Form 1 0-5 Long Instrument

National Survey of Children’s Health
0 to 5 year old children
A study by the U.S. Department of Health and Human Services to better
understand the health issues being faced by children in the United States today.

Your household was chosen at random from all households in the U.S. to participate in this scientific study.
The results will provide vital information used to improve health services—information that is not available anywhere else. The results
will help policymakers, researchers, and educators understand the health service needs of our diverse population as health situations
throughout the country continue to change.

National Survey of Children’s Health
Survey Instructions
Please mark your response with an “X” using blue or black ink, as in the examples below.
Example:

Example:
Right Way

Other, specify:

Wrong Way

Start Here
A while back, you completed a survey that asked about the children living in your household. Thank you for taking the time to
complete that survey.
We now have some follow up questions to ask about one of the children you provided information for in the earlier survey. In
the cover letter that came with this questionnaire, you will find instructions on which child in your household we would like you
to answer these questions for.
Thank you for taking the time to complete this survey.

2

A. Your Child’s General Health
A1

In general, how would you describe your child’s health?

A4

Excellent
Very Good
Good
Fair
Poor
A2

Yes
a. Breathing or other respiratory problems
(such as wheezing or shortness of breath)

How would you describe the condition of your child’s
teeth?

b. Eating or swallowing because of a health
condition
c. Digesting food, including stomach/intestinal
problems, constipation, or diarrhea

Excellent
Very Good
Good
Fair
Poor
A3

d. Repeated or chronic physical pain,
including headaches or other back or body
pain
e. Using his or her hands

How well does each of these items describe your child?

a. Your child is affectionate
and tender with you

D
 uring the past 12 months, has your child had difficulty
with or experienced any of the following?

Definitely Somewhat
true
true

f. Coordination or moving around

Not
true

g. Deafness or problems with hearing
h. Blindness or problems with seeing, even
when wearing glasses

b. Your child bounces back
quickly when things do
not go his or her way

i. Toothaches
j. Bleeding gums

c. Your child shows interest
and curiosity in learning
new things

k. Decayed teeth or cavities

d. Your child smiles and
laughs a lot

3

No

Chronic Conditions

A12

Has a doctor or other health care provider ever told you
that your child has…
A5

Allergies (including food, drug, insect, or other)?
Yes
No
If yes, does the child currently have the condition?
Yes
No

If yes, would you describe it as mild, moderate,
or severe?
Mild
Moderate
Severe
A13

If yes, would you describe it as mild, moderate, or
severe?
Mild
Moderate
Severe
A6

Arthritis?
Yes
No
If yes, does the child currently have the condition?
Yes
No

Asthma?
Yes
No
If yes, does the child currently have the condition?
Yes
No

A14

Blood Disorders (such as sickle cell disease, thalassemia,
or hemophilia)?
Yes
No
If yes, does the child currently have the condition?
Yes
No

A15

Brain injury, concussion or head injury?
Yes
No
If yes, does the child currently have the condition?
Yes
No

A16

Cerebral Palsy?
Yes
No
If yes, does the child currently have the condition?
Yes
No

A17

A18

Tourette Syndrome?
Yes
No
If yes, does the child currently have the condition?
Yes
No
If yes, would you describe it as mild, moderate,
or severe?
Mild
Moderate
Severe

Cystic Fibrosis?
Yes
No
If yes, does the child currently have the condition?
Yes
No
If yes, would you describe it as mild, moderate, or
severe?
Mild
Moderate
Severe

Frequent or severe headaches, including migraine?
Yes
No
If yes, does the child currently have the condition?
Yes
No
If yes, would you describe it as mild, moderate,
or severe?
Mild
Moderate
Severe

If yes, would you describe it as mild, moderate, or
severe?
Mild
Moderate
Severe
A11

Heart Condition?
Yes
No
If yes, does the child currently have the condition?
Yes
No
If yes, would you describe it as mild, moderate,
or severe?
Mild
Moderate
Severe

If yes, would you describe it as mild, moderate, or
severe?
Mild
Moderate
Severe
A10

