Survey Questions (variable
name) |
Survey Question Number |
0-5 Years Survey |
6-11 Years Survey |
12-17 Years Survey |
A. This Child's Health |
In general, how would you describe this
child’s health? (K2Q01) |
A1 |
A1 |
A1 |
How would you describe the condition of this
child’s teeth? (K2Q01_D)
|
A2 |
A2 |
A2 |
DURING THE PAST 12 MONTHS, has this child
had FREQUENT or CHRONIC difficulty with any of the following?
|
A3 |
A3 |
A3 |
Breathing or other respiratory problems (such as
wheezing or shortness of breath)
(BREATHING)
|
A3a |
A3a |
A3a |
Eating or swallowing because of a health
condition
(SWALLOWING)
|
A3b |
A3b |
A3b |
Digesting food, including stomach/intestinal
problems, constipation, or diarrhea
(STOMACH)
|
A3c |
A3c |
A3c |
Repeated or chronic physical pain, including
headaches or other back or body pain
(PHYSICALPAIN)
|
A3d |
A3d |
A3d |
Using their hands
(HANDS)
|
A3e |
- |
- |
Coordination or moving around
(COORDINATION)
|
A3f |
- |
- |
Toothaches
(TOOTHACHES)
|
A3g |
A3e |
A3e |
Bleeding gums
(GUMBLEED)
|
A3h |
A3f |
A3f |
Decayed teeth or cavities
(CAVITIES)
|
A3i |
A3g |
A3g |
Does this child have any of the
following?
|
A4 |
A4 |
A4 |
Serious difficulty concentrating, remembering,
or making decisions because of a physical, mental, or emotional condition
(MEMORYCOND)
|
- |
A4a |
A4a |
Serious difficulty walking or climbing stairs
(WALKSTAIRS)
|
- |
A4b |
A4b |
Difficulty dressing or bathing
(DRESSING)
|
- |
A4c |
A4c |
Difficulty doing errands alone, such as visiting
a doctor’s office or shopping, because of a physical, mental, or emotional condition
(ERRANDALONE)
|
- |
- |
A4d |
Deafness or problems with hearing
(K2Q43B)
|
A4a |
A4d |
A4e |
Blindness or problems with seeing, even when
wearing glasses
(BLINDNESS)
|
A4b |
A4e |
A4f |
Has a doctor or other health care provider
EVER told you that this child has:
|
|
|
|
*Allergies (including food, drug, insect, seasonal or other)?
(ALLERGIES)
|
A5 |
A5 |
A5 |
Asthma?
(K2Q40A)
|
A6 |
A6 |
A6 |
^Autoimmune disease (such as Type 1 Diabetes, Celiac, or Juvenile
Idiopathic Arthritis)?
(AUTOIMMUNE)
|
A7 |
A7 |
A7 |
Cerebral Palsy?
(K2Q61A)
|
A8 |
A8 |
A8 |
*Type 2 Diabetes?
(DIABETES)
|
A9 |
A9 |
A9 |
Epilepsy or Seizure Disorder?
(K2Q42A)
|
A10 |
A10 |
A10 |
Heart condition?
(HEART)
|
A11 |
A11 |
A11 |
If yes, was this child born with the
condition. (HEART_BORN)
|
Frequent or severe headaches, including
migraine?
(HEADACHE)
|
A12 |
A12 |
A12 |
Tourette Syndrome?
(K2Q38A)
|
A13 |
A13 |
A13 |
Anxiety problems?
(K2Q33A)
|
A14 |
A14 |
A14 |
Depression?
(K2Q32A)
|
A15 |
A15 |
A15 |
If YES to any of the items A5-A6 and A9-A15 (0-17 yrs), two follow up questions are asked:
|
|
|
|
Does this child CURRENTLY have the condition?
(variable name differs based on condition)
|
x |
x |
x |
Is it Mild, Moderate, or Severe?
(variable name differs based on condition)
|
x |
x |
x |
If YES to the items A7 and A8, a follow-up question is asked:
|
x |
x |
x |
Is it Mild, Moderate, or Severe? (AUTOIMMUNE_DESC) (CERPALS_DESC)
|
x |
x |
x |
Has a doctor or other health care provider
EVER told you that this child has: |
|
|
|
Down Syndrome?
(DOWNSYN)
|
A16 |
A16 |
A16 |
Blood Disorders (such as Sickle Cell Disease,
Thalassemia, or Hemophilia)?
(BLOOD)
|
A17 |
A17 |
A17 |
Cystic Fibrosis?
(CYSTFIB)
|
A18 |
A18 |
A18 |
Other genetic or inherited condition?
(GENETIC) (if yes, specify)
|
A19 |
A19 |
A19 |
If YES to above question under A17 (0-17
yrs), a follow up question is asked:
|
|
|
|
Is it Mild, Moderate, or Severe? (BLOOD_DESC)
|
x |
x |
x |
Was this child diagnosed with Sickle Cell Disease, Thalassemia,
Hemophilia,
Other Blood Disorders? (SICKLECELL,
THALASSEMIA, HEMOPHILIA, BLOOD_OTHER)
|
x |
x |
x |
Were any of these blood disorders identified through a blood test done shortly after birth? These tests are sometimes called newborn screening. (BLOOD_SCREEN)
|
x |
x |
x |
If YES to any of the items from A18 and
A19 (0-17 yrs), follow up questions are asked:
|
|
|
|
If YES, is it Mild, Moderate, or Severe? (CYSTFIB_DESC, GENETIC_DESC)
|
x |
x |
x |
Was this condition identified through a blood test done shortly after
birth? (These tests are sometimes called newborn screening) (BLOOD_SCREEN, CYSTFIB_SCREEN, GENETIC_SCREEN)
|
x |
x |
x |
^Fetal Alcohol Spectrum Disorder (FASD)?
(FASD)
|
A20 |
A20 |
A20 |
Has a doctor, other health care provider, or
educator EVER told you that this child has:
|
|
|
|
Behavioral or conduct problems?
(K2Q34A)
|
A21 |
A21 |
A21 |
Developmental Delay?
(K2Q36A)
|
A22 |
A22 |
A22 |
Intellectual Disability (formerly known as
Mental Retardation)?
(K2Q60A)
|
A23 |
A23 |
A23 |
Speech or other language disorder?
(K2Q37A)
|
A24 |
A24 |
A24 |
Learning Disability?
