CHIP Enrollees and Disenrollees

ATTACHMENT B1
CHIP SURVEY OF ENROLLEES AND DISENROLLEES

PAGE INTENTIONALLY LEFT BLANK FOR DOUBLE—SIDED COPYING

Form Approved
OMB No. 0990Exp. Date XX/XX/20XX

Children’s Health Insurance Program (CHIP)
Survey of Enrollees and Disenrollees

As the survey instrument will be administered electronically (Computer-Assisted
Telephone Interview – CATI), it will be made available to the interviewer to read to
respondents as needed by accessing the help screen.

Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0990- . The time required to complete this information collection is estimated to average 30 minutes
per response, including the time to review instructions, search existing data resources, gather the data needed,
and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports
Clearance Officer.

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CHIP 2011 Survey: OMB

Mathematica Policy Research

CHIP 2011 SURVEY
OVERVIEW OF CHIP 2011 SURVEY INSTRUMENT
The CHIP 2011 survey is designed to capture information on children in each of three sampling
domains determined during selection: new enrollees, established enrollees (enrolled at least
12 months), and recent disenrollees in either CHIP or Medicaid. These sample domains will be
constructed using enrollment records provided by each state. A child’s enrollment status may change
between selection and interview, and sometimes respondents report an enrollment status that differs
from the child’s actual status. Consequently, in addition to the sample domains, three more factors
help determine the questions asked of each child (pathing) and the time frames about which the
questions are asked:
• Whether the sample child was enrolled or disenrolled at the time of the interview
(question 1.1)
• Whether the difference between the actual and reported date of enrollment or
disenrollment was 9 months or more (calculated based on responses to questions 1.2–1.4
and 2.1–2.12); and
• Whether a sample child in the disenrollee domain was enrolled in CHIP or Medicaid for
12 months or more (calculated based on responses to questions to 2.1–2.12). (Note:
established enrollees are, by definition, enrolled 12 months or more.)
Based on combinations of these four factors, there are 12 different question “paths” with differing
timeframes to questions asked about the sample child (see Table 1.0).
Table 1.0. Pathing Definitions: Interaction of Sample Domains and Time Frames

Sample
Domain and
Pathing
Definition

Reported
Current
Enrollment
Status
(Q.1.1)

Difference Between
Actual and Reported Dates
(Q1.2–Q1.4 and Q2.1–Q2.12)

Length of
Previous
Enrollment
(Q2.1–Q2.12)

Time Frame for
Questions (May Vary
by Questionnaire
Section)

New Enrollees
P=1

Enrolled

<=9 months (enrollment date)

NA

P=2
P=3

Enrolled
Disenrolled

> 9 months (enrollment date)
<=9 months (enrollment date)

NA
NA

P=4

Disenrolled

> 9 months (enrollment date)

NA

Prior to current
enrollment
NA
Prior to last
enrollment
NA

Established Enrollees
P=5
P=6

Enrolled
Disenrolled

NA
NA

NA
NA

1

Last 12 months
Since disenrollment/
last 12 months

CHIP 2011 Survey: OMB

Sample
Domain and
Pathing
Definition

Reported
Current
Enrollment
Status
(Q.1.1)

Mathematica Policy Research

Difference Between
Actual and Reported Dates
(Q1.2–Q1.4 and Q2.1–Q2.12)

Length of
Previous
Enrollment
(Q2.1–Q2.12)

Time Frame for
Questions (May Vary
by Questionnaire
Section)

Recent Disenrollees
P=7

Disenrolled

<= 9 months (disenrollment date)

P=8

Disenrolled

<= 9 months (disenrollment date)

P=9
P = 10

Disenrolled
Enrolled

P = 11

Enrolled

P = 12

Enrolled

> 9 months (disenrollment date)
<=9 months (prior disenrollment
date)
<=9 months (prior disenrollment
date)
> 9 months (prior disenrollment
date)

<12
months
12+
months
NA
<12
months
12+
months
NA

Since disenrollment
Since disenrollment/
before disenrollment
NA
Since disenrollment/
NA
Since disenrollment/
before disenrollment
NA

Finally, different paths through the questionnaire also are dictated by responses to individual
questions. The result is a combination of intricate and technically complex survey instruments that
are difficult to explain to a lay audience.
At the start of each of the six questionnaire sections, we chart the variations in question flow
and time frame wording based on the variations discussed above.
Throughout the questionnaire, above each question, we note its source and whether we
modified the wording of the question. We also note the entrance condition or “universe” of the
question, that is, which respondents are asked each question. We have used generic question text
(either no time frame, or “in the past 12 months”) to avoid making the text variation for each
individual question confusing. Following each question are response categories (with “go to”
instructions) and any interviewer instructions. Note that if there is no “go to” instruction next to a
response category, it is assumed that the response goes to the next question. Frequently we show
boxes with instructions to programmers for complex operations.
In addition, readers will find the following information useful for understanding some of the
entrance conditions – that is, who is asked each question.
For a complete overview, readers may refer to Appendix 1 to review a table called Survey
Questions and Associated Timeframes, by Sample Domain.

2

CHIP 2011 Survey: OMB

Mathematica Policy Research

Sample File Information
S1 Insurance Type
1 = CHIP
2 = Medicaid
S2 Domain
1 = New enrollees
2 = Established enrollees
3 = Recent disenrollees
S3 = Enrollment/Disenrollment Actual Dates (on file)
1 = New enrollees current start date
2 = Established enrollees current start date
3 = Recent disenrollees most recent end date
S4 CHILD’s Birth Date of Record: MM DD YYYY
S5 CHILD’s Gender of Record
1 = Male
2 = Female
S6 Child’s FULL NAME of Record
S7 CHILD’s FIRST NAME of Record [CHILD]
S8 Respondent’s FULLNAME of Record
S9 Respondent’s FIRST NAME of Record
S10 = State program names for CHIP

3

CHIP 2011 Survey: OMB

Mathematica Policy Research

SECTION 1: APPLICATION, ENROLLMENT, REDETERMINATION,
DISENROLLMENT
A. Section 1 Overview
A sample child’s “path” through Section 1 is based on a combination of his or her sample
domain and his or her parent’s answer to question Q1.1: Is [CHILD] covered by [CHIP/Medicaid]
right now? Since final question timeframes are not established until after questions 2.1 – 2.12 are
answered, all questions in Section 1 refer to the ‘current’ time frame. We show Table 1.1 to provide
a sense of how respondents move through Section 1.
Table I.1. Pathing in Section 1

Sample Domain
and Enrollment
Status

New Enrollees,
Currently
Enrolled (Future
P = 1 or 2)
New Enrollees,
Currently
Disenrolled
(Future P = 3
or 4)
Established
Enrollees,
Currently
Enrolled
(Future P = 5)
Established
Enrollees
Currently
Disenrolled
(Future P = 6)
Recent
Disenrollees
Currently
Disenrolled
(Future P = 7, 8
or 9)
Recent
Disenrollees
Currently
Enrolled
(Future P = 10,
11, or 12)

Current
Enrollment
Status
(Q1.1)

Disenrolled:
Current
Disenrollment
Date
(Q1.2–1.5)

Why
Disenrolled
(Q1.6–1.7)

X

X

X

X

X

Application
(Q1.8–
1.12)

Enrollment
Process
(Q1.13–
1.23)

Renewal
Knowledge
(Q1.24–
1.25)

X

X

X

X

X

X

Renewal
Process
(Q1.26–
1.37)

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

4

ESTABLISH REPORTED CURRENT ENROLLMENT STATUS
2001 CHIP 3.2

S2 = 1, 2, or 3
1.1
First, is [CHILD] covered by [CHIP/Medicaid] right now?
PROBE: This is the health insurance program you call [CHIP STATE NAME/MEDICAID STATE NAME].
YES, COVERED BY NAMED PROGRAM ........... 00
YES, CHANGED FROM CHIP TO MEDICAID .... 02
YES, CHANGED FROM MEDICAID TO CHIP .... 03
NO ................................................................. 00
DK .................................................................. D
REF ................................................................. R

GO TO Q1.8
GO TO Q1.8
GO TO Q1.8
GO TO Q6.1
GO TO Q7.1

ESTABLISH DISENROLLMENT DATE (F4) FOR SAMPLE MEMBERS DISENROLLED AT THE TIME OF INTERVIEW
2001 CHIP 3.3

If Q1.1 = 00 currently disenrolled
1.2
About how many months has it been since [CHILD]’s [CHIP/Medicaid] coverage ended?
INSTRUCTION: FOR LESS THAN ONE MONTH, RECORD 00.
RECORD NUMBER OF MONTHS: |__|__|

GO TO BOX 1.6

DK .................................................................. D
REF ................................................................. R
2001 CHIP 3.4

If Q1.2 = D, R
1.3 Would you say it has been about...
CODE ONLY ONE
Less than 1 month ........................................
1 month but less than 2 months ..................
2 months but less than 3 months .................
3 months but less than 4 months .................
4 months but less than 5 months .................
5 months but less than 6 months .................
6 months .......................................................
7 months or more ........................................
DK ..................................................................
REF .................................................................

01
02
03
04
05
06
07
08 GO TO Q1.5
D GO TO Q1.5
R GO TO Q1.5

2001 CHIP 3.5

If Q1.2 = 6 months or fewer or Q1.3 = 01 – 06
1.4
So, [CHILD] has not been covered by [CHIP/Medicaid] since [DATE FROM BOX 1.3]. Is that correct?
YES .................................................................
NO .................................................................
DK .................................................................
REF ................................................................

01 GO TO BOX 1.6
00
D
R

5

2001 CHIP 3.5.1a & 3.5.1b modified

If Q1.3 = 08, D, R or Q1.4 = 0, D, R
If Q1.5 = YEAR and/or 01 – 12, go to Box 1.6
1.5
In about what month and year did [CHILD]’s [CHIP/Medicaid] coverage end? Your best estimate is fine.
PROBE: Was it near a holiday or a birthday or some other time you remember?
2 0 __ __ YEAR
CODE ONE ONLY
JANUARY ....................................................... 01
FEBRUARY ..................................................... 02
MARCH ......................................................... 03
APRIL ............................................................. 04
MAY .............................................................. 05
JUNE ............................................................. 06
JULY ............................................................... 07
AUGUST ........................................................ 08
SEPTEMBER .................................................. 09
OCTOBER ...................................................... 10
NOVEMBER ................................................... 11
DECEMBER .................................................... 12
DK .................................................................. D GO TO Q6.1
REF ................................................................. R GO TO Q7.1
DISENROLLMENT REASONS REPORTED BY DISENROLLEES
2001 CHIP 3.26 modified

If Q1.1 = 00
1.6
Now I am going to read some reasons why [CHILD]’s [CHIP/Medicaid] coverage may have ended. Did
[his/her] coverage end because…. CODE ONE RESPONSE PER ROW.
YES (01)
01. You obtained some other kind of insurance for [CHILD]?
02. [CHILD] was too old to remain enrolled?
03. Your income changed so that [CHILD] was no longer eligible?
04. The payment to stay enrolled was late or not paid?
05. [CHILD] moved out of state?
06. [CHILD] left household – for example, [he/she] is living with
another family member or is in foster care?
07. You decided not to re-enroll [CHILD]?
08. Some other reason I didn’t mention (SPECIFY)
Box 1.7. Programmer: If any response Q1.6 = 01 - 06 or 08, go to Q1.8.
If Q1.6 = 07, go to Q1.7.

6

NO (00)

DK (D)

REF (R)

2001 CHIP 3.26 modified

If Q1.1 = 00 and Q1.6.07= 01
1.7
Why did you decide not to re-enroll [CHILD] in [CHIP/Medicare]?
CODE ONE ONLY
COULD NO LONGER AFFORD IT .................................. 01
UNHAPPY WITH HEALTH CARE/SERVICES ................... 02
NOT NEEDED/CHILD DOES NOT GET SICK .................. 03
TOO MUCH WORK TO REAPPLY .................................. 04
DK ............................................................................... D
REF ............................................................................... R
APPLICATION (NEW ENROLLEES ONLY )
Box 1.8, programmer: If S2 = 2 or 3, go to Q1.24 (note: these cases will be designated P = 5 – 12 in Section 2)
2001 CHIP 2.1.15 modified

If S2 = 1 (note, these cases will be designated P = 1 – 4 in the future)
1.8 How did you hear about [CHIP/Medicaid]? Was it from…
PROBES IF NEEDED:
TANF = TEMPORARY ASSISTANCE TO NEEDY FAMILIES
WIC = WOMEN, INFANTS, & CHILDREN
SNAP = SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM
NOTE: WE WILL LIST STATE PROGRAMS BY STATE WHEN STATES ARE IDENTIFIED
CODE ALL THAT APPLY
A friend or family member? ........................................ 01
A hospital or doctor’s office or clinic? ......................... 02
School .......................................................................... 03
Another program such as TANF, SNAP or
WIC? ............................................................. 04
TV, radio, newspaper or the internet? ........................ 05
Religious Group or Organization? ............................... 06
Some other way? (SPECIFY) ........................................ 07
DK ................................................................................ D GO TO Q1.10
REF ............................................................................... R GO TO Q1.10
Box 1.9, programmer: if only one response to Q1.8 (01 – 07, or d, r), go to Q1.10. If two or more responses in Q1.8,
display them in Q1.9.
2001 CHIP 2.2.1 modified

If 2 or more responses were coded in Q1.8 and S2 = 1
1.9
What source of information was the most useful or helpful in making the decision to enroll [CHILD] in
[CHIP/Medicaid]? Was it...READ TWO OR MORE RECORDED RESPONSES FROM Q1.8.
RECORD MOST USEFUL CODE FROM Q1.9 HERE: ____
DK ............................................................................... D
REF ............................................................................... R

7

2001 CHIP 2.14 modified

If S2 = 1 and Q1.1 = 01 - 03 (currently enrolled) or 00 (currently disenrolled)
1.10
Now think back to when you enrolled [CHILD] in [CHIP/Medicaid]. Did you decide to enroll [him/her] at
that time because [CHILD]…..
CODE ONE FOR EACH ROW
YES (01)
NO (00)
01. was sick or injured and needed medical
care?
02. had a problem with [his/her] teeth that
needed dental care?
03. needed prescription medicine that the
family could not afford?

DK (D)

REF (R)

2001 CHIP 2.14 modified

If S2 = 1 and Q1.1 = 01 - 03 (currently enrolled) or 00 (currently disenrolled)
1.11
Is there another important reason you decided to enroll [CHILD] in [CHIP/Medicaid] that I did not already
mention?
YES, WANTED CHILD TO BE INSURED ...........
YES, OTHER REASON(S) .................................
NO .................................................................
DK ..................................................................
REF .................................................................

01
02
00 GO TO Q1.13
D GO TO Q1.13
R GO TO Q1.13

2001 CHIP 2.14 modified

If S2 = 1 and Q1.1 = 01 - 03 or 00 and Q1.11 = 01 or 02
1.12 Why else did you want [CHILD] to be insured by [CHIP/Medicaid]?
PROBE: ANYTHING ELSE? UNTIL R SAYS: NOTHING ELSE.
INSTRUCTION: IF R ANSWERS “BECAUSE IT WAS/IS REQUIRED,” ASK WHO REQUIRED YOU TO GET
INSURANCE FOR [CHILD]? WAS IT A SCHOOL, SPORTS PROGRAM, OR SOME OTHER ORGANIZATION?
CODE ALL THAT APPLY.
LOST OTHER INSURANCE
PARENT LOST OR CHANGED JOB ................................ 01
LOST OTHER HEALTH INSURANCE .............................. 02
AFFORDABILITY
COULD NOT AFFORD OTHER COVERAGE .................... 03
CHIP/MEDICAID IS LESS EXPENSIVE............................. 04
OTHER
CHILD HAS A MEDICAL CONDITION ............................. 05
GET BETTER CARE THAN WITH OTHER COVERAGE ..... 06
REQUIRED BY SCHOOL (PHYSICAL/VACCINATIONS) .... 07
REQUIRED BY SPORTS PROGRAM/OTHER ORG. .......... 08
SOME OTHER REASON (SPECIFY) ................................ 09
DK ............................................................................... D
REF .............................................................................. R

8

ENROLLMENT PROCESS FOR NEW ENROLLEES ONLY
2001 CHIP 2.17 modified

If S2 = 1 and Q1.1 = 01 - 03 (currently enrolled) or 00 (currently disenrolled)
1.13
New enrollee, currently enrolled. When you enrolled [CHILD] in [CHIP/Medicaid] did you complete an
application form…
New enrollee, currently disenrolled. The last time that you enrolled [CHILD] in [CHIP/Medicaid], did you
complete an application form …
INSTRUCTION: STOP AFTER FIRST YES (01) RESPONSE.
YES (01)

NO (00)

DK (D)

REF (R)

01. By mail or fax?
02. By telephone?
03. Online – that is, by using the internet or a website?
04. In-person?
Box 1.14, programmer: if any responses from Q1.13.01- Q1.13.03 = 01, go to Q1.15
If Q1.13.04 = 01, continue to Q1.14.
If all responses Q1.13.01 – 1.13.04 = 00 or D, go to Q1.14.
2001 Chip 2.17 modified using 2001 CHIP 2.18 response categories

If Q1.13 = 04 or all responses in Q1.13=00, d, r
1.14
So, where did you complete the application?
CODE ALL THAT APPLY
WELFARE OFFICE OR OTHER AGENCY OFFICE ............ 01
HOSPITAL OR HOSPITAL EMERGENCY ROOM ............ 02
DOCTOR’S OFFICE ........................................................ 03
PHARMACY ................................................................. 04
SCHOOL OR CHURCH/RELIGIOUS ORGANIZATION ...... 05
HOME OF FRIEND OR RELATIVE ................................. 06
SOME OTHER PLACE .................................................... 07
DK ............................................................................... D
REF .............................................................................. R
2001 CHIP 2.29 modified

If S2 = 01 and Q1.1 = 01 - 03 or 00
1.15
Thinking about the entire application process, how easy or hard was it to get the required documents
together? Was it…
CODE ONE ONLY
Very easy .................................................................... 01
Somewhat easy .......................................................... 02
Somewhat hard .......................................................... 03
Very hard .................................................................... 04
WAS NOT REQUIRED TO GET ANY DOCUMENTS ........ 05
DK ............................................................................... D
REF .............................................................................. R

9

2001 CHIP 2.29 modified

If S2 = 1 and Q1.1 = 01 - 03 or 00
1.16 Was the application form written in English, Spanish, or another language?
CODE ONE ONLY
ENGLISH ......................................................... 01
SPANISH ........................................................ 02
OTHER LANGUAGE (SPECIFY) ....................... 03
DK ................................................................. D
REF ................................................................ R
2001 CHIP 2.20

If S2 = 1 and Q1.16 = answered, d, r
1.17
Did a translator or another professional help translate the application form into a language you could
understand?
PROBE: Please don’t count family members or friends who might have helped with the translation.
YES ................................................................
NO .................................................................
DK .................................................................
REF ................................................................

01
00
D
R

2001 CHIP 2.21 modified

If S2 = 1 and Q1.1 = 01 - 03 or 00
1.18
If Q1.17 = YES, Besides help with translating did you get any other help in completing the application?
If Q1.17 = NO, d, r, Did you get any help in completing the application?
YES ................................................................
NO .................................................................
DK ..................................................................
REF .................................................................