Genetic or inherited condition?
Yes
No
If yes, does the child currently have the condition?
Yes
No
If yes, would you describe it as mild, moderate,
or severe?
Mild
Moderate
Severe

If yes, would you describe it as mild, moderate, or
severe?
Mild
Moderate
Severe
A9

Epilepsy or seizure disorder?
Yes
No
If yes, does the child currently have the condition?
Yes
No
If yes, would you describe it as mild, moderate,
or severe?
Mild
Moderate
Severe

If yes, would you describe it as mild, moderate, or
severe?
Mild
Moderate
Severe
A8

Down Syndrome?
Yes
No
If yes, does the child currently have the condition?
Yes
No
If yes, would you describe it as mild, moderate,
or severe?
Mild
Moderate
Severe

If yes, would you describe it as mild, moderate, or
severe?
Mild
Moderate
Severe
A7

Diabetes?
Yes
No
If yes, does the child currently have the condition?
Yes
No

4

Emotional, Behavioral, and
Developmental Conditions/Problems

A25

Has a doctor or other health care provider ever told you
that your child has...
A19

Anxiety Problems?
Yes
No
If yes, does the child currently have the condition?
Yes
No

If yes, would you describe it as mild, moderate,
or severe?
Mild
Moderate
Severe
A26

If yes, would you describe it as mild, moderate, or
severe?
Mild
Moderate
Severe
A20

Any Other Mental Health Condition?
Yes
No
If yes, please specify

Does the child currently have the condition?
Yes
No

Depression?
Yes
No
If yes, does the child currently have the condition?
Yes
No
If yes, would you describe it as mild, moderate, or
severe?
Mild
Moderate
Severe

A21

Learning Disability?
Yes
No
If yes, does the child currently have the condition?
Yes
No

If yes, would you describe it as mild, moderate,
or severe?
Mild
Moderate
Severe
A27

Has a doctor or other health care provider ever told you
that your child had Autism or Autism Spectrum Disorder
(ASD)? Please include diagnoses of Asperger’s Disorder or
Pervasive Developmental Disorder (PDD).

Behavioral or Conduct Problems?
Yes
No
If yes, does the child currently have the condition?
Yes
No

Yes
No
[Skip to question A28]
If yes, does the child currently have the condition?
Yes
No

If yes, would you describe it as mild, moderate, or
severe?
Mild
Moderate
Severe
A22

If yes, would you describe it as mild, moderate,
or severe?
Mild
Moderate
Severe

Developmental Delay?
Yes
No
If yes, does the child currently have the condition?
Yes
No

If yes, would you describe it as mild, moderate, or
severe?
Mild
Moderate
Severe
A23

Years

Don’t know

What type of doctor or other health care provider
was the first to tell you that your child had Autism,
ASD or PDD? Please check only one
Primary Care Provider
Specialist
School Psychologist/Counselor
Other Psychologist (Non-School)
Psychiatrist
Other, please specify:

Intellectual Disability (also known as Mental Retardation)?
Yes
No
If yes, does the child currently have the condition?
Yes
No
If yes, would you describe it as mild, moderate, or
severe?
Mild
Moderate
Severe

A24

How old was your child when a doctor or other
health care provider first told you that he or she
had Autism, ASD or PDD?

Speech or other language disorder?
Yes
No
If yes, does the child currently have the condition?
Yes
No

Is your child currently taking medication for
Autism, ASD or PDD?
Yes
No
At any time during the past 12 months, did your
child receive behavioral treatment for Autism,
ASD or PDD, such as training or an intervention
that you or your child received to help with his/her
behavior?
Yes
No

If yes, would you describe it as mild, moderate, or
severe?
Mild
Moderate
Severe

5

A28

Has a doctor or other health care provider ever told you
that your child had Attention Deficit Disorder or AttentionDeficit/Hyperactivity Disorder, that is, ADD or ADHD?
Yes
No

If yes, does the child currently have the condition?
Yes
No
If yes, would you describe it as mild, moderate, or
severe?
Mild
Moderate
Severe

A29

During the past 12 months, how often have your child’s
health conditions or problems affected his or her ability to
do things other children his/her age do?
Never
[Skip to Section B]
Sometimes
Usually
Always 

Is your child currently taking medication for ADD or
ADHD?
Yes
No

Please answer the following question only if you
answered YES to any of the health conditions or
problems listed in A1 through A28. Otherwise, skip to
the next section.

