38.12 Revised Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

36M Questionnaire – Child, Phase 2g

OMB Specification

36M Questionnaire - Child

Event Category:	Time-Based
Event:	36M
Administration:	N/A
Instrument Target:	Child
Instrument Respondent:	Primary Caregiver
Domain:	Questionnaire
Document Category:	Questionnaire
Method:	Data Collector Administered
Mode (for this instrument*):	In-Person, CAI; Phone, CAI
OMB Approved Modes:	In-Person, CAI; Phone, CAI; Web-Based, CAI
Estimated Administration Time:	20 minutes
Multiple Child/Sibling Consideration:	Per Child
Special Considerations:	N/A
Version:	1.0
MDES Release:	4.0

*This instrument is OMB-approved for multi-mode administration but this version of the instrument is designed for administration in this/these mode(s) only.

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36M Questionnaire - Child

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

PHYSICAL ACTIVITY 3

NOISE EXPOSURE 6

TOILET TRAINING 10

SUN EXPOSURE 12

DEMOGRAPHICS (RACE/ETHNICITY) 14

SOCIAL ACTIVITIES 19

RISK AND SAFETY BEHAVIORS 22

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36M Questionnaire - Child

GENERAL PROGRAMMER INSTRUCTIONS:

WHEN PROGRAMMING INSTRUMENTS, VALIDATE FIELD LENGTHS AND TYPES AGAINST THE MDES TO ENSURE DATA COLLECTION RESPONSES DO NOT EXCEED THOSE OF THE MDES. SOME GENERAL ITEM LIMITS USED ARE AS FOLLOWS:

DATA ELEMENT FIELDS	MAXIMUM CHARACTERS PERMITTED	DATA TYPE	PROGRAMMER INSTRUCTIONS
ADDRESS AND EMAIL FIELDS	100	CHARACTER
UNIT AND PHONE FIELDS	10	CHARACTER
_OTH AND COMMENT FIELDS	255	CHARACTER	Limit text to 255 characters
FIRST NAME AND LAST NAME	30	CHARACTER	Limit text to 30 characters
ALL ID FIELDS	36	CHARACTER
ZIP CODE	5	NUMERIC
ZIP CODE LAST FOUR	4	NUMERIC
CITY	50	CHARACTER
DOB AND ALL OTHER DATE FIELDS (E.G., DT, DATE, ETC.)	10	NUMERIC CHARACTER	DISPLAY AS MM/DD/YYYY STORE AS YYYY-MM-DD HARD EDITS: MM MUST EQUAL 01 TO 12 DD MUST EQUAL 01 TO 31 YYYY MUST BE BETWEEN 1900 AND CURRENT YEAR.
TIME VARIABLES	TWO-DIGIT HOUR AND TWO-DIGIT MINUTE, AM/PM DESIGNATION	NUMERIC	HARD EDITS: HOURS MUST BE BETWEEN 00 AND 12; MINUTES MUST BE BETWEEN 00 AND 59

Instrument Guidelines for Participant and Respondent IDs:

PRENATALLY, THE P_ID IN THE MDES HEADER IS THAT OF THE PARTICIPANT (E.G. THE NON-PREGNANT WOMAN, PREGNANT WOMAN, OR THE FATHER).

POSTNATALLY, A RESPONDENT ID WILL BE USED IN ADDITION TO THE PARTICIPANT ID BECAUSE SOMEBODY OTHER THAN THE PARTICIPANT MAY BE COMPLETING THE INTERVIEW. FOR EXAMPLE, THE PARTICIPANT MAY BE THE CHILD AND THE RESPONDENT MAY BE THE MOTHER, FATHER, OR ANOTHER CAREGIVER. THEREFORE, MDES VERSION 2.2 AND ALL FUTURE VERSIONS CONTAIN A R_P_ID (RESPONDENT PARTICIPANT ID) HEADER FIELD FOR EACH POST-BIRTH INSTRUMENT. THIS WILL ALLOW ROCs TO INDICATE WHETHER THE RESPONDENT IS SOMEBODY OTHER THAN THE PARTICIPANT ABOUT WHOM THE QUESTIONS ARE BEING ASKED.

