• SECTION 1: Family Identification
• SECTION 2: Health Status & Limitations
• SECTION 3: Family Food Security
• SECTION 4: Injuries & Poisoning
• SECTION 5: Access to Health Care & Utilization
• SECTION 6: Health Insurance
• SECTION 7: Socio-Demographic
• SECTION 8: Family Income

SECTION 1: Family Identification

• Respondent’s Interviewer confirms: (HHCHANGE) (CWHAT2)
  1. Name
  2. Age or DOB
  3. Sex
  4. National origin
  5. Race
• Are you now married, widowed, divorced, separated, never married, or living with a partner? (MARITAL) (14 years of age or older)
  • Is your spouse living in the household? (SPOUS)
    • [Display all possible spouse candidates] (SPOUS2)
  • Have you ever been married? (COHAB1)
  • What is your current legal marital status? (COHAB2)
• Child’s type of relationship with father: biological, adoptive, step, foster, or [son/daughter] in law? (DEGREE4)
• Child’s type of relationship with mother: biological, adoptive, step, foster, or [son/daughter] in law? (DEGREE5)
• Is [your/ALIAS]’s mother a household member? (Include biological (natural), adoptive, step, or foster mother or mother-in-law) (MOTHER)
  • Is [mother] biological (natural), adoptive, step, or foster mother or mother-in-law? (MOTHERCK_A)
• Is [your/ALIAS]’s father a household member? (Include biological (natural), adoptive, step, or foster father or father-in-law)? (FATHER)
  • Is [father] biological (natural), adoptive, step, or foster father or father-in-law? (FATHERCK_A)

SECTION 2: Health Status & Limitations

• Is [child’s name] limited in the kind or amount of play activities [he/she] can do because of a physical, mental, or emotional problem? (FLAPLYLM) (PLAPLYLM) (less than 5 years of age)
  • Is [child’s name] able to take part AT ALL in the usual kinds of play activities done by most children [child]’s age? (FLAPLYUN) (PLAPLYUN) (less than 5 years of age)
• Does [child’s name] receive Special Educational or Early Intervention Services? (FSPEDEIS) (PSPEDEIS)
  • Does [child’s name] receive these services because of an emotional or behavioral problem? (PSPEDEM)
• Because of a physical, mental, or emotional problem, does [anyone in family] need the help of other persons with PERSONAL CARE NEEDS, such as eating, bathing, dressing, or getting around inside this home? (FLAADL) (PLAADL) (3 years of age or older)
  1. Bathing or showering (LABATH)
  2. Dressing (LADRESS)
  3. Eating (LAEAT)
  4. Getting in or out of bed or chairs (LABED)
  5. Using the toilet, including getting to the toilet (LATOILT)
  6. Getting around inside the home (LAHOME)
• Because of a health problem, does [anyone in family] have difficulty walking without using any special equipment? (FLAWALK) (PLAWALK)
• Is [anyone in family] LIMITED IN ANY WAY because of difficulty remembering or because [you/he/she] experience periods of confusion? (FLAREMEM) (PLAREMEM)
• Is [family member] LIMITED IN ANY WAY in any activities because of physical, mental or emotional problems? (FLIMANY) (PLIMANY)

If child has at least one reported limitation:

• What conditions or health problems cause limitations? (LAHCC)
  • How long [have you/has ALIAS] had the problem:
    1. Vision problem or problem seeing? (LHCL01N)
    2. Hearing problem? ( LHCL02N)
    3. Speech problem? ( LHCL03N)
    4. Asthma or a breathing problem? (LHCL04N)
    5. Birth defect
    6. The injury that caused limitation? (LHCL06N)
    7. Intellectual disability, also known as mental retardation? (LHCL07N)
    8. Developmental problem (eg. Cerebral palsy)? (LHCL08N)
    9. Mental, emotional, or behavioral problem? (LHCL09N)
    10. Bone, joint, or muscle problem? (LHCL10N)
    11. Epilepsy or seizures? (LHCL11N)
    12. Learning disability? (LHCL12N)
    13. Attention deficit/hyperactivity disorder? (LHCL13N)
    14. [Other]? (LAHCC_S1) (LHCL90N)
    15. [Other]? (LAHCC_S2) (LHCL91N)

