Child Preventive Health Supplement (CS) Section

BOX_00A

THE CS SECTION IS ASKED IN ROUNDS 2 AND 4 ONLY. IF
IT IS ROUND 1, 3, OR 5, CONTINUE TO THE NEXT
SECTION.

BOX_00

CONTEXT HEADER DISPLAY INSTRUCTIONS:
DISPLAY PERS.FULLNAME.

BOX_01

IF ANY RU MEMBERS < OR = 17 YEARS OF AGE OR IN AGE
CATEGORIES 1 THROUGH 4, CONTINUE WITH LOOP_01

OTHERWISE, GO TO BOX_08

LOOP_01

FOR EACH ELEMENT IN THE RU-MEMBERS-ROSTER,
ASK NAV_CS01 - END_LP01

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

NAVIGATOR DETAILS: LOOP_01 USES NAV_CS01 TO
CONTROL THE FLOW OF THE LOOP.

NAV_CS01

SERIES: All Child Preventive Health Questions (i.e., child’s
health needs, behavioral ratings, etc.)

USE THE LINKS BELOW TO COMPLETE ALL QUESTIONS WITHIN THIS SERIES.

WHEN ALL LINKS ARE MARKED "DONE," USE [Continue Interview] TO GO
PAST THIS SERIES.

IF NEEDED, [Previous Page] WILL TAKE YOU TO QUESTIONS BEFORE THIS
SERIES.

RU Member

[1. First Name,[Middle Name],Last Name-65] [Status-25]
[2. First Name,[Middle Name],Last Name-65] [Status-25]
[3. First Name,[Middle Name],Last Name-65] [Status-25]

ROSTER DETAILS:
COL # 1 HEADER: RU MEMBER
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)
COL # 2 HEADER: EMPTY
INSTRUCTIONS: DISPLAY THE MOST CURRENT NAVIGATOR
STATUS FOR EACH RU MEMBER EACH TIME THE NAVIGATOR
IS PRESENTED

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS WHO MEET 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

CONTINUE WITH CS01 FOR SELECTED RU MEMBER

CS01

{PERSON’S FIRST MIDDLE AND LAST NAME}

SHOW CARD CS-1.

{Now I’d like to talk about {you/{PERSON}}.}

The following are statements about {your/{PERSON}’s} general health
status.

How true or false is each of these statements for {you/him/her}?

USE TAB TO GO TO NEXT LINE.

1 = DEFINITELY TRUE
2 = MOSTLY TRUE
3 = DON’T KNOW
4 = MOSTLY FALSE
5 = DEFINITELY FALSE

CS01_01

a. {I/He/She} seem{s} to be less healthy than other
children that I know. ( )

CS01_02

b. {I/He/She} {have/has} has never been seriously ill. ( )

CS01_03

c. When there is something going around, {I/he/she}
usually catch{es} it. ( )

CS01_04

d. I expect {I/he/she} will have a very healthy life. ( )

CS01_05

e. I worry more about {my/his/her} health than other
people worry about their children’s health. ( )

DISPLAY "Now I’d like to talk about {you/
{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.

REFUSED (-7) ALLOWED ON ALL ENTRY FIELDS.

CONTINUE WITH BOX_01A

BOX_01A

IF FIRST CYCLE OF LOOP, CONTINUE WITH CS02

OTHERWISE, GO TO CS03

CS02

{PERSON’S FIRST MIDDLE AND LAST NAME}

The next questions are about {your/{PERSON}’s} health needs and whether
{you/he/she} {have/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}

{Do/Does} {you/{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}

{Do/Does} {you/{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}

{Are/Is} {you/PERSON}} limited or prevented in any way in {your/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}

{Do/Does} {you/{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}

{Do/Does} {you/{PERSON}} have any kind of emotional, developmental or
behavioral problem for which {you/he/she} need{s} or get{s} 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

IF RU MEMBER BEING ASKED ABOUT IS AGED 5-17 YEARS,
INCLUSIVE, OR IN AGE CATEGORIES 3 OR 4, CONTINUE
WITH CS08

OTHERWISE, GO TO CS09A

CS08

{PERSON’S FIRST MIDDLE AND LAST NAME}

SHOW CARD CS-2.

The following questions are about some aspects of {your/{PERSON}’s}
health.

In this series of questions, please rate {yourself/him/her} 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 {you/{PERSON}} {have/has}
{have/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 {you/he/she} {have/has} with (ACTIVITY).

CODE 99 IF RESPONDENT INDICATES THE QUESTION IS INAPPLICABLE.

CS08_01. a. Getting along with {your/his/her} mother? ( )
CS08_02. b. Getting along with {your/his/her} father? ( )
CS08_03. c. Feeling unhappy or sad? ( )
CS08_04. d. {Your/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. {Your/His/Her} schoolwork? ( )
CS08_12. l. {Your/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}

In the last 12 months, did {you/{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 {you/{PERSON}} needed care right away, how
often did {you/he/she} get care as soon as you thought {you/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 {you/{PERSON}} needed
health care right away, did you make any appointments for {your/his/her}
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 {you/{PERSON}} needed health
care right away, how often did {you/he/she} get an appointment for
health care at a doctor’s office or clinic as soon as you thought
{you/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-4.

In the last 12 months, not counting times {you/{PERSON}} went to an
emergency room, how many times did {you/he/she} 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 {you/{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 {your/{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 {your/{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 {your/{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 {you/{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 {your/{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 {you/{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 {you/{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}

Has a doctor or other health provider ever measured {your/{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 {are/is} {you/{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

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 {your/{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 {do/does} {you/{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

{PROBE FOR OUNCES IF NOT REPORTED.}

OUNCES:

[Enter Ounces] ........................ {BOX_03}
REF ................................... –7 {BOX_03}
DK .................................... –8 {BOX_03}

DISPLAY ‘PROBE FOR OUNCES IF NOT REPORTED.’ IF
CS25_01 IS < OR = 20 POUNDS.

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 {your/{PERSON}’s}
vision?

YES .................................... 1 {BOX_04}
NO ..................................... 2 {BOX_04}
TRIED, BUT {YOU/HE/SHE} {WERE/WAS}
UNCOOPERATIVE .......................... 3 {BOX_04}
REF ................................... -7 {BOX_04}
DK .................................... -8 {BOX_04}

[Code One]

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 {your/{PERSON}’s}
blood pressure?

YES .................................... 1 {CS27OV}
NO ..................................... 2 {CS28}
TRIED, BUT {YOU/HE/SHE} {WERE/WAS} ..... 3 {CS27OV}
REF ................................... -7 {CS28}
DK .................................... -8 {CS28}

[Code One]

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 {{him/her}} 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."

DISPLAY ‘or {PERSON}’ AND ‘{him/her}’ IF PERSON
BEING ASKED ABOUT IS NOT SELECTED AS THE
RESPONDENT. OTHERWISE, (PERSON BEING ASKED ABOUT
IS SELECTED AS THE RESPONDENT), USE A NULL
DISPLAY.

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 {{him/her}} 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 {you/he/she} 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 {{him/her}} 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 {{him/her}} 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 {{him/her}} 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 {{him/her}} 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 {your/{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 {you/{PERSON}} had a health care visit, did a doctor
or other health provider spend any time alone with {you/him/her}
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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