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2017 NHIS Questionnaire - Sample Child
Child Identification
Document Version Date: 04-Jun-18

Question ID: CID.001_00.000

Instrument Variable Name: CURRES
Questionnaire File Name: Sample Child
Question Text:
* Enter the line number of the person to whom you are speaking.
01-25 Person number of the respondent for Sample Child
Universe Text: Sample child section not started or not completed
Skip Instructions:
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
Hard Edit: endif ERR_CURRES
* You have selected a non-selectable person.
* Please correct.

Question ID: CID.010_00.000

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

Question ID: CID.030_00.000

Instrument Variable Name: CSRELTIV
Questionnaire File Name: Sample Child
Question Text:
(book) C1
[fill1: The next questions are about [fill2: ALIAS of Sample Child].]
What is your relationship to [fill2: ALIAS of Sample Child]?
01 Parent (Biological, adoptive, or step)
02 Grandparent
03 Aunt/Uncle
04 Brother/Sister
05 Other relative
06 Legal guardian
07 Foster parent
08 Other non-relative
97 Refused
99 Don't know
Universe Text: Someone identified as knowledgeable about child's health
Skip Instructions:
(1-8,R,D) If CSRESP = demographics.hhc.RELRESP_A
goto child.chs.BWGT_LB
elseif CSRESP = demographics.hhc.HHRESP
goto child.chs.BWGT_LB
else]
goto CSPVERF_S
endif]

Question ID: CID.040_00.000

Instrument Variable Name: CSPVERF_S
Questionnaire File Name: Sample Child
Question Text:
* Please verify the following information about the sample child before proceeding:
I have recorded [fill1: ALIAS of Sample Child]'s sex as [fill2: Sex of Sample Child]. Is this correct?
* If respondent "refuses" or says "don't know", enter "1" for "yes".

1 Yes
2 No
Universe Text: Respondent is not the person entered in HHRESP or RELRESP_A.
Skip Instructions:
(1) goto CSPVERF_A
(2) goto NEWSEX

Question ID: CID.041_00.000

Instrument Variable Name: NEWSEX
Questionnaire File Name: Sample Child
Question Text:
Is [fill: ALIAS of Sample Child] Male or Female?
* If don’t know or refused enter your best guess of the child's sex.
1 Male
2 Female

Universe Text: Respondent said child's sex is not correct.
Skip Instructions:
(1,2) store NEWSEX in SEX
goto ERR_NEWSEX
reset CSPVERF_S
goto CSPVERF_S
Hard Edit: ERR_NEWSEX
* The gender will now be changed to [fill: NEWSEX].
goto CSPVERF_S (as the default goto)

Question ID: CID.042_00.000

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

Question ID: CID.043_00.000

Instrument Variable Name: NEWAGE
Questionnaire File Name: Sample Child
Question Text:
How old is [fill1: ALIAS of Sample Child]?
* If age given in months, weeks, or days, convert age to appropriate year. If less than one year old, enter "0".
000-120 Age in years
Universe Text: Respondent said child's age is not correct
Skip Instructions:
(0-120, Refused, Don't know)
if NEWAGE = 'Refused' or NEWAGE = 'Don't know' or NEWAGE = AGE
reset CSPVERF_A
goto ERR_NEWAGE
else
store NEWAGE in AGE
goto NEWDOB_M
Hard Edit: ERR_NEWAGE
*Age of [fill1: ALIAS of Sample Child] remains [fill2: Age of Sample Child] years old.
goto CSPVERF_A (whether suppressed or not)

Question ID: CID.044_00.000

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

Question ID: CID.046_01.000

Instrument Variable Name: NEWDOB_M
Questionnaire File Name: Sample Child
Question Text:
1 of 3
What is [fill: ALIAS of Sample Child]'s birthday?
*Enter month of birth.
01 January
02 February
03 March
04 April
05 May
06 June
07 July
08 August
09 September
10 October
11 November
12 December
Universe Text: Respondent said child's date of birth is not correct or child's age is not correct
Skip Instructions:
(01-12, Refused, Don't know) goto NEWDOB_D

Question ID: CID.046_02.000

Instrument Variable Name: NEWDOB_D
Questionnaire File Name: Sample Child
Question Text:
2 of 3
* Enter day of birth.
01-31 Day of the month
Universe Text: Respondent said child's date of birth is not correct or child's age is not correct
Skip Instructions:
(01-31,Refused,Don't know) goto NEWDOB_Y
If days not valid, goto ERR_NEWDOB_D
Hard Edit: ERR_NEWDOB_D
* [fill2: NEWDOB_D] is not a valid day for [fill3: NEWDOB_M].
* Please correct.

Question ID: CID.046_03.000

Instrument Variable Name: NEWDOB_Y
Questionnaire File Name: Sample Child
Question Text:
3 of 3
* Enter year of birth.
1880-2020 Year of birth
Universe Text: Respondent said child's date of birth is not correct or child's age is not correct
Skip Instructions:
(1880-2020, Refused, Don't know) if CSPVERF_A = '2' (No) then reset CSPVERF_A to empty
goto CSPVERF_A
elseif CSPVERF_D = '2' (No) then reset CSPVERF_D to empty
goto CSPVERF_D
endif
(if year GT current year) or (if year = current year and month GT current month) or (if year = current year and month = current month and day GT current day)
goto ERR1_NEWDOB_Y
endif
(if birth month = '02' and birth day = '29' and this is not a leap year)
goto ERR2_NEWDOB_Y
endif
(if NEWDOB_M = 'Ref' or 'DK') or (if NEWDOB_D = 'Ref' or 'DK') or (if NEWDOB_Y = 'Ref' or 'DK')
goto ERR3_NEWDOB_Y
else
store NEWDOB_M in DOBM
store NEWDOB_D in DOBD
store NEWDOB_Y in DOBY
if CSPVERF_A = '2' (No) then reset CSPVERF_A to empty
goto CSPVERF_A
elseif CSPVERF_D = '2' (No) then reset CSPVERF_D to empty
goto CSPVERF_D
endif
endif
Calculate age from NEWDOB_M, NEWDOB_D, and NEWDOB_Y.
if age from NEWDOB items is ne AGE and age from NEWDOB items is valid
reset CSPVERF_A or CSPVERF_D
goto ERR4_NEWDOB_Y
endif
Hard Edit: ERR1_NEWDOB_Y
*Future date invalid: [fill2: (NEWDOB_M) (NEWDOB_D), (NEWDOB_Y)]
*Please correct.
goto NEWDOB_M (whether suppressed or not)
ERR2_NEWDOB_Y
*Not a valid day: [fill2: (NEWDOB_M) (NEWDOB_D), (NEWDOB_Y)]
*Please correct.
goto NEWDOB_M (whether suppressed or not)
ERR3_NEWDOB_Y
*DOB of [fill1: ALIAS of Sample Child] remains [fill3: (DOBM) (DOBD), (DOBY)]
goto CSPVERF_A
ERR4_NEWDOB_Y
*Data mismatched. Please fix Age or Birthday.
goto CSPVERF_A (whether suppressed or not)