A REMINDER:

ALL RESPONDENTS MUST BE CONSENTED AND HAVE RECORDS IN THE PERSON, PARTICIPANT, PARTICIPANT_CONSENT AND LINK_PERSON_PARTICIPANT TABLES, WHICH CAN BE PRELOADED INTO EACH INSTRUMENT. ADDITIONALLY, IN POST-BIRTH QUESTIONNAIRES WHERE THERE IS THE ABILITY TO LOOP THROUGH A SET OF QUESTIONS FOR MULTIPLE CHILDREN, IT IS IMPORTANT TO CAPTURE AND STORE THE CORRECT CHILD P_ID ALONG WITH THE LOOP INFORMATION. IN THE MDES VARIABLE LABEL/DEFINITION COLUMN, THIS IS INDICATED AS FOLLOWS: EXTERNAL IDENTIFIER: PARTICIPANT ID FOR CHILD DETAIL.

PHYSICAL ACTIVITY

(TIME_STAMP_PA_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP.

PA01000. These next questions are about {C_FNAME/the child}’s physical activity.

PA02000/(MED_LIMIT_PA). Does {C_FNAME/the child} have any physical or medical condition that affects {his/her} ability to play and be physically active?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (Modified) 

PA03000/(COMPARE_AGE). How active would you say {C_FNAME/the child} is compared with other {girls/boys} {C_FNAME/the child}’s age? Would you say:

Label	Code	Go To
A lot less active	1
Less active	2
The same	3
More active	4
A lot more active	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (Modified) 

PROGRAMMER INSTRUCTIONS

• IF CHILD_SEX = 1, DISPLAY "boys"

• IF CHILD_SEX = 2, DISPLAY  "girls"

• OTHERWISE, DISPLAY "girls/boys"

PA04000. Thinking about yesterday (or the most recent day you were home with {C_FNAME/the child}), how much time did {he/she} spend in active play?

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (Modified) 

(OUTDOOR_YEST_HRS) |___|
HOURS

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(OUTDOOR_YEST_MIN) |____|____|

MINUTES

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

PA09000. Do you have access to any of the following facilities?

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) 

PA10000/(PLAY_EQUIP_BACKYARD). Play equipment like a swing set, slide, or climbing gym?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (Modified) 

PA11000/(POOL_BACKYARD). Pool or spa? 

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) 

PA12000/(BIKE_AREA_BACKYARD). Area suitable to ride a tricycle, bike or scooter?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (Modified) 

PA16000/(PART_OFTEN_CAREGIVERS). How often does {C_FNAME/The child} participate in physical activity with parents and caregivers.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NEVER	1
RARELY	2
SOMETIMES	3
OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Family Health Behavior Scale (Modified) 

(TIME_STAMP_PA_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP.

NOISE EXPOSURE

(TIME_STAMP_NE_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP.

• PRELOAD PARTICIPANT ID (P_ID) FOR CHILD AND RESPONDENT ID (R_P_ID) FOR ADULT CAREGIVER.

• PRELOAD C_FNAME AND DISPLAY NAME IN "C_FNAME" THROUGHOUT THE INSTRUMENT.

• IF C_FNAME = -1 OR -2, DISPLAY "the child" IN APPROPRIATE FIELDS THROUGHOUT THE INSTRUMENT.

• PRELOAD CHILD_SEX AND IF = 1, DISPLAY "he", him" AND "his" IN APPROPRIATE FIELDS THROUGHOUT INSTRUMENT.

• IF CHILD_SEX = 2, DISPLAY "she" AND "her" IN APPROPRIATE FIELDS THROUGHOUT INSTRUMENT.

NE10000. We would now like to ask you some questions about noise in and around the child’s home.

NE11000/(NOISE_OUTSIDE). When inside {C_FNAME/the child}’s home, how much would you say noise from outdoor sources bothers, disturbs, or annoys {CHILD’s Name}? 

Label	Code	Go To
Extremely	1
Very much	2
Moderately	3
Slightly	4
Not at all	5	NOISE_INSIDE
REFUSED	-1	NOISE_INSIDE
DON'T KNOW	-2	NOISE_INSIDE

SOURCE

The International Commission on Biological Effects of Noise’s (ICBEN’s) Community Response to Noise Team, Cohen/Bronzaft airport studies (Modified) 

NE13000/(NOISE_OUTSIDE_TYPE). What types of outdoor noise bother, disturb or annoy {C_FNAME/the child} when {he/she} is inside?

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

• SELECT ALL THAT APPLY.

