4 04_Updated MCH Survey_RMI_English

CASE ID:

Section A.Screener (PROGRAMMER: Add Timestamp)

A1. Are there any children 0-17 years old who usually live or stay at this household?

1. ☐ NO [IF NO, STOP HERE. THIS IS THE END OF THE SURVEY]

2. ☐ YES

A2. How many children 0-17 years old usually live or stay at this household?

NUMBER OF CHILDREN LIVING OR STAYING AT THIS ADDRESS

A3. What is the primary language spoken in the household?

1. ☐ ENGLISH

2. ☐ SPANISH

3. ☐ ANOTHER LANGUAGE, PLEASE SPECIFY:

Answer the remaining questions for each of the children 0-17 years old who usually live or stay at this address.

Start with the youngest child, who we will call "Child 1" and continue with the next youngest until you have answered the questions for all children who usually live or stay at this address.

A4. CHILD 1

What is this child’s first name, initials, or nickname?

A5. Is this child of Hispanic, Latino, or Spanish origin?

1. ☐ No, not of Hispanic, Latino, or Spanish origin

2. ☐ Yes, Mexican, Mexican American, Chicano

3. ☐ Yes, Puerto Rican

4. ☐ Yes, Cuban

5. ☐ Yes, another Hispanic, Latino, or Spanish origin, please specify:

A6. What is this child’s race? SELECT ONE OR MORE.

1. ☐ WHITE

2. ☐ BLACK OR AFRICAN AMERICAN

3. ☐ AMERICAN INDIAN OR ALASKA NATIVE, PLEASE SPECIFY:

4. ☐ ASIAN INDIAN

5. ☐ CHINESE

6. ☐ FILIPINO

7. ☐ JAPANESE

8. ☐ KOREAN

9. ☐ VIETNAMESE

10. ☐ OTHER ASIAN, PLEASE SPECIFY:

11. ☐ NATIVE HAWAIIAN

12. ☐ GUAMANIAN OR CHAMORRO

13. ☐ SAMOAN

14. ☐ OTHER PACIFIC ISLANDER, PLEASE SPECIFY:

A7. What is this child’s sex?

1. ☐ MALE

2. ☐ FEMALE

A8. How old is this child? If the child is less than one month old, round age in months to 1.

YEARS (OR) MONTHS

IF THIS CHILD IS YOUNGER THAN 4 YEARS OLD, GO TO A10.

A9. PUERTO RICO: How well does this child speak Spanish?

ALL OTHER JURISDICTIONS: How well does this child speak English?

1. ☐ Very well

2. ☐ Well

3. ☐ Not well

4. ☐ Not at all

A10. Does this child currently need or use medicine prescribed by a doctor, other than vitamins?

1. ☐ YES

2. ☐ NO [GO TO A11]

[IF YES] is this child’s need for prescription medicine because of any medical, behavioral, or other health condition?

1. ☐ YES

2. ☐ NO [GO TO A11]

[IF YES] is this a condition that has lasted or is expected to last 12 months or longer?

1. ☐ YES

2. ☐ NO

A11. Does this child need or use more medical care, mental health, or educational services than is usual for most children of the same age?

1. ☐ YES

2. ☐ NO [GO TO A12]

[IF YES] is this child’s need for medical care, mental health, or educational services because of any medical, behavioral, or other health condition?

1. ☐ YES

2. ☐ NO [GO TO A12]

[IF YES] is this a condition that has lasted or is expected to last 12 months or longer?

1. ☐ YES

2. ☐ NO

A12. Is this child limited or prevented in any way in his or her ability to do the things most children of the same age can do?

1. ☐ YES

2. ☐ NO [GO TO A13]

[IF YES] is this child’s limitation in abilities because of any medical, behavioral, or other health condition?

1. ☐ YES

2. ☐ NO [GO TO A13]

[IF YES] is this a condition that has lasted or is expected to last 12 months or longer?

1. ☐ YES

2. ☐ NO

A13. Does this child need or get special therapy, such as physical, occupational, or speech therapy?

1. ☐ YES

2. ☐ NO [GO TO A14]

[IF YES] is this because of any medical, behavioral, or other health condition?

1. ☐ YES

2. ☐ NO [GO TO A14]

[IF YES] is this a condition that has lasted or is expected to last 12 months or longer?

1. ☐ YES

2. ☐ NO

A14. Does this child have any kind of emotional, developmental, or behavioral problem for which he or she needs treatment or counseling?

1. ☐ YES

2. ☐ NO [GO TO A15]

[IF YES] has his or her emotional, developmental, or behavioral problem lasted or is it expected to last 12 months or longer?

1. ☐ YES

2. ☐ NO

IF RESPONDENT HAS ANOTHER CHILD, CONTINUE WITH A15. ELSE CONTINUE WITH
SECTION B.

A15. CHILD 2

What is this child’s first name, initials, or nickname?

A16. Is this child of Hispanic, Latino, or Spanish origin?

1. ☐ No, not of Hispanic, Latino, or Spanish origin

2. ☐ Yes, Mexican, Mexican American, Chicano

3. ☐ Yes, Puerto Rican

4. ☐ Yes, Cuban

5. ☐ Yes, another Hispanic, Latino, or Spanish origin, please specify:

A17. What is this child’s race? SELECT ONE OR MORE.

1. ☐ WHITE

2. ☐ BLACK OR AFRICAN AMERICAN

3. ☐ AMERICAN INDIAN OR ALASKA NATIVE, PLEASE SPECIFY:

4. ☐ ASIAN INDIAN

5. ☐ CHINESE

6. ☐ FILIPINO

7. ☐ JAPANESE

8. ☐ KOREAN

9. ☐ VIETNAMESE

10. ☐ OTHER ASIAN, PLEASE SPECIFY:

11. ☐ NATIVE HAWAIIAN

12. ☐ GUAMANIAN OR CHAMORRO

13. ☐ SAMOAN

14. ☐ OTHER PACIFIC ISLANDER, PLEASE SPECIFY:

A18. What is this child’s sex?

1 ☐ MALE

2 ☐ FEMALE

A19. How old is this child? If the child is less than one month old, round age in months to 1.

YEARS (OR) MONTHS

IF THIS CHILD IS YOUNGER THAN 4 YEARS OLD, GO TO A21.

A20. PUERTO RICO: How well does this child speak Spanish?

ALL OTHER JURISDICTIONS: How well does this child speak English?

1 ☐ Very well

2 ☐ Well

3 ☐ Not well

4 ☐ Not at all

A21. Does this child currently need or use medicine prescribed by a doctor, other than vitamins?

1 ☐ YES

2 ☐ NO [GO TO A22]

[IF YES] is this child’s need for prescription medicine because of any medical, behavioral, or other health condition?

1. ☐ YES

2. ☐ NO [GO TO A22]

[IF YES] is this a condition that has lasted or is expected to last 12 months or longer?

1. ☐ YES

2. ☐ NO

A22. Does this child need or use more medical care, mental health, or educational services than is usual for most children of the same age?

1. ☐ YES

2. ☐ NO [GO TO A23]

[IF YES] is this child’s need for medical care, mental health, or educational services because of any medical, behavioral, or other health condition?

1. ☐ YES

2. ☐ NO [GO TO A23]

[IF YES] is this a condition that has lasted or is expected to last 12 months or longer?

1. ☐ YES

2. ☐ NO

A23. Is this child limited or prevented in any way in his or her ability to do the things most children of the same age can do?

1. ☐ YES

2. ☐ NO [GO TO A24]

[IF YES] is this child’s limitation in abilities because of any medical, behavioral, or other health condition?

1. ☐ YES

2. ☐ NO [GO TO A24]

[IF YES] is this a condition that has lasted or is expected to last 12 months or longer?

1. ☐ YES

2. ☐ NO

A24. Does this child need or get special therapy, such as physical, occupational, or speech therapy?

1. ☐ YES

2. ☐ NO [GO TO A25]

[IF YES] is this because of any medical, behavioral, or other health condition?

1. ☐ YES

2. ☐ NO [GO TO A25]

[IF YES] is this a condition that has lasted or is expected to last 12 months or longer?

1. ☐ YES

2. ☐ NO

A25. Does this child have any kind of emotional, developmental, or behavioral problem for which he or she needs treatment or counseling?

1. ☐ YES

2. ☐ NO [GO TO A26]

[IF YES] has his or her emotional, developmental, or behavioral problem lasted or is it expected to last 12 months or longer?

1. ☐ YES

2. ☐ NO

IF RESPONDENT HAS ANOTHER CHILD, CONTINUE WITH A26. ELSE CONTINUE WITH
SECTION B.

A26. CHILD 3

What is this child’s first name, initials, or nickname?

A27. Is this child of Hispanic, Latino, or Spanish origin?

1. ☐ No, not of Hispanic, Latino, or Spanish origin

2. ☐ Yes, Mexican, Mexican American, Chicano

3. ☐ Yes, Puerto Rican

4. ☐ Yes, Cuban

5. ☐ Yes, another Hispanic, Latino, or Spanish origin, please specify:

A28. What is this child’s race? SELECT ONE OR MORE.

1. ☐ WHITE

2. ☐ BLACK OR AFRICAN AMERICAN

3. ☐ AMERICAN INDIAN OR ALASKA NATIVE, PLEASE SPECIFY:

4. ☐ ASIAN INDIAN

5. ☐ CHINESE

6. ☐ FILIPINO

7. ☐ JAPANESE

8. ☐ KOREAN

9. ☐ VIETNAMESE

10. ☐ OTHER ASIAN, PLEASE SPECIFY:

11. ☐ NATIVE HAWAIIAN

12. ☐ GUAMANIAN OR CHAMORRO

13. ☐ SAMOAN

14. ☐ OTHER PACIFIC ISLANDER, PLEASE SPECIFY:

A29. What is this child’s sex?

1. ☐ MALE

2. ☐ FEMALE

A30. How old is this child? If the child is less than one month old, round age in months to 1.