(K2Q30A)
|
A25 |
A25 |
A25 |
If YES to any of the items from A21 to A25 (0-17 yrs) to this point, two follow up questions are asked:
|
|
|
|
If yes, does this child CURRENTLY have the condition? (variable name differs based on condition)
|
x |
x |
x |
If YES, is it Mild, Moderate, or Severe? (variable name differs based on condition)
|
x |
x |
x |
Has a doctor or other health care provider
EVER told you that this child has Autism or Autism Spectrum Disorder (ASD)? Include diagnoses of
Asperger’s Disorder or Pervasive Developmental Disorder (PDD). (K2Q35A)
|
A26 |
A26 |
A26 |
If yes, does this child CURRENTLY have the condition? (K2Q35B)
|
If yes, is it Mild, Moderate, or Severe? (K2Q35C)
|
How old was this child when a doctor or other health care provider FIRST told you that they had Autism, ASD, Asperger’s Disorder or PDD? (K2Q35A_1_YEARS)
|
A27 |
A27 |
A27 |
What type of doctor or other health care provider was the FIRST to tell you that this child had Autism, ASD, Asperger’s Disorder or PDD? (K2Q35D)
|
A28 |
A28 |
A28 |
Is this child CURRENTLY taking medication
for Autism, ASD, Asperger’s Disorder or PDD? (AUTISMMED)
|
A29 |
A29 |
A29 |
At any time DURING THE PAST 12 MONTHS, did
this child receive behavioral treatment for Autism, ASD, Asperger’s Disorder or PDD, such as
training or an intervention that you or this child received to help with their behavior? (AUTISMTREAT)
|
A30 |
A30 |
A30 |
Has a doctor or other health care provider
EVER told you that this child has Attention Deficit Disorder or Attention Deficit/Hyperactivity
Disorder, that is, ADD or ADHD? (K2Q31A)
|
A31 |
A31 |
A31 |
If yes, does this child CURRENTLY have the condition? (K2Q31B)
|
If yes, is it Mild, Moderate, or Severe? (K2Q31C)
|
Is this child CURRENTLY taking medication for ADD or ADHD? (K2Q31D)
|
A32 |
A32 |
A32 |
At any time DURING THE PAST 12 MONTHS, did this child receive
behavioral treatment for ADD or ADHD, such as training or an intervention that you or this child
received to help with their behavior? (ADDTREAT)
|
A33 |
A33 |
A33 |
Do you think this child has EVER had a concussion or brain injury?
(CONCUSSION)
|
A34 |
A34 |
A34 |
If yes, did you seek medical care from a doctor or other health care
provider? (SEEKCARE)
|
If yes, did a doctor or other health care provider tell you that your
child had a concussion or brain injury? (CONFIRMINJURY)
|
DURING THE PAST 12 MONTHS, how often have
this child’s health conditions or problems affected their ability to do things other children
their age do? (HCABILITY)
|
A35 |
A35 |
A35 |
To what extent do this
child’s health conditions or problems affect their ability to do things? (HCEXTENT)
|
A36 |
A36 |
A36 |
B. This Child as an Infant
|
Was this child born more than 3 weeks before their due date? (K2Q05) |
B1 |
B1 |
B1 |
What month and year was this child
born? (BIRTH_YR) |
B2 |
B2 |
B2 |
How much did they weigh when born? (BIRTHWT_OZ_S) |
B3 |
B3 |
B3 |
What was the age of the mother when this child was born? (MOMAGE) |
B4 |
B4 |
B4 |
Was this child EVER breastfed or fed breast milk? (K6Q40) |
B5 |
- |
- |
If yes, how old was this child when they COMPLETELY stopped breastfeeding or being fed breast milk? (BREASTFEDEND) (K6Q41R_STILL) |
B6 |
- |
- |
How old was this child when they were FIRST fed formula? (FRSTFORMULA) (K6Q42R_NEVER) |
B7 |
- |
- |
How old was this child when they were FIRST fed anything other than
breast milk or formula? (FRSTSOLIDS) (K6Q43R_NEVER) |
B8 |
- |
- |
C. Health Care Services
|
Health Care Visits |
*DURING THE PAST 12 MONTHS, did this child see a doctor, nurse, or other
health care professional for sick-child care, well-child checkups, physical exams, hospitalizations
or any kind of medical care? Include health care visits done by video or phone. (S4Q01)
|
C1 |
C1 |
C1 |
If yes, at their LAST medical care visit, did this
child have a chance to speak with a doctor or other health care provider privately, without you
or another caregiver in the room? (DOCPRIVATE) |
- |
- |
C2 |
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? (K4Q20R) |
C2 |
C2 |
C3 |
Thinking about the LAST TIME you took this child for a PREVENTIVE
check-up, about how long was the doctor or health care provider who examined this child in the room
with you? (DOCROOM) |
C3 |
C3 |
C4 |
Height and Weight |
What is this child’s CURRENT height? (HEIGHT) |
- |
C4 |
C5 |
How much does this child CURRENTLY weigh? (WEIGHT)
[Data from the items on height and weight is not released individually, but
they are combined to create a variable BMICLASS (10-17 years only) which is released.] |
- |
C5 |
C6 |
Are you concerned about this child’s weight? (WGTCONC) |
C4 |
C6 |
C7 |
Has a doctor or other health care provider
ever told you that his child is overweight? (OVERWEIGHT) |
C5 |
C7 |
C8 |
Eating and/or Body Image Problems |
^DURING THE PAST 12 MONTHS, did this child engage in any of the following?
|
- |
C8 |
C9 |
^Skipping meals or fasting (DO NOT include skipping meals or fasting for
religious reasons) (ENGAGE_FAST) |
- |
C8 |
C9 |
^Having low interest in food (ENGAGE_INTEREST) |
- |
C8 |
C9 |
^Extremely picky eating (ENGAGE_PICKY) |
- |
C8 |
C9 |
^Binge eating (ENGAGE_BINGE) |
- |
C8 |
C9 |
^Purging or vomiting after eating (ENGAGE_PURG) |
- |
C8 |
C9 |
^Using diet pills, laxatives, or diuretics (water pills) to lose or maintain
weight without a doctor’s orders (ENGAGE_PILLS) |
- |
C8 |
C9 |
^Over-exercising (ENGAGE_EXERCISE) |
- |
C8 |
C9 |
^Not eating due to fear of vomiting or choking (ENGAGE_NOEAT) |
- |
C8 |
C9 |
^if YES for at least one item above: |
- |
C9 |
C10 |
^DURING THE PAST 12 MONTHS, how concerned were you about this child
engaging in these behaviors? (ENGAGECONCERN) |
- |
C9 |
C10 |
^DURING THE PAST 12 MONTHS, how concerned was this child about their weight,
body shape, or body size? (BODYIMAGE) |
- |
C10 |
C11 |
Developmental Concerns & Screening |
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?