Question ID: CHS.010_01.000

Instrument Variable Name: BWGT_LB
Questionnaire File Name: Sample Child
Question Text:
?[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
Universe Text: Sample children less than 18
Skip Instructions:
(1-12) [goto BWGT_OZ]
(13-15) [goto ERR1_BWGT_LB]
(R,D) [goto CHGT_FT]
(M) [goto BWGT_GR]
[If NE (1-15, M, D, R) goto 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
Questionnaire File Name: Sample Child
Question Text:
* Enter ounces.
00-15 0-15 ounces
97 Refused
99 Don't know
Blank Blank
Universe Text: Sample children less than 18 who have a value entered for weight in pounds.
Skip Instructions:
(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
Questionnaire File Name: Sample Child
Question Text:
* Enter weight in grams.
0500 500 grams or less
0501-6899 501-6899 grams
6900 6900+ grams
9997 Refused
9999 Don't know
Universe Text: Sample children (18 whose birth weight will be entered in metric.
Skip Instructions:

(500-5485, R,D) [goto CHGT_FT]
(5486-6900) [goto 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
Questionnaire File Name: Sample Child
Question Text:
?[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
Universe Text: Sample children 12+
Skip Instructions:

(empty) [goto CHGT_IN]
(0-7) [goto CHGT_IN]
(R,D) [goto CWGT_LB]
(M) [goto 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
Questionnaire File Name: Sample Child
Question Text:
* Enter inches.
00-36 0-36 inches
97 Refused
99 Don't know
Universe Text: Sample children 12+ whose height in feet is 0-7 or is left empty.
Skip Instructions:
(0-36,R,D) If (CHGT_FT = ‘0’, ’empty’) and (CHGT_IN = ‘0’, ‘empty’)
goto ERR1_CHGT_IN
elseif CHGT_FT = ‘1-7’ and CHGT_IN ge ‘12’
goto 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’))
goto ERR3_CHGT_IN
else
goto 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
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children 12+ whose current height will be entered in metric.
Skip Instructions:

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

Question ID: CHS.021_02.000

Instrument Variable Name: CHGT_CM
Questionnaire File Name: Sample Child
Question Text:
* Enter centimeters.
000-241 0-241 centimeters
Blank Blank

Universe Text: Sample children 12+ whose weight will be entered in metric, and who entered "0-2" for height in meters or left it empty.
Skip Instructions:

(0-241,R,D) If (CHGT_M = ‘0’, ’empty’) and (CHGT_CM = ‘0’, ‘empty’)
goto ERR1_CHGT_CM
elseif (CHGT_M eq ‘2’ and CHGT_CM gt ‘41’) or (CHGT_M eq ‘1’ and CHGT_CM gt ‘141’)
goto 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’))
goto ERR3_CHGT_CM
else
goto 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
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children 12+
Skip Instructions:
(1-500) if CWGT_LB lt ‘1’ or CWGT_LB gt ‘500’
goto 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’))
goto ERR2_CWGT_LB
elseif CHGT_FLG = ‘1’ and CWGT_FLG = ‘1’ and AGE ge ‘2’
goto ADD_1
elseif CHGT_FLG = ‘1’ and CWGT_FLG = ‘1’ and AGE lt ‘2’
goto ADD1_2
else
calculate the BMI (Body Mass Index) – See CBMI spec page (R,D) if AGE ge ‘2’ goto ADD_1
else
goto ADD1_2
(M) goto 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
Questionnaire File Name: Sample Child
Question Text:
* Enter weight in kilograms.
002-226 2-226 kilograms
Universe Text: Sample children 12+ whose weight will be entered in metric.
Skip Instructions:
(2-226) if CWGT_KG lt ‘2’ or CWGT_KG gt ‘226’
goto 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’))
goto ERR2_CWGT_KG
elseif CHGT_FLG = ‘1’ and CWGT_FLG = ‘1’ and AGE ge ‘2’
goto ADD_1
elseif CHGT_FLG = ‘1’ and CWGT_FLG = ‘1’ and AGE lt ‘2’ goto ADD1_2
else
calculate the BMI (Body Mass Index) – See CBMI spec page
(R,D) if AGE ge ‘2’
goto ADD_1
else
goto 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
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children less than 2
Skip Instructions:
(1,2,R,D) [goto ADD1_3]

Question ID: CHS.031_03.000

Instrument Variable Name: ADD1_3
Questionnaire File Name: Sample Child
Question Text:
?[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
Universe Text: Sample children (2
Skip Instructions:
(1,2,R,D) [goto CONDL]

Question ID: CHS.031_04.010

Instrument Variable Name: ADD1_2N
Questionnaire File Name: Sample Child
Question Text:
?[F1]
Does [fill: S.C. name] currently have an intellectual disability, also known as mental retardation?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text:
Sample children less than 2 who have been told by a doctor or other health professional that they have an intellectual disability, also known as mental retardation
Skip Instructions:

(1,2,R,D) if ADD1_3=1 [goto ADD1_3N];
else [goto CONDL]

Question ID: CHS.031_05.010

Instrument Variable Name: ADD1_3N
Questionnaire File Name: Sample Child
Question Text:
?[F1]
Does [fill: S.C. name] currently have any other developmental delay?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text:
Sample children less than 2 who have been told by a doctor or other health professional that they have any other developmental delay
Skip Instructions:

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

Question ID: CHS.032_01.000

Instrument Variable Name: ADD_1
Questionnaire File Name: Sample Child
Question Text:
?[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
Universe Text: Sample children 2-17
Skip Instructions:
(1,2,R,D) [go to ADD_2]

Question ID: CHS.032_02.000

Instrument Variable Name: ADD_2
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children 2-17
Skip Instructions:
(1,2,R,D) [go to AUTISM]

Question ID: CHS.032_02.010

Instrument Variable Name: AUTISM
Questionnaire File Name: Sample Child
Question Text:
?[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
Universe Text: Sample children 2-17
Skip Instructions:
(1,2,R,D) [go to ADD_3]

Question ID: CHS.032_03.000

Instrument Variable Name: ADD_3
Questionnaire File Name: Sample Child
Question Text:
?[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
Universe Text: Sample children 2-17
Skip Instructions:
(1,2,R,D) [go to CONDL]

Question ID: CHS.032_04.010

Instrument Variable Name: ADD_1N
Questionnaire File Name: Sample Child
Question Text:
?[F1]
Does [S.C. name] currently have Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD)?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children 2-17 who have ever been told by a doctor or other health professional that they had Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD)

Skip Instructions:

(1,2,R,D) if ADD_2=1 [go to ADD_2N]; else if AUTISM=1 [goto AUTISMN] else if ADD_3=1 [goto ADD_3N]; else [goto CONDL]

Question ID: CHS.032_05.010

Instrument Variable Name: ADD_2N
Questionnaire File Name: Sample Child
Question Text:
?[F1] Does [fill: S.C. name] currently have an Intellectual disability, also known as mental retardation?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children 2-17 who have ever been told by a doctor or other health professional that they had an intellectual disability, aka mental retardation
Skip Instructions:

(1,2,R,D) if AUTISM=1 [goto AUTISMN] else if ADD_3=1 [goto ADD_3N]; else [goto CONDL]

Question ID: CHS.032_06.010

Instrument Variable Name: AUTISMN
Questionnaire File Name: Sample Child
Question Text:
?[F1]
Does [fill: S.C. name] currently have Autism, Asperger’s disorder, pervasive developmental disorder, or autism spectrum disorder?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children 2-17 who have ever been told by a doctor or other health professional that they had Autism, Asperger's Disorder, pervasive developmental disorder, or autism spectrum disorder
Skip Instructions:

(1,2,R,D) if ADD_3=1 [goto ADD_3N]; else [goto CONDL]

Question ID: CHS.032_07.010

Instrument Variable Name: ADD_3N
Questionnaire File Name: Sample Child
Question Text:
?[F1]
Does [fill: S.C. name] currently have any other developmental delay?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children 2-17 who have ever been told by a doctor or other health professional that they had any other developmental delay
Skip Instructions:
(1,2,R,D) [go to CONDL]

Question ID: CHS.060_00.000

Instrument Variable Name: CONDL
Questionnaire File Name: Sample Child
Question Text:
(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
Diabetes
Arthritis
Congenital heart disease
Other heart condition
Universe Text: Sample children (18
Skip Instructions:
(1) [goto CONDL1]
(2,R,D) [goto CPOX]

Question ID: CHS.061_00.000

Instrument Variable Name: CONDL1
Questionnaire File Name: Sample Child
Question Text:
(book) C2 ? [F1]
Which ones?
* Enter all that apply, separate with commas.
Universe Text: Sample children (18 and CONDL=1
Skip Instructions:
(1-9, R,D) [go to CPOX]

Question ID: CHS.070_00.000

Instrument Variable Name: CPOX
Questionnaire File Name: Sample Child
Question Text:
Has [fill: SC Name] EVER had chickenpox?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children less than 18
Skip Instructions:

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

Question ID: CHS.072_00.000

Instrument Variable Name: CPOX12MO
Questionnaire File Name: Sample Child
Question Text:
Has [fill: SC name] had chickenpox DURING THE PAST 12 MONTHS?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children (18 who have had chickenpox
Skip Instructions:

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

Question ID: CHS.080_00.000

Instrument Variable Name: CASHMEV
Questionnaire File Name: Sample Child
Question Text:
? [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
Universe Text: Sample children less than 18
Skip Instructions:

(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
Questionnaire File Name: Sample Child
Question Text:
Does [fill: SC name] still have asthma?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children less than 18 and doctor has informed that child had asthma
Skip Instructions:
(1,2,R,D) [go to CASHYR]

Question ID: CHS.090_00.000

Instrument Variable Name: CASHYR
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children less than 18 and doctor has informed that child had asthma
Skip Instructions:

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

Question ID: CHS.100_00.000

Instrument Variable Name: CASMERYR
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children less than 18 and doctor has informed that child had asthma
Skip Instructions:

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

Question ID: CHS.111_01.000

Instrument Variable Name: CCONDT1_1
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children LE 2
Skip Instructions:
(1,2,R,D) [go to CCONDT1_2]

Question ID: CHS.111_02.000

Instrument Variable Name: CCONDT1_2
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children LE 2
Skip Instructions:
(1,2,R,D) [go to CCONDT1_3]

Question ID: CHS.111_03.000

Instrument Variable Name: CCONDT1_3
Questionnaire File Name: Sample Child
Question Text:
* 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

Universe Text: Sample children LE 2
Skip Instructions:
(1,2,R,D) [go to CCONDT1_4]

Question ID: CHS.111_04.000

Instrument Variable Name: CCONDT1_4
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children LE 2
Skip Instructions:
(1,2,R,D) [go to CCONDT1_5]

Question ID: CHS.111_05.000

Instrument Variable Name: CCONDT1_5
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children LE 2
Skip Instructions:
(1,2,R,D) [go to CCONDT1_6]

Question ID: CHS.111_06.000

Instrument Variable Name: CCONDT1_6
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children LE 2
Skip Instructions:
(1,2,R,D) [go to CCONDT1_8]

Question ID: CHS.111_08.000

Instrument Variable Name: CCONDT1_8
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children LE 2
Skip Instructions:
(1,2,R,D) [go to CCONDT1_9]

Question ID: CHS.111_09.000

Instrument Variable Name: CCONDT1_9
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children LE 2
Skip Instructions:
(1,2,R,D) [go to CHSTATYR]

Question ID: CHS.115_01.000

Instrument Variable Name: CCONDT_1
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children = 3-17
Skip Instructions:
(1,2,R,D) [go to CCONDT_2]

Question ID: CHS.115_02.000

Instrument Variable Name: CCONDT_2
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children = 3-17
Skip Instructions:
(1,2,R,D) [go to CCONDT_3]

Question ID: CHS.115_03.000

Instrument Variable Name: CCONDT_3
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children = 3-17
Skip Instructions:
(1,2,R,D) [go to CCONDT_4]

Question ID: CHS.115_04.000

Instrument Variable Name: CCONDT_4
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children = 3-17
Skip Instructions:
(1,2,R,D) [go to CCONDT_5]

Question ID: CHS.115_05.000

Instrument Variable Name: CCONDT_5
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children = 3-17
Skip Instructions:
(1,2,R,D) [go to CCONDT_6]

Question ID: CHS.115_06.000

Instrument Variable Name: CCONDT_6
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children = 3-17
Skip Instructions:
(1,2,R,D) [go to CCONDT_7]

Question ID: CHS.115_07.000

Instrument Variable Name: CCONDT_7
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children = 3-17
Skip Instructions:
(1,2,R,D) [go to CCONDT_8]

Question ID: CHS.115_08.000

Instrument Variable Name: CCONDT_8
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children = 3-17
Skip Instructions:
(1,2,R,D) [go to CCONDT_9]

Question ID: CHS.115_09.000

Instrument Variable Name: CCONDT_9
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children = 3-17
Skip Instructions:
(1,2,R,D) [go to CCONDT_10]

Question ID: CHS.115_10.000

Instrument Variable Name: CCONDT_10
Questionnaire File Name: Sample Child
Question Text:
* 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

Universe Text: Sample children = 3-17
Skip Instructions:
(1,2,R,D) [goto CHSTATYR]
Question ID: CHS.210_00.000

Instrument Variable Name: CHSTATYR
Questionnaire File Name: Sample Child
Question Text:
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

Universe Text:Sample children less than 18
Skip Instructions:
(1-3,R,D) [if AGE le (4) goto CCOLD2W; else goto SCHDAYR]

Question ID: CHS.220_00.000

Instrument Variable Name: SCHDAYR
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text:Sample children 5-17
Skip Instructions:
(0-99,996,R,D) [goto CCOLD2W]
(100-240) [go to ERR1_SCHDAYR]
(241-995) [goto 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
Questionnaire File Name: Sample Child
Question Text:

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
Universe Text: Sample children less than 18
Skip Instructions:
(1,2,R,D) [goto CINTIL2W]