YEARS (OR) MONTHS

IF THIS CHILD IS YOUNGER THAN 4 YEARS OLD, GO TO A32.

A31. PUERTO RICO: How well does this child speak Spanish?

ALL OTHER JURISDICTIONS: How well does this child speak English?

1. ☐ Very well

2. ☐ Well

3. ☐ Not well

4. ☐ Not at all

A32. Does this child currently need or use medicine prescribed by a doctor, other than vitamins?

1. ☐ YES

2. ☐ NO [GO TO A33]

[IF YES] is this child’s need for prescription medicine because of any medical, behavioral, or other health condition?

1. ☐ YES

2. ☐ NO [GO TO A33]

[IF YES] is this a condition that has lasted or is expected to last 12 months or longer?

1. ☐ YES

2. ☐ NO

A33. Does this child need or use more medical care, mental health, or educational services than is usual for most children of the same age?

1. ☐ YES

2. ☐ NO [GO TO A34]

[IF YES] is this child’s need for medical care, mental health, or educational services because of any medical, behavioral, or other health condition?

1. ☐ YES

2. ☐ NO [GO TO A34]

[IF YES] is this a condition that has lasted or is expected to last 12 months or longer?

1. ☐ YES

2. ☐ NO

A34. Is this child limited or prevented in any way in his or her ability to do the things most children of the same age can do?

1. ☐ YES

2. ☐ NO [GO TO A35]

[IF YES] is this child’s limitation in abilities because of any medical, behavioral, or other health condition?

1. ☐ YES

2. ☐ NO [GO TO A35]

[IF YES] is this a condition that has lasted or is expected to last 12 months or longer?

1. ☐ YES

2. ☐ NO

A35. Does this child need or get special therapy, such as physical, occupational, or speech therapy?

1. ☐ YES

2. ☐ NO [GO TO A36]

[IF YES] is this because of any medical, behavioral, or other health condition?

1. ☐ YES

2. ☐ NO [GO TO A36]

[IF YES] is this a condition that has lasted or is expected to last 12 months or longer?

1. ☐ YES

2. ☐ NO

A36. Does this child have any kind of emotional, developmental, or behavioral problem for which he or she needs treatment or counseling?

1. ☐ YES

2. ☐ NO [GO TO A37]

[IF YES] has his or her emotional, developmental, or behavioral problem lasted or is it expected to last 12 months or longer?

1. ☐ YES

2. ☐ NO

IF RESPONDENT HAS ANOTHER CHILD, CONTINUE WITH A37. ELSE CONTINUE WITH
SECTION B.

A37. CHILD 4

What is this child’s first name, initials, or nickname?

A38. Is this child of Hispanic, Latino, or Spanish origin?

1. ☐ No, not of Hispanic, Latino, or Spanish origin

2. ☐ Yes, Mexican, Mexican American, Chicano

3. ☐ Yes, Puerto Rican

4. ☐ Yes, Cuban

5. ☐ Yes, another Hispanic, Latino, or Spanish origin, please specify:

A39. What is this child’s race? SELECT ONE OR MORE.

1. ☐ WHITE

2. ☐ BLACK OR AFRICAN AMERICAN

3. ☐ AMERICAN INDIAN OR ALASKA NATIVE, PLEASE SPECIFY:

4. ☐ ASIAN INDIAN

5. ☐ CHINESE

6. ☐ FILIPINO

7. ☐ JAPANESE

8. ☐ KOREAN

9. ☐ VIETNAMESE

10. ☐ OTHER ASIAN, PLEASE SPECIFY:

11. ☐ NATIVE HAWAIIAN

12. ☐ GUAMANIAN OR CHAMORRO

13. ☐ SAMOAN

14. ☐ OTHER PACIFIC ISLANDER, PLEASE SPECIFY:

A40. What is this child’s sex?

1. ☐ MALE

2. ☐ FEMALE

A41. How old is this child? If the child is less than one month old, round age in months to 1.

YEARS (OR) MONTHS

IF THIS CHILD IS YOUNGER THAN 4 YEARS OLD, GO TO A43

A42. PUERTO RICO: How well does this child speak Spanish?

ALL OTHER JURISDICTIONS: How well does this child speak English?

1. ☐ Very well

2. ☐ Well

3. ☐ Not well

4. ☐ Not at all

A43. Does this child currently need or use medicine prescribed by a doctor, other than vitamins?

1. ☐ YES

2. ☐ NO [GO TO A44]

[IF YES] is this child’s need for prescription medicine because of any medical, behavioral, or other health condition?

1. ☐ YES

2. ☐ NO [GO TO A44]

[IF YES] is this a condition that has lasted or is expected to last 12 months or longer?

1. ☐ YES

2. ☐ NO

A44. Does this child need or use more medical care, mental health, or educational services than is usual for most children of the same age?

1. ☐ YES

2. ☐ NO [GO TO A45]

[IF YES] is this child’s need for medical care, mental health, or educational services because of any medical, behavioral, or other health condition?

1. ☐ YES

2. ☐ NO [GO TO A45]

[IF YES] is this a condition that has lasted or is expected to last 12 months or longer?

1. ☐ YES

2. ☐ NO

A45. Is this child limited or prevented in any way in his or her ability to do the things most children of the same age can do?

1. ☐ YES

2. ☐ NO [GO TO A46]

[IF YES] is this child’s limitation in abilities because of any medical, behavioral, or other health condition?

1. ☐ YES

2. ☐ NO [GO TO A46]

[IF YES] is this a condition that has lasted or is expected to last 12 months or longer?

1. ☐ YES

2. ☐ NO

A46. Does this child need or get special therapy, such as physical, occupational, or speech therapy?

1. ☐ YES

2. ☐ NO [GO TO A47]

[IF YES] is this because of any medical, behavioral, or other health condition?

1. ☐ YES

2. ☐ NO [GO TO A47]

[IF YES] is this a condition that has lasted or is expected to last 12 months or longer?

1. ☐ YES

2. ☐ NO

A47. Does this child have any kind of emotional, developmental, or behavioral problem for which he or she needs treatment or counseling?

1. ☐ YES

2. ☐ NO [GO TO A48]

[IF YES] has his or her emotional, developmental, or behavioral problem lasted or is it expected to last 12 months or longer?

1. ☐ YES

2. ☐ NO

IF THERE ARE NO OTHER CHILDREN, CONTINUE TO SECTION B.

IF THERE ARE MORE THAN FOUR CHILDREN 0-17 YEARS OLD WHO USUALLY LIVE OR STAY AT THIS ADDRESS, LIST THE AGE AND SEX FOR EACH. DO NOT REPEAT INFORMATION FOR CHILDREN ALREADY INCLUDED FOR CHILD 1 THROUGH CHILD 4.

A48. CHILD 5

What is this child’s first name, initials, or nickname?

A49. How old is this child?

YEARS (OR) MONTHS

A50. What is this child’s sex?

1. ☐ MALE

2. ☐ FEMALE

A51. CHILD 6

What is this child’s first name, initials, or nickname?

A52. How old is this child?

YEARS (OR) MONTHS

A53. What is this child’s sex?

1. ☐ MALE

2. ☐ FEMALE

A54. CHILD 7

What is this child’s first name, initials, or nickname?

A55. How old is this child?

YEARS (OR) MONTHS

A56. What is this child’s sex?

1. ☐ MALE

2. ☐ FEMALE

A57. CHILD 8

What is this child’s first name, initials, or nickname?

A58. How old is this child?

YEARS (OR) MONTHS

A59. What is this child’s sex?

1. ☐ MALE

2. ☐ FEMALE

A60. CHILD 9

What is this child’s first name, initials, or nickname?

A61. How old is this child?

YEARS (OR) MONTHS

A62. What is this child’s sex?

1. ☐ MALE

2. ☐ FEMALE

A63. CHILD 10

What is this child’s first name, initials, or nickname?

A64. How old is this child?

YEARS (OR) MONTHS

A65. What is this child’s sex?

1. ☐ MALE

2. ☐ FEMALE

Section B.This Child’s Health (PROGRAMMER: Add Timestamp)

We now have some follow up questions to ask about [SPECIFY CHILD]. These questions will collect more detailed information on various aspects of this child’s health including his or her health status, visits to health care providers, health care costs, and health insurance coverage. We have selected only one child per household in an effort to minimize the amount of time necessary to complete the follow-up questions.

B1. In general, how would you describe this child’s health?

1. ☐ Excellent

2. ☐ Very Good

3. ☐ Good

4. ☐ Fair

5. ☐ Poor

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

B2. How would you describe the condition of this child’s teeth?

1. ☐ Excellent

2. ☐ Very Good

3. ☐ Good

4. ☐ Fair

5. ☐ Poor

6. ☐ CHILD DOES NOT HAVE TEETH

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

B3. During the past 12 months, has this child had frequent or chronic difficulty with any of the following?

	YES	NO	DON’T KNOW	PREFER NOT TO ANSWER
B3a. Breathing or other respiratory problems (such as wheezing or shortness of breath)	1 ☐	2 ☐	77 ☐	99 ☐
B3b. Eating or swallowing because of a health condition	1 ☐	2 ☐	77 ☐	99 ☐
B3c. Digesting food, including stomach/intestinal problems, constipation, or diarrhea	1 ☐	2 ☐	77 ☐	99 ☐
B3d. Repeated or chronic physical pain, including headaches or other back or body pain	1 ☐	2 ☐	77 ☐	99 ☐
B3e. Using his or her hands	1 ☐	2 ☐	77 ☐	99 ☐
B3f. Coordination or moving around	1 ☐	2 ☐	77 ☐	99 ☐
B3g. Toothaches	1 ☐	2 ☐	77 ☐	99 ☐
B3h. Bleeding gums	1 ☐	2 ☐	77 ☐	99 ☐
B3i. Decayed teeth or cavities	1 ☐	2 ☐	77 ☐	99 ☐
B3j. Ear infections	1 ☐	2 ☐	77 ☐	99 ☐

B4. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

Does this child have any of the following?

