Child Preventive Health Supplement (CS) Section
BOX_00A
=======
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| THE CS SECTION IS ASKED IN ROUNDS 2 AND 4 ONLY. IF|
| IT IS ROUND 1, 3, OR 5, CONTINUE TO THE NEXT |
| SECTION. |
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BOX_00
======
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| CONTEXT HEADER DISPLAY INSTRUCTIONS: |
| DISPLAY PERS.FULLNAME. |
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BOX_01
======
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| IF ANY RU MEMBERS < OR = 17 YEARS OF AGE OR IN AGE |
| CATEGORIES 1 THROUGH 4, CONTINUE WITH LOOP_01 |
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| OTHERWISE, GO TO BOX_08 |
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LOOP_01
=======
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| FOR EACH ELEMENT IN THE RU-MEMBERS-ROSTER, |
| ASK CS01-END_LP01 |
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| LOOP DEFINITION: LOOP_01 COLLECTS INFORMATION |
| ABOUT A CHILD’S RESISTANCE TO ILLNESS, HEALTH NEEDS|
| A CHILD MAY HAVE BECAUSE OF A HEALTH CONDITION |
| (LWIM), RATINGS ON THE CHILD’S BEHAVIOR AND |
| RELATIONSHIPS (CIS), HEALTH CARE THE CHILD RECEIVED|
| IN THE LAST YEAR (CAHPS), AND INFORMATION ABOUT THE|
| CHILD’S USE OF CLINICAL PREVENTIVE SERVICES. THIS |
| LOOP CYCLES ON EACH PERSON IN THE RU-MEMBERS-ROSTER|
| WHO MEETS THE FOLLOWING CONDITIONS: |
| |
| - PERSON IS A CURRENT OR INSTITUTIONALIZED RU |
| MEMBER |
| AND |
| - PERSON IS NOT DECEASED |
| AND |
| - PERSON IS < OR = 17 YEARS OF AGE OR IN AGE |
| CATEGORIES 1 THROUGH 4 |
-----------------------------------------------------
CS01
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
SHOW CARD CS-1.
{Now I’d like to talk about (PERSON).}
The following are statements about (PERSON)’s general health status.
How true or false is each of these statements for (PERSON)?
1 = DEFINITELY TRUE
2 = MOSTLY TRUE
3 = DON’T KNOW
4 = MOSTLY FALSE
5 = DEFINITELY FALSE
CS01_01
=======
a. (PERSON) seems to be less healthy than other
children that I know. ( )
CS01_02
=======
b. (PERSON) has never been seriously ill. ( )
CS01_03
=======
c. When there is something going around, (PERSON)
usually catches it. ( )
CS01_04
=======
d. I expect (PERSON) will have a very healthy life. ( )
CS01_05
=======
e. I worry more about (PERSON)’s health than other
people worry about their children’s health. ( )
----------------------------------------------------
| DISPLAY “Now I’d like to talk about (PERSON).” IF |
| NOT FIRST CYCLE THROUGH LOOP_01. OTHERWISE (THAT |
| IS, IF IT IS THE FIRST CYCLE THROUGH LOOP_01), USE|
| A NULL DISPLAY. |
----------------------------------------------------
----------------------------------------------------
| OPTIONS 1-5 ARE RADIO BUTTONS IN EACH ROW TO THE |
| RIGHT OF THE QUESTION TEXT, CS01_01 THROUGH |
| CS01_05. CS01_01 THROUGH CS01_05 ARE DISPLAYED ON |
| THE SCREEN TOGETHER. |
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| REFUSED (-7) ALLOWED ON ALL ENTRY FIELDS. |
----------------------------------------------------
CS02
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
The next questions are about (PERSON)’s health needs and whether
(PERSON) has a health condition. A health condition can be
physical, mental or behavioral. Health conditions may affect a
child’s development, daily functioning or need for services.
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
CS03
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Does (PERSON) currently need or use medicine prescribed by a
doctor, other than vitamins?
YES .................................... 1 {CS03OV1}
NO ..................................... 2 {CS04}
REF ................................... -7 {CS04}
DK .................................... -8 {CS04}
CS03OV1
=======
Is this because of any medical, behavioral or other health
condition?
YES .................................... 1 {CS03OV2}
NO ..................................... 2 {CS04}
REF ................................... -7 {CS04}
DK .................................... -8 {CS04}
CS03OV2
=======
Is this a condition that has lasted or is expected to last for
at least 12 months?