Question ID: CHS.240_00.000

Instrument Variable Name: CINTIL2W
Questionnaire File Name: Sample Child
Question Text:

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
Universe Text: Sample children less than 18
Skip Instructions:
(1,2,R,D) [goto CHEARST1]

Question ID: CHS.250_00.000

Instrument Variable Name: CHEARST1
Questionnaire File Name: Sample Child
Question Text:
Which statement best describes [fill: S.C. 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
Universe Text: Sample children less than 18
Skip Instructions:
(1-6,R,D) [go to CVISION]

Question ID: CHS.260_00.000

Instrument Variable Name: CVISION
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children less tha 18
Skip Instructions:
(1) [goto CBLIND]
(2,R,D) [if AGE (6 goto CVISTST;
if AGE =6-17 goto CVISGLAS]

Question ID: CHS.270_00.000

Instrument Variable Name: CBLIND
Questionnaire File Name: Sample Child
Question Text:
Is [fill: SC name] blind or unable to see at all?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children less than 18 having trouble seeing
Skip Instructions:
(1) [if AGE (6 go to IHSPEQ;
else if AGE = 6-17 go to CVISACT]
(2,R,D) [if AGE (6 goto CVISTST;
else if AGE = 6-17 goto CVISGLAS]

Question ID: CHS.270_00.010

Instrument Variable Name: CVISTST
Questionnaire File Name: Sample Child
Question Text:
?[F1]
Has [fill: SC name] EVER had [fill: his/her] vision tested by a doctor or other health professional?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text:Sample children less than 6 who is not blind
Skip Instructions:

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

Question ID: CHS.270_00.020

Instrument Variable Name: CVISLT
Questionnaire File Name: Sample Child
Question Text:
When was [fill: his/her] vision last tested?
1 In the last 12 months
2 In the last 13-24 months
3 Over 24 months
7 Refused
9 Don't know
Universe Text:Sample children less than 6 ever had vision tested
Skip Instructions:
(1-3,R,D) [go to IHSPEQ]

Question ID: CHS.270_00.025

Instrument Variable Name: CVISGLAS
Questionnaire File Name: Sample Child
Question Text:
Does [fill: SC name] wear eyeglasses or contact lenses?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text:Sample children less than 18 who is not blind
Skip Instructions:

(1) [goto CVISDIST]
(2,R,D) [go to CVISACT]

Question ID: CHS.270_00.030

Instrument Variable Name: CVISDIST
Questionnaire File Name: Sample Child
Question Text:
Does [fill: SC name] wear eyeglasses or contact lenses to read road and street signs, see the blackboard, play sports, watch TV, or see things in the distance?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children less than 18 wear glasses or contact lenses
Skip Instructions:
(1,2,R,D) [go to CVISREAD]

Question ID: CHS.270_00.035
Instrument Variable Name: CVISREAD
Questionnaire File Name: Sample Child
Question Text:
Does [fill: SC name] wear eyeglasses or contact lenses to read books, write, play hand-held games, or do other things that require [fill: him/her] to see well up close?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children less than 18 wear glasses or contact lenses
Skip Instructions:
(1,2,R,D) [AGE GE 6 go to CVISACT;
else go to IHSPEQ]

Question ID: CHS.270_00.040

Instrument Variable Name: CVISACT
Questionnaire File Name: Sample Child
Question Text:
Does [fill: SC name] participate in sports, hobbies, or other activities that can cause eye injury? This includes activities such as baseball, basketball, soccer and mowing the lawn.
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children 6-17
Skip Instructions:
(1) [go to CVISPROT]
(2,R,D) [go to IHSPEQ]

Question ID: CHS.270_00.050

Instrument Variable Name: CVISPROT
Questionnaire File Name: Sample Child
Question Text:

When doing these activities, on average, does [fill: he/she] wear eye protection always, most of the time, some of the time, or none of the time?
1 Always
2 Most of the time
3 Some of the time
4 None of the time
7 Refused
9 Don't know
Universe Text: Sample children 6-17 participate in sports that cause eye injuries
Skip Instructions:
(1-4,R,D) [go to IHSPEQ]

Question ID: CHS.290_00.000

Instrument Variable Name: IHSPEQ
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children less than 18
Skip Instructions:
(1,2,R,D) [goto IHMOB]

Question ID: CHS.300_00.000

Instrument Variable Name: IHMOB
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children less than 18
Skip Instructions:
(1) [goto IHMOBYR]
(2,R,D) [goto PROBRX]

Question ID: CHS.310_00.000

Instrument Variable Name: IHMOBYR
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children less than 18 that have limited ability to crawl, walk, run, or play
Skip Instructions:
(1,2,R,D) [goto PROBRX]

Question ID: CHS.311_00.000

Instrument Variable Name: PROBRX
Questionnaire File Name: Sample Child
Question Text:
?[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
Universe Text: Sample children less than 18
Skip Instructions:
(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
Questionnaire File Name: Sample Child
Question Text:
?[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
Universe Text: Sample children 3-17
Skip Instructions:
(1,2,R,D) [if AGE ) 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
Questionnaire File Name: Sample Child
Question Text:
(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
Universe Text: Male sample children 2-3
Skip Instructions:
(0-2,R,D) [go to CMHAGM11_2]

Question ID: CHS.321_02.000

Instrument Variable Name: CMHAGM11_2
Questionnaire File Name: Sample Child
Question Text:
(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
Universe Text: Male sample children 2-3
Skip Instructions:
(0-2,R,D) [go to CMHAGM11_3]

Question ID: CHS.321_03.000

Instrument Variable Name: CMHAGM11_3
Questionnaire File Name: Sample Child
Question Text:
(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 speech problems?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
Universe Text: Male sample children 2-3
Skip Instructions:
(0-2,R,D) [go to CMHAGM11_4]

Question ID: CHS.321_04.000

Instrument Variable Name: CMHAGM11_4
Questionnaire File Name: Sample Child
Question Text:
(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 been unhappy, sad, or depressed?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
Universe Text: Male sample children 2-3
Skip Instructions:
(0-2,R,D) [go to CAU.CUSUALPL]

Question ID: CHS.361_01.000

Instrument Variable Name: CMHAGF11_1
Questionnaire File Name: Sample Child
Question Text:
(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
Universe Text: Female sample children 2-3
Skip Instructions:
(0-2,R,D) [go to CMHAGF11_2]

Question ID: CHS.361_02.000

Instrument Variable Name: CMHAGF11_2
Questionnaire File Name: Sample Child
Question Text:
(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
Universe Text: Female sample children 2-3
Skip Instructions:
(0-2,R,D) [go to CMHAGF11_3]

Question ID: CHS.361_03.000

Instrument Variable Name: CMHAGF11_3
Questionnaire File Name: Sample Child
Question Text:
(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 been nervous or high-strung?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
Universe Text: Female sample children 2-3
Skip Instructions:
(0-2,R,D) [go to CMHAGF11_4]