(K6Q10)
[If child is <9 months, skip to C10] |
C6 |
- |
- |
DURING THE PAST 12 MONTHS, did a doctor or other health care provider have
you or another caregiver fill out a questionnaire about observations or concerns you may have about
this child’s development, communications, or social behaviors? (K6Q12) |
C7 |
- |
- |
If yes, [and child is 9-23 months], did the
questionnaire ask about your concerns or observations about: |
x |
- |
- |
How this child talks or makes speech sounds? (K6Q13A)
|
x |
- |
- |
How this child interacts with you and others? (K6Q13B)
|
x |
- |
- |
If yes, [and child is 2-5 years], did the
questionnaire ask about your concerns or observations about: |
x |
- |
- |
Words and phrases this child uses and understands? (K6Q14A)
|
x |
- |
- |
How this child behaves and gets along with you and others? (K6Q14B)
|
x |
- |
- |
Usual Source of Care |
Is there a place you or another caregiver USUALLY take this child when they are sick or you need advice about their health? (K4Q01) |
C8 |
C11 |
C12 |
If yes, where does this child USUALLY go first? (K4Q02_R) |
C9 |
C12 |
C13 |
Is there a place that this child USUALLY goes when they need routine
preventive care, such as a physical examination or well-child check-up? (USUALGO) |
C10 |
C13 |
C14 |
If yes, is this the same place this child goes they are sick? (USUALSICK) |
C11 |
C14 |
C15 |
Vision Testing |
Has this child EVER (0-5 years)/DURING THE PAST 2 YEARS, has this child (6-17 years) received a vision screening from a provider other than an eye doctor? (VISIONSCREENOTHER) (0-5 years), (VISIONSCREENOTHER) (6-17 years)
If yes, was it recommended that this child see an eye doctor or other eye care provider for an eye examination or additional vision service as a result of the vision screening? (VISIONEXAMREC) |
C12 |
C15 |
C16 |
Has this child EVER (0-5 years)/DURING THE PAST 2 YEARS (6-17 years) seen an eye doctor? (EYEDOCTOR) (0-5 years), (EYEDOCTOR) (6-17 years)
If yes, what care has this child received from the eye doctor?
Received eye examination (EYECARE1)
Prescribed eyeglasses or contact lenses (EYECARE2)
Diagnosis of a vision disorder other than nearsighted, farsighted, or
astigmatism (EYECARE3)
Some other care (EYECARE4) |
C13 |
C16 |
C17 |
Dental Health Care |
DURING THE PAST 12 MONTHS, did this child see a dentist or other oral
health care provider for any kind of dental or oral health care?Mark ALL that apply. |
C14 |
C17 |
C18 |
Saw a dentist (K4Q30_R_1) |
C14 |
C17 |
C18 |
Saw other oral health care provider (K4Q30_R_2) |
C14 |
C17 |
C18 |
No (K4Q30_R_3) |
C14 |
C17 |
C18 |
If yes, DURING THE PAST 12 MONTHS, did this child see
a dentist or other oral health care provider for preventive dental care, such as check-ups,
dental cleanings, dental sealants, or fluoride treatments? (DENTISTVISIT) |
C15 |
C18 |
C19 |
If yes, DURING THE PAST 12 MONTHS, what PREVENTATIVE
dental services did this child receive? (DENTALSERV1-7) |
C16 |
C19 |
C20 |
Mental Health Care and Other Types of Care
|
DURING THE PAST 12 MONTHS, has this child received any treatment or
counseling from a mental health professional? (K4Q22_R) |
C17 |
C20 |
C21 |
How
difficult was it to get the mental health treatment or counseling that this
child needed? (TREATNEED)
|
C18 |
C21 |
C22 |
DURING THE PAST 12 MONTHS, has this child taken any medication because of
difficulties with his or her emotions, concentration, or behavior? (K4Q23) |
C19 |
C22 |
C23 |
DURING THE PAST 12 MONTHS, did this child see a specialist other than a
mental health professional? (K4Q24_R) |
C20 |
C23 |
C24 |
How difficult was
it to get the specialist care that this child needed? (K4Q26) |
C21 |
C24 |
C25 |
DURING THE PAST 12 MONTHS, did this child use any type of alternative
health care or treatment? (ALTHEALTH)
|
C22 |
C25 |
C26 |
Forgone Health Care |
DURING THE PAST 12 MONTHS, was there any time when this child needed
health care but it was not received? (K4Q27)
|
C23 |
C26 |
C27 |
If yes, which types of care were not received? (K4Q28X01-05, K4Q28X_EAR) |
C24 |
C27 |
C28 |
Did any of the following reasons contribute to this
child not receiving needed health services?: |
C25 |
C28 |
C29 |
This child was not eligible for the services (NOTELIG)
|
C25a |
C28a |
C29a |
The services this child needed were not available in your area (AVAILABLE)
|
C25b |
C28b |
C29b |
There were problems getting an appointment when this child needed one (APPOINTMENT)
|
C25c |
C28c |
C29c |
There were problems with getting transportation or child care(TRANSPORTCC)
|
C25d |
C28d |
C29d |
The clinic or doctor's office wasn’t open when this child needed care
(NOTOPEN)
|
C25e |
C28e |
C29e |
There were issues related to cost (ISSUECOST)
|
C25f |
C28f |
C29f |
DURING THE PAST 12 MONTHS, how often were you frustrated in your efforts
to get services for this child? (C4Q04) |
C26 |
C29 |
C30 |
ER Use |
*DURING THE PAST 12 MONTHS, how many times did this child visit a hospital
emergency room? Do NOT include visits to urgent care centers. (HOSPITALER) |
C27 |
C30 |
C31 |
DURING THE PAST 12 MONTHS, was this child
admitted to the hospital to stay for at least one night? (HOSPITALSTAY) |
C28 |
C31 |
C32 |
Educational & Developmental Services
|
Has this child EVER had a special education or early intervention plan?