YES .................................... 1 {CS04}
NO ..................................... 2 {CS04}
REF ................................... -7 {CS04}
DK .................................... -8 {CS04}
CS04
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Does (PERSON) need or use more medical care, mental health or
educational services than is usual for most children of the same
age?
YES .................................... 1 {CS04OV1}
NO ..................................... 2 {CS05}
REF ................................... -7 {CS05}
DK .................................... -8 {CS05}
CS04OV1
=======
Is this because of any medical, behavioral or other health
condition?
YES .................................... 1 {CS04OV2}
NO ..................................... 2 {CS05}
REF ................................... -7 {CS05}
DK .................................... -8 {CS05}
CS04OV2
=======
Is this a condition that has lasted or is expected to last for
at least 12 months?
YES .................................... 1 {CS05}
NO ..................................... 2 {CS05}
REF ................................... -7 {CS05}
DK .................................... -8 {CS05}
CS05
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Is (PERSON) limited or prevented in any way in (his/her) ability
to do the things most children of the same age can do?
YES .................................... 1 {CS05OV1}
NO ..................................... 2 {CS06}
REF ................................... -7 {CS06}
DK .................................... -8 {CS06}
CS05OV1
=======
Is this because of any medical, behavioral or other health
condition?
YES .................................... 1 {CS05OV2}
NO ..................................... 2 {CS06}
REF ................................... -7 {CS06}
DK .................................... -8 {CS06}
CS05OV2
=======
Is this a condition that has lasted or is expected to last for
at least 12 months?
YES .................................... 1 {CS06}
NO ..................................... 2 {CS06}
REF ................................... -7 {CS06}
DK .................................... -8 {CS06}
CS06
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Does (PERSON) need or get special therapy such as physical,
occupational or speech therapy?
YES .................................... 1 {CS06OV1}
NO ..................................... 2 {CS07}
REF ................................... -7 {CS07}
DK .................................... -8 {CS07}
CS06OV1
=======
Is this because of any medical, behavioral or other health
condition?
YES .................................... 1 {CS06OV2}
NO ..................................... 2 {CS07}
REF ................................... -7 {CS07}
DK .................................... -8 {CS07}
CS06OV2
=======
Is this a condition that has lasted or is expected to last for
at least 12 months?
YES .................................... 1 {CS07}
NO ..................................... 2 {CS07}
REF ................................... -7 {CS07}
DK .................................... -8 {CS07}
CS07
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Does (PERSON) have any kind of emotional, developmental or
behavioral problem for which (he/she) needs or gets treatment
or counseling?
YES .................................... 1 {CS07OV}
NO ..................................... 2 {BOX_02}
REF ................................... -7 {BOX_02}
DK .................................... -8 {BOX_02}
CS07OV
======
Is this a condition that has lasted or is expected to last for
at least 12 months?
YES .................................... 1 {BOX_02}
NO ..................................... 2 {BOX_02}
REF ................................... -7 {BOX_02}
DK .................................... -8 {BOX_02}
BOX_02
======
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| IF RU MEMBER BEING ASKED ABOUT IS AGED 5-17 YEARS,|
| INCLUSIVE, OR IN AGE CATEGORIES 3 OR 4, CONTINUE |
| WITH CS08 |
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----------------------------------------------------
| OTHERWISE, GO TO CS09A |
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CS08
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
SHOW CARD CS-2.
The following questions are about some aspects of (PERSON)’s
health.
In this series of questions, please rate (PERSON) on a scale of
0 to 4 where 0 indicates no problem and 4 indicates a very big
problem.
In general, how much of a problem do you think (PERSON) has with:
PROBE: Please rate on a scale of 0 to 4 where 0 indicates no
problem and 4 indicates a very big problem, how much of a
problem you think (PERSON) has with (ACTIVITY).
CODE 99 IF RESPONDENT INDICATES THE QUESTION IS INAPPLICABLE.
