Child Preventive Health (CS) Section

BOX_00 (CS1000)

BOX_10 (CS1001)

BOX_20 (CS1005)

BOX_30 (CS1010)

BOX_40 (CS1030)

CS10 (CS1065)

BLAISE NAME: NeedRxMed

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

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.

{Do/Does} {you/{PERSON}} currently need or use medicine prescribed by a doctor, other than vitamins?

HELP: F1

Responses: YES 1 CS20 (CS1070)

NO 2 CS40 (CS1080)

REFUSED RF CS40 (CS1080)

DON'T KNOW DK CS40 (CS1080)

Display Instructions: Display CS10, CS20, and CS30 on the same form pane.

CS20 (CS1070)

BLAISE NAME: RxMedCond

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

Is this because of any medical, behavioral or other health condition?

Responses: YES 1 CS30 (CS1075)

NO 2 CS40 (CS1080)

REFUSED RF CS40 (CS1080)

DON'T KNOW DK CS40 (CS1080)

Display Instructions: Display CS10, CS20, and CS30 on the same form pane.

CS30 (CS1075)

BLAISE NAME: RxCond12Mon

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

Is this a condition that has lasted or is expected to last for at least 12 months?

Responses: YES 1 CS40 (CS1080)

NO 2 CS40 (CS1080)

REFUSED RF CS40 (CS1080)

DON'T KNOW DK CS40 (CS1080)

Display Instructions: Display CS10, CS20, and CS30 on the same form pane.

CS40 (CS1080)

BLAISE NAME: MoreMedical

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

{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?

Responses: YES 1 CS50 (CS1085)

NO 2 CS70 (CS1095)

REFUSED RF CS70 (CS1095)

DON'T KNOW DK CS70 (CS1095)

Display Instructions: Display CS40, CS50, and CS60 on the same form pane.

CS50 (CS1085)

BLAISE NAME: MoreMedCond

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

Is this because of any medical, behavioral or other health condition?

Responses: YES 1 CS60 (CS1090)

NO 2 CS70 (CS1095)

REFUSED RF CS70 (CS1095)

DON'T KNOW DK CS70 (CS1095)

Display Instructions: Display CS40, CS50, and CS60 on the same form pane.

CS60 (CS1090)

BLAISE NAME: MoreMedCond12Mon

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

Is this a condition that has lasted or is expected to last for at least 12 months?

Responses: YES 1 CS70 (CS1095)

NO 2 CS70 (CS1095)

REFUSED RF CS70 (CS1095)

DON'T KNOW DK CS70 (CS1095)

Display Instructions: Display CS40, CS50, and CS60 on the same form pane.

CS70 (CS1095)

BLAISE NAME: LmtAbility

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

{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?

Responses: YES 1 CS80 (CS1100)

NO 2 CS100 (CS1110)

REFUSED RF CS100 (CS1110)

DON'T KNOW DK CS100 (CS1110)

Display Instructions: Display CS70, CS80, and CS90 on the same form pane.

CS80 (CS1100)

BLAISE NAME: LmtAbilityCond

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

Is this because of any medical, behavioral or other health condition?

Responses: YES 1 CS90 (CS1105)

NO 2 CS100 (CS1110)

REFUSED RF CS100 (CS1110)

DON'T KNOW DK CS100 (CS1110)

Display Instructions: Display CS70, CS80, and CS90 on the same form pane.

CS90 (CS1105)

BLAISE NAME: LmtAbilityCond12Mon

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

Is this a condition that has lasted or is expected to last for at least 12 months?

Responses: YES 1 CS100 (CS1110)

NO 2 CS100 (CS1110)

REFUSED RF CS100 (CS1110)

DON'T KNOW DK CS100 (CS1110)

Display Instructions: Display CS70, CS80, and CS90 on the same form pane.

CS100 (CS1110)

BLAISE NAME: SpeclThrpy

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

{Do/Does} {you/{PERSON}} need or get special therapy such as physical, occupational or speech therapy?

Responses: YES 1 CS110 (CS1115)

NO 2 CS130 (CS1125)

REFUSED RF CS130 (CS1125)

DON'T KNOW DK CS130 (CS1125)

Display Instructions: Display CS100, CS110, and CS120 on the same form pane.

CS110 (CS1115)

BLAISE NAME: SpeclThrpyCond

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

Is this because of any medical, behavioral or other health condition?

Responses: YES 1 CS120 (CS1120)

NO 2 CS130 (CS1125)

REFUSED RF CS130 (CS1125)

DON'T KNOW DK CS130 (CS1125)

Display Instructions: Display CS100, CS110, and CS120 on the same form pane.

CS120 (CS1120)

BLAISE NAME: SpeclThrpyCond12Mon

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

Is this a condition that has lasted or is expected to last for at least 12 months?

Responses: YES 1 CS130 (CS1125)

NO 2 CS130 (CS1125)

REFUSED RF CS130 (CS1125)

DON'T KNOW DK CS130 (CS1125)

Display Instructions: Display CS100, CS110, and CS120 on the same form pane.