(K6Q15) |
C29 |
C32 |
C33 |
If yes, how old was this child at the time of the
FIRST plan? (SESPLANYR, SESPLANMO) |
C30 |
C33 |
C34 |
Is this child CURRENTLY receiving services under one
of these plans? (SESCURRSVC)
|
C31 |
C34 |
C35 |
*Has this child EVER received special services to meet their
developmental needs? Special services can include therapies such as speech, occupational, physical or
behavioral or other services received to meet developmental needs. (K4Q36) |
C32 |
C35 |
C36 |
If yes, how old was this child when they began
receiving these special services? (K4Q37) |
C33 |
C36 |
C37 |
Is this child CURRENTLY receiving these special
services? (K4Q38) |
C34 |
C37 |
C38 |
^Has a doctor, other health care provider, or eduator EVER recommended that this
child be evaluated for a Fetal Alcohol Spectrum Disorder? (EVALFASD) |
C35 |
C38 |
C39 |
^Has this child EVER received an evaluation for a Fetal Alcohol Spectrum Disorder? (RECEVALFASD) |
C36 |
C39 |
C40 |
D. Experience with This
Child's Health Care Providers |
Personal Doctor or Nurse |
Do you have one or more persons you think of as this child’s
personal doctor or nurse? (K4Q04_R) |
D1 |
D1 |
D1 |
Referrals for Care |
DURING THE PAST 12 MONTHS, did this child need a referral to see any
doctors or receive any services? (K5Q10) |
D2 |
D2 |
D2 |
How difficult
was it to get referrals? (K5Q11) |
D3 |
D3 |
D3 |
Family-Centered Care |
{Only answer questions D4-D12 if child had a health
care visit in the past 12 months} DURING THE PAST 12 MONTHS, how often did this
child’s doctors or other health care providers: |
D4
|
D4 |
D4 |
Spend enough time with this child? (K5Q40)
|
D4a
|
D4a
|
D4a
|
Listen carefully to you? (K5Q41)
|
D4b |
D4b |
D4b |
Show sensitivity to your family’s values and customs? (K5Q42)
|
D4c
|
D4c
|
D4c
|
Provide the specific information you needed concerning this child? (K5Q43)
|
D4d
|
D4d
|
D4d
|
Help you feel like a partner in this child’s care? (K5Q44)
|
D4e
|
D4e
|
D4e
|
Shared Decision Making |
DURING THE PAST 12 MONTHS, did this child
need any decisions to be made regarding his or her health care, such as whether to get
prescriptions, referrals, or procedures? (DECISIONS) |
D5 |
D5 |
D5 |
If yes, DURING THE PAST 12 MONTHS, how often did this
child’s doctors or other health care providers: |
D6 |
D6 |
D6 |
Discuss with you the range of options to consider for their health care
or treatment? (DISCUSSOPT)
|
D6a
|
D6a
|
D6a
|
Make it easy for you to raise concerns or disagree with recommendations for
the child’s health care? (RAISECONC)
|
D6b
|
D6b
|
D6b
|
Work with you to decide together which health care and treatment choices
would be best for this child? (BESTFORCHILD)
|
D6c
|
D6c
|
D6c
|
Care Coordination |
DURING THE PAST 12 MONTHS, did anyone help you arrange or coordinate this
child’s care among the different doctors or services that this child uses? (K5Q20_R)
|
D7 |
D7 |
D7 |
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? {If No, skip to D10} (K5Q21) |
D8 |
D8 |
D8 |
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?
(K5Q22) |
D9 |
D9 |
D9 |
DURING THE PAST 12 MONTHS, how satisfied were you with the communication
among this child’s doctors and other health care providers? (K5Q30) |
D10 |
D10 |
D10 |
DURING THE PAST 12 MONTHS, did this child’s health care provider
communicate with the child’s school, child care provider, or special education
program? (K5Q31_R) |
D11 |
D11 |
D11 |
If yes, during this time, how satisfied were you with the health
care provider’s communication with the school, child care provider, or special education
program? (K5Q32) |
D12 |
D12 |
D12 |
Transition to Adult Health Care |
Do any of this child’s doctors or other health care providers treat
only children? (TREATCHILD) |
- |
- |
D13 |
If yes, have they talked with you about having this
child eventually see doctors or other health care providers who treat adults? (TREATADULT) |
- |
- |
D14 |
Has this child’s doctor or other health care provider actively
worked with this child to: |
- |
- |
D15 |
Make positive choices about his or her heath? (POSCHOICE)
|
- |
- |
D15a |
Gain skills to manage his or her health and health care? (GAINSKILLS)
|
- |
- |
D15b |
Understand the changes in health care that happen at age 18? (CHANGEAGE)
|
- |
- |
D15c |
Did you and this child receive a summary of
your child's medical history (for example, medical conditions, allergies, medications,
immunizations)? (MEDHISTORY)
|
- |
- |
D16 |
Have this child’s doctors or other health care providers worked with
you and this child to create a plan of care to meet his or her
health goals and needs? (WRITEPLAN) |
- |
- |
D17 |
If yes, do you and this child have access to this plan of care? (RECEIVECOPY) |
- |
- |
D18 |
Does this plan of care address
transition to doctors and other health care providers who treat adults? (PLANNEEDS_R) |
- |
- |
D19 |
Eligibility for health insurance often changes in young adulthood. Do you
know how this child will be insured as they become an adult? (HEALTHKNOW) |
- |
- |
D20 |
If no, has anyone discussed with you how to obtain or
keep some type of health insurance coverage as this child becomes an adult? (KEEPINSADULT) |