Question ID: CHS.361_04.000

Instrument Variable Name: CMHAGF11_4
Questionnaire File Name: Sample Child
Question Text:
(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 been unhappy, sad, or depressed?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
Universe Text: Female sample children 2-3
Skip Instructions:
(0-2,R,D) [go to CAU.CUSUALPL]

Question ID: CAU.020_00.000

Instrument Variable Name: CUSUALPL
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children less than 18
Skip Instructions:

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

Question ID: CAU.030_00.000

Instrument Variable Name: CPLKIND
Questionnaire File Name: Sample Child
Question Text:
[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
Universe Text: Sample children less than 18 with one or more usual places to go when sick or need health advice
Skip Instructions:
(1-5) [go to CHCPLROU]
(6,R,D) [go to CHCPLKND]

Question ID: CAU.035_00.000

Instrument Variable Name: CHCPLROU
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children less than 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
Skip Instructions:

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

Question ID: CAU.037_00.000

Instrument Variable Name: CHCPLKND
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children less than 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.
Skip Instructions:

(0-6,R,D) if CUSUALPL=2,R,D [goto CPRVTRYR]; ELSE [goto CHCCHGYR]

Question ID: CAU.040_00.000

Instrument Variable Name: CHCCHGYR
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children less than 18 with one or more place to go when sick/need advice [or who reported same place as usual source of routine/preventive care]
Skip Instructions:

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

Question ID: CAU.050_00.000

Instrument Variable Name: CHCCHGHI
Questionnaire File Name: Sample Child
Question Text:

Was this change for a reason related to health insurance?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children less than 18 that have changed their usual place of health care in the past 12 months
Skip Instructions:

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

Question ID: CAU.052_00.010

Instrument Variable Name: CPRVTRYR
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children less than 18
Skip Instructions:
(1) [goto CPRVTRFD ] (2,R,D) [goto CDRNANP]

Question ID: CAU.053_00.010

Instrument Variable Name: CPRVTRFD
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children less than 18 who had trouble finding a provider in the last year
Skip Instructions:
(1,2,R,D) [goto CDRNANP]

Question ID: CAU.055_00.010

Instrument Variable Name: CDRNANP
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children less than 18
Skip Instructions:
(1,2,R,D)[goto CDRNAI]

Question ID: CAU.056_00.010

Instrument Variable Name: CDRNAI
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children less than 18
Skip Instructions:
(1,2,R,D)[goto CHCDLYR_1]

Question ID: CAU.080_01.000

Instrument Variable Name: CHCDLYR1_1
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children less than 18
Skip Instructions:
(1,2,R,D) [goto CHCDLYR1_2]

Question ID: CAU.080_02.000

Instrument Variable Name: CHCDLYR1_2
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children less than 18
Skip Instructions:
(1,2,R,D) [goto CHCDLYR1_3]

Question ID: CAU.080_03.000

Instrument Variable Name: CHCDLYR1_3
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children less than 18
Skip Instructions:
(1,2,R,D) [goto CHCDLYR1_4]

Question ID: CAU.080_04.000

Instrument Variable Name: CHCDLYR1_4
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children less than 18
Skip Instructions:
(1,2,R,D) [goto CHCDLYR1_5]

Question ID: CAU.080_05.000

Instrument Variable Name: CHCDLYR1_5
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children less than 18
Skip Instructions:
(1,2,R,D) [if AGE GE (2) goto CHCAFYR1_1; else goto CHCAFYR]

Question ID: CAU.130_00.000

Instrument Variable Name: CHCAFYR
Questionnaire File Name: Sample Child
Question Text:

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
Universe Text: Sample children less than 2
Skip Instructions:
(1,2,R,D) [goto CHCAFYRN]

Question ID: CAU.133_00.010

Instrument Variable Name: CHCAFYRN
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children less than 2
Skip Instructions:
(1,2,R,D) [goto CHCAFYRF]

Question ID: CAU.133_00.020

Instrument Variable Name: CHCAFYRF
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children less than 2
Skip Instructions:
(1,2,R,D) [if AGE (1 goto CHCSYR1_2; else goto CDENLONG]

Question ID: CAU.135_01.000

Instrument Variable Name: CHCAFYR1_1
Questionnaire File Name: Sample Child
Question Text:

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
Universe Text: Sample children GE 2
Skip Instructions:
(1,2,R,D) [goto CHCAFYR1_2]

Question ID: CAU.135_02.000

Instrument Variable Name: CHCAFYR1_2
Questionnaire File Name: Sample Child
Question Text:

* 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
Universe Text: Sample children GE 2
Skip Instructions:
(1,2,R,D) [goto CHCAFYR1_3]

Question ID: CAU.135_03.000

Instrument Variable Name: CHCAFYR1_3
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children GE 2
Skip Instructions:
(1,2,R,D) [goto CHCAFYR1_4]

Question ID: CAU.135_04.000

Instrument Variable Name: CHCAFYR1_4
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children GE 2
Skip Instructions:
(1,2,R,D) [goto CHCAFYR1_5]

Question ID: CAU.135_05.010

Instrument Variable Name: CHCAFYR1_5
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children GE 2
Skip Instructions:
(1,2,R,D) [goto CHCAFYR1_6]

Question ID: CAU.135_06.010

Instrument Variable Name: CHCAFYR1_6
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children GE 2
Skip Instructions:
(1,2,R,D) [goto CDENLONG]

Question ID: CAU.160_00.000

Instrument Variable Name: CDENLONG
Questionnaire File Name: Sample Child
Question Text:

(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
Universe Text: Sample children GE 1
Skip Instructions:
(0-5,R,D) [if AGE GE (2) goto CHCSYR_1; else go to CHCSYR1_2]

Question ID: CAU.170_01.000

Instrument Variable Name: CHCSYR1_2
Questionnaire File Name: Sample Child
Question Text:

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
Universe Text: Sample children less than 2
Skip Instructions:
(1,2,R,D) [goto CHCSYR1_3]

Question ID: CAU.170_02.000

Instrument Variable Name: CHCSYR1_3
Questionnaire File Name: Sample Child
Question Text:
?[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
Universe Text: Sample children less than 2
Skip Instructions:
(1,2,R,D) [goto CHCSYR1_5]

Question ID: CAU.170_03.000

Instrument Variable Name: CHCSYR1_5
Questionnaire File Name: Sample Child
Question Text:
?[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
Universe Text: Sample children less than 2
Skip Instructions:
(1,2,R,D) [goto CHCSYR1_6]

Question ID: CAU.170_04.000

Instrument Variable Name: CHCSYR1_6
Questionnaire File Name: Sample Child
Question Text:

* 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
Universe Text: Sample children less than 2
Skip Instructions:
(1,2,R,D) [goto CHCSYR8_1]

Question ID: CAU.175_01.000

Instrument Variable Name: CHCSYR_1
Questionnaire File Name: Sample Child
Question Text:

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
Universe Text: Sample children GE 2
Skip Instructions:
(1,2,R,D) [goto CHCSYR_2]

Question ID: CAU.175_02.000

Instrument Variable Name: CHCSYR_2
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children GE 2
Skip Instructions:
(1,2,R,D) [goto CHCSYR_3]