CS08_01. a. Getting along with (his/her) mother? ( )
CS08_02. b. Getting along with (his/her) father? ( )
CS08_03. c. Feeling unhappy or sad? ( )
CS08_04. d. (His/Her) behavior at school? ( )
CS08_05. e. Having fun? ( )
CS08_06. f. Getting along with other adults? ( )
CS08_07. g. Feeling nervous or afraid? ( )
CS08_08. h. Getting along with brothers and sisters? ( )
CS08_09. i. Getting along with other kids? ( )
CS08_10. j. Getting involved in activities like sports or
hobbies? ( )
CS08_11. k. (His/Her) schoolwork? ( )
CS08_12. l. (His/Her) behavior at home? ( )
CS08_13. m. Staying out of trouble? ( )
----------------------------------------------------
| ONLY THE VALUES OF 0 AND 4 WILL BE DEFINED IN THE |
| TEXT OF THE QUESTION. HOWEVER, THE VALUES OF ALL |
| THE ANSWER CATEGORIES ARE: |
| |
| 0 = NO PROBLEM |
| 1 |
| 2 = SOME PROBLEM |
| 3 |
| 4 = VERY BIG PROBLEM |
| -7 = REF |
| -8 = DK |
| 99 = INAPPLICABLE |
----------------------------------------------------
----------------------------------------------------
| NOTE: THIS SCREEN WILL BE SPLIT INTO TWO SCREENS |
| IN CAPI. THE FIRST SCREEN (CS08A) WILL CONTAIN |
| THE FOLLOWING PARTS OF THE QUESTION AS SPECIFIED |
| BELOW: |
| - THE SHOW CARD LINE |
| - THE FIRST THREE BLOCKS OF TEXT |
| - THE INTERVIEWER INSTRUCTION: ‘CODE 99...’ |
| - CS08_01 (a.) THROUGH CS08_08 (h.) DISPLAYED IN |
| MULTIPLE ROWS, WITH CS08_01 AND CS08_02 IN THE |
| FIRST ROW, CS08_03 AND CS08_04 IN THE SECOND |
| ROW, CS08_05 AND CS08_06 IN THE THIRD ROW, AND |
| CS08_07 AND CS08_08 IN THE LAST ROW. |
| |
| THE SECOND SCREEN (CS08B) WILL CONTAIN THE |
| FOLLOWING PARTS OF THE QUESTION AS SPECIFIED |
| BELOW: |
| - THE SHOW CARD LINE |
| - THE PROBE |
| - THE INTERVIEWER INSTRUCTION: ‘CODE 99...’ |
| - CS08_09 (i.) THROUGH CS08_13 (m.) DISPLAYED IN |
| MULTIPLE ROWS, WITH CS08_09 AND CS08_10 IN THE |
| FIRST ROW, CS08_11 AND CS08_12 IN THE SECOND |
| ROW, AND CS08_13 IN THE LAST ROW. |
----------------------------------------------------
----------------------------------------------------
| SPECIAL CHECK: |
| THE VALUES FOR MOTHPROB, FATHPROB, UNHAPSAD, |
| BEHVSCHL, HAVFUNPR, ADULPROB, NERVAFRD, SIBSPROB, |
| KIDSPROB, SPORTHOB, SCHLWORK, BEHVHOME AND TROUBLE|
| SHOULD BE BETWEEN 0 AND 4 AND SHOULD ALSO INCLUDE |
| 99. A CHECK SHOULD BE CONDUCTED TO ENSURE THAT ANY|
| VALUES OUTSIDE OF THOSE DEFINED PRODUCE AN ERROR |
| AND PROHIBIT THE INTERVIEWER FROM CONTINUING UNTIL|
| CORRECTED. |
----------------------------------------------------
CS09
====
OMITTED.
CS10
====
OMITTED.
CS11
====
OMITTED.
CS09A
=====
{PERSON’S FIRST MIDDLE AND LAST NAME}
The following questions are about the health care (PERSON)
received in the last 12 months.
In the last 12 months, did (PERSON) have an illness, injury or
condition that needed care right away in a clinic, emergency
room, or doctor’s office?
YES .................................... 1 {CS10A}
NO ..................................... 2 {CS11A}
REF ................................... -7 {CS11A}
DK .................................... -8 {CS11A}
CS12
====
OMITTED.
CS10A
=====
{PERSON’S FIRST MIDDLE AND LAST NAME}
SHOW CARD CS-3.
In the last 12 months, when (PERSON) needed care right away, how often
did (PERSON) get care as soon as you thought (he/she) needed?
NEVER .................................. 1 {CS11A}
SOMETIMES .............................. 2 {CS11A}
USUALLY ................................ 3 {CS11A}
ALWAYS ................................. 4 {CS11A}
REF ................................... -7 {CS11A}
DK .................................... -8 {CS11A}
[Code One]
----------------------------------------------------
| IN PANEL 12, ROUND 4 AND PANEL 13, ROUND 2, THE |
| QUESTION WORDING AT CS10A WAS UPDATED TO BE MORE |
| CONSISTENT WITH CAHPS VERSION 4.0 QUESTION |
| WORDING. |
----------------------------------------------------
CS11A
=====
{PERSON’S FIRST MIDDLE AND LAST NAME}
In the last 12 months, not counting the times (PERSON) needed
health care right away, did you make any appointments for (PERSON)’s
health care at a doctor’s office or clinic?