01
00 GO TO Q1.21
D GO TO Q1.21
R GO TO Q1.21

2001 CHIP 2.22 modified

If Q1.18= 01
1.19 Who helped you complete the application form? Was it...STOP AFTER FIRST YES (01) RESPONSE
YES (01)
01. Someone from a government office or community
organization?
02. Someone at a hospital, clinic, or doctor’s office?
03. A friend or family member?
04. Some other person? (Specify)

10

NO (00)

DK (D)

REF (R)

2001 CHIP 2.24.1 modified

If any answers to Q1.19.1 – Q1.19.4 = 01
1.20 How helpful was the assistance you received? Would you say it was...
CODE ONE ONLY
Very helpful ................................................... 01
Somewhat helpful ........................................ 02
Not very helpful ............................................. 03
Not at all helpful ............................................ 04
DK .................................................................. D
REF ................................................................. R
2001 CHIP 2.29.1 modified

If S2 = 1 and Q1.1 = 01 - 03 or 00 and Q1.18 = 00, D, R or Q1.19 = 00, D, R and Q1.20 = answered
1.21
Thinking about all the experiences you just told me about, would you say your overall experience applying
for [CHIP/Medicaid] was it…
CODE ONE ONLY
Very easy ...................................................... 01
Somewhat easy ............................................ 02
Somewhat hard ............................................ 03
Very hard ...................................................... 04
DK ................................................................. D
REF ................................................................ R
2001 CHIP 2.30 modified

If S2 = 1 and Q1.1 = 01 - 03 or 00
1.22
After you completed and submitted the entire application, about how long did it take before you were
notified that [CHILD] was enrolled in [CHIP/Medicaid]? PROBE: You may answer in weeks and/or months.
__ WEEKS .................................................................... GO TO Q1.24
__ MONTHS ............................................................... GO TO Q1.24
NOTIFIED OF ENROLLMENT RIGHT AWAY ................... 00 GO TO Q1.24
NEVER NOTIFIED ........................................................ 999 GO TO Q1.24
DK ............................................................................... D
REF ............................................................................... R
GO TO Q1.24
2001 CHIP 2.30.1

If Q1.22 = D
1.23 Would you say…
CODE ONE ONLY
Less than 1 week? ...................................................... 01
At least 1 week but less than 2 weeks? ...................... 02
At least 2 weeks but less than 3 weeks? .................... 03
At least 3 weeks but less than 4 weeks? .................... 04
At least 4 weeks but less than 8 weeks? .................... 05
At least 2 months but less than 3 months? ................. 06
Three months or more ............................................... 07
DK ............................................................................... D
REF .............................................................................. R

11

KNOWLEDGE OF RENEWAL / REDETERMINATION: ALL SAMPLE MEMBERS
2001 CHIP 2.34 modified

If S = 1 – 3 and Q1.1 = 01 - 03 or 00
1.24
After enrolling in [CHIP/Medicaid], you may need to renew [CHILD]’s coverage by filling out a form or
providing information in some other way that will help determine if [CHILD] can stay enrolled. Have you
ever heard about this renewal requirement for [CHIP/Medicaid]?
YES ................................................................
NO .................................................................
DK ..................................................................
REF .................................................................

01
00
D
R

2001 CHIP 2.34 modified

If Q1.27 = 01
1.25
Based on what you know, how often do you need to complete this renewal requirement? Would you
say…
CODE ONE ONLY
Every month ................................................. 01
Every 3 months ............................................. 02
Every 6 months ............................................. 03
Once a year ................................................... 04
Once every 2 years ....................................... 05
OTHER TIME PERIOD (SPECIFY) ..................... 06
NEVER ............................................................ 07
DK ................................................................. D
REF ................................................................ R
EXPERIENCE WITH THE RENEWAL/REDETERMINATION PROCESS: ESTABLISHED ENROLLEES AND RECENT
DISENROLLEES
Box 1.26. Programmer: If S2 = 1 (NEW ENROLLEE) GO TO Q2.1.
IF S2 = 2 (ESTABLISHED ENROLLEES) OR 3 (RECENT DISENROLLEES), CONTINUE.
2001 CHIP 2.34 modified

If S2 = 02 or 03 and Q1.24=01
1.26
Have you or another family member ever received a renewal form, perhaps as part of a packet, and been
asked to complete it so that [CHILD] could stay enrolled in the program?
YES ................................................................
NO .................................................................
DK ..................................................................
REF .................................................................

01
00 GO TO Q2.1
D GO TO Q2.1
R GO TO Q2.1

12

New

If S2 = 02 or 03 and Q1.26=01 and P = 5 – 12
1.27
How did you or your family member get the renewal form or packet? Did you….
STOP AFTER FIRST YES (01) RESPONSE
YES (01)

NO (00)

DK (D)

01. get it in the mail?
02. get it from a website?
03. get it at a government office or a community
organization?
04. get it some other way (SPECIFY)?
2001 CHIP 2.43 modified

If Q1.26=01
1.28 The last time you got a renewal form or packet, did you complete the form and return it?
YES .................................................................
NO .................................................................
DK ..................................................................
REF .................................................................

01 GO TO Q1.30
00
D GO TO Q2.1
R GO TO Q2.1

New

If Q1.28= 00
1.29
Why did you not return the form? PROBE: What else, till R answers: “nothing”
CODE ALL THAT APPLY
[CHILD] NO LONGER ELIGIBLE
GOT OTHER INSURANCE .............................................. 01
CHILD TOO OLD .......................................................... 02
DID NOT MEET INCOME RULES ................................... 03
MOVED OUT OF STATE ................................................ 04
DID NOT WANT TO RE-ENROLL
COULD NOT AFFORD IT .............................................. 05
NOT INTERESTED/NOT SATISFIED/NOT NEEDED......... 06
OTHER REASONS
FORGOT ...................................................................... 07
FORMS CONFUSING .................................................... 08
GATHERING DOCUMENTS DIFFICULT .......................... 09
SOME OTHER REASON (SPECIFY__________) ............ 10
DK ................................................................................ D
REF ............................................................................... R

13

REF (R)

Box 1.30 . Programmer: If Q1.29 = answered, go to Q2.1.
New

If S2 = 2 or 3 and Q1.28 = 01
1.30 Did you get help to complete the renewal form?
YES ................................................................
NO .................................................................
DK ..................................................................
REF .................................................................

01
00 GO TO Q1.34
D GO TO Q1.34
R GO TO Q1.34

New

If S2 = 2 or 3 and Q1.28=01
1.31 How easy or hard was it to get help to complete the renewal form? Would you say it was…
Very easy ...................................................... 01
Somewhat easy ............................................ 02
Somewhat hard ............................................ 03
Very hard ...................................................... 04
DK ................................................................. D
REF ................................................................. R GO TO Q1.34
New

If Q1.31=answered
1.32 Who helped you complete the renewal form?
STOP AFTER FIRST YES (01) RESPONSE
YES (01)
NO (00)
01. Someone from a government office or agency?
02. Someone at a hospital, clinic, or doctor’s office?
03. A friend or family member?
04. Some other person? (Specify)
New

If any response Q1.32.01 – Q1.32.04 = 01, ELSE go to Q1.34.
1.33
How helpful was the assistance you received? Would you say it was...
CODE ONE ONLY
Very helpful .................................................. 01
Somewhat helpful ........................................ 02
Not very helpful ............................................ 03
Not at all helpful ........................................... 04
DK ................................................................. D
REF ................................................................ R

14

DK (D)

REF (R)

New

If Q1.30 = 00, D, R
1.34
After you submitted the renewal form, did someone tell you through a letter, phone call, or some other
way that you had any missing information?
YES ................................................................
NO .................................................................
DK ..................................................................
REF .................................................................

01
00 GO TO Q1.37
D GO TO Q1.37
R GO TO Q1.37

New

If Q1.34=01
1.35
Did you provide this information?
YES .................................................................
NO .................................................................
DK ..................................................................
REF .................................................................

01 GO TO Q1.37
00
D GO TO Q1.37
R GO TO Q1.37

New

If Q.1.35=00
1.36 Why did you not provide this information?
CODE ALL THAT APPLY
FORGOT ...................................................................... 01
TOO DIFFICULT/TOO MUCH WORK TO PROVIDE ....... 02
OTHER (SPECIFY).......................................................... 03
DK .............................................................................. D
REF ............................................................................... R
2001 CHIP 2.44 modified

If Q1.28=01
1.37
Based on your overall experience, how easy or hard was it to complete the renewal form? Was it…
CODE ONE ONLY
Very easy ...................................................... 01
Somewhat easy ............................................ 02
Somewhat hard ............................................ 03
Very hard ...................................................... 04
DK ................................................................. D
REF ................................................................. R

15

CHIP SECTION 2: CHILD’S HEALTH CARE COVERAGE
Section 2 Overview
Responses to questions 2.1–2.12 will define the questionnaire paths and time frame of
questions about the sample child in the disenrollee domain. The questions will determine (1)
reported enrollment and disenrollment dates of the sample child’s past episodes with
CHIP/Medicaid and (2) the difference between the actual and reported enrollment and
disenrollment dates. Below we show questions sequences that will be answered about the sample
child (pathing definitions). See Table 1.0 for the definitions of the paths.
Table 2.1. Pathing in Section 2

Pathing
Definitions

Last/Current
Start Date
(Q2.1–Q 2.4)

Previous
End Date
(Q2.5–
Q2.8)

Previous
Start Date
(Q2.9Q2.12)

Reasons
coverage
ended
(Q2.13–
Q2.13.1)

Prior
Coverage
(Q2.14–
Q2.27)

Coverage Post
Enrollment
(Q2.28–Q2.34)

New Enrollees
P
P
P
P

=
=
=
=

1
2
3
4

X
X
X
X

X
X
Established Enrollees

P=5
P=6

X
X

X
Recent Disenrollees

P=7
X
X
P=8
X
X
P=9
X
X
P = 10
X
X
X
X
X
P = 11
X
X
X
X
X
P = 12
X
X
X
Timeframe wording variations in Section 2 will be based on the following pathing definitions after they are
established in question 2.1 – 2.12:
New enrollees
P = 1 respondents are asked about the 12 months prior to sample child’s current enrollment
P = 2 respondents are skipped to Q3.1 after questions Q2.1 – Q2.4
P = 3 respondents are asked about the 12 months prior to previous enrollment
P = 4 respondents are skipped to Q3.1 after questions Q2.1 – Q2.4
Established enrollees
P = 5 respondents are skipped to Q3.1 after questions Q2.1 – Q2.4
P = 6 respondents are asked a subset of questions about the period since they disenrolled
Recent disenrollees
P = 7 respondents are asked a subset of questions about the period since they disenrolled
P = 8 respondents are asked a subset of questions about the period since they disenrolled
P = 9 respondents are asked a subset of questions about the period since they disenrolled
P = 10 respondents are asked most questions about the period since they disenrolled
P = 11 respondents are asked most questions about the period since they disenrolled
P = 12 respondents are skipped to Q3.1 after questions Q2.1 – Q2.12
Establish Last/ Current Enrollment Date (F5)

16

2001 CHIP 3.7

Q1.1 = 01 – 03 (currently enrolled) or 00 (currently disenrolled)
2.1
Currently enrolled: How many months and/or years has [CHILD] been covered by [CHIP/Medicaid]
without any interruption in coverage?
Currently disenrolled: Before [CHILD]’s [CHIP/Medicaid] coverage ended in [F4 DATE], how many months
and/or years was [CHILD] covered without any interruption in coverage?
__ YEARS AND/OR __MONTHS...................... GO TO Q2.3
DK ................................................................. D
REF ................................................................. R
2001 CHIP 3.8

If Q2.1 = d, r
2.2
Would you say…
Less than 1 month ....................................................... 01
1 month but less than 2 months ................................. 02
2 months but less than 3 months ................................ 03
3 months but less than 4 months ................................ 04
4 months but less than 5 months ................................ 05
5 months but less than 6 months ................................ 06
6 months ..................................................................... 07
Longer than 6 months ................................................. 08 GO TO Q2.4
DK ................................................................................ D GO TO Q2.4
REF ............................................................................... R GO TO Q2.4

2001 CHIP 3.9

If Q2.1 = months or years or Q2.2= 01-07
2.3
Currently enrolled. So, [CHILD]’s current [CHIP/Medicaid] coverage started in [F5 date]. Is that correct?
Currently disenrolled. So, [CHILD]’s last [CHIP/Medicaid] coverage started in [F5 date]. Is that correct?
YES ................................................................. 01 GO TO BOX 2.5
NO ................................................................. 00
DK ................................................................ D
REF ................................................................. R

17

2001 CHIP 3.9.1.A and 3.91B modified

If Q2.2 = 08, d, r or Q2.3=00, d, r
2.4
In about what month and year did [CHILD]’s [CHIP/Medicaid] coverage start? Your best estimate is fine.
PROBE: Was it near a holiday or a birthday or some other time you remember?
2 0__ __YEAR
JANUARY ........................................................ 01
FEBRUARY ...................................................... 02
MARCH ......................................................... 03
APRIL ............................................................. 04
MAY .............................................................. 05
JUNE ............................................................. 06
JULY .............................................................. 07
AUGUST ........................................................ 08
SEPTEMBER .................................................. 09
OCTOBER ...................................................... 10
NOVEMBER .................................................... 11
DECEMBER..................................................... 12
DK .................................................................. D GO TO Q7.1 END SURVEY
REF ................................................................. R GO TO Q7.1 END SURVEY
Box 2.5. Programmer:
If P = 1 or 3, go to Q2.14
If P = 2, 4, or 5, go to Q3.1
If P = 6, 7, 8, or 9 go to Q2.28 ELSE CONTINUE TO Q2.5 (This will determine P = 10, 11, 12)
ESTABLISH PREVIOUS DISENROLLMENT DATE FOR DISENROLLEES WHO REENROLLED (F6)
2001 CHIP 3.11

If Q2.3 = 1 or Q2.4 = answered
2.5
Now I am going to ask about the time that [CHILD]’s current [CHIP/Medicaid] coverage started in [F5
DATE] and [his/her] previous [CHIP/Medicaid] coverage ended. How many months were there between
these two periods of [CHIP/Medicaid] coverage?
INSTRUCTION: IF LESS THAN ONE MONTH, CODE 00 MONTHS
__ MONTHS ................................................. GO TO Q2.7
DK .................................................................. D
REF ................................................................. R

18

2001 CHIP 3.12

If Q2.5 = d, r
2.6 Would you say…
Less than 1 months........................................ 01
1 month but less than 2 months ................... 02
2 months but less than 3 months .................. 03
3 months but less than 4 months .................. 04
4 months but less than 5 months .................. 05
5 months but less than 6 months .................. 06
6 months ....................................................... 07
Longer than 6 months ................................... 08 GO TO Q2.8
DK .................................................................. D GO TO Q2.8
REF ................................................................. R GO TO Q2.8
2001 CHIP 3.13

If Q2.6 = 01 – 07
2.7
So, [CHILD]’s previous [CHIP/Medicaid] coverage ended on [F6 DATE]. Is that correct?
YES ................................................................. 01 GO TO Q2.9
NO ................................................................. 00
DK .................................................................. D
REF ................................................................. R
2001 CHIP 3.13.1A and 3.13.1B modified

If Q2.7=00,d,r
2.8
In about what month and year did [CHILD]’s previous [CHIP/ Medicaid] coverage end? Your best estimate
is fine. PROBE: Was it near a holiday or a birthday or some other time you remember?
2 0__ __YEAR
JANUARY ........................................................ 01
FEBRUARY ...................................................... 02
MARCH ......................................................... 03
APRIL ............................................................. 04
MAY .............................................................. 05
JUNE ............................................................. 06
JULY .............................................................. 07
AUGUST ........................................................ 08
SEPTEMBER .................................................. 09
OCTOBER ...................................................... 10
NOVEMBER .................................................... 11
DECEMBER..................................................... 12
DK .................................................................. D GO TO Q7.1, END SURVEY
REF ................................................................. R GO TO Q7.1 , END SURVEY

19

ESTABLISH PREVIOUS START DATE FOR DISENROLLEES WHO REENROLLED (F7)
2001 CHIP 3.14

Q2.7=01 or Q2.8=answered
2.9
Before [CHILD]’s previous [CHIP/ Medicaid] coverage ended in [F6 DATE], how many months and/or years
was [he/she] covered by [CHIP/ Medicaid] without any interruption in coverage?
INSTRUCTION: IF LESS THAN ONE MONTH, CODE 00 MONTHS
__YEARS AND/OR __ MONTHS...................... GO TO Q2.11
DK .................................................................. D
REF ................................................................ R
2001 CHIP 3.15

If Q2.9 = d, r
2.10 Would you say…
Less than 1 months...................................................... 01
1 month but less than 2 months ................................. 02
2 months but less than 3 months ................................ 03
3 months but less than 4 months ................................ 04
4 months but less than 5 months ................................ 05
5 months but less than 6 months ................................ 06
6 months ..................................................................... 07
Longer than 6 months ................................................. 08 GO TO Q2.12
DK ................................................................................ D GO TO Q2.12
REF ............................................................................... R GO TO Q2.12
2001 CHIP 3.16

If Q2.9 = answered
2.11
So, [CHILD]’s previous [CHIP/ Medicaid] coverage started in [F7 DATE]. Is that correct?
YES ................................................................. 01 GO TO Q2.13
NO ................................................................. 00
DK .................................................................. D
REF ................................................................. R

20

3.16.1A AND 3.16.1B modified

If Q2.10=08,d, r and Q2.11=00, d,r
2.12
In about what month and year did [CHILD]’s previous [CHIP/ Medicaid] coverage start? Your best estimate
is fine. PROBE: Was it near a holiday or a birthday or some other time you remember?
2 0__ __YEAR
JANUARY ........................................................ 01
FEBRUARY ...................................................... 02
MARCH ......................................................... 03
APRIL ............................................................. 04
MAY .............................................................. 05
JUNE ............................................................. 06
JULY .............................................................. 07
AUGUST ........................................................ 08
SEPTEMBER .................................................. 09
OCTOBER ...................................................... 10
NOVEMBER .................................................... 11
DECEMBER..................................................... 12
DK .................................................................. D GO TO Q7.1 -END SURVEY
REF ................................................................. R GO TO Q7.1 - END SURVEY
Box 2.13. Code case P = 10, 11, 12 based on answers to S2, Q1.1, and Q2.6 – Q2.12.
If P = 12, go to Q3.1
RECENT DISENROLLEE WHO REENROLLED
2001 CHIP 3.26 modified

If Q2.11=01 and Q2.12 = answered and P = 10, 11
2.13
Now I’m going to read you some reasons why [CHILD]’s [CHIP/Medicaid] coverage may have ended in [ F6
DATE]. There can be more than one reason so I’ll ask you about each one.. Did [CHILD]’s coverage end
because… CODE ONE RESPONSE PER ROW
REASON COVERAGE ENDED
01. you obtained other insurance for [him/her]?
02. [he/she] was too old to remain enrolled?
03. your income changed so [he/she] was no
longer eligible?
04. the payment to stay enrolled was late or not
paid?
05. [CHILD] moved out of state?