	YES	NO	DON’T KNOW	PREFER NOT TO ANSWER
B4a. Deafness or problems with hearing	1 ☐	2 ☐	77 ☐	99 ☐
B4b. Blindness or problems with seeing, even when wearing glasses	1 ☐	2 ☐	77 ☐	99 ☐

B5. Has a doctor or other health care provider ever told you that this child has any of the following? If yes, does this child currently have the condition?

	Ever?	Currently?	DON’T KNOW	PREFER NOT TO ANSWER
B5a. Asthma	1 ☐ YES 2 ☐ NO	1 ☐ YES 2 ☐ NO	77 ☐	99 ☐
B5b. Diabetes	1 ☐ YES 2 ☐ NO	1 ☐ YES 2 ☐ NO	77 ☐	99 ☐
B5c. Down Syndrome	1 ☐ YES 2 ☐ NO	1 ☐ YES 2 ☐ NO	77 ☐	99 ☐
B5d. Frequent or Severe Headaches, including Migraine	1 ☐ YES 2 ☐ NO	1 ☐ YES 2 ☐ NO	77 ☐	99 ☐
B5e. Brain Injury, Concussion or Head Injury	1 ☐ YES 2 ☐ NO	1 ☐ YES 2 ☐ NO	77 ☐	99 ☐
B5f. Anxiety	1 ☐ YES 2 ☐ NO	1 ☐ YES 2 ☐ NO	77 ☐	99 ☐
B5g. Depression	1 ☐ YES 2 ☐ NO	1 ☐ YES 2 ☐ NO	77 ☐	99 ☐
B5h. Autism, ASD, Autism Spectrum Disorder (ASD), Asperger’s Disorder, or Pervasive Developmental Disorder (PDD)	1 ☐ YES 2 ☐ NO	1 ☐ YES 2 ☐ NO	77 ☐	99 ☐
B5i. Attention Deficit Disorder (ADD) or Attention Deficit/Hyperactivity Disorder (ADHD)	1 ☐ YES 2 ☐ NO	1 ☐ YES 2 ☐ NO	77 ☐	99 ☐
B5j. Developmental Delay	1 ☐ YES 2 ☐ NO	1 ☐ YES 2 ☐ NO	77 ☐	99 ☐
B5k. Behavior or Conduct Problems	1 ☐ YES 2 ☐ NO	1 ☐ YES 2 ☐ NO	77 ☐	99 ☐
B5l. Intellectual Disability (also known as mental retardation)	1 ☐ YES 2 ☐ NO	1 ☐ YES 2 ☐ NO	77 ☐	99 ☐
B5m. Speech or Other Language Disorder	1 ☐ YES 2 ☐ NO	1 ☐ YES 2 ☐ NO	77 ☐	99 ☐
B5n. Learning Disability	1 ☐ YES 2 ☐ NO	1 ☐ YES 2 ☐ NO	77 ☐	99 ☐
B5o. Another Mental Health Condition	1 ☐ YES 2 ☐ NO	1 ☐ YES 2 ☐ NO	77 ☐	☐

B6. During the past 12 months, how often has this child’s health conditions or problems affected his or her ability to do things other children his or her age do?

1. ☐ THIS CHILD DOES NOT HAVE ANY HEALTH CONDITIONS [GO TO B8]

2. ☐ Never [GO TO B8]

3. ☐ Sometimes

4. ☐ Usually

5. ☐ Always

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

B7. To what extent do this child’s health conditions or problems affect his or her ability to do things?

1. ☐ Very little

2. ☐ Somewhat

3. ☐ A great deal

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

B8. [ONLY ASK THIS QUESTION IF CHILD IS 6-17 YEARS OLD]

Has a doctor or other health care provider ever told you that this child has Substance Abuse Disorder? Substance Abuse Disorder occurs when the frequent or continued use of alcohol and/or drugs have caused health problems, disability, and failure to meet major responsibilities at work, school, or home.

1. ☐ YES

2. ☐ NO [GO TO B9]

77. ☐ DON’T KNOW [GO TO B9]

99. ☐ PREFER NOT TO ANSWER [GO TO B9]

[IF YES] does this child currently have the condition?

1. ☐ YES

2. ☐ NO [GO TO B9]

77. ☐ DON’T KNOW [GO TO B9]

99. ☐ PREFER NOT TO ANSWER [GO TO B9]

[IF YES] is it:

1. ☐ Mild

2. ☐ Moderate

3. ☐ Severe

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

B9. [ONLY ASK THIS QUESTION IF CHILD IS 6-17 YEARS OLD]

Does this child have any of the following?

	YES	NO	DON’T KNOW	PREFER NOT TO ANSWER
B9a. Serious difficulty concentrating, remembering, or making decisions because of a physical, mental, or emotional condition	1 ☐	2 ☐	77 ☐	99 ☐
B9b. Serious difficulty walking or climbing stairs	1 ☐	2 ☐	77 ☐	99 ☐
B9c. Difficulty dressing or bathing	1 ☐	2 ☐	77 ☐	99 ☐
B9d. Difficulty doing errands alone, such as visiting a doctor’s office or shopping, because of a physical, mental, or emotional condition	1 ☐	2 ☐	77 ☐	99 ☐
B9e. Deafness or problems with hearing	1 ☐	2 ☐	77 ☐	99 ☐
B9f. Blindness or problems with seeing, even when wearing glasses	1 ☐	2 ☐	77 ☐	99 ☐

B 10. Has a doctor or other health care provider ever told you that this child had…

	YES	NO	DON’T KNOW	PREFER NOT TO ANSWER
B10a. Rheumatic heart disease	1 ☐	2 ☐	77 ☐	99 ☐
B10b. Rheumatic fever	1 ☐	2 ☐	77 ☐	99 ☐
B10c. Impetigo (or other skin infections)	1 ☐	2 ☐	77 ☐	99 ☐

[IF YES TO RHEUMATIC HEART DISEASE OR FEVER] Do they take any medication for this condition?

1. ☐ YES

2 ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

[IF YES] Do they take Oral medication (pills) or get a shot?

1. ☐ ORAL MEDICATION (PILLS) [GO TO B11]

2. ☐ SHOT [GO TO B11]

[IF NO] Why not? CHECK ALL THAT APPLY.

1. ☐ Cannot afford the cost.

2. ☐ No transportation.

3 ☐ No-one to take my child to hospital.

4 ☐ Not important

5 ☐ OTHER REASON, PLEASE SPECIFY

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

B11. Has a doctor or other health care provider ever told you that this child had blood problems such as leukemia, anemia or sickle cell disease? Please do not include Sickle Cell Trait.

[READ IF NECESSARY]: Children with anemia have problems with their blood that can cause them to be very tired.

1. ☐ YES

2. ☐ NO

77. ☐ DON'T KNOW

99. ☐ PREFER NOT TO ANSWER

Now I’m going to ask you a few questions about injury prevention for your child.

B12. Have you or any other adult in your child's life discussed avoidance of violence or prevention of injury with your child? For example, the dangers of playing on the road, climbing trees, and swimming in the ocean.

1. ☐ Yes, avoidance of violence

2. ☐ Yes, prevention of injury

3. ☐ Both

4. ☐ Neither

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

B13. Do you accompany your child during outdoor activities like swimming or playing?

1. ☐ YES

4. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

B14. [ONLY ASK THIS QUESTION IF CHILD IS 6-17 YEARS OLD]

When your child rides a bicycle, how often does he or she wear a helmet?

1. ☐ My child does not ride a bicycle

5. ☐ Never wears a helmet

6. ☐ Rarely wears a helmet

7. ☐ Sometimes wears a helmet

8. ☐ Most of the time wears a helmet

9. ☐ Always wears a helmet

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

B15. [ONLY ASK THIS QUESTION IF CHILD IS 0-11 YEARS OLD]

How often does your child ride in a child safety seat or booster seat?

1. ☐ Always

10. ☐ Nearly always

11. ☐ Sometimes

12. ☐ Seldom

13. ☐ Never [IF CHILD 0-5 YEARS OLD, GO TO B17; IF CHILD 6-11 YEARS OLD, GO TO C1]

14. ☐ MY CHILD DOES NOT RIDE IN CARS [IF CHILD 0-5 YEARS OLD, GO TO B17; IF CHILD 6-11 YEARS OLD, GO TO C1]

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

B16. [ONLY ASK THIS QUESTION IF CHILD IS 0-11 YEARS OLD]

Where is your child's safety seat located in your car?

1. ☐ Front passenger

15. ☐ Behind passenger

16. ☐ Behind driver

17. ☐ Middle of the back seat

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

B17. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

Are your child's immunizations up to date?

1. ☐ YES

1. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

Section C.This Child as an Infant (PROGRAMMER: Add Timestamp)

C1. Was this child born more than 3 weeks before his or her due date?

1. ☐ YES

19. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

C2. How much did he or she weigh when born? Answer in pounds and ounces or kilograms and grams. Provide your best estimate. [IF NEEDED, READ: YOUR BEST GUESS IS FINE. IT DOES NOT HAVE TO BE EXACT].

POUNDS AND OUNCES

KILOGRAMS AND GRAMS

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

C3. How old were you when this child was born?

YEARS

C4. [ONLY ASK THIS QUESTION IF CHILD IS 0-1 YEAR OLD]

In which position do you most often lay this baby down to sleep now?

1. ☐ On his or her side

20. ☐ On his or her back

21. ☐ On his or her stomach

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

C5. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD. ELSE GO TO SECTION D]

Was this child EVER breastfed or fed breast milk?

1. ☐ YES

22. ☐ NO [GO TO C6]

77. ☐ DON’T KNOW [GO TO C6]

99. ☐ PREFER NOT TO ANSWER [GO TO C6]

[IF YES] how old was this child when he or she completely stopped breastfeeding or being fed breast milk?