YES .................................... 1 {CS12A}
NO ..................................... 2 {CS13}
REF ................................... -7 {CS13}
DK .................................... -8 {CS13}
----------------------------------------------------
| IN PANEL 12, ROUND 4 AND PANEL 13, ROUND 2, THE |
| QUESTION WORDING AT CS11A WAS UPDATED TO BE MORE |
| CONSISTENT WITH CAHPS VERSION 4.0 QUESTION |
| WORDING. |
----------------------------------------------------
CS12A
=====
{PERSON’S FIRST MIDDLE AND LAST NAME}
SHOW CARD CS-3.
In the last 12 months, not counting times (PERSON) needed health
care right away, how often did (PERSON) get an appointment for
health care at a doctor’s office or clinic as soon as you thought
(he/she) needed?
NEVER .................................. 1 {CS13}
SOMETIMES .............................. 2 {CS13}
USUALLY ................................ 3 {CS13}
ALWAYS ................................. 4 {CS13}
REF ................................... -7 {CS13}
DK .................................... -8 {CS13}
[Code One]
----------------------------------------------------
| IN PANEL 12, ROUND 4 AND PANEL 13, ROUND 2, THE |
| QUESTION WORDING AT CS12A WAS UPDATED TO BE MORE |
| CONSISTENT WITH CAHPS VERSION 4.0 QUESTION |
| WORDING. |
----------------------------------------------------
CS13
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
SHOW CARD CS-3A.
In the last 12 months, not counting times (PERSON) went to an
emergency room, how many times did (PERSON) go to a doctor’s
office or clinic to get health care?
NONE ................................... 0 {CS20}
1 TIME ................................. 1 {CS14A}
2 TIMES ................................ 2 {CS14A}
3 TIMES ................................ 3 {CS14A}
4 TIMES ................................ 4 {CS14A}
5 TO 9 TIMES............................ 5 {CS14A}
10 OR MORE TIMES ....................... 6 {CS14A}
REF ................................... -7 {CS20}
DK .................................... -8 {CS20}
[Code One]
----------------------------------------------------
| IN PANEL 12, ROUND 4 AND PANEL 13, ROUND 2, THE |
| QUESTION WORDING AT CS13 WAS UPDATED TO BE MORE |
| CONSISTENT WITH CAHPS VERSION 4.0 QUESTION |
| WORDING. |
----------------------------------------------------
CS14A
=====
{PERSON’S FIRST MIDDLE AND LAST NAME}
In the last 12 months, did you or a doctor believe (PERSON)
needed any care, tests, or treatment?
YES .................................... 1 {CS14}
NO ..................................... 2 {CS15}
REF ................................... -7 {CS15}
DK .................................... -8 {CS15}
CS14
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
SHOW CARD CS-3.
In the last 12 months, how often was it easy to get the care,
tests, or treatments you or a doctor believed necessary?
NEVER .................................. 1 {CS15}
SOMETIMES .............................. 2 {CS15}
USUALLY ................................ 3 {CS15}
ALWAYS ................................. 4 {CS15}
REF ................................... -7 {CS15}
DK .................................... -8 {CS15}
[Code One]
----------------------------------------------------
| IN PANEL 12, ROUND 4 AND PANEL 13, ROUND 2, THE |
| QUESTION WORDING AND RESPONSE CATEGORIES AT CS14 |
| WERE CHANGED TO BE MORE CONSISTENT WITH CAHPS |
| VERSION 4.0 QUESTION WORDING AND RESPONSE |
| CATEGORIES. THE RESPONSE SCALE CHANGED FROM A |
| PROBLEM SCALE TO A TIME FRAME SCALE |
----------------------------------------------------
CS15
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
SHOW CARD CS-3.
In the last 12 months, how often did (PERSON)’s doctors or other
health providers listen carefully to you?
NEVER .................................. 1 {CS16}
SOMETIMES .............................. 2 {CS16}
USUALLY ................................ 3 {CS16}
ALWAYS ................................. 4 {CS16}
REF ................................... -7 {CS16}
DK .................................... -8 {CS16}
[Code One]
CS16
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
SHOW CARD CS-3.