YES (01)

NO (00)

06. [he/she] left the household, and, is living with
another family member or is in foster care, for
example?
07. You decided not to re-enroll?
08. of some other important reason that I did not
mention?
Box 2.13.1. Programmer, if Q2.13.07 = 01, go to Q2.13.1, else go to Q2.28

21

DK (D)

REF (R)

2001 CHIP 3.26 modified

If Q2.13.07 = 01 and P = 10 or 11
2.13.1 Why did you decide not to re-enroll [CHILD] in [CHIP/Medicaid]?
LISTEN AND CODE ALL THAT APPLY. PROBE: “Anything else?” UNTIL R ANSWERS “nothing else.”
COULD NO LONGER AFFORD IT .................................. 01
UNHAPPY WITH HEALTH CARE/SERVICES ................... 02
NOT NEEDED/CHILD DOES NOT GET SICK .................. 03
TOO MUCH WORK TO REAPPLY .................................. 04
DK ............................................................................... D
REF ............................................................................... R
Box 2.14. Programmer, If P = 10 or 11, go to Q2.28
NEW ENROLLEES’ COVERAGE DURING 12 MONTHS PRIOR TO LAST/CURRENT START DATE (F5)
2001 CHIP 3.31 modified

If P = 1 or 3
2.14
Currently enrolled (P = 1). Now, I am going to ask you some questions about the 12 months before
[CHILD]’s current [CHIP/Medicaid] coverage started, in [F5 DATE].
Currently disenrolled (P = 3). Now, I am going to ask you some questions about the 12 months before
[CHILD]’s previous [CHIP/Medicaid] coverage started, in [F5 DATE].
Just before [F5 DATE], was [CHILD] without health insurance coverage or did [he/she] have health
insurance, such as [Medicaid or private insurance\ CHIP or private insurance?]
WITHOUT HEALTH INSURANCE ................................... 01 GO TO Q2.15
HAD HEALTH INSURANCE ............................................ 02 GO TO BOX 2.17.1
[PROGRAMMER CHECK CHILD’S BIRTH DATE
(S3) AND LAST START DATE (F5)] IF
CHILD BORN WHEN COVERAGE
STARTED AND NEW ENROLLEE (S2 = 01)
.............................................................................. 03 GO TO Q6.1
[PROGRAMMER CHECK CHILD’S BIRTH DATE
(S3) AND LAST START DATE (F5)] IF
CHILD BORN WHEN COVERAGE
STARTED AND ESTABLISHED ENROLLEE
(S2 = 02)................................................................ 04 GO TO Q2.31
DK .............................................................................. D
REF .............................................................................. R

22

2001 CHIP 3.35.1 modified

Q2.14=D, R and P = 1 or 3
2.14.1
Was [CHILD] covered by health insurance such as [Medicaid or private insurance \CHIP or private
insurance] at any time during the twelve months before [his/her]
Currently enrolled (P = 1) current [CHIP/Medicaid] coverage started, that is before [F5 DATE]?
Currently disenrolled (P = 3). last [CHIP/Medicaid] coverage started, that is before [F5 DATE]?

YES
NO
DK
REF

.............................................................................. 01 GO TO Q2.17.1
.............................................................................. 00 GO TO BOX Q2.28
.............................................................................. D GO TO BOX Q2.28
.............................................................................. R GO TO BOX Q2.28

2001 CHIP 3.32 modified

If Q2.14=01 and P = 1 or 3
2.15
How many months or years was [CHILD] without health insurance just before [his/her]
Currently enrolled (P = 1). …current [CHIP/ Medicaid] coverage started at [F5 DATE]?
Currently disenrolled (P = 3). …last [CHIP/ Medicaid] coverage started at [F5 DATE]?
INSTRUCTION: IF LESS THAN ONE MONTH, CODE 00 MONTHS
__ YEARS AND/OR __MONTHS
NEVER HAD INSURANCE .............................................. 999 GO TO Q3.1
DK ................................................................................ D
REF ............................................................................... R

23

2001 CHIP 3.34 modified

If Q2.15 = months, years, d, r and P = 1 or 3
2.16
What was the main reason [CHILD] was without any health insurance during this period?
INSTRUCTION: LISTEN CAREFULLY BEFORE CODING.
PROBE: I can only record the main reason.. PROBE FIRST WITH MAJOR CATEGORIES AND, IF NEEDED,
GIVE EXAMPLES FROM THE SUBCATEGORIES.
CODE ONE ONLY
FAMILY SITUATION
PARENT GOT DIVORCED, SEPARATED OR DIED
01
CHILD CUSTODY CHANGED
02
JOB-RELATED REASON
PARENT LOST A JOB
03
NO ONE IN FAMILY HAS A JOB
04
EMPLOYER DOES NOT OFFER/STOPPED OFFERING ANY INSURANCE
EMPLOYER DOES NOT OFFER/STOPPED OFFERING INSURANCE
FOR CHILD
06
COST REASONS
INSURANCE IS TOO EXPENSIVE
07
COST OF INSURANCE FROM JOB WENT UP, GOT TOO EXPENSIVE 08
DROPPED OTHER INSURANCE
09
OTHER REASONS
DROPPED INSURANCE TO QUALIFY FOR CHIP (WAITING PERIOD) 10
INSURANCE COMPANY REFUSED COVERAGE/PREEXISTING
CONDITION OR CHILD’S HEALTH
11
INSURANCE DID NOT MEET CHILD’S NEEDS
12
INSURANCE NOT NEEDED / CHILD DOES NOT GET SICK
13
NO LONGER ELIGIBLE FOR COVERAGE
14
TOO DIFFICULT / TOO MUCH WORK TO RENEW
15
OTHER (SPECIFY)
16
DK
D
REF
R

05

Box 2.17.1 Programmer, if P = 1 or 3 and Q2.15 > 12 months (uninsured for 12 months or more just prior to CHIP
enrollment), GO TO 3.1, ELSE, CONTINUE TO Q2.17.1.
2001 CHIP 3.36.1A modified

If P = 1 or 3 and Q2.14= 02 (insured before enrolling at F5) or if Q2.14 = 01 (not insured before enrolling at F5) and
Q2.15 = <12 months (uninsured less than 12 months)
2.17.1 If Q2.14 = 02, d, r. Just prior to enrolling in [CHIP/Medicaid],
If Q2.14 = 01 d, r and Q2.15 = <12 months. Just prior to being uninsured,
…was [CHILD] covered by insurance from a current or past employer or union?
YES ................................................................ 01 GO TO Q2.18
NO ................................................................. 00
DK ................................................................ D
REF ................................................................. R

24

2001 CHIP 3.36.1B modified

If Q2.17.1=00,D,R and P = 1 or 3
2.17.2 If Q2.14 = 02, d, r. Just prior to enrolling in [CHIP/Medicaid],
If Q2.14 = 01, d, r and Q2.15 = <12 months. Just prior to being uninsured,
…was [CHILD] covered by a private insurance plan purchased directly from an insurance company? Do not
include plans that only provide extra cash while in the hospital or those that cover only one type of
service, such as dental care, vision care, nursing home care, or accidents.
YES ................................................................. 01 GO TO Q2.18
NO ................................................................. 00
DK ................................................................ D
REF ................................................................. R
Box 2.17.3. Programmer, If S1=01 (CHIP) and Q2.14=02 (had insurance just prior to CHIP enrollment), go to
Q2.17.4
2001 CHIP 3.36.1G

If S1= 02 (Medicaid) and Q2.14=01,02, D,R and Q2.17.2=00,D,R and P= 1 or 3
2.17.3 If Q2.14 = 02, d, r. Just prior to enrolling in [Medicaid]
If Q2.14 = 01, d, r and Q2.15 = <12 months. Just prior to being uninsured,
…was [CHILD] covered by [CHIP]?
YES ................................................................. 01 GO TO Q2.18
NO ................................................................. 00
DK ................................................................ D
REF ................................................................. R
Box 2.17.4. Programmer, If S1=02 (Medicaid) and Q2.14=02 (had insurance just prior to CHIP enrollment), go to
Q2.17.5.
2001 CHIP 3.36.1D

If S1=01 (CHIP) and Q2.14=01, 02, D, R and P = 1 or 3
2.17.4 If Q2.14 = 02, d, r. Just prior to enrolling in [CHIP]
If Q2.14 = 01, d, r and Q2.15 = <12 months. Just prior to being uninsured,
…was [CHILD] covered by Medicaid or a Medicaid HMO, the government assistant program for people in
need?
YES ................................................................. 01 GO TO Q2.18
NO ................................................................. 00
DK ................................................................ D
REF ................................................................. R

25

2001 CHIP 3.36.1H modified

If Q2.14=01 or 02 or D or R and Q2.17.4=00,D,R and P = 1 or 3
2.17.5 If Q2.14 = 02, d, r. Just prior to enrolling in [CHIP/Medicaid],
If Q2.14 = 01, d, r and Q2.15 = <12 month. Just prior to being uninsured,
…was [CHILD] covered by some other type of coverage, I have not yet mentioned?
YES- SPECIFY .................................................. 01
NO ................................................................. 00 GO TO Q3.1
DK ................................................................ D GO TO Q3.1
REF ................................................................. R GO TO Q3.1
2001 CHIP 3.36.1AM modified

If any Q2.17.1 – Q2.17.5 = 01 and P = 1 or 3
2.18
About how many years and/ or months was [CHILD] covered by this insurance?
INSTRUCTION: IF LESS THAN ONE MONTHS, CODE 00 FOR MONTHS.
__ YEARS AND/OR __ MONTHS
DK ................................................................. D
REF ................................................................. R
Box 2.18.1. Programmer, If Q2.17.1=01 (covered by employer or union), continue to Q2.18.1. ELSE go to Box 2.19.1
3.38.2 modified

If Q2.17.1=01 and P = 1 or 3
2.18.1 Did the employer pay all, some, or none of the premium for this health insurance?
ALL ................................................................. 01
SOME ............................................................. 02
NONE ............................................................. 03
DK ................................................................. D
REF ................................................................. R
NHIS FHI.074_00.000 modified

IF Q2.17.1 = 01 and P = 1 or 3
2.18.2
Did [CHILD] have any type of insurance that paid for dental care?
YES ................................................................ 01
NO ................................................................. 00
DK ................................................................ D
REF ................................................................. R

26

NEW

If Q2.17.1= 01 (covered by employer or union) and P = 1 or 3
2.18.3 Is the person who had this insurance still working for the employer that offered it?
YES ................................................................. 01
NO ................................................................. 00 GO TO BOX 2.19.1
DK .................................................................. D GO TO BOX 2.19.1
REF ................................................................. R GO TO BOX 2.19.1
New

If Q2.17.1= 01 and P = 1 or 3
2.18.4 Does this employer still offer insurance for children of its employees?
YES ................................................................. 01
NO ................................................................. 00
DK .................................................................. D
REF ................................................................ R

GO TO Q2.18.5
GO TO BOX 2.19.1
GO TO Q2.18.5
GO TO BOX 2.19.1

New

If Q2.18.4=01 or D and P = 1 or 3
2.18.5 What was the main reason [CHILD]’s coverage ended just before the …
Variations:
Currently enrolled (P = 1) …current period of [CHIP/Medicaid] coverage started?
Currently disenrolled (P = 3)…last period of [CHIP/Medicaid] coverage started?
PROBE: I can only record the main reason why coverage ended.
INSTRUCTION: PROBE TO DISTINGUISH BETWEEN TWO “COULD NOT AFFORD” REASONS
CODE ONE ONLY
WAITING PERIOD
DROPPED PLAN TO QUALIFY FOR CHIP (WAITING PERIOD)
FAMILY SITUATION
PARENT GOT DIVORCED, SEPARATED OR DIED
CHILD CUSTODY CHANGED
03
COULD NOT AFFORD
FAMILY INCOME CHANGED
04
COST OF INSURANCE OR DEPENDENT COVERAGE WENT UP
PLAN CHANGED/LESS DESIRABLE
EMPLOYER SWITCHED TO LESS GENEROUS PLAN
OTHER REASONS
CHIP COSTS LESS/ HAS BETTER BENEFITS
INSURANCE NOT NEEDED / CHILD DOES NOT GET SICK
OTHER (SPECIFY)
09
DK
D
REF
R

01
02

05
06
07
08

Box 2.19.1. Programmer, if Q2.15 + Q2.18 = 12 months or more, go to Q2.24
If Q2.15 + Q2.18 = <12 months, continue with Q2.19.1

27

2001 CHIP 3.31 modified

If Q2.15 + Q2.18 is less than 12 months and P = 1 or 3
2.19.1 Just prior to being covered by this insurance, was [CHILD] without health insurance?

CHILD WITHOUT COVERAGE ......................... 01
CHILD HAD COVERAGE .................................. 02 GO TO BOX 2.20.1
DK ................................................................ D GO TO BOX 2.20.1
REF ................................................................. R GO TO BOX 2.20.1
2001 CHIP 3.36.1B modified

If Q2.19.1 = 01 and P = 1 or 3
2.19.2 About how many months was [CHILD] without health insurance at this time?
INSTRUCTION: IF LESS THAN ONE MONTH, CODE 00 MONTHS
__ MONTHS
DK ................................................................. D
REF ................................................................. R
Box 2.20.1. Programmer, if Q2.15 + Q2.18 + Q2.19.2= 12 months or more, go to Q2.24
If Q2.15 + Q2.18 + Q2.19.2 < 12 months, continue to Q2.20.1
2001 CHIP 3.36.1A modified

If P = 1 or 3 and Q2.14 = 01 or 02 and Q2.15 + 2.18 + 2.19.2 =< 12 months
2.20.1 If Q2.19.1 = 01. Just prior to being uninsured,
If Q2.19.1=02. Just prior to being covered by this insurance,
… was [CHILD] covered by an (If Q2.17.1 = 01 another) insurance plan from a current or past employer or
union?
YES ................................................................. 01 GO TO Q2.21
NO ................................................................. 00
DK ................................................................ D
REF ................................................................ R
2001 CHIP 3.36.1B modified

If P = 1 or 3 and Q2.14=01 or 02 and Q2.20.1=00,D,R
2.20.2 If Q2.19.1 = 01. Just prior to being uninsured,
If Q2.19.1=02. Just prior to being covered by this insurance,
…was [CHILD] covered by a (if Q2.17.2 = 01 another) private insurance plan purchased directly from an
insurance company? Do not include plans that only provide extra cash while in the hospital or those that
cover only one type of service, such as dental care, vision care, nursing home care, or accidents.
YES ................................................................. 01 GO TO Q2.21
NO ................................................................. 00
DK ................................................................ D
REF ................................................................. R
Box 2.20.3. Programmer, If Q2.19.1 = 02,D,R and Q2.17.3 = 01, go to Q2.20.4.

28

2001 CHIP 3.36.1G modified

If S1 = 2 (Medicaid) and Q2.20.2=00,D,R and P = 1 or 3
2.20.3 If Q2.19.1 = 01. Just prior to being uninsured,
If Q2.19.1=02. Just prior to being covered by this insurance,
…was [CHILD] covered by [CHIP]?
YES ................................................................. 01 GO TO Q2.21
NO ................................................................. 00
DK ................................................................ D
REF ................................................................. R
Box 2.20.4. Programmer, If 2.19.1=02,D,R and 2.17.4=01, go to 2.20.5
2001 CHIP 3.36.1D modified
If S1 = 1 (CHIP) and Q2.20.3=00,D,R and P = 1 or 3
2.20.4 If Q2.19.1 = 01. Just prior to being uninsured,
If Q2.19.1=02. Just prior to being covered by this insurance,
…was [CHILD] covered by Medicaid or a Medicaid HMO, the government assistance program for people
need?

in

YES ................................................................. 01 GO TO Q2.21
NO ................................................................. 00
DK ................................................................ D
REF ................................................................. R
2001 CHIP 3.36.1H modified

If Q2.20.4=00,D,R or Q2.20.3=00,D, R and P = 1 or 3
2.20.5 If Q2.19.1 = 01. Just prior to being uninsured,
If Q2.19.1=02. Just prior to being covered by this insurance,
… was [CHILD] covered by some other type of coverage, I have not yet mentioned?
YES (SPECIFY) ................................................. 01NO
00 GO TO Q2.24
DK .................................................................. D GO TO Q2.24
REF ................................................................. R GO TO Q2.24
2001 CHIP 3.36.1AM modified

If any Q2.20.1 - Q2.20.5=01 and P = 1 or 3
2.21
About how many months was [CHILD] covered by this insurance?
INSTRUCTION: IF LESS THAN ONE MONTHS, CODE 00 MONTHS
__ MONTHS
DK ................................................................. D
REF ................................................................. R
Box 2.22. Programmer: If Q2.14 does not equal 01 and Q2.19.1 does not equal 01 (no uninsurance spells reported
yet) and (Q2.18 + Q2.21) < 12 MONTHS, continue to Q2.22. ELSE go to BOX 2.28

29

2001 CHIP 3.31 modified

If Q2.14 NE 01 and Q2.19.1 NE 01 AND (Q2.18 +Q2.21) < 12 months and P = 1 or 3
2.22
In the 12 months before [CHILD] enrolled in [CHIP/Medicaid] in [F5], was there a period in which [he/she]
was without health insurance coverage?
YES ................................................................. 01
NO ................................................................. 00 GO TO Q2.24
DK .................................................................. D GO TO Q2.24
REF ................................................................. R GO TO Q2.24
2001 CHIP 3.32 modified

If Q2.14 NE 01 and Q2.22=01 and P = 1 or 3
2.23
During the 12 months before [CHILD] enrolled in [CHIP/Medicaid], how many months was [CHILD] without
health insurance coverage?
__ MONTHS
DK .................................................................. D
REF ................................................................. R
NSCH K3Q20 modified

If Q2.18 >00 and P = 1 or 3
2.24
The next questions are about the health insurance or health care plans [CHILD] had during the 12 months
before enrolling in [CHIP/Medicaid].
Did [CHILD’s] health insurance offer benefits or cover services that meet [his/her] needs? Would you say
the benefits and coverage…
CODE ONE ONLY
Never met [his/her] needs? .......................... 01
Sometimes met [his/her] needs? ................. 02
Usually met [his/her] needs? ........................ 03
Always met [his/her] needs? ......................... 04
DK .................................................................. D
REF ................................................................. R

NSCH K3Q22 modified

Q2.18= more than 00 and P = 1 or 3
2.25
Did [CHILD]’s health insurance allow [him/her] to see the health care providers [he/she] needed? Would
you say:…
CODE ONE ONLY
Never ............................................................. 01
Sometimes .................................................... 02
Usually ........................................................... 03
Always ........................................................... 04
DK .................................................................. D
REF ................................................................. R

30

NSCH K3Q21A

If Q2.18>00 and P = 1 or 3
2.26
Not including health insurance premiums or costs that were covered by insurance, did you pay any money
for [CHILD]’s health care?
PROMPT: Include out-of-pocket payments for all types of health-related needs such as copayments,
dental or vision care, medications, and any kind of therapy.
YES ................................................................. 01
NO ................................................................. 00 GO TO BOX 2.28
DK .................................................................. D GO TO BOX 2.28
REF ................................................................. R GO TO BOX 2.28
NSCH K3Q21B

If Q2.26 = 01 and P = 1 or 3
2.27
How often were these costs reasonable? Would you say never, sometimes, usually or always?
CODE ONE ONLY
Never ............................................................. 01
Sometimes ..................................................... 02
Usually ........................................................... 03
Always ........................................................... 04
DK .................................................................. D
REF ................................................................. R
Box 2.28. Programmer, If P = 1, 3, 5, go to Q3.1
If P = 6 – 11, continue with Q2.28
COVERAGE POST DISENROLLMENT
2001 CHIP 3.60 modified

