2018 NHIS Questionnaire - Sample Child
Child Identification
Document Version Date: 12-Jun-19

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
endif
Hard Edit: 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

Questionnaire File Name: Sample Child
Instrument Variable Name: NEWSEX
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

Questionnaire File Name: Sample Child
Instrument Variable Name: CSPVERF_A
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 (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 less than 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 less than 2
Skip Instructions:

(1,2,R,D) if ADD1_2=1 [goto ADD1_2N; else if ADD1_3=1 [goto ADD1_3N; else [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) if ADD_1=1 [goto ADD_1N]; else 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_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 less than 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 less than 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 less than 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 CASSTILL =1 or CASHYR=1 [goto CASMHSP];
else if AGE LE 2 [go to CCONDT1_1];
else [go to CCONDT_1]

Question ID: CHS.100_00.010

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

DURING THE PAST 12 MONTHS, has [fill: S.C. name] stayed overnight in a hospital because of asthma?
*If in hospital for asthma AND other reasons, enter '1'.

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample child less than 18 who still have asthma or who had asthma episode/attack in past 12 months
Skip Instructions:

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

Question ID: CHS.100_00.030

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

DURING THE PAST 12 MONTHS, HOW MANY DAYS of [fill1: daycare or preschool/fill2: school/fill3: school or work] did [fill: S.C. name] miss because of [fill: his/her] asthma?
*Enter '0' for none.
*Enter 995 if child home schooled.
*Enter 996 if child did not go to [fill1: daycare or preschool/fill2: school/fill3: school or work]

000 None
001-365 Days missed
995 Home schooled
996 Did not got to daycare, preschool, school or work
997 Refused
999 Don?t know

Universe Text: Sample child less than 18 who still have asthma or who had asthma episode/attack in past 12 months
Skip Instructions:

(0-100,995,996,R,D) [go to CASMPMED]
(101-365) [go to ERR1_CWZMSWK]
(366-994) [go to ERR2_CWZMSWK]
Hard Edit: if CWZMSWK = 366-994 then display ERR2_CWZMSWK:
"366-994 days not allowed in this field.
* Please correct."
Soft Edit: if CWZMSWK )100 and ne 996 then display ERR1_CWZMSWK:
"CWZMSWK is an unusually large number; Did [fill: S.C. name] miss CWZMSWK days of [fill1/fill2/fill3] due to asthma?"
1 correct proceed to CASMPMED;
2 incorrect, change answer

Question ID: CHS.100_00.060

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

Now I'm going to ask you about two different kinds of ASTHMA medicine. One prevents symptoms over the long term.
The other is for quick relief of symptoms during an attack or episode. This quick relief medicine is breathed in through your mouth using a canister inhaler or a disk inhaler.
DURING THE PAST 3 MONTHS, has [fill: S.C. name] used the kind of PRESCRIPTION asthma inhaler that gives QUICK relief from asthma symptoms during an attack? Include only medications prescribed by a health care professional.

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample child less than 18 who still have asthma or who had asthma episode/attack in past 12 months
Skip Instructions:

(1) [goto CASMTYP]
(2,R,D) [go to CASMDTP2]

Question ID: CHS.100_00.065

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

When [fill: S.C. name] takes [fill: his/her] rescue prescription asthma medication, would you say that [fill: he/she] most often uses an inhaler and/or disk, or does [he/she] most often use a nebulizer?
*Read if necessary: Both an inhaler or a disk inhaler are very portable canisters or devices used to inhale medication in one or two breaths. A nebulizer is a machine that turns liquid medication into a mist that you inhale into the lungs over a few minutes.

1 Inhaler or disk
2 Nebulizer
7 Refused
9 Don't know

Universe Text: Sample child less than 18 who have used a quick relief prescription asthma inhaler in the past three months
Skip Instructions:

(1) [go to CASMCAN]
(2,R,D) [go to CASMDTP2]

Question ID: CHS.100_00.070

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

DURING THE PAST 3 MONTHS, did [fill: S.C. name] use more than three canisters or disks of this type of quick relief inhaler?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample child less than 18 who have used a prescription asthma inhaler/disk most often in the past three months
Skip Instructions:

(1,2,R,D) [go to CASMDTP2]

Question ID: CHS.100_00.090

Instrument Variable Name: CASMDTP2
Questionnaire File Name: Sample Child
Question Text:

The second kind of asthma medication is different from inhalers used for quick relief. It is the preventive kind that is used to protect your lungs and keep you from having attacks. It can be either a pill or an inhaler.
Is [fill: S.C. name] NOW taking a preventive asthma medication every day or almost every day, less often, or never?