In the last 12 months, how often did (PERSON)’s doctors or other
health providers explain things in a way that was easy to understand?
NEVER .................................. 1 {CS17}
SOMETIMES .............................. 2 {CS17}
USUALLY ................................ 3 {CS17}
ALWAYS ................................. 4 {CS17}
REF ................................... -7 {CS17}
DK .................................... -8 {CS17}
[Code One]
----------------------------------------------------
| IN PANEL 12, ROUND 4 AND PANEL 13, ROUND 2, THE |
| QUESTION WORDING AT CS16 WAS UPDATED TO BE MORE |
| CONSISTENT WITH CAHPS VERSION 4.0 QUESTION |
| WORDING |
----------------------------------------------------
CS17
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
SHOW CARD CS-3.
In the last 12 months, how often did (PERSON)’s doctors or other
health providers show respect for what you had to say?
NEVER .................................. 1 {CS18}
SOMETIMES .............................. 2 {CS18}
USUALLY ................................ 3 {CS18}
ALWAYS ................................. 4 {CS18}
REF ................................... -7 {CS18}
DK .................................... -8 {CS18}
[Code One]
CS18
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
SHOW CARD CS-3.
In the last 12 months, how often did doctors or other health
providers spend enough time with (PERSON)?
NEVER .................................. 1 {CS19}
SOMETIMES .............................. 2 {CS19}
USUALLY ................................ 3 {CS19}
ALWAYS ................................. 4 {CS19}
REF ................................... -7 {CS19}
DK .................................... -8 {CS19}
[Code One]
CS19
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
SHOW CARD CS-5.
Using any number from 0 to 10 where 0 is the worst health care
possible, and 10 is the best health care possible, what number
would you use to rate all (PERSON)’s health care in the last 12
months?
RATING FROM 0-10:
[Enter Number] ........................
REF ................................... -7 {CS20}
DK .................................... -8 {CS20}
----------------------------------------------------
| HARD CHECK: 0-10 |
----------------------------------------------------
CS20
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
When you answer the next questions, do not include dental visits.
Specialists are doctors like surgeons, heart doctors, allergy
doctors, skin doctors, and others who specialize in one area of
health care.
In the last 12 months, did you or a doctor think (PERSON) needed to
see a specialist?
YES .................................... 1 {CS21}
NO ..................................... 2 {CS22}
REF ................................... -7 {CS22}
DK .................................... -8 {CS22}
CS21
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
SHOW CARD CS-3.
In the last 12 months, how often was it easy to see a specialist
that (PERSON) needed to see?
NEVER .................................. 1 {CS22}
SOMETIMES .............................. 2 {CS22}
USUALLY ................................ 3 {CS22}
ALWAYS ................................. 4 {CS22}
REF ................................... -7 {CS22}
DK .................................... -8 {CS22}
[Code One]
----------------------------------------------------
| IN PANEL 12, ROUND 4 AND PANEL 13, ROUND 2, THE |
| QUESTION WORDING AND RESPONSE CATEGORIES AT CS21 |
| WERE CHANGED TO BE MORE CONSISTENT WITH CAHPS |
| VERSION 4.0 QUESTION WORDING AND RESPONSE |
| CATEGORIES. THE RESPONSE SCALE CHANGED FROM A |
| PROBLEM SCALE TO A TIME FRAME SCALE. |
----------------------------------------------------
CS22
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
The following questions are about amounts and types of preventive
care (PERSON) may receive when (he/she) goes to see a doctor or
other health provider.
Has a doctor or other health provider ever measured (PERSON)’s
height?
YES .................................... 1 {CS22OV}
NO ..................................... 2 {CS23_01}
REF ................................... -7 {CS23_01}
DK .................................... -8 {CS23_01}
CS22OV
======
When was that?
WITHIN PAST YEAR ....................... 1 {CS23_01}
WITHIN PAST 2 YEARS .................... 2 {CS23_01}
MORE THAN 2 YEARS ...................... 3 {CS23_01}
REF ................................... -7 {CS23_01}
DK .................................... -8 {CS23_01}
[Code One]
CS23_01
=======
{PERSON’S FIRST MIDDLE AND LAST NAME}
About how tall is (PERSON) without shoes?
PROBE FOR INCHES IF NOT REPORTED.