Label	Code	Go To
AIRPLANE	1
CAR/TRUCK	2
GARDEN EQUIPMENT	3
DOGS BARKING	4
LOUD MUSIC	5
NEIGHBOR VOICES	6
ROWDY PASSERBY VOICES	7
NO PARTICULAR SOURCE	8
SOME OTHER SOURCE	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

The International Commission on Biological Effects of Noise's Cohen/Bronzaft airport studies (Modified) 

PROGRAMMER INSTRUCTIONS

• IF NOISE_OUTSIDE_TYPE = ANY COMBINATION OF 1 THROUGH 7, GO TO NOISE_INSIDE.

• IF NOISE_OUTSIDE_TYPE = -5 OR ANY COMBINATION OF 1 THROUGH 7 AND -5, GO TO NOISE_OUTSIDE_OTH.

• IF NOISE_OUTSIDE_TYPE = 8, -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES, AND GO TO NOISE_INSIDE.

NE14000/(NOISE_OUTSIDE_OTH). What other type of outdoor noise?

 

SPECIFY: ___________________________________

INTERVIEWER INSTRUCTIONS

• PROBE “Anything else?” 

• LIST ALL OTHER OUTDOOR NOISE SOURCES SEPARATED BY COMMAS. 

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

The International Commission on Biological Effects of Noise's Cohen/Bronzaft airport studies (Modified) 

NE15000/(NOISE_INSIDE). At {C_FNAME/the child}’s home, how much would you say noise from indoor sources bothers, disturbs, or annoys {C_FNAME/the child}?

Label	Code	Go To
Extremely	1
Very much	2
Moderately	3
Slightly	4
Not at all	5	NOISE_INTERFERE
REFUSED	-1	NOISE_INTERFERE
DON'T KNOW	-2	NOISE_INTERFERE

SOURCE

The International Commission on Biological Effects of Noise’s (ICBEN’s) Community Response to Noise Team (Modified) 

NE17000/(NOISE_INSIDE_TYPE). What types of indoor noise would you say bother, disturb or annoy {C_FNAME/the child}?

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

• SELECT ALL THAT APPLY.

Label	Code	Go To
BUILDING/MECHANICAL NOISE SUCH AS – FAN, AIR CONDITIONING, ETC	1
LOUD MUSIC	2
LOUD TALKING, CRYING, ETC. BY HOUSEHOLD MEMBERS, INCLUDING CHILDREN	3
DOGS BARKING	4
SOME OTHER SOURCE	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

The International Commission on Biological Effects of Noise’s (ICBEN’s) Community Response to Noise Team (Modified) 

DATA COLLECTOR INSTRUCTIONS

• IF NOISE_INSIDE_TYPE = ANY COMBINATION OF 1 THROUGH 4, GO TO NOISE_INTERFERE.

• IF NOISE_INSIDE_TYPE = -5, OR ANY COMBINATION OF 1 THROUGH 4 AND -5, GO TO NOISE_INSIDE_OTH.

• IF NOISE_INSIDE_TYPE = -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES, AND GO TO NOISE_INTERFERE.

NE18000/(NOISE_INSIDE_OTH). What other type of indoor noise?

 

SPECIFY: ___________________________________

INTERVIEWER INSTRUCTIONS

• PROBE “Anything else?” 

• LIST ALL OTHER INDOOR NOISE SOURCES SEPARATED BY COMMAS. 

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

The International Commission on Biological Effects of Noise’s (ICBEN’s) Community Response to Noise Team (Modified) 

(TIME_STAMP_NE_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP.

TOILET TRAINING

(TIME_STAMP_TT_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP.

TT01000. These next questions ask about {C_FNAME/the child} and toilet training.

TT02000/(TOILET_TRAIN_STATUS). Which of the following best describes {C_FNAME/the child}…

INTERVIEWER INSTRUCTIONS

• IF ADULT CAREGIVER NEEDS CLARIFICATION OF "Not yet toilet trained" SAY, "For example, {he/she} wears diapers all the time, day and night"

• IF ADULT CAREGIVER NEEDS CLARIFICATION OF "Partially toilet trained" SAY, "For example, {he/she} wears diapers at night-time only, or during extended outings, or urinates in the toilet but does not yet have bowel movements in the toilet."

• IF ADULT CAREGIVER NEEDS CLARIFICATION OF "Fully toilet trained" SAY, "For example, {he/she} no longer needs to wear diapers."