At any time during the past 12 months, did your child
receive behavioral treatment for ADD or ADHD,
such as training or an intervention that you or your
child received to help with his/her behavior?
Yes
No

To what extent do your child’s health conditions
or problems affect his/her ability to do things?
A great deal
Some
Very little

B. Infant Health
B1

Was your child born more than 3 weeks before his or her
due date?
Yes

B2

B3

Yes

No

How much did he or she weigh when born?
Please provide your best estimate.
pounds

Was your child ever breastfed or fed breast milk?
No
How old was your child when he or she
completely stopped breastfeeding or being fed
breast milk?

ounces

Month(s)

OR
kilograms

Check this box if child is
still breastfeeding



grams

How old was your child when he or she was first
fed formula?
Month(s)

Check this box if child has
never been fed formula

B4

How old was your child when he or she was first
fed anything other than breast milk or formula?

Please include juice, cow’s milk, sugar water, baby food, or
anything else that your child might have been given, even
water.
Month(s)

Check this box if child has
never been fed anything
other than breast milk or
formula

6

C. Health Care Services
C1

During the past 12 months, did your child see a
doctor, nurse, or other health care professional for
sick-child care, well-child check-ups, physical exams,
hospitalizations or any other kind of medical care?
Yes

C2

C8

[Skip to Question C4]

No

A
 nswer C8 if your child is 9 months of age or older.
Otherwise go to Question C9.

How your child talks or makes speech sounds?
 How your child interacts with you and others?

Words and phrases your child uses and
understands?
How your child behaves and gets along with you
and others?
C9

centimeters

ounces

grams

Are you concerned about your child’s weight?
Yes, too high
Yes, too low
No, I am not concerned

C10

During the past 12 months, did your child’s doctors or
other health care providers ask if you have concerns
about your child’s learning, development, or behavior?
Yes

No

[Skip to Question C11]

 here does your child usually go? Please check one
W
box below
Doctor’s Office
Hospital Emergency Department
Hospital Outpatient Department
Clinic or Health Center
Retail Store Clinic or “Minute Clinic”
School (Nurse’s Office, Athletic Trainer’s Office)
Some other place

OR
kilograms

Is there a place that your child usually goes when he or
she is sick or you need advice about his or her health?
Yes

How much does your child currently weigh?
pounds

C7

D
 id the questionnaire ask about your concerns
or observations about: Check all that apply.

inches

meters

C6

If your child is 2-5 Years:

OR

D
 id the questionnaire ask about your concerns
or observations about: Check all that apply.

What is your child’s current height?

No

If your child is 9-23 Months:

Thinking about the last time you took your child for a
preventive check-up, about how long was the doctor
or healthcare provider who examined your child in the
room with you? Your best estimate is fine.

feet

C5

Yes

Less than 10 minutes
10-20 minutes
More than 20 minutes
C4

During the past 12 months, or since your child’s
birth, did a doctor or other health care provider have
you fill out a questionnaire about specific concerns
or observations you may have about your child’s
development, communication, or social behaviors?

During the past 12 months, how many times did
your child visit a doctor, nurse, or other health care
professional to receive a preventive check-up? A
preventive check-up is when your child was not sick or
injured, such as an annual or sports physical, or well-child
visit.
0 visits
[Skip to Question C4]
1 visit
2 or more visits

C3

Sometimes a child’s doctor or other health care provider
will ask a parent to fill out a questionnaire at home or
during their child’s visit.

Is there a place that your child usually goes when he or
she needs routine preventive care, such as a physical
examination or well-child check-up?
Yes

No

[Skip to Question C11]

Is that the same place where your child goes when
he or she is sick?
Yes
No

No

7

C11

Please answer C11 if your child is 6 months of age or
older. Otherwise, please skip to Question C12.