FEET:
[Enter Feet] .......................... {CS23_02}
REF ................................... -7 {CS24}
DK .................................... -8 {CS24}
----------------------------------------------------
| SOFT CHECK: |
| SOFT RANGE CHECK: 0 TO 7 |
----------------------------------------------------
----------------------------------------------------
| NOTE THAT CS23_02 IS AN OVERLAY ON CS23_01. |
----------------------------------------------------
CS23_02
=======
INCHES:
[Enter Inches] ........................ {CS24}
REF ................................... –7 {CS24}
DK .................................... –8 {CS24}
----------------------------------------------------
| SOFT CHECK: |
| SOFT RANGE CHECK: 0-12 |
----------------------------------------------------
----------------------------------------------------
| EDIT: IF FEET (CS23_01) = 0, INCHES (CS23_02) |
| MUST BE 1-30. IF FEET (CS23_01) > 0, INCHES |
| (CS23_02) MUST BE 0-12. |
----------------------------------------------------
CS24
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Has a doctor or other health provider ever measured (PERSON)’s
weight?
YES .................................... 1 {CS24OV}
NO ..................................... 2 {CS25_01}
REF ................................... -7 {CS25_01}
DK .................................... -8 {CS25_01}
CS24OV
======
When was that?
WITHIN PAST YEAR ....................... 1 {CS25_01}
WITHIN PAST 2 YEARS .................... 2 {CS25_01}
MORE THAN 2 YEARS ...................... 3 {CS25_01}
REF ................................... -7 {CS25_01}
DK .................................... -8 {CS25_01}
[Code One]
CS25_01
=======
{PERSON’S FIRST MIDDLE AND LAST NAME}
About how much does (PERSON) weigh without shoes?
POUNDS:
[Enter Pounds] ........................
REF ................................... -7 {BOX_03}
DK .................................... -8 {BOX_03}
----------------------------------------------------
| IF CS25_01 IS < OR = 20 POUNDS, CONTINUE WITH |
| CS25_02 |
----------------------------------------------------
----------------------------------------------------
| IF CS25_01 IS > 20 POUNDS, GO TO BOX_03 |
----------------------------------------------------
----------------------------------------------------
| SOFT CHECK: |
| SOFT RANGE CHECK: 1 TO 300 |
----------------------------------------------------
----------------------------------------------------
| NOTE THAT CS25_02 IS AN OVERLAY ON CS25_01. |
----------------------------------------------------
CS25_02
=======
OUNCES:
[Enter Ounces] ........................ {BOX_03}
REF ................................... –7 {BOX_03}
DK .................................... –8 {BOX_03}
PROBE FOR OUNCES IF NOT REPORTED.
----------------------------------------------------
| SOFT CHECK: |
| SOFT RANGE CHECK: 0-15 |
----------------------------------------------------
----------------------------------------------------
| EDIT: IF POUNDS (CS25_01) = 0, THEN OUNCES MUST |
| BE 1-16. |
----------------------------------------------------
BOX_03
======
----------------------------------------------------
| IF RU MEMBER BEING ASKED ABOUT IS AGED 3-6 YEARS, |
| INCLUSIVE, OR IN AGE CATEGORIES 2 OR 3, CONTINUE |
| WITH CS26 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_04 |
----------------------------------------------------
CS26
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Has a doctor or other health provider ever checked (PERSON)’s
vision?
YES .................................... 1 {BOX_04}
NO ..................................... 2 {BOX_04}
TRIED, BUT (PERSON) WAS UNCOOPERATIVE .. 3 {BOX_04}
REF ................................... -7 {BOX_04}
DK .................................... -8 {BOX_04}
----------------------------------------------------
| ‘(PERSON)’ IN THE TEXT FOR CATEGORY 3 SHOULD BE IN|
| PURPLE. |
----------------------------------------------------
BOX_04
======
----------------------------------------------------
| IF RU MEMBER BEING ASKED ABOUT IS > OR = 2 YEARS |
| OF AGE OR IN AGE CATEGORIES 2 THROUGH 4, CONTINUE |
| WITH CS27 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_05 |
----------------------------------------------------
CS27
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Has a doctor or other health provider ever measured (PERSON)’s
blood pressure?
YES .................................... 1 {CS27OV}
NO ..................................... 2 {CS28}
TRIED, BUT (PERSON) WAS UNCOOPERATIVE .. 3 {CS27OV}
REF ................................... -7 {CS28}
DK .................................... -8 {CS28}
----------------------------------------------------
| ‘(PERSON)’ IN THE TEXT FOR CATEGORY 3 SHOULD BE IN|
| PURPLE. |
----------------------------------------------------
CS27OV
======
When was that?