If P = 6 – 11
2.28
P = 6, 7, 8, 9. Now, I would like to ask you questions about the time since [CHILD]’s last [CHIP/ Medicaid]
coverage ended in [F4 DATE]. Since [F4 DATE], was (CHILD) without health insurance, or did he/she have
health insurance coverage, such as [Medicaid or private insurance/ CHIP or private insurance]?]
P = 10, 11. Now, I would like to ask you some questions about the time between [F6 DATE] when [CHILD]’s
previous coverage ended and [F5 DATE] when the current coverage started. Just after [his/her] previous
[CHIP/ Medicaid] coverage ended was [CHILD] without health insurance coverage or did [he/she] have
health insurance such as [Medicaid or private insurance/ CHIP or private insurance?] since [CHILD]’s last
[CHIP/ Medicaid] coverage ended, that is since (F4 DATE).
WITHOUT HEALTH INSURANCE ................................... 01
HAD HEALTH INSURANCE ............................................ 02 GO TO Q2.31.1
DK ................................................................................ D GO TO Q2.31
REF ............................................................................... R GO TO Q2.31

31

2001 CHIP 3.63

If 2.28=01 and P = 6 - 11
2.29
How many months was [CHILD] without any health insurance coverage just after [his/her]…
P = 6, 7, 8, 9 … last [CHIP/Medicaid] coverage ended on [F4 date]?
P = 10, 11 …previous [CHIP/Medicaid] coverage ended on [F6 date]?
INSTRUCTION: IF LESS THAN ONE MONTH, CODE 00 MONTHS
__ MONTHS
WHOLE PERIOD ............................................. 999 GO TO Q3.1
DK .................................................................. D GO TO Q2.31
REF ................................................................. R GO TO Q2.31
Box 2.30. Programmer, add number of months disenrolled at Q2.29 to F4 date. If this = interview month, go to
Q3.1, else continue.
2001 CHIP 3.64

If Q2.28=01 and P = 6, 7, 8, 9
Or if P = 10 or 11 and Q2.28=01
2.30
P = 6, 7, 8, 9. Since [CHILD]’s last [CHIP/Medicaid] coverage ended on [F4 DATE], has [he/she] been
covered by any health insurance?
P = 10, 11. Since [CHILD]’s previous [CHIP/Medicaid] coverage ended in [F6 DATE] and before [CHILD] was
enrolled again in [F5 DATE], was [he/she] covered by any health insurance?
YES ................................................................. 01
NO ................................................................. 00
DK .................................................................. D GO TO Q3.1
REF ................................................................. R GO TO Q3.1
2001 CHIP 3.64.1

IF Q2.30= 01 and P= 6 – 11
2.31
P = 6, 7, 8, 9 How many months was [CHILD] covered by health insurance just after [his/her] last [CHIP/
Medicaid] coverage ended on [F4 DATE]?/
P = 10, 11 How many months was [CHILD] covered by health insurance between [F6 DATE] and [F5
DATE]?]
INSTRUCTION: IF LESS THAN ONE MONTH, CODE 00 MONTHS
__ MONTHS
WHOLE PERIOD ............................................. 999
DK .................................................................. D
REF ................................................................. R

32

2001 CHIP 3.65.A

If Q2.31 = 00 - 999 (answered) and P= 6 – 11
2.31.1 During this time, was [CHILD] covered by insurance from a current or past employer or union?
YES ................................................................. 01
NO ................................................................. 00
DK .................................................................. D
REF ................................................................. R
2001 CHIP 3.65.B modified

If Q2.31 = 00- 999 (answered) and P= 6 – 11
2.31.2 During this time, was [CHILD] covered by a private insurance plan purchased directly from an insurance
company? Do not include plans that only provide extra cash while in the hospital or plans for only one
type of service, such as dental care, vision care, nursing home care or accidents.
YES ................................................................. 01
NO ................................................................. 00
DK .................................................................. D
REF ................................................................. R
Box 2.31.3. Programmer, if S1 = 1 (CHIP), go to Q2.31.4.
2001 CHIP 3.65.G

If Q2.31=00-999 (answered)and S1 = 02 and P= 6 – 11
2.31.3 Was [CHILD] covered by [CHIP]?
YES ................................................................. 01
NO ................................................................. 00
DK .................................................................. D
REF ................................................................. R
Box 2.31.4. Programmer, If S1 = 2 (MEDICAID) , go to Q2.31.5
2001 CHIP 3.65.D

If Q2.31= 00 - 999 and S1 ne 02 and P= 6 – 11
2.31.4 Was [CHILD] covered by Medicaid or a Medicaid HMO, the government assistance program for people in
need?
YES ................................................................. 01
NO ................................................................. 00
DK .................................................................. D
REF ................................................................. R
2001 CHIP 3.65.H

If Q2.31 =00 – 999 and P= 6 – 11
2.31.5 Was [CHILD] covered by some other type of coverage I have not yet mentioned?
YES ................................................................. 01
NO ................................................................. 00
DK .................................................................. D
REF ................................................................. R

33

2001 CHIP 3.66.1-3.66.7

If Q2.31.1 – Q2.31.5 has more than one answer = 01 (YES) and P= 6 – 11
2.32
Of the health insurance plan(s) you just mentioned, which plan or plans did [CHILD] have….
P = 6, 7, 8, 9 ….just after the last period of [CHIP/Medicaid] coverage ended in (F4 DATE)?
P = 10, 11… just after [CHILD] became uninsured?
PROGRAMMER: DISPLAY ONLY YES RESPONSES TO 2.31.1 – 2.31.5 HERE AND ALLOW CODE ALL THAT APPLY.
___________________________________
___________________________________
___________________________________
Box 2.33. Programmer, if Q2.31.1= 01 (insurance through employer), continue to Q2.33.
If all responses in Q2.31.1 – Q2.31.5 = 00, d, r, go to Q3.1.
2001 CHIP 3.66.2

If Q2.31.1 , Q2.31.2 or Q2.31.5 =01 and P= 6 – 11
2.33
If insurance only through employer (Q2.31-1 = 01). Did the employer pay all, some, or none of the
premium for this health insurance?
If insurance through employer and other sources (Q2.31.01 = 01 and any other Q2.31.2 – Q2.31.52 = 01)
For the health insurance from an employer, did the employer pay all, some, or none of the premium for
this health insurance?
ALL ................................................................. 01
SOME ............................................................. 02
NONE ............................................................. 03
DK .................................................................. D
REF ................................................................. R
2001 CHIP 3.66.3

If Q2.33 = 01 or 02 and P= 6 – 11
2.34
Is [CHILD] covered by this insurance coverage right now?
YES ................................................................. 01
NO ................................................................. 00
DK .................................................................. D
REF ................................................................. R
GO TO 3.1.

34

SECTION 3: CHILD’S HEALTH
Section 3 Overview
Section 3 questions will be asked about the sample child’s current or on-going health; thus,
there will be no need to vary question timeframe wording depending on the sample domain and
current enrollment status. All questions in the final questionnaire will be worded exactly as they
appear in this OMB document.
Table 3.1. Pathing in Section 3
Pathing
Status

General Health
Status
(Q3.1 – 3.4)

CSHCN Screener
(Q3.7 – 3.24)

Acute/ Chronic
Conditions
(Q3.25 – 3.37)

x

x

x

x

x

x

x
x

x
x

x
x

x
x

x
x

x
x
x

x
x

x
x

Height/ Weight
(Q3.5 – 3.6)
New Enrollees

P=1
P=2
P=3
P=4

x

Q3.1, Q3.3
x
Q3.1, Q3.3

Established Enrollees
P=5
P=6

x
x

x
x
Recent Disenrollees

P
P
P
P
P
P

=
=
=
=
=
=

7
8
9
10
11
12

x
x
Q3.1, Q3.3
x
x
Q3.1, Q3.3

35

The next questions are about your child’s health at this time.
GENERAL HEALTH STATUS
2001 CHIP 4.1 modified; NSCH K2Q01 modified

If P = 1 – 12
3.1 In general, how would you describe [CHILD]’s health. Would you say [his/her] health is…
CODE ONE ONLY
Excellent ....................................................... 01
Very Good ..................................................... 02
Good ............................................................. 03
Fair ................................................................ 04
Poor .............................................................. 05
DK ................................................................. D
REF ................................................................ R
Box 3.2. Programmer: note 1: if S4 = 12 months or fewer, go to Q3.3.
Note 2: If P = 2,4,9, or 12, go to Q3.3.
2001 CHIP 4.2

If P = 1, 3, 5, 6, 7, 8, 10, 11 and S4>12 months
3.2
Compared to 12 months ago, would you say [CHILD]’s health is now…
CODE ONE ONLY
Better ............................................................ 01
Worse ........................................................... 02
About the same ............................................ 03
DK ................................................................. D
REF ................................................................ R
MEPS PE PE00B response categories

If P = 1 – 12
3.3 In general, how would you describe [CHILD]’s mental health? Would you say [his/her] mental health is…
CODE ONE ONLY
Excellent ....................................................... 01
Very Good ..................................................... 02
Good ............................................................. 03
Fair ................................................................ 04
Poor .............................................................. 05
DK ................................................................. D
REF ................................................................ R
Box 3.4. Programmer, if P = 2, 4, 9, or 12, go to Q6.1

36

NSCH K2Q02

If P = 1, 3, 5, 6, 7, 8, 10, 11
3.4 How would you describe the condition of [CHILD]’s teeth?
CODE ONE ONLY
Excellent ....................................................... 01
Very Good ..................................................... 02
Good ............................................................. 03
Fair ................................................................ 04
Poor .............................................................. 05
DK ................................................................. D
REF ................................................................ R
Box 3.5 Programmer, If P = 2, 4, 9 or 12, skip to Q6.1.
HEIGHT/ WEIGHT
NSCH K2Q03

If P = 1, 3, 5, 6, 7, 8, 10, 11
3.5 How tall is [CHILD] now?
PROBE: Your best estimate is fine. You may answer in feet and inches or meters and centimeters.
Feet: |__| and |__ ___| Inches
OR
|__ ___| Centimeters
INSTRUCTION: If parent answers in inches or centimeters for a child less than 12 months, record 0 feet or
0 meters.
NSCH K2Q03

If P = 1, 3, 5, 6, 7, 8, 10, 11
3.6 How much does [CHILD] weigh now?
PROBE: Your best estimate is fine. You may answer in pounds or kilograms.
Pounds:
|___|___|___| AND |__|__|Ounces
OR
Kilograms: |___|___|___|
PRESENCE OF A SPECIAL HEALTH CARE NEED (BASED ON CSHCN SCREENER)
NSCH K2Q10 modified

If P = 1, 3, 5, 6, 7, 8, 10, 11
3.7
Does [CHILD] currently need or use medicine prescribed by a doctor, other than vitamins?
PROBE: This does not include routine immunizations or over-the-counter medication such as cold or
headache medicines
YES ................................................................ 01
NO ................................................................. 00 GO TO Q3.11
DK .................................................................. D GO TO Q3.11
REF ................................................................. R GO TO Q3.11

37

NSCH K2Q11

If Q3.7=01 and P = 1, 3, 5, 6, 7, 8, 10, 11
3.8 Is [his/her] need for prescription medicine because of any medical, behavioral or other health condition?
YES ................................................................ 01
NO ................................................................ 00 GO TO Q3.10
DK ................................................................ D GO TO Q3.10
REF ................................................................. R GO TO Q3.10
NSCH K2Q12 modified

If Q3.8=01 and P = 1, 3, 5, 6, 7, 8, 10, 11
3.9 Is this a condition that has lasted or is expected to last 12 months or longer?
YES ................................................................. 01 GO TO Q3.11
NO ................................................................ 00 GO TO Q3.11
DK ................................................................ D GO TO Q3.11
REF ............................................................... R GO TO Q3.11
NSCH K2Q12A

If Q3.8 = 00, D, R and P = 1, 3, 5, 6, 7, 8, 10, 11
3.10 Has [CHILD]'s need for prescription medication lasted or is it expected to last 12 months or longer?
YES ................................................................ 01
NO ................................................................. 00
DK ................................................................. D
REF ................................................................. R
NSCH K2Q13

If P = 1, 3, 5, 6, 7, 8, 10, 11
3.11
Does [CHILD] need or use more medical care, mental health, or educational services than is usual for most
children of the same age?
YES ................................................................ 01
NO ................................................................ 00 GO TO Q3.15
DK .................................................................. D GO TO Q3.15
REF ................................................................. R GO TO Q3.15
NSCH K2Q14

If Q3.11=01 and P = 1, 3, 5, 6, 7, 8, 10, 11
3.12
Is [his/her] need for medical care, mental health or educational services because of any medical,
behavioral or other health condition?
YES ................................................................ 01
NO ................................................................. 00 GO TO Q 3.14
DK .................................................................. D GO TO Q 3.14
REF ................................................................. R GO TO Q 3.14

38

NSCH K2Q15

If Q3.12=01 and P = 1, 3, 5, 6, 7, 8, 10, 11
3.13 Is this a condition that has lasted or is expected to last 12 months or longer?
YES ................................................................. 01 GO TO Q3.15
NO ............................................................... 00 GO TO Q3.15
DK ................................................................ D GO TO Q3.15
REF ............................................................... R GO TO Q3.15
NSCH K2Q15A

If Q3.12=00, D, R and P = 1, 3, 5, 6, 7, 8, 10, 11
3.14
Has [CHILD]'s need for medical care, mental health, or educational services lasted or is it expected to last
12 months or longer?
YES ................................................................ 01
NO ................................................................. 00
DK ................................................................. D
REF ................................................................. R
NSCH K2Q16

If P = 1, 3, 5, 6, 7, 8, 10, 11
3.15
Is [CHILD] limited or prevented in any way in [his/her] ability to do the things most children of the same
age can do?
YES ................................................................ 01
NO ................................................................. 00 GO TO Q3.19
DK ................................................................ D GO TO Q3.19
REF ............................................................... R GO TO Q3.19
NSCH K2Q17

If Q3.15=01 and P = 1, 3, 5, 6, 7, 8, 10, 11
3.16 Is [his/her] limitation in abilities because of any medical, behavioral, or other health condition?
YES ................................................................ 01
NO ................................................................. 00 GO TO Q3.18
DK ................................................................ D GO TO Q3.18
REF ............................................................... R GO TO Q3.18
NSCH K2Q18

If Q3.16=01 and P = 1, 3, 5, 6, 7, 8, 10, 11
3.17 Is this a condition that has lasted or is expected to last 12 months or longer?
YES ................................................................. 01 GO TO Q3.19
NO ................................................................ 00 GO TO Q3.19
DK ................................................................ D GO TO Q3.19
REF ............................................................... R GO TO Q3.19

39

NSCH K2Q18A

If Q3.16=00, D, R and P = 1, 3, 5, 6, 7, 8, 10, 11
3.18 Has [CHILD]'s limitation in abilities lasted or is it expected to last 12 months or longer?
YES ................................................................ 01
NO ................................................................. 00
DK ................................................................. D
REF ................................................................. R
NSCH K2Q19

If P = 1, 3, 5, 6, 7, 8, 10, 11
3.19
Does [CHILD] need or get special therapy, such as physical, occupational, or speech therapy?
PROBE: This does not include psychological therapy.
YES ................................................................ 01
NO ................................................................. 00 GO TO Q3.23
DK ................................................................ D GO TO Q3.23
REF ............................................................... R GO TO Q3.23
NSCH K2Q20

If Q3.19=01 and P = 1, 3, 5, 6, 7, 8, 10, 11
3.20 Is [CHILD]’s need for special therapy because of any medical, behavioral, or other health condition?
YES ................................................................ 01
NO ................................................................. 00 GO TO Q3.22
DK ................................................................ D GO TO Q3.22
REF ............................................................... R GO TO Q3.22
NSCH K2Q21

If Q3.20=01 and P = 1, 3, 5, 6, 7, 8, 10, 11
3.21 Is this a condition that has lasted or is expected to last 12 months or longer?
YES ................................................................. 01 GO TO Q3.23
NO ............................................................... 00 GO TO Q3.23
DK ............................................................... D GO TO Q3.23
REF ............................................................... R GO TO Q3.23
NSCH K2Q21A

If Q3.20=00, D, R and P = 1, 3, 5, 6, 7, 8, 10, 11
3.22 Has [CHILD]’s need for special therapy lasted or is it expected to last 12 months or longer?
YES ................................................................ 01
NO ................................................................. 00
DK ................................................................. D
REF ................................................................. R

40

NSCH K2Q22

If P = 1, 3, 5, 6, 7, 8, 10, 11
3.23
Does [CHILD] have any kind of emotional, developmental, or behavioral problem for which [he/she] needs
treatment or counseling?
YES ................................................................ 01
NO ................................................................. 00 GO TO Q3.25
DK .................................................................. D GO TO Q3.25
REF ................................................................. R GO TO Q3.25
NSCH K2Q23

If Q3.23=01 and P = 1, 3, 5, 6, 7, 8, 10, 11
3.24
Has [his/her] emotional, developmental, or behavioral problem lasted or is it expected to last 12 months
or longer?
YES ................................................................ 01
NO ................................................................. 00
DK ................................................................. D
REF ................................................................. R
ACUTE/CHRONIC CONDITIONS (P = 1, 3, 5, 6, 7, 8, 10, 11)
2001 CHIP 4.13

If P = 1, 3, 5, 6, 7, 8, 10, 11
3.25
The next questions ask about common acute and chronic conditions [CHILD] might have. Has a doctor or
other health provider ever told you that [he/she] had a mental health condition or behavioral problem?
PROBE IF ASKED: Please include only conditions diagnosed by a doctor or other health provider.
YES ................................................................ 01
NO ................................................................ 00 GO TO Q3.31
DK .................................................................. D GO TO Q3.27
REF ................................................................. R GO TO Q3.27
2001 CHIP 4.14 (not in public access file)

If Q3.25=01 and P = 1, 3, 5, 6, 7, 8, 10, 11
3.26
How old was [CHILD] when a doctor or other health care provider first said [he/she] had a mental health
condition or a behavioral problem?
____ AGE IN YEARS (LESS THAN 1, CODE 00)
DK ................................................................. D
REF ................................................................ R

41

NSCH K2Q31A modified

If S4 = 24 months or older and P = 1, 3, 5, 6, 7, 8, 10, 11
3.27
Has a doctor or other health care provider ever told you that [CHILD] had Attention Deficit Disorder (ADD)
or Attention Deficit Hyperactive Disorder (ADHD)?
YES ................................................................ 01
NO ................................................................. 00 GO TO Q3.29
DK .................................................................. D GO TO Q3.29
REF ................................................................. R GO TO Q3.29
NSCH K2Q32B

If Q3.27=01 and S4 = 24 months or older and P = 1, 3, 5, 6, 7, 8, 10, 11
3.28 Does [CHILD] currently have ADD or ADHD?
YES ................................................................ 01
NO ................................................................. 00
DK ................................................................. D
REF ................................................................. R
NSCH K2Q34A modified

If Q1.1=01-03 or 00 and S4 = 24 months or older and P = 1, 3, 5, 6, 7, 8, 10, 11
3.29
Has a doctor or other health care provider ever told you that [CHILD] had behavioral or conduct problems,
such an oppositional defiant disorder or conduct disorder?
YES ................................................................ 01
NO ................................................................. 00 GO TO Q3.31
DK .................................................................. D GO TO Q3.31
REF ................................................................. R GO TO Q3.31
NSCH K2Q35B

If Q3.29=01 and S4 = 24 months or older and P = 1, 3, 5, 6, 7, 8, 10, 11
3.30 Does [CHILD] currently have behavioral or conduct problems?
YES ................................................................ 01
NO ................................................................. 00
DK ................................................................. D
REF ................................................................. R
NSCH K2Q40A modified

If P = 1, 3, 5, 6, 7, 8, 10, 11
3.31 Has a doctor or other health care provider ever told you that [CHILD] had asthma?
YES ................................................................ 01
NO ................................................................. 00 GO TO Q3.36
DK .................................................................. D GO TO Q3.36
REF ................................................................. R GO TO Q3.36

42

2001 CHIP 4.10

If Q3.31=01 (provider ever told you child had asthma) and P = 1, 3, 5, 6, 7, 8, 10, 11
3.32 How old was [CHILD] when [he/she] had [his/her] first episode of asthma or first asthma attack?
____ AGE IN YEARS (IF LESS THAN 1, CODE 0)
DK ................................................................. D
REF ................................................................. R
NSCH K2Q41B

If Q3.31=01 (provider ever told you child had asthma) and P = 1, 3, 5, 6, 7, 8, 10, 11
3.33 Does [CHILD] currently have asthma?
YES ................................................................ 01
NO ................................................................. 00 GO TO Q3.36
DK .................................................................. D GO TO Q3.36
REF ................................................................. R GO TO Q3.36
NSCH K2Q40C

If Q3.31 = 01 (provider ever told you child had asthma) and P = 1, 3, 5, 6, 7, 8, 10, 11
3.34 During the past 12 months, would you describe [his/her] asthma as mild, moderate, or severe?