SECTION 3: Family Food Security

DURING THE PAST 30 DAYS:

• "We worried whether our food would run out before we got money to buy more." (FSRUNOUT)
• "The food that we bought just didn't last, and we didn't have money to get more." (FSLAST)
• "We couldn't afford to eat balanced meals." (FSBALANC)

If any of the statement is often or sometimes true:

• In the last 30 days, did [you/you or other adults in your family] ever
  1. Cut the size of your meals or skip meals because there wasn’t enough money for food? (FSSKIP)
     • In the past 30 days, how many days did it happen?  (FSSKDAYS)
  2. Eat less than you felt you should because there wasn’t enough money for food? (FSLESS)
  3. Hungry but didn’t eat because there wasn’t enough money for food? (FSHUNGRY)
• In the last 30 days, did you lose weight because there wasn’t enough money for food? (FSWEIGHT)

Families where adult(s) experienced any of the above:

• In the last 30 days, did [you/you or other adults in your family] ever not eat for a whole day because there wasn’t enough money for food? (FSNOTEAT)
  • In the last 30 days, how many days did this happen? (FSNEDAYS)

SECTION 4: Injuries & Poisoning

DURING THE PAST THREE MONTHS:

1. Did [anyone in your family] have an injury where any part of [the] body was hurt, for example, with a (random set of injury examples)]? (FINJ3M) (WFINJ3M)
2. Was [ALIAS] poisoned by swallowing or breathing in a harmful substance such as bleach, carbon monoxide, or too many pills or drugs? Do not include food poisoning, sun poisoning, or ivy rashes. (FPOI3M) (WFPOI3M)
   • How many different times was [ALIAS]
     1. Injured? (TFINJ3M)
     2. Poisoned? Do not include food poisoning, sun poisoning, or poison ivy rashes. (TFPOI3M)
        • Did [ALIAS] talk to or see a medical professional about
          1. [his/her] injury or injuries? (MFINJ3M)
          2. [his/her] poisoning or poisonings? (MFPOI3M)
             • Of [TFINJ3M/TFPOI3M/all the] times that [ALIAS] was...
               1. Injured, how many of those times was the poisoning serious enough that a medical professional was consulted? (MTFINJ3M)
               2. Poisoned, how many of those times was the poisoning serious enough that a medical professional was consulted? (MTFPOI3M)
                  • Did [ALIAS] get MEDICAL ADVICE, TREATMENT, or FOLLOW-UP CARE for this poisoning from...
                    1. A phone call to poison control center? (PPCC)
                    2. An emergency vehicle, such as an ambulance or fire truck? (IPEV)
                    3. A visit to an emergency room? (IPER)
                    4. A visit to a doctor’s office or other health clinic? (IPDO)
                    5. A phone call to a doctor, nurse, or other health care professional? (IPPCHCP)
                    6. Any place else? (IPOTH) (IPOTHOS)
                    • [ALIAS] DID NOT receive any medical advice, treatment, or follow-up for this [injury/poisoning]. Is that correct? (IPVER)
                    • Was [ALIAS] hospitalized for at least one night as a result of this [injury/poisoning]? (IPHOSP)
                      • How many nights [fill: were you/was ALIAS] in the hospital? (IPIHNO)