1 Every day or almost every day
2 Less often
3 Never
7 Refused
9 Don't know

Universe Text: Sample child les than 18 who still have asthma or who had asthma episode/attack in past 12 months
Skip Instructions:

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

Question ID: CHS.100_00.100

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

An asthma action plan is a printed form with specific instructions based on [fill: S.C. name]'s asthma that tells when to change the amount or type of medicine, when to call the doctor for advice, and when to go to the emergency room.
Has a doctor or other health professional EVER given [fill: S.C. name] an asthma action plan?
*Read if necessary: Include nurses and asthma educators.

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample child less than 18 who still have asthma or who had asthma episode/attack in past 12 months
Skip Instructions:

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

Question ID: CHS.100_00.110

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

Has [fill: S.C. name] ever taken a course or class on how to manage [fill: his/her] asthma?
*Include adult(s) who took a course for the child's asthma.

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample child less than 18 who still have asthma or who had asthma episode/attack in past 12 months
Skip Instructions:

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

Question ID: CHS.100_00.116

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

Has a doctor or other health professional EVER taught [fill: S.C. name] or [fill: his/her] parent or guardian
...how to recognize early signs or symptoms of an asthma episode?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample child less than 18 who still have asthma or who had asthma episode/attack in past 12 months
Skip Instructions:

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

Question ID: CHS.100_00.117

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

*Read if necessary: Has a doctor or other health professional EVER taught [fill: S.C. name] or [fill: his/her] parent or guardian
...how to respond to episodes of asthma?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample child less than 18 who still have asthma or who had asthma episode/attack in past 12 months
Skip Instructions:

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

Question ID: CHS.100_00.118

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

*Read if necessary: Has a doctor or other health professional EVER taught [fill: S.C. name] or [fill: his/her] parent or guardian
...how to monitor peak flow for daily therapy?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample child less than 18 who still have asthma or who had asthma episode/attack in past 12 months
Skip Instructions:

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

Question ID: CHS.100_00.130

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

Has a doctor or other health professional EVER advised you to change things in [fill: S.C. name]'s home, school, or work environment to improve [fill: his/her] asthma?

1 Yes
2 No
3 Was told no changes needed
7 Refused
9 Don't know

Universe Text: Sample child less than 18 who still have asthma or who had asthma episode/attack in past 12 months
Skip Instructions:

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

Question ID: CHS.100_00.135

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

DURING THE PAST 12 MONTHS, how many times did [fill: S.C. name] see a doctor or other health professional for a routine checkup for [fill: his/her] asthma? Please do not include emergency room visits, visits to urgent care centers, or other visits for acute care for an asthma episode or attack.
*Enter '0' for none.

000 None
001-365 Times
997 Refused
999 Don't know

Universe Text: Sample child less than 18 who still have asthma or who had asthma episode/attack in past 12 months
Skip Instructions:

(0-50,R,D) [go to CASYMPT]
(51-365) [goto ERR_CAROUTIN]
Soft Edit: ERR_CAROUTIN
[fill4: CAROUTIN] is an unusually large number.
* Please verify.

Question ID: CHS.100_00.140

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

The next three questions are about the last time [S.C. name] saw a doctor or other health care professional for routine care or for any reason.
At [fill: his/her] last visit, did [fill: S.C. name]'s doctor or other health professional ask HOW OFTEN
....[fill: he/she] had asthma symptoms?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample child less than 18 who still have asthma or who had asthma episode/attack in past 12 months
Skip Instructions:

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

Question ID: CHS.100_00.145

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

*Read if necessary:
At [fill: his/her] last visit, did [fill: S.C. name]?s doctor or other health professional ask HOW OFTEN
...[fill: he/she] used a quick relief inhaler?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample child less than 18 who still have asthma or who had asthma episode/attack in past 12 months
Skip Instructions:

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

Question ID: CHS.100_00.150

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

*Read if necessary:
At [fill: his/her] last visit, did [fill: S.C. name]?s doctor or other health professional ask HOW OFTEN
...asthma symptoms limited [fill: his/her] daily activities?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample child less than 18 who still have asthma or who had asthma episode/attack in past 12 months
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 than 18
Skip Instructions:

(1) [goto CBLIND]
(2,R,D) [goto IHSPEQ]

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:

(1,2,R,D) [goto 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 than18
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:

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:

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:

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:

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 CHCDLYR1_1];
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) to CHCDLYR1_1]

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 CHCDLYR1_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:

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) [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 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 than 18
Skip Instructions:

(0-8,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 than 18
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

Universe Text: Sample children less than 18
Skip Instructions:

(0-5,R,D)
If AGE LT 4 [goto CH1N1_1]
If AGE GE 4 [goto CMHCOPY]

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:

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:

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:

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 ofvaccine 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]

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