Label	Code	Go To
Not yet toilet trained	1	INTEREST_TOILET
Partially toilet trained	2	TT04000
Fully toilet trained	3
REFUSED	-1	TIME_STAMP_TT_ET
DON'T KNOW	-2	TIME_STAMP_TT_ET

SOURCE

New

TT03000/(AGE_TOILET_TRAIN). At what age was {C_FNAME/the child} fully toilet trained?

Label	Code	Go To
Less than 1 year old	1
Between 12 and 18 months	2
Between 19 and 24 months	3
Between 25 and 30 months	4
Between 31 and 36 months	5
After 36 months	6
REFUSED	-1
DON'T KNOW	-2

SOURCE

New

(TIME_STAMP_TT_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP.

SUN EXPOSURE

(TIME_STAMP_SE_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP.

SE01000. These next questions ask about you, {C_FNAME/the child}, and your views and habits when out in the sun.

SOURCE

Sun Habits Survey

SE02000/(HOURS_SUN_WEEKDAY). On average, how long was {C_FNAME/the child} outdoors in the sun on weekdays between 10 a.m. and 4 p.m. last summer? 

Label	Code	Go To
1 HOUR OR LESS	1
2 HOURS	2
3 HOURS	3
4 HOURS	4
5 HOURS	5
6 HOURS	6
REFUSED	-1
DON'T KNOW	-2

SOURCE

Sun Habits Survey

SE03000/(HOURS_SUN_WEEKEND). On average, how long was {C_FNAME/the child} outdoors in the sun on weekends between 10 a.m. and 4 p.m. last summer? 

Label	Code	Go To
1 HOUR OR LESS	1
2 HOURS	2
3 HOURS	3
4 HOURS	4
5 HOURS	5
6 HOURS	6
REFUSED	-1
DON'T KNOW	-2

SOURCE

Sun Habits Survey

SE04000. When {C_FNAME/the child} is outdoors in the sun, how often does (he/she) wear sunscreen?

SOURCE

Sun Habits Survey

SE16000/(EVER_SUNBURN). Has {C_FNAME/the child} ever had a sunburn?

Label	Code	Go To
YES	1
NO	2	TIME_STAMP_SE_ET
REFUSED	-1	TIME_STAMP_SE_ET
DON'T KNOW	-2	TIME_STAMP_SE_ET

SOURCE

Sun Habits Survey

SE17000/(NUM_SUNBURNS_PREV_SUMMER). How many times last summer did {C_FNAME/the child} get a sunburn?

Label	Code	Go To
NONE	0
ONE	1
TWO	2
THREE	3
FOUR	4
FIVE OR MORE	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Sun Habits Survey

(TIME_STAMP_SE_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP.

DEMOGRAPHICS (RACE/ETHNICITY)

(TIME_STAMP_DEM_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP.

DEM01000/(BABY_ETHNIC_ORIGIN). Is {C_FNAME/the child} of Hispanic, Latino/a or Spanish origin?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act. (Modified) 

PROGRAMMER INSTRUCTIONS

• IF BABY_ETHNIC_ORIGIN = 1, GO TO BABY_ETHNIC_ORIGIN_1.

• IF BABY_ETHNIC_ORIGIN ≠ 1,  AND
  
  

• IF MODE = CAPI, GO TO BABY_RACE_NEW.

• IF MODE = CATI, GO TO ​BABY_RACE_1. 

DEM02000/(BABY_ETHNIC_ORIGIN_1). Is {C_FNAME/the child} one or more of the following?

INTERVIEWER INSTRUCTIONS

• SELECT ALL THAT APPLY.

• PROBE: Anything else?

Label	Code	Go To
Mexican, Mexican American, Chicano/a	1
Puerto Rican	2
Cuban	3
Another Hispanic, Latino/a, or Spanish origin	4
OTHER	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act. (Modified) 

PROGRAMMER INSTRUCTIONS

• IF BABY_ETHNIC_ORIGIN_1 = ANY COMBINATION OF 1 THROUGH 4, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING BABY_ETHNIC_ORIGIN_1.

• IF BABY_ETHNIC_ORIGIN_1 = -5, OR ANY COMBINATION OF 1 THROUGH 4 AND -5, GO TO BABY_ETHNIC_ORIGIN_1_OTH.

