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Medical Expenditure Panel Survey
Your Child’s Health & Health Care
What are your experiences with your child’s health care?
The Agency for Healthcare Research and Quality and
The National Center for Health Statistics of the U.S. Public Health Service
OMB # 0935-0104
Name of person completing booklet: ______________________________________________
Relationship to child named above: ________________________________________________
SURVEY INSTRUCTIONS: Please answer every question by checking one box.
If you are unsure
about how to answer a question, please give the best answer you can.
Your participation is voluntary and all of your answers will be kept
confidential. If you have any
questions about this booklet, please call Alex Scott at 1-800-945-MEPS
(6377).
When you have completed the booklet, please fold it, seal it with this
label,
and place it in the envelope provided. Have it ready to give to your
interviewer at his or her next visit.
Child health care is an area of special interest in MEPS. Please take
a few
minutes to answer the questions in this booklet about the health and
health
care of the child named below. The questions should be answered by the
adult household member who knows the most about this child’s health
care.
Complete this booklet for:
RUID: __________________ VERSION: ____________
NAME: ________________________________________
DOB: __________________ PID: ________________
YOUR CHILD’S HEALTH CARE IN THE LAST 12 MONTHS
1. A health provider could be a general doctor, a specialist
doctor, a nurse practitioner, a physician assistant, a
nurse, or anyone else your child would see for health
care.
In the last 12 months, did you make any appointments
for your child with a doctor or other health
provider for regular or routine health care?
Yes..........................................
No .........................................GO TO QUESTION 3
2. In the last 12 months, how often did your child get an
appointment for regular or routine health care as
soon as you wanted?
Never ..................................................
Sometimes..........................................
Usually................................................
Always ................................................
My child didn’t need an appointment for regular or routine care
in the last
12 months.........................................
3. In the last 12 months, did your child have an illness
or injury that needed care right away from a doctor’s
office, clinic, or emergency room?
Yes..........................................
No .........................................GO TO QUESTION 5
4. In the last 12 months, when your child needed care
right away for an illness or injury, how often did
your child get care as soon as you wanted?
Never ..................................................
Sometimes..........................................
Usually................................................
Always ................................................
My child didn’t need care right away for an illness or injury in
the last
12 months.........................................
5. In the last 12 months (not counting times your child
went to an emergency room), how many times did
your child go to a doctor’s office or clinic?
None ..................................................
1 ........................................................
2 ........................................................
3 ........................................................
4 ........................................................
5 to 9 ..................................................
10 or more..........................................
GETTING NEEDED CARE
6. In the last 12 months, how much of a problem, if any,
was it to get care for your child that you or a doctor
believed necessary?
A big problem ....................................
A small problem ................................
Not a problem....................................
My child had no visits in the last 12 months. .........
7. In the last 12 months, how often did your child’s doctors
or other health providers listen carefully to you?
Never ..................................................
Sometimes..........................................
Usually................................................
Always ................................................
I don’t know ......................................
My child had no visits in the last 12 months.............
8. In the last 12 months, how often did your child’s doctors
or other health providers explain things in a way
you could understand?
Never ..................................................
Sometimes..........................................
Usually................................................
Always ................................................
I don’t know ......................................
My child had no visits in the last 12 months. ..............
9. In the last 12 months, how often did your child’s doctors
or other health providers show respect for what
you had to say?
Never ..................................................
Sometimes..........................................
Usually................................................
Always ................................................
I don’t know ......................................
My child had no visits in the last 12 months..............
10. In the last 12 months, how often did doctors or other
health providers spend enough time with you and
your child?
Never ..................................................
Sometimes..........................................
Usually................................................
Always ................................................
I don’t know ......................................
My child had no visits in the last 12 months. .............
OVERALL RATING OF CHILD’S HEALTH CARE
11. We want to know your rating of all your child’s health
care in the last 12 months from all doctors and other
health providers.
Use any number from 0 to 10 where 0 is the worst health
care possible, and 10 is the best health care possible. How
would you rate all your child’s health care?