MILD ............................................................. 01
MODERATE ................................................... 02
SEVERE .......................................................... 03
DK ................................................................. D
REF ................................................................ R
2009 NHIS Child CHS.090_00. 000

If Q3.31 = 01 (provider ever told you child had asthma) and P = 1, 3, 5, 6, 7, 8, 10, 11
3.35 During the past 12 months, has [CHILD] had an episode of asthma or an asthma attack?
YES ................................................................ 01
NO ................................................................. 00
DK ................................................................. D
REF ................................................................. R
Box 3.36. Programmer, if S4 = 59 months or less, go to Q4.1.

43

NHIS 2009, CHS.220_00.000 modified

If S4=60 months or older and P = 1, 3, 5, 6, 7, 8, 10, 11
3.36
During the past 12 months, that is, since [DATE ONE YEAR PRIOR TO INTERVIEW DATE], about how many
days did [CHILD] miss school because of illness or injury? Please include doctor’s appointments related to
that illness or injury. Was it…
PROBE: Do not include visits to the doctor for checkups or routine shots.
CODE ONE ONLY
No days .......................................................... 00
1-2 days ......................................................... 01
3-4 days ........................................................ 02
5-10 days ..................................................... 03
More than 10 days ....................................... 04
Not currently enrolled in school .................... 05
DK ................................................................. D
REF ................................................................. R
NHIS 2009, CHS.220_00.000, modified

If Q3.31 = 01 and Q3.36=01-04 and S4=60 months or older and P = 1, 3, 5, 6, 7, 8, 10, 11
3.37
During the past 12 months, that is, since [DATE ONE YEAR PRIOR TO INTERVIEW DATE] about how many
days did [CHILD] miss school because of asthma? Was it …
CODE ONE ONLY
None .............................................................. 00
1-2 days ......................................................... 01
3-4 days ........................................................ 02
5-10 days ..................................................... 03
More than 10 days ....................................... 04
DK ................................................................. D
REF ................................................................. R

GO TO Q4.1

44

SECTION 4: ACCESS TO AND SATISFACTION WITH USUAL PLACE OF CARE
AND HEALTH SERVICE UTILIZATION
Section 4 Overview
Question language in Section 4 is shown as “generic” in this document. The specific timeframe
language to be programmed into the final questionnaire will depend on the pathing definitions laid
out below.
Table 4.1 Timeframe Pathing in Section 4
Usual Source
of Care
(Q4.1 –Q 4.11)

Service Use
(Q4.12 –
Q4.34)

1
2
3
4

x

x

x

x

P=5
P=6

x
x

x
x

P=7

Q4.1 – Q4.3,
Q4.8 – Q4.11
x
Q4.1 – Q4.3,
Q4.8 – Q4.11

Q4.15 –
Q4.16
x
Q4.15 –
Q4.16

Pathing
Definitions

Content of
Care
(Q4.36 Q4.39)

Adequacy
of Care
(Q4.40 – Q4.50)

Willing to
Pay
(Q4.51 –
Q4.52)

x

x

x

x

x

x

x

x

x
x

x
x

x
x

x

Q4.40 - 4.45,
Q4.47, Q4.48
x
Q4.40 - Q4.45
Q4.47, Q4.48

x

Unmet Need
(Q4.35 –
Q4.35a)
New Enrollees

P
P
P
P

=
=
=
=

Established Enrollees
x
x
Recent Disenrollees

P = 8a*
P = 8b*

x
x
x

P=9
P = 10
P = 11
x
x
x
x
x
x
P = 12
P = 8a* All recent disenrollees, currently disenrolled but having 12+ months of CHIP/Medicaid experience will be asked
Section 4 questions in two time frames: once for the time frame prior to disenrollment and then a second small subset
of questions for the time frame after their disenrollment.

1) Where the difference between actual and reported enrollment or disenrollment dates varies by more than 9 months,
we assume respondents will have poor recall and they will be skipped out of Section 4 entirely (P = 2, 4, 9, 10, and 12)
to Q6.1.
2) Where the difference between actual and reported enrollment and disenrollment dates varies by less than 9 months,
we assume respondents will have good recall and they will be asked appropriate questions in all subsections of Section
4.
P = 1 will be asked about the 12 months prior to current enrollment
P = 3 will be asked about the 12 months prior to last enrollment
P = 8a will be asked about the 12 months prior to disenrollment

P = 8b (same respondents as P = 8a) will be asked a subset of questions about the time since disenrollment

P = 11 will be asked about the 12 months prior to disenrollment

3) Where the difference between actual and reported enrollment and disenrollment dates varies by less than 9 months
and the respondent was previously enrolled less than one year, we assume that, while the recall may be good, the
CHIP/Medicaid experience will be minimal. Therefore, we ask these respondents only a subset of questions in Section 4.
P = 7 will be asked a subset of questions since disenrollment

4) By definition, established enrollees have 12+ months of enrollment experience. They will be asked all appropriate
questions in all subsections of Section 4.
P = 5 will be asked about the past 12 months
P = 6 will be asked about the past 12 months

45

USUAL SOURCE OF CARE
Box 4.1. Programmer: If P = 2, 4, 9, 10, 12 GO TO Q6.1
NSCH K4Q01 modified

If P = 1, 3, 5, 6, 7, 8a, 8b, 11

4. 1

The next questions are about [CHILD]’s usual place of care. Is there a place where [he/she]
usually goes when [he/she] is sick or you need advice about [his/her] health?
PROBE: This is the usual place of medical care, not child care.
PROBE IF RESPONDENT SAYS “YES”: Was that one place or more than one place?
CODE ONE ONLY
YES, ONE PLACE ONLY ...................................
YES, MORE THAN ONE PLACE ........................
NO ................................................................
DK ..................................................................
REF .................................................................

01
02
00 GO TO Q4.6
D GO TO Q4.6
R GO TO Q4.6

NSCH K4Q02 modified

If P = 1, 3, 5, 6, 7, 8a, 8b, 11
4.2
I’m going to read a list of places [CHILD] might go for health care.
If Q4.1 = 01. What kind of place is it?
If Q4.1 = 02. What kind of place does [he/she] go to most often?
PROBE: I can only record one place.
CODE ONE ONLY
Private doctor’s office or group practice ..................... 01
An HMO-run office or facility .................................... 02
A public clinic or community health center ................ 03
A hospital emergency room ........................................ 04
A hospital outpatient department .............................. 05
Another type of clinic or health center ....................... 06
DK ................................................................................ D

GO TO Q4.4
GO TO Q4.4
GO TO Q4.4
GO TO Q4.6
GO TO Q4.4

NSCH K4Q03 modified

If Q4.2 = 06 and P = 1, 3, 5, 6, 7, 8a, 8b, 11
4.3 What kind of place does [CHILD] go to most often?
_________ (RECORD VERBATIM RESPONSE)
DK ................................................................. D
REF ................................................................. R
Box 4.4. Programmer if P = 7 or 8b, GO TO Q4.8, ELSE CONTINUE.

46

GO TO Q4.4

MEPS, 2009, AC24

If Q 4.1 = 01 or 02 and Q4.2 not equal to 04 and P = 1, 3, 5, 6, 8a, 11
4.4
Does [CHILD]’s usual place of care have office hours at night or on the weekends?
YES .................................................................
NO .................................................................
DK .................................................................
REF .................................................................

01
00
D
R

CAHPS Health Plan Survey 1158a_engchild survey_40.doc, Q2020, modified

If Q4.1 = 01 or 02 and P = 1, 3, 5, 6, 7, 8a, 8b, 11
4.5
During the past 12 months, how often has it been easy to get appointments for [CHILD] at this place?
Would you say it was…
CODE ONE ONLY
Never easy ................................................................... 01
Somewhat easy ........................................................... 02
Usually easy ................................................................. 03
Always easy ................................................................. 04
DID NOT TRY TO GET APPOINTMENT .......................... 05
DK ................................................................................ D
REF ............................................................................... R
2001 CHIP 5.23.2

Q4.1= 01 or Q4.2 is not equal to 04 and P = 1, 3, 5, 6, 8a, 11
4.6
If [CHILD]’s usual place of care were closed and [he/she] got sick would you be able to reach and talk to a
doctor or other health care provider from the usual place of care about [his/her] condition?
YES ................................................................
NO .................................................................
DK .................................................................
REF ................................................................

01
00
D
R

2001 CHIP 5.27B modified

If P = 1, 3, 5, 6, 8a, 11
4.7
Think about the [place if 4.1=01/places if 4.1=02] [CHILD] usually goes for medical care.
When you take [him/her] for a health care visit, when [he/she] arrived on time for an appointment, about
how long would [he/she] usually have to wait before getting medical care?
CODE ONE ONLY
__ MINUTES
GO TO Q4.9
PLACE DID NOT TAKE APPOINTMENTS .......... 1
GO TO Q4.9
DK .................................................................. D
REF ................................................................. R

47

2001 CHIP 5.27.1 modified

If Q4.7 = d, r and P = 1, 3, 5, 6, 8a, 11
4.8 Would [he/she] have to wait…
CODE ONE ONLY
Less than 15 minutes ..................................... 01
15 minutes but less than 30 minutes ............ 02
30 minutes but less than 45 minutes ............ 03
45 minutes but less than one hour ............... 04
One hour but less than two hours................. 05
Two hours or more ........................................ 06
DK ................................................................. D
REF ................................................................. R
NSCH K4Q04

P = 1, 3, 5, 6, 7, 8a, 8b, 11
4.9
A personal doctor or nurse is a health care provider who knows your child well and is familiar with your
child’s health history. This can be a general doctor, a pediatrician, a specialist doctor, a nurse practitioner,
or a physician’s assistant.
Do you have one or more persons you think of as [CHILD]’s personal doctor or nurse?
PROBE: IF RESPONDENT ANSWERS “YES”, ASK: Is that one person or more than one person?
CODE ONE ONLY
YES, ONE PERSON .........................................
YES, MORE THAN ONE PERSON .....................
NO .................................................................
DK .................................................................
REF ................................................................

01
02
00
D
R

NSCH K4Q01 modified for dental

If P = 1, 3, 5, 6, 7, 8a, 8b, 11
4.10
The next questions are about [CHILD]’s usual place of dental care.
Is there a place that [CHILD] usually goes for a dental check-up or when [he/she] needs care for [his/her]
teeth?
YES ................................................................ 01
NO ................................................................. 00
DK .................................................................. D
REF ................................................................. R

GO TO Q4.13
GO TO Q 4.13
GO TO Q4.13

MEPS 2009, AC24 modified

If Q4.10 = 01 and P = 1, 3,5, 6, 7, 8a, 8b, 11
4.11 Does [CHILD]’s usual dental provider have office hours at night or on weekends?
YES ................................................................ 01
NO ................................................................. 00
DK .................................................................. D
REF ................................................................. R

48

CAHPS Health Plan Survey 1158a_engchild survey_40.doc, Q2020

If Q4.10 = 01 and P = 1, 3, 5, 6, 7, 8a, 8b, 11
4.12
During the past 12 months, how often has it been easy to get appointments for [him/her] with that
dentist? Would you say it was…
CODE ONE ONLY
Never easy ................................................................... 01
Somewhat easy ........................................................... 02
Usually easy ................................................................. 03
Always easy ................................................................. 04
DID NOT TRY TO GET APPOINTMENT .......................... 05
DK ................................................................................ D
REF ............................................................................... R

Box 4.13. Programmer, if P = 7 or 8b, GO TO Q4.15
USE OF SERVICES
2001 CHIP 6.2

If Q4.12 = 04 or 05 and P = 1, 3, 5, 6, 8a, 11
4.13
The next questions are about different kinds of places [CHILD] may have received medical care.
During the past 12 months, how many different times did [he/she] stay in the hospital?
___ TIMES
NEVER ............................................................ 00 GO TO Q 4.15
DK .................................................................. D GO TO Q4.15
REF ................................................................. R GO TO Q4.15
2001 CHIP 6.2.1

If 4.13 = 1 or more times and P = 1, 3, 5, 6, 8a, 11
4.14
During the [if Q4.13 = 1: time /if Q4.13 = >1: times] [CHILD] stayed in the hospital, how many nights was
[he/she] in the hospital altogether?
___ NIGHTS
DK .................................................................. D
REF ................................................................. R
NHIS 2009 CAU_280_00.000

P = 1, 3, 5, 6, 7, 8a, 8b, 11
4.15
In the past 12 months, how many times did [he/she] go to a hospital emergency room about [his/her]
health? This includes emergency room visits that resulted in a hospital admission.
___ TIMES ..................................................... GO TO Q4.17
NEVER ............................................................ 00 GO TO Q4.18
DK ................................................................. D
REF ................................................................. R GO TO Q4.18

49

2001 CHIP 6.7

If Q4.15=d and P = 1, 3, 5, 6, 7, 8a, 8b, 11
4.16
Would you say…
1 time ............................................................ 01
2 or 3 times.................................................... 02
4 to 9 times.................................................... 03
10 to 12 times................................................ 04
13 or more times .......................................... 05
DK ................................................................ D
REF ................................................................ R GO TO Q4.18
Box 4.17. Programmer: If P = 7 or 8b, GO TO Q4.35
New

If Q3.31=01 (ever told child had asthma) and Q4.15 = 1 or more times or Q4.16 = 01 - 05 or d and P = 1, 3, 5, 6,
8a, 11
4.17
If Q4.15 = 01 or Q4.16 = 01 (one visit only) Was the emergency room visit for asthma?
If Q4.15 =>2 or Q4.16 => 02 (more than one visit) How many of the emergency room visits were for
asthma?
INSTRUCTION: IF ZERO VISITS, RECORD ‘O’
___ NUMBER OF VISITS FOR ASTHMA
DK .................................................................. D
REF ................................................................. R
NHIS 2009 CAU.320_00.000 modified

If Q4.16 = r and If P = 1, 3, 5, 6, 8a, 11
4.18
During the past 12 months, how many times did [CHILD] see a health care provider about [his/her] health
at a doctor’s office, a clinic, or some other place?
Do not include times [he/she] was hospitalized overnight, visits to hospital emergency rooms, home visits,
dental visits or telephone calls.
___ TIMES
GO TO Q4.20
NEVER ............................................................ 00 GO TO Q4.20
ONE TIME ONLY ............................................. 01 GO TO Q4.20
DK .................................................................. D
REF ................................................................. R GO TO Q4.20

50

2001 CHIP 6.9.1

If Q4.18 = d and P = 1, 3, 5, 6, 8a, 11
4.19
Would you say [he/she] saw a health care provider…
CODE ONE ONLY
1 time only,.................................................... 01
2 or 3 times, ................................................. 02
4 to 9 times, .................................................. 03
10 to 12 times, or ......................................... 04
13 or more times? ......................................... 05
DK .................................................................. D
REF ................................................................. R
NSCH 2007 K4Q22 modified

If S = 24 months or older and P = 1, 3, 5, 6, 8a, 11
4.20
Mental health providers include psychiatrists, psychologists, psychiatric nurses, and clinical social workers.
During the past 12 months, has [CHILD} received any treatment or counseling from a mental health
service provider?
YES ................................................................. 01
NO ................................................................. 00 GO TO Q4.22
DK ............................................................... D GO TO Q4.22
REF ................................................................. R GO TO Q4.22
NSCH 2007 K4Q22 modified for N of visits

If S4 = 24 months or older and Q4.20 = 01 (any mental health visits) and P = 1, 3, 5, 6, 8a, 11
4.21
During the past 12 months, how many times did [he/she] receive treatment or counseling from a mental
health provider?
___ TIMES
DK.......................................................................... d
REF......................................................................... r
NEW

If S4 = 24 months or older and Q4.21 is answered. and P = 1, 3, 5, 6, 8a, 11
4.21.1
How many of these visits were with a mental health professional in [his/her] school?
___ TIMES
DK.......................................................................... d
REF......................................................................... r

51

NSCH 2007 K4Q24

If P = 1, 3, 5, 6, 8a, 11
4.22
Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and others who
specialize in one area of health care. During the past 12 months did [he/she] see a specialist [other than a
mental health specialist]?
YES ......................................................................01
NO (......................................................................00
GO TO Q4.24
DK ......................................................................D GO TO Q4.24
REF (......................................................................R
GO TO Q4.24
NSCH 2007 K4Q24 modified for N visits

If Q4.22 = 01 and P = 1, 3, 5, 6, 8a, 11
4.23
During the past 12 months, how many times did [CHILD] see a specialist [other than a mental health
specialist]?
___ TIMES
DK.......................................................................... d
REF......................................................................... r
NHIS 2009 CAU.270_00.000 modified

If P = 1, 3, 5, 6, 8a, 11
4.24
During the past 12 months did [CHILD] receive a well-child check-up, that is, a general check-up, when
[he/she] was not sick or injured?
YES .......................................................................01
NO (......................................................................00
DK ( ......................................................................D
REF(v.....................................................................R

GO TO Q4.26
GO TO Q4.26
GO TO Q4.26

NHIS 2009 CAU.270_00.000 modified

If Q4.24 = 01 and S4 = 35 months or less and P = 1, 3, 5, 6, 8a, 11
4.25
And, how many times during the past 12 months did [he/she] receive a well-child check-up, that is, a
general check-up, when [he/she] was not sick or injured?
___ TIMES
DK.......................................................................... DK
REF......................................................................... R
NHIS 2010 CFI.010_00.000 modified

If P = 1, 3, 5, 6, 8a, 11
4.26
During the past 12 months, has [CHILD] had a flu vaccination (shot or nasal spray)? A flu vaccination is
usually given in the fall and protects against influenza for the flu season.
YES......................................................................... 01
NO......................................................................... 00
DK.......................................................................... D
REF......................................................................... R

52

LA Healthy Kids QD14 modified probe and NSCH K2Q10 modified

If P = 1, 3, 5, 6, 8a, 11
4.27
Other than vitamins, during the past 12 months, has [CHILD] used medicine prescribed by a doctor?
PROBE: Please do not include over-the-counter medications, such as cold or headache medication, or
other vitamins, minerals or supplements purchased without a prescription.
YES ................................................................. 01
NO ................................................................. 00
DK .................................................................. D
REF ................................................................ R