C14

During the past 12 months, did your child see a dentist
or other oral health care provider for any kind of dental
care?
Yes

No

 uring the past 12 months, did your child see a
D
specialist other than a mental health professional?
Specialists are doctors like surgeons, heart doctors, allergy
doctors, skin doctors, and others who specialize in one area
of health care.
Yes
No, but my child needed to see a specialist

[Skip to Question C12]

No. My child did not need to see a specialist.
to Question C15]



C12

During the past 12 months, how many times
did your child visit a dentist or other oral health
care provider for preventive dental care, such as
check-ups and dental cleanings?
1 visit
2 or more visits
No preventive visits in past 12 months
[Skip to Question C12]



During the past 12 months, what preventive dental
services did your child receive? Check all that apply.
Checkup
Cleaning
Instruction on tooth brushing and oral health care
X-Rays
Fluoride treatment
Sealant (plastic coatings on back teeth)
Don’t know

C15

During the past 12 months, has your child received
any treatment or counseling from a mental health
professional? Mental health professionals include
psychiatrists, psychologists, psychiatric nurses, and clinical
social workers.

No. My child did not need to see a mental
health professional.
[Skip to Question C13]

C17

During the past 12 months, has your child taken any
medication because of difficulties with his or her
emotions, concentration, or behavior?
Yes

No

S
 ometimes people have difficulty getting health care
when they need it. During the past 12 months, was there
any time when your child needed health care but it was
not received? By health care, we mean medical care as
well as other kinds of care like dental care, vision care, and
mental health services.
No

[Skip to Question C18]

If yes, which type of care was not received. Check all
that apply.
Medical Care
Dental Care
Vision Care
Hearing Care
Mental Health Services
Other, please specify:

No, but my child needed to see a mental
health professional

C13

During the past 12 months, did your child use any type
of alternative health care or treatment? Alternative health
care can include acupuncture, chiropractic care, relaxation
therapies, herbal supplements, and others. Some therapies
involve seeing a health care provider, while others can be
done on your own.

Yes

Yes

How much of a problem was it to get the mental

health treatment or counseling that your child
needed?
 Big problem
 Small problem
 Not a problem

How much of a problem was it to get the specialist
care that your child needed?
 Big problem
 Small problem
 Not a problem

Yes
C16

[Skip

W
 ere these difficulties in getting services for your child
because:
Yes
a. Your child was not eligible for the
services?

No

b. The services your child needed were not
available in your area?
c. There were problems getting an
appointment when your child needed one?
d. There were problems with getting
transportation or child care?
e. The (clinic/doctor’s) office wasn’t open
when your child needed care?
f. There were issues related to cost?

8

No

C18

C19

During the past 12 months, how often were you
frustrated in your efforts to get services for your child?
Never
Sometimes
Usually
Always

C21

Yes

During the past 12 months, how many times did your
child visit a hospital emergency department?

Years
Is your child currently receiving these therapy
services?
Yes
No

Does your child receive Special Educational
Services? Children receiving these services often have
an Individualized Family Service Plan or Individualized
Education Plan.
Yes

[Skip to Section D]

No

How old was your child when he/she began receiving
these therapy services? Age in years

1 visit
2 or more visits
No visits
C20

Has your child ever received therapy services to meet
his/her developmental needs, such as occupational
therapy, speech therapy, or behavioral therapy?

No

D. Experience with Your Child’s Health Care Providers
D1

Does your child have a primary doctor or nurse? A
primary doctor or nurse is the one your child would see if
he or she needs a check-up or gets sick or hurt.
Yes

D2

No

During the past 12 months, did your child need a referral
to see any doctors or receive any services?
Yes

No

D5

a. Discuss with
you the range of
options to consider
for his or her
health care or
treatment?

 uring the past 12 months, how often did your child’s
D
doctors or other health care providers:
Sometimes

b. Make it easy
for you to raise
concerns or
disagree with
recommendations
for your child’s
health care?