DAYS (OR)

WEEKS (OR)

MONTHS (OR)

YEARS

CHILD IS STILL BREASTFEEDING

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

C6. How old was this child when he or she was first fed anything other than breast milk or formula? Include juice, cow’s milk, sugar water, baby food or cereal, or anything else that your child might have been given, even water.

DAYS (OR) WEEKS (OR) MONTHS

AT BIRTH

CHECK THIS BOX IF CHILD HAS NEVER BEEN FED ANYTHING

OTHER THAN BREAST MILK OR FORMULA

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

Section D.Health Care Services (PROGRAMMER: Add Timestamp)

D1. During the past 12 months, did this child see a doctor, nurse, or other health care professional for sick-child care, well-child check-ups, physical exams, hospitalizations or any other kind of medical care?

1. ☐ YES

23. ☐ NO [GO TO D2]

77. ☐ DON’T KNOW [GO TO D2]

99. ☐ PREFER NOT TO ANSWER [GO TO D2]

[IF YES] During the past 12 months, how many times did this child visit a doctor, nurse, or other health care professional to receive a PREVENTIVE check-up? A preventive check-up is when this child was not sick or injured, such as an annual or sports physical, or well-child visit.

1. ☐ 0 VISITS

2. ☐ 1 VISIT

24. ☐ 2 OR MORE VISITS

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

D2. Are you concerned about this child’s weight?

1. ☐ Yes, it's too high

25. ☐ Yes, it's too low

26. ☐ No, I am not concerned

77. ☐ DON'T KNOW

99. ☐ PREFER NOT TO ANSWER

D3. What is this child’s current height (or length)? Please provide your best estimate. [IF NEEDED, READ: YOUR BEST GUESS IS FINE. IT DOES NOT HAVE TO BE EXACT].

FEET AND INCHES

METERS AND CENTIMETERS

77. ☐ DON'T KNOW

99. ☐ PREFER NOT TO ANSWER

D4. How much does this child currently weigh? Please provide your best estimate. [IF NEEDED, READ: YOUR BEST GUESS IS FINE. IT DOES NOT HAVE TO BE EXACT].

POUNDS AND OUNCES

KILOGRAMS AND GRAMS

77. ☐ DON'T KNOW

99. ☐ PREFER NOT TO ANSWER

D5. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

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

1. ☐ YES

27. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

D6. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

[IF THIS CHILD IS YOUNGER THAN 9 MONTHS, GO TO D7]

During the past 12 months, did a doctor or other health care provider have you or another caregiver fill out a questionnaire about specific concerns or observations you may have about this child’s development, communication, or social behaviors? Sometimes a child’s doctor or other health care provider will ask a parent to do this at home or during a child’s visit.

1. ☐ YES

28. ☐ NO [GO TO D7]

77. ☐ DON’T KNOW [GO TO D7]

99. ☐ PREFER NOT TO ANSWER [GO TO D7]

[IF THIS CHILD IS 9-23 MONTHS]

Did the questionnaire ask about your concerns or observations about: CHECK ALL THAT APPLY

1. ☐ How this child talks or makes speech sounds?

2. ☐ How this child interacts with you and others?

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

[IF THIS CHILD IS 2-5 YEARS]

Did the questionnaire ask about your concerns or observations about: CHECK ALL THAT APPLY.

1. ☐ Words and phrases this child uses and understands?

2 ☐ How this child behaves and gets along with you and others?

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

D7. Is there a place that this child usually goes when he or she is sick or you or another caregiver needs advice about his or her health?

1. ☐ YES

29. ☐ NO [GO TO D8]

77. ☐ DON’T KNOW [GO TO D8]

99. ☐ PREFER NOT TO ANSWER [GO TO D8]

[IF YES] where does this child usually go?

1. ☐ Private doctor's office

2. ☐ Hospital emergency room

30. ☐ Hospital outpatient department

31. ☐ Community health clinic, community clinic, or public health clinic

32. ☐ School (nurse's office, athletic trainer's office)

33. ☐ Village dispensary

34. ☐ Some other place, PLEASE SPECIFY

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

D8. Is there a place that this child usually goes when he or she needs routine preventive care, such as a physical examination or well-child check-up?

1. ☐ YES

35. ☐ NO [GO TO D9]

77. ☐ DON’T KNOW [GO TO D9]

99. ☐ PREFER NOT TO ANSWER [GO TO D9]

[IF YES] is this the same place this child goes when he or she is sick?

1. ☐ YES

2. ☐ NO

D9. During the past 12 months, did this child use any of the following types of health care or services? Check all that apply. Alternative health care can include acupuncture, chiropractic care, relaxation therapies, traditional herbal medicine, and others. Some therapies involve seeing a health care provider, while others can be done on your own.

1. ☐ Medical Care

36. ☐ Vision Care

37. ☐ Hearing Care

38. ☐ Dental or Oral Care

39. ☐ Mental Health Services

40. ☐ Alternative Health Care or Treatment

41. ☐ None of these [GO TO D10]

77. ☐ DON’T KNOW [GO TO D10]

99. ☐ PREFER NOT TO ANSWER [GO TO D10]

[IF VISION CARE] What kind of place or places did this child have his or her vision tested? Check all that apply.

1. ☐ Eye doctor or eye specialist (ophthalmologist, optometrist) office

2. ☐ Pediatrician or other private doctor’s office

42. ☐ Community health clinic, community clinic, or public health clinic

43. ☐ School

44. ☐ Another place, PLEASE SPECIFY

D10. During the past 12 months, was there any time when this child needed health care but it was not received or not available? By health care, we mean medical care as well as other kinds of care like dental care, vision care, and mental health services.

1. ☐ YES

45. ☐ NO [GO TO D12]

77. ☐ DON’T KNOW [GO TO D12]

99. ☐ PREFER NOT TO ANSWER [GO TO D12]

[IF YES] which types of care were not received or not available? Check all that apply.

1. ☐ Medical Care

2. ☐ Dental or Oral Care

46. ☐ Vision Care

47. ☐ Hearing Care

48. ☐ Mental Health Services

49. ☐ Another type, PLEASE SPECIFY

D11. Which of the following contributed to this child not receiving needed health services:

	YES	NO	DON’T KNOW	PREFER NOT TO ANSWER
D11a. This child was not eligible for the services?	1 ☐	2 ☐	77 ☐	99 ☐
D11b. The services this child needed were not available in your area?	1 ☐	2 ☐	77 ☐	99 ☐
D11c. There were problems getting an appointment when this child needed one?	1 ☐	2 ☐	77 ☐	99 ☐
D11d. There were problems with getting transportation or child care?	1 ☐	2 ☐	77 ☐	99 ☐
D11e. The (clinic/doctor’s) office wasn’t open when this child needed care?	1 ☐	2 ☐	77 ☐	99 ☐
D11f. There were issues related to cost?	1 ☐	2 ☐	☐	☐

D12. In the past 12 months, has this child been admitted to the hospital? Please include emergency room visits and overnight hospital stays.

1. ☐ Yes

2. ☐ No

77. ☐ DON’T KNOW

99. ☐ REFUSED

[IF YES] In the past 12 months, how many times has this child been admitted to the hospital for an injury? By ‘injury’, we mean physical harm or damage caused by an accident or an attack. Injuries could include, but are not limited to, broken bones, strains, cuts, burns, bites/stings, or harm from being hit by something.

TIMES

77. ☐ DON’T KNOW

Section E.Experience with This Child’s Health Care Providers (PROGRAMMER: Add Timestamp)

E1. Do you have one or more persons you think of as this child’s personal doctor or nurse? A personal doctor or nurse is a health professional who knows this child well and is familiar with this child’s health history. This can be a general doctor, a pediatrician, a specialist doctor, a nurse practitioner, or a physician’s assistant.

1. ☐ YES, ONE PERSON

50. ☐ YES, MORE THAN ONE PERSON

51. ☐ NO

E2. During the past 12 months, did this child need a referral to see any doctors or receive any services?

1. ☐ YES

52. ☐ NO [GO TO E3]

77. ☐ DON’T KNOW [GO TO E3]

99. ☐ PREFER NOT TO ANSWER [GO TO E3]

[IF YES] how much of a problem was it to get referrals?

1. ☐ Not a problem

2. ☐ Small problem

53. ☐ Big problem

E3. [ANSWER THE FOLLOWING QUESTIONS ONLY IF THIS CHILD HAD A HEALTH CARE VISIT IN THE PAST 12 MONTHS. OTHERWISE, GO TO E4.]

During the past 12 months, how often did this child’s doctors or other health care providers:

	Always	Usually	Sometimes	Never	DON’T KNOW	PREFER NOT TO ANSWER
E3a. Spend enough time with this child?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
E3b. Listen carefully to you?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
E3c. Show sensitivity to your family’s values and customs?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
E3d. Provide the specific information you needed concerning this child?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	99 ☐
E3e. Help you feel like a partner in this child’s care?	1 ☐	2 ☐	3 ☐	4 ☐	77 ☐	☐

E4. Does anyone help you arrange or coordinate this child’s care among the different doctors or services that this child uses?

1. ☐ YES

54. ☐ NO

55. ☐ DID NOT SEE MORE THAN ONE HEALTH CARE PROVIDER IN PAST 12 MONTHS
    [GO TO E7]

E5. During the past 12 months, have you felt that you could have used extra help arranging or coordinating this child’s care among the different health care providers or services?

1. ☐ YES

56. ☐ NO [GO TO E6]

[IF YES] During the past 12 months, how often did you get as much help as you wanted with arranging or coordinating this child’s health care?

1. ☐ Usually

2. ☐ Sometimes

57. ☐ Never

E6. Overall, how satisfied are you with the communication among this child’s doctors and other health care providers?

1. ☐ Very satisfied

58. ☐ Somewhat satisfied

59. ☐ Somewhat dissatisfied

60. ☐ Very dissatisfied

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

E7. [ONLY ASK THIS QUESTION IF CHILD IS 12-17 YEARS OLD]

Do any of this child’s doctors or other health care providers treat only children?