- |
- |
D21 |
E. This Child's Health
Insurance Coverage |
DURING THE PAST 12 MONTHS, was this child EVER covered by ANY kind of
health insurance or health coverage plan? (K3Q04_R) {If child was covered all 12
months, skip to E4} |
E1 |
E1 |
E1 |
Indicate whether any of the following is a reason this
child was not covered by health insurance DURING THE PAST 12 MONTHS: |
E2 |
E2 |
E2 |
Change in employer or employment status (K12Q01_A)
|
E2a
|
E2a
|
E2a
|
Cancellation due to overdue premiums (K12Q01_B)
|
E2b
|
E2b
|
E2b
|
Dropped coverage because it was unaffordable (K12Q01_C)
|
E2c
|
E2c
|
E2c
|
Dropped coverage because benefits were inadequate (K12Q01_D)
|
E2d
|
E2d
|
E2d
|
Dropped coverage because choice of health care providers was inadequate (K12Q01_E)
|
E2e
|
E2e
|
E2e
|
Problems with application or renewal process (K12Q01_F)
|
E2f
|
E2f
|
E2f
|
Other, specify (K12Q01_G)
|
E2g
|
E2g
|
E2g
|
Is this child CURRENTLY covered by ANY kind of health insurance or health
coverage plan? {If child is not currently covered by any kind of health insurance or health
coverage plan, skip to F1} (CURRCOV) |
E3 |
E3 |
E3 |
Is this child CURRENTLY covered by any of the following types of
health insurance or health coverage plans? |
E4 |
E4 |
E4 |
Insurance through a current or former employer or union (K12Q03)
|
E4a
|
E4a
|
E4a
|
Insurance purchased directly from an insurance company (K12Q04)
|
E4b
|
E4b
|
E4b
|
Medicaid, Medical Assistance, or any kind of government assistance plan for
those with low incomes or a disability (K12Q12)
|
E4c
|
E4c
|
E4c
|
TRICARE or other military health care (TRICARE)
|
E4d
|
E4d
|
E4d
|
Indian Health Service (K11Q03R)
|
E4e
|
E4e
|
E4e
|
Other, specify (HCCOVOTH)
|
E4f
|
E4f
|
E4f
|
How often does this child’s health insurance
offer benefits or cover services that meet this child’s needs? (K3Q20) |
E5 |
E5 |
E5 |
How often does this child’s health insurance
allow them to see the health care providers they need? (K3Q22) |
E6 |
E6 |
E6 |
Thinking specifically about this child’s mental
or behavioral health needs, how often does this child’s health insurance offer benefits or
cover services that meet these needs? (MENBEVCOV) |
E7 |
E7 |
E7 |
F. Providing for This
Child's Health |
Including co-pays and amounts reimbursed from Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA), how much money did you pay for this child’s medical, health, dental, and vision care DURING THE PAST 12 MONTHS? (HOWMUCH) |
F1 |
F1 |
F1 |
How often are these costs reasonable? (K3Q21B) |
F2 |
F2 |
F2 |
DURING THE PAST 12 MONTHS, did your family have
problems paying for any of this child’s medical or health care bills? (K3Q25) |
F3 |
F3 |
F3 |
DURING THE PAST 12 MONTHS, have you or other family members: |
F4 |
F4 |
F4 |
Left a job or taken a leave of absence because of this child’s health or
health conditions? (STOPWORK)
|
F4a
|
F4a
|
F4a
|
Cut down on the hours you work because of this child’s health or health
conditions? (CUTHOURS)
|
F4b
|
F4b
|
F4b
|
Avoided changing jobs because of concerns about maintaining health insurance
for this child? (AVOIDCHG)
|
F4c
|
F4c
|
F4c
|
IN AN AVERAGE WEEK, how many hours do you or other family members spend
providing health care at home for this child? (ATHOMEHC) |
F5 |
F5 |
F5 |
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? (ARRANGEHC) |
F6 |
F6 |
F6 |
G. This Child's Learning
(0-5 years) |
Is this child able to do the following...
{if child is <1 year, skip to question G25} |
G1 |
- |
- |
Say at least one word, such as "hi" or "dog"?
(ONEWORD)
|
G1a |
- |
- |
Use 2 words together, such as "car go"? (TWOWORDS)
|
G1b |
- |
- |
Use 3 words together in a sentence, such as,
"Mommy come now."? (THREEWORDS)
|
G1c |
- |
- |
Ask questions like "who," "what," "when,"
"where"? (ASKQUESTION)
|
G1d |
- |
- |
Ask questions like "why," and "how? (ASKQUESTION2)
|
G1e |
- |
- |
Tell a story with a beginning, middle, and end?
(TELLSTORY)
|
G1f |
- |
- |
Understand the meaning of the word
"no"? (UNDERSTAND)
|
G1g |
- |
- |
Follow a verbal direction without hand gestures,
such as "Wash your hands."? (DIRECTIONS)
|
G1h |
- |
- |
Point to things in a book when asked? (POINT)
|
G1i |
- |
- |
Follow 2-step directions, such as "Get your
shoes and put them in the basket."? (DIRECTIONS2)
|
G1j |
- |
- |
Understand words such as "in," "on," and
"under"? (UNDERSTAND2)
|
G1k |
- |
- |
Is this child 3 years old or
older? (SC_AGE_YEARS) {If child is <3 years, skip to question G25} |
G2 |
- |
- |
Has this child started school? (STARTSCHOOL) |
G3 |
- |
- |
How often can this child recognize the beginning sound of a word? (RECOGBEGIN) |
G4 |
- |
- |
^How often can this child come up with words that start with the same sound? (SAMESOUND) |
G5 |
- |
- |
*How often can this child explain things they have seen or done so that you know what happened? (CLEAREXP) |
G6 |
- |
- |
How often can this child write their first name, even if some of the letters aren’t
quite right or are backwards? (WRITENAME) |
G7 |
- |
- |
^How often can this child focus on a task you give them for at least a few minutes?