Usually Always

a. Spend enough time
with your child?
b. Listen carefully to
you?

c. Work with you to
decide together
which health care
and treatment
choices would be
best for your child?

c. Show sensitivity to
your family’s values
and customs?
d. Provide the specific
information you
needed concerning
your child?
e. Help you feel like
a partner in your
child’s care?

9

[Skip to

During the past 12 months, how often did your child’s
doctors or other healthcare providers:
Never

Please answer the following questions only if your child
had a health care visit in the past 12 months. Otherwise,
skip to section E.

Never

During the past 12 months, were any decisions needed
about your child’s health care services or treatment,
such as whether to start or stop a prescription or therapy
services, get a referral to a specialist, or have a medical
procedure?
Yes
No, no health care decisions were needed
Section E]

[Skip to Question D3]

 as getting referrals a big problem, a small problem,
W
or not a problem?
Big problem
Small problem
Not a problem
D3

D4

Sometimes

Usually Always

D6

Does anyone help you arrange or coordinate your child’s
care among the different doctors or services that your child
uses?

D8

Yes
No
Did not see more than one health care
provider in past 12 months
[Skip to Question D9]
D7

 uring the past 12 months, have you felt that you could
D
have used extra help arranging or coordinating your child’s
care among the different health care providers or services?
Yes
No
[Skip to Question D8]

O
 verall, how satisfied are you with the communication
among your child’s doctors and other health care
providers?
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied

D9

During the past 12 months, how often did
you get as much help as you wanted with
arranging or coordinating your child’s health
care?
Never

During the past 12 months, did your child’s health care
provider communicate with the child’s school, child care
provider, or special education program?
Yes

No

[Skip to Section E]

Overall, how satisfied are you with that
communication?
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied

Sometimes
Usually
Always

E. Your Child’s Health Insurance Coverage
E1

During the past 12 months, was your child EVER covered
by ANY kind of health insurance or health coverage
plan?

b. Insurance purchased directly from an
insurance company
c. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes or a
disability

No

d. TRICARE or other military health care

a. Change in employer or employment
status

e. Indian Health Service

b. Cancellation due to overdue premiums

f. Other, please specify:

c. Dropped coverage because it was
unaffordable
d. Dropped coverage because benefits
were inadequate

E5

e. Dropped coverage because choice of
health care providers was inadequate

g. Other, please specify:
E6

No

How often does your child’s health insurance allow
him/her to see the health care providers he/she needs?
Never
Sometimes
Usually
Always

Is your child CURRENTLY covered by ANY kind of health
insurance or health coverage plan?
Yes

How often does your child’s health insurance offer
benefits or cover services that meet your child’s needs?
Never
Sometimes
Usually
Always

f. Problems with application or renewal
process

E3

No

a. Insurance through a current or former
employer or union

Please indicate whether any of the following is a reason
your child was not covered by health insurance during
the past 12 months:
Yes

Is your child covered by any of the following types of
health insurance or health coverage plans?
Yes

[Skip to

Yes, my child was covered all 12 months
Question E3]
Yes, but my child had a gap in coverage
No
E2

E4

[Skip to Section F]

10

E7

Not including health insurance premiums or costs that
are covered by insurance, do you pay any money for
your child’s health care?
Yes

No

E8

[Skip to Question E8]

How often are these costs reasonable?
Never
Sometimes
Usually
Always

Please answer this question only if your child uses
mental or behavioral health services. Otherwise, skip to
section F. Thinking specifically about your child’s mental
or behavioral health needs, does your child’s health
insurance offer benefits or cover services that meet these
needs?

Yes, it sometimes covers these services
Yes, it usually covers these services.
Yes, it always covers these services.
No, it never covers these services.

F. Providing for Your Child ’s Health
F1

How much money did you pay for this child’s medical
and health care during the past 12 months? Please do not
include health insurance premiums or costs that were or will
be reimbursed by insurance or another source.

F5

During the past 12 months, did your family have
problems paying for any of your child’s medical or health
care bills?