CS130 (CS1125)

BLAISE NAME: ProbTrtmt

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

{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?

Responses: YES 1 CS140 (CS1130)

NO 2 BOX_50 (CS1135)

REFUSED RF BOX_50 (CS1135)

DON'T KNOW DK BOX_50 (CS1135)

Display Instructions: Display CS130 and CS140 on the same form pane.

CS140 (CS1130)

BLAISE NAME: ProbTrtmt12Mon

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

Is this a condition that has lasted or is expected to last for at least 12 months?

Responses: YES 1 BOX_50 (CS1135)

NO 2 BOX_50 (CS1135)

REFUSED RF BOX_50 (CS1135)

DON'T KNOW DK BOX_50 (CS1135)

Display Instructions: Display CS130 and CS140 on the same form pane.

BOX_50 (CS1135)

CS150A (CS1145)

BLAISE NAME: ProbTrouble

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

& CS-1.

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

{In this series of questions, please/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} with:

CODE 99 IF RESPONDENT INDICATES THE QUESTION IS INAPPLICABLE.

a. Getting into trouble?

Responses: 1 CS150B (CS1150)

REFUSED RF CS150B (CS1150)

DON'T KNOW DK CS150B (CS1150)

Programmer Instructions: Range check:

The values for TROUBLE should be between 0 and 4 and should also include 99. A check should be conducted to ensure that any values outside of these defined produce an error and prohibit the interviewer from continuing until corrected. If a value entered is outside the allowable range, display the following hard error message: "VALUE MUST BE BETWEEN 0 AND 4 OR 99 TO INDICATE INAPPLICABLE QUESTION. VERIFY AND CORRECT."

Display Instructions: The CS150 question series represent a stem and leaf question format. Each leaf in this stem and leaf series (CS150A - CS150D) should display on the same form pane. Use the same question stem display.

Display "{The following questions are about some aspects of {your/{PERSON}'s} health.}" only when presenting the first (stem) question for this person. Otherwise, use a null display.

Display "{In this series of questions, please…}" only when presenting the first (stem) question for this person in bold, black standard text. Otherwise, display "Please rate {yourself/him/her} on a scale of 0 to 4…" in grayed-out text for each subsequent (leaf) question in this series.

Display "In general, how much of a problem do you think {you/{PERSON}} {have/has} with: " in bold black standard text for the first question (stem) for this person. Otherwise, display it in brackets and "grayed-out" text for each subsequent (leaf) question in this series.

Display each leaf in bold black standard text when its entry field is active. Otherwise, always display in "grayed-out" text.

CS150B (CS1150)

BLAISE NAME: ProbMother

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

&CS-1.

[Please rate 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} with:]

CODE 99 IF RESPONDENT INDICATES THE QUESTION IS INAPPLICABLE.

b. Getting along with {your/his/her} mother?

Responses: 1 CS150C (CS1155)

REFUSED RF CS150C (CS1155)

DON'T KNOW DK CS150C (CS1155)

Programmer Instructions: Range check:

The values for MOTHPROB should be between 0 and 4 and should also include 99. A check should be conducted to ensure that any values outside of these defined produce an error and prohibit the interviewer from continuing until corrected. If a value entered is outside the allowable range, display the following hard error message: "VALUE MUST BE BETWEEN 0 AND 4 OR 99 TO INDICATE INAPPLICABLE QUESTION. VERIFY AND CORRECT."

Display Instructions: See CS150A for display instructions.

CS150C (CS1155)

BLAISE NAME: ProbFather

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

&CS-1.

[Please rate 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} with:]

CODE 99 IF RESPONDENT INDICATES THE QUESTION IS INAPPLICABLE.

c. Getting along with {your/his/her} father?

Responses: 1 CS150D (CS1160)

REFUSED RF CS150D (CS1160)

DON'T KNOW DK CS150D (CS1160)

Programmer Instructions: Range check:

The values for FATHPROB should be between 0 and 4 and should also include 99. A check should be conducted to ensure that any values outside of these defined produce an error and prohibit the interviewer from continuing until corrected. If a value entered is outside the allowable range, display the following hard error message: "VALUE MUST BE BETWEEN 0 AND 4 OR 99 TO INDICATE INAPPLICABLE QUESTION. VERIFY AND CORRECT."

Display Instructions: See CS150A for display instructions.

CS150D (CS1160)

BLAISE NAME: ProbSad

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

&CS-1.

[Please rate 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} with:]

CODE 99 IF RESPONDENT INDICATES THE QUESTION IS INAPPLICABLE.

d. Feeling unhappy or sad?

Responses: 1 CS160A (CS1165)

REFUSED RF CS160A (CS1165)

DON'T KNOW DK CS160A (CS1165)

Programmer Instructions: Range check:

The values for UNHAPSAD should be between 0 and 4 and should also include 99. A check should be conducted to ensure that any values outside of these defined produce an error and prohibit the interviewer from continuing until corrected. If a value entered is outside the allowable range, display the following hard error message: "VALUE MUST BE BETWEEN 0 AND 4 OR 99 TO INDICATE INAPPLICABLE QUESTION. VERIFY AND CORRECT."