(FOCUSON) |
G8 |
- |
- |
^How often can this child read one-digit numbers? (READONEDIGIT) |
G9 |
- |
- |
^How often can this child correctly do simple addition? (SIMPLEADDITION) |
G10 |
- |
- |
^How often can this child tell which group of objects has more? (GROUPOFOBJECTS) |
G11 |
- |
- |
*If asked to count objects, how high can this child count correctly? (COUNTTO_R) |
G12 |
- |
- |
About how many letters of the alphabet can this child recognize? (RECOGABC) |
G13 |
- |
- |
*How well can this child come up with words that rhyme? (RHYMEWORD_R) |
G14 |
- |
- |
^How often can this child recognize and name their own emotions? (NAMEEMOTIONS) |
G15 |
- |
- |
*How often does this child have difficulty when asked to end one activity and start a new activity? (STARTNEWACT) |
G16 |
- |
- |
How often does this child play well with other children? (PLAYWELL) |
G17 |
- |
- |
How often does this child lose their temper? (TEMPER_R) |
G18 |
- |
- |
How often does this child get easily distracted? (DISTRACTED) |
G19 |
- |
- |
*How often does this child show concern when they see others who are hurt or unhappy?(HURTSAD) |
G20 |
- |
- |
*How often does this child have trouble calming down? (CALMDOWN_R) |
G21 |
- |
- |
^How often does this child have difficulty waiting for their turn? (WAITFORTURN) |
G22 |
- |
- |
^How often does this child keep working at a task even when it is hard for them? (HARDWORK) |
G23 |
- |
- |
^How often does this child share toys or games with other children? (SHARETOYS) |
G24 |
- |
- |
^How well can this child bounce a ball for several seconds? (BOUNCEBALL) |
G25 |
- |
- |
^How well can this child draw a circle? (DRAWACIRCLE) |
G26 |
- |
- |
^How well can this child draw a face with eyes and mouth? (DRAWAFACE) |
G27 |
- |
- |
^How well can this child draw a person with a head, body, arms, and legs? (DRAWAPERSON) |
G28 |
- |
- |
How often |
G29 |
- |
- |
Is this child affectionate and tender with you? (K6Q70_R)
|
G29a |
- |
- |
Does this child bounce back quickly when things do not go their way? (K6Q73_R)
|
G29b |
- |
- |
Does this child show interest and curiosity in learning new things? (K6Q71_R)
|
G29c |
- |
- |
Does this child smile and laugh? (K6Q72_R)
|
G29d |
- |
- |
G. This Child's Schooling
and Activities (6-17 years) |
DURING THE PAST 12 MONTHS, about how many days did this child miss school
because of illness or injury? (K7Q02R_R)
|
- |
G1 |
G1 |
DURING THE PAST 12 MONTHS, how many times has this child’s school
contacted you or another adult in your household about any problems they are having with school?
(K7Q04R_R) |
- |
G2 |
G2 |
^Across all subjects, what grades did this child get during the 2021-2022 school year? (GRADES) |
- |
G3 |
G3 |
SINCE STARTING KINDERGARTEN, has this child repeated any grades? (REPEATED) |
- |
G4 |
G4 |
DURING THE PAST 12 MONTHS, did this child participate in: |
- |
G5 |
G5 |
A sports team or did they take sports lessons after school or on
weekends? (K7Q30)
|
- |
G5a |
G5a |
Any clubs or organizations after school or on weekends? (K7Q31)
|
- |
G5b |
G5b |
Any other organized activities or lessons, such as music, dance, language, or
other arts? (K7Q32)
|
- |
G5c |
G5c |
Any type of community service or volunteer work at school, place of worship, or in the community? (K7Q37)
|
- |
G5d |
G5d |
Any paid work, including regular jobs as well as babysitting, cutting grass,
or other occasional work? (K7Q38)
|
- |
G5e |
G5e |
DURING THE PAST 12 MONTHS, how often did you attend events or activities that
this child participated in? (K7Q33) |
- |
G6 |
G6 |
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? (PHYSACTIV) |
- |
G7 |
G7 |
Compared to other children their age, how much difficulty does this
child have making or keeping friends? (MAKEFRIEND) |
- |
G8 |
G8 |
*DURING THE PAST 12 MONTHS, how often was this child bullied, picked on, or excluded by other children? Do not include siblings (for children 6-17) or dating partners (for children 12-17). (BULLIED_R) (6-11 years), (BULLIED_R) (12-17 years) |
- |
G9 |
G9 |
*DURING THE PAST 12 MONTHS, how often did this child bully others, pick on them, or exclude them? Do not include siblings (for children 6-17) or dating partners (for children 12-17). (BULLY) (6-11 years), (BULLY) (12-17 years) |
- |
G10 |
G10 |
How often does this child |
- |
G11 |
G11 |
Show interest and curiosity in learning new things? (K6Q71_R)
|
- |
G11a |
G11a |
Work to finish tasks they start? (K7Q84_R)
|
- |
G11b |
G11b |
Stay calm and in control when faced with a challenge? (K7Q85_R)
|
- |
G11c |
G11c |
Care about doing well in school? (K7Q82_R)
|
- |
G11d |
G11d |
Do all required homework? (K7Q83_R)
|
- |
G11e |
G11e |
Argue too much? (K7Q70_R)
|
- |
G11f |
G11f |
H. About You and This Child
|
Was this child born in the United States? (If yes, skip to
H3} (BORNUSA) |
H1 |
H1 |
H1 |
If no, how long has this child been living in the
United States? (LIVEUSA_YR/LIVEUSA_MO) |
H2 |
H2 |
H2 |
How many times has this child moved to a new address since they were
born? (K11Q43R) |
H3 |
H3 |
H3 |
How often does this child go to bed at about the same time on weeknights?
(BEDTIME) |
H4 |
H4 |
H4 |
DURING THE PAST WEEK, how many hours of sleep did this child get [during
an average day (count both nighttime sleep and naps) (HOURSLEEP05)/ on most weeknights]? (HOURSLEEP) |
H5 |
H5 |
H5 |
In which position do you most often lay this baby down to sleep now?
{<12 months old only} (SLEEPPOS) |
H6 |
-
|
-
|
DURING THE PAST WEEK, how many times did this child drink sugary drinks such as soda, fruit drinks, sport drinks, or sweet tea? (SUGARDRINK) |
H7 |
-
|
-
|
DURING THE PAST WEEK, how many times did this child eat vegetables? (VEGETABLES) |
H8 |
-
|
-
|
DURING THE PAST WEEK, how many times did this child eat fruit? (FRUIT) |
H9 |
-
|
-
|
ON MOST WEEKDAYS, how much time does this child spend playing outdoors? (OUTDOORSWKDAY) |
H10 |
-
|
-
|
ON AN AVERAGE WEEKEND DAY, how much time does this child spend playing outdoors? (OUTDOORSWKEND) |
H11 |
-
|
-
|
ON MOST WEEKDAYS, about how much time does
this child usually spend in front of a TV, computer, cellphone or other electronic device
watching programs, playing games, accessing the internet or using social media? (Do not include
time spent doing schoolwork.) (SCREENTIME) |
H12 |
H6 |
H6 |
DURING THE PAST WEEK, how many days did you or other family members read
to this child? (K6Q60_R) |
H13 |
- |
- |
DURING THE PAST WEEK, how many days did you or other family members tell
stories or sing songs to this child? (K6Q61_R) |
H14 |
- |
- |
How well can you and this child share ideas or talk about things that
really matter? (K8Q21) |
- |
H7 |
H7 |
How well do you think you are handling the day-to-day demands of raising
children? (K8Q30) |
H15 |
H8 |
H8 |
DURING THE PAST MONTH, how often have you felt: |
H16 |
H9 |
H9 |
That this child is much harder to care for than most children their age?
