2014 NHIS Questionnaire: Sample Child
Child Identification

Document Version Date: 28-May-15

Question ID: CID.001_00.000

instrument Variable Name: CURRES
QuestionText:

* Enter the line number of the person to whom you are speaking.

01-25 Person number of the respondent for Sample Child

UniverseText: Sample child section not started or not completed
Skipinstructions:

if CSTAT ne empty and CSTAT ne '2' THEN
if ASTAT = empty or ASTAT = '2' THEN
goto adult.aid.SADULT
elseif recontact.RCIFLAG ne '1' THEN
goto recontact.RCI_BEGIN procedure
else
goto back.OUTCOMEB1 procedure
endif
goto back.OUTCOMEB1 procedure
endif
(01-25) if this is NOT an allowable line number
goto ERR_CURRES
elseif CURRES = a line number entered in KNOWSC2
store CURRES in CSPAVAIL and CSRESP
goto CSRELTIV
elseif KNOWSC2 = 'Don't know' or 'Refused' or empty (no line numbers in KNOWSC2)
goto KNOAVAIL
else
goto CSPAVAIL
endif
Hard Edit: ERR_CURRES
* You have selected a non-selectable person.
* Please correct.

Question ID: CAU.020_00.000

instrument Variable Name: CUSUALPL
QuestionText:

The next questions are about health care.
Is there a place that [fill1: alias] USUALLY goes when [fill2: he/she] is sick or you need advice about [fill3: his/her] health?

1 Yes
2 There is NO place
3 There is MORE THAN ONE place
7 Refused
9 Don't know

UniverseText: Sample children (18
SkipInstructions:

(1,3> [go to CPLKIND]
(2,R,D) [go to CHCPLKND]

Question ID: CAU.030_00.000

instrument Variable Name: CPLKIND
QuestionText:

[fill1: What kind of place is it / What kind of place does [fill2: alias] go to most often] - a clinic, doctor's office, emergency room, or some other place?

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

UniverseText: Sample children (18 with one or more usual places to go when sick or need health advice
SkipInstructions:

(1-5> [go to CHCPLROU]
(6,R,D) [go to CHCPLKND]

Question ID: CAU.035_00.000

instrument Variable Name: CHCPLROU
QuestionText:

Is that [fill1: CPLKIND/CAU.030] the same place [fill2: alias] USUALLY goes when [fill3: he/she] needs routine or preventive care, such as a physical examination or (well baby/child) check-up?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children (18 with one or more usual places to go when sick or need health advice who reported that place as a clinic or health center, doctor's office or HMO, hospital emergency room, hospital outpatient department, or some other place
SkipInstructions:

(1) [go to CHCCHGYR]
(2,R,D) [go to CHCPLKND]

Question ID: CAU.037_00.000

instrument Variable Name: CHCPLKND
QuestionText:

What kind of place does [fill1: alias] USUALLY go to when [fill2: he/she] needs routine or preventive care, such as a physical examination or (well baby/child) check-up?

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

UniverseText: Sample children (18 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
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 (18 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
QuestionText:

Was this change for a reason related to health insurance?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children (18 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
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 (18 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
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 (18
SkipInstructions:

(1) [goto CPRVTRFD ]
(2,R,D) [goto CDRNANP]

Question ID: CAU.053_00.010

instrument Variable Name: CPRVTRFD
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 less than 18 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
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 (18
Skipinstructions:

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

Question ID: CAU.056_00.010

instrument Variable Name: CDRNAI
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 (18
SkipInstructions:

(1,2,R,D)[goto CHCDLYR_1]

Question ID: CAU.080_01.000

instrument Variable Name: CHCDLYR1_1
QuestionText:

There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the following reasons IN THE PAST 12 MONTHS...
You couldn't get through on the telephone.

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children (18
SkipInstructions:

(1,2,R,D) [goto CHCDLYR1_2]

Question ID: CAU.080_02.000

instrument Variable Name: CHCDLYR1_2
QuestionText:

* Read if necessary.
There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the following reasons IN THE PAST 12 MONTHS...
You couldn't get an appointment for [fill: alias] soon enough.

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children (18
SkipInstructions:

(1,2,R,D) [goto CHCDLYR1_3]

Question ID: CAU.080_03.000

instrument Variable Name: CHCDLYR1_3
QuestionText:

* Read if necessary.
There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the following reasons IN THE PAST 12 MONTHS...
Once you get there, [fill: alias] has to wait too long to see the doctor.

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children (18
SkipInstructions:

(1,2,R,D) [goto CHCDLYR1_4]

Question ID: CAU.080_04.000

instrument Variable Name: CHCDLYR1_4
QuestionText:

* Read if necessary.
There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the following reasons IN THE PAST 12 MONTHS...
The (clinic/doctor's office) wasn't open when you could get there.

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children (18
SkipInstructions:

(1,2,R,D) [goto CHCDLYR1_5]

Question ID: CAU.080_05.000

instrument Variable Name: CHCDLYR1_5
QuestionText:

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children (18
SkipInstructions:

(1,2,R,D) [if AGE GE (2> goto CHCAFYR1_1; else goto CHCAFYR]

Question ID: CAU.130_00.000

instrument Variable Name: CHCAFYR
QuestionText:

DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't get it because you couldn't afford it...
Prescription medicines?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children (2
SkipInstructions:

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

Question ID: CHS.010_01.000

instrument Variable Name: BWGT_LB
QuestionText:

?[F1] 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 LT 18
Skipinstructions:

(1-12) [go to BWGT_OZ]
(13-15) [go to ERR1_BWGT_LB]
(R,D) [go to CHGT_FT]
(M) [go to BWGT_GR]
[If NE (1-15, M, D, R) go to ERR2_BWGT_LB]

Hard Edit: ERR2_BWGT_LB

* Only "1-15" or "M" or "Don't know/Refused" allowed in this field.
* Please correct.

Soft Edit: ERR1_BWGT_LB

* [fill: BWGT_LB] is an unusually high number.
* Please verify.

Question ID: CHS.010_02.000

Instrument Variable Name: BWGT_OZ
QuestionText:

* Enter ounces.

00-15 0-15 ounces
97 Refused
99 Don't know
Blank Blank

UniverseText: Sample children lt 18 who have a value entered for weight in pounds.
SkipInstructions:

(0-15,R,D) [goto CHGT_FT]
[if BWGT_LB = (0-15, D, R) and BWGT_OZ = (empty) go to CHGT_FT]

Question ID: CHS.011_00.000

instrument Variable Name: BWGT_GR
QuestionText:

* Enter weight in grams.

0500 500 grams or less
0501-6899 501-6899 grams
6900 6900+ grams
9997 Refused
9999 Don't know

UniverseText: Sample children LT 18 whose birth weight will be entered in metric.
Skipinstructions:

(500-5485, R,D) [go to CHGT_FT]
(5486-6900) [go to ERR_BWGT_GR]

Soft Edit: ERR_BWGT_GR

* [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
QuestionText:

?[F1] 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) [go to CHGT_IN]
(0-7) [go to CHGT_IN]
(R,D) [go to CWGT_LB]
(M) [go to CHGT_M]
[If NE (0-7, M, D, R) go to ERR_CHGT_FT]

Hard Edit: ERR_CHGT_FT

* 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
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,R,D) If (CHGT_FT = '0', 'empty') and (CHGT_IN = '0', 'empty')
go to ERR1_CHGT_IN
elseif CHGT_FT = '1-7' and CHGT_IN ge '12'
go to ERR2_CHGT_IN

elseif (SEX = '1' and
AGE = '12' and (CHTINCH lt '53' or CHTINCH gt '68')) or
AGE = '13' and (CHTINCH lt '55' or CHTINCH gt '72')) or
AGE = '14' and (CHTINCH lt '58' or CHTINCH gt '73')) or
AGE = '15' and (CHTINCH lt '60' or CHTINCH gt '74')) or
AGE = '16' and (CHTINCH lt '61' or CHTINCH gt '74')) or
AGE = '17' and (CHTINCH lt '62' or CHTINCH gt '75')) or

(SEX = '2' and
AGE = '12' and (CHTINCH lt '54' or CHTINCH gt '68')) or
AGE = '13' and (CHTINCH lt '55' or CHTINCH gt '69')) or
AGE = '14' and (CHTINCH lt '57' or CHTINCH gt '69')) or
AGE = '15' and (CHTINCH lt '57' or CHTINCH gt '69')) or
AGE = '16' and (CHTINCH lt '57' or CHTINCH gt '70')) or
AGE = '17' and (CHTINCH lt '57' or CHTINCH gt '69'))

go to ERR3_CHGT_IN
else
go to CWGT_LB

Hard Edit: ERR1_CHGT_IN

* Must enter an answer in at least the inches item.
* Please correct.
ERR2_CHGT_IN

* Number of inches exceeds maximum allowed.
* Please correct.

Soft Edit: ERR3_CHGT_IN

* Please verify that the height was entered correctly. Probe only if necessary.

Question ID: CHS.021_01.000

instrument Variable Name: CHGT_M
QuestionText:

* Enter height in metric.
* If the child's height is given in centimeters, press 'ENTER' at meters and enter the measure in centimeters (241 centimeters maximum).

0-2 0-2 meters
7 Refused
9 Don't know
Blank Blank

UniverseText: Sample children 12+ whose current height will be entered in metric.
Skipinstructions:

(0-2,empty) [go to CHGT_CM]
(R,D) [go to CWGT_LB]

Question ID: CHS.021_02.000

instrument Variable Name: CHGT_CM
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,R,D) If (CHGT_M = '0', 'empty') and (CHGT_CM = '0', 'empty')
go to ERR1_CHGT_CM
elseif (CHGT_M eq '2' and CHGT_CM gt '41') or (CHGT_M eq '1' and CHGT_CM gt '141')
go to ERR2_CHGT_CM

elseif (SEX = '1' and
AGE = '12' and (CHTCM lt '137' or CHTCM gt '174')) or
AGE = '13' and (CHTCM lt '140' or CHTCM gt '184')) or
AGE = '14' and (CHTCM lt '148' or CHTCM gt '186')) or
AGE = '15' and (CHTCM lt '152' or CHTCM gt '189')) or
AGE = '16' and (CHTCM lt '156' or CHTCM gt '189')) or
AGE = '17' and (CHTCM lt '157' or CHTCM gt '192')) or

(SEX = '2' and
AGE = '12' and (CHTCM lt '138' or CHTCM gt '173')) or
AGE = '13' and (CHTCM lt '141' or CHTCM gt '176')) or
AGE = '14' and (CHTCM lt '145' or CHTCM gt '176')) or
AGE = '15' and (CHTCM lt '145' or CHTCM gt '177')) or
AGE = '16' and (CHTCM lt '145' or CHTCM gt '177')) or
AGE = '17' and (CHTCM lt '145' or CHTCM gt '176'))

go to ERR3_CHGT_CM
else
go to CWGT_LB

Hard Edit: ERR1_CHGT_CM

* Must enter an answer at least in the centimeters item.
* Please correct.
ERR2_CHGT_CM

* Total height exceeds maximum allowed.
* Please correct.

Soft Edit: ERR3_CHGT_CM

* Please verify that the height was entered correctly. Probe only if necessary.

Question ID: CHS.022_00.000

instrument Variable Name: CWGT_LB
QuestionText:

How much does [fill: S.C. name] weigh now (without shoes)?
* Enter 'M' to record metric measurements.
* Enter '500' if 500 pounds or more.

001-500 1-500 pounds
997 Refused
999 Don't know
M Metric

UniverseText: Sample children 12+
Skipinstructions:

(1-500) if CWGT_LB lt '1' or CWGT_LB gt '500'
go to ERR1_CWGT_LB
elseif (SEX = '1' and
AGE = '12' and (CWGT_LB lt '62' or CWGT_LB gt '209')) or
AGE = '13' and (CWGT_LB lt '70' or CWGT_LB gt '247')) or
AGE = '14' and (CWGT_LB lt '83' or CWGT_LB gt '266')) or
AGE = '15' and (CWGT_LB lt '94' or CWGT_LB gt '267')) or
AGE = '16' and (CWGT_LB lt '98' or CWGT_LB gt '306')) or
AGE = '17' and (CWGT_LB lt '106' or CWGT_LB gt '317')) or
(SEX = '2' and
AGE = '12' and (CWGT_LB lt '62' or CWGT_LB gt '212')) or
AGE = '13' and (CWGT_LB lt '73' or CWGT_LB gt '238')) or
AGE = '14' and (CWGT_LB lt '84' or CWGT_LB gt '252')) or
AGE = '15' and (CWGT_LB lt '84' or CWGT_LB gt '238')) or
AGE = '16' and (CWGT_LB lt '87' or CWGT_LB gt '257')) or
AGE = '17' and (CWGT_LB lt '90' or CWGT_LB gt '292'))
go to ERR2_CWGT_LB
elseif CHGT_FLG = '1' and CWGT_FLG = '1' and AGE ge '2'
go to ADD_1
elseif CHGT_FLG = '1' and CWGT_FLG = '1' and AGE lt '2'
go to ADD1_2
else
calculate the BMI (Body Mass Index)
(R,D) if AGE ge '2'
go to ADD_1
else
go to ADD1_2
(M) go to CWGT_KG

Hard Edit: ERR1_CWGT_LB

* Weight is out of range (1-500).
* Please correct.

Soft Edit: ERR2_CWGT_LB

* Please verify that the weight was entered correctly. Probe only if necessary.

Question ID: CHS.023_00.000

instrument Variable Name: CWGT_KG
QuestionText:

* Enter weight in kilograms.

002-226 2-226 kilograms

UniverseText: Sample children 12+ whose weight will be entered in metric.
Skipinstructions:

(2-226) if CWGT_KG lt '2' or CWGT_KG gt '226'
go to ERR1_CWGT_KG
elseif (SEX = '1' and
AGE = '12' and (CWGT_KG = '28' or CWGT_KG = '95')) or
AGE = '13' and (CWGT_KG = '32' or CWGT_KG = '112')) or
AGE = '14' and (CWGT_KG = '38' or CWGT_KG = '121')) or
AGE = '15' and (CWGT_KG = '42' or CWGT_KG = '121')) or
AGE = '16' and (CWGT_KG = '44' or CWGT_KG = '139')) or
AGE = '17' and (CWGT_KG = '48' or CWGT_KG = '144')) or
(SEX = '2' and
AGE = '12' and (CWGT_KG = '28' or CWGT_KG = '96')) or
AGE = '13' and (CWGT_KG = '33' or CWGT_KG = '108')) or
AGE = '14' and (CWGT_KG = '38' or CWGT_KG = '114')) or
AGE = '15' and (CWGT_KG = '38' or CWGT_KG = '108')) or
AGE = '16' and (CWGT_KG = '39' or CWGT_KG = '117')) or
AGE = '17' and (CWGT_KG = '41' or CWGT_KG = '133'))
go to ERR2_CWGT_KG
elseif CHGT_FLG = '1' and CWGT_FLG = '1' and AGE ge '2'
go to ADD_1
elseif CHGT_FLG = '1' and CWGT_FLG = '1' and AGE lt '2'
go to ADD1_2
else
calculate the BMI (Body Mass Index)
(R,D) if AGE ge '2'
go to ADD_1
else
go to ADD1_2

Hard Edit: ERR1_CWGT_KG

* Weight is out of range (2-226).
* Please correct.

Soft Edit: ERR2_CWGT_KG

* Please verify that the weight was entered correctly. Probe only if necessary.

Question ID: CHS.031_02.000

instrument Variable Name: ADD1_2
QuestionText:

Has a doctor or health professional ever told you that [fill: S.C. name] had_ an intellectual disability, also known as mental retardation?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 2
Skipinstructions:

(1,2,R,D) [go to ADD1_3]

Question ID: CHS.031_03.000

instrument Variable Name: ADD1_3
QuestionText:

?[F1] * 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 LT 2
Skipinstructions:

(1,2,R,D) [go to CONDL]

Question ID: CHS.032_01.000

instrument Variable Name: ADD_1
QuestionText:

?[F1] Has a doctor or health professional ever told you that [fill: S.C. name] had_ Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD)?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children 2-17
Skipinstructions:

(1,2,R,D) [go to ADD_2]

Question ID: CHS.032_02.000

instrument Variable Name: ADD_2
QuestionText:

* Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had_. 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_02.010

Instrument Variable Name: AUTISM
QuestionText:

?[F1] * Read if necessary. Has a doctor or health professional ever told you that [fill: S.C. name] had... Autism, Asperger?s disorder, pervasive developmental disorder, or autism spectrum disorder?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children 2-17
SkipInstructions:

(1,2,R,D) [go to ADD_3]

Question ID: CHS.032_03.000

instrument Variable Name: ADD_3
QuestionText:

?[F1] * Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had_ Any other developmental delay?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children 2-17
Skipinstructions:

(1,2,R,D) [go to CONDL]

Question ID: CHS.060_00.000

instrument Variable Name: CONDL
QuestionText:

(book) C2 ?[F1] Looking at this list, has a doctor or health professional ever told you that [fill: SC name] had any of these conditions?
*Read if necessary.
Down syndrome
Cerebral palsy
Muscular dystrophy
Cystic fibrosis
Sickle cell anemia
Autism/Autism spectrum disorder
Diabetes
Arthritis
Congenital heart disease
Other heart condition

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18
Skipinstructions:

(1) [go to CONDL1]
(2,R,D) [go to CPOX]

Question ID: CHS.061_00.000

instrument Variable Name: CONDL1
QuestionText:

(book) C2 ?[F1] Which ones?
* Enter all that apply, separate with commas.

01 Down syndrome
02 Cerebral palsy
03 Muscular dystrophy
04 Cystic fibrosis
05 Sickle cell anemia
06 Autism/Autism spectrum disorder
07 Diabetes
08 Arthritis
09 Congenital heart disease
10 Other heart condition

UniverseText: Sample children LT 18 and CONDL=1
Skipinstructions:

(1-10, R,D) [go to CPOX]

Question ID: CHS.070_00.000

instrument Variable Name: CPOX
QuestionText:

Has [fill: SC Name] EVER had chickenpox?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18
Skipinstructions:

(1) [go to CPOX12MO]
(2, D, R) [go to CASHMEV]

Question ID: CHS.072_00.000

instrument Variable Name: CPOX12MO
QuestionText:

Has [fill: SC name] had chickenpox DURING THE PAST 12 MONTHS?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18 who have had chickenpox
Skipinstructions:

(1,2,R,D) [go to CASHMEV]

Question ID: CHS.080_00.000

instrument Variable Name: CASHMEV
QuestionText:

? [F1] Has a doctor or other health professional EVER told you that [fill: SC name] had asthma?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18
Skipinstructions:

(1) [go to CASSTILL]
(2,R,D) if AGE LE 2 [go to CCONDT1_1];
else [go to CCONDT_1]

Question ID: CHS.085_00.000

instrument Variable Name: CASSTILL
QuestionText:

Does [fill: SC name] still have asthma?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18 and doctor has informed that child had asthma
Skipinstructions:

(1,2,R,D) [go to CASHYR]

Question ID: CHS.090_00.000

instrument Variable Name: CASHYR
QuestionText:

The following questions are about [fill: SC 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 LT 18 and doctor has informed that child had asthma
Skipinstructions:

(1,2,R,D) [go to CASMERYR]

Question ID: CHS.100_00.000

instrument Variable Name: CASMERYR
QuestionText:

DURING THE PAST 12 MONTHS, did [fill1: SC 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 LT 18 and doctor has informed that child had asthma
Skipinstructions:

(1,2,R,D) if CASSTILL=1 or CASHYR=1 [go to CASMHSP]; else if CASSTILL=2,R,D and CASHYR=2,R,D and AGE LE 2 [go to CCONDT1_1]; else [go to CCONDT_1]

Question ID: CHS.111_01.000

instrument Variable Name: CCONDT1_1
QuestionText:

DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions_ Hay fever?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LE 2
Skipinstructions:

(1,2,R,D) [go to CCONDT1_2]

Question ID: CHS.111_02.000

instrument Variable Name: CCONDT1_2
QuestionText:

* Read if necessary. DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions_ Any kind of respiratory allergy?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LE 2
Skipinstructions:

(1,2,R,D) [go to CCONDT1_3]

Question ID: CHS.111_03.000

instrument Variable Name: CCONDT1_3
QuestionText:

* Read if necessary. DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions_ Any kind of food or digestive allergy?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LE 2
Skipinstructions:

(1,2,R,D) [go to CCONDT1_4]

Question ID: CHS.111_04.000

instrument Variable Name: CCONDT1_4
QuestionText:

* Read if necessary. DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions_ Eczema or any kind of skin allergy?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LE 2
Skipinstructions:

(1,2,R,D) [go to CCONDT1_5]

Question ID: CHS.111_05.000

instrument Variable Name: CCONDT1_5
QuestionText:

* Read if necessary. DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions_ Frequent or repeated diarrhea or colitis?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LE 2
Skipinstructions:

(1,2,R,D) [go to CCONDT1_6]

Question ID: CHS.111_06.000

instrument Variable Name: CCONDT1_6
QuestionText:

* Read if necessary. DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions_ Anemia?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LE 2
Skipinstructions:

(1,2,R,D) [go to CCONDT1_8]

Question ID: CHS.111_08.000

instrument Variable Name: CCONDT1_8
QuestionText:

* Read if necessary. DURING THE PAST 12 MONTHS, has [fill: SC 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
QuestionText:

* Read if necessary. DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions_ Seizures?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LE 2
Skipinstructions:

(1,2,R,D) [go to CHSTATYR]

Question ID: CHS.115_01.000

instrument Variable Name: CCONDT_1
QuestionText:

DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions_ Hay fever?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children = 3-17
Skipinstructions:

(1,2,R,D) [go to CCONDT_2]

Question ID: CHS.115_02.000

instrument Variable Name: CCONDT_2
QuestionText:

* Read if necessary. DURING THE PAST 12 MONTHS, has [fill: SC 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
QuestionText:

* Read if necessary. DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions_ Any kind of food or digestive allergy?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children = 3-17
Skipinstructions:

(1,2,R,D) [go to CCONDT_4]

Question ID: CHS.115_04.000

instrument Variable Name: CCONDT_4
QuestionText:

* Read if necessary. DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions_ Eczema or any kind of skin allergy?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children = 3-17
Skipinstructions:

(1,2,R,D) [go to CCONDT_5]

Question ID: CHS.115_05.000

instrument Variable Name: CCONDT_5
QuestionText:

* Read if necessary. DURING THE PAST 12 MONTHS, has [fill: SC 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
QuestionText:

* Read if necessary. DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions_ Anemia?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children = 3-17
Skipinstructions:

(1,2,R,D) [go to CCONDT_7]

Question ID: CHS.115_07.000

instrument Variable Name: CCONDT_7
QuestionText:

* Read if necessary. DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions_ Frequent or severe headaches, including migraines?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children = 3-17
Skipinstructions:

(1,2,R,D) [go to CCONDT_8]

Question ID: CHS.115_08.000

instrument Variable Name: CCONDT_8
QuestionText:

* Read if necessary. DURING THE PAST 12 MONTHS, has [fill: SC 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
QuestionText:

* Read if necessary. DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions_ Seizures?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children = 3-17
Skipinstructions:

(1,2,R,D) [go to CCONDT_10]

Question ID: CHS.115_10.000

instrument Variable Name: CCONDT_10
QuestionText:

* Read if necessary. DURING THE PAST 12 MONTHS, has [fill: SC name] had any of the following conditions_ Stuttering or stammering?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children = 3-17
Skipinstructions:

(1,2,R,D) [go to CHSTATYR]

Question ID: CHS.210_00.000

instrument Variable Name: CHSTATYR
QuestionText:

Compared with 12 months ago, would you say [fill: SC 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) go to CCOLD2W; else go to SCHDAYR]

Question ID: CHS.220_00.000

instrument Variable Name: SCHDAYR
QuestionText:

DURING THE PAST 12 MONTHS about how many days did [fill2: SC 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) [go to CCOLD2W]
(100-240) [go to ERR1_SCHDAYR]
(241-995) [go to ERR2_SCHDAYR]

Hard Edit: ERR2_SCHDAYR

* "241-995" days not allowed in this field.
* Please correct.

Soft Edit: ERR1_SCHDAYR

[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
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 LT 18
Skipinstructions:

(1,2,R,D) [go to CINTIL2W]

Question ID: CHS.240_00.000

instrument Variable Name: CINTIL2W
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 LT 18
Skipinstructions:

(1,2,R,D) [go to CHEARST1]

Question ID: CHS.250_00.000

instrument Variable Name: CHEARST1
QuestionText:

Which statement best describes [fill: SC name]'s hearing without a hearing aid: Excellent, good, a little trouble hearing, moderate trouble, a lot of trouble, or is [fill: SC's name] deaf?

1 Excellent
2 Good
3 A little trouble hearing
4 Moderate trouble
5 A lot of trouble
6 Deaf
7 Refused
9 Don't know

UniverseText: Sample children LT 18
Skipinstructions:

(1) [goto CHRWHISP] (2-6,R,D) [go to CHRWORS]

Question ID: CHS.251_00.010

instrument Variable Name: CHRWORS
QuestionText:

Without a hearing aid?
Is [fill: SC name]'s hearing WORSE in one ear than the other?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18 who have other than excellent hearing
SkipInstructions:

(1) [goto CHRWORSE]
(2,R,D) [goto CHRWHISP]

Question ID: CHS.251_00.030

instrument Variable Name: CHRWHISP
QuestionText:

*Read if necessary:
Without a hearing aid?
Can [fill: SC name] usually HEAR AND UNDERSTAND what a person says without seeing his or her face if that person WHISPERS to [fill: him/her] from across a QUIET room?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18
SkipInstructions:

(1) if CHEARST2=6 and CHRWORS=2,R,D [goto CHEARAG1]; else [goto CHRFAM] (2,R,D) [goto CHRTALK]

Question ID: CHS.251_00.040

instrument Variable Name: CHRTALK
QuestionText:

*Read if necessary:
Without a hearing aid?
Can [fill: SC name] usually HEAR AND UNDERSTAND what a person says without seeing his or her face if that person TALKS IN A NORMAL VOICE to [fill: him/her] from across a QUIET room?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18 who cannot hear whispers across a quiet room or REF/DK that question
SkipInstructions:

(1) if CHEARST2=6 and CHRWORS=2,R,D [goto CHEARAG1]; else [goto CHRFAM] (2,R,D) [goto CHRSHOUT]

Question ID: CHS.251_00.050

instrument Variable Name: CHRSHOUT
QuestionText:

*Read if necessary:
Without a hearing aid?
Can [fill: SC name] usually HEAR AND UNDERSTAND what a person says without seeing his or her face if that person SHOUTS to [fill: him/her] from across a QUIET room?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18 who cannot hear a normal voice across a quiet room or REF/DK that question
SkipInstructions:

(1) if CHEARST2=6 and CHRWORS=2,R,D [goto CHEARAG1]; else [goto CHRFAM](2,R,D) [goto CHRSPEAK]

Question ID: CHS.251_00.060

instrument Variable Name: CHRSPEAK
QuestionText:

*Read if necessary:
Without a hearing aid?
Can [fill: SC name] usually HEAR AND UNDERSTAND what a person says without seeing his or her face if that person SPEAKS LOUDLY into [fill: his/her] [fill1: ear/better ear]

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18 who cannot hear a shouting voice across a quiet room or REF/DK that question
SkipInstructions:

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

Question ID: CHS.251_00.070

instrument Variable Name: CHRCOCRC
QuestionText:

A cochlear (KOH-klee-uhr) implant is an electrical device that a surgeon puts in a person's ear(s) if they have severe hearing loss or are almost totally deaf. Has a doctor or other health care professional ever recommended a cochlear implant for [fill: SC name]?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18 who cannot hear a shouting voice across a quiet room or REF/DK that question
SkipInstructions:

(1) [goto CHRCOCIM] (2,R,D) if CHEARST2=6 and CHRWORS=2,R,D [goto CHEARAG1]; else [goto CHRFAM]

Question ID: CHS.251_00.080

instrument Variable Name: CHRCOCIM
QuestionText:

Has [fill: SC name] had cochlear implant surgery?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18 who have had a cochlear implant recommended
SkipInstructions:

(1,2,R,D) if CHEARST2=6 and CHRWORS=2,R,D [goto CHEARAG1]; else [goto CHRFAM]

Question ID: CHS.252_00.010

instrument Variable Name: CHRFAM
QuestionText:

Has anyone, friends, relatives, teachers or others, ever told you that [fill: SC name] has a hearing problem?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18 who are not deaf or who are deaf but hear worse in one ear
SkipInstructions:

(1,2,R,D) If (AGE MT3 and CHEARST2=1,2) or (CHEARST2=2 and CHRWORS=2,R,D) [goto CHRPRBHP]; else [goto CHEARAG1]; else if AGE 3-11 [goto CHRMIS]; else [goto CHRUNDNS]

Question ID: CHS.252_00.020

instrument Variable Name: CHRMIS
QuestionText:

When you speak directly to [fill: SC name], how often does [fill: he/she] hear something different from what you said?

*Read categories below.
1 Always
2 Usually
3 About half the time
4 Seldom
5 Never
7 Refused
9 Don't know

UniverseText: Sample children age 3-11 who are not deaf or who are deaf but hear worse in one ear
SkipInstructions:

(1-5,R,D) [goto CHRUNDST]

Question ID: CHS.252_00.030

instrument Variable Name: CHRUNDST
QuestionText:

How often does [fill: SC name] have difficulty understanding what people say to her/him?

*Read categories below.
1 Always
2 Usually
3 About half the time
4 Seldom
5 Never
7 Refused
9 Don't know

UniverseText: Sample children age 3-11 who are not deaf or who are deaf but hear worse in one ear
SkipInstructions:

(1-5,R,D) [goto CHRUNDNS]

Question ID: CHS.252_00.040

instrument Variable Name: CHRUNDNS
QuestionText:

How often does [fill: SC name] have difficulty understanding a conversation if there is background NOISE, for example, when other people are talking, TV or radio is on, or children are playing close by?

*Read categories below.
1 Always
2 Usually
3 About half the time
4 Seldom
5 Never
7 Refused
9 Don't know

UniverseText: Sample children 3+ who are not deaf or who are deaf but hear worse in one ear
SkipInstructions:

(1-5,R,D) if CHEARST2=1 or (CHEARST2=2 and CHRWORS=2,R,D) [goto CHRPRBHP]; else [goto CHEARAG1]

Question ID: CHS.253_00.010

instrument Variable Name: CHEARAG1
QuestionText:

How old was [fill: SC name] when [fill: he/she] began to have ANY [fill: hearing loss/hearing loss in either ear]?

01 At birth 02 0 to 2 years of age 03 3 to 5 years of age 04 6 to 8 years of age 05 9 to 11 years of age 06 12 to 14 years of age 07 15 to 17 years of age 97 Refused 99 Don't know

UniverseText: Sample children LT 18 whose hearing is not excellent or good, or who reported good hearing, but hear worse in one ear than the other
SkipInstructions:

(1-7,R,D) [goto CHRCAUS1]

Question ID:CHS.253_00.020

instrument Variable Name:CHRCAUS1
QuestionText:

What is the MAIN cause of [fill: SC name]?s hearing loss?

01 Mother had infection while pregnant, e.g., cytomegalovirus (CMV), rubella
02 Genetic reason(s)
03 Born very early, preterm birth or low birth weight
04 Child had infectious disease after birth (measles, meningitis, mumps, etc.)
05 Ear infections (fluid in middle ear, otitis, glue ear, etc.)
06 Ear injury or head/neck trauma
07 Ear disease or surgery
08 Medications/drugs, such as gentamicin (aminoglycosides), cisplatin (cancer drugs), antibiotics, anti-inflammatory drugs, diuretics
09 Loud, brief noise from firecrackers, nearby fireworks, gunfire, blasts, or explosions
10 Sudden hearing loss, unexplained by loud, brief noise or other known causes
11 Long term noise exposure from machinery, aircraft, power tools, loud music, loud toys, appliances, personal stereos or MP3 players, hair dryers, etc.
12 Other
97 Refused
99 Don't know

UniverseText: Sample children LT 18 whose hearing is not excellent or good, or who reported good hearing, but hear worse in one ear than the other
SkipInstructions:

(1-12,R,D) [goto CHRPRBHP]

Question ID: CHS.253_00.030

instrument Variable Name: CHRPRBHP
QuestionText:

When was the LAST time [fill: SC name] saw a doctor or other health care professional about any hearing or ear problems?

0 Never
1 In the past year
2 1 to 2 years ago
3 3 to 4 years ago
4 5 to 9 years ago
5 10 to 14 years ago
6 15 or more years ago
7 Refused
9 Don't know

UniverseText: Sample children LT 18
SkipInstructions:

(0,4-6,R,D) [goto CHREHDI] (1-3> [goto CHRENT]

Question ID: CHS.253_00.040

instrument Variable Name: CHRENT
QuestionText:

IN THE PAST 5 YEARS, has [fill: SC name] seen or been referred by your doctor or other health care professional to a... Hearing specialist, such as an Ear, Nose, and Throat (ENT) doctor, or to an audiologist? *Read if necessary. Include Otolaryngologist (OH-toh-LAYR-ehn-GAHL-oh-jist) or Otologist (OH-tol-o-jist).

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18 who saw a doctor or other health care professional about hearing or ear problems 4 or less years ago
SkipInstructions:

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

Question ID: CHS.253_00.050

instrument Variable Name: CHREHDI
QuestionText:

Was [fill: SC name] checked with a screening test, for example, with an otoacoustic emissions test (OAE), or auditory brainstem response (ABR) test for hearing loss at birth?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18
SkipInstructions:

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

Question ID: CHS.253_00.060

instrument Variable Name: CHREIAGE
QuestionText:

At what age did [fill: SC name] FIRST have an earache or an ear infection?

00 Never
01 Less than 6 months old
02 6 to 11 months of age
03 12 to 17 months of age
04 18 to 23 months of age
05 2 to 3 years of age
06 4 to 5 years of age
07 6 to 8 years of age
08 9 years or older
97 Refused
99 Don't know

UniverseText: Sample children LT 18
SkipInstructions:

(0-8,R,D) [goto CHRTUBE]

Question ID: CHS.253_00.070

Instrument Variable Name: CHRTUBE
QuestionText:

Did [fill: SC name] EVER have a tube placed in one or both ears to drain fluid from the ear(s)?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children lt 18
SkipInstructions:

(1) [goto CHRTBAGE];
(2,R,D) if AGE LT 5 [goto CHRTEST];
else if AGE 5-17 [goto CHRTSCH]

Question ID: CHS.253_00.080

instrument Variable Name: CHRTBAGE
QuestionText:

At what age did [fill: SC name] FIRST have an ear tube placed in one or both ears to drain fluid from the ear(s)?

01 Less than 6 months old
02 6 to 11 months of age
03 12 to 17 months of age
04 18 to 23 months of age
05 2 to 3 years of age
06 4 to 5 years of age
07 6 to 8 years of age
08 9 years or older
97 Refused
99 Don't know

UniverseText: Sample children LT 18 who have ever had tube placed in ear(s)
SkipInstructions:

(1-8,R,D) if AGE LT 5 [goto CHRTEST]; else if AGE 5-17 [goto CHRTSCH]

Question ID: CHS.253_00.090

instrument Variable Name: CHRTSCH
QuestionText:

Has [fill: SC name] EVER had a hearing test at school?

1 Yes
2 No
3 Home schooled
7 Refused
9 Don't know

UniverseText: Sample children 5+
SkipInstructions:

(1) [goto CHRTSCHM] (2,3,R,D) [goto CHRTEST]

Question ID: CHS.253_00.100

instrument Variable Name: CHRTSCHM
QuestionText:

Has [fill: SC name] had [his/her] hearing tested more than once at school?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children 5+ who have had their hearing tested in school
SkipInstructions:

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

Question ID: CHS.253_00.105

instrument Variable Name: CHRTSCHR
QuestionText:

When did [fill: SC name] have [his/her] most recent hearing test at school?

1 Less than 1 year ago 2 1 to 2 years ago 3 3 to 4 years ago 4 5 to 9 years ago 5 10 or more years ago 7 Refused 9 Don't know

UniverseText: Sample children 5+ who have had their hearing tested in school
SkipInstructions:

(1-5,R,D) [goto CHRTEST]

Question ID: CHS.253_00.110

instrument Variable Name: CHRTEST
QuestionText:

A hearing test by a specialist is done in a sound-treated booth or room, or with headphones. Hearing specialists include audiologists, ear-nose-throat (ENT) doctors and trained health technicians or nurses (include hearing exams conducted in schools). When was the last time [fill: SC name] had [fill: his/her] hearing tested by a hearing specialist?

0 Never
1 In the past year
2 1 to 2 years ago
3 3 to 4 years ago
4 5 to 9 years ago
5 10 to 14 years ago
6 15 or more years ago
7 Refused
9 Don't know

UniverseText: Sample children LT 18
SkipInstructions:

(0-6,R,D) [goto CHRAIDNW]

Question ID: CHS.253_00.120

instrument Variable Name: CHRAIDNW
QuestionText:

A hearing aid is a small electronic device that amplifies the sounds you hear. It is worn in or behind the ear to help children and adults hear. Does [fill: SC name] NOW use a hearing aid(s)?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18
SkipInstructions:

(1) [goto CHRAIDLG] (2,R,D) [goto CHRAIDEV]

Question ID: CHS.253_00.130

instrument Variable Name: CHRAIDLG
QuestionText:

How long has [fill: SC name] used a hearing aid(s)?

01 Less than 6 weeks
02 6 weeks to 11 months
03 1 to 2 years
04 3 to 4 years
05 5 to 9 years
06 10 to 14 years
07 15 years or more
97 Refused
99 Don't know

UniverseText: Sample children LT 18 who now use a hearing aid
SkipInstructions:

(1,7,R,D) [goto CHRAIDYR

Question ID: CHS.253_00.140

instrument Variable Name: CHRAIDYR
QuestionText:

Think about how much [fill: SC name] used [his/her] present hearing aid(s) over the past two weeks. On an average day, how many hours did [fill: he/she] use a hearing aid(s)?

0 None
1 Less than 1 hour a day
2 1 to 3 hours a day
3 4 to 7 hours a day
4 8 or more hours per day
7 Refused
9 Don't know

UniverseText: Sample children LT 18 who now use a hearing aid
SkipInstructions:

(0) [goto CHRAIDNT]
(1-4,R,D) if CHEARST2=1 or (CHEARST2=2 and CHRWORS=2,R,D and AGE GE 6) [goto CHRFIRE]; else if CHEARST2=1 or (CHEARST2=2 and CHRWORS=2,R,D and AGE LE 5) [goto CHRFRCRK]; else [goto CHRAUD]

Question ID: CHS.253_00.150

instrument Variable Name: CHRAIDEV
QuestionText:

Has [fill: SC name] ever used a hearing aid(s) in the past?

1 Yes
2 No
3 Refused
4 Don't know

UniverseText: Sample children LT 18 who do not now use a hearing aid or Ref/DK whether they now use a hearing aid
SkipInstructions:

(1) [goto CHRAIDLP] (2,R,D) [goto CHRAIDRC]

Question ID: CHS.253_00.160

instrument Variable Name: CHRAIDRC
QuestionText:

Has a hearing specialist, your doctor, or other health care professional ever recommended a hearing aid(s) for [fill: SC name]?

1 Yes
2 No
3 Refused
4 Don't know

UniverseText: Sample children LT 18 who do not now use a hearing aid or who have not used one in the past or who refused to answer whether they use or have used a hearing aid
SkipInstructions:

(1) [goto CHRAIDNT]

(2,R,D) if CHEARST2=1 or (CHEARST2=2 and CHRWORS=2,R,D and AGE GE 6) [goto CHRFIRE]; else if CHEARST2=1 or (CHEARST2=2 and CHRWORS=2,R,D and AGE LE 5) [goto CHRFRCRK]; else [goto CHRAUD]

Question ID: CHS.253_00.170

instrument Variable Name: CHRAIDLP
QuestionText:

How long did [fill: SC name] use a hearing aid(s) in the past?

01 Less than 6 weeks
02 6 weeks to 11 months
03 1 to 2 years
04 3 to 4 years
05 5 to 9 years
06 10 to 14 years
07 15 years or more
97 Refused
99 Don't know

UniverseText: Sample children LT 18 who have used a hearing aid in the past, but not currently
SkipInstructions:

(1-7,R,D) [goto CHRAIDOF]

Question ID: CHS.253_00.180

instrument Variable Name: CHRAIDOF
QuestionText:

When [fill: SC name] used to wear a hearing aid, on an average day, how many hours did [he/she] use it?

0 None
1 Less than
1 hour a day
2 1 to 3 hours a day
3 4 to 7 hours a day
4 8 or more hours per day
7 Refused
9 Don't know

UniverseText: Sample children LT 18 who have used a hearing aid in the past, but not currently
SkipInstructions:

(0-4,R,D) [goto CHRAIDNT]

Question ID:
CHS.253_01.190

instrument Variable Name:
CHRAIDNT
QuestionText:

Why did [fill: SC name] decide not to use a hearing aid(s)?
*Enter all that apply, separate with commas.

1 It didn't help
2 It made everything too loud
3 Didn't like the way it sounded (unwanted sounds such as whistling or other noises)
4 She/he didn?t like the way her/his voice sounded when wearing the hearing aid
5 It was uncomfortable
6 It had frequent breakdowns/Needed repairs
7 Didn't like the way it looked
8 It cost too much
9 She/he didn?t think she/he needed a hearing aid
10.It was misplaced or lost
11. Other reason
12.Refused
13. Don't know

UniverseText: Sample children LT 18 who said they currently use a hearing aid but have not used one in the past 2 weeks, or who have ever used a hearing aid, but not currently, or who have had a hearing aid recommended
SkipInstructions:

(1-11,R,D) if CHEARST2=1 or (CHEARST2=2 and CHRWORS=2,R,D and AGE GE 6) [goto CHRFIRE]; else if CHEARST2=1 or (CHEARST2=2 and CHRWORS=2,R,D and AGE LE 5) [goto CHRFRCRK]; else [goto CHRAUD]

Question ID: CHS.253_13.195

instrument Variable Name: CHRAUD
QuestionText:

Auditory training includes learning how to use visual cues to enhance your listening skills, placing yourself in the best listening situation in a room, or for example, if you use a hearing aid, learning how to use it in specific circumstances, such as on the telephone or in a noisy place. Did [fill: SC name] ever receive instruction or training to improve [his/her] ability to hear?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18 whose hearing is not excellent or good, or who reported good hearing, but hear worse in one ear than the other
SkipInstructions:

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

Question ID: CHS.253_13.197

instrument Variable Name: CHRALDS
QuestionText:

BECAUSE OF [fill: SC name]?s HEARING, has [he/she] EVER used assistive technology to communicate, such as FM systems, instant or text messages, classroom amplification systems, headsets, closed-caption television, amplified telephone, relay services, or live video streaming?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18 whose hearing is not excellent or good, or who reported good hearing, but hear worse in one ear than the other
SkipInstructions:

(1) [goto CHRALDTP] (2,R,D) if age 6-17 [goto CHRFIRE]; else [goto CHRFRCRK]

Question ID:
CHS.253_13.220

instrument Variable Name: CHRALDTP
QuestionText:

What assistive technology devices or types has [fill: SC name] EVER used?
*Enter all that apply, separate with commas.

01 FM system, pocket talker or other personal listening device
02 Instant or text messages
03 Classroom amplification systems
04 Amplified telephone
05 Amplified or vibrating alarm clock
06 Notification or signaling alarm system (light signaler for doorbell, etc.)
07 Headset with Television/Theater or closed-captioned TV
08 TTY (teletypewriter), TDD (telecommunications device for the deaf), or telephone relay service
09 Video relay service
10 Live video streaming (for example, video on computers or phones) using sign language or other means to communicate
11 Sign language interpreter
12 Other
97 Refused
99 Don't know

UniverseText: Sample children LT 18 who have ever used assistive listening devices
SkipInstructions:

(1-12,R,D) if age 6-17 [goto CHRFIRE]; else [goto CHRFRCRK]

Question ID: CHS.254_00.010

instrument Variable Name: CHRFIRE
QuestionText:

The next questions are about [fill: SC name]'s exposure to loud sounds or noises.
Has [fill: SC name] ever shot a gun or been close to others who were using firearms for any reason? Close means standing next to or nearby to others who were using firearms.

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children 6-17
SkipInstructions:

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

Question ID: CHS.254_00.020

instrument Variable Name: CHRFRCRK
QuestionText:

Has [fill: SC name] ever lit firecrackers, been nearby to others lighting firecrackers, or close to explosive sounds such as fireworks displays or other explosive noises?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18
SkipInstructions:

(1,2,R,D) if CHRFIRE=1 or CHRFRCRK=1 [goto CHRTOTR]; else if age 6-17 [goto CHRWKVLN]; else [goto CHRLESNS]

Question ID: CHS.254_00.030

instrument Variable Name: CHRTOTR
QuestionText:

About how many TOTAL explosive events has [fill: SC name] experienced, including gun shots, firecrackers going off, nearby fireworks explosions, and any other explosive noises?
*Read categories if necessary.
*Include target shooting, hunting, lighting firecrackers, other explosive noises.
*One "event" equals one shot, one firecracker, one fireworks explosion, etc.

1 1 to less than 100 events
2 100 to less than 1000 events
3 1000 to less than 10,000 events
4 10,000 to less than 50,000 events
5 50,000 events or more
7 Refused
9 Don't know

UniverseText: Sample children LT 18 who have ever used/been close to explosives
SkipInstructions:

(1-5,R,D) [goto CHRFRPRT]

Question ID: CHS.254_00.040

instrument Variable Name: CHRFRPRT
QuestionText:

When [fill1: shooting guns,] lighting firecrackers or being close to others who were [fill: shooting guns,] lighting firecrackers, or when explosive sounds occurred, how often did [fill: SC name] wear hearing protection, such as earplugs or ear muffs? Would you say?

*Read categories below.
1 Always
2 Usually
3 About half the time
4 Seldom
5 Never
7 Refused
9 Don't know

UniverseText: Sample children LT 18 who have ever used/been close to explosives
SkipInstructions:

(1-5,R,D) if age 6-17 [goto CHRWKVLN]; else [goto CHRLESNS]

Question ID: CHS.254_00.050

instrument Variable Name: CHRWKVLN
QuestionText:

Has [fill: SC name] ever had a job, or combination of jobs or chores, where she/he was exposed to VERY LOUD sounds or noise for 4 or more hours a day, several days a week?
VERY LOUD means so loud that one must shout in order to be understood by a person standing 3 feet (arm?s length) away.

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children 6-17
SkipInstructions:

(1) [goto CHRWKVLT] (2,R,D) [goto CHRLESNS]

Question ID: CHS.254_00.060

instrument Variable Name: CHRWKVLT
QuestionText:

In working on a job or doing chores, how many months or years has [fill: SC name] been exposed to VERY LOUD sounds or noise for 4 or more hours a day, several days a week?
VERY LOUD means so loud that one must shout in order to be understood by a person standing 3 feet (arm?s length) away.

01 Less than 3 months
02 3 to 11 months
03 1 to 2 years
04 3 to 4 years
05 5 to 9 years
06 10 to 14 years
07 15 years or more
97 Refused
99 Don't know

UniverseText: Sample children 6-17 who have had job/chores that exposed them to very loud noise 4 or more hours a day, several days a week
SkipInstructions:

(1-7,R,D) [goto CHRWKPRT]

Question ID: CHS.254_00.070

instrument Variable Name: CHRWKPRT
QuestionText:

About how often did [fill: SC name] wear hearing protection, such as ear plugs or ear muffs when exposed to VERY LOUD sounds or noise at work or while doing chores? Would you say?

*Read categories below.
1 Always
2 Usually
3 About half the time
4 Seldom
5 Never
7 Refused
9 Don't know

UniverseText: Sample children 6-17 who have had job/chores that exposed them to very loud noise 4 or more hours a day, several days a week
SkipInstructions:

(1-5,R,D) [goto CHRLESNS]

Question ID: CHS.254_00.080

instrument Variable Name: CHRLESNS
QuestionText:

[fill: Outside of working on a job or doing chores, has/Has] [fill: SC name] ever been exposed to VERY LOUD sounds or noise 10 or more times a year? This includes noise from extremely loud toys, gunfire, fireworks, power tools or machinery, very loud music, sporting events, recreational vehicles, racing or speedways, some household appliances, or other things?]
*Read if necessary.
VERY LOUD means so loud that one must shout in order to be understood by a person standing 3 feet (arm?s length) away.

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18
SkipInstructions:

(1) [goto CHRLESTP] (2,R,D) [goto CHRINT]

Question ID: CHS.254_00.090

instrument Variable Name: CHRLESTP
QuestionText:

What types of VERY LOUD activities has [fill: SC name] ever been exposed to 10 or more times a year?

*Enter all that apply, separate with commas.
01 Motorcycles/auto racing/snowmobile/motor boat/recreational vehicles
02 Operating farm machinery
03 Woodworking, other workshop power tools
04 Lawn mower, electric trimmer, leaf/snow blower, chain saw
05 Guns, firearms
06 Firecrackers or fireworks
07 Very loud household appliances (vacuum cleaners, hair dryers, etc.)
08 CD Player/MP3 Player/iPod, etc.
09 Playing a musical instrument
10 Extremely loud toys
11 Other music-related activities: Rock concerts, stereos, disco/clubs or bars
12 Other activities (such as computer/video games, home theater, loud sporting events)
97 Refused
99 Don't know

UniverseText: Sample children LT 18 who have been exposed to very loud leisure time sounds/noise 10 or more times a year
SkipInstructions:

(1-12,R,D) [goto CHRLSPRT]

Question ID: CHS.255_00.005

instrument Variable Name: CHRLSPRT
QuestionText:

When [fill: SC name] was exposed to VERY LOUD noise or music from activities outside of work, about how often did [he/she] wear hearing protection, such as ear plugs or ear muffs? Would you say?

*Read categories below.
1 Always
2 Usually
3 About half the time
4 Seldom
5 Never
7 Refused
9 Don't know

UniverseText: Sample children LT 18 who have been exposed to very loud leisure time sounds/noise 10 or more times a year
SkipInstructions:

(1-5,R,D) [goto CHRINT]

Question ID: CHS.255_00.010

instrument Variable Name: CHRINT
QuestionText:

DURING THE PAST 12 MONTHS, did anyone get information from the internet about [fill: SC name]?s health, medical treatments, or rehabilitation services?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18
SkipInstructions:

(1) [goto CHRINTHL]
(2,R,D) [goto CVISION]

Question ID: CHS.255_00.020

instrument Variable Name: CHRINTHL
QuestionText:

DURING THE PAST 12 MONTHS, did anyone get information from the internet on?
Hearing loss for [fill: SC name]

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18 whose parent/respondent used the internet in the past year to get information about health, medical treatment, or rehabilitation services
SkipInstructions:

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

Question ID: CHS.255_00.030

instrument Variable Name: CHRINTHA
QuestionText:

*Read if necessary:
DURING THE PAST 12 MONTHS, did anyone get information from the internet on?
Hearing aids, including cochlear implants or other devices or assistive technology for [fill: SC name]

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18 whose parent/respondent used the internet in the past year to get information about health, medical treatment, or rehabilitation services
SkipInstructions:

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

Question ID: CHS.255_00.040

instrument Variable Name: CHRINTHP
QuestionText:

*Read if necessary:
DURING THE PAST 12 MONTHS, did anyone get information from the internet on?Hearing protection such as ear plugs or earmuffs for [fill: SC name]

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18 whose parent/respondent used the internet in the past year to get information about health, medical treatment, or rehabilitation services
Skipinstructions:

(1,2,R,D) if CHRINTHL=1 or CHRINTHA=1 or CHRINTHP=1 [goto CHRINHPR]; else [goto next CVISION]

Question ID: CHS.255_00.050

Instrument Variable Name: CHRINHPR
QuestionText:

Was any of this information written by a doctor, other health professionals, medical associations, or other health-related organizations?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18 whose parent/respondent used the internet in the past year to get information about hearing loss, hearing aids, or hearing protection
SkipInstructions:

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

Question ID: CHS.260_00.000

instrument Variable Name: CVISION
QuestionText:

Does [fill1: SC 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 LT 18
Skipinstructions:

(1) [go to CBLIND]
(2,R,D) [go to IHSPEQ]

Question ID: CHS.270_00.000

instrument Variable Name: CBLIND
QuestionText:

Is [fill: SC name] blind or unable to see at all?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18 having trouble seeing
Skipinstructions:

(1,2,R,D) [go to IHSPEQ]

Question ID: CHS.290_00.000

instrument Variable Name: IHSPEQ
QuestionText:

Does [fill1: SC 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 LT 18
Skipinstructions:

(1,2,R,D) [go to IHMOB]

Question ID: CHS.300_00.000

instrument Variable Name: IHMOB
QuestionText:

Does [fill1: SC 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 LT 18
Skipinstructions:

(1) [go to IHMOBYR]
(2,R,D) [go to PROBRX]

Question ID: CHS.310_00.000

instrument Variable Name: IHMOBYR
QuestionText:

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

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18 that have limited ability to crawl, walk, run, or play
Skipinstructions:

(1,2,R,D) [go to PROBRX]

Question ID: CHS.311_00.000

instrument Variable Name: PROBRX
QuestionText:

?[F1] Does [fill1: SC 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 LT 18
Skipinstructions:

(1,2,R,D) [if AGE LE (1) go to CAU.CUSUALPL;
else if AGE GE 3 go to LEARND;
else if AGE = 2 and SEX = 1 go to CMHAGM11_1;
if AGE = 2 and SEX = 2 go to CMHAGF11_1]

Question ID: CHS.312_00.000

instrument Variable Name: LEARND
QuestionText:

?[F1] Has a representative from a school or a health professional ever told you that [fill: SC 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 LT 3 go to CUSUALPL;
if AGE =3 and SEX = 1 go to CMHAGM11_1;
if AGE = 3 and SEX = 2 go to CMHAGF11_1];

Question ID: CHS.321_01.000

instrument Variable Name: CMHAGM11_1
QuestionText:

(book) C3 ?[F1] 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: SC name] DURING THE PAST TWO MONTHS.
He: Has been uncooperative?

0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know

UniverseText: Male sample children 2-3
Skipinstructions:

(0-2,R,D) [go to CMHAGM11_2]

Question ID: CHS.321_02.000

instrument Variable Name: CMHAGM11_2
QuestionText:

(book) C3 ?[F1] * 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: SC name] DURING THE PAST TWO MONTHS.
He: Has trouble getting to sleep?

0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know

UniverseText: Male sample children 2-3
Skipinstructions:

(0-2,R,D) [go to CMHAGM11_3]

Question ID: CHS.321_03.000

instrument Variable Name: CMHAGM11_3
QuestionText:

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
QuestionText:

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 CAU.CUSUALPL]

Question ID: CHS.361_01.000

instrument Variable Name: CMHAGF11_1
QuestionText:

(book) C3 ?[F1]
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
She: Has temper tantrums or a hot temper?

0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know

UniverseText: Female sample children 2-3
Skipinstructions:

(0-2,R,D) [go to CMHAGF11_2]

Question ID: CHS.361_02.000

instrument Variable Name: CMHAGF11_2
QuestionText:

(book) C3 ?[F1] * 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
QuestionText:

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
QuestionText:

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 CAU.CUSUALPL]

Question ID: CAU.020_00.000

instrument Variable Name: CUSUALPL
QuestionText:

The next questions are about health care. Is there a place that [fill1: alias] USUALLY goes when [fill2: he/she] is sick or you need advice about [fill3: his/her] health?

1 Yes
2 There is NO place
3 There is MORE THAN ONE place
7 Refused
9 Don't know

UniverseText: Sample children LT 18
Skipinstructions:

(1,3) [go to CPLKIND]
(2,R,D) [go to CHCPLKND]

Question ID: CAU.030_00.000

instrument Variable Name: CPLKIND
QuestionText:

[fill1: What kind of place is it / What kind of place does [fill2: alias] go to most often] - a clinic, doctor's office, emergency room, or some other place?

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

UniverseText: Sample children LT 18 with one or more usual places to go when sick or need health advice
Skipinstructions:

(1-5) [go to CHCPLROU]
(6,R,D) [go to CHCPLKND]

Question ID: CAU.035_00.000

instrument Variable Name: CHCPLROU
QuestionText:

Is that [fill1: CPLKIND/CAU.030] the same place [fill2: alias] USUALLY goes when [fill3: he/she] needs routine or preventive care, such as a physical examination or (well baby/child) check-up?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18 with one or more usual places to go when sick or need health advice who reported that place as a clinic or health center, doctor's office or HMO, hospital emergency room, hospital outpatient department, or some other place
Skipinstructions:

(1) [go to CHCCHGYR]
(2,R,D) [go to CHCPLKND]

Question ID: CAU.037_00.000

instrument Variable Name: CHCPLKND
QuestionText:

What kind of place does [fill1: alias] USUALLY go to when [fill2: he/she] needs routine or preventive care, such as a physical examination or (well baby/child) check-up?

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 [go to CNOUSLPL]; else if CUSUALPL=,R,D [go to CPRVTRYR]; else [go to CHCCHGYR]

Question ID: CAU.040_00.000

instrument Variable Name: CHCCHGYR
QuestionText:

At any time IN THE PAST 12 MONTHS did you CHANGE the place(s) to which [fill: alias] USUALLY goes for health care?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18 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) [go to to CPRVTRYR]

Question ID: CAU.050_00.000

instrument Variable Name: CHCCHGHI
QuestionText:

Was this change for a reason related to health insurance?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT18 that have changed their usual place of health care in the past 12 months

Skipinstructions:

(1,2,R,D) [go to CPRVTRYR]

Question ID: CAU.050_00.010

instrument Variable Name: CNOUSLPL
QuestionText:

Why doesn't [fill: alias] have a usual source of medical care?
*Enter all that apply, separate with commas.

UniverseText: Sample children LT 18 who don't have a usual place of care
Skipinstructions:

(1-9,R,D) [go to CPRVTRYR]

Question ID: CAU.052_00.010

instrument Variable Name: CPRVTRYR
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 LT 18
Skipinstructions:

(1) [go to CPRVTRFD ]
(2,R,D) [go to CDRNANP]

Question ID: CAU.053_00.010

instrument Variable Name: CPRVTRFD
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 LT 18 who had trouble finding a provider in the last year
Skipinstructions:

(1,2,R,D) [go to CDRNANP]

Question ID: CAU.055_00.010

instrument Variable Name: CDRNANP
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 LT 18
Skipinstructions:

(1,2,R,D) [go to CDRNAI]

Question ID: CAU.056_00.010

instrument Variable Name: CDRNAI
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 LT 18
Skipinstructions:

(1,2,R,D) [go to CHCDLYR_1]

Question ID: CAU.080_01.000

instrument Variable Name: CHCDLYR1_1
QuestionText:

There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the following reasons IN THE PAST 12 MONTHS_ You couldn't get through on the telephone.

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18
Skipinstructions:

(1,2,R,D) [go to CHCDLYR1_2]

Question ID: CAU.080_02.000

instrument Variable Name: CHCDLYR1_2
QuestionText:

* Read if necessary. There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the following reasons IN THE PAST 12 MONTHS_ You couldn't get an appointment for [fill: alias] soon enough.

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18
Skipinstructions:

(1,2,R,D) [go to CHCDLYR1_3]

Question ID: CAU.080_03.000

instrument Variable Name: CHCDLYR1_3
QuestionText:

* Read if necessary. There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the following reasons IN THE PAST 12 MONTHS_ Once you get there, [fill: alias] has to wait too long to see the doctor.

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18
Skipinstructions:

(1,2,R,D) [go to CHCDLYR1_4]

Question ID: CAU.080_04.000

instrument Variable Name: CHCDLYR1_4
QuestionText:

* Read if necessary. There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the following reasons IN THE PAST 12 MONTHS_ The (clinic/doctor's office) wasn't open when you could get there.

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18
Skipinstructions:

(1,2,R,D) [go to CHCDLYR1_5]

Question ID: CAU.080_05.000

instrument Variable Name: CHCDLYR1_5
QuestionText:

* Read if necessary. There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the following reasons IN THE PAST 12 MONTHS_ You didn't have transportation.

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18
Skipinstructions:

(1,2,R,D) [if AGE GE (2) go to CHCAFYR1_1; else go to CHCAFYR]

Question ID: CAU.130_00.000

instrument Variable Name: CHCAFYR
QuestionText:

DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't get it because you couldn't afford it_ Prescription medicines?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 2
Skipinstructions:

(1,2,R,D) [go to CHCAFYRN]

Question ID: CAU.133_00.010

instrument Variable Name: CHCAFYRN
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 LT 2
Skipinstructions:

(1,2,R,D) [go to CHCAFYRF]

Question ID: CAU.133_00.020

instrument Variable Name: CHCAFYRF
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 LT 2
Skipinstructions:

(1,2,R,D) [if AGE LT 1 go to CHCSYR1_2; else go to CDENLONG]

Question ID: CAU.135_01.000

instrument Variable Name: CHCAFYR1_1
QuestionText:

DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't get it because you couldn't afford it_ Prescription medicines?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children GE 2
Skipinstructions:

(1,2,R,D) [go to CHCAFYR1_2]

Question ID: CAU.135_02.000

instrument Variable Name: CHCAFYR1_2
QuestionText:

* Read if necessary. DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't get it because you couldn't afford it_ Mental health care or counseling?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children GE 2
Skipinstructions:

(1,2,R,D) [go to CHCAFYR1_3]

Question ID: CAU.135_03.000

instrument Variable Name: CHCAFYR1_3
QuestionText:

* Read if necessary. DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't get it because you couldn't afford it_ Dental care (including check-ups)?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children GE 2
Skipinstructions:

(1,2,R,D) [go to CHCAFYR1_4]

Question ID: CAU.135_04.000

instrument Variable Name: CHCAFYR1_4
QuestionText:

* Read if necessary. DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't get it because you couldn't afford it_ Eyeglasses?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children GE 2
Skipinstructions:

(1,2,R,D) [go to CHCAFYR1_5]

Question ID: CAU.135_05.010

instrument Variable Name: CHCAFYR1_5
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) [go to CHCAFYR1_6]

Question ID: CAU.135_06.010

instrument Variable Name: CHCAFYR1_6
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) [go to CDENLONG]

Question ID: CAU.160_00.000

instrument Variable Name: CDENLONG
QuestionText:

(book) C4 About how long has it been since [fill: alias] last saw a dentist? Include all types of dentists, such as orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists.

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

UniverseText: Sample children GE 1
Skipinstructions:

(0-5,R,D) [if AGE GE (2) go to CHCSYR_1; else go to CHCSYR1_2]

Question ID: CAU.170_01.000

instrument Variable Name: CHCSYR1_2
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 LT 2
Skipinstructions:

(1,2,R,D) [go to CHCSYR1_3]

Question ID: CAU.170_02.000

instrument Variable Name: CHCSYR1_3
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 LT 2
Skipinstructions:

(1,2,R,D) [go to CHCSYR1_5]

Question ID: CAU.170_03.000

instrument Variable Name: CHCSYR1_5
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 LT 2
Skipinstructions:

(1,2,R,D) [go to CHCSYR1_6]

Question ID: CAU.170_04.000

instrument Variable Name: CHCSYR1_6
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 LT 2
Skipinstructions:

(1,2,R,D) [go to CHCSYR8_1]

Question ID: CAU.175_01.000

instrument Variable Name: CHCSYR_1
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) [go to CHCSYR_2]

Question ID: CAU.175_02.000

instrument Variable Name: CHCSYR_2
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) [go to CHCSYR_3]

Question ID: CAU.175_03.000

instrument Variable Name: CHCSYR_3
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) [go to CHCSYR_4]

Question ID: CAU.175_04.000

instrument Variable Name: CHCSYR_4
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) [go to CHCSYR_5]

Question ID: CAU.175_05.000

instrument Variable Name: CHCSYR_5
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) [go to CHCSYR_6]

Question ID: CAU.175_06.000

instrument Variable Name: CHCSYR_6
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 go to CHCSYR7; else go to CHCSYR8_1]

Question ID: CAU.230_00.000

instrument Variable Name: CHCSYR7
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) [go to CHCSYR8_1]

Question ID: CAU.240_01.000

instrument Variable Name: CHCSYR8_1
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 LT 18
Skipinstructions:

(1,2,R,D) [go to CHCSYR8_2]

Question ID: CAU.240_02.000

instrument Variable Name: CHCSYR8_2
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 LT 18
Skipinstructions:

(1) [go to CHCSYR10]
(2,R,D) [go to CHPEXYR]

Question ID: CAU.260_00.000

instrument Variable Name: CHCSYR10
QuestionText:

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

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18 who have seen or talked to a general doctor during the past 12 months
Skipinstructions:

(1,2,R,D) [go to CHCSYREM]

Question ID: CAU.265_00.000

instrument Variable Name: CHCSYREM
QuestionText:

Did you see or talk to this general doctor because of an emotional or behavioral problem that [fill1: alias] may have?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18 who have seen a general doctor in the past 12 months
Skipinstructions:

(1,2,R,D) [go to CHPEXYR]

Question ID: CAU.270_00.000

instrument Variable Name: CHPEXYR
QuestionText:

DURING THE PAST 12 MONTHS, did [fill1: alias] receive a well-child check-up, that is a general check-up, when [fill2: he/she] was not sick or injured?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18
Skipinstructions:

(1,2,R,D) [go to CHERNOYR]

Question ID: CAU.280_00.000

instrument Variable Name: CHERNOYR
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 LT 18
Skipinstructions:

(0,R,D) [go to CHCHYR]
(1-8) [go to CERVISND]

Question ID: CAU.281_00.010

instrument Variable Name: CERVISND
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 LT 18 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
QuestionText:

Did this emergency room visit result in a hospital admission?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18 who had at least one ER visit in the past year
Skipinstructions:

(1,2,R,D) [go to CERREAS1]

Question ID: CAU.283_01.010

instrument Variable Name: 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 LT 18 who had at least one ER visit in the past year
Skipinstructions:

(1,2,R,D) [go to CERREAS2]

Question ID: CAU.283_02.020

instrument Variable Name: CERREAS2
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 LT 18 who had at least one ER visit in the past year
Skipinstructions:

(1,2,R,D) [go to CERREAS3]

Question ID: CAU.283_03.030

instrument Variable Name: CERREAS3
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
Skipinstructions:

(1,2,R,D) [go to CERREAS4]

Question ID: CAU.283_04.040

instrument Variable Name: CERREAS4
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 LT 18 who had at least one ER visit in the past year
Skipinstructions:

(1,2,R,D) [go to CERREAS5]

Question ID: CAU.283_05.050

instrument Variable Name: CERREAS5
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 LT 18 who had at least one ER visit in the past year
Skipinstructions:

(1,2,R,D) [go to CERREAS6]

Question ID: CAU.283_06.060

instrument Variable Name: 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 LT 18 who had at least one ER visit in the past year
Skipinstructions:

(1,2,R,D) [go to CERREAS7]

Question ID: CAU.283_07.070

instrument Variable Name: CERREAS7
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 LT 18 who had at least one ER visit in the past year
Skipinstructions:

(1,2,R,D) [go to CERREAS8]

Question ID: CAU.283_08.080

instrument Variable Name: CERREAS8
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 LT 18 who had at least one ER visit in the past year
Skipinstructions:

(1,2,R,D) [go to CHCHYR]

Question ID: CAU.290_00.000

instrument Variable Name: CHCHYR
QuestionText:

DURING THE PAST 12 MONTHS, did [fill1: alias] receive care AT HOME from a nurse or other health care professional?

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18
Skipinstructions:

(1) [go to CHCHMOYR]
(2,R,D) [go to CHCNOYR]

Question ID: CAU.300_00.000

instrument Variable Name: CHCHMOYR
QuestionText:

DURING THE PAST 12 MONTHS, how many months did [fill: alias] receive care AT HOME from a health care professional?

01-12 1-12 months
97 Refused
99 Don't know

UniverseText: Sample children LT 18 that have received home care from health professional during the past 12 months
Skipinstructions:

(01-12,R,D) [go to CHCHNOYR]

Question ID: CAU.310_00.000

instrument Variable Name: CHCHNOYR
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 LT 18 that have received home care from health professional during the past 12 months
Skipinstructions:

(1-8,R,D) [go to CHCNOYR]

Question ID: CAU.320_00.000

instrument Variable Name: CHCNOYR
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 LT 18
Skipinstructions:

(0-8,R,D) [go to CSRGYR]

Question ID: CAU.330_00.000

instrument Variable Name: CSRGYR
QuestionText:

DURING THE PAST 12 MONTHS has [fill1: alias] had SURGERY or other surgical procedures either as an inpatient or outpatient?
* Read if necessary. This includes both major surgery and minor procedures such as setting bones or removing growths.

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample children LT 18
Skipinstructions:

(1) [go to CSRGNOYR]
(2,R,D) [go to CMDLONG]

Question ID: CAU.340_00.000

instrument Variable Name: CSRGNOYR
QuestionText:

Including any times you may have already told me about, HOW MANY DIFFERENT TIMES has [fill1: alias] had surgery DURING THE PAST 12 MONTHS?
* Enter '95' for 95 or more times.

01-94 1-94 times
95 95+ times
97 Refused
99 Don't know

UniverseText: Sample children LT 18 that have undergone surgery during the past 12 months
Skipinstructions:

(1-10,R,D) [go to CMDLONG]
(11-95) [go to ERR_CMDLONG]

Soft Edit: ERR_CMDLONG

[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
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.

UniverseText: Sample children LT 18
Skipinstructions:

(0-5, D, R) [if AGE=4-17 goto CMHCOPY; else goto CH1N1_1]

Question ID: CMB.010_00.000

instrument Variable Name: CMHCOPY
QuestionText:

* The following statements are not to be read to the respondent. They are displayed and included here for legal reasons.
* The next 6 items contained in CMHMF_1 through CMHDIFF are included in this survey with permission as indicated below.
* The SDQ questions are copyrighted by Robert Goodman, Ph.D., FRCPSYCH, MRCP. State and local agencies may use these questions without charge and without seeking separate permission provided the wording is not modified, all the questions are retained, and Dr. Goodman's copyright is acknowledged.
* Enter 1 to Continue.

1 Enter 1 to continue

UniverseText: Sample children GE 4
Skipinstructions:

(1) [go to CMHMF_1]

Question ID: CMB.020_01.000

instrument Variable Name: CMHMF_1
QuestionText:

(book) C7 I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE, SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: SC name] DURING THE PAST SIX MONTHS_ [fill2: He/She] _is generally well behaved, usually does what adults request.

0 Not true
1 Somewhat true
2 Certainly true
7 Refused
9 Don't know

UniverseText: Sample children GE 4
Skipinstructions:

(1-3,D,R) [go to CMHMF_2]

Question ID: CMB.020_02.000

instrument Variable Name: CMHMF_2
QuestionText:

(book) C7 * Read if necessary.
I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE, SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: SC name] DURING THE PAST SIX MONTHS_ [fill2: He/She] _has many worries, or often seems worried.

0 Not true
1 Somewhat true
2 Certainly true
7 Refused
9 Don't know

UniverseText: Sample children GE 4
Skipinstructions:

(1-3,D,R) [go to CMHMF_3]

Question ID: CMB.020_03.000

instrument Variable Name: CMHMF_3
QuestionText:

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) [go to CMHMF_4]

Question ID: CMB.020_04.000

instrument Variable Name: CMHMF_4
QuestionText:

(book) C7 * Read if necessary. I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE, SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: SC name] DURING THE PAST SIX MONTHS_ [fill2: He/She] _gets along better with adults than with other [fill3: children/youth].

0 Not true
1 Somewhat true
2 Certainly true
7 Refused
9 Don't know

UniverseText: Sample children GE 4
Skipinstructions:

(1-3,D,R) [go to CMHMF_5]

Question ID: CMB.020_05.000

instrument Variable Name: CMHMF_5
QuestionText:

(book) C7 * Read if necessary. I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE, SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: SC name] DURING THE PAST SIX MONTHS_ [fill2: He/She] _has good attention span, sees chores or homework through to the end.

0 Not true
1 Somewhat true
2 Certainly true
7 Refused
9 Don't know

UniverseText: Sample children GE 4
Skipinstructions:

(1-3,D,R) [go to CMHDIFF]

Question ID: CMB.030_00.000

instrument Variable Name: CMHDIFF
QuestionText:

(book) C8 Overall, do you think that [fill1: SC name] has difficulties in any of the following areas: emotions, concentration, behavior, or being able to get along with other people?

1 No
2 Yes, minor difficulties
3 Yes, definite difficulties
4 Yes, severe difficulties
7 Refused
9 Don't know

UniverseText: Sample children GE 4
Skipinstructions:

(1-4,R,D) [go to next section]

Question ID: CFI.005_00.010

instrument Variable Name: CH1N1_1
QuestionText:

?[F1] 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.

1 Yes
2 No
7 Refused
9 Don't know

UniverseText: Sample Child LE 17 years
Skipinstructions:

(1) [go to CH1N1_2]
(2,R,D) [go to next section]

Question ID: CFI.005_00.020

instrument Variable Name: CH1N1_2
QuestionText:

How many vaccinations has {S.C. name} received?

1 1 vaccination or dose
2 2 or more vaccination doses
7 Refused
9 Don't know

UniverseText: Sample Child LE 17 years who have had an vaccine dose
Skipinstructions:

(1,2) [go to CH1N1_3M]
(R,D) [go to next section]

Question ID: CFI.005_00.030

instrument Variable Name: CH1N1_3M
QuestionText:

1 of 2 During what month and year did {S.C. name} receive {fill: his/her} most recent flu vaccine?

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

UniverseText: Sample Child LE 17 who have had one or more vaccine doses
Skipinstructions:

(1-12,D) [ go to CH1N1_4Y]
(R) [go to CH1N1_5]

Question ID: CFI.005_00.040

instrument Variable Name: CH1N1_4Y
QuestionText:

2 of 2 *Enter year of most recent flu vaccine.

Year Year
9997 Refused
9999 Don't know

UniverseText: Sample Child LE 17 years who have had one or more vaccine doses and gave month/don't know month of vaccine dose
Skipinstructions:

(valid year,R,D) [go to CH1N1_5]
[If CH1N1_3M and CH1N1_4Y = a future date] go to ERR1_ CH1N1_4Y]
[If CH1N1_3M and CH1N1_4Y = a date prior to birth] go to ERR2_ CH1N1_4Y]
[If CH1N1_3M and CH1N1_4Y = a date prior to 12 months ago] go to ERR3_ CH1N1_4Y]

Hard Edit: ERR1_ CH1N1_4Y

*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
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).

1 Flu shot
2 Flu nasal spray (spray, mist or drop in nose)
7 Refused
9 Don't know

UniverseText: Sample Child LE 17 years who have had one or more vaccine doses
Skipinstructions:

(1-2,R,D) IF CH1N1_2=1 [go to next section]; else if CH1N1_2=2 [go to CH1N1_6M]

Question ID: CFI.005_00.060

instrument Variable Name: CH1N1_6M
QuestionText:

1 of 2 During what month and year did {S.C. name} receive {fill: his/her} next most recent flu vaccine?

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

UniverseText: Sample Child LE 17 years who have had more than one vaccine doses
Skipinstructions:

(1-12,D) [ go to CH1N1_7Y]
(R) [go to CH1N1_8]

Question ID: CFI.005_00.070

instrument Variable Name: CH1N1_7Y
QuestionText:

2 of 2 *Enter year of next most recent flu vaccine.

Year Year
9997 Refused
9999 Don't know

UniverseText: Sample Child LE 17 years who have had more than one vaccine doses and gave month/don't know month of vaccine dose
Skipinstructions:

(valid year,R,D) [go to CH1N1_8]
[If CH1N1_6M and CH1N1_7Y = a future date] go to ERR1_ CH1N1_7Y]
[If CH1N1_6M and CH1N1_7Y = a date prior to birth] go to ERR2_ CH1N1_7Y]
[If CH1N1_6M and CH1N1_7Y = a date prior to 12 months ago] go to ERR3_ CH1N1_7Y]

Hard Edit: ERR1_ CH1N1_7Y
*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
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).

1 Flu shot
2 Flu nasal spray (spray, mist or drop in nose)
7 Refused
9 Don't know

UniverseText: Sample Child LE 17 years who have more than one vaccine dose
Skipinstructions:

(1-2,R,D) [go to next section]

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