Display Instructions: See CS150A for display instructions.

CS160A (CS1165)

BLAISE NAME: ProbSchBehav

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

&CS-1.

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 would you say {you/{PERSON}} {have/has}:

CODE 99 IF RESPONDENT INDICATES THE QUESTION IS INAPPLICABLE.

e. With {your/his/her} behavior at school?

Responses: 1 CS160B (CS1170)

REFUSED RF CS160B (CS1170)

DON'T KNOW DK CS160B (CS1170)

Programmer Instructions: Range check:

The values for should be between 0 and 4 and should also include 99. A check should be conducted to ensure that any values outside of these defined produce an error and prohibit the interviewer from continuing until corrected. If a value entered is outside the allowable range, display the following hard error message: "VALUE MUST BE BETWEEN 0 AND 4 OR 99 TO INDICATE INAPPLICABLE QUESTION. VERIFY AND CORRECT."

Display Instructions: The CS160 question series represent a stem and leaf question format. Each leaf in this stem and leaf series (CS160A - CS160C) should display on the same form pane. Use the same question stem display.

Display "Please rate on a scale of 0 to 4 where 0 indicates no problem and 4 indicates a very big problem" in bold black text for the first question (stem) in this series, otherwise, display this text in brackets and grayed-out text for each subsequent (leaf) question in this series.

Display "How much of a problem would you say {you/{PERSON}} {have/has}:" in bold black standard text for the first (stem) question. Otherwise, display it in brackets and grayed out text for each subsequent (leaf) question in this series.

Display each leaf in bold black standard text when its entry field is active. Otherwise, always display in "grayed-out" text.

CS160B (CS1170)

BLAISE NAME: ProbHaveFun

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

&CS-1.

CODE 99 IF RESPONDENT INDICATES THE QUESTION IS INAPPLICABLE.

[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 would you say {you/{PERSON}} {have/has}:]

f. With having fun?

Responses: 1 CS160C (CS1175)

REFUSED RF CS160C (CS1175)

DON'T KNOW DK CS160C (CS1175)

Programmer Instructions: Range check:

The values for HAVFUNPR should be between 0 and 4 and should also include 99. A check should be conducted to ensure that any values outside of these defined produce an error and prohibit the interviewer from continuing until corrected. If a value entered is outside the allowable range, display the following hard error message: "VALUE MUST BE BETWEEN 0 AND 4 OR 99 TO INDICATE INAPPLICABLE QUESTION. VERIFY AND CORRECT."

Display Instructions: See CS160A for display instructions.

CS160C (CS1175)

BLAISE NAME: ProbAdults

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

&CS-1.

[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 would you say {you/{PERSON}} {have/has}:]

CODE 99 IF RESPONDENT INDICATES THE QUESTION IS INAPPLICABLE.

g. Getting along with adults other than {your/his/her} mother/father?

Responses: 1 CS170A (CS1180)

REFUSED RF CS170A (CS1180)

DON'T KNOW DK CS170A (CS1180)

Programmer Instructions: Range check:

The values for ADULPROB should be between 0 and 4 and should also include 99. A check should be conducted to ensure that any values outside of these defined produce an error and prohibit the interviewer from continuing until corrected. If a value entered is outside the allowable range, display the following hard error message: "VALUE MUST BE BETWEEN 0 AND 4 OR 99 TO INDICATE INAPPLICABLE QUESTION. VERIFY AND CORRECT."

Display Instructions: See CS160A for display instructions.

CS170A (CS1180)

BLAISE NAME: ProbFearful

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

&CS-1.

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 {do/does} {you/{PERSON}} have:

CODE 99 IF RESPONDENT INDICATES THE QUESTION IS INAPPLICABLE.

h. With feeling nervous or afraid?

Responses: 1 CS170B (CS1185)

REFUSED RF CS170B (CS1185)

DON'T KNOW DK CS170B (CS1185)

Programmer Instructions: Range check:

The values for NERVAFRD should be between 0 and 4 and should also include 99. A check should be conducted to ensure that any values outside of these defined produce an error and prohibit the interviewer from continuing until corrected. If a value entered is outside the allowable range, display the following hard error message: "VALUE MUST BE BETWEEN 0 AND 4 OR 99 TO INDICATE INAPPLICABLE QUESTION. VERIFY AND CORRECT."

Display Instructions:

The CS170 question series represent a stem and leaf question format. Each leaf in this stem and leaf series (CS170A - CS170C) should display on the same form pane. Use the same question stem display.

Display "Please rate on a scale of 0 to 4 where 0 indicates no problem and 4 indicates a very big problem." In bold black text for the first question (stem) in this series, otherwise, display in brackets and grayed-out text for each subsequent (leaf) question in the series.

Display "How much of a problem {do/does} {you/{PERSON}} have:" in bold black standard text for the first (stem) question. Otherwise, display it in brackets and grayed out text for each subsequent (leaf) question in the series.