1. ☐ YES

61. ☐ NO [GO TO E8]

77. ☐ DON’T KNOW [GO TO E8]

99. ☐ PREFER NOT TO ANSWER [GO TO E8]

[IF YES] have they talked with you about having this child eventually see doctors or other health care providers who treat adults?

1. ☐ YES

2. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

E8. [ONLY ASK THIS QUESTION IF CHILD IS 12-17 YEARS OLD]

Has this child’s doctor or other health care provider actively worked with this child to:

	YES	NO	DON’T KNOW	PREFER NOT TO ANSWER
E8a. Think about and plan for his or her future. For example, by taking time to discuss future plans about education, work, relationships, and development of independent living skills?	1 ☐	2 ☐	77 ☐	99 ☐
E8b. Make positive choices about his or her health. For example, by eating healthy, getting regular exercise, not using tobacco, alcohol or other drugs, or delaying sexual activity?	1 ☐	2 ☐	77 ☐	99 ☐
E8c. Gain skills to manage his or her health and health care. For example, by understanding current health needs, knowing what to do in a medical emergency, or taking medications he or she may need?	1 ☐	2 ☐	77 ☐	99 ☐
E8d. Understand the changes in health care that happen at age 18. For example, by understanding changes in privacy, consent, access to information, or decision-making?	1 ☐	2 ☐	77 ☐	99 ☐

E9. [ONLY ASK THIS QUESTION IF CHILD IS 12-17 YEARS OLD]

Have this child’s doctors or other health care providers worked with you and this child to create a written plan to meet his or her health goals and needs?

1. ☐ YES

62. ☐ NO [GO TO E10]

77. ☐ DON’T KNOW [GO TO E10]

99. ☐ PREFER NOT TO ANSWER [GO TO E10]

[IF YES] does this plan identify specific health goals for this child and any health needs or problems this child may have and how to get these needs met?

1. ☐ YES

2. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

Did you and this child receive a written copy of this plan of care?

1. ☐ YES

2. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

Is this plan currently up-to-date for this child?

1. ☐ YES

2. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

E10. Eligibility for health insurance often changes in young adulthood. Do you know how this child will be insured as he or she becomes an adult?

1. ☐ YES [GO TO F]

63. ☐ NO

[IF NO] has anyone discussed with you how to obtain or keep some type of health insurance coverage as this child becomes an adult?

1. ☐ YES

2. ☐ NO

Section F.This Child’s Health Insurance Coverage (PROGRAMMER: Add Timestamp)

F1. During the past 12 months, was this child ever covered by any kind of health insurance or health coverage plan? This includes medical savings accounts, supplemental health, and government funded or subsidized insurance programs.

1. ☐ Yes, this child was covered all 12 months or, if under 1 year old, since birth [GO TO F4]

64. ☐ Yes, but this child had a gap in coverage

65. ☐ No

F2. Please indicate whether each of the following is a reason this child was not covered by health insurance during the past 12 months:

	YES	NO
F2a. Change in employer or employment status	1 ☐	2 ☐
F2b. Cancellation from inability to pay insurance fee	1 ☐	2 ☐
F2c. Dropped coverage because it was unaffordable	1 ☐	2 ☐
F2d. Dropped coverage because benefits were inadequate	1 ☐	2 ☐
F2e. Dropped coverage because choice of health care providers was inadequate	1 ☐	2 ☐
F2f. Problems with application or renewal process	1 ☐	2 ☐
F2g. Another reason, please specify	1 ☐	☐

F3. Is this child currently covered by any kind of health insurance or health coverage plan?

1. ☐ YES

66. ☐ NO [GO TO SECTION G]

77. ☐ DON’T KNOW [GO TO SECTION G]

99. ☐ PREFER NOT TO ANSWER [GO TO SECTION G]

F4. Is this child covered by any of the following types of health insurance or health coverage plans? [Interviewer Note: Only read jurisdiction-specific insurance types for your jurisdiction].

	YES	NO
F4a. Private health insurance	1 ☐	2 ☐
F4b. Insurance through your (or your spouse’s) current or former employer or union	1 ☐	2 ☐
F4c. Medicaid, Medical Assistance, or any kind of government assistance plan (includes Guam Medical Indigent Program, Palau National Health Insurance Program, and Puerto Rico Government Health Plan)	1 ☐	2 ☐
F4d. Other government funded or subsidized insurance (includes Micronesia MiCare or Chuuk State, Marshall Islands Public Insurance, and Marshall Islands Supplemental Health Fund)	1 ☐	2 ☐
F4e. Medical savings account	1 ☐	2 ☐
F4f. CHIP (Children’s Health Insurance Program)	1 ☐	2 ☐
F4g. TRICARE or other military health care	1 ☐	2 ☐
F4h. Indian Health Service	1 ☐	2 ☐
F4i. Another type, please specify	1 ☐	☐

F5. How often does this child’s health insurance offer benefits or cover services that meet this child’s needs? Examples include dental or vision services, prescription medications, emergency room visits, maternity services, mental health services, and yearly check-ups or screenings.

1. ☐ Always

67. ☐ Usually

68. ☐ Sometimes

69. ☐ Never

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

F6. How often does this child’s health insurance allow him or her to see the health care providers he or she needs?

1. ☐ Always

1. ☐ Usually

2. ☐ Sometimes

3. ☐ Never

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

Section G.Providing for This Child’s Health (PROGRAMMER: Add Timestamp)

G1. Including co-pays and amounts from medical savings accounts, how much money did you pay for this child’s medical, health, dental, and vision care during the past 12 months? Do not include health insurance premiums or costs that were or will be reimbursed by insurance or another source.

1. ☐ $0 (NO MEDICAL OR HEALTH-RELATED EXPENSES) [GO TO G4]

73. ☐ $1-$249

74. ☐ $250-$499

75. ☐ $500-$999

76. ☐ $1,000-$5,000

77. ☐ MORE THAN $5,000

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

G2. How often are these costs reasonable?

1. ☐ Always

78. ☐ Usually

79. ☐ Sometimes

80. ☐ Never

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

G3. During the past 12 months, did your family have problems paying for any of this child’s medical or health care bills?

1. ☐ YES

81. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

G4. During the past 12 months, have you or other family members:

	YES	NO	DON’T KNOW	PREFER NOT TO ANSWER
G4a. Stopped working because of this child’s health or health conditions?	1 ☐	2 ☐	77 ☐	99 ☐
G4b. Cut down on the hours you work because of this child’s health or health conditions?	1 ☐	2 ☐	77 ☐	99 ☐
G4c. Avoided changing jobs because of concerns about maintaining health insurance for this child?	1 ☐	2 ☐	77 ☐	99 ☐
G4d. Received help from extended family members?	1 ☐	2 ☐	77 ☐	99 ☐

G5. In an average week, how many hours do you or other family members spend providing health care at home for this child? Care might include changing bandages, or giving medication and therapies when needed.

1. ☐ This child does not need health care provided on a weekly basis

82. ☐ No at home care was provided by me or other family members

83. ☐ Less than 1 hour per week

84. ☐ 1-4 hours per week

85. ☐ 5-10 hours per week

86. ☐ 11 or more hours per week

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

G6. In an average week, how many hours do you or other family members spend arranging or coordinating health or medical care for this child, such as making appointments or locating services?

1. ☐ This child does not need health care provided on a weekly basis

1. ☐ No at home care was provided by me or other family members

2. ☐ Less than 1 hour per week

3. ☐ 1-4 hours per week

4. ☐ 5-10 hours per week

5. ☐ 11 or more hours per week

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

Section H.This Child’s Learning (PROGRAMMER: Add Timestamp)

H1. On an average weekday, about how much time does this child usually spend in front of a TV watching TV programs, videos, or playing video games?

1. ☐ None

92. ☐ Less than 1 hour

93. ☐ 1 hour

94. ☐ 2 hours

95. ☐ 3 hours

96. ☐ 4 or more hours

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

H2. On an average weekday, about how much time does this child usually spend with computers, cell phones, handheld video games, and other electronic devices, doing things other than schoolwork?

1. ☐ None

97. ☐ Less than 1 hour

98. ☐ 1 hour

99. ☐ 2 hours

100. ☐ 3 hours

101. ☐ 4 or more hours

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

H3. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

How well is this child learning to do things for him or herself?

1. ☐ Very well

102. ☐ Somewhat

103. ☐ Poorly

104. ☐ Not at all

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

H4. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

How confident are you that this child will be successful in elementary or primary school?

1. ☐ Very confident

105. ☐ Mostly confident

106. ☐ Somewhat confident

107. ☐ Not confident at all

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

H5. [ONLY ASK THIS QUESTION IF CHILD IS 6-17 YEARS OLD]

During the past 12 months, about how many days did this child miss school because of illness or injury?

1. ☐ NO MISSED SCHOOL DAYS

108. ☐ 1-3 DAYS

109. ☐ 4-6 DAYS

110. ☐ 7-10 DAYS

111. ☐ 11 OR MORE DAYS

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

H6. [ONLY ASK THIS QUESTION IF CHILD IS 6-17 YEARS OLD]

During the past 12 months, how many times has this child’s school contacted you or another adult in your household about any problems he or she is having with school?

1. ☐ NO TIMES

112. ☐ 1 TIME

113. ☐ 2 OR MORE TIMES

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

H7. [ONLY ASK THIS QUESTION IF CHILD IS 12-17 YEARS OLD]

The next 2 questions ask about bullying. Bullying is when 1 or more students tease, threaten, spread rumors about, hit, shove, or hurt another student over and over again. It is not bullying when two students of about the same strength or power argue or fight or tease each other in a friendly way.

Has your child ever been bullied on school property?

1. ☐ YES

2. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

H8. [ONLY ASK THIS QUESTION IF CHILD IS 12-17 YEARS OLD]

Has your child ever been electronically bullied? (Count being bullied through texting, Instagram, Facebook, or other social media.)

1. ☐ YES

2. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

H9. [ONLY ASK THIS QUESTION IF CHILD IS 6-17 YEARS OLD]

Since starting kindergarten, has this child repeated any grades?