• IF BABY_ETHNIC_ORIGIN_1 = -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO PROGRAMMER INSTRUCTIONS FOLLOWING BABY_ETHNIC_ORIGIN_1.

DEM03000/(BABY_ETHNIC_ORIGIN_1_OTH). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act. (Modified)

PROGRAMMER INSTRUCTIONS

• IF MODE = CAPI, GO TO BABY_RACE_NEW.

• IF MODE = CATI, GO TO BABY_RACE_1

DEM04000/(BABY_RACE_NEW). What is {C_FNAME/the child}'s race? (One or more categories may be selected).

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

• SELECT ALL THAT APPLY.

• CODE “SOME OTHER RACE” ONLY IF VOLUNTEERED.

• PROBE: Anything else?

Label	Code	Go To
WHITE	1
BLACK OR AFRICAN AMERICAN	2
AMERICAN INDIAN OR ALASKA NATIVE	3
ASIAN INDIAN	4
CHINESE	5
FILIPINO	6
JAPANESE	7
KOREAN	8
VIETNAMESE	9
OTHER ASIAN	10
NATIVE HAWAIIAN	11
GUAMANIAN OR CHAMORRO	12
SAMOAN	13
OTHER PACIFIC ISLANDER	14
SOME OTHER RACE	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act. (Modified) 

PROGRAMMER INSTRUCTIONS

• IF BABY_RACE_NEW = ANY COMBINATION OF 1 THROUGH 14, GO TO TIME_STAMP_DEM_ET.

• IF BABY_RACE_NEW = -5, OR ANY COMBINATION OF 1 THROUGH 14 AND -5, GO TO BABY_RACE_NEW_OTH.

• IF BABY_RACE_NEW = -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO TIME_STAMP_DEM_ET.

DEM05000/(BABY_RACE_NEW_OTH). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act. (Modified)

PROGRAMMER INSTRUCTIONS

• GO TO TIME_STAMP_DEM_ET.

DEM06000/(BABY_RACE_1). ​​What is {C_FNAME/the child}'s race? (One or more categories may be selected).

INTERVIEWER INSTRUCTIONS

• SELECT ALL THAT APPLY.

• CODE "SOME OTHER RACE" ONLY IF VOLUNTEERED.

• PROBE: Anything else?

Label	Code	Go To
White	1
Black or African American	2
American Indian or Alaska native	3
Asian	4
Native Hawaiian or other Pacific Islander	5
SOME OTHER RACE	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act. (Modified)

PROGRAMMER INSTRUCTIONS

• IF BABY_RACE_1 = ANY COMBINATION OF 1 THROUGH 3, GO TO TIME_STAMP_DEM_ET.

• IF BABY_RACE_1 = 4 OR ANY COMBINATION OF 4 AND 1, 2, 3, AND/OR 5, GO TO BABY_RACE_2.

• IF BABY_RACE_1 = 5 OR ANY COMBINATION OF 5 AND 1 THROUGH 3, GO TO BABY_RACE_3.

• IF BABY_RACE_1 = -5, OR ANY COMBINATION OF 1 THROUGH 5 AND -5, GO TO BABY_RACE_1_OTH.

• IF BABY_RACE_1 =  -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO TIME_STAMP_DEM_ET.

DEM07000/(BABY_RACE_1_OTH). SPECIFY _______________________________________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act. (Modified)

PROGRAMMER INSTRUCTIONS

• IF BABY_RACE_1 = 4 OR 4 AND ANY COMBINATION OF 1, 2, 3, AND/OR 5, GO TO BABY_RACE_2.

• IF BABY_RACE_1 = 5 OR 5 AND ANY COMBINATION OF 1 THROUGH 3, GO TO BABY_RACE_3.

• ​OTHERWISE, GO TO TIME_STAMP_DEM_ET.

DEM08000/(BABY_RACE_2). ​​What is {C_FNAME/the child}'s race? (One or more categories may be selected).

INTERVIEWER INSTRUCTIONS

• PROBE FOR ANY OTHER RESPONSES.

• SELECT ALL THAT APPLY.

Label	Code	Go To
Asian Indian	1
Chinese	2
Filipino	3
Japanese	4
Korean	5
Vietnamese	6
Other Asian	7
REFUSED	-1
DON'T KNOW	-2

SOURCE

​U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act. (Modified)

PROGRAMMER INSTRUCTIONS

• IF BABY_RACE_1 = ANY COMBINATION WITH 4 AND 5, GO TO BABY_RACE_3.