GO TO Q4.30
GO TO Q4.30
GO TO Q4.30

NEW

If Q4.27= 01 and Q3.31 = 01 (provider ever told you child had asthma) and P = 1, 3, 5, 6, 8a, 11
4.28
In the past 12 months, has [CHILD] taken any medication for asthma?
YES ................................................................. 01
NO ................................................................. 00
DK .................................................................. D
REF ................................................................. R
K2Q31D modified

If Q3.35, Q3.27 or Q3.29 = 01 and P = 1, 3, 5, 6, 8a, 11
4.29
During the past 12 months, has [CHILD] taken medication for ADD or ADHD or because of difficulties
with [his/her] emotions, concentration, or behavior?
PROBE: ADD IS ATTENTION DEFICIT DISORDER; ADHD IS ATTENTION DEFICIT HYPERACTIVITY DISORDER.
YES ................................................................. 01
NO ................................................................. 00
DK .................................................................. D
REF ................................................................. R
2001 CHIP 6.20 and NSCH 2007 K4Q21 modified

If P = 1, 3, 5, 6, 8a, 11
4.30
During the past 12 months, did [CHILD] go to a dentist or dental hygienist for preventive dental care, such
a check-up or dental cleaning?
YES ................................................................. 01
NO ................................................................. 00
DK ................................................................ D
REF ............................................................... R

GO TO Q4.32
GO TO Q4.32
GO TO Q4.32

NEW

If Q4.30 = 01 and P = 1, 3, 5, 6, 8a, 9
4.30.1 Did the dentist recommend additional or follow up treatment other than a future check up?
YES ................................................................. 01
NO ................................................................. 00
DK ................................................................ D
REF ............................................................... R

GO TO Q4.32
GO TO Q4.32
GO TO Q4.32

53

NSCH 20007 K4Q21

If P = 1, 3, 5, 6, 8a, 11
4.31
During the past 12 months, did [CHILD] go to a dentist for a dental procedure, such as having a cavity
treated or a tooth pulled?
YES ................................................................. 01
NO ................................................................. 00
DK .................................................................. D
REF ................................................................. R
Maine Child Health Survey modified, Q35

If S4 = 72 months or more and P = 1, 3, 5, 6, 8a, 11
4.32
Has [CHILD] ever had dental sealants placed on [his/her] back teeth?
PROBE: Sealants are a clear or white material placed on the chewing surface of teeth to prevent cavities.
YES ................................................................. 01
NO ................................................................. 00
DK ................................................................ D
REF ............................................................... R

GO TO Q4.33
GO TO Q4.33
GO TO Q4.33

New

If Q4.32=01 and P = 1, 3, 5, 6, 8a, 11
4.32.1 Were the sealants placed on [his/her] teeth at…
CODE ONE ONLY
…[his/her] dentist’s office? ........................... 01
…through a school program? ........................ 02
DK .................................................................. D
REF ................................................................. R
2011 NSCH “new 18”

If P = 1, 3, 5, 6, 8a, 11
4.33
If child is less than 60 months: Has [CHILD] ever had [his/her] vision tested with pictures, shapes or
letters?
If child is 60 months or more: During the past two years, that is, since [DATE], has [CHILD] had [his/her]
vision tested with pictures, shapes or letters?
PROBE: IF RESPONDENT REPORTS CHILD IS BLIND, RECORD 02.
YES ................................................................. 01
NO ................................................................. 00
CHILD IS BLIND............................................... 02
DK .................................................................. D
REF ................................................................. R

GO TO Q4.35
GO TO Q4.35
GO TO Q4.35
GO TO Q4.35

Box 4.34. Programmer: For Q4.34 if S4 = 24 months or more, display 01 and 02. If S4= 36 months or more, also
display 03.

54

New

Q4.33 = 01 and P = 1, 3, 5, 6, 8a, 11
4.34
Was [his/her] vision last tested…
In the past 12 months?.................................. 01
In the past 13-24 months? ............................ 02
Longer ago than 24 months?......................... 03
DK .................................................................. D
Ref ................................................................. R
UNMET NEEDS
2001 CHIP 6.23, 31, 36; NSHCN 2005-2006 modified C4Q05_X06

If P = 1, 3, 5, 6, 7, 8a, 8b, 11
4.35
Now I am going to ask you some questions about experiences [CHILD] may have had getting health care.
During the past 12 months, was there a time [he/she] did not get or postponed...
PROBE: REREAD STEM IF NEEDED. [IF R SAYS CHILD HAD TO WAIT A LONG TIME IN THE WAITING ROOM,
THIS IS NOT A POSTPONEMENT. POSTPONE MEANS “PUT OFF DOING SOMETHING TILL A LATER TIME.”
CODE ONE FOR EACH ROW
YES (01)

NO (00)

DK (D)

01. …getting hospital care when you thought [he/she]
needed it?
02. …getting care from a specialist when you thought
[he/she] needed it?
03. …getting care from a regular doctor or other health
care provider for an illness, accident or injury when you
thought [he/she] needed it?
04. …getting a medical test, treatment or follow-up
recommended by a doctor?
05. …(If S4 = 12 month or more) getting dental care
when you thought [he/she] needed it?
06. …getting physical, occupational, speech therapy
when you thought [he/she] needed it?
07. …getting eyeglasses or vision care when you
thought [he/she] needed it?
08. …getting mental health services when you thought
[he/she] needed it?
09. …getting a prescription drug when you thought
[he/she] needed it?

Box 4.35a. Programmer: If ANY Q4.35.01-08 = 01 GO TO Box 4.36. If Q4.35.09 = 1, GO TO Q4.35a

55

REF (R)

2001 CHIP 6.58

If 4.34.09 = 01 and Q3.7=01 (used or needed rx in past 12 months) and P = 1, 3, 5, 6, 7. 8a. 8b, 11
4.35a During the past 12 months was there a time [CHILD] took less than the recommended dosage of a
prescription drug or took the drug less frequently so that it would last longer?
YES ................................................................. 01
NO ................................................................. 00
DK .................................................................. D
REF ................................................................. R
Box 4.36. Programmer, If P = 7 or 8b, GO TO Q4.40
CONTENT OF CARE: DEVELOPMENTAL SCREENING FOR CHILDREN
Box 4.36. Programmer:
If child age (S4) = 72 months or more, go to Q4.38.
If child age (S4) = 10 months to 71 months, continue with Q4.36.
NSCH K6Q12 modified

If S4 = 10 months or more and S4 <72 months and P = 1, 3, 5, 6, 8a, 11
4.36
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. During the past 12 months, did a doctor or other health care provider
have you fill out a questionnaire about specific concerns or observations you may have about [CHILD’s]
development, communication, or social behaviors?
INSTRUCTIONS: IF ANOTHER PERSON READ THE QUESTIONNAIRE TO THE PARENT AND FILLED IN THE
ANSWERS ON A QUESTIONNAIRE FOR THE PARENT, THEN CODE 01 FOR YES. BUT IF A DOCTOR OR NURSE
JUST ASKED ABOUT CONCERNS AND DID NOT FILL OUT A QUESTIONNAIRE, THEN CODE 00 FOR NO.
YES ................................................................. 01
NO ................................................................. 00 GO TO Q4.38
DK .................................................................. D GO TO Q4.38
REF ................................................................. R GO TO Q4.38
Box 4.37. Programmer. In Q4.37, If S4 = 10 months or older but less than 24 months DISPLAY Q4.37.01- 02.
If S4 = 24 months or older but less than 72 months, DISPLAY Q4.37.03 – 04.
NCHS K6Q13A-D modified

If S4 = 10 months or older but less than 72 months and P = 1, 3, 6a, 9 and S2 = 2
4.37
Did this questionnaire ask about your concerns or observations about the following…
CODE ONE ONLY PER ROW
YES (01)
01. …how [CHILD] talks or makes speech sounds?
02. …how [CHILD] interacts with you and others?
03. …the words and phrases [CHILD] uses and
understands?
04. …how [CHILD] behaves and gets along with you and
others?

56

NO (00)

DK (D)

REF (R)

2008 MEPS Child Preventive Health (CS) CS22, CS23_01, CS23_02, CS24, CS25_01, CS25_02 modified

If P = 1, 3, 5, 6, 8a, 11
4.38
During the past 12 months, has a doctor or other health care provider ever measured the child’s height
and weight?
YES ................................................................. 01
NO ................................................................. 00
DK .................................................................. D
REF ................................................................. R
CAHPS Clinician and Group Survey Q17HI1 (Q5.26.01-03), MEPS-Child Preventative Health (5.27.04) modified

P = 1, 3, 5, 6, 8a, 11
4.39
During the last 12 months, did a doctor or other health care provider talk with you about any of the
following topics?
CODE ONE ONLY PER ROW
YES (01)

NO (00)

DK (D)

REF (R)

01. How to keep [CHILD] from getting injured?
02. How much or what kinds of food [he, she] eats?
03. How much and/or what kind of exercise [he/she]
gets?
04. How smoking in the house can be bad for [he/she]
health?
ADEQUACY OF INSURANCE
2001 CHIP 6.59

If P = 1, 3, 5, 6, 7, 8a, 8b, 11
4.40
During the past 12 months, how confident have you been that [CHILD] could get health care if [he/she]
needed it? Would you say…

Very confident ............................................... 01
Somewhat confident ..................................... 02
Not very confident ........................................ 03
Not confident at all........................................ 04
DK .................................................................. D
REF ................................................................. R
2001 CHIP 6.62

If P = 1, 3, 5, 6, 7, 8a, 8b, 11
4.41
And during the past 12 months, how often did you feel stress about meeting [CHILD’s] health care needs?
All of the time ................................................ 01
Very often ...................................................... 02
Not very often ............................................... 03
Never ............................................................. 04
DK .................................................................. D
REF ................................................................. R

57

NSCH K3Q20 modified

If P = 1, 3, 5, 6, 7, 8a, 8b, 11
4.42
The next questions are about [CHILD’s] health insurance or health care plans during the past 12 months.
During the past 12 months, how often has [CHILD’s] coverage under [CHIP/Medicaid] offered benefits or
covered services that met [his/her] needs?
Would you say the benefits and coverage…

CODE ONE ONLY
Never met [his/her] needs? .......................... 01
Sometimes met [his/her] needs? ................. 02
Usually met [his/her] needs? ........................ 03
Always met [his/her] needs? ......................... 04
DK .................................................................. D
REF ................................................................. R
NSCH K3Q20 modified

If P = 1, 3, 5, 6, 7, 8a, 8b, 11
4.43
Does [CHILD’s] [CHIP/ Medicaid] offer dental benefits or cover dental services?
YES ................................................................. 01
NO ................................................................. 00
DK .................................................................. D
REF ................................................................. R
MEPS 2009: CS21 modified

P = 1, 3, 5, 6, 7, 8a, 8b, 11
4.44
During the past 12 months, how often has it been easy to see a dental health care provider that [CHILD]
needed to see?
Would you say:
CODE ONE ONLY
Never? ........................................................... 01
Sometimes? ................................................... 02
Usually? ......................................................... 03
Always?.......................................................... 04
DK .................................................................. D
REF ................................................................. R

58

MEPS 2009: CS21

If P = 1, 3, 5, 6, 7, 8a, 8b, 11
4.45
During the past 12 months, how often has it been easy to see a specialist that [CHILD] needed to see?
Would you say:
CODE ONE ONLY
Never? ........................................................... 01
Sometimes? ................................................... 02
Usually? ......................................................... 03
Always?.......................................................... 04
DK .................................................................. D
REF ................................................................. R
Box 4.46. Programmer: If P = 7, 8b, go to Q4.47
NSCH K3Q21A modified

If P = 1, 3, 5, 6, 8a, 11
4.46
During the past 12 months, how often have you paid any money for [CHILD]’s health care, not including
health insurance premiums or costs that are covered by insurance? NOTE: WE MAY NEED TO REMOVE
THIS QUESTION FOR STATE PROGRAMS WITH NO PREMIUMS.
PROMPT: Include out of pocket payments for all types of health-related needed such as copayments,
dental or vision care, medications and any kind of therapy.
CODE ONE ONLY
Never? ........................................................... 01
Sometimes? ................................................... 02
Usually? ......................................................... 03
Always?.......................................................... 04
DK .................................................................. D
REF ................................................................. R
Health Tracking Household Survey, C94 modified

If Q4.45 is not equal to 01 or Q2.36.3 = 01 and P = 1, 3, 5, 6, 7, 8a, 8b, 11
4.47
For health care that [CHILD] received in the past 12 months, has your family had a big problem, a small
problem, or no problem paying [CHILD]’s medical bills?
PROMPT: This includes doctor or hospital bills, dentist bills, or bills for prescription drugs.
CODE ONE ONLY
BIG PROBLEM ................................................ 01
SMALL PROBLEM ........................................... 02
NO PROBLEM................................................. 03
DK .................................................................. D
REF ................................................................ R

59

Health Tracking Household Survey, C93 modified

If Q4.47 = answered and P = 1, 3, 5, 6, 7, 8a, 8b, 11
4.48
How much do you currently owe in health care bills, if any, for health care that [CHILD] received in the
past 12 months? Is it….

$000 (You do not owe anything) ................... 01
Less than $500 .............................................. 02
$501 - $1,000 ................................................ 03
$1,001 - $2,000.............................................. 03
Or more than $2,000 .................................... 04
DK .................................................................. D
REF ................................................................. R
Box 4.49. Programmer: if P = 7, go to Q6.1
If P = 8b, go to Q5.1
NEW based on Kaiser Health Tracking Poll: March 2011 Q42 and MEPS-HC HX45, modified

If P = 1, 3, 5, 6, 8a, 11
4.49
During the past 12 months, did anyone in the family pay a premium for [CHILD’s] enrollment in
[CHIP/Medicaid]?
PROBE: A premium is the amount paid each month or year for enrollment in health insurance coverage.
YES ................................................................. 01
NO ................................................................. 00 GO TO Q4.51
DK ................................................................. D GO TO Q4.51
REF ................................................................. R GO TO Q4.51
Health Tracking Household Survey, C94 modified

If Q4.49= 01 or if admin data (S15 = 1) indicates a premium was paid and P = 1, 3, 5, 6, 8a, 11
4.50
During the past 12 months, has your family had a big problem, a small problem, or no problem paying the
premium for [CHILD]’s enrollment in [CHIP/Medicaid]?
PROMPT: If the premium includes coverage for family members other than [CHILD], try to think about
only the part of the premium related to [CHILD’s] coverage.

CODE ONE ONLY
BIG PROBLEM ................................................ 01
SMALL PROBLEM .......................................... 02
NO PROBLEM ................................................ 03
DK .................................................................. D
REF ................................................................. R

60

WILLINGNESS TO PAY
LA Care “Health Kids Program Survey to Assess Premium Contribution Capacity” 2009, modified

P = 1, 3, 5, 6, 8a, 11
4.51
If necessary, would you be willing to pay [If Q4.49=00, D, R: some money\If Q4.49=01: additional money]
every month to continue coverage for [CHILD] in [CHIP/Medicaid]? Would you say, definitely yes,
probably yes, probably no, or definitely no?
CODE ONE ONLY
DEFINITELY YES .............................................. 01
PROBABLY YES .............................................. 02
PROBABLY NO ............................................... 03
DEFINITELY NO .............................................. 03 GO TO Q5.1
DK .................................................................. D
REF ................................................................. R GO TO Q5.1
Box 4.52. Programmer: rotate monthly [AMOUNT] / additional monthly [AMOUNT] of $10, $15, $20 for each case.
LA Care “Health Kids Program Survey to Assess Premium Contribution Capacity” 2009, modified

If Q4.49=01 and Q4.51 = 01 or 02 (would be willing to pay some/more money to continue CHIP/Medicaid) and P =
1, 3, 5, 6, 8a, 11
4.52
What if the [If Q4.49=00, D, R: monthly amount \ If Q4.49=01: additional monthly amount] was
[AMOUNT], would you be willing to pay this amount to continue coverage for [CHILD] in [CHIP/Medicaid]?
Would you say, definitely yes, probably yes, probably no, or definitely no?
CODE ONE ONLY
DEFINITELY YES .............................................. 01
PROBABLY YES .............................................. 02
PROBABLY NO ............................................... 03
DEFINITELY NO .............................................. 03
DK .................................................................. D
REF ................................................................. R
GO TO Q5.1

61

CHIP SECTION 5: PATIENT- CENTEREDNESS OF HEALTH CARE
Section 5 Overview
Section 5 is asked for different timeframes depending on the pathing definitions.
If P = 1 or 3, questions are asked about the 12 months prior to current or last enrollment
If P = 2, 4, 7, 9, 10, 12, respondents skip to Q6.1
If P = 5 or 6 (established enrollees), questions are asked about the past 12 months
If P = 8 or 11, questions are asked about the time prior to disenrollment.
As usual, the time frame language in the questions for the OMB version of the instrument is
either unspecified or “in the past 12 months.”
Table 5.2 Pathing in Section 5
Pathing Definitions

Q5.1 – 5.15 PCMH Series
New Enrollees

P
P
P
P

=
=
=
=

1
2
3
4

x
x
Established Enrollees

P=5
P=6

x
x
Recent Disenrollees

P
P
P
P
P
P

=
=
=
=
=
=

7
8
9
10
11
12

x
x

62

Box 5.1. Programmer: If P = 2, 4, 7, 9, 10, 12 GO TO Q6.1
NSCH K5Q10

P = 1, 3, 5, 6, 8, 11
5.1
During the past 12 months, did [CHILD] need a referral to see any doctors or receive any services?
YES ................................................................. 01
NO ................................................................. 00
DK ................................................................ D
REF ................................................................. R

GO TO Q5.3
GO TO Q5.3
GO TO Q5.3

NSCH K5Q11

If Q5.1= 01 and P = 1, 3, 5, 6, 8, 11
5.2 Was getting referrals a big problem, a small problem, or not a problem?
BIG PROBLEM ................................................ 01
SMALL PROBLEM ........................................... 00
NOT A PROBLEM ........................................... 03
DK .................................................................. D
REF ................................................................. R
Box 5.3. Programmer: Count the types of services received from Q4.20 , Q4.22, Q4.24, and Q4.30. The maximum
number is 4.
If number = 0, go to Q5.14
If number = 2 OR MORE, go to Q5.3
If number = 1, go to Q5.7
NSCH K5Q20

If services received at Q4.20 , Q4.22, Q4.24, Q4.30 = 2 or more and P = 1, 3, 5, 6, 8, 11
5.3
Does anyone help you arrange or coordinate [CHILD]’s care among the different doctors or services that
[he/she] uses?
PROBE: By “arrange or coordinate,” I mean: Is there anyone who helps you make sure that [CHILD] gets all
the health care and services [he/she] needs, that health care providers share information, and that these
services fit together and are paid for in a way that works for you?
PROBE: This is during the past 12 months.
YES ................................................................ 01
NO ................................................................. 00
DK ................................................................. D
REF ................................................................ R

63

NSCH K5Q21

If services received at Q4.20 , Q4.22, Q4.24, Q4.30 = 2 or more and P = 1, 3, 5, 6, 8, 11
5.4
During the past 12 months, have you felt that you could have used extra help arranging or coordinating
[CHILD]’s care among the different health care providers or services?
YES ................................................................
NO .................................................................
DK ..................................................................
REF .................................................................