SECTION 5: Access to Health Care & Utilization

• DURING THE PAST 12 MONTHS, has medical care been delayed because of worry about the cost? (FDMED12M) (PDMED12M)
• DURING THE PAST 12 MONTHS, was there any time when [ALIAS] needed medical care, but did not get it because the family couldn’t afford it? (FNMED12M) (PNMED12M)
• Has [ALIAS] been hospitalized OVERNIGHT in the past 12 months? Do not include an overnight stay in the emergency room. (FHOSPYR/a>) (PHOSPYR)
  • How many different times did [ALIAS] stay in any hospital overnight or longer DURING THE PAST 12 MONTHS? (HOSPNO)
  • Altogether how many nights was [ALIAS] in the hospital DURING THE PAST 12 MONTHS? (HPNITE)
• DURING THE LAST 2 WEEKS, did [ALIAS] receive care AT HOME from a nurse or other health care professional? (FHCHM2W) (PHCHM2W)
  • How many home visits did [ALIAS] receive DURING THE LAST 2 WEEKS? (PHCHMN2W)
• DURING THE LAST 2 WEEKS, did [ALIAS] get any medical advice or test results over the PHONE from a doctor, nurse, or other health care professional? (FHCPH2W) (PHCPH2W)
  • How many telephone calls were made about [child]? (PHCPHN2W)
• DURING THE LAST 2 WEEKS, did [ALIAS] see a doctor or other health care professional at a doctoR’s OFFICE, a clinic, an emergency room, or some other place? (FHCHV2W) (PHCDV2W)
  • How many times did [ALIAS] visit a doctor or other health care professional DURING THE LAST 2 WEEKS? (PHCDVN2W)
• DURING THE PAST 12 MONTHS, did [ALIAS] receive care from doctors or other health care professionals 10 or more times? Do not include telephone calls. (F10DVYR) (P10DVYR)

SECTION 6: Health Insurance

• [Are you/Is anyone in the family] covered by any kind of health insurance or some other kind of health care plan? (FHICOV)
  • What kind of health insurance or health care coverage does [ALIAS] have? INCLUDE those that pay for only one type of service (nursing home care, accidents, or dental care). EXCLUDE private plans that only provide extra cash while hospitalized. (HIKIND)

If no insurance coverage of any type:

• There is a program called Medicaid that pays for health care for persons in need. In this State, it is called (*fill State name). Is [ALIAS] covered by Medicaid? (MCAIDPRB)
• Does [ALIAS] have any type of insurance that pays for only one type of service such as dental, vision, or prescriptions? (SINCOV)
  • What type of service or care does [ALIAS]’s single service plan or plans pay for? (SSOTHER)
• I have recorded [ALIAS] is covered by [type of insurance] / not covered by health insurance. Is this correct? (HICHANGE)

If child has Medicare:

• What type of Medicare coverage does [ALIAS] you have? (MCPART)

If child has Medicaid/SCHIP/State Sponsored Health Plan/"Other" Government Plan:

• Can [ALIAS] go to ANY doctor who will accept [type of insurance] or MUST [he/she] choose from a book or list of doctors or is a doctor assigned? (MACHMD) (STDOC1) (STDOC2) (STDOC3)

If cannot go to ANY doctor (for Medicaid only):

• What is the name of the health plan that provided the book or list? (MACHMD1)
• What is the name of the health plan that assigned the doctor? (MACHMD2)
• Was the Health Plan name obtained from a Health Plan Card or something with the Health Plan name on it? (MANAM)

• Is [ALIAS] required to sign up with a certain primary care doctor, group of doctors, or certain clinic which [he/she] must go to for all of [his/her] routine care? Do not include emergency care or care from a specialist [he/she was] referred to? (MAPCMD) (STPCMD1) (STPCMD2) (STPCMD3)
• Under [ALIAS]’s [type of insurance], if [he/she] needs to go to a different doctor or place for special care, does [he/she] need approval or a referral? Do not include emergency care. (MAREF) (STREF1) (STREF2) (STREF3)

If child does not have health insurance or has only single service plans:

• Not including Single Service Plans, about how long has it been since [ALIAS] last had health care coverage? (HILAST)
• [Which of these are reasons [ALIAS] stopped being covered?/Which of these are reasons [ALIAS] does not have health insurance?] (HISTOP)
• In the PAST 12 MONTHS, was there any time when [ALIAS] did NOT have ANY health insurance or coverage? (HINOTYR)

• In the PAST 12 MONTHS, about how many months [ALIAS] without coverage? (HINOTMYR)

• In the PAST 12 MONTHS, about how much did [your family] spend for medical care and dental care? (HCSPFYR)
• In the past 12 months did [you/anyone in the family] have problems paying or were unable to pay any medical bills? (MEDBILL)
• [Do you/Does anyone in your family] currently have any medical bills that are being paid off over time? (MEDBPAY)
  • [Do you/Does anyone in your family] currently have any medical bills that you are unable to pay at all? (MEDBNOP)
• [Do you/Does anyone in your family] have a Flexible Spending Account for health expenses? (FSA)