(K8Q31)
|
H16a
|
H9a
|
H9a
|
That this child does things that really bother you a lot? (K8Q32)
|
H16b
|
H9b
|
H9b
|
Angry with this child? (K8Q34)
|
H16c
|
H9c
|
H9c
|
DURING THE PAST 12 MONTHS, was there someone that you could turn to for
day-to-day emotional support with parenting or raising children? (K8Q35) |
H17 |
H10 |
H10 |
If yes, did you receive emotional support
from: |
H18 |
H11 |
H11 |
Spouse or domestic partner? (EMOSUPSPO)
|
H18a
|
H11a
|
H11a
|
Other family member or close friend? (EMOSUPFAM)
|
H18b
|
H11b
|
H11b
|
Health care provider? (EMOSUPHCP)
|
H18c
|
H11c
|
H11c
|
Place of worship or religious leader? (EMOSUPWOR)
|
H18d
|
H11d
|
H11d
|
Support or advocacy group related to specific health condition? (EMOSUPADV)
|
H18e
|
H11e
|
H11e
|
Peer support group? (EMOSUPPEER)
|
H18f
|
H11f
|
H11f
|
Counselor or other mental health professional? (EMOSUPMHP)
|
H18g
|
H11g
|
H11g
|
Other person, specify (EMOSUPOTH)
|
H18h
|
H11h
|
H11h
|
Does this child receive care for at least 10 hours per week from someone
other than their parent or guardian? (K6Q20) |
H19 |
- |
- |
DURING THE PAST 12 MONTHS, did you or anyone in the family have to quit a
job, not take a job, or greatly change your job because of problems with child care for this child?
(K6Q27) |
H20 |
- |
- |
I. About Your Family and
Household |
DURING THE PAST WEEK, on how many days did all the family members who live
in the household eat a meal together? (K8Q11)
|
I1 |
I1 |
I1 |
Does anyone living in your household use cigarettes, cigars, or pipe
tobacco? (K9Q40) |
I2 |
I2 |
I2 |
If yes, does anyone smoke inside your home? (K9Q41) |
I3 |
I3 |
I3 |
^Does anyone vape or use e-cigarettes inside your home? (VAPE)
|
I4 |
I4 |
I4 |
SINCE THIS CHILD WAS BORN, how often has it been very hard to cover the basics, like food or housing, on your family’s income? (ACE1)
|
I5 |
I5 |
I5 |
Which of these statements best describes your household’s ability to afford the food you need DURING THE PAST 12 MONTHS? (FOODSIT)
|
I6 |
I6 |
I6 |
At any time DURING THE PAST 12 MONTHS, even for one month, did anyone in
your family receive: |
I7 |
I7 |
I7 |
Cash assistance from a government welfare program? (K11Q60)
|
I7a
|
I7a
|
I7a
|
Food Stamps or Supplemental Nutrition Assistance Program benefits (SNAP) (K11Q61)?
|
I7b
|
I7b
|
I7b
|
Free or reduced-cost breakfasts or lunches at school? (K11Q62)
|
I7c
|
I7d
|
I7c
|
^School meal debit/Electronic Benefits Transfer (EBT) cards? (EBTCARDS)
|
I7d
|
I7c
|
I7d
|
Benefits from the Women, Infants, and Children (WIC) Program? (S9Q34)
|
I7e
|
I7e
|
I7e
|
^Does this child receive SSI, that is, Supplemental Security Income? (SSI)
|
I8
|
I8
|
I8
|
^If yes, is this for a disability they have? (SSIDISABILITY)
|
I8
|
I8
|
I8
|
^DURING THE PAST 12 MONTHS, was there a time when you were not able to pay the mortgage or rent on this? (MISSMORTGAGE)
|
I9
|
I9
|
I9
|
^DURING THE PAST 12 MONTHS, how often were you worried or stressed about being evited, foreclosed on, or having your housing condemned? (HOMEEVIC)
|
I10
|
I10
|
I10
|
^DURING THE PAST 12 MONTHS, how many places has this child lived? (PLACESLIVED)
|
I11
|
I11
|
I11
|
^SINCE THIS CHILD WAS BORN, have they have ever been homeless or lived in a
shelter? (EVERHOMELESS)
|
I12
|
I12
|
I12
|
In your neighborhood, is/are there: |
I13 |
I13 |
I13 |
Sidewalks or walking paths? (K10Q11)
|
I3a
|
I3a
|
I3a
|
A park or playground? (K10Q12)
|
I3b
|
I3b
|
I3b
|
A recreation center, community center, or boys’ and girls’ club?