01
00 GO TO Q5.6
D GO TO Q5.6
R GO TO Q5.6

NSCH K5Q22

If Q5.4=01 and P = 1, 3, 5, 6, 8, 11
5.5
During the past 12 months, how often did you get as much help as you wanted with arranging or
coordinating [CHILD]’s care? Would you say never, sometimes, or usually?
NEVER ............................................................ 01
SOMETIMES ................................................... 02
USUALLY ........................................................ 03
DK .................................................................. D
REF ................................................................ R
NSCH K5Q30

If services received at Q4.20 , Q4.22, Q4.24, Q4.30 = 2 or more and P = 1, 3, 5, 6, 8, 11
5.6
Overall, are you satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied with the
communication among [CHILD]’s doctors and other health care providers?
PROBE: This is during the past 12 months.
VERY SATISFIED ........................................................... 01
SOMEWHAT SATISFIED ................................................ 02
SOMEWHAT DISSATISFIED .......................................... 03
VERY DISSATISFIED ...................................................... 04
NO COMMUNICATION NEEDED OR WANTED ............. 05
DK ................................................................................ D
REF ............................................................................... R

64

NSCH K5Q31

If services received at Q4.20 , Q4.22, Q4.24, Q4.30 = 1 or more and P = 1, 3, 5, 6, 8, 11
5.7 Do [CHILD]’s doctors or other health care providers need to communicate with [his/her] … [TEXT]
PROGRAMMER: CHECK CHILD’S AGE AT S4 AND DISPLAY AT ‘TEXT’
IF S4 = less than 36 months, child care providers or early intervention program?
If S4 = 36 or more months but less than 72 months, child care providers, school, or special education
program?
If S4 = 72 months or more (and no special health care needs), that is, Q3.9 = 00 and or Q3.13 = 00 and
Q3.17 = 00 and Q3.21 = 00 and Q3.24 = 00, d, r, school?
If S4 = 72 months or more but less than 144 months and (yes, special health care needs), that is, Q3.9 = 01
or Q3.13 = 01 or Q3.17 = 01 or Q3.21 = 01 or Q3.24 = 01, school or special education program?
If S4 = 144 months or more and (yes, special health care needs) Q3.9 = 01 or Q3.13 = 01 or Q3.17 = 01 or
Q3.21 = 01 or 3.24 = 01, school, special education program, or vocational education program?
YES ................................................................. 01
NO ................................................................ 00
DK .................................................................. D
REF ................................................................. R

GO TO Q5.9
GO TO Q5.9
GO TO Q5.9

NSCH K5Q32

If Q5.7= 01 and P = 1, 3, 5, 6, 8, 11
5.8
Overall, are you very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied with that
communication?
VERY SATISFIED ........................................................... 01
SOMEWHAT SATISFIED ............................................... 02
SOMEWHAT DISSATISFIED .......................................... 03
VERY DISSATISFIED ..................................................... 04
NO COMMUNICATION NEEDED OR WANTED ............. 05
DK ............................................................................... D
REF .............................................................................. R
NSCH K5Q40

If services received at Q4.20 , Q4.22, Q4.24, Q4.30 = 1 or more and P = 1, 3, 5, 6, 8, 11
5.9
During the past 12 months, how often did [CHILD]’s doctors and other health care providers spend
enough time with [him/her]? Would you say never, sometimes, usually, or always?
NEVER ........................................................... 01
SOMETIMES .................................................. 02
USUALLY ........................................................ 03
ALWAYS ........................................................ 04
DK ................................................................. D
REF ................................................................ R

65

NSCH K5Q41

If services received at Q4.20 , Q4.22, Q4.24, Q4.30 = 1 or more and P = 1, 3, 5, 6, 8, 11
5.10
During the past 12 months, how often did [CHILD]’s doctors and other health care providers listen
carefully to you? Would you say never, sometimes, usually, or always?
NEVER ........................................................... 01
SOMETIMES .................................................. 02
USUALLY ....................................................... 03
ALWAYS ........................................................ 04
DK .................................................................. D
REF ................................................................. R
NSCH K5Q42

If services received at Q4.20 , Q4.22, Q4.24, Q4.30 = 1 or more and P = 1, 3, 5, 6, 8, 11
5.11
When [CHILD] is seen by doctors or other health care providers, how often are they sensitive to your
family’s values and customs? Would you say never, sometimes, usually, or always?
NEVER ........................................................... 01
SOMETIMES .................................................. 02
USUALLY ....................................................... 03
ALWAYS ........................................................ 04
DK .................................................................. D
REF ................................................................. R
NSCH K5Q43

If services received at Q4.20 , Q4.22, Q4.24, Q4.30 = 1 or more and P = 1, 3, 5, 6, 8, 11
5.12
Information about a child’s health or health care can include things such as the causes of any health
problems, how to care for a child now, and what changes to expect in the future. During the past 12
months, how often did you get the specific information you needed from [CHILD]’s doctors and other
health care providers? Would you say never, sometimes, usually, or always?
NEVER ........................................................... 01
SOMETIMES .................................................. 02
USUALLY ....................................................... 03
ALWAYS ........................................................ 04
DK .................................................................. D
REF ................................................................. R
NSCH K5Q44

If services received at Q4.20 , Q4.22, Q4.24, Q4.30 = 1 or more and P = 1, 3, 5, 6, 8, 11
5.13
During the past 12 months, how often did [CHILD]’s doctors or other health care providers help you feel
like a partner in [his/her] care? Would you say never, sometimes, usually, or always?
NEVER ........................................................... 01
SOMETIMES .................................................. 02
USUALLY ....................................................... 03
ALWAYS ........................................................ 04
DK .................................................................. D
REF ................................................................. R

66

NSCH K5Q45

If answer to screener question about language is a language other than English and P = 1, 3, 5, 6, 8, 11
5.14
In the past 12 months, did you or [CHILD] need an interpreter to help speak with [his/her] doctors or
other health care providers?
PROMPT: An interpreter is someone who repeats what one person says in a language used by another
person.
YES ................................................................. 01
NO ................................................................. 00
DK .................................................................. D
REF ................................................................. R

GO TO Q6.1
GO TO Q6.1
GO TO Q6.1

NSCH K5Q44

If Q5.14 = 01 and P = 1, 3, 5, 6, 8, 11
5.15
When you or [CHILD] needed an interpreter, how often were you able to get someone other than a family
member to help you speak with [his/her] doctors or other health care providers? Would you say …
Never ............................................................ 01
Sometimes .................................................... 02
Usually ........................................................... 03
Always ........................................................... 04
DK .................................................................. D
REF ................................................................. R
GO TO 6.1

67

CHIP SECTION 6: SOCIO- DEMOGRAPHICS AND ATTITUDES
Section 6 Overview
All questions in Section 6 are asked about the ‘current’ timeframe.
Table 6.1 Pathing in Section 6

Pathing
Definitions
P=1
P=2

Child’s
Race &
Ethnicity
(Q6.1 –
Q6.2)
x
x

Respondent’s
Health
(Q6.3 – Q6.5)
x

Attitudes
about
Health &
Insurance
(Q6.6 –
Q6.8)
x

Household
Composition
(Q6.9 –
Q6.13)
x

Parent
Demographics
(Q6.14 –
Q6.17)

Parents’
Coverage
(Q6.18 –
Q6.33)

Parent
Income
(Q6.34
–
Q6.44)

Health Care
Expenditure
(Q6.45 –
Q6.46)

x
x
x
x
Age, marital
x
status,
education*
P=3
x
x
x
x
x
x
x
x
P=4
x
Age, marital
x
status,
education*
P=5
x
x
x
x
x
x
x
x
P=6
x
x
x
x
x
x
x
x
P=7
x
x
x
x
x
x
x
x
P=8
x
x
x
x
x
x
x
x
P=9
x
Age, marital
x
status,
education*
P = 10
x
x
x
x
x
x
x
x
P = 11
x
x
x
x
x
x
x
x
P = 12
x
Age, marital
x
status,
education*
* These questions are for the Parent/Guardian #1: Age = Q6.14; Marital Status = Q6.11.1 (previously 6.16), and Q6.15 =
education.

68

CHILD’S RACE AND ETHNICITY
2001 CHIP 7.109

If P = 1 - 12
6.1
The next questions ask about [CHILD] [himself/herself]. Do you consider [him/her] to be of Hispanic or
Latino origin?
YES .................................................................
NO .................................................................
DK ..................................................................
REF .................................................................

01
00 GO TO Q6.3
D GO TO Q6.3
R GO TO Q6.3

NSCH K11Q02EX modified

If Q6.1 = 01 and P = 1 - 12
6.2
Now I’m going to read a list of categories. Please choose one or more of the following categories to
describe [CHILD]’s race. You may choose more than one. Is [CHILD] ….
CODE ALL THAT APPLY
White ............................................................. 01
Black or African American ............................. 02
American Indian or Alaskan Native ............... 03
Asian .............................................................. 04
Native Hawaiian or Other Pacific Islander ..... 05
DK ................................................................. D
REF ................................................................. R
Box 6.3. Programmer, If P = 2, 4, 9, or 12 GO TO Q6.11
RESPONDENT’S HEALTH
2001 CHIP 7.3.21

If P = 1, 3, 5, 6, 7, 8, 10, 11
6.3 The next questions are about you. In general, would you say that your health is…
Excellent ....................................................... 01
Very Good...................................................... 02
Good .............................................................. 03
Fair ................................................................. 04
Poor ............................................................... 05
DK ................................................................. D
REF ................................................................ R

69

NSCH K9Q23

If P = 1, 3, 5, 6, 7, 8, 10, 11
6.4
Would you say that, in general, your mental and emotional health is…
Excellent ....................................................... 01
Very Good...................................................... 02
Good .............................................................. 03
Fair ................................................................. 04
Poor ............................................................... 05
DK ................................................................. D
REF ................................................................ R
NSCH K9Q41 modified

If P = 1, 3, 5, 6, 7, 8, 10, 11
6. 5
Does anyone smoke cigarettes, cigars, or pipe tobacco inside [CHILD]’s home?
YES ................................................................. 01
NO ................................................................. 00
DK .................................................................. D
REF ................................................................. R
ATTITUDES ABOUT HEALTH AND INSURANCE
2001 CHIP 7.3.32, 7.3.38, 7.3.40, 7.3.41 modified

If P = 1, 3, 5, 6, 7, 8, 10, 11
6.6
Now, I am going to read you some statements about health and health insurance. For each statement,
please tell me if in your opinion the statement is definitely true, mostly true, mostly false, or definitely
false. First, …
DEFINITELY
TRUE
(01)

MOSTLY
TRUE
(02)

MOSTLY DEFINITELY
FALSE
FALSE
(04)
(03)

01. You can overcome most illnesses
without help from a medically trained
professional.
02. Doctors and nurses look down on
people who are in [CHIP/Medicaid].
03. Getting a child enrolled in
[CHIP/Medicaid] whenever you want is
easy if the child is eligible.
04. Children on [CHIP/Medicaid] get
better health care than children with
no insurance.
Box 6.7. Programmer: display either Q6.7 or Q6.8: rotate Q6.7 and Q6.8

70

DK
(D)

REF
(R)

New

If P = 1, 3, 5, 6, 7, 8, 10, 11
6.7
Next, I’m going to read a list of factors that some people consider when choosing a health plan. On a scale
of 1 to 10 where 1 is not at all important and 10 is very important, how important to you are each of these
factors? PROBE: If asked: out-of-pocket means the amount you pay in deductibles and co-pays when you
use services.

01. The premium, that is, the monthly
cost of paying for coverage?
02. The amount of out-of-pocket costs
required to use services?
03. Your choice of providers in the
plan?
04. Your ability to keep [CHILD]’s
current providers?
05. Whether everyone in the family
who is covered has health insurance
coverage in the same plan?
06. Whether the plan covers speech,
occupational, or other therapy
services?
07. Whether the plan covers services
with a mental health provider?
08. Whether the plan covers
transportation to and from services?

Not at all important ............... Very Important
1 2 3 4 5 6 7 8 9 10
1 ................................................................. 10
1 ................................................................. 10
1 ................................................................. 10
1 ................................................................. 10
1 ................................................................. 10

1 ................................................................. 10

1 ................................................................. 10
1 ................................................................. 10

71

DK
(D)

REF
(R)

New

If P = 1, 3, 5, 6, 7, 8, 10, 11
6.8.
Next, I’m going to read a list of factors that some people consider when choosing a health plan. On a scale
of 1 to 10 where 1 is not at all important and 10 is very important, how important to you are each of
these factors? PROBE: If asked: out-of-pocket means the amount you pay in deductibles and co-pays
when you use services.

01. Whether the plan covers speech
occupational, or other therapy
services?
02. Whether the plan covers services
with a mental health provider?
03. Whether the plan covers
transportation to and from services?
04. The premium, that is, the monthly
cost of paying for coverage?
05. The amount of out-of-pocket costs
required to use services?
06. Your choice of providers in the
plan?
07. Your ability to keep [CHILD]’S
current providers?
08. Whether everyone in the family
who is covered has health insurance
coverage in the same plan?

Not at all important ............... Very Important
1 2 3 4 5 6 7 8 9 10
1 ................................................................. 10

DK
(D)

REF
(R)

1 ................................................................. 10
1 ................................................................. 10
1 ................................................................. 10
1 ................................................................. 10
1 ................................................................. 10
1 ................................................................. 10
1 ................................................................. 10

HOUSEHOLD COMPOSITION
NSCH K9Q00 modified

If P = 1, 3, 5, 6, 7, 8, 10, 11
6.9
The next questions are about your household. Including yourself and all the adults and all the children,
how many people live in your household? By “live in your household” I mean all people who usually stay
here. Please do include people who are away, such as students, people on vacation or traveling for
business, or people who are in the hospital for a brief stay. Do not include people in institutions, in the
military, or people who are temporary visitors.
____ NUMBER OF PEOPLE IN THE HOUSEHOLD
DK ................................................................. D
REF ................................................................. R

72

2001 CHIP 7.4.1.1

If P = 1, 3, 5, 6, 7, 8, 10, 11
6.10
Including yourself, how many people in the household are 18 years or older?
PROGRAMMER: IF ONLY ONE ADULT IN HOUSEHOLD, GO TO Q6.12.
____ NUMBER OF PEOPLE WHO ARE 18 OR OLDER
DK .................................................................. D
REF ................................................................. R
Box 6.11. Programmer, prepare a roster for all adults in Q6.10. Each cell of the roster Q6.12. Q6.13, Q6.15, Q6.16,
or Q6.17 should have drop down boxes with categories listed in the question order below. Allow collection of
Q6.14 – Q6.17 ONLY for the parents or guardians of sample child. Collect information by question number
(“down”).
ROSTER
6.11

Name of adults (18 or older)
1. RESPONDENT
2. SPOUSE/PARTNER NAME
3. PERSON 3 NAME
4. PERSON 4 NAME
n. PERSON 5…N NAME

6.12
Relation
to
[CHILD]

6.13

Parent/Guardian

6.14
Age
as of
last
bday

6.15

6.16

6.17

Highest grade
or year of
school

Country
of Origin

Citizenship

CHIP 6.14 modified

If Q6.10 = >1 and P = 1 - 12
6.11

Do you have a spouse or partner who lives with you in this household? Please do not include a spouse or
partner who lives elsewhere.
YES ................................................................. 01
NO ................................................................. 00 GO TO Q6.11.2
DK .................................................................. D GO TO Q6.11.2
REF ................................................................. R GO TO Q6.11.2

Box 6.11.2 Programmer: If P = 2, 4, 9, 12, go to Q6.14.
New

If Q6.11=01 and P = 1, 3, 5, 6, 7, 8, 10, 11
6.11.1 What is the first name of your spouse/partner?
PROGRAMMER RECORD SPOUSE/ PARTNER NAME IN Q6.11, LINE 2 OF ROSTER: ____________________
NEW

If Q6.10 = 2 or more adults and Q6.11 = 01 and P = 1, 3, 5, 6, 7, 8, 10, 11
6.11.2 Please tell me the first names of the other adults besides yourself and your spouse or partner who live in
this household with you.
PROGRAMMER: RECORD EACH NAME IN ROSTER AT Q6.11, LINES 3…..n

73

NEW

If P = 1, 3, 5, 6, 7, 8, 10, 11
6.12 What is [your]\[other person’s (#2 – n)] relationship to [CHILD]?
PROGRAMMER: RECORD CODE FROM DROP DOWN BOX IN Q6.12 FOR EACH PERSON IN THE ROSTER
BIOLOGICAL PARENT ..................................... 01
STEP PARENT ................................................. 02
ADOPTIVE PARENT ........................................ 03
GUARDIAN ..................................................... 04
SIBLING .......................................................... 05
UNCLE/AUNT ................................................. 06
GRANDPARENT .............................................. 07
OTHER RELATIVE ........................................... 08
NON-RELATIVE............................................... 09
DK .................................................................. D
REF ................................................................. R
2001 CHIP 6.15 modified

If P = 1, 3, 5, 6, 7, 8, 10, 11
6.13
[Are you]/[Is spouse/partner]/[Is person #3….n] [CHILD]’s parent or guardian?
PROGRAMMER: ASK Q6.13 FOR EACH PERSON LISTED ON THE ROSTER: STOP ASKING WHEN TWO
PARENT/GUARDIANS (PGs) ARE IDENTIFIED (THAT IS, Q6.13 HAS TWO YES (01) RESPONSES )
CHECK: PROGRAMMER: IF Q6.10 = >1 AND THE ROSTER INDICATES ONLY ONE PG DISPLAY THIS CHECK:
Can you please confirm that [you are/other person is] the only parent or guardian of [CHILD] currently
living in this household? YES/NO. PERMIT CORRECTION IF NEEDED.
YES: PARENT OR GUARDIAN .......................... 01
NO ................................................................. 00
DK .................................................................. D
REF ................................................................. R
PARENT/GUARDIAN (PG) BOX:
PROGRAMMER: BASED ON RESPONSES TO Q6.10 and Q6.13, IDENTIFY UP TO TWO PARENT/GUARDIANS
(PGs)
ONLY ONE PG :
Q6.10 = 1 and RESPONDENT IS THE ONLY PG: L1
ANOTHER HOUSEHOLD MEMBER IS THE ONLY PG = L2
TWO PGs
RESPONDENT IS ONE OF TWO PGs: = L3
RESPONDENT NOT PG: ANOTHER HOUSEHOLD MEMBER IS A PG = L4
AN ADDITIONAL HOUSEHOLD MEMBER IS ALSO A PG: = L5

74

2001 CHIP 6.16 modified

If Q6.13 identified one or two PGs and P = 1 – 12
ASK Q6.14 only for the PGs and record in roster.
6.14 What is [your\NAME]’s age as of the last birthday?
AGE ............................................................... 01
DK .................................................................. D
REF ................................................................. R
2001 CHIP 6.17 modified

If Q6.13 identified one or two PGs and P = 1 – 12
ASK Q6.15 only for the PGs and record in roster
6.15
What is the highest grade of school [you\NAME] completed?
CODE ONE ONLY
8TH GRADE OR LESS ...................................... 01
9TH – 12TH GRADE, NO DIPLOMA ................ 02
HIGH SCHOOL: DIPLOMA/GED ...................... 03
SOME COLLEGE/NO DEGREE ......................... 04
ASSOCIATE’S DEGREE .................................... 05
BACHELOR’S OR HIGHER ............................... 06
DK .................................................................. D
REF ................................................................. R
Box 6.16. Programmer: If P = 2, 4, 9, 12, go to Q6.34
2001 CHIP 6.18 modified

If Q 6.13 identified one or two PGs and P = 1, 3, 5, 6, 7, 8, 10, o r 11
ASK Q6.16 only for the PGs and record in roster
6.16
In what country [were you \ was NAME] born?
CODE ONE ONLY
USA ................................................................ 01 GO TO Q6.18
OTHER............................................................ 02
DK .................................................................. D
REF ................................................................. R
2001 CHIP 6.19 modified

If Q6.13 identified one or two PGs and Q6.16 = 02, d, r and P = 1, 3, 5, 6, 7, 8, 10, or 11
Ask Q6.17 only for the PGs and record in roster.
6.17 [Are you\Is NAME] a citizen of the U.S.?
YES ................................................................
NO .................................................................
DK ..................................................................
REF .................................................................