During the past 12 months, have you or other family
members:
Yes

In an average week, how many hours do you or other
family members spend arranging or coordinating
health or medical care for your child, such as making
appointments or locating services?
Less than 1 hour per week
1-4 hours per week
5-10 hours per week
11 or more hours per week

Yes
No
F3

In an average week, how many hours do you or other
family members spend providing health care at home
for your child? Care might include changing bandages, or
giving medication and therapies when needed.
Less than 1 hour per week
1-4 hours per week
5-10 hours per week
11 or more hours per week

[Skip to

$0 (No medical or health-related expenses)
Question F3]
$1-$249
$250-$499
$500-$999
$1,000-$5,000
More than $5,000
F2

F4

No

a. Stopped working because of your
child’s health status?
b. Cut down on the hours you work
because of your child’s health or
health conditions?
c. Avoided changing jobs because of
concerns about maintaining health
insurance for your child?

11

G. School Readiness
Please answer Section G only if your child is age 4 or
older. Otherwise, please skip to the next section.

G1

G10

G3

G11

Can your child recognize the beginning sound of a
word? For example, can he/she tell you that the word “ball”
starts with the “buh” sound?
Yes

G4

G5

Can your child recognize the letters of the alphabet?

G6

G8

G13

G14

Compared to other children his/her age, how much
difficulty does your child have making or keeping
friends?
A lot of difficulty
A little difficulty
No difficulty

G15

Compared to other children his/her age, how often is
your child unable to sit still?
Never
Rarely
Sometimes
Usually
Always

Can your child recognize basic shapes [e.g., triangle,
circle, square]?
All of the time
Most of the time
Some of the time
None of the time

Does your child play well with others?
Never
Rarely
Sometimes
Usually
Always

Can your child count to 20?
All of the time
Most of the time
Some of the time
None of the time

Can your child use a pencil or crayon?
Never
Rarely
Sometimes
Usually
Always

C
 an your child write his/her first name, even if some of
the letters aren’t quite right or are backwards?
All of the time
Most of the time
Some of the time
None of the time

G7

G12

Can your child clearly explain things he or she has
seen or done so that you get a very good idea what
happened?
All of the time
Most of the time
Some of the time
None of the time

When he or she is paying attention, how often is your
child able to carry out a simple instruction?
Never
Rarely
Sometimes
Usually
Always

No

All of the letters of the alphabet
Most of them
Some of them
None of them

How often does your child keep working at something
until he/she is finished?
Never
Rarely
Sometimes
Usually
Always

How concerned are you about how your child is learning
to do things for him or herself?
A lot
A little
Not at all

How often is your child easily distracted?
Never
Rarely
Sometimes
Usually
Always

How concerned are you about your child’s readiness to
start school?
A lot
A little
Not at all

G2

G9

G16

Does your child seem nervous or afraid?
Yes

G17

Does your child fight with other children?
Yes

12

No
No

H. About Your Child
H1

Was your child born in the United States?

H7

Yes
[Skip to Question H2]
No
How long has your child been in the United States?
Years
H2

None
Less than 1 hour
1-2 hours
3-4 hours
More than 4 hours

Months

How many times has your child moved to a new address
since he or she was born?
H8

Number of times

H3

H4

H5

H9

Please answer this question only if your child is less
than 12 months old. Otherwise, please skip to Question
H6. In which one position do you most often lay your
baby down to sleep now? Check only one

H10

In general, how well do you feel that you are coping with
the day-to-day demands of raising children?
Very well
Somewhat well
Not very well
Not very well at all

H11

During the past month, how often have you felt:
Never Rarely Sometimes Usually Always

On his or her side
On his or her back
On his or her stomach

H6

During the past week, how many days did you or other
family members tell stories or sing songs to your child?
0 days
1-3 days
4-6 days
Every day

During the past week, how many hours of sleep did your
child get on an average weeknight?
Less than 6 hours
6-7 hours
8-9 hours
10 or more hours

During the past week, how many days did you or other
family members read to your child?
0 days
1-3 days
4-6 days
Every day

How often does your child go to bed at about the same
time on weeknights?
Never
Rarely
Sometimes
Usually
Always

On an average weekday, about how much time does
your child usually spend with computers, cell phones,
handheld video games, and other electronic devices,
doing things other than schoolwork?

a. That your child is
much harder to
care for than most
children his/her
age?