WITHIN PAST YEAR ....................... 1 {CS28}
WITHIN PAST 2 YEARS .................... 2 {CS28}
MORE THAN 2 YEARS ...................... 3 {CS28}
REF ................................... -7 {CS28}
DK .................................... -8 {CS28}
[Code One]
CS28
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Has a doctor or other health provider ever given you or (PERSON)
advice about (PERSON) having regular dental check-ups?
YES .................................... 1 {CS28OV}
NO ..................................... 2 {CS29}
REF ................................... -7 {CS29}
DK .................................... -8 {CS29}
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
CS28OV
======
When was that?
WITHIN PAST YEAR ....................... 1 {CS29}
WITHIN PAST 2 YEARS .................... 2 {CS29}
MORE THAN 2 YEARS ...................... 3 {CS29}
REF ................................... -7 {CS29}
DK .................................... -8 {CS29}
[Code One]
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
CS29
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Has a doctor or other health provider ever given you or (PERSON)
advice about (PERSON) eating healthy?
YES .................................... 1 {CS29OV}
NO ..................................... 2 {CS30}
REF ................................... -7 {CS30}
DK .................................... -8 {CS30}
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
CS29OV
======
When was that?
WITHIN PAST YEAR ....................... 1 {CS30}
WITHIN PAST 2 YEARS .................... 2 {CS30}
MORE THAN 2 YEARS ...................... 3 {CS30}
REF ................................... -7 {CS30}
DK .................................... -8 {CS30}
[Code One]
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
CS30
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Has a doctor or other health provider ever given you or (PERSON)
advice about the amount and kind of exercise, sports, or
physically active hobbies (PERSON) should have?
YES .................................... 1 {CS30OV}
NO ..................................... 2 {BOX_05}
REF ................................... -7 {BOX_05}
DK .................................... -8 {BOX_05}
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
CS30OV
======
When was that?
WITHIN PAST YEAR ....................... 1 {BOX_05}
WITHIN PAST 2 YEARS .................... 2 {BOX_05}
MORE THAN 2 YEARS ...................... 3 {BOX_05}
REF ................................... -7 {BOX_05}
DK .................................... -8 {BOX_05}
[Code One]
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
BOX_05
======
----------------------------------------------------
| IF RU MEMBER BEING ASKED ABOUT: |
| - HAS A WEIGHT AT CS25_01 < OR = 40 POUNDS, |
| OR |
| - IF CS25_01 IS CODED ‘REF’ OR ‘DK’ |
| AND |
| - PERSON < OR = 4 YEARS OF AGE (OR IN AGE |
| CATEGORIES 1 OR 2), |
| CONTINUE WITH CS31 |
----------------------------------------------------
----------------------------------------------------
| IF RU MEMBER BEING ASKED ABOUT: |
| - HAS A WEIGHT AT CS25_01 > 40 AND < OR = 80 |
| POUNDS |
| OR |
| - IF CS25_01 IS CODED ‘REF’ OR ‘DK’ |
| AND |
| - PERSON > 4 AND < OR = 9 YEARS OF AGE (OR IN AGE |
| CATEGORY 3), |
| GO TO CS32 |
----------------------------------------------------
----------------------------------------------------
| IF RU MEMBER BEING ASKED ABOUT: |
| - HAS A WEIGHT AT CS25_01 > 80 POUNDS, |
| OR |
| - IF CS25_01 IS CODED ‘REF’ OR ‘DK’ |
| AND |
| - PERSON > 9 YEARS OF AGE (OR IN AGE CATEGORY 4), |
| GO TO CS33 |
----------------------------------------------------
CS31
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Has a doctor or other health provider ever given you or (PERSON)
advice about (PERSON) using a child safety seat while riding in
the car?
YES .................................... 1 {CS31OV}
NO ..................................... 2 {BOX_06}
REF ................................... -7 {BOX_06}
DK .................................... -8 {BOX_06}
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
CS31OV
======
When was that?
WITHIN PAST YEAR ....................... 1 {BOX_06}
WITHIN PAST 2 YEARS .................... 2 {BOX_06}
MORE THAN 2 YEARS ...................... 3 {BOX_06}
REF ................................... -7 {BOX_06}
DK .................................... -8 {BOX_06}
[Code One]
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
CS32
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Has a doctor or other health provider ever given you or (PERSON)
advice about (PERSON) using a booster seat when riding in the car?