1. ☐ YES

114. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

H10. [ONLY ASK THIS QUESTION IF CHILD IS 6-17 YEARS OLD]

During the past week, on how many days did this child exercise, play a sport, or participate in physical activity for at least 60 minutes?

1. ☐ 0 DAYS

1. ☐ 1-3 DAYS

2. ☐ 4-6 DAYS

3. ☐ EVERY DAY

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

Section I.About You and This Child (PROGRAMMER: Add Timestamp)

I1. How many times has this child moved to a new address or location since he or she was born?

NUMBER OF TIMES

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

I2. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

During the past week, how many days did you or other family members read to this child?

1. ☐ 0 DAYS

118. ☐ 1-3 DAYS

119. ☐ 4-6 DAYS

120. ☐ EVERY DAY

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

I3. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

During the past week, how many days did you or other family members tell stories or sing songs to this child?

1. ☐ 0 DAYS

121. ☐ 1-3 DAYS

122. ☐ 4-6 DAYS

123. ☐ EVERY DAY

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

I4. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

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

1. ☐ YES

1. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

Section J.About Your Family and Household (PROGRAMMER: Add Timestamp)

J1. Does anyone living in your household use cigarettes, e-cigarettes or vapors, cigars, pipe tobacco, chewing tobacco, or chew betel nut? [READ IF NECESSARY: Please answer to the best of your ability. Betel nut is the seed of the fruit of the areca palm. It is also known as areca nut. Betel nut chewing is an important cultural practice in some regions in south and south-east Asia and the Asia Pacific. It is often chewed wrapped inside betel leaves (paan) or with tobacco (betel quid)].

1. ☐ YES

125. ☐ NO [GO TO J3]

77. ☐ DON’T KNOW [GO TO J3]

99. ☐ PREFER NOT TO ANSWER [GO TO J3]

J2. Does anyone smoke inside your home?

1. ☐ YES

126. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

IF PUERTO RICO, GO TO J5

J3. Has your child ever chewed betel nut? [READ IF NECESSARY: Betel nut is the seed of the fruit of the areca palm. It is also known as areca nut. Betel nut chewing is an important cultural practice in some regions in south and south-east Asia and the Asia Pacific. It is often chewed wrapped inside betel leaves (paan) or with tobacco (betel quid)].

1. ☐ YES

127. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

J4. Are you aware of the effects of chewing betel nut?

1. ☐ YES

128. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

The next three questions are about money.

J5. Since this child was born, how often has it been very hard to get by on your family’s income – hard to cover the basics like food or housing?

1. ☐ Never

129. ☐ Rarely

130. ☐ Somewhat often

131. ☐ Very often

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

J6. The next question is about whether you were able to afford the food you need. Which of these statements best describes the food situation in your household IN THE PAST 12 MONTHS?

1. ☐ We could always afford to eat good nutritious meals.

132. ☐ We could always afford enough to eat but not always the kinds of food we should eat.

133. ☐ Sometimes we could not afford enough to eat.

134. ☐ Often we could not afford enough to eat.

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

J7. At any time during the past 12 months, even for one month, did anyone in your family receive:

	YES	NO	DON’T KNOW	PREFER NOT TO ANSWER
J7a. Cash assistance from a government welfare program?	1 ☐	2 ☐	77 ☐	99 ☐
J7b. [Programming note: Do not show for Puerto Rico] Food Stamps or Supplemental Nutrition Assistance Program benefits (SNAP)? [Programming note: For Puerto Rico Show the Following] Nutrition Assistance Program (NAP) (known as PAN)	1 ☐	2 ☐	77 ☐	99 ☐
J7c. Free or reduced-cost breakfasts or lunches at school?	1 ☐	2 ☐	77 ☐	99 ☐
J7d. [Programming note: Do not show for RMI, Palau, FSM, Puerto Rico] Benefits from the Woman, Infants, and Children (WIC) Program?	1 ☐	2 ☐	77 ☐	99 ☐

Section K.About You (PROGRAMMER: Add Timestamp)

COMPLETE THE QUESTIONS FOR EACH OF THE TWO ADULTS IN THE HOUSEHOLD WHO ARE THIS CHILD’S PRIMARY CAREGIVERS. IF THERE IS JUST ONE ADULT, PROVIDE ANSWERS FOR THAT ADULT.

K1. ADULT 1

How are you related to this child?

1. ☐ BIOLOGICAL PARENT

135. ☐ ADOPTIVE PARENT

136. ☐ STEP-PARENT

137. ☐ GRANDPARENT

138. ☐ FOSTER PARENT

139. ☐ AUNT OR UNCLE

140. ☐ OTHER: RELATIVE

141. ☐ OTHER: NON-RELATIVE

K2. What is your sex?

1. ☐ MALE

142. ☐ FEMALE

K3. What is your age?

AGE IN YEARS

K4. What is the highest grade or year of school you have completed? MARK ONE ONLY.

1. ☐ 8TH GRADE OR LESS

143. ☐ 9TH-12TH GRADE; NO DIPLOMA

144. ☐ HIGH SCHOOL GRADUATE OR GED COMPLETED

145. ☐ COMPLETED A VOCATIONAL, TRADE, OR BUSINESS SCHOOL PROGRAM

146. ☐ SOME COLLEGE CREDIT, BUT NO DEGREE

147. ☐ ASSOCIATE DEGREE (AA, AS)

148. ☐ BACHELOR’S DEGREE (BA, BS, AB)

149. ☐ MASTER’S DEGREE (MA, MS, MSW, MBA)

150. ☐ DOCTORATE (PHD, EDD) OR PROFESSIONAL DEGREE (MD, DDS, DVM, JD)

K5. What is your marital status?

1. ☐ MARRIED [GO TO K7]

151. ☐ NEVER MARRIED

152. ☐ DIVORCED

153. ☐ SEPARATED

154. ☐ WIDOWED

99. ☐ PREFER NOT TO ANSWER [GO TO K7]

K6. Do you currently live with a romantic partner?

1. ☐ YES

155. ☐ NO

99. ☐ PREFER NOT TO ANSWER

K7. In general, how is your physical health?

1. ☐ Excellent

156. ☐ Very Good

157. ☐ Good

158. ☐ Fair

159. ☐ Poor

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

K8. In general, how is your mental or emotional health?

1. ☐ Excellent

160. ☐ Very Good

161. ☐ Good

162. ☐ Fair

163. ☐ Poor

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

K9. Were you employed at least 50 out of the past 52 weeks?

1. ☐ YES

164. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

K10. Is there another adult in this household who is this child’s caregiver or guardian?

1. ☐ YES

165. ☐ NO [GO TO SECTION L]

99. ☐ PREFER NOT TO ANSWER [GO TO SECTION L]

This other caregiver or guardian will now be referred to as Adult 2.

K11. How is Adult 2 related to this child?

1. ☐ BIOLOGICAL PARENT

166. ☐ ADOPTIVE PARENT

167. ☐ STEP-PARENT

168. ☐ GRANDPARENT

169. ☐ FOSTER PARENT

170. ☐ AUNT OR UNCLE

171. ☐ OTHER: RELATIVE

172. ☐ OTHER: NON-RELATIVE

K12. What is Adult 2’s sex?

1. ☐ MALE

173. ☐ FEMALE

K13. What is Adult 2’s age?

AGE IN YEARS

K14. What is the highest grade or year of school Adult 2 has completed? MARK ONE ONLY.

1. ☐ 8TH GRADE OR LESS

174. ☐ 9TH-12TH GRADE; NO DIPLOMA

175. ☐ HIGH SCHOOL GRADUATE OR GED COMPLETED

176. ☐ COMPLETED A VOCATIONAL, TRADE, OR BUSINESS SCHOOL PROGRAM

177. ☐ SOME COLLEGE CREDIT, BUT NO DEGREE

178. ☐ ASSOCIATE DEGREE (AA, AS)

179. ☐ BACHELOR’S DEGREE (BA, BS, AB)

180. ☐ MASTER’S DEGREE (MA, MS, MSW, MBA)

181. ☐ DOCTORATE (PHD, EDD) OR PROFESSIONAL DEGREE (MD, DDS, DVM, JD)

K15. What is Adult 2’s marital status?

1. ☐ MARRIED [GO TO K17]

182. ☐ NEVER MARRIED

183. ☐ DIVORCED

184. ☐ SEPARATED

185. ☐ WIDOWED

99. ☐ PREFER NOT TO ANSWER [GO TO K17]

K16. Does Adult 2 currently live with a romantic partner?

1. ☐ YES

186. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

K17. In general, how is Adult 2’s physical health?

1. ☐ Excellent

187. ☐ Very Good

188. ☐ Good

189. ☐ Fair

190. ☐ Poor

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

K18. In general, how is Adult 2’s mental or emotional health?

1. ☐ Excellent

191. ☐ Very Good

192. ☐ Good

193. ☐ Fair

194. ☐ Poor

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

K19. Was Adult 2 employed at least 50 out of the past 52 weeks?

1. ☐ YES

1. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

Section L.Health of Child’s Mother (PROGRAMMER: Add Timestamp)

L1. A routine checkup is a general physical exam, not an exam for a specific injury, illness,
or condition. About how long has it been since you last visited a doctor for a routine checkup?

1. ☐ Within the past year (ANYTIME LESS THAN 12 MONTHS AGO)

196. ☐ Within the past 2 years (1 YEAR BUT LESS THAN 2 YEARS AGO)

197. ☐ Within the past 5 years (2 YEARS BUT LESS THAN 5 YEARS AGO)

198. ☐ 5 or more years ago

199. ☐ Never

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

L2. During the past 12 months, have you received any treatment or counseling from a mental health professional? Mental health professionals include psychiatrists, psychologists, psychiatric nurses, and clinical social workers.