(K10Q13)
|
I3c
|
I3c
|
I3c
|
A library or bookmobile? (K10Q14)
|
I3d
|
I3d
|
I3d
|
Litter or garbage on the street or sidewalk? (K10Q20)
|
I3e
|
I3e
|
I3e
|
Poorly kept or rundown housing? (K10Q22)
|
I3f
|
I3f
|
13f
|
Vandalism such as broken windows or graffiti? (K10Q23)
|
I3g
|
I3g
|
I3g
|
To what extent do you agree with these statements about your neighborhood
or community? |
I14 |
I14 |
I14 |
People in this neighborhood help each other out (K10Q30)
|
I14a
|
I14a
|
I14a
|
We watch out for each other’s children in this neighborhood (K10Q31)
|
I14b
|
I14b
|
I14b
|
This child is safe in our neighborhood (K10Q40_R)
|
I14c
|
I14c
|
I14c
|
When we encounter difficulties, we know where to go for help in our community
(GOFORHELP)
|
I14d
|
I14d
|
I14d
|
This child is safe at school (K10Q41_R )
|
- |
I14e
|
I14e
|
Other than you or other adults in your home, is there at least one other
adult in this child’s school, neighborhood, or community who knows this child well and who they can rely on for advice or guidance? (K9Q96) |
- |
I15 |
I15 |
To the best of your knowledge, has this child EVER experienced any of the
following? |
I15 |
I16 |
I16 |
Parent or guardian divorced or separated (ACE3)
|
I15a
|
I16a
|
I16a
|
Parent or guardian died (ACE4)
|
I15b
|
I16b
|
I16b
|
Parent or guardian served time in jail or prison (ACE5)
|
I15c
|
I16c
|
I16c
|
Saw or heard parents or adults slap, hit, kick punch one another in the home
(ACE6)
|
I15d
|
I16d
|
I16d
|
Was a victim of violence or witnessed violence in neighborhood (ACE7)
|
I15e
|
I16e
|
I16e
|
Lived with anyone who was mentally ill, suicidal, or severely depressed (ACE8)
|
I15f
|
I16f
|
I16f
|
Lived with anyone who had a problem with alcohol or drugs (ACE9)
|
I15g
|
I16g
|
I16g
|
Treated or judged unfairly because of his or her race or ethnic group (ACE10)
|
I15h
|
I16h
|
I16h
|
Treated or judged unfairly because of their sexual orientation or gender identity (ACE11)
|
-
|
I16i
|
I16i
|
Treated or judged unfairly because of a health condition or disability (ACE12)
|
I15i |
I16j
|
I16j
|
When your family faces problems, how often are you likely to do each of
the following? |
I16 |
I17 |
I17 |
Talk together about what to do (TALKABOUT)
|
I16a
|
I17a
|
I17a
|
Work together to solve our problems (WKTOSOLVE)
|
I16b
|
I17b
|
I17b |
Know we have strengths to draw on (STRENGTHS)
|
I16c
|
I17c
|
I17c
|
Stay hopeful even in difficult times (HOPEFUL)
|
I16d
|
I17d
|
I17d
|
Impact of the Coronavirus Pandemic |
DURING THE PAST 12 MONTHS, has this child had any health care visits by video or phone? (VIDEOPHONE)
If yes, were any of this child's health care visits by video or phone because of the coronavirus pandemic? (VIDEOPHONECOVID) |
I17 |
I18 |
I18 |
DURING THE PAST 12 MONTHS, did this child miss, delay or skip any PREVENTATIVE check-ups because of the coronavirus pandemic? (COVIDCHECKUPS)
|
I18 |
I19 |
I19 |
DURING THE PAST 12 MONTHS, have any of this child’s regular (daycare or) childcare arrangements been closed or unavailable at any time because of the coronavirus pandemic? (COVIDARRANGE) (0-5 years),(COVIDARRANGE) (6-11 years)
|
I19 |
I20 |
- |
J. Child's Caregivers |
The questions are first asked of the respondent (“About you”) and then asked for a second adult if “Yes” to J13 “Does this child have another parent or adult caregiver who lives in this household?”. In 2022, the second adult (if any) is referred to as “other parent or caregiver in the household” |
How are you/this other caregiver related to this child? (A1_RELATION) (A2_RELATION) .... |
J1/J14 |
J1/J14
|
J1/J14
|
What is your/this caregiver's sex? (A1_SEX) (A2_SEX) |
J2/J15 |
J2/J15
|
J2/J15
|
What is your/this caregiver's age? (A1_AGE) (A2_AGE) |
J3/J16 |
J3/J16
|
J3/J16
|
Where were you/this caregiver born? (A1_BORN) (A2_BORN) |
J4/J17 |
J4/J17
|
J4/J17
|
{If outside of the U.S.} When did
you/this caregiver come to live in the United States? (A1_LIVEUSA) (A2_LIVEUSA) |
J5/J18 |
J5/J18
|
J5/J18
|
What is the highest grade or year of school you/this caregiver have completed? (A1_GRADE) (A2_GRADE) |
J6/J19 |
J6/J19
|
J6/J19
|
What is your/this caregiver's marital status? (A1_MARITAL) (A2_MARITAL) |
J7/J20 |
J7/J20
|
J7/J20
|
In general, how is your/this caregiver's physical health? (A1_PHYSHEALTH) (A2_PHYSHEALTH) |
J8/J21 |
J8/J21
|
J8/J21
|
In general, how is your/this caregiver's mental or emotional health? (A1_MENTHEALTH) (A2_MENTHEALTH) |
J9/J22 |
J9/J22
|
J9/J22
|
Which of the following best describes your/this caregiver’s current employment status? (A1_EMPLOYED) (A2_EMPLOYED) |
J10/J23 |
J10/J23
|
J10/J23
|
Have you/this caregiver ever served on active duty in the
U.S. Armed forces, Reserves, or the National Guard? (A1_ACTIVE) (A2_ACTIVE) |
J11/J24 |
J11/J24 |
J11/J24 |
Were you/this caregiver deployed at any time during this
child’s life? (A1_DEPLSTAT) (A2_DEPLSTAT) |
J12/J25 |
J12/J25 |
J12/J25 |
Does this child have another parent or adult caregiver who lives in this household? |
j13 |
j13 |
j13 |
K. Household Information
|
How many people are living or staying at this address? (HHCOUNT) |
K1 |
K1 |
K1 |
How many of these people in your household are family members? (FAMCOUNT) |
K2 |
K2 |
K2 |
Income in 2021 (The public use file does not include the following individual
variables# but are presented as an aggregate variable labeled FPL (if
imputed FPL_I).
|
K3 |
K3 |
K3 |
Income in 2021. Mark Yes or No for each type of income this child’s family received, and give best estimate of the total amount in the last calendar year. |
Wages, salary, commissions, bonuses, or tips from all jobs? (INCWAGES)#
|
K3a
|
K3a
|
K3a
|
Self-employment income from own nonfarm businesses or farm businesses,
including proprietorships and partnerships? (INCSELFEMP)#
|
K3b
|
K3b
|
K3b
|
Interest, dividends, net rental income, royalty income, or income from estates
and trusts? (INCINTDIV)#
|
K3c
|
K3c
|
K3c
|
Social security or railroad retirement; retirement,
survivor, or disability pensions? (INCSSRR)
|
K3d
|
K3d
|
K3d
|
Supplemental security income (SSI); any public assistance or welfare payments
from the state or local welfare office? (INCSSIPA)#
|
K3e
|
K3e
|
K3e
|
Any other sources of income received regularly such as Veterans’ (VA)
payments, unemployment compensation, child support, or alimony? (INCOTHER)#
|
K3f
|
K3f
|
K3f
|
Think about your total combined family income IN THE LAST CALENDAR YEAR
for all members of the family. What is that amount before taxes? (TOTINCOME)# |
K4 |
K4 |
K4 |