0 Worst health care possible ..............
1 ........................................................
2 ........................................................
3 ........................................................
4 ........................................................
5 ........................................................
6 ........................................................
7 ........................................................
8 ........................................................
9 ........................................................
10 Best health care possible ..............
My child had no visits in the last 12 months..............
GETTING HEALTH CARE FROM A SPECIALIST
When answering the next questions, do not include dental
visits.
12. 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 your
child needed to see a specialist?
Yes..........................................
No .........................................GO TO QUESTION 14
13. In the last 12 months, how much of a problem, if any,
was it to get a referral to a specialist that your child
needed to see?
A big problem ....................................
A small problem ................................
Not a problem....................................
My child didn’t need to see a specialist in the last 12 months.......
QUESTIONS ABOUT YOUR CHILD’S HEALTH
The next questions are about your child’s health needs
and whether your child has a health condition. A health
condition can be physical, mental, or behavioral. Health
conditions may affect a child’s development, daily function,
or need for services.
14. Does your child currently need or use medicine
prescribed by a doctor, other than vitamins?
Yes..........................................
No .......................................GO TO QUESTION 15
A. Is this because of any medical, behavioral,
or other health condition?
Yes..........................................
No .......................................GO TO QUESTION 15
B. Is this a condition that has lasted or is expected
to last for at least 12 months?
Yes..........................................
No ..........................................
15. Does your child need or use more medical care,
mental health, or educational services than is usual
for most children of the same age?
Yes.........................................
No .........................................GO TO QUESTION 16
A. Is this because of any medical, behavioral,
or other health condition?
Yes..........................................
No .........................................GO TO QUESTION 16
B. Is this a condition that has lasted or is expected
to last for at least 12 months?
Yes..........................................
No ..........................................
16. Is your child limited or prevented in any way in his
or her ability to do the things most children of the
same age can do?
Yes..........................................
No ..........................................GO TO QUESTION 17
A. Is this because of any medical, behavioral, or other health condition?
Yes..........................................
No .........................................GO TO QUESTION 17
B. Is this a condition that has lasted or is expected
to last for at least 12 months?
Yes..........................................
No ..........................................
17. Does your child need or get special therapy, such
as physical, occupational, or speech therapy?
Yes..........................................
No .........................................GO TO QUESTION 18
A. Is this because of any medical, behavioral, or
other health condition?
Yes..........................................
No .........................................GO TO QUESTION 18
B. Is this a condition that has lasted or is expected
to last for at least 12 months?
Yes..........................................
No ..........................................
18. Does your child have any kind of emotional, developmental,
or behavioral problem for which he or she
needs or gets treatment or counseling?
Yes..........................................
No ..........................................THANK YOU FOR YOUR
PARTICIPATION.
A. Has this problem lasted or is it expected to last
for at least 12 months?
Yes..........................................
No ..........................................
Thank you for taking the time to complete this survey.
Remember to fold it, seal it, and place it in the envelope provided.
This survey is part of the Medical Expenditure Panel Survey, conducted
by the U.S. Public Health Service. This survey is authorized under Section
902(a)
of the Public Health Service Act [42 U.S.C. 299a]. The confidentiality
of personal information is protected by Federal statute, Section 903(c)
and Section
308(d) of the Public Health Service Act [42 U.S.C 299a – 1(c) and
242m(d)]. This law prohibits release of personal information outside
the public health
agencies sponsoring the survey or their contractors without first obtaining
permission from the person who gave the information. The Federal government
requires that all persons asked to respond to one of its surveys be given
the following information: Public reporting burden for this collection
of information
is estimated to average 5 minutes per interview, the estimated time required
to complete the survey about Your Child’s Health and Health Care.
Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing
this burden,
to:
Reports Clearance Officer
Attention: PRA, United States Public Health Service
Paperwork Reduction Project (0935-0098)
Hubert H. Humphrey Building, Room 721-B
200 Independence Avenue, SW
Washington, DC 20201
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