SECTION 7: Socio-Demographic

• Was [ALIAS] born in the United States? (PLBORN)
  • If 'Yes': In what state was [ ] born? (PLBORN1)
  • If 'No': 
    • In what country was[ALIAS] born?& (PLBORN2)
    • In what year did [ALIAS] come to the United States to stay? (USYR)
    • About how long has [ALIAS] been in the United States? (USLONG)
    • Is [ALIAS] a CITIZEN of the United States? (CITIZEN)
• Is [ALIAS] now attending Head Start? (HEADST)(less than 7 years of age)
  • If 'NO and less than 18 years of age' Has [ALIAS] ever attended Head Start? (HEADSTEV)
• What is the HIGHEST level of school [child] has completed or the highest degree [child] has received? (EDUC) (5 years of age or older)

SECTION 8: Family Income

• Did any family members 18 and older, receive income in last calendar year from...wages and salaries? (FSAL) (PSAL)
• [Did you/ALIAS/any family members 18 and older receive income in last calendar year from self-employment including business and farm income? (FSEINC) (PSEINC)
• Did [you/any family members living here] receive income in last calendar year from:
  • Social Security or Railroad Retirement? (FSSRR) (PSSRR)
    • Was [your/any family member’s] Social Security or Railroad Retirement income received as a disability benefit? (FSSRRD) (PSSRRDB)
  • Any disability pension [other than Social Security or Railroad Retirement]? (FPENS) (PPENS)
  • Any retirement or survivor pension other [than Social Security or Railroad Retirement/than a disability pension/than Social Security, Railroad Retirement, or a disability pension]? (FOPENS) (POPENS)
• Did [you/any family members] receive:
  • Supplemental Security Income (SSI)? (FSSI) (PSSI)
    • Did [you/ALIAS] receive SSI because [you have/he has/she has] a disability? (PSSID)
• At any time during last calendar year, did [you/any family members living here] receive
  • Any CASH assistance from a state or county welfare program, such as (* fill specific program name)? (FTANF) (PTANF)
  • Any OTHER kind of welfare assistance such as help with getting a job, placement in education or job training programs, or help with transportation or child care? (FOWBEN) (POWBEN)
• Did [you/any family members living here] receive income from
  • Interest bearing checking accounts, savings accounts, IRAs or certificates of deposit, money market funds, treasury notes, bonds, or any other investments that earn interest? (FINTRST) (PINTRST)
  • Dividends from stocks or mutual funds, or net rental income from property, royalties, estates or trusts? (FDIVD) (PDIVD)
  • Child support? (FCHLDSP) (PCHLDSP)
  • Any other source such as alimony, contributions from family/others, VA payments, Worker’s Compensation, or unemployment compensation? (FINCOT) (PINCOT)
• What is your best estimate of [your total income/the total income of all family members] from all sources, before taxes, in last calendar year? (FINCTOT)
• Have you/any family members living here EVER applied for Supplemental Security Income (SSI), even if the claim was denied? (FSSAPL) (PSDAPL)
• Is this house/apartment owned or being bought, rented, or occupied by some other arrangement by you [fill: /or someone in your family]? (HOUSEOWN)
• Have you/any family members living here EVER applied for disability benefits from Social Security, even if the claim was denied? (FSDAPL) (PSDAPL)
• Earlier I recorded that [you/ALIAS] received cash assistance from programs such as welfare or public assistance in last calendar year. About how many months did [you/ALIAS] receive this assistance? (TANFMYR)
• At any time during last calendar year, did you/any family members living here receive food stamp benefits/SNAPNAME or food stamp benefits? (FSNAP)
  • About how many months were food stamp benefits/SNAPNAME or food stamp benefits received? (FSNAPMYR)
• At any time during last calendar year did you/anyone in your family receive benefits from the WIC program, that is, the Women, Infants and Children program? (FINWIC) (PWIC)