Question ID: CAU.175_03.000

Instrument Variable Name: CHCSYR_3
Questionnaire File Name: Sample Child
Question Text:
?[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
Universe Text: Sample children GE 2
Skip Instructions:
(1,2,R,D) [goto CHCSYR_4]

Question ID: CAU.175_04.000

Instrument Variable Name: CHCSYR_4
Questionnaire File Name: Sample Child
Question Text:
?[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
Universe Text: Sample children GE 2
Skip Instructions:
(1,2,R,D) [goto CHCSYR_5]

Question ID: CAU.175_05.000

Instrument Variable Name: CHCSYR_5
Questionnaire File Name: Sample Child
Question Text:
?[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
Universe Text: Sample children GE 2
Skip Instructions:
(1,2,R,D) [goto CHCSYR_6]

Question ID: CAU.175_06.000

Instrument Variable Name: CHCSYR_6
Questionnaire File Name: Sample Child
Question Text:
?[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
Universe Text: Sample children GE 2
Skip Instructions:
(1,2,R,D) [if SEX eq (2) and AGE GE 15 goto CHCSYR7; else goto CHCSYR8_1]

Question ID: CAU.230_00.000

Instrument Variable Name: CHCSYR7
Questionnaire File Name: Sample Child
Question Text:
?[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
Universe Text: Sample children GE 15 who are female
Skip Instructions:
(1,2,R,D) [goto CHCSYR8_1]

Question ID: CAU.240_01.000

Instrument Variable Name: CHCSYR8_1
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children less than 18
Skip Instructions:
(1,2,R,D) [goto CHCSYR8_2]

Question ID: CAU.240_02.000

Instrument Variable Name: CHCSYR8_2
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children less than 18
Skip Instructions:

(1) [goto CHCSYR10]
(2,R,D) [goto CHPEXYR]

Question ID: CAU.260_00.000

Instrument Variable Name: CHCSYR10
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children less than 18 who have seen or talked to a general doctor during the past 12 months
Skip Instructions:
(1,2,R,D) [goto CHCSYREM]

Question ID: CAU.265_00.000

Instrument Variable Name: CHCSYREM
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children less than 18 who have seen a general doctor in the past 12 months
Skip Instructions:
(1,2,R,D) [goto CHPEXYR]

Question ID: CAU.270_00.000

Instrument Variable Name: CHPEXYR
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children less than 18
Skip Instructions:
(1,2,R,D) [goto CHERNOYR]

Question ID: CAU.280_00.000

Instrument Variable Name: CHERNOYR
Questionnaire File Name: Sample Child
Question Text:
(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
Universe Text: Sample children less than18
Skip Instructions:
(0,R,D) [goto CHCHYR] (1-8) [goto CERVISND]

Question ID: CAU.281_00.010

Instrument Variable Name: CERVISND
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children less than 18 who had at least one ER visit in the past year
Skip Instructions:
(1,2,R,D) [go to CERHOS]

Question ID: CAU.282_00.010

Instrument Variable Name: CERHOS
Questionnaire File Name: Sample Child
Question Text:
Did this emergency room visit result in a hospital admission?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children less than 18 who had at least one ER visit in the past year
Skip Instructions:
(1,2,R,D) [go to CERREAS1]

Question ID: CAU.283_01.010

Instrument Variable Name: CERREAS1
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children less than 18 who had at least one ER visit in the past year
Skip Instructions:
(1,2,R,D) [goto CERREAS2]

Question ID: CAU.283_02.020

Instrument Variable Name: CERREAS2
Questionnaire File Name: Sample Child
Question Text:
*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
Universe Text: Sample children less than 18 who had at least one ER visit in the past year
Skip Instructions:
(1,2,R,D) [goto CERREAS3]

Question ID: CAU.283_03.030

Instrument Variable Name: CERREAS3
Questionnaire File Name: Sample Child
Question Text:
*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
Universe Text: Sample children less than 18 who had at least one ER visit in the past year
Skip Instructions:
(1,2,R,D) [goto CERREAS4]

Question ID: CAU.283_04.040

Instrument Variable Name: CERREAS4
Questionnaire File Name: Sample Child
Question Text:
*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

Universe Text: Sample children less than 18 who had at least one ER visit in the past year
Skip Instructions:
(1,2,R,D) [goto CERREAS5]

Question ID: CAU.283_05.050

Instrument Variable Name: CERREAS5
Questionnaire File Name: Sample Child
Question Text:
*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
Universe Text: Sample children less than 18 who had at least one ER visit in the past year
Skip Instructions:
(1,2,R,D) [goto CERREAS6]

Question ID: CAU.283_06.060

Instrument Variable Name: CERREAS6
Questionnaire File Name: Sample Child
Question Text:
*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
Universe Text: Sample children less than 18 who had at least one ER visit in the past year
Skip Instructions:
(1,2,R,D) [goto CERREAS7]

Question ID: CAU.283_07.070

Instrument Variable Name: CERREAS7
Questionnaire File Name: Sample Child
Question Text:
*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
Universe Text: Sample children less than 18 who had at least one ER visit in the past year
Skip Instructions:
(1,2,R,D) [goto CERREAS8]

Question ID: CAU.283_08.080

Instrument Variable Name: CERREAS8
Questionnaire File Name: Sample Child
Question Text:
*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
Universe Text: Sample children less than 18 who had at least one ER visit in the past year
Skip Instructions:
(1,2,R,D) [goto CHCHYR]

Question ID: CAU.290_00.000

Instrument Variable Name: CHCHYR
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children less than 18
Skip Instructions:

(1) [goto CHCHMOYR]
(2,R,D) [goto CHCNOYR]

Question ID: CAU.300_00.000

Instrument Variable Name: CHCHMOYR
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children less than 18 that have received home care from health professional during the past 12 months
Skip Instructions:
(01-12,R,D) [goto CHCHNOYR]

Question ID: CAU.310_00.000

Instrument Variable Name: CHCHNOYR
Questionnaire File Name: Sample Child
Question Text:
(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
Universe Text: Sample children less than 18 that have received home care from health professional during the past 12 months
Skip Instructions:
(1-8,R,D) [goto CHCNOYR]

Question ID: CAU.320_00.000

Instrument Variable Name: CHCNOYR
Questionnaire File Name: Sample Child
Question Text:
(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
Universe Text: Sample children less than 18
Skip Instructions:
(0-8,R,D) [goto CSRGYR]

Question ID: CAU.330_00.000

Instrument Variable Name: CSRGYR
Questionnaire File Name: Sample Child
Question Text:

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
Universe Text: Sample children less than18
Skip Instructions:

(1) [goto CSRGNOYR]
(2,R,D) [goto CMDLONG]

Question ID: CAU.340_00.000

Instrument Variable Name: CSRGNOYR
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample children less than 18 that have undergone surgery during the past 12 months
Skip Instructions:

(1-10,R,D) [goto CMDLONG]
(11-95) [goto 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
Questionnaire File Name: Sample Child
Question Text:
(book) C4
About how long has it been since anyone in the family last saw or talked to a doctor or other health care professional about [fill1: alias]'s health? Include doctors seen while [fill2: he/she] was a patient in a hospital.
0 Never
1 6 months or less
2 More than 6 months, but not more than 1 year ago
3 More than 1 year, but not more than 2 years ago
4 More than 2 years, but not more than 5 years ago
5 More than 5 years ago
7 Refused
9 Don't know
Universe Text: Sample children less than 18
Skip Instructions:
(0-5, D, R) [if AGE=4-17 goto CMHCOPY; else goto CH1N1_1]

Question ID: CMB.010_00.000

Instrument Variable Name: CMHCOPY
Questionnaire File Name: Sample Child
Question Text:
* 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
Universe Text: Sample children GE 4
Skip Instructions:
(1) [goto CMHMF_1]

Question ID: CMB.020_01.000

Instrument Variable Name: CMHMF_1
Questionnaire File Name: Sample Child
Question Text:
(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
Universe Text: Sample children GE 4
Skip Instructions:
(1-3,D,R) [goto CMHMF_2]

Question ID: CMB.020_02.000

Instrument Variable Name: CMHMF_2
Questionnaire File Name: Sample Child
Question Text:
(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
Universe Text: Sample children GE 4
Skip Instructions:
(1-3,D,R) [goto CMHMF_3]

Question ID: CMB.020_03.000

Instrument Variable Name: CMHMF_3
Questionnaire File Name: Sample Child
Question Text:
(book) C7
* Read if necessary.
I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE,
SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: SC name] DURING THE PAST SIX MONTHS...
[fill2: He/She]
...is often unhappy, depressed or tearful.
0 Not true
1 Somewhat true
2 Certainly true
7 Refused
9 Don't know
Universe Text: Sample children GE 4
Skip Instructions:
(1-3,D,R) [goto CMHMF_4]

Question ID: CMB.020_04.000

Instrument Variable Name: CMHMF_4
Questionnaire File Name: Sample Child
Question Text:
(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
Universe Text: Sample children GE 4
Skip Instructions:
(1-3,D,R) [goto CMHMF_5]

Question ID: CMB.020_05.000

Instrument Variable Name: CMHMF_5
Questionnaire File Name: Sample Child
Question Text:
(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
Universe Text: Sample children GE 4
Skip Instructions:
(1-3,D,R) [goto CMHDIFF]

Question ID: CMB.030_00.000

Instrument Variable Name: CMHDIFF
Questionnaire File Name: Sample Child
Question Text:
(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
Universe Text: Sample children GE 4
Skip Instructions:
(1-4,R,D) [goto next section]

Question ID: CFI.005_00.010

Instrument Variable Name: CH1N1_1
Questionnaire File Name: Sample Child
Question Text:
?[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
Universe Text: Sample Child LE 17 years
Skip Instructions:
(1) [goto CH1N1_2]
(2,R,D) [goto next section]

Question ID: CFI.005_00.020

Instrument Variable Name: CH1N1_2
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample Child LE 17 years who have had an vaccine dose
Skip Instructions:
(1,2) [goto CH1N1_3M]
(R,D) [goto next section]

Question ID: CFI.005_00.030

Instrument Variable Name: CH1N1_3M
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample Child LE 17 who have had one or more vaccine doses
Skip Instructions:
(1-12,D) [ goto CH1N1_4Y]
(R) [goto CH1N1_5]

Question ID: CFI.005_00.040

Instrument Variable Name: CH1N1_4Y
Questionnaire File Name: Sample Child
Question Text:
2 of 2
*Enter year of most recent flu vaccine.
Year Year
9997 Refused
9999 Don't know
Universe Text: Sample Child LE 17 years who have had one or more vaccine doses and gave month/don't know month of vaccine dose
Skip Instructions:
(valid year,R,D) [goto CH1N1_5]
[If CH1N1_3M and CH1N1_4Y = a future date] goto ERR1_ CH1N1_4Y]
[If CH1N1_3M and CH1N1_4Y = a date prior to birth] goto ERR2_ CH1N1_4Y]
[If CH1N1_3M and CH1N1_4Y = a date prior to 12 months ago] goto ERR3_ CH1N1_4Y]
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
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample Child LE 17 years who have had one or more vaccine doses
Skip Instructions:
(1-2,R,D) IF CH1N1_2=1 [goto next section]; else if CH1N1_2=2 [goto CH1N1_6M]

Question ID: CFI.005_00.060

Instrument Variable Name: CH1N1_6M
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample Child LE 17 years who have had more than one vaccine doses
Skip Instructions:
(1-12,D) [ goto CH1N1_7Y] (R) [goto CH1N1_8]

Question ID: CFI.005_00.070

Instrument Variable Name: CH1N1_7Y
Questionnaire File Name: Sample Child
Question Text:
2 of 2
*Enter year of next most recent flu vaccine.
Year Year
9997 Refused
9999 Don't know
Universe Text: Sample Child LE 17 years who have had more than one vaccine doses and gave month/don't know month of vaccine dose
Skip Instructions:
(valid year,R,D) [goto CH1N1_8]
[If CH1N1_6M and CH1N1_7Y = a future date] goto ERR1_ CH1N1_7Y]
[If CH1N1_6M and CH1N1_7Y = a date prior to birth] goto ERR2_ CH1N1_7Y]
[If CH1N1_6M and CH1N1_7Y = a date prior to 12 months ago] goto ERR3_ CH1N1_7Y]
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
Questionnaire File Name: Sample Child
Question Text:
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
Universe Text: Sample Child LE 17 years who have more than one vaccine dose
Skip Instructions:
(1-2,R,D) [goto next section]

Question ID: CCH.010_00.000

Instrument Variable Name: CNAT_USM
Questionnaire File Name: Sample Child
Question Text:
? [F1]
Now I am going to ask you about some health services (fill1: S.C. name) may have used.
DURING THE PAST 12 MONTHS, did (fill1: S.C. name) see a practitioner for naturopathy (nay-chur-AH-puh-thee)?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children 4+
Skip Instructions:
(1,2,R,D) [goto CCHE_USM]

Question ID: CCH.020_00.000

Instrument Variable Name: CCHE_USM
Questionnaire File Name: Sample Child
Question Text:
? [F1]
* Read if necessary: DURING THE PAST 12 MONTHS
… did (fill1: S.C. name) see a practitioner for chelation (key-LAY-shun) therapy?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children 4+
Skip Instructions:
(1,2,R,D) [goto CTRD_USM]

Question ID: CCH.030_00.000

Instrument Variable Name: CTRD_USM
Questionnaire File Name: Sample Child
Question Text:
? [F1]
* Read if necessary: DURING THE PAST 12 MONTHS
… did (fill1: S.C. name) see a practitioner for traditional medicine such as a Shaman (SHAH-man), curandero (coo-rahnDEHR-oh), Yerbero (yehr-BEHR-oh), sobador (so-bah-DOHR), or Native American Healer?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children 4+
Skip Instructions:
(1) [goto CTRD_US1]
(2,R,D) [goto CHOM_USM]