01
00
D
R

PARENT/ GUARDIAN COVERAGE

75

2001 CHIP 7.63

P = 1, 3, 5, 6, 7, 8, 10, 11
Q6.18 SKIPS
IF PG = L1 or L2 and Q6.18.1 = 01 (YES), go to Q6.20.
If PG = L3 or L4 or L5 and Q6.18.1 and/or Q6.18.2 = 01 (ONE OR BOTH PGs HAVE COVERAGE) GO TO Q6.19
If PG = L1 or L2, THERE IS NO L5 SO DO NOT DISPLAY Q6. 18.2
IF NO PG HAS COVERAGE (Q6.18. 1 = 00, d, r and Q6.18. 2 = 00, d, r) GO TO Q6.27.
6.18
The next questions are about [your/name’s] insurance coverage]\[the insurance coverage of the parents
or guardians of [CHILD]]. ASK FIRST FOR Q6.18.1 then for Q6.18.2: [Are you/Is name] covered by any
health insurance, such as Medicaid or CHIP, right now?
YES (01)

NO (00)

DK (D)

REF (R)

6.18.1. L1 or L2 or L3 or L4
6.18.2 . L5
2001 CHIP 7.66

If Q6.18.1 = 01 and/or Q6.18.2=01 (at least one PG is insured) and P = 1, 3, 5, 6, 7, 8, 10, 11
6.19 Is [L5 name] covered by the same health insurance as [L3 you are\ L4 NAME] is]?
YES ................................................................
NO .................................................................
DK ..................................................................
REF ................................................................

01
00
D
R

Box 6.20. SKIPS FOR Q6.20 – Q6.26
If Q6.19 = 01 (YES, L5 covered by L3 or L4 insurance), DO NOT ASK QUESTIONS Q6.20 – Q6.26 ABOUT L5
If PG = L1 or L2, DO NOT ASK QUESTIONS Q6.20 – Q6.26 ABOUT L5 (THERE IS ONLY ONE PG)
2001 CHIP 7.70.1-7.70.5 modified

If Q6.18.1 = 01 or Q6.18.2=01 (at least one PG is insured) and Q6.19 = 00, d, r (L5 not covered by same insurance)
and P = 1, 3, 5, 6, 7, 8, 10, 11
6.20
[Are you/Is [NAME]] covered by any of the kinds of health insurance I’m going to read for you? You may
answer more than one kind of insurance.
INSTRUCTION: : IF R INDICATES EITHER PARENT/GUARDIAN IS COVERED BY A SPOUSE OR PARTNER’S
INSURANCE FROM A CURRENT OR PAST EMPLOYER OR UNION, RECORD YES.
Column 1 (L1 or L2 or L3 or L4)
Column 2 (L5)
[YOU\name]
[name]
YES
NO
DK
REF
YES
NO
DK
REF
(01)
(00)
(D)
(R)
(01)
(00)
(D)
(R)
6.20.1. Insurance from a current or past
employer or union?
6.20.2. Private insurance purchased
directly from an insurance company?
6.20.3. [Medicaid]?
6.20.4. [CHIP]?
6.20.5. Medicare?
6.20.6. Some other type of coverage I
have not yet mentioned?
Box 6.21. Programmer, ifQ6.20.1 = 01 for COLUMN 1 OR COLUMN 2 (regardless of responses to Q6.20.2 - 6), go to
Q6.23. Else, continue to Q6.21.

76

MEPS-HC, EM114 modified

If Q6.13 identified 1 or 2 PGs and Q6.20.01 = 00, d, r for one or two PGs and P = 1, 3, 5, 6, 7, 8, 10, 11
SKIPS FOR Q6.21
If PG = L1 or L2, THERE IS NO L5 SO DO NOT DISPLAY Q6. 21.2
If Q6.21.1 and Q6.21.2 = 00, d, r, GO TO Q6.27 ELSE CONTINUE to Q6.22
6.21
6.21.1 [Do you]/[Does [L2 or L4 name] have an offer of insurance through [your\his or her] job or
business?
6.21.2 Does [L5 name] have an offer of insurance through [his or her] job or business?
YES (01)

NO (00)

DK (D)

REF (R)

6.21.1. L1 or L2 or L3 or L4
6.21.2 .L5
NEW

If Q6.21. 1=01 or 6.21. 2=01 and P = 1, 3, 5, 6, 7, 8, 10, 11
If PG = L1 or L2, THERE IS NO L5 SO DO NOT DISPLAY Q6. 22.2
6.22
6.22.1 Does this health insurance offered through [your]/[L2 NAME’s or L4 NAME’s] job or business offer
health insurance for (your/ [his or her] children?]
6.22.2 Does this health insurance offered through [L5 NAME’s] job or business offer health insurance for
[his or her] children?
INSTRUCTION: IF RESPONDENT IS SELF-EMPLOYED, THESE QUESTIONS STILL APPLY.
YES (01)

NO (00)

DK (D)

REF (R)

6.22.1. L1 or L2 or L3 or L4
6.22.2 .L5

Box 6.23. Programmer: If Q6.21.1 and Q6.21.2 and Q6.22.1 and Q6.22.2 = answered go to Q6.27
2001 CHIP 7.71 + 7.73

If Q6.20. 1=01 (insurance through an employer/ union) for any PG (L1 – L5) and P = 1, 3, 5, 6, 7, 8, 10, 11
If PG = L1 or L2, THERE IS NO L5 SO DO NOT DISPLAY Q6. 23.2
6.23
[Does the employer pay all, some or none of the premium for this health insurance?]/[For the health
insurance from an employer, does the employer pay all, some or none of the premium for this health
insurance?] Please tell me first for [yourself/L2 or L4 NAME] then [L5 NAME]. ASK FIRST FOR 6.23.1 THEN
6.23.2.
ALL (01)

SOME (02)

6.23.1 L1 or L2 or L3 or
L4
6.23.2 L5

77

NONE (03)

DK (D)

REF (R)

2001 CHIP 7.79 (LPER1) AND 7.80 (LPER2) modified

If Q6.20.01 = 01 (insurance through an employer/ union) for any PG (L1 - L5) and P = 1, 3, 5, 6, 7, 8, 10, 11
If PG = L1 or L2, THERE IS NO L5 SO DO NOT DISPLAY Q6. 24.2
6.24
6.24.1 Could [CHILD] be covered by [your\L2 NAME or L4 NAME]’s health insurance?
6.24.2 And how about [L5 NAME]’s health insurance?
YES (01)

NO (00)

DK (D)

REF (R)

6.24.1. L1 or L2 or L3 or L4
6.24.2 L5
2001 CHIP 7.79.1.1 AND 7.79.1.2

If Q6.24.1 OR 6.24.2 = 01 and P = 1, 3, 5, 6, 7, 8, 10, 11
If PG = L1 or L2, THERE IS NO L5 SO DO NOT DISPLAY Q6. 25.2
6.25
6.25.1 For this health insurance from the [your/L2 NAME or L4 NAME]’s employer, would the employer
pay all, some or none of the premium to cover [CHILD]?
6.25.2 And how about [L5 NAME]’s insurance from an employer?
ALL (01)

SOME (02)

NONE (03)

DK (D)

REF (R)

6.25.1. L1 or L2 or L3 or L4
6.25.2 L5

Box 6.26. SKIPS:
If Q6.25.1 and Q6.25.2 = 03, d, r, GO TO Q6.27, ELSE CONTINUE
2001 CHIP 7.79.1 AND 7.79.2 modified

If Q6.25.1 or Q6.25.2=01 and P = 1, 3, 5, 6, 7, 8, 10, 11
6.26
6.26.1 What is the main reason [CHILD] is not covered by [your\NAME ]’s health insurance?
6.26.2 And what is the main reason why [CHILD] is not covered by [L5 NAME‘s health insurance?
INSTRUCTION: LISTEN CAREFULLY AND PROBE FOR REASONS REGARDING AFFORDABILITY (ITEMS 03 AND 04) AND
TO DISTINGUISH BETWEEN 02 AND 03.

REASONS
01. SERVICES DO NOT MEET THE CHILD’S HEALTH CARE NEEDS.
02 CHILD CANNOT SEE THE HEALTH CARE PROVIDERS [HE/SHE] NEEDS.
03. CANNOT AFFORD: PREMIUM TOO EXPENSIVE
04. CANNOT AFFORD: OUT OF POCKET COSTS TOO HIGH
05. CHIP COSTS LESS
06. CHIP HAS BETTER BENEFITS
07. ALREADY COVERED BY OTHER INSURANCE
08. DO NOT BELIEVE IN HEALTH INSURANCE FOR CHILD
09. OTHER (SPECIFY)
D. DK
R. REF

78

L1 – L4
your/NAME

L5
NAME

Box 6.27. SKIP
If Q6.11 = 00, D, R (NO SPOUSE/ PARTNER), GO TO Q6.34.
2001 CHIP 7.82 modified

If Q6.11 = 01 AND Q6.13 = 00 (PG NOT =L5, only one PG)and Q6.18.1 AND Q6.18.2 = 00,D,R (no PG coverage) and
Q6.24.1 AND Q6.24.2 = 00,D,R or Q6.25.1 AND Q6.25.2 = 00,D,R and P = 1, 3, 5, 6, 7, 8, 10, 11
6.27 Is [NAME] covered by any health insurance, such as Medicaid or private insurance, right now?
YES .................................................................
NO .................................................................
DK ..................................................................
REF .................................................................

01
00 GO TO Q6.34
D GO TO Q6.34
R GO TO Q6.34

2001 CHIP 7.83 modified

If Q6.11 = 01 AND Q6.13 = 00 (PG NOT = L5) and Q6.27 = 01 and P = 1, 3, 5, 6, 7, 8, 10, 11
6.28 Is [NAME] covered by the same health insurance as (you are\NAME is)?
YES .................................................................
NO .................................................................
DK .................................................................
REF .................................................................

01 GO TO Q6.34
00
D
R

2001 CHIP 7.84.1 - 7.84.5 modified

If Q6.28 = 00, D, R and P = 1, 3, 5, 6, 7, 8, 10, 11
6.29
Is [NAME] covered by health insurance from an employer, a private insurance purchased directly from an
insurance company, Medicaid, CHIP or any other health insurance coverage? If [NAME] has more than
one coverage, please mention all health insurance coverage this person currently has.
INSURANCE FROM A CURRENT OR PAST
EMPLOYER OR UNION ................................. 01
PRIVATE INSURANCE PURCHASED DIRECTLY FROM
AN INSURANCE COMPANY ............................ 02 GO TO Q6.34
MEDICAID .................................................................... 03 GO TO Q6.34
CHIP
...................................................................... 04 GO TO Q6.34
SOME OTHER TYPE OF COVERAGE I HAVE NOT
YET MENTIONED ........................................... 05 GO TO Q6.34
DK
...................................................................... D GO TO Q6.34
REF
...................................................................... R GO TO Q6.34
2001 CHIP 7.85

If Q6.29=01and P = 1, 3, 5, 6, 7, 8, 10, 11
6.30
Does the employer pay all, some or none of the premium for this health insurance?/ [If Q6.29.01 = 01 plus
any other code 02 – 05]: For the health insurance from an employer, does the employer pay all, some, or
none of the premium for this health insurance?
ALL ................................................................. 01
SOME ............................................................. 02
NONE ............................................................. 03
DK .................................................................. D
REF ................................................................. R

79

2001 CHIP 7.89.1

If Q6.29 = 01 and P = 1, 3, 5, 6, 7, 8, 10, 11
6.31 Could [CHILD] be covered by this health insurance?
YES .................................................................
NO .................................................................
DK ..................................................................
REF .................................................................

01
00 GO TO Q6.34
D GO TO Q6.34
R GO TO Q6.34

2001 CHIP 7.89.1.1

If Q6.31=01 and P = 1, 3, 5, 6, 7, 8, 10, 11
6.32
For the health insurance from an employer, would the employer pay all, some, or none of the premium to
cover [CHILD]?
ALL .................................................................
SOME .............................................................
NONE .............................................................
DK .................................................................
REF .................................................................

01
02
03 GO TO Q6.34
D
R

2001 CHIP 7.89.2 modified

If 6.11.1 = 01 and Q6.32= 01, 02, d, r and P = 1, 3, 5, 6, 7, 8, 10, 11
6.33
What is the main reason [CHILD] is not covered by this health insurance?
INSTRUCTION: PROBE FOR REASONS REGARDING AFFORDABILITY (ITEMS 03 AND 04)
CODE ONE ONLY
01. SERVICES DO NOT MEET THE CHILD’S HEALTH CARE NEEDS.
02. CHILD CANNOT SEE THE HEALTH CARE PROVIDERS HE/SHE
NEEDS.
03. CANNOT AFFORD: PREMIUM TOO EXPENSIVE
04. CANNOT AFFORD: OUT OF POCKET COSTS TOO HIGH
05. CHIP COSTS LESS
06. CHIP HAS BETTER BENEFITS
07. ALREADY COVERED BY OTHER INSURANCE
08. DO NOT BELIEVE IN HEALTH INSURANCE FOR CHILD
09. OTHER (SPECIFY)
D. DK
R. REF
PARENT INCOME
SCHIP 7.90

If P = 1-12
6.34
The next questions are about money people living in the household with (CHILD) have earned at a job or
through self-employment. Remember, this information is completely confidential and will not be reported
to any agency or program.

80

SCHIP 7.91 (LPER1) AND 7.92 (LPER2)

If P = 1-12
6.35
In the past 12 months, did (you, L2 or L4 NAME) work at a job or business, either full-time or part-time,
for pay or profit? What about [L5 NAME]?
YES (01)

NO (00)

DK (D)

REF (R)

6.35.1 L1 or L2 or L3 or L4
6.35.2 L5
NHIS ASD.060_00.000 modified

If P = 1-12
6.36
What is [your/L2 or L4 NAME]’s current working status? I will read each category for you. Please answer
first for [yourself\L2 or L4 NAME] then [L5 NAME]
INSTRUCTION: ANSWER ONLY ONE STATUS FOR EACH PERSON.)
Work Status
01. Working 35 or more hours per week at main full time job
02. Working 35 or more hours per week at one or more jobs
03. Working less than 35 hours per week on one or more jobs
04. Not working
D. DK
R. REF

L1 – L4

L5

NSCH K12Q66

If Q6.36= 01 or 02 or 03 for any L1-L5
6.37
6.37.1 Think about all the locations where [your/NAME]’s employer operates. Would you say that the
total number of persons who work for this employer is above or below 100?
6.37.2 And what about where [L5 NAME] works?
PROBE: Would you say the total number of person who work for this employer is above or below 100?
100 OR MORE
(01)

LESS THAN 100
(02)

DK (D)

REF (R)

6.37.1 L1 or L2 or L3 or L4
6.37.2 L5
Box 6.38. SKIP:
If Q6.37.1 or Q6.37.2 NE 02 GO TO Q6.39, ELSE CONTINUE
NSCH K12Q67 (based on 2011 NSCH/SLAITS)

If Q6.36 = 01 or 02 and Q6.37. 1 or 6.37. 2 =02
6.38
6.38.1 Is the total number of persons who work for [your, NAME]’s employer above or below 50?
6.38.2 And what about [L5 NAME]’s employer.
PROBE: Is that above or below 50 employees?
50 OR MORE (01)

LESS THAN 50 (02)

6.38.1 L1 or L2 or L3 or L4
6.38.2 L5

81

DK (D)

REF (R)

2001 CHIP 7.93

If P = 1 -12
6.39
In the past 12 months, was the total household income from all jobs and all other sources $25,000 or less
or more than $25,000? CODE ONE ONLY.
$25,000 or less .........................................................................
More than $25,000 ..................................................................
DK .............................................................................................
REF .............................................................................................

01
02 GO TO Q6.41
D
R GO TO Q6.45

2001 CHIP 7.100

If Q6.39=01 or d
6.40
Would you say it was…
INSTRUCTION: STOP READING CATEGORIES WHEN RESPONDENT ANSWERS.
$5,000 or less?........................................................................... 01 GO TO Q6.45
$5,001 but less than $10,000 .................................................... 02 GO TO Q6.45
$10,001but less than $15,000 ................................................... 03 GO TO Q6.45
$15,001 but less than $20,000 .................................................. 04 GO TO Q6.45
$20,001but less than $25,000 ................................................... 05 GO TO Q6.45
DK .............................................................................................. D GO TO Q 6.45
REF ............................................................................................. R GO TO Q6.45
2001 CHIP 7.101

If Q6.39=02
6.41 Was it below $60,000 or $60,000 or more?
Below $60,000 ..........................................................................
$60,000 or more .......................................................................
DK .............................................................................................
REF .............................................................................................

01
02 GO TO Q6.43
D
R GO TO Q6.45

New

If Q6.41 = 01, d
6.42 Would you say it was…
INSTRUCTION: STOP READING CATEGORIES WHEN RESPONDENT ANSWERS.
$25,001 but less than $30,000? .................................. 01 GO TO Q6.45
$30,001 but less than $40,000? .................................. 02 GO TO Q6.45
$40,001 but less than $50,000? .................................. 03 GO TO Q6.45
$50,001 but less than $60,000? .................................. 04 GO TO Q6.45

82

New

If Q6.41 = 02
6.43 Was it below $100,000 or $100,000 or more?
Below $100,000 ......................................................................
$100,000 or more .....................................................................
DK .............................................................................................
REF .............................................................................................

01
02 GO TO Q6.45
D
R GO TO Q6.45

New

If Q6.43 = 01,d
6.44 Would you say it was….
INSTRUCTION: STOP READING CATEGORIES WHEN RESPONDENT ANSWERS.
$60,001 but less than $70,000? .................................. 05
$70,001 but less than $80,000? .................................. 06
$80,001 but less than $90,000? .................................. 07
$90,001 but less than $100,000? ................................ 08
More than $100,000? .................................................. 09
DK ................................................................................ D
REF ............................................................................... R
Box 6.45. If P = 2, 4, 9, 12, go to Q7.1
SCHIP 7.103

If P = 1, 3, 5, 6, 7, 8, 10, 11
6.45
During the past 12 months, about how much did your household spend on health care, that is, money you
or someone else in the household paid for doctors’ visits, hospital stays, or prescription drugs? Please
include all out-of-pocket expenses that health insurance does not or will not pay for. Do not include any
cost for health insurance premiums, non-prescription drugs or dental care.
DID NOT PAY ANYTHING ........................................................... 00 GO TO SECTION 7
LESS THAN $500 ........................................................................ 01
$501 BUT LESS THAN $1,000 ..................................................... 02
$1001 BUT LESS THAN $2,000 ................................................... 03
$2,001 OR MORE ....................................................................... 04
DK ............................................................................................ D
REF ............................................................................................. R
HSC Household Survey c96 modified

If Q6.45=01 – 04
6.46
During the past 12 months has your family had a big problem, a small problem, or no problem paying
medical bills for your entire family?
BIG PROBLEM ................................................ 01
SMALL PROBLEM ........................................... 02
NO PROBLEM................................................. 03
DK .................................................................. D
REF ................................................................. R

GO TO SECTION 7

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