiatrist or neurologist
SkipInstructions:
(1,2,R,D) if CMHDIFF=1,R,D and DIFF6M=2,R,D then [goto TRETHELP]; else [goto NSDUH21]


Question ID: CMS.014_00.000

Instrument Variable Name: NSDUH21 : Sample Child
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.
DURING THE PAST 6 MONTHS, did [fill: S.C. name] receive any treatment or
counseling FROM A SCHOOL SOCIAL WORKER, SCHOOL PSYCHOLOGIST, SCHOOL NURSE, SCHOOL COUNSELOR, SPECIAL ED TEACHER, OR SCHOOL 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 : Sample Child
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) [go to NSDUH31 (2,R,D) [go to NSDUH4]


Question ID: CMS.015_00.010

Instrument Variable Name: NSDUH31 : Sample Child
QuestionText:
Was it a day school or school where {S.C. name} stayed overnight or longer?
1 Day School
2 Overnight School
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 attend a special needs school
SkipInstructions:
(1) [goto NSDUH32] (2,R,D [got to NSDUH4]


Question ID: CMS.015_00.020

Instrument Variable Name: NSDUH32 : Sample Child
QuestionText:
Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
1 Special Ed teacher
2 Other school 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 needs day school with program for these difficulties
SkipInstructions:
(1-5,R,D) [goto NSDUH4];


Question ID: CMS.016_00.000

Instrument Variable Name: NSDUH4 : Sample Child
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]


Question ID: CMS.017_00.000

Instrument Variable Name: NSDUH5 : Sample Child
QuestionText:
Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
1 Special Ed teacher
2 Other school 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 school program for difficulties with emotions, concentration, behavior
SkipInstructions:
(1-5,R,D) age 4-6 [goto TRETWHR1]; else [goto TRETWHR2]


Question ID: CMS.020_01.000

Instrument Variable Name: TRETWHR1 : Sample Child
QuestionText:
Now I'd like to ask about places other than {S.C.name}'s school 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]


Question ID: CMS.020_02.000

Instrument Variable Name: TRETWHO1 : Sample Child
QuestionText:
(book) C9
Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
1 Pediatrician or family doctor
2 Psychiatrist, psychologist, clinical social worker or psychiatric nurse
3 Speech, occupational or physical therapist
4 Religious or spiritual counselor or advisor
5 Probation of juvenile corrections officer or court counselor
6 Other
7 Refused
9 Don't know
UniverseText: Sample children 4-6 who received counseling at daycare, child care, or play group
SkipInstructions:
(1,3-6,R,D) [goto TRETWHR2] (2) [goto TRTMHP1]


Question ID: CMS.020_03.000

Instrument Variable Name: TRTMHP1 : Sample Child
QuestionText:
You just told me [S.C. name] received treatment from a psychiatrist, psychologist, clinical social worker or psychiatric nurse. Who was this?
*Enter all that apply, separate with commas
1 Psychiatrist
2 Psychologist
3 Clinical social worker
4 Psychiatric nurse
7 Refused
9 Don't know
UniverseText: Sample children 4-6 who received counseling or treatment at daycare, child care, or play group from mental health provider
SkipInstructions:
(1-4,R,D) [goto TRETWHR2]


Question ID: CMS.021_01.000

Instrument Variable Name: TRETWHR2 : Sample Child
QuestionText:
[fill2: Now I'd like to ask about places other than {S.C. name}'s school 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]


Question ID: CMS.021_02.000

Instrument Variable Name: TRETWHO2 : Sample Child
QuestionText:
(book) C9
Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
1 Pediatrician or family doctor
2 Psychiatrist, psychologist, clinical social worker or psychiatric nurse
3 Speech, occupational or physical therapist
4 Religious or spiritual counselor or advisor
5 Probation or juvenile corrections officer or court counselor
6 Other
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who received counseling at an office, clinic or community center
SkipInstructions:
(1,3-6,R,D) [goto TRETWHR3] (2) [goto TRTMHP2]


Question ID: CMS.021_03.000

Instrument Variable Name: TRTMHP2 : Sample Child
QuestionText:
You just told me [S.C. name] received treatment from a psychiatrist, psychologist, clinical social worker or psychiatric nurse. Who was this?
*Enter all that apply, separate with commas
1 Psychiatrist
2 Psychologist
3 Clinical social worker
4 Psychiatric nurse
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who received counseling or treatment at an office, clinic or community center from mental health provider
SkipInstructions:
(1-4,R,D) [goto TRETWHR3]


Question ID: CMS.022_01.000

Instrument Variable Name: TRETWHR3 : Sample Child
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]


Question ID: CMS.022_02.000

Instrument Variable Name: TRETWHO3 : Sample Child
QuestionText:
(book) C9
Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
1 Pediatrician or family doctor
2 Psychiatrist, psychologist, clinical social worker or psychiatric nurse
3 Speech, occupational or physical therapist
4 Religious or spiritual counselor or advisor
5 Probation or juvenile corrections officer or court counselor
6 Other
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who received counseling at home from visiting teacher or counselor
SkipInstructions:
(1,3-6,R,D) [goto TRETWHR4] (2) [goto TRTMHP3]


Question ID: CMS.022_03.000

Instrument Variable Name: TRTMHP3 : Sample Child
QuestionText:
You just told me [S.C. name] received treatment from a psychiatrist, psychologist, clinical social worker or psychiatric nurse. Who was this?
*Enter all that apply, separate with commas
1 Psychiatrist
2 Psychologist
3 Clinical social worker
4 Psychiatric nurse
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who received counseling or treatment at home from mental health provider
SkipInstructions:
(1-4,R,D) [goto TRETWHR4]


Question ID: CMS.023_01.000

Instrument Variable Name: TRETWHR4 : Sample Child
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]


Question ID: CMS.023_02.000

Instrument Variable Name: TRETWHO4 : Sample Child
QuestionText:
(book) C9
Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
1 Pediatrician or family doctor
2 Psychiatrist, psychologist, clinical social worker or psychiatric nurse
3 Speech, occupational or physical therapist
4 Religious or spiritual counselor or advisor
5 Probation or juvenile corrections officer or court counselor
6 Other
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who received counseling at hospital/ER/crisis center/shelter
SkipInstructions:
(1,3-6,R,D) [goto TRETWHR5] (2) [goto TRTMHP4]


Question ID: CMS.023_03.000

Instrument Variable Name: TRTMHP4 : Sample Child
QuestionText:
You just told me [S.C. name] received treatment from a psychiatrist, psychologist, clinical social worker or psychiatric nurse. Who was this?
*Enter all that apply, separate with commas
1 Psychiatrist
2 Psychologist
3 Clinical social worker
4 Psychiatric nurse
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who received counseling or treatment at hospital/ER/crisis center/shelter from mental health provider
SkipInstructions:
(1-4,R,D) [goto TRETWHR5]


Question ID: CMS.024_01.000

Instrument Variable Name: TRETWHR5 : Sample Child
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 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 TRETWHO5] (2,R,D) [goto TRETWHR6]


Question ID: CMS.024_02.000

Instrument Variable Name: TRETWHO5 : Sample Child
QuestionText:
(book) C9
Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
1 Pediatrician or family doctor
2 Psychiatrist, psychologist, clinical social worker or psychiatric nurse
3 Speech, occupational or physical therapist
4 Religious or spiritual counselor or advisor
5 Probation or juvenile corrections officer or court counselor
6 Other
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who received counseling at day treatment program in a hospital or community
SkipInstructions:
(1,3-6,R,D) [goto TRETWHR6] (2) [goto TRTMHP5]


Question ID: CMS.024_03.000

Instrument Variable Name: TRTMHP5 : Sample Child
QuestionText:
You just told me [S.C. name] received treatment from a psychiatrist, psychologist, clinical social worker or psychiatric nurse. Who was this?
*Enter all that apply, separate with commas
1 Psychiatrist
2 Psychologist
3 Clinical social worker
4 Psychiatric nurse
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who received counseling or treatment at day treatment program in a hospital or community from mental health provider
SkipInstructions:
(1-4,R,D) [goto TRETWHR6]


Question ID: CMS.025_01.000

Instrument Variable Name: TRETWHR6 : Sample Child
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]


Question ID: CMS.025_02.000

Instrument Variable Name: TRETWHO6 : Sample Child
QuestionText:
(book) C9
Who provided the treatment or counseling?
*Enter all that apply, separate with commas.
1 Pediatrician or family doctor
2 Psychiatrist, psychologist, clinical social worker or psychiatric nurse
3 Speech, occupational or physical therapist
4 Religious or spiritual counselor or advisor
5 Probation or juvenile corrections or court counselor
6 Other
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who received counseling at another place
SkipInstructions:
(1,3-6,R,D) [goto OVERNT6M] (2) [goto TRTMHP6]


Question ID: CMS.025_03.000

Instrument Variable Name: TRTMHP6 : Sample Child
QuestionText:
You just told me [S.C. name] received treatment from a psychiatrist, psychologist, clinical social worker or psychiatric nurse. Who was this?
*Enter all that apply, separate with commas
1 Psychiatrist
2 Psychologist
3 Clinical social worker
4 Psychiatric nurse
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who received counseling or treatment at another place from mental health provider
SkipInstructions:
(1-4,R,D) [goto OVERNT6M]


Question ID: CMS.050_00.000

Instrument Variable Name: OVERNT6M : Sample Child
QuestionText:
DURING THE PAST 6 MONTHS, in addition to a school you may have told me about, 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 prison, training school or jail, foster care home, or another special type of center or shelter 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]


Question ID: CMS.060_00.000

Instrument Variable Name: OVERWHCH : Sample Child
QuestionText:
Which ones?
*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 : Sample Child
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 : Sample Child
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]


Question ID: CMS.100_00.000

Instrument Variable Name: CASEM6M : Sample Child
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) IF PRESCP6M=1 or NSDUH21=1 or NSDUH3=1 or NSDUH4=1 or TRETWHR1=1 or
TRETWHR2=1 or TRETWHR3=1 or TRETWHR4=1 or TRETWHR5=1 or TRETWHR6=1 or OVERNT6M=1
or SH1=1 or SH2=1 or CASEM6M=1 [goto TRETHELP]; else [goto TRTNEED1]


Question ID: CMS.110_00.000

Instrument Variable Name: CASEMWHO : Sample Child
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 friend
08 Pediatrician 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 TRETHELP]


Question ID: CMS.115_00.000

Instrument Variable Name: TRETHELP : Sample Child
QuestionText:
You told us that [S.C. child] has received treatment or counseling for difficulties with emotions, concentration, behavior, or being able to get along with others. During the past 6 months, how much has this treatment or counseling helped [S.C.
child]? Would you say...
* Read answer categories below.
1 Not at all
2 A little
3 Some
4 A lot
7 Refused
9 Don't know
UniverseText: Sample children 4-17 who received treatment in the past 6 months
SkipInstructions:
(1-4,R,D) if CMHDIFF=2-4 and DIFF6M=1 [goto TRPAYPHI];
else [goto next section]


Question ID: CMS.120_01.000

Instrument Variable Name: TRPAYPHI : Sample Child
QuestionText:
Next I'm going to read a list of ways that treatment and counseling get paid for. Please tell me who pays or paid for [fill1:
S.C. name]'s treatment or counseling during the past 6 months.
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 received some type of treatment or counseling in the
past 6 months
SkipInstructions:
(1,2,R,D) [goto TRPAYSCH]


Question ID: CMS.120_02.000

Instrument Variable Name: TRPAYSCH : Sample Child
QuestionText:
*Read if necessary: Please tell me who pays or paid for [fill1: S.C. name]'s treatment or counseling during the past 6 months.
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 received some type of treatment or counseling in the past 6 months
SkipInstructions:

(1,2,R,D) [goto TRPAYSLF]


Question ID: CMS.120_03.000

Instrument Variable Name: TRPAYSLF : Sample Child
QuestionText:
*Read if necessary: Please tell me who pays or paid for [fill1: S.C. name]'s treatment or counseling during the past 6 months.
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 received some type of treatment or counseling in the past 6 months
SkipInstructions:
(1,2,R,D) [goto TRPAYMED]


Question ID: CMS.120_04.000

Instrument Variable Name: TRPAYMED : Sample Child
QuestionText:
(Book) F14
*Read if necessary: Please tell me who pays or paid for [fill1: S.C. name]'s treatment or counseling during the past 6 months.
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 received some type of treatment or counseling in the past 6 months
SkipInstructions:
(1,2,R,D) [goto TRPAYCHP]


Question ID: CMS.120_05.000

Instrument Variable Name: TRPAYCHP : Sample Child
QuestionText:
*Read if necessary: Please tell me who pays or paid for [fill1: S.C. name]'s treatment or counseling during the past 6 months.
[fill2: A state CHIP/SCHIP 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 received some type of treatment or counseling in the past 6 months
SkipInstructions:
(1,2,R,D) [goto TRPAYMIL]


Question ID: CMS.120_06.000

Instrument Variable Name: TRPAYMIL : Sample Child
QuestionText:
*Read if necessary: Please tell me who pays or paid for [fill1: S.C. name]'s treatment or counseling during the past 6
months.
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 received some type of treatment or counseling in the
past 6 months
SkipInstructions:
(1,2,R,D) [goto TRPAYSHP]


Question ID: CMS.120_07.000

Instrument Variable Name: TRPAYSHP : Sample Child
QuestionText:
*Read if necessary: Please tell me who pays or paid for [fill1: S.C. name]'s treatment or counseling during the past 6 months.
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 received some type of treatment or counseling in the past 6 months
SkipInstructions:
(1,2,R,D) [goto TRPAYIHS]


Question ID: CMS.120_09.000

Instrument Variable Name: TRPAYIHS : Sample Child
QuestionText:
*Read if necessary: Please tell me who pays or paid for [fill1: S.C. name]'s treatment or counseling during the past 6 months.
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 received some type of treatment or counseling in the past 6 months
SkipInstructions:
(1,2,R,D) [goto TRPAYOTH]


Question ID: CMS.120_10.000

Instrument Variable Name: TRPAYOTH : Sample Child
QuestionText:
*Read if necessary: Please tell me who pays or paid for [fill1: S.C. name]'s treatment or counseling during the past 6 months.
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 received some type of treatment or counseling in the past 6 months
SkipInstructions:
(1,2,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 TRTNEED1]


Question ID: CMS.120_12.000

Instrument Variable Name: TRETFREE : Sample Child
QuestionText:
Was ALL OF THE treatment or counseling [fill1: S.C. name] RECEIVED during the past 6 months 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 TRTNEED1]


Question ID: CMS.150_00.000

Instrument Variable Name: TRTNEED1 : Sample Child
QuestionText:
DURING THE PAST 6 MONTHS, did [fill1: S.C. name] need treatment or counseling for these difficulties but didn't get it ?
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 NTRTCOST] (2,R,D) [goto next section]


Question ID: CMS.150_01.000

Instrument Variable Name: NTRTCOST : Sample Child
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 : Sample Child
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]


Question ID: CMS.150_03.000

Instrument Variable Name: NTRTNEXP : Sample Child
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 : Sample Child
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 : Sample Child
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]


Question ID: CMS.150_06.000

Instrument Variable Name: NTRTSAY : Sample Child
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 : Sample Child
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 : Sample Child
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]


Question ID: CMS.150_09.000

Instrument Variable Name: NTRTINCV : Sample Child
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 : Sample Child
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 : Sample Child
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]


Question ID: CMS.150_12.000

Instrument Variable Name: NTRTOTH : Sample Child
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:
(1,2,R,D) [goto next section]

Child Influenza Immunization


Question ID: CFI.005_00.010

Instrument Variable Name: CH1N1_1 : Sample Child
QuestionText:
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 last fall, or either of the two types available last season, one called "seasonal" and the other called
"H1N1" or "swine" flu vaccine.
UniverseText: Sample Child LE 17 years
SkipInstructions:
(1) [goto CH1N1_2]
(2,R,D) [goto next section]


Question ID: CFI.005_00.020

Instrument Variable Name: CH1N1_2 : Sample Child
QuestionText:
How many vaccinations has {S.C. name} received?
UniverseText: Sample Child LE 17 years who have had a flu vaccine dose
SkipInstructions:
(1,2) [goto CH1N1_3M]
(R,D) [goto next section]


Question ID: CFI.005_00.030

Instrument Variable Name: CH1N1_3M : Sample Child
QuestionText:
1 of 2
During what month and year did {S.C. name} receive {fill: his/her} most recent flu vaccine?
UniverseText: Sample Child LE 17 who have had one or more vaccine doses
SkipInstructions:
(1-12,D) [ goto CH1N1_4Y] (R) [goto CH1N1_5]
Question ID: CFI.005_00.040

Instrument Variable Name: CH1N1_4Y : Sample Child
QuestionText:
2 of 2
*Enter year of most recent flu vaccine.
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]
ERR1_ CH1N1_4Y
Hard Edit:
*Future date invalid.
ERR2_ CH1N1_4Y
*Date before birth.
ERR3_ CH1N1_4Y
*Date before 12 months ago.


Question ID: CFI.005_00.050

Instrument Variable Name: CH1N1_5 : Sample Child
QuestionText:
Was this a shot, or was it a vaccine sprayed in the nose?
*Read if necessary: The flu nasal spray is called FluMist(trademark).
UniverseText: Sample Child LE 17 years who have had one or more vaccine doses
SkipInstructions:
(1-2,R,D) IF CH1N1_2=1 [goto next section]; else if CH1N1_2=2 [goto CH1N1_6M]


Question ID: CFI.005_00.060

Instrument Variable Name: CH1N1_6M : Sample Child
QuestionText:
1 of 2
During what month and year did {S.C. name} receive {fill: his/her} next most recent flu vaccine?
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 : Sample Child
QuestionText:
2 of 2
*Enter year of next most recent flu vaccine.
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]
ERR1_ CH1N1_7Y
Hard Edit:
*Future date invalid.
ERR2_ CH1N1_7Y
*Date before birth.
ERR3_ CH1N1_7Y
*Date before 12 months ago.


Question ID: CFI.005_00.080

Instrument Variable Name: CH1N1_8 : Sample Child
QuestionText:
Was this a shot, or was it a vaccine sprayed in the nose?
*Read if necessary: The flu nasal spray is called FluMist(trademark).
UniverseText: Sample Child LE 17 years who have more than one vaccine dose
SkipInstructions:
(1-2,R,D) [goto next section]