On an average weekday, about how much time does
your child usually spend in front of a TV watching TV
programs, videos, or playing video games?

b. That your child
does things that
really bother you
a lot?

None
Less than 1 hour
1-2 hours
3-4 hours
More than 4 hours

c. Angry with your
child?

13

H12

During the past 12 months, was there someone that
you could turn to for day-to-day emotional support with
parenting or raising children?
Yes

H13

No

H14

[Skip to Section I]


If yes, did you receive emotional support from:
Yes

Does your child receive care for at least 10 hours
per week from someone other than his/her parent or
guardian? This could be a day care center, preschool,
Head Start program, family child care home, nanny, au pair,
babysitter or relative.
Yes

No

H15

a. Healthcare provider?
b. Family member or close friend?

During the past 12 months, did you or anyone in the
family have to quit a job, not take a job, or greatly
change your job because of problems with child care for
your child?
Yes

c. Place of worship or religious leader?

No

No

d. Support or advocacy group related to
specific health condition?
e. Peer support group?
f. Counselor or other mental health
professional?
g. Other, please specify:

I. About Your Family and Household
I1

During the past week, on how many days did all the
family members who live in the household eat a meal
together?

I4

0 days
1-3 days
4-6 days
Every day
I2

Very often
Somewhat often
Rarely
Never

Does anyone living in your household use cigarettes,
cigars, or pipe tobacco?
Yes

I5

No

Does anyone smoke inside your home?
Yes
No
I3

Since your child was born, how often has it been very
hard to get by on your family’s income – hard to cover
the basics like food or housing?

We could always afford to eat good nutritious meals
We could always afford enough to eat but not always the
kinds of food we should eat
Sometimes we could not afford enough to eat
Often we could not afford enough to eat

When your family faces problems, how often are you
likely to do each of the following?
None of Some of Most of All of the
the time the time the time
time

The next question is about whether you were able to
afford the food you need. Which of these statements
best describes the food situation in your household in
the last 12 months?

I6

At any time during the past 12 months, even for one
month, did anyone in this household receive:

a. Talk together about
what to do

Yes

b. Work together to
solve our problems

a. Cash assistance from a government
welfare program?

c. Know we have
strengths to draw on

b. Food Stamps or Supplemental
Nutrition Assistance Program
benefits?

d. Stay hopeful even in
difficult times

c. Free or reduced-cost breakfasts or
lunches at school?
d. Benefits from the Women, Infants, and
Children (WIC) Program?

14

No

I7

I9

b. A park or playground?

Families must sometimes face hardships such as
divorce or separation, the loss of a loved one, or drug
and alcohol addiction. The next question asks about
experiences and events that may have occurred during
your child’s life. We understand the sensitive nature of
this question, so we ask that you answer to the best of
your ability.

c. A recreation center, community center,
or boys’ and girls’ club?

 o the best of your knowledge, has your child ever
T
experienced any of the following?

In your neighborhood, are there:
Yes

No

a. Sidewalks or walking paths?

d. A library or bookmobile?

Yes

e. Litter or garbage on the street or
sidewalk?

a. Parent/guardian divorced or separated
b. Parent/guardian died

f. Poorly kept or rundown housing?

c. Parent/guardian served time in jail

g. Vandalism such as broken windows or
graffiti?
I8

d. Saw or heard parents or adults slap,
hit, kick, punch one another in the
home

To what extent do you agree with these statements about
your neighborhood or community:

e. Was a victim of violence or witnessed
violence in neighborhood

Definitely Somewhat Somewhat Definitely
agree
agree
disagree disagree

f.

a. People in this
neighborhood
help each other
out.

Lived with anyone who was mentally
ill, suicidal, or severely depressed

g. Lived with anyone who had a problem
with alcohol or drugs
h

b. We watch out
for each other’s
children in this
neighborhood.
c. My child is
safe in our
neighborhood.
d. When we
encounter
difficulties, we
know where to
go for help in our
community.