• OTHERWISE, GO TO TIME_STAMP_DEM_ET.

DEM09000/(BABY_RACE_3). ​What is {C_FNAME/the child}'s race? (One or more categories may be selected).

INTERVIEWER INSTRUCTIONS

• PROBE FOR ANY OTHER RESPONSES

• SELECT ALL THAT APPLY

Label	Code	Go To
Native Hawaiian	1
Guamanian or Chamorro	2
Samoan	3
Other Pacific Islander	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

U.S. Department of Health and Human Services Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status required by Section 4302 of the Affordable Care Act. (Modified)

(TIME_STAMP_DEM_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP.

SOCIAL ACTIVITIES

(TIME_STAMP_SA_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP.

SA01000. These next questions are about social activities you share with {C_FNAME/the child}. 

SA03000/(FUN_OUT_FREQ). How often does any family member get a chance to take {C_FNAME/the child} on some kind of outing (e.g., shopping, to the park, on a picnic, to a restaurant, to the zoo, etc.)?

Label	Code	Go To
A few times a year	1
About once a month	2
About 2 or 3 times a month	3
Several times a week	4
Almost every day	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Home Observation Measurement of the Environment – Short Form (for Children Who  Are 3 to 5 Years Old) (Modified) 

SA08000/(FAMILY_MEAL_FREQ). How often does {C_FNAME/the child} eat a meal with the rest of the family?  

Label	Code	Go To
More than once a day	1
Once a day	2
Several times a week	3
Once a week	4
Once a month or less often	5
Never	6
REFUSED	-1
DON'T KNOW	-2

SOURCE

Home Observation Measurement of the Environment – Short Form (for Children Who  Are Less than 3 Years Old and for Children Who Are 3 to 5 Years Old) (Modified) 

SA19000/(REACT_ANGER). Most children get angry at their parents from time to time.  If {C_FNAME/the child} got so angry that he or she hit you, what would you do?  

INTERVIEWER INSTRUCTIONS

• SELECT ALL THAT APPLY.

Label	Code	Go To
Hit him/her back	1
Send him/her to room	2
Spank him/her	3
Talk to him/her	4
Ignore it	5
Give him/her household chore	6
Take away his/her allowance	7
Hold child’s hands until he/she is calm	8
OTHER	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Home Observation Measurement of the Environment – Short Form (for Children Who are 3 to 5 Years Old) (Modified) 

PROGRAMMER INSTRUCTIONS

• IF REACT_ANGER = ANY COMBINATION OF 1 THROUGH 8, GO TO SPANK_FREQ.

• IF REACT_ANGER = -5 ONLY, OR ANY COMBINATION OF 1 THROUGH 8 AND -5, GO TO REACT_ANGER_OTH.

• IF REACT_ANGER = -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO SPANK_FREQ.

SA20000/(REACT_ANGER_OTH). SPECIFY: ______________________________________________

INTERVIEWER INSTRUCTIONS

• PROBE “Anything else?”

• LIST ALL OTHER REACTIONS SEPARATED BY COMMAS. 

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

Home Observation Measurement of the Environment – Short Form (for Children Who are 3 to 5 Years Old) (Modified) 

(TIME_STAMP_SA_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP.

RISK AND SAFETY BEHAVIORS

(TIME_STAMP_RAS_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP.

RAS01000. The next questions are about your home and prevention of injury.

SOURCE

National Health Interview Survey 1998 & 2003 

RAS02000/(SMOKE_ALARM). Do you have at least one working smoke alarm on each floor of your home, including in a finished basement or attic?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health Interview Survey, 2003

RAS05000. I have a few questions about {C_FNAME/the child} and behaviors in a car.

RAS07000/(SEATBELT_CHILD). When riding in a car, is {C_FNAME/the child} buckled in (a child safety seat) all or most of the time, some of the time, once in a while, or never?

Label	Code	Go To
ALL OR MOST OF THE TIME	1
SOME OF THE TIME	2
ONCE IN AWHILE	3
NEVER	4
DOESN’T RIDE IN CAR	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health Interview Survey, 1998 (Modified) 

(TIME_STAMP_RAS_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP.

Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593*). Do not return the completed form to this address.