YES .................................... 1 {CS32OV}
NO ..................................... 2 {BOX_05A}
REF ................................... -7 {BOX_05A}
DK .................................... -8 {BOX_05A}
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
CS32OV
======
When was that?
WITHIN PAST YEAR ....................... 1 {BOX_05A}
WITHIN PAST 2 YEARS .................... 2 {BOX_05A}
MORE THAN 2 YEARS ...................... 3 {BOX_05A}
REF ................................... -7 {BOX_05A}
DK .................................... -8 {BOX_05A}
[Code One]
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
BOX_05A
=======
----------------------------------------------------
| IF CS25_01 IS CODED ‘REF’ OR ‘DK’ FOR RU MEMBER |
| BEING ASKED ABOUT AND PERSON IS IN AGE CATEGORY 3 |
| (AGE IS UNKNOWN), CONTINUE WITH CS33 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_06 |
----------------------------------------------------
CS33
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Has a doctor or other health provider ever given you or (PERSON)
advice about (PERSON) using lap and shoulder belts when driving
or riding in a car?
YES .................................... 1 {CS33OV}
NO ..................................... 2 {BOX_06}
REF ................................... -7 {BOX_06}
DK .................................... -8 {BOX_06}
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
CS33OV
======
When was that?
WITHIN PAST YEAR ....................... 1 {BOX_06}
WITHIN PAST 2 YEARS .................... 2 {BOX_06}
MORE THAN 2 YEARS ...................... 3 {BOX_06}
REF ................................... -7 {BOX_06}
DK .................................... -8 {BOX_06}
[Code One]
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
BOX_06
======
----------------------------------------------------
| IF RU MEMBER BEING ASKED ABOUT IS > OR = 2 YEARS |
| OF AGE OR IN AGE CATEGORIES 2 THROUGH 4, CONTINUE |
| WITH CS34 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO CS35 |
----------------------------------------------------
CS34
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Has a doctor or other health provider ever given you or (PERSON)
advice about (PERSON) using a helmet when riding a bicycle or
motorcycle?
YES .................................... 1 {CS34OV}
NO ..................................... 2 {CS35}
REF ................................... -7 {CS35}
DK .................................... -8 {CS35}
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU (ABOUT
HELMETS).”
CS34OV
======
When was that?
WITHIN PAST YEAR ....................... 1 {CS35}
WITHIN PAST 2 YEARS .................... 2 {CS35}
MORE THAN 2 YEARS ...................... 3 {CS35}
REF ................................... -7 {CS35}
DK .................................... -8 {CS35}
[Code One]
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU (ABOUT
HELMETS).”
CS35
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Has a doctor or other health provider ever given you advice about
how smoking in the house can be bad for (PERSON)’s health?
YES .................................... 1 {CS35OV}
NO ..................................... 2 {BOX_07}
REF ................................... -7 {BOX_07}
DK .................................... -8 {BOX_07}
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
CS35OV
======
When was that?
WITHIN PAST YEAR ....................... 1 {BOX_07}
WITHIN PAST 2 YEARS .................... 2 {BOX_07}
MORE THAN 2 YEARS ...................... 3 {BOX_07}
REF ................................... -7 {BOX_07}
DK .................................... -8 {BOX_07}
[Code One]
HELP AVAILABLE FOR DEFINITION OF “ADVICE TO YOU.”
BOX_07
======
----------------------------------------------------
| IF RU MEMBER BEING ASKED ABOUT IS > OR = 12 YEARS |
| OF AGE OR IN AGE CATEGORY 4, CONTINUE WITH CS36 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO END_LP01 |
----------------------------------------------------
CS36
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
The last time (PERSON) had a health care visit, did a doctor
or other health provider spend any time alone with (PERSON)
without a parent, relative or guardian in the room?
YES .................................... 1 {END_LP01}
NO ..................................... 2 {END_LP01}
REF ................................... -7 {END_LP01}
DK .................................... -8 {END_LP01}
END_LP01
========
----------------------------------------------------
| CYCLE ON NEXT PERSON IN THE RU-MEMBERS-ROSTER WHO |
| MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION|
----------------------------------------------------
----------------------------------------------------
| IF NO OTHER PERSONS MEET THE STATED CONDITIONS, |
| END LOOP_01 AND CONTINUE WITH BOX_08 |
----------------------------------------------------
BOX_08
======
---------------------------------------------------
| GO TO NEXT QUESTIONNAIRE SECTION |
---------------------------------------------------
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