Question ID: CCH.040_00.000

Instrument Variable Name: CTRD_US1
Questionnaire File Name: Sample Child
Question Text:
Which practitioners for traditional medicine did (fill1: S.C. name) see in the past 12 months?
* Enter all that apply, separate with commas.
1 Shaman (SHAH-man)
2 Curandero (coo-rahn-DEHR-oh), Machi (MAH-chee), or Parchero (pahr-CHEH-roh)
3 Yerbero (yehr-BEH-roh) or Hierbista (yehr-BEE-stah)
4 Sobador (so-bah-DOHR)
5 Native American Healer or Medicine Man
6 Other
7 Refused
9 Don't know
Universe Text: Sample children 4+ who have seen a traditional healer in the past 12 months
Skip Instructions:
(1-6,R,D) [goto CHOM_USM]

Question ID: CCH.050_00.000

Instrument Variable Name: CHOM_USM
Questionnaire File Name: Sample Child
Question Text:
? [F1]
Practitioners of homeopathy (ho-mee-AH-puh-thee) recommend small pills or drops that are often placed under the tongue to treat health problems.
DURING THE PAST 12 MONTHS, did (fill1: S.C. name) see a practitioner for homeopathic treatment?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children 4+
Skip Instructions:
(1,2,R,D) [goto CMBOU_MN]

Question ID: CCH.060_00.000

Instrument Variable Name: CMBOU_MN
Questionnaire File Name: Sample Child
Question Text:
? [F1]
DURING THE PAST 12 MONTHS, did (fill1: S.C. name) use
… Mantra Meditation, including Transcendental Meditation, Relaxation Response, and Clinically Standardized Meditation?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children 4+
Skip Instructions:
(1,2,R,D) [goto CMBOU_MD]

Question ID: CCH.070_00.000

Instrument Variable Name: CMBOU_MD
Questionnaire File Name: Sample Child
Question Text:
? [F1]
* Read if necessary: DURING THE PAST 12 MONTHS, did (fill1: S.C. name) use
... Mindfulness meditation, including Vipassana (vih-PAS-sah-nah), Zen Buddhist meditation, Mindfulness-based Stress Reduction, and Mindfulness-based Cognitive Therapy?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children 4+
Skip Instructions:
(1,2,R,D) [goto CMBOU_SP]

Question ID: CCH.080_00.000

Instrument Variable Name: CMBOU_SP
Questionnaire File Name: Sample Child
Question Text:
? [F1]
* Read if necessary: DURING THE PAST 12 MONTHS, did (fill1: S.C. name) use
... Spiritual meditation including Centering Prayer and Contemplative Meditation?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children 4+
Skip Instructions:
(1,2,R,D) [goto CMBOU_IM]

Question ID: CCH.090_00.000

Instrument Variable Name: CMBOU_IM
Questionnaire File Name: Sample Child
Question Text:
? [F1]
* Read if necessary: DURING THE PAST 12 MONTHS, did (fill1: S.C. name) use
… Guided imagery
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children 4+
Skip Instructions:
(1,2,R,D) [goto CMBOU_PR]

Question ID: CCH.100_00.000

Instrument Variable Name: CMBOU_PR
Questionnaire File Name: Sample Child
Question Text:
? [F1]
* Read if necessary: DURING THE PAST 12 MONTHS, did (fill1: S.C. name) use
... Progressive relaxation?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children 4+
Skip Instructions:
(1,2,R,D) [goto CYTQU_YG]

Question ID: CCH.110_00.000

Instrument Variable Name: CYTQU_YG
Questionnaire File Name: Sample Child
Question Text:
? [F1]
DURING THE PAST 12 MONTHS, did (fill1: S.C. name) practice Yoga for (fill2: himself/herself)?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children 4+
Skip Instructions:
(1) [goto CYTQ_BTY]
(2,R,D) [goto CYTQU_TA]

Question ID: CCH.120_00.000

Instrument Variable Name: CYTQ_BTY
Questionnaire File Name: Sample Child
Question Text:
Did (fill1: S.C. name) do breathing exercises as part of Yoga? Breathing exercises may involve actively controlling the way air is drawn in, or the rate or depth of breathing.
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children 4+ who have practiced Yoga in the past 12 months
Skip Instructions:
(1,2,R,D) [goto CYTQ_MDY]

Question ID: CCH.130_00.000

Instrument Variable Name: CYTQ_MDY
Questionnaire File Name: Sample Child
Question Text:
Did (fill1: S.C. name) do meditation as part of Yoga?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children 4+ who have practiced Yoga in the past 12 months
Skip Instructions:
(1,2,R,D) [goto CYTQU_TA]

Question ID: CCH.140_00.000

Instrument Variable Name: CYTQU_TA
Questionnaire File Name: Sample Child
Question Text:
? [F1]
DURING THE PAST 12 MONTHS, did (fill1: S.C. name) practice Tai Chi (tie-CHEE) for (fill2: himself/herself)?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children 4+
Skip Instructions:
(1) [goto CYTQ_BTT]
(2,R,D) [goto CYTQU_QG]

Question ID: CCH.150_00.000

Instrument Variable Name: CYTQ_BTT
Questionnaire File Name: Sample Child
Question Text:
Did (fill1: S.C. name) do breathing exercises as part of Tai-Chi? Breathing exercises may involve actively controlling the way air is drawn in, or the rate or depth of breathing.
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children 4+ who have practiced Tai-Chi in the past 12 months
Skip Instructions:
(1,2,R,D) [goto CYTQ_MDT]

Question ID: CCH.160_00.000

Instrument Variable Name: CYTQ_MDT
Questionnaire File Name: Sample Child
Question Text:
Did (fill1: S.C. name) do meditation as part of Tai-Chi?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children 4+ who have practiced Tai-Chi in the past 12 months
Skip Instructions:
(1,2,R,) [goto CYTQU_QG]

Question ID: CCH.170_00.000

Instrument Variable Name: CYTQU_QG
Questionnaire File Name: Sample Child
Question Text:
? [F1]
DURING THE PAST 12 MONTHS, did (fill1: S.C. name) practice Qi Gong (chee-GONG) for (fill2: himself/herself)?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children 4+
Skip Instructions:
(1) [goto CYTQ_BTQ]
(2,R,D) [goto next section]

Question ID: CCH.180_00.000

Instrument Variable Name: CYTQ_BTQ
Questionnaire File Name: Sample Child
Question Text:
Did (fill1: S.C. name) do breathing exercises as part of Qi Gong? Breathing exercises may involve actively controlling the way air is drawn in, or the rate or depth of breathing.
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children 4+ who have practiced Qi Gong in the past 12 months
Skip Instructions:
(1,2,R,D) [goto CYTQ_MDQ]

Question ID: CCH.190_00.000

Instrument Variable Name: CYTQ_MDQ
Questionnaire File Name: Sample Child
Question Text:
Did (fill1: S.C. name) do meditation as part of Qi Gong?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children 4+ who have practiced Qi Gong in the past 12 months
Skip Instructions:
(1,2,R,D) [goto next section]