1. ☐ Yes

200. ☐ No, but I needed to see a mental health professional

201. ☐ No, I did not need to see a mental health professional [GO TO L4]

77. ☐ DON’T KNOW [GO TO L4]

99. ☐ PREFER NOT TO ANSWER [GO TO L4]

L3. How much of a problem was it to get the mental health treatment or counseling that
you needed?

1. ☐ Not a problem

202. ☐ Small problem

203. ☐ Big problem

L4. During your most recent pregnancy, did you have your teeth cleaned by a dentist or dental hygienist?

1. ☐ YES

204. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

L5. Who makes the healthcare decisions for your health?

1. ☐ You

205. ☐ Your spouse

206. ☐ You and your spouse/partner together

207. ☐ Your parents

208. ☐ Someone else, PLEASE SPECIFY

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

L6. Who makes the healthcare decisions for your child(ren)?

1. ☐ You

209. ☐ Your spouse

210. ☐ You and your spouse/partner together

211. ☐ Your parents

212. ☐ ANOTHER PERSON, PLEASE SPECIFY

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

The next questions ask about smoking, drinking, and drug use. Please remember that all information you share is confidential. Only members of the research team will have access to this information. Please answer to the best of your ability.

L7. During the past 30 days, on how many days did you smoke cigarettes?

1. ☐ 0 DAYS

213. ☐ 1 OR 2 DAYS

214. ☐ 3 TO 5 DAYS

215. ☐ 6 TO 9 DAYS

216. ☐ 10 TO 19 DAYS

217. ☐ 20 TO 29 DAYS

218. ☐ ALL 30 DAYS

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

L8. Do you drink alcohol, including drinks you brew or make at home?

1. ☐ YES

219. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

L9. During your life, have you ever used any of the following: [READ IF NECESSARY: Betel nut is the seed of the fruit of the areca palm. It is also known as areca nut. Betel nut chewing is an important cultural practice in some regions in south and south-east Asia and the Asia Pacific. It is often chewed wrapped inside betel leaves (paan) or with tobacco (betel quid). Funta, or fronto, is a dark tobacco leaf that can be used for smoking].

	YES	NO	DON’T KNOW	PREFER NOT TO ANSWER
L9a. Betel nut	1 ☐	2 ☐	77 ☐	99 ☐
L9b. Vape or e-cigarette	1 ☐	2 ☐	77 ☐	99 ☐
L9c. Funta	1 ☐	2 ☐	77 ☐	99 ☐
L9d. Marijuana (also called grass, pot, weed, or reefer)	1 ☐	2 ☐	77 ☐	99 ☐
L9e. Cocaine, including powder, crack, or freebase	1 ☐	2 ☐	77 ☐	99 ☐
L9f. Heroin (also called smack, junk, or China White)	1 ☐	2 ☐	77 ☐	99 ☐
L9g. Methamphetamines (also called speed, crystal, crank, or ice)	1 ☐	2 ☐	77 ☐	99 ☐
L9h. Ecstasy (also called MDMA)	1 ☐	2 ☐	77 ☐	99 ☐
L9i. Synthetic marijuana (also called K2, Spice, fake weed, King Kong, Yucatan Fire, Skunk, or Moon Rocks)	1 ☐	2 ☐	77 ☐	99 ☐
L9j. Steroid pills or shots without a doctor's prescription	1 ☐	2 ☐	77 ☐	99 ☐
L9k. Prescription pain medicine without a doctor's prescription or differently than how a doctor told you to use it? (Count drugs such as codeine, Vicodin, OxyContin, Hydrocodone, and Percocet)	1 ☐	2 ☐	77 ☐	99 ☐

IF RESPONDENT CHEWED BETEL NUT, CONTINUE TO L10. ELSE IF RESPONDENT USED ANY OTHER SUBSTANCE IN L9 GO TO L11. ELSE IF NO SUBSTANCES USED, GO TO L12.

L10. During the past 30 days, on how many days did you chew betel nut?

1. ☐ 0 DAYS

220. ☐ 1 OR 2 DAYS

221. ☐ 3 TO 5 DAYS

222. ☐ 6 TO 9 DAYS

223. ☐ 10 TO 19 DAYS

224. ☐ 20 TO 29 DAYS

225. ☐ ALL 30 DAYS

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

L11. Have you been referred to, or did you receive, any form of intervention/counseling/treatment for substance use issues?

1. ☐ YES

226. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

L12. Has your doctor or health care professional told you that you had type 1 or type 2 diabetes?

1. ☐ TYPE 1 DIABETES

227. ☐ TYPE 2 DIABETES

228. ☐ NEITHER [GO TO L14]

77. ☐ DON’T KNOW [GO TO L14]

99. ☐ PREFER NOT TO ANSWER [GO TO L14]

L13. Are you taking medication for this?

1. ☐ Insulin

229. ☐ Pills

230. ☐ Insulin and Pills

231. ☐ I do not take medication

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

L14. Has a doctor or other health care provider EVER told you that you have any of the following conditions…?

	YES	NO	DON’T KNOW	PREFER NOT TO ANSWER
L14a. Rheumatic heart disease	1 ☐	2 ☐	77 ☐	99 ☐
L14b. Rheumatic fever	1 ☐	2 ☐	77 ☐	99 ☐
L14c. Cervical cancer	1 ☐	2 ☐	77 ☐	99 ☐
L14d. Anemia	1 ☐	2 ☐	77 ☐	99 ☐

L15. How do you describe your weight?

1. ☐ Very underweight

232. ☐ Slightly underweight

233. ☐ About the right weight

234. ☐ Slightly overweight

235. ☐ Very overweight

L16. Which of the following are you trying to do about your weight?

1. ☐ Lose weight

236. ☐ Gain weight

237. ☐ Stay the same weight

238. ☐ I AM NOT TRYING TO DO ANYTHING ABOUT MY WEIGHT

L17. During the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day? Add up all the time you spent in any kind of physical activity that increased your heart rate and made you breathe hard some of the time.

1. ☐ 0 DAYS

239. ☐ 1 DAY

240. ☐ 2 DAYS

241. ☐ 3 DAYS

242. ☐ 4 DAYS

243. ☐ 5 DAYS

244. ☐ 6 DAYS

245. ☐ 7 DAYS

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

L18. Are you currently pregnant?

1. ☐ Yes

246. ☐ No

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

IF RESPONDENT IS PREGNANT AND/OR HAS INFANT 12-MONTHS OR YOUNGER,
GO TO L19; ELSE, GO TO M1.

These next questions are about Zika virus. Zika virus infection is an illness that is most often spread by the bite of a mosquito but may also be spread by having sex with a man who has the Zika virus.

L19. During your most recent pregnancy, how worried were you about getting infected with Zika virus? Check ONE answer.

1. ☐ Very worried

247. ☐ Somewhat worried

248. ☐ Not at all worried

249. ☐ I HAD NEVER HEARD OF ZIKA VIRUS DURING MY MOST RECENT PREGNANCY
     [GO TO M1]

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

L20. At any time during your most recent pregnancy, did you talk with a doctor, nurse, or other healthcare worker about Zika virus?

1. ☐ No

250. ☐ Yes, a healthcare worker talked with me without my asking about it

251. ☐ Yes, a healthcare worker talked with me, but only after I asked about it

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

L21. During your most recent pregnancy, did you get a blood test for Zika virus?

1. ☐ YES

252. ☐ NO [GO TO L23]

77. ☐ DON’T KNOW [GO TO L23]

99. ☐ PREFER NOT TO ANSWER [GO TO L23]

L22. Were you diagnosed with Zika during your most recent pregnancy?

1. ☐ YES

253. ☐ NO [GO TO M1]

77. ☐ DON’T KNOW [GO TO M1]

99. ☐ PREFER NOT TO ANSWER [GO TO M1]

[IF YES] which child were you carrying?

IF PUERTO RICO, GO TO SECTION M

The next questions are about travel during your most recent pregnancy.

L23. During your most recent pregnancy, did you travel to areas with the Zika virus?

1. ☐ YES

254. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

[IF YES] During your most recent pregnancy, were you aware of recommendations that pregnant women should avoid travel to areas with Zika virus?

1. ☐ YES

2. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

[IF NO] During your most recent pregnancy, did you avoid travel to areas with the Zika virus because of recommendations that pregnant women should avoid travel to those areas?

1. ☐ YES

2. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

Section M.Household Information (PROGRAMMER: Add Timestamp)

M1. How many people are living or staying at this address? Include everyone who usually lives or stays at this address. Do not include anyone who is living somewhere else for more than two months, such as a college student living away or someone in the Armed Forces on deployment.

NUMBER OF PEOPLE

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

M2. How many of these people in your household are family members? Family is defined as anyone related to this child by blood, marriage, adoption, or through foster care.

NUMBER OF PEOPLE

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

M3. The following information is for data analysis purposes only so that MCH can better assess services received and potential health care needs among different income groups. Only members of the research team will have access to this information. Your best guess is fine. It does not have to be exact. Think about your total combined family income for the year for all members of the family. What is that amount before taxes? Include money from jobs, child support, social security, retirement income, unemployment payments, public assistance, and so forth. Also, include income from interest, dividends, net income from business, farm, or rent, and any other money income received.

, , TOTAL AMOUNT ($)

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

M4. How about if I give you some categories? Would you say your household’s income was…

1. ☐ Less than $10,000

2. ☐ $10,000 to less than $15,000

3. ☐ $15,000 to less than $20,000

4. ☐ $20,000 to less than $25,000

5. ☐ $25,000 to less than $35,000

6. ☐ $35,000 to less than $50,000

7. ☐ $50,000 to less than $75,000

8. ☐ $75,000 or more

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

Section N.Marshall Islands Jurisdiction Specific Module (PROGRAMMER: Add Timestamp)

[ONLY ASK THIS QUESTION IF CHILD IS 0-1 YEAR OLD AND IF BIOLOGICAL MOTHER]

I am going to ask a few questions about your health.

1. During your most recent pregnancy, how many times did you visit a doctor, nurse, or other health care professional to receive a prenatal check-up?