Display each leaf in bold black standard text when its entry field is active. Otherwise, always display in "grayed-out" text.

CS170B (CS1185)

BLAISE NAME: ProbSiblings

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

&CS-1.

[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 {do/does} {you/{PERSON}} have:]

CODE 99 IF RESPONDENT INDICATES THE QUESTION IS INAPPLICABLE.

i. Getting along with {your/his/her} brothers and sisters?

Responses: 1 CS170C (CS1190)

REFUSED RF CS170C (CS1190)

DON'T KNOW DK CS170C (CS1190)

Programmer Instructions: Range check:

The values for SIBSPROB should be between 0 and 4 and should also include 99. A check should be conducted to ensure that any values outside of these defined produce an error and prohibit the interviewer from continuing until corrected. If a value entered is outside the allowable range, display the following hard error message: "VALUE MUST BE BETWEEN 0 AND 4 OR 99 TO INDICATE INAPPLICABLE QUESTION. VERIFY AND CORRECT."

Display Instructions: See CS170A for display instructions.

CS170C (CS1190)

BLAISE NAME: ProbOthCh

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

&CS-1.

[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 {do/does} {you/{PERSON}} have:]

CODE 99 IF RESPONDENT INDICATES THE QUESTION IS INAPPLICABLE.

j. Getting along with other kids {your/his/her} age?

Responses: 1 CS180A (CS1195)

REFUSED RF CS180A (CS1195)

DON'T KNOW DK CS180A (CS1195)

Programmer Instructions: Range check:

The values for KIDSPROB should be between 0 and 4 and should also include 99. A check should be conducted to ensure that any values outside of these defined produce an error and prohibit the interviewer from continuing until corrected. If a value entered is outside the allowable range, display the following hard error message: "VALUE MUST BE BETWEEN 0 AND 4 OR 99 TO INDICATE INAPPLICABLE QUESTION. VERIFY AND CORRECT."

Display Instructions: See CS170A for display instructions.

CS180A (CS1195)

BLAISE NAME: ProbSportHobby

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

&CS-1.

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 would you say {you/{PERSON} {have/has}:

CODE 99 IF RESPONDENT INDICATES THE QUESTION IS INAPPLICABLE.

k. Getting involved in activities like sports or hobbies?

Responses: 1 CS180B (CS1200)

REFUSED RF CS180B (CS1200)

DON'T KNOW DK CS180B (CS1200)

Programmer Instructions: Range check:

The values for SPORTHOB should be between 0 and 4 and should also include 99. A check should be conducted to ensure that any values outside of these defined produce an error and prohibit the interviewer from continuing until corrected. If a value entered is outside the allowable range, display the following hard error message: "VALUE MUST BE BETWEEN 0 AND 4 OR 99 TO INDICATE INAPPLICABLE QUESTION. VERIFY AND CORRECT."

Display Instructions: The CS180 question series represent a stem and leaf question format. Each leaf in this stem and leaf series (CS180A - CS180C) should display on the same form pane. Use the same question stem display.

Display "Please rate on a scale of 0 to 4 where 0 indicates no problem and 4 indicates a very big problem." In bold black standard text for the first question (stem) in this series, otherwise, display in brackets and grayed-out text for each subsequent (leaf) question in this series.

Display "How much of a problem would you say {you/{PERSON}} {have/has}:" in bold black standard text for the first (stem) question. Otherwise, display it in brackets and grayed out text for each subsequent (leaf) question in this series.

Display each leaf in bold black standard when its entry field is active. Otherwise, always display in "grayed-out" text.

CS180B (CS1200)

BLAISE NAME: ProbSchWork

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

&CS-1.

[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 would you say {you/{PERSON}} {have/has}:]

CODE 99 IF RESPONDENT INDICATES THE QUESTION IS INAPPLICABLE.

l. With {your/his/her} school work {or doing {your/his/her} job}}?

Responses: 1 CS180C (CS1205)

REFUSED RF CS180C (CS1205)

DON'T KNOW DK CS180C (CS1205)

Programmer Instructions: Range check:

The values for SCHLWORK should be between 0 and 4 and should also include 99. A check should be conducted to ensure that any values outside of these defined produce an error and prohibit the interviewer from continuing until corrected. If a value entered is outside the allowable range, display the following hard error message: "VALUE MUST BE BETWEEN 0 AND 4 OR 99 TO INDICATE INAPPLICABLE QUESTION. VERIFY AND CORRECT."

Display Instructions: See CS180A for display instructions.

Display 'or doing {your/his/her}job}}' if RU member is = or > 16 years old (or in age category 4).

Otherwise, use a null display.

CS180C (CS1205)

BLAISE NAME: ProbHomeBehav

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

&CS-1.

[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 would you say {you/{PERSON}} {have/has}:]

CODE 99 IF RESPONDENT INDICATES THE QUESTION IS INAPPLICABLE.

m. With {your/his/her} behavior at home?

Responses: 1 BOX_60 (CS1206)

REFUSED RF BOX_60 (CS1206)

DON'T KNOW DK BOX_60 (CS1206)

Programmer Instructions: Range check:

The values for BEHVHOME should be between 0 and 4 and should also include 99. A check should be conducted to ensure that any values outside of these defined produce an error and prohibit the interviewer from continuing until corrected. If a value entered is outside the allowable range, display the following hard error message: "VALUE MUST BE BETWEEN 0 AND 4 OR 99 TO INDICATE INAPPLICABLE QUESTION. VERIFY AND CORRECT."

Display Instructions: See CS180A for display instructions.

BOX_60 (CS1206)

CS190 (CS1210)

BLAISE NAME: AcuteIll12Mon

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

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?

Responses: YES 1 CS200 (CS1215)

NO 2 CS210 (CS1220)

REFUSED RF CS210 (CS1220)

DON'T KNOW DK CS210 (CS1220)

Display Instructions: Display CS190 and CS200 on the same form pane.

CS200 (CS1215)

BLAISE NAME: AcuteCare12Mon

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

&CS-2.

Looking at card CS-2, in the last 12 months, when {you/{PERSON}} needed care right away, how often did {you/he/she} get care as soon as {you/he/she} needed?

Responses: NEVER 1 CS210 (CS1220)

SOMETIMES 2 CS210 (CS1220)

USUALLY 3 CS210 (CS1220)

ALWAYS 4 CS210 (CS1220)

REFUSED RF CS210 (CS1220)

DON'T KNOW DK CS210 (CS1220)

Display Instructions: Display CS190 and CS200 on the same form pane.

CS210 (CS1220)

BLAISE NAME: RoutnAppt12Mon

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

In the last 12 months, did you make any appointments for a check-up or routine care for {yourself/{PERSON}} at a doctor's office or clinic?

Responses: YES 1 CS220 (CS1225)

NO 2 CS230 (CS1230)

REFUSED RF CS230 (CS1230)

DON'T KNOW DK CS230 (CS1230)

Display Instructions: Display CS210 and CS220 on the same form pane.

CS220 (CS1225)

BLAISE NAME: OftRoutnAppt12Mon

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

&CS-2.

Looking at card CS-2, in the last 12 months, how often did you get an appointment for a check-up or routine care for {yourself/{PERSON}} at a doctor's office or clinic as soon as {you/he/she} needed?

Responses: NEVER 1 CS230 (CS1230)

SOMETIMES 2 CS230 (CS1230)

USUALLY 3 CS230 (CS1230)

ALWAYS 4 CS230 (CS1230)

REFUSED RF CS230 (CS1230)

DON'T KNOW DK CS230 (CS1230)

Display Instructions: Display CS210 and CS220 on the same form pane.

CS230 (CS1230)

BLAISE NAME: SeeProv12Mon

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

&CS-3.

Looking at card CS-3, 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?

Responses: NONE 0 CS290 (CS1270)

1 TIME 1 CS240 (CS1245)

2 TIMES 2 CS240 (CS1245)

3 TIMES 3 CS240 (CS1245)

4 TIMES 4 CS240 (CS1245)

5 TO 9 TIMES 5 CS240 (CS1245)

10 OR MORE TIMES 6 CS240 (CS1245)

REFUSED RF CS290 (CS1270)

DON'T KNOW DK CS290 (CS1270)

Display Instructions:

CS240 (CS1245)

BLAISE NAME: ProvExplain12Mon

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

&CS-2.

Looking at card CS-2, in the last 12 months, how often did {your/{PERSON}'s} doctors or other health professionals explain things about {your/his/her} health in a way that was easy to understand?

Responses: NEVER 1 CS250 (CS1250)

SOMETIMES 2 CS250 (CS1250)

USUALLY 3 CS250 (CS1250)

ALWAYS 4 CS250 (CS1250)

REFUSED RF CS250 (CS1250)

DON'T KNOW DK CS250 (CS1250)

Display Instructions:

CS250 (CS1250)

BLAISE NAME: ProvListen12Mon

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

&CS-2.

Looking at card CS-2, in the last 12 months, how often did {your/{PERSON}'s} doctors or other health professionals listen carefully to you?

Responses: NEVER 1 CS260 (CS1255)

SOMETIMES 2 CS260 (CS1255)

USUALLY 3 CS260 (CS1255)

ALWAYS 4 CS260 (CS1255)

REFUSED RF CS260 (CS1255)

DON'T KNOW DK CS260 (CS1255)

Display Instructions:

CS260 (CS1255)

BLAISE NAME: ProvRespect12Mon

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

&CS-2.

Looking at card CS-2, in the last 12 months, how often did {your/{PERSON}'s} doctors or other health professionals show respect for what you had to say?

Responses: NEVER 1 CS270 (CS1260)

SOMETIMES 2 CS270 (CS1260)

USUALLY 3 CS270 (CS1260)

ALWAYS 4 CS270 (CS1260)

REFUSED RF CS270 (CS1260)

DON'T KNOW DK CS270 (CS1260)

Display Instructions:

CS270 (CS1260)

BLAISE NAME: ProvTime12Mon

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

&CS-2.

Looking at card CS-2, in the last 12 months, how often did {your/{PERSON}'s} doctors or other health professionals spend enough time with {you/him/her}?

Responses: NEVER 1 CS280 (CS1265)

SOMETIMES 2 CS280 (CS1265)

USUALLY 3 CS280 (CS1265)

ALWAYS 4 CS280 (CS1265)

REFUSED RF CS280 (CS1265)

DON'T KNOW DK CS280 (CS1265)

Display Instructions:

CS280 (CS1265)

BLAISE NAME: RateHCare12Mon

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

&CS-4.

Please look at card CS-4. 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?

ENTER RATING:

Responses: 1 CS290 (CS1270)

REFUSED RF CS290 (CS1270)

DON'T KNOW DK CS290 (CS1270)

Display Instructions:

CS290 (CS1270)

BLAISE NAME: SpeclAppt12Mon

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

When you answer the next questions, do not include dental visits or care {you/{PERSON}} got when {you/he/she} stayed overnight in a hospital.

Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care.

In the last 12 months, did you make any appointments for {yourself/{PERSON}} to see a specialist?

Responses: YES 1 CS300 (CS1275)

NO 2 BOX_70 (CS1276)

REFUSED RF BOX_70 (CS1276)

DON'T KNOW DK BOX_70 (CS1276)

Display Instructions:

CS300 (CS1275)

BLAISE NAME: OftSpeclAppt12Mon

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

&CS-2.

Looking at card CS-2, in the last 12 months, how often did you get appointments for {yourself/{PERSON}} to see a specialist as soon as {you/he/she} needed?

Responses: NEVER 1 BOX_70 (CS1276)

SOMETIMES 2 BOX_70 (CS1276)

USUALLY 3 BOX_70 (CS1276)

ALWAYS 4 BOX_70 (CS1276)

REFUSED RF BOX_70 (CS1276)

DON'T KNOW DK BOX_70 (CS1276)

Display Instructions:

BOX_70 (CS1276)

Programmer Instructions: Subsection 4: The fourth subsection is the MEPS historical series on preventive care (CS310- CS520).

If the calendar year of CAPI administration is an even year, this subsection will be administered in round 2 (FirstPanYear=even),. If the calendar year of CAPI administration is an odd year (FirstPanYear=odd), this subsection will be administered in round 4 (panel 22 (2017) round 4 or panel 23 (2018) round 2).

If subsection is on route for inclusion in this round, continue with CS310. Otherwise, go to BOX_140.

CS310 (CS1280)

BLAISE NAME: ProvMeasrHeight

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

Has a doctor or other health provider ever measured {your/{PERSON}'s} height?

Responses: YES 1 CS320 (CS1285)

NO 2

REFUSED RF

DON'T KNOW DK

Programmer Instructions: If coded '2' (NO), 'RF' (REFUSED), or 'DK' (DON'T KNOW) and RU member is < or =5 years old (or in age categories 1 or 2), go to CS340. Otherwise, if coded '2' (NO), 'RF' (REFUSED), or 'DK' (DON'T KNOW) and RU member is > or = 6 years old (or in age categories 3 or 4), go to CS330_01.

Display Instructions: Display CS310 and CS320 on the same form pane.

CS320 (CS1285)

BLAISE NAME: WhenMeasrHeight

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

When was that?

Responses: WITHIN PAST YEAR 1

WITHIN PAST 2 YEARS 2

MORE THAN 2 YEARS 3

REFUSED RF

DON'T KNOW DK

Programmer Instructions: If RU member is < or = 5 years old (or in age categories 1 or 2), go to CS340. Otherwise, continue with CS330_01.

Display Instructions: Display CS310 and CS320 on the same form pane.

CS330_01 (CS1295)

BLAISE NAME: HeightFeet

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

About how tall {are/is} {you/{PERSON}} without shoes?

ENTER FEET

PROBE FOR INCHES IF NOT REPORTED.

Responses: 1 CS330_02 (CS1300)

REFUSED RF CS340 (CS1305)

DON'T KNOW DK CS340 (CS1305)

Programmer Instructions: Soft check: If amount is above 7, display the following message: "VALUE IS HIGHER THAN USUAL. VERIFY AND CORRECT IF NEEDED."

Display Instructions: Display CS330_01 and CS330_02 on the same form pane.

CS330_02 (CS1300)

BLAISE NAME: HeightInch

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

[About how tall {are/is} {you/{PERSON}} without shoes?]

ENTER INCHES

[PROBE FOR INCHES IF NOT REPORTED.]

Responses: 1 CS340 (CS1305)

REFUSED RF CS340 (CS1305)

DON'T KNOW DK CS340 (CS1305)

Programmer Instructions: Soft check:

If amount is above 11 when feet (CS330_01) > 0, display the following message: "VALUE IS HIGHER THAN USUAL. VERIFY AND CORRECT IF NEEDED."

If feet (CS330_01) = 0, inches (CS330_02) must be 1-30. If feet (CS330_01) > 0, inches (CS330_02) must be 0-11.

Display Instructions: Display CS330_01 and CS330_02 on the same form pane.

Display question text: "About how tall {are/is} {you/{PERSON}} without shoes?" in brackets and grayed out text.

CS340 (CS1305)

BLAISE NAME: ProvMeasrWeight

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

Has a doctor or other health provider ever measured {your/{PERSON}'s} weight?

Responses: YES 1 CS350 (CS1310)

NO 2

REFUSED RF

DON'T KNOW DK

Programmer Instructions: If coded '2' (NO), 'RF' (REFUSED), or 'DK' (DON'T KNOW) and RU member is < or = 5 years old (or in age categories 1 or 2), go to BOX_80. Otherwise, if coded '2' (NO), 'RF' (REFUSED), or 'DK' (DON'T KNOW) and RU member is > or = 6 years old (or in age categories 3 or 4), go to CS360.

Display Instructions: Display CS340 and CS350 on the same form pane.

CS350 (CS1310)

BLAISE NAME: WhenMeasrWeight

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

When was that?

Responses: WITHIN PAST YEAR 1

WITHIN PAST 2 YEARS 2

MORE THAN 2 YEARS 3

REFUSED RF

DON'T KNOW DK

Programmer Instructions: If RU member is < or = 5 years old (or in age categories 1 or 2), go to BOX_80. Otherwise, go to CS360.

Display Instructions: Display CS340 and CS350 on the same form pane.

CS360 (CS1320)

BLAISE NAME: WeightPound

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

About how much {do/does} {you/{PERSON}} weigh without shoes?

ENTER POUNDS

Responses: 1 BOX_80 (CS1330)

REFUSED RF BOX_80 (CS1330)

DON'T KNOW DK BOX_80 (CS1330)

Programmer Instructions: Soft check:

If amount is above 300, display the following message: "VALUE IS HIGHER THAN USUAL. VERIFY AND CORRECT IF NEEDED."

Display Instructions:

BOX_80 (CS1330)

CS370 (CS1335)

BLAISE NAME: ProvCheckVision

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

Has a doctor or other health provider ever checked {your/{PERSON}'s} vision?

Responses: YES 1 BOX_90 (CS1340)

NO 2 BOX_90 (CS1340)

TRIED, BUT {YOU/HE/SHE} {WERE/WAS} UNCOOPERATIVE 3 BOX_90 (CS1340)

REFUSED RF BOX_90 (CS1340)

DON'T KNOW DK BOX_90 (CS1340)

Display Instructions:

BOX_90 (CS1340)

CS380 (CS1365)

BLAISE NAME: AdvHlthFood

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

Has a doctor or other health provider ever given you {or {PERSON}} advice about {him/her} eating healthy?

HELP: F1

Responses: YES 1 CS390 (CS1370)

NO 2 CS400 (CS1375)

REFUSED RF CS400 (CS1375)

DON'T KNOW DK CS400 (CS1375)

Display Instructions: Display 'or {PERSON}' and '{him/her}' if RU member being asked about is not selected as the respondent. Otherwise, (RU member being asked about is selected as the respondent), use a null display.

Display CS380 and CS390 on the same form pane.

CS390 (CS1370)

BLAISE NAME: WhenAdvHlthFood

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

When was that?

Responses: WITHIN PAST YEAR 1 CS400 (CS1375)

WITHIN PAST 2 YEARS 2 CS400 (CS1375)

MORE THAN 2 YEARS 3 CS400 (CS1375)

REFUSED RF CS400 (CS1375)

DON'T KNOW DK CS400 (CS1375)

Display Instructions: Display CS380 and CS390 on the same form pane.

CS400 (CS1375)

BLAISE NAME: AdvExer

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

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?

HELP: F1

Responses: YES 1 CS410 (CS1380)

NO 2 BOX_100 (CS1385)

REFUSED RF BOX_100 (CS1385)

DON'T KNOW DK BOX_100 (CS1385)

Display Instructions: Display CS400 and CS410 on the same form pane.

Display 'or {PERSON}' if RU member being asked about is NOT selected as the respondent.

Otherwise, (RU member being asked about is selected as the respondent), use a null display.

CS410 (CS1380)

BLAISE NAME: WhenAdvExer

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

When was that?

Responses: WITHIN PAST YEAR 1 BOX_100 (CS1385)

WITHIN PAST 2 YEARS 2 BOX_100 (CS1385)

MORE THAN 2 YEARS 3 BOX_100 (CS1385)

REFUSED RF BOX_100 (CS1385)

DON'T KNOW DK BOX_100 (CS1385)

Display Instructions: Display CS400 and CS410 on the same form pane.

BOX_100 (CS1385)

CS420 (CS1390)

BLAISE NAME: AdvSafetySeat

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

Has a doctor or other health provider ever given you advice about {him/her} using a child safety seat while riding in the car?

HELP: F1

Responses: YES 1 CS430 (CS1395)

NO 2 BOX_120 (CS1425)

REFUSED RF BOX_120 (CS1425)

DON'T KNOW DK BOX_120 (CS1425)

Display Instructions: Display CS420 and CS430 on the same form pane.

CS430 (CS1395)

BLAISE NAME: WhenAdvSafetySeat

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

When was that?

Responses: WITHIN PAST YEAR 1 BOX_120 (CS1425)

WITHIN PAST 2 YEARS 2 BOX_120 (CS1425)

MORE THAN 2 YEARS 3 BOX_120 (CS1425)

REFUSED RF BOX_120 (CS1425)

DON'T KNOW DK BOX_120 (CS1425)

Display Instructions: Display CS420 and CS430 on the same form pane.

CS440 (CS1400)

BLAISE NAME: AdvBooster

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

Has a doctor or other health provider ever given you advice about {him/her} using a booster seat when riding in the car?

HELP: F1

Responses: YES 1 CS450 (CS1405)

NO 2 BOX_110 (CS1410)

REFUSED RF BOX_110 (CS1410)

DON'T KNOW DK BOX_110 (CS1410)

Display Instructions: Display CS440 and CS450 on the same form pane.

CS450 (CS1405)

BLAISE NAME: WhenAdvBooster

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

When was that?

Responses: WITHIN PAST YEAR 1 BOX_110 (CS1410)

WITHIN PAST 2 YEARS 2 BOX_110 (CS1410)

MORE THAN 2 YEARS 3 BOX_110 (CS1410)

REFUSED RF BOX_110 (CS1410)

DON'T KNOW DK BOX_110 (CS1410)

Display Instructions: Display CS440 and CS450 on the same form pane.

BOX_110 (CS1410)

CS460 (CS1415)

BLAISE NAME: AdvBelts

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

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?

HELP: F1

Responses: YES 1 CS470 (CS1420)

NO 2 BOX_120 (CS1425)

REFUSED RF BOX_120 (CS1425)

DON'T KNOW DK BOX_120 (CS1425)

Display Instructions: Display 'or {PERSON}' and '{him/her}' if RU member being asked about is not selected as the respondent. Otherwise, (RU member being asked about is selected as the respondent), use a null display.

Display CS460 and CS470 on the same form pane.

CS470 (CS1420)

BLAISE NAME: WhenAdvBelts

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

When was that?

Responses: WITHIN PAST YEAR 1 BOX_120 (CS1425)

WITHIN PAST 2 YEARS 2 BOX_120 (CS1425)

MORE THAN 2 YEARS 3 BOX_120 (CS1425)

REFUSED RF BOX_120 (CS1425)

DON'T KNOW DK BOX_120 (CS1425)

Display Instructions: Display CS460 and CS470 on the same form pane.

BOX_120 (CS1425)

CS480 (CS1430)

BLAISE NAME: AdvHelmet

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

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?

HELP: F1

Responses: YES 1 CS490 (CS1435)

NO 2 CS500 (CS1440)

REFUSED RF CS500 (CS1440)

DON'T KNOW DK CS500 (CS1440)

Display Instructions: Display 'or {PERSON}' and '{him/her}' if RU member being asked about is not selected as the respondent. Otherwise, (RU member being asked about is selected as the respondent), use a null display.

Display CS480 and CS490 on the same form pane.

CS490 (CS1435)

BLAISE NAME: WhenAdvHelmet

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

When was that?

Responses: WITHIN PAST YEAR 1 CS500 (CS1440)

WITHIN PAST 2 YEARS 2 CS500 (CS1440)

MORE THAN 2 YEARS 3 CS500 (CS1440)

REFUSED RF CS500 (CS1440)

DON'T KNOW DK CS500 (CS1440)

Display Instructions: Display CS480 and CS490 on the same form pane.

CS500 (CS1440)

BLAISE NAME: AdvSmoking

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

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?

HELP: F1

Responses: YES 1 CS510 (CS1445)

NO 2 BOX_130 (CS1450)

REFUSED RF BOX_130 (CS1450)

DON'T KNOW DK BOX_130 (CS1450)

Display Instructions: Display CS500 and CS510 on the same form pane.

CS510 (CS1445)

BLAISE NAME: WhenAdvSmoking

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

When was that?

Responses: WITHIN PAST YEAR 1 BOX_130 (CS1450)

WITHIN PAST 2 YEARS 2 BOX_130 (CS1450)

MORE THAN 2 YEARS 3 BOX_130 (CS1450)

REFUSED RF BOX_130 (CS1450)

DON'T KNOW DK BOX_130 (CS1450)

Display Instructions: Display CS500 and CS510 on the same form pane.

BOX_130 (CS1450)

CS520 (CS1455)

BLAISE NAME: ProvAlone

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

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?

Responses: YES 1 BOX_140 (CS1465)

NO 2 BOX_140 (CS1465)

REFUSED RF BOX_140 (CS1465)

DON'T KNOW DK BOX_140 (CS1465)

Display Instructions:

BOX_140 (CS1465)

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