15

Was ever discriminated against

No

J. Adult Demographics
Please fill out a column for each of the two adults in the household who are the child’s primary caregivers. If there is just one adult, please provide answer for that adult.

ADULT 1 (Respondent)

ADULT 2

J1

How are you related to the selected child?
Biological or Adoptive Parent
Step-parent
Grandparent
Foster Parent
Aunt or Uncle
Other: Relative
Other: Non-Relative

J9

How is Adult 2 related to the selected child?
Biological or Adoptive Parent
Step-parent
Grandparent
Foster Parent
Aunt or Uncle
Other: Relative
Other: Non-Relative

J2

What is your sex?
Male
Female

J10

What is Adult 2’s sex?
Male
Female

J3

What is your age?

J11

What is Adult 2’s age?

(Print numbers in boxes)
J4

Where were you born?
In the United States
Outside of the United States

When did you come to the United States?

(Print numbers in boxes)
J12

Where was Adult 2 born?
In the United States
Outside of the United States

When did Adult 2 come to the United States?
YEAR (Print numbers in boxes)

YEAR (Print numbers in boxes)
J5

What is the highest grade or year of school you have
completed?
8th grade or less
9th-12th grade; No diploma
High School Graduate or GED Completed
Completed a vocational, trade, or business school program
Some College Credit, but No Degree
Associate Degree (AA, AS)
Bachelor’s Degree (BA, BS, AB)
Master’s Degree (MA, MS, MSW, MBA)
Doctorate (PhD, EdD) or Professional Degree (MD, DDS,
DVM, JD)

J13

What is the highest degree or level of school Adult 2 has
completed?
8th grade or less
9th-12th grade; No diploma
High School Graduate or GED Completed
Completed a vocational, trade, or business school program
Some College Credit, but No Degree
Associate Degree (AA, AS)
Bachelor’s Degree (BA, BS, AB)
Master’s Degree (MA, MS, MSW, MBA)
Doctorate (PhD, EdD) or Professional Degree (MD, DDS,
DVM, JD)

J6

What is your marital status?
Married
Not married, but living with a partner
Never Married
Divorced
Separated
Widowed

J14

What is Adult 2’s marital status?
Married
Not married, but living with a partner
Never Married
Divorced
Separated
Widowed

J7

In general, what is your physical health status?
Excellent
Very Good
Good
Fair
Poor

J15

In general, what is Adult 2’s physical health status?
Excellent
Very Good
Good
Fair
Poor

J8

In general, what is your mental or emotional health
status?
Excellent
Very Good
Good
Fair
Poor

J16

In general, what is Adult 2’s mental or emotional health
status?
Excellent
Very Good
Good
Fair
Poor

16

J17

Was anyone in the household employed at least 50 weeks
out of the past 52 weeks?
Yes
No

J18

The following question is about your income and is
very important for our research. Think about your total
combined family income during last year for all members
of the family. Can you please tell us that amount before
taxes?

Include money from jobs, child support, social security,

retirement income, unemployment payments, public
assistance, and so forth. Also, include income from
interest, dividends, net income from business, farm, or
rent, and any other money income received.

$

Don’t know/Don’t remember

For the purposes of this survey, it is important
to get at least a range for the total income
received by all members of your household
last year. To the best of your knowledge,
please select the range that best applies to
your household.

J19

 o income
N
Less than $20,000
$20,000 up to 29,999
$30,000 up to 49,999
$50,000 up to 69,999
$70,000 up to 99,999
$100,000 up to 124,999
$
 125,000 up to 149,999
$150,000 or more

How many people are living or staying at this address?

Please include everyone who is living or staying here for more than
two months. Include yourself if you are living here for more than two
months. Include anyone else staying here how does not have another
place to stay, even if they are here for two months or less. Do NOT
include anyone who is living somewhere else for more than two months,
such as a college student living away or someone in the Armed Forces
on deployment.

Number of people

17

Mailing Instructions
Please place the completed questionnaire into the postage-paid return envelope. If the envelope has been
misplaced, please mail the questionnaire to:
NORC at the University of Chicago
P.O. Box 123456, Chicago, IL

Thank you for your participation.

18