1. ☐ 0 VISITS

255. ☐ 1 VISIT [GO TO MI2]

256. ☐ 2 VISITS [GO TO MI2]

257. ☐ 3 VISITS [GO TO MI2]

258. ☐ 4 OR MORE VISITS [GO TO MI2]

77. ☐ DON’T KNOW [GO TO MI2]

99. ☐ PREFER NOT TO ANSWER [GO TO MI2]

[IF 0 VISITS] Did any of these things keep you from having a prenatal checkup?

	YES	NO	DON’T KNOW	PREFER NOT TO ANSWER
MI1a. I couldn’t get an appointment when I wanted one	1 ☐	2 ☐	77 ☐	99 ☐
MI1b. I didn’t have any transportation to get to the clinic or doctor’s office	1 ☐	2 ☐	77 ☐	99 ☐
MI1c. The doctor or my health plan would not start as early as I wanted	1 ☐	2 ☐	77 ☐	99 ☐
MI1d. I had too many things going on	1 ☐	2 ☐	77 ☐	99 ☐
MI1e. I couldn’t take time off from work or school	1 ☐	2 ☐	77 ☐	99 ☐
MI1f. I didn’t have anyone to take care of my children	1 ☐	2 ☐	77 ☐	99 ☐
MI1g. I didn’t know that I was pregnant	1 ☐	2 ☐	77 ☐	99 ☐
MI1h. I didn’t have health insurance to cover the cost of the visit	1 ☐	2 ☐	77 ☐	99 ☐
MI1i. I felt fine and did not think I needed to have a visit	1 ☐	2 ☐	77 ☐	99 ☐
MI1j. I didn’t want prenatal care	1 ☐	2 ☐	77 ☐	99 ☐
MI1k. I didn’t want anyone else to know I was pregnant	1 ☐	2 ☐	77 ☐	99 ☐
MI1l. Other, please specify	1 ☐	2 ☐	77 ☐	99 ☐

We would like to ask you some specific questions about your experiences with breast and cervical cancer screening.

2. [ONLY ASK THIS QUESTION OF WOMEN 25-49 AND BIOLOGICAL MOTHER]

Have you ever had a pap smear done by a doctor or other health professional?

1. ☐ YES

259. ☐ NO

77. ☐ DON’T KNOW [GO TO MI3]

99. ☐ PREFER NOT TO ANSWER [GO TO MI3]

[IF NO] Why did you not receive a pap smear?

[GO TO MI3]

[IF YES] When did you have your most recent pap smear?

1. ☐ A YEAR AGO OR LESS

260. ☐ MORE THAN 1 YEAR, BUT NOT MORE THAN 2 YEARS

261. ☐ MORE THAN 2 YEARS, BUT NOT MORE THAN 3 YEARS

262. ☐ MORE THAN 3 YEARS, BUT NOT MORE THAN 5 YEARS

263. ☐ OVER 5 YEARS AGO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

What was the main reason you had this test?

1. ☐ Part of a routine exam

264. ☐ Because of a problem

265. ☐ Other reason

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

Did you receive the result?

1. ☐ YES

1. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

3. [ONLY ASK THIS QUESTION OF WOMEN 25-49 AND IF BIOLOGICAL MOTHER]

Have you ever had a mammogram? A mammogram is an x-ray taken only of the breast by a machine that presses against the breast.

1. ☐ YES

267. ☐ NO

77. ☐ DON’T KNOW [GO TO MI4]

99. ☐ PREFER NOT TO ANSWER [GO TO MI4]

[IF NO] Why did you not have a mammogram?

[IF YES] When did you have your most recent mammogram?

1. ☐ A YEAR AGO OR LESS

1. ☐ MORE THAN 1 YEAR, BUT NOT MORE THAN 2 YEARS

2. ☐ MORE THAN 2 YEARS, BUT NOT MORE THAN 3 YEARS

3. ☐ MORE THAN 3 YEARS, BUT NOT MORE THAN 5 YEARS

4. ☐ OVER 5 YEARS AGO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

4. [ONLY ASK THIS QUESTION IF BIOLOGICAL MOTHER]

Have you ever had a breast exam done by a doctor or other health professional to check for lumps or other signs of breast cancer? A breast exam is when the breasts are felt by a doctor or other health professional to check for lumps or other signs of breast cancer.

1. ☐ YES

272. ☐ NO [GO TO MI5]

77. ☐ DON’T KNOW [GO TO MI5]

99. ☐ PREFER NOT TO ANSWER [GO TO MI5]

[IF YES] When did you have your most recent breast exam?

1. ☐ A YEAR AGO OR LESS

1. ☐ MORE THAN 1 YEAR, BUT NOT MORE THAN 2 YEARS

2. ☐ MORE THAN 2 YEARS, BUT NOT MORE THAN 3 YEARS

3. ☐ MORE THAN 3 YEARS, BUT NOT MORE THAN 5 YEARS

4. ☐ OVER 5 YEARS AGO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

5. Do you know where to find good information and help with the following issues if needed about the following issues?

   	YES	NO	DON’T KNOW	PREFER NOT TO ANSWER
   MI5a. Awareness of and access to resources for women experiencing gender violence.	1 ☐	2 ☐	77 ☐	99 ☐
   MI5b. Awareness of and access to resources on diabetes, smoking, and drinking.	1 ☐	2 ☐	77 ☐	99 ☐
   MI5c. Awareness of nutrition, access to resources to obtain food.	1 ☐	2 ☐	77 ☐	99 ☐

6. [ONLY ASK THIS QUESTION IF CHILD IS CSHCN]

Are you aware of the following mosquito borne illnesses?

	YES	NO	DON’T KNOW	PREFER NOT TO ANSWER
MI6a. Zika Virus	1 ☐	2 ☐	77 ☐	99 ☐
MI6b. Dengue Fever	1 ☐	2 ☐	77 ☐	99 ☐
MI6c. Chickingunya	1 ☐	2 ☐	77 ☐	99 ☐

Now we have a few questions about car safety.

7. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

When your child rides in a car, truck, or van, how often does he or she ride in an infant car seat?

1. ☐ Always

1. ☐ Often

2. ☐ Sometimes

3. ☐ Rarely

4. ☐ Never [GO TO MI10]

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

8. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

When your child rides in an infant car seat, is he or she usually in the front or back seat of the car, truck, or van?

1. ☐ FRONT SEAT

1. ☐ BACK SEAT

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

9. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

When your child rides in an infant car seat, is he or she usually facing forward or facing the rear of the car, truck, or van?

1. ☐ FACING FORWARD

1. ☐ FACING THE REAR

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

10. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

Does the car, truck, or van that your child usually rides in have an airbag on the passenger side?

1. ☐ YES

1. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

11. How often do you use seat belts when you drive or ride in a car? Would you say:

1. ☐ Always

284. ☐ Nearly always

285. ☐ Sometimes

286. ☐ Rarely

287. ☐ Never

288. ☐ Never drive or ride in a car

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

[ONLY ASK THIS QUESTION IF BIOLOGICAL MOTHER]

Now I would like to ask you some questions about family planning and prenatal care.

12. Are you aware of family planning methods? Family planning methods include things that women or their partners may use to prevent pregnancy such as birth control, condoms, implants, or withdrawal.

1. ☐ YES

289. ☐ NO

77. ☐ DON’T KNOW [GO TO MI13 (15-43); MI14 (>15, 43<)]

99. ☐ PREFER NOT TO ANSWER [GO TO MI13 (15-43); MI14 (>15, 43<)]

[IF YES] Have you used any family planning methods?

1. ☐ YES

290. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

[IF NO] Have you tried to find resources on family planning methods?

1. ☐ YES

1. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

13. [ONLY ASK THIS QUESTION OF WOMEN AGE 15-44 AND IF BIOLOGICAL MOTHER]

Do you currently use any family planning services, such as birth control, from the Ministry of Health and Human Services clinic?

1. ☐ YES

1. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

14. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD AND IF BIOLOGICAL MOTHER]

Have you ever been counseled on breastfeeding during prenatal care?

1. ☐ YES

1. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

15. Are you aware of the immunization services available and the importance of immunizing your child?

1. ☐ YES

1. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

16. Are you aware that there are agencies who can provide assistance to women experiencing gender violence?

1. ☐ YES

1. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

17. Have you been screened for diabetes?

1. ☐ YES

296. ☐ NO

77. ☐ DON’T KNOW [GO TO MI18 (CSHCN); MI20 (NOT CSHCN, 0-5); END(NOT CSHCN, 6-11)]

99. ☐ PREFER NOT TO ANSWER [GO TO MI18 (CSHCN); MI20 (NOT CSHCN, 0-5); END (NOT CSHCN, 6-11)]

[IF YES] What was the result?

1. ☐ Negative/Do not have diabetes

297. ☐ Positive/Have diabetes

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

[IF NO] Why have you not been screened for diabetes?

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

The next few questions are about health care services for your child.

18. [ONLY ASK THIS QUESTION IF CHILD IS CSHCN]

Are you aware that there are agencies that can provide assistance to disabled children?

1. ☐ YES

1. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

19. [ONLY ASK THIS QUESTION IF CHILD IS CSHCN]

Are you aware that screening of children with disabilities can be done at the hospital?

1. ☐ YES

1. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

20. [ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

Has your child ever been given a developmental milestone assessment before he or she was 6 years old? Examples are: Ages and Stages Questionnaire (ASQ), Survey of Well-being of Young Children (SWYC), Pediatric Symptom Checklist, Modified Checklist for Autism in Toddlers (M-CHAT), among others.

1. ☐ YES

300. ☐ NO

77. ☐ DON’T KNOW

99. ☐ PREFER NOT TO ANSWER

(END TIME: : )

Thank you for your participation.

On behalf of the U.S. Department of Health and Human Services, we would like to thank you for the time and effort you have spent sharing information about this child, you, and your family.

Your answers are important to us and will help researchers, policymakers, and family advocates to better understand the health and health care needs of children in our diverse population.

6