CP,YP, YA, YX

B1. INTERVIEWER ENTER: With whom are you speaking?

> (NAME'S) PARENT OR GUARDIAN 01
>
> (NAME) HIM/HER SELF 02

PROXY FOR (NAME) 03

CP, YP, YA, YX

B1a. CREATE VARIABLE "RTYPE"

> (NAME'S) PARENT OR GUARDIAN 01

(NAME) HIM/HER SELF 02 *Go to B3*

PROXY FOR (NAME) 03 *Go to B3*

CP, YP, YA, YX

B2. Just to confirm, are you living with a spouse or partner in this
household? If yes, which one?

Sólo para confirmar, ¿Vive Ud. con un(a) esposo(a) o un(a) parejo(a) en
este hogar? ¿Si es correcto, Cual?

SPOUSE 01

PARTNER 02

NO SPOUSE OR PARTNER 00

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

1999 NHIS Family Core

B3. Next I'm going to ask you about (FILL "NAME'S" IF RTYPE=01, 03;
"YOUR" IF RTYPE=02) general health. Would you describe (FILL "NAME'S" IF
RTYPE=01, 03; "YOUR" IF RTYPE=02) health as excellent, very good, good,
fair, or poor?

> Ahora le voy a hacer unas preguntas acerca del estado general (FILL"de
> la
>
> salud de (NAME)" IF RTYPE=01,03 ; "su propia salud"  IF RTYPE=02).
>
> ¿Describiría a su salud como excelente, muy buena, buena, regular o
> pobre (mala)?
>
> EXCELLENT 01
>
> VERY GOOD 02
>
> GOOD 03
>
> FAIR 04
>
> POOR 05
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

FACCT2 /CSHCN

B4. These next questions are about any kind of health problems,
concerns, or conditions that may affect (FILL "NAME'S" IF RTYPE=01, 03;
"YOUR" IF RTYPE=02) behavior, learning, growth, or physical development.
Some of these problems may affect the kind or amount of services (FILL
"NAME NEEDS" IF RTYPE=01, 03; "YOU NEED" IF RTYPE=02) (IF AGE \<17 ADD:
Some of these health problems may affect (FILL "NAME'S" IF RTYPE=01, 03;
"YOUR" IF RTYPE=02) abilities and activities at school or play).

(FILL "DOES NAME" IF RTYPE=01, 03; "DO YOU" IF RTYPE=02) need or use
**more** medical care, mental health, or educational services than is
usual for most (FILL "CHILDREN" IF AGE \< 17; "YOUNG PEOPLE" IF AGE IS
17+) of the same age?

Las próximas preguntas son acerca de cualquier tipo de problemas,
preocupaciones, o estado de salud (FILL "NAME" IF RTYPE=01, 03; "UD." IF
RTYPE=02) que tal vez afecten (Fill "la conducta, el saber, el
crecimiento, o el desarrollo físico de (NAME)" if RTYPE=01, 03; "su
conducta, saber, crecimiento, o desarrollo físico" IF RTYPE=02). Algunos
de estos problemas pueden afectar el tipo o la cantidad de servicios que
(FILL  "NAME" IF RTYPE=01, 03; "Ud. " IF RTYPE=02) necesita. (IF AGE
\<17 ADD: Algunos de estos problemas de salud pueden afectar (FILL "las
habilidades y actividades de NAME IF RTYPE=01, 03; sus habilidades y
actividades IF RTYPE=02) en la escuela o al jugar.

¿Necesita o usa (FILL "NAME" IF RTYPE=01, 03; "UD." IF RTYPE=02) **más**
servicios, médicos, de salud mental, o de educación de lo que es normal
para la mayoría de (FILL "LOS niños" IF AGE=\<17; "LA GENTE" IF AGE=17+)
de su misma edad?

PROBE: These questions refer to a **current** condition, not a condition
in the past.

PROBE : Estas preguntas se refieren a una condición en **la
actualidad**, no en el pasado.

> YES 01
>
> ![](media/image1.wmf)NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

FACCT/CSHCN

B5. Is (FILL "NAME'S" IF RTYPE=01, 03; "YOUR" IF RTYPE=02) need for
medical care, mental health or educational services because of any
medical, behavioral, or other health condition?

¿Necesita (FILL "NAME" IF RTYPE=01, 03; "UD." IF RTYPE=02) servicios
médicos, de salud mental, o de educación por causa de cualquier
condición médica, o de conducta, u otra condición de salud ?

> YES 01
>
> ![](media/image2.wmf)NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

FACCT/CSHCN

B6. Is this a condition that has lasted or is expected to last 12 months
or longer?

¿Es esta una condición que ya ha durado, o que esperan que va a durar 12
meses o más?

> YES 01
>
> NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

FACCT1/CSHCN

B7. (FILL "DOES NAME" IF RTYPE=01, 03; "DO YOU" IF RTYPE=02) currently
need or use **medicine prescribed by a doctor**, other than vitamins?

Actualmente, además de vitaminas, ¿necesita o usa (FILL "NAME" IF
RTYPE=01, 03; "UD." IF RTYPE=02) **medicina recetada por un doctor**?

PROBE: Over-the-counter medication such as cold or headache medication
is not included.

PROBE: No se incluye medicación sin receta tal como para catarro o dolor
de cabeza.

> INTERVIEWER: THESE QUESTIONS REFER ONLY TO A CURRENT CONDITION. THE
> RESPONDENT SHOULD ANSWER "YES" ONLY IF THE CHILD CURRENTLY HAS A
> SPECIAL HEALTH CARE NEED.
>
> YES 01
>
> ![](media/image3.wmf)NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

FACCT/CSHCN

B8. Is (FILL "NAME'S" IF RTYPE=01, 03; "YOUR" IF RTYPE=02) need for
prescription medicine because of any medical, behavioral, or other
health condition?

¿Necesita (FILL "NAME" IF RTYPE=01, 03; "UD." IF RTYPE=02) **medicina
recetada** por causa de cualquier condición médica, o de conducta, u
otra condición de salud ?

> ![](media/image4.wmf)YES 01
>
> NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

FACCT/CSHCN

B9. Is this a condition that has lasted or is expected to last 12 months
or longer?

¿Es esta una condición que ya ha durado, o que esperan que va a durar 12
meses o más?

> YES 01
>
> NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

FACCT3/CSHCN

B10. (FILL "IS NAME" IF RTYPE=01, 03; "ARE YOU" IF RTYPE=02) **limited
or prevented** in any way in (FILL "HIS/HER" IF RTYPE=01, 03; "YOUR" IF
RTYPE=02) ability to do the things (FILL "CHILDREN" IF AGE \< 17; "YOUNG
PEOPLE" IF AGE IS 17+) of the same age can do?

> ¿Está (FILL "NAME" IF RTYPE=01, 03; "UD." IF RTYPE=02) **limitado(a) o
> impedido(a)** en su habilidad de hacer las cosas que la mayoría de
> (FILL "los niños" IF \<17; "LoS JÓVENES" IF 17+) de su misma edad
> pueden hacer?
>
> PROBE: In other words, are there things (FILL "NAME" IF RTYPE=01, 03;
> "YOU" IF RTYPE=02) can't do as much or can't do at all that (FILL
> "CHILDREN" IF AGE \< 17; "YOUNG PEOPLE" IF AGE IS 17+) the same age
> can?
>
> PROBE: En otras palabras, ¿Hay cosas que (FILL "NAME" IF RTYPE=01, 03;
> "Ud" IF RTYPE=02) no puede hacer tanto, o no puede hacer de ninguna
> manera, que (FILL "los niños" IF AGE \<17; "LoS JÓVENES" IF AGE=17+)
> de su misma edad pueden hacer?
>
> YES 01
>
> ![](media/image5.wmf)NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

FACCT/CSHCN

B11. Is (FILL "NAME'S" IF RTYPE=01, 03; "YOUR" IF RTYPE=02) limitation
in abilities because of any medical, behavioral, or other health
condition?

> ¿Es ( FILL "la limitación de habilidades de NAME" IF RTYPE=01, 03; su
> limitación de habilidades IF RTYPE=02) por causa de cualquier
> condición médica, o de conducta, u otra condición de salud?
>
> YES 01
>
> ![](media/image6.wmf)NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

FACCT/CSHCN

B12. Is this a condition that has lasted or is expected to last 12
months or longer?

¿Es esta una condición que ya ha durado, o que esperan que va a durar 12
meses o más?

> YES 01
>
> NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

FACCT4/CSHCN

B13. (FILL "DOES NAME" IF RTYPE=01, 03; "DO YOU" IF RTYPE=02) need or
get **special therapy**, such as physical, occupational, or speech
therapy?

¿Necesita (FILL "NAME" IF RTYPE=01, 03; "UD" IF RTYPE=02) conseguir
**terapia especial**, tal como terapia física, ocupacional o del habla
(logopedia)?

> YES 01
>
> ![](media/image7.wmf)NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

FACCT/CSHCN

B14. Is (FILL "NAME'S" IF RTYPE=01, 03; "YOUR" IF RTYPE=02) need for
special therapy because of **any** medical, behavioral, or other health
condition?

> ¿Necesita (FILL "NAME" IF RTYPE=01, 03; "UD" IF RTYPE) terapia
> especial por causa de **cualquier** condición médica, o de conducta, u
> otra condición de salud ?
>
> YES 01
>
> ![](media/image8.wmf)NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

FACCT/CSHCN

B15. Is this a condition that has lasted or is expected to last 12
months or longer?

¿Es esta una condición que ya ha durado, o que esperan que va a durar 12
meses o más?

> YES 01
>
> NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

FACCT5/CSHCN

B16. (FILL "DOES NAME" IF RTYPE=01, 03; "DO YOU" IF RTYPE=02) need or
get treatment or counseling for any kind of emotional, developmental, or
behavioral problem?

¿Necesita o recibe (FILL "NAME" IF RTYPE=01, 03; "UD" IF RTYPE=02)
conseguir tratamiento o consejo por cualquier problema emocional, de
desarrollo, o de conducta?

PROBE: Treatment or counseling includes remedies, therapy or guidance a
child

or young person may receive for his/her health condition.

**Emotional Problems** such as depression or schizophrenia.

**Developmental problems** such as stunted growth.

> **Behavioral problems** such as aggressive behavior or Attention
> Deficit Disorder, also know as A-D-D.
>
> PROBE: Tratamiento o consejo incluye remedias, terapia o consejos que
> pueda recibir un(a) niño(a) o jóven por su condición de salud.

**Problemas emiciales** tales como depresion o esquisofrenia

**Problemas de desarrollo** tal como crecimiento enano

> **Problemas de conducta** tales como conducta agresivo o Attention
> Deficit Disorder, que también se conoce como A-D-D.
>
> YES 01
>
> ![](media/image9.wmf)NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

FACCT/CSHCN

B17. Has (FILL "NAME'S" IF RTYPE=01, 03; "YOUR" IF RTYPE=02) emotional,
developmental or behavioral problem lasted or is it expected to last 12
months or longer?

¿Ya ha durado, o esperan que va a durar 12 meses o más (FILL "EL
problema emocional, de desarrollo, o de conducta de (NAME)" IF RTYPE=01,
03 ; su problema emocional, de desarrollo, o de conducta IF RTYPE=02) ?

YES 01

> NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

B18. CHECK AGE: Is NAME's age...

\<17 01 *Continue*

17+ 02 *Go to B20*

CP

FACCT/CSHCN

B19. FACCT SCREENER DECISION (modified): Is B4=1, or B7=1, or B10=1, or
B13=1, or B16=1, that is, does (NAME) have a health condition?

YES 01 *Go to B27*

NO 00 *Go to B23*

YP, YA, YX

1999 NHIS Family Core (modified)

B20. Does a medical, behavioral, or other health condition **now**
prevent (FILL "NAME" IF RTYPE=01, 03; "YOU" IF RTYPE=02) from working at
a job or business, or attending school?

> ¿Algún problema físico, mental, o emocional no le permite a (FILL
> "NAME" IF RTYPE=01, 03; "UD." IF RTYPE=02) **AHORA** trabajar en un
> empleo o un negocio, o asistir a la escuela?

YES.........................................................01 *Go to
B22*

> NO 00
>
> DON'T KNOW d
>
> REFUSED r

YP, YA, YX

1999 NHIS Family Core (modified)

B21. (FILL "IS NAME" IF RTYPE=01, 03; "ARE YOU" IF RTYPE=02) **limited**
in the kind **or** amount of work or school (FILL "HE/SHE" IF RTYPE=01,
03; "YOU" IF RTYPE=02) can do because of a medical, behavioral, or other
health condition?

> ¿Está (FILL "NAME" IF RTYPE=01, 03; "UD." IF RTYPE=02) **limitado(a)**
> en el tipo **o** en la cantidad de trabajo o de estudios que (FILL
> "ÉL/ELLA" IF RTYPE=01, 03; "UD." IF RTYPE=02) puede hacer por causa de
> algún problema físico, mental, o emocional?
>
> YES 01
>
> NO 00
>
> DON'T KNOW d
>
> REFUSED r

YP, YA, YX

FACCT/CSHCN

B22. FACT SCREENER DECISION (modified): Is B4=1, or B7=1, or B10=1, or
B13=1, or B16=1, or B20=1, or B21=1, that is, does NAME have a health
condition or is limited in work or school activities?

YES 01 *Go to B27*

NO 00 *Go to B24*

CP

1999 NHIS Family Core

B23. (FILL "IS NAME" IF RTYPE=01 OR 03; "ARE YOU" IF RTYPE=02) now
limited **in any way** in any activities because of a medical,
behavioral, or other health condition?

> ¿Está (FILL "NAME" IF RTYPE=01, 03; "UD." IF RTYPE=02) limitado(a) en
> cualquier forma, en cualquier actividad, por causa de algún problema
> físico, mental, o emocional?

YES 01 *Go to B27*

> NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

Created

B24. Thinking back to (INSERT YEAR OF APPLICATION) when (FILL "NAME'S"
IF RTYPE=03; "YOUR" IF RTYPE=01, 02) family applied for Supplemental
Security Income, or SSI, for (FILL "NAME" IF RTYPE=01, 03; "YOU" IF
RTYPE=02), did (FILL "NAME" IF RTYPE=01, 03; "YOU" IF RTYPE=02) have a
medical, behavioral, or other health condition then?

Pensando en (INSERT YEAR OF APPLICATION) cuando (FILL "su familia" IF
RTYPE=01, 02; "la familia de (NAME)" IF RTYPE=03) aplicó para
Supplemental Security Income (Seguridad de Ingreso Suplementario), o
SSI, para (FILL "NAME" IF RTYPE=01, 03; "UD." IF RTYPE=02); ¿tenía (FILL
"NAME" IF RTYPE=01, 03; "UD." IF RTYPE=02) una condición médica, o de
conducta, u otra condición de salud, en ese entonces?

> YES 01
>
> ![](media/image10.wmf)NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

Created

B25. What health condition or problem was that?

¿Qué condición o problema de salud era?

PROBE FOR SPECIFIC ANSWER. ANSWERS SUCH AS "HE'S SLOW," "DOESN'T TALK
WELL," OR "IS A SPECIAL NEEDS CHILD" ARE NOT SPECIFIC ENOUGH.

PROBE 1: By what name do doctors call (FILL "NAME'S" IF RTYPE=01, 03;
"YOUR" IF RTYPE=02) health condition?

PROBE 2: What causes this condition?

PROBE 1: ¿Cómo llaman los doctores (FILL "la condición de salud de
(NAME) IF RTYPE=01, 03; "su condición de salud " IF RTYPE=02)?

PROBE 2: ¿Cuál es la causa de esta condición ?

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

B26. CHECK FACCT SCREENER(s): Is B19=01 or B22=01, that is, does NAME
have a **current** health condition or problem?

YES 01 *Continue*

NO 02 *Go to B30*

CP, YP, YA, YX (with health condition)

CSHCN

B27. The next questions are about any physical, mental, learning, or
developmental conditions or problems that (FILL "NAME HAS" IF RTYPE=01,
03; "YOU HAVE" IF RTYPE=02). (FILL "IN THE PAST 12 MONTHS" IF AGE 1+;
"SINCE BIRTH" IF AGE \<1), how often has (FILL "NAME'S" IF RTYPE=01, 03;
"YOUR" IF RTYPE=02) health condition or problem affected (FILL "HIS/HER"
IF RTYPE=01, 03; "YOUR" IF RTYPE=02) ability to do things other (FILL
"CHILDREN" IF AGE \<17; "YOUNG PEOPLE" IF AGE=17+) do? Would you say:

> Las próximas preguntas son acerca de cualesquier condiciones o
> problemas
>
> físicos, mentales, de saber, o de desarrollo que tiene (FILL "NAME" IF
>
> RTYPE=01, 03; "UD." IF RTYPE=02). (FILL "EN LOS 12 MESES PASADOS" IF
>
> AGE 1+; "DESDE EL NACIMIENTO" IF AGE \<1), ¿cuántas veces ha influido
> su
>
> condición o problema de salud en su habilidad de hacer cosas que hacen
> otros
>
> (FILL "niños" IF AGE \<17; "jóvenes" IF AGE=17+)? Diría:
>
> interviewer: If the condition is episodic, for example, asthma
> attacks, respondents should consider the entire 12 months of episodes,
> not just one specific episode.

INTERVIEWER: READ LIST, CODE ONE ANSWER

*Read list, Code one answer*

> Never 01
>
> Sometimes 02
>
> Usually 03
>
> Always 04
>
> Nunca 01
>
> A veces 02
>
> Generalmente 03

Siempre 04

DON'T KNOW d

> REFUSED r

CP, YP, YA, YX (with health condition)

CSHCN

B28. Does (FILL "NAME'S" IF RTYPE=01, 03; "YOUR" IF RTYPE=02) health
condition or problem affect (FILL "HIS/HER" IF RTYPE=01, 03; "YOUR" IF
RTYPE=02) ability to do things a great deal, some, or very little?

¿Influye (FILL "la condición o problema de salud de (NAME)" IF RTYPE=01,
03; "su condición o problema de salud" IF RTYPE=02) en su habilidad de
hacer cosas mucho, algo, o muy poco?

> A GREAT DEAL 01
>
> SOME 02
>
> VERY LITTLE 03
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX (with health condition)

CSHCN

B29. Overall, how would you rank (FILL "HIS/HER" IF RTYPE=01, 03; "YOUR"
IF RTYPE=02) health condition(s) or problem(s). Please pick a number
between zero and ten where zero is the mildest and ten is the most
severe.

> En general, ¿cómo clasificaría la(s) condición (condiciones) o el
> (los)
>
> problema(s) de salud de (FILL "NAME" IF RTYPE=01, 03; "UD." IF
> RTYPE=02)?
>
> Por favor escoja un número entre cero (0) y diez (10), con cero siendo
> lo más
>
> leve, y diez lo más severo o grave.
>
> interviewer: If name has more than one condition, then the respondent
> should rate the most severe condition rather than trying to average
> severity across all of the conditions.

\|\_\_\|\_\_\| NUMBER BETWEEN ZERO AND TEN

NAME DOESN'T HAVE A HEALTH

CONDITION OR PROBLEM 11

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

CSHCN

B30. Which of the following statements best describes (FILL "NAME'S" IF
RTYPE=01, 03; "YOUR" IF RTYPE=02) health care needs?

> ¿Cuál de las siguientes frases mejor describe las necesidades de
> servicios
>
> de salud de (FILL "NAME" IF RTYPE=01, 03; "UD." IF RTYPE=02)?

*Read list, code only one response*

(FILL "NAME'S" IF RTYPE=01, 03; "YOUR"

IF RTYPE=02) health care needs change

all the time 01

(FILL "NAME'S" IF RTYPE=01, 03; "YOUR"

IF RTYPE=02) health care needs change

> only once in a while 02

(FILL "NAME'S" IF RTYPE=01, 03; "YOUR"

IF RTYPE=02) health care needs are

usually stable 03

None of these 04

> Las necesidades de servicios de salud
>
> de (FILL "NAME" IF RTYPE=01, 03; "UD."
>
> IF RTYPE=02) cambian todo el tiempo 01

Las necesidades de servicios de salud

de (FILL "NAME" IF RTYPE=01, 03; "UD."

IF RTYPE=02) sólo cambian de vez en

cuando 02

> Las necesidades de servicios de salud
>
> de (FILL "NAME" IF RTYPE=01, 03; "UD."
>
> IF RTYPE=02) son, por lo general, estables 03

Ninguno de estos 04

DON'T KNOW d

REFUSED r

B31. CHECK AGE: Is NAME's age...

\<17 01 *Continue*

17+ 02 *Go to B33*

CP

1998 NHIS Child Core (modified)

B32. (FILL "DOES NAME" IF RTYPE=01, 03) use any medical devices or
supplies? These include things like a respirator, glucose monitor, a
wheelchair, hearing aid, or feeding tube.

> ¿Usa (FILL "NAME" IF RTYPE=01, 03) algún aparato o equipo médico?
> Estos incluyen cosas tales como un respirador, un monitor de glucosa,
> una silla deruedas, un aparato para sordos o un tubo de alimentación.

PROBE: This includes canes and walkers.

PROBE: Esto incluye bastones y caminetes (walkers).

> YES 01
>
> NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

1999 NHIS Child Core

B33. Which statement best describes (FILL "NAME'S" IF RTYPE=01, 03;
"YOUR" IF RTYPE=02) hearing (without a hearing aid): good, a little
trouble, a lot of trouble, or deaf?

> ¿Cuál de estas frases mejor describe al (sentido del) oído de (FILL
> "NAME" IF
>
> RTYPE=01, 03; "UD." IF RTYPE=02) (sin usar un aparato para sordos):
> bueno,
>
> un poco difícil, bastante difícil, o es sordo(a)?
>
> GOOD 01
>
> A LITTLE TROUBLE 02
>
> A LOT OF TROUBLE 03
>
> DEAF 04
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

1999 NHIS Child Core

B34. (FILL "DOES NAME" IF RTYPE=01, 03; "DO YOU" IF RTYPE=02) have any
trouble seeing? (IF AGE=2+ ADD) even when wearing glasses or contact
lenses?

> ¿Tiene (FILL "NAME" IF RTYPE=01, 03; "UD." IF RTYPE=02) alguna
> dificultad
>
> en ver? (FILL IF 2+" ¿Aún cuando está usando anteojos o lentes de
> contacto?")
>
> ![](media/image11.wmf)YES 01
>
> NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

1999 NHIS Child Core

B35. (FILL "IS NAME" IF RTYPE=01, 03; "ARE YOU" IF RTYPE=02) blind or
unable to see?

¿Es (FILL "NAME" IF RTYPE=01, 03; "UD." IF RTYPE=02) ciego(a) o incapaz
de ver?

> YES 01
>
> NO 00
>
> DON'T KNOW d
>
> REFUSED r

B36. CHECK FACCT SCREENER(s): Is B19=01 or B22=01, that is, does (NAME)
have a health condition or problem?

YES 01 *Continue*

NO 02 *Go to B41*

CP, YP, YA, YX (with health condition)

1978 SSA Survey (modified)

B37. Considering everything you just told me about, what do you consider
(FILL "NAME'S" IF RTYPE=01, 03; "YOUR" IF RTYPE=02) main health
condition or problem to be?

Considerando todo lo que me acaba de contar, ¿cuál considera usted que
es la principal condición o el principal problema de salud de (FILL
"NAME" IF RTYPE=01, 03; "UD." IF RTYPE=02)?

PROBE FOR SPECIFIC ANSWER. ANSWERS SUCH AS "HE'S SLOW," "DOESN'T TALK
WELL," OR "IS A SPECIAL NEEDS CHILD" ARE NOT SPECIFIC ENOUGH.

> PROBE 1: By what name do doctors call (FILL "NAME'S" IF RTYPE=01, 03;
> "YOUR" IF RTYPE=02) health condition?

PROBE 2: What causes this condition?

PROBE 1: ¿Cómo llaman los doctores (FILL "la condición de salud de
"NAME" IF RTYPE=01, 03; "su condición de salud" IF RTYPE=02)?

PROBE 2: ¿Cuál es la causa de esta condición?

*Record verbatim*

[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

CP, YP, YA, YX (with health condition)

1999 NHIS Family Core

B38. How many years (FILL "HAS NAME" IF RTYPE=01, 03; "HAVE YOU" IF
RTYPE=02) had this health condition or problem?

¿Cuántos años ha tenido (FILL "NAME" IF RTYPE=01, 03; "UD." IF RTYPE=02)
esta condición o problema de salud?

[NUMBER]{.underline} [TIME PERIOD]{.underline}

\|\_\_\_\|\_\_\_\| (01-94) DAYS 01

95 + 95 WEEKS 02

SINCE BIRTH 96 MONTHS 03

DON\'T KNOW d YEARS 04

REFUSED r DON\'T KNOW d

REFUSED r

CP, YP, YA, YX (with health condition)

1978 SSA Survey

B39. (FILL "DOES NAME" IF RTYPE=01, 03; "DO YOU" IF RTYPE=02) have any
other health conditions or problems?

¿Tiene (FILL "NAME" IF RTYPE=01, 03; "UD." IF RTYPE=02) cualesquier
otras condiciones u otros problemas de salud?

> YES 01
>
> ![](media/image12.wmf)NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX (with health condition)

1978 SSA Survey

B40. What are these?

¿Cuáles son?

PROBE FOR SPECIFIC ANSWER. ANSWERS SUCH AS "HE'S SLOW," "DOESN'T TALK
WELL," OR "IS A SPECIAL NEEDS CHILD" ARE NOT SPECIFIC ENOUGH.

PROBE 1: By what name do doctors call (FILL "NAME'S" IF RTYPE=01, 03;
"YOUR" IF RTYPE=02) health condition?

PROBE 2: What causes this condition?

PROBE 1: ¿Cómo llaman los doctores (FILL "la condición de salud de
(NAME)" IF RTYPE=01, 03; "su condición de salud" IF RTYPE=02)?

PROBE 2: ¿Cuál es la causa de esta condición?

*Record verbatim*

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

B41. CHECK AGE: Is NAME's age...

\<17 01 *Go to B45*

17+ 02 *Continue*

YP, YA, YX (age 17+)

1999 NHIS Adult Core (modified)

B42. (FILL "DOES NAME" IF RTYPE=01, 03; "DO YOU" IF RTYPE=02) use
special equipment, such as a cane, a wheelchair, a special bed, or a
special telephone?

> ¿Usa (FILL "NAME" IF RTYPE=01, 03; "UD." IF RTYPE=02) equipo especial,
> tal como un bastón (cane), una silla de ruedas, una cama especial, o
> un teléfono especial?
>
> YES 01
>
> NO 00
>
> DON'T KNOW d
>
> REFUSED r

YP, YA, YX (age 17+)

1999 NHIS Adult Core (modified)

B43. During the past 12 months, that is, since (FILL LAST MONTH, LAST
YEAR), about how many days did (FILL "NAME" IF RTYPE=01, 03; "YOU" IF
RTYPE=02) miss work or school because of illness or injury?

Durante los últimos 12 meses, o sea, desde (LAST MONTH, LAST YEAR),

¿más o menos cuántos días faltó (FILL "NAME" IF RTYPE=01, 03; "UD." IF
RTYPE=02) al trabajo o a los estudios por causa de enfermedad o una
herida (lesión)?

\|\_\_\_\|\_\_\_\|\_\_\_\| DAYS (1-365)

NONE 00

DON'T WORK/ATTEND SCHOOL n

DON'T KNOW d

REFUSED r

YP, YA, YX (age 17+)

1999 NHIS Adult Core

B44. During the past 12 months, about how many days did illness or
injury keep (FILL "NAME" IF RTYPE=01, 03; "YOU" IF RTYPE=02) in bed more
than half of the day?

> Durante los últimos 12 meses, ¿más o menos cuántos días tuvo (FILL
> "NAME"
>
> IF RTYPE=01, 03; " UD." IF RTYPE=02) que quedarse en cama por más de
> la
>
> mitad del día por causa de enfermedad o una herida (lesión)?
>
> PROBE: Include days while an overnight patient in a hospital. Also
> include days for mental or emotional problems.

PROBE: Incluya días que fue paciente internado(a) en un hospital.
También incluya días para problemas mentales o emocionales.

\|\_\_\_\|\_\_\_\|\_\_\_\| DAYS (1-365)

NONE 00

DON'T KNOW d

REFUSED r

B45. CHECK AGE: Is (NAME'S) age ...

5+ 01  *Continue*

\<5 00  *Go to B51*

CP, YP, YA, YX (age 5+)

1999 NHIS Family Core (modified)

B46. (FILL "DOES NAME" IF RTYPE=01, 03; "DO YOU" IF RTYPE=02) need the
help of other persons with personal care needs, such as eating, bathing,
dressing, or getting around inside the home?

¿Necesita (FILL "NAME" IF RTYPE=01, 03; "UD." IF RTYPE=02) la ayuda de
otras personas con sus necesidades de cuidado o atención personal, tales
como: comer, bañarse, vestirse, o moverse de un lugar a otro dentro del
hogar?

> YES 01
>
> ![](media/image13.wmf)NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX (age 5+)

NHIS-D (Adult Followback)

B47. (FILL "DOES NAME" IF RTYPE=01, 03; "DO YOU" IF RTYPE=02) need the
help or supervision of other persons with \...

> ¿Necesita (FILL "NAME" IF RTYPE=01, 03; "UD." IF RTYPE=02) la ayuda de
> otras personas para . . .

*Code one for each*

> [YES]{.underline} [NO]{.underline} [DK]{.underline} [RF]{.underline}
>
> A. Bathing or showering 01 00 d r
>
> B. Dressing 01 00 d r
>
> C. Eating 01 00 d r
>
> D. Getting in or out of bed or chairs 01 00 d r
>
> E. (IF AGE=17+) Walking 01 00 d r
>
> F. (IF AGE=17+) Getting outside 01 00 d r
>
> G. Using the toilet, including getting to the
>
> toilet 01 00 d r
>
> H. Getting around inside the home 01 00 d r
>
> A. Bañarse o ducharse 01 00 d r
>
> B. Vestirse 01 00 d r
>
> C. Comer 01 00 d r

D.  Acostarse, sentarse o levantarse

> de la cama o una silla 01 00 d r
>
> E. (IF AGE=17+) Caminar 01 00 d r
>
> F. (IF AGE=17+) Salir afuera 01 00 d r

G. Usar el inodoro (toilet) incluyendo

> ir al inodoro 01 00 d r

H.  Moverse de un lugar a otro dentro

> del hogar 01 00 d r

B48. CHECK AGE: Is NAME's age....

\<17 01 *Go to B52*

17+ 02 *Continue*

YP, YA, YX (age 17+)

1999 NHIS Family Core (modified)

B49. (FILL "DOES NAME" IF RTYPE=01, 03; "DO YOU" IF RTYPE=02) need the
help of other persons in handling routine needs such as preparing meals,
managing money, doing housework, or managing medications?

¿Necesita (FILL "NAME" IF RTYPE=01, 03; "UD." IF RTYPE=02) la ayuda de
otras personas en necesidades de rutina tales como: preparar comidas,
manejar su dinero, quehaceres domésticos (trabajo de casa), o en
administrar su medicación?

> YES 01
>
> ![](media/image14.wmf)NO 00
>
> DON'T KNOW d
>
> REFUSED r

YP, YA, YX (age 17+)

NHIS-D (Adult Followback)

B50. (FILL "DOES NAME" IF RTYPE=01, 03; "DO YOU" IF RTYPE=02) need the
help or supervision of other persons with\...

> ¿Necesita (FILL "NAME" IF RTYPE=01, 03; "UD." IF RTYPE=02) la ayuda o
> supervisión de otras personas para...

*Code one for each*

> [YES]{.underline} [NO]{.underline} [DK]{.underline} [RF]{.underline}
>
> A. Preparing meals 01 00 d r
>
> B. Shopping for personal items or
>
> groceries 01 00 d r
>
> C. Managing money 01 00 d r
>
> D. Using the telephone 01 00 d r
>
> E. Doing heavy housework 01 00 d r
>
> F. Doing light housework 01 00 d r

G.  Going to places outside of walking

> distance 01 00 d r
>
> H. Managing medications 01 00 d r
>
> A. Preparar comidas 01 00 d r
>
> B. Comprar artículos personales o
>
> comestibles 01 00 d r
>
> C. Manejar dinero 01 00 d r
>
> D. Usar el teléfono 01 00 d r
>
> E. Hacer quehaceres duros 01 00 d r
>
> F. Hacer quehaceres ligeros 01 00 d r

G.  Ir a lugares a los cuales

> no puede ir andando 01 00 d r
>
> H. Manejar medicación 01 00 d r

B51. CHECK: Is A42D_1 -- A42D_14 OR A91D_1 -- A91D_14=02, 03, 04, 05,
07, 08, 09, 10, 11,15? That is, is (NAME) living with his/her parents,
his/her brothers or sisters, other relatives, or with his/her own spouse
or children?

YES 01 *Continue*

NO 00 *Go to Section C*

CP, YP, YA, YX (living with family)

CSHCN

B52. Many families provide health care at home such as changing
bandages, care of feeding or breathing equipment, transportation to
appointments, and giving medication and therapies. Do any family members
provide health care at home for (FILL "NAME" IF RTYPE=01, 03; "YOU" IF
RTYPE=02)?

> Muchas familias proporcionan (algunos) servicios de salud en el hogar,
> en cosas tales como cambiar vendas, mantenimiento de equipo
> respiratorio o de alimentación, transporte a citas, y en dar medicina
> y terapias. ¿Le proporcionan miembros de la familia servicios de salud
> en el hogar a (FILL "NAME" IF RTYPE=01, 03; "UD." IF RTYPE=02)?
>
> YES 01
>
> ![](media/image15.wmf)NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX (living with family)

CSHCN

B53. How many hours per week do family members spend providing this kind
of health care for (FILL "NAME" IF RTYPE=01, 03; "YOU" IF RTYPE=02)?

¿Cuántas horas por semana pasan miembros de la familia proporcionando
este tipo de servicio de salud a (FILL "NAME" IF RTYPE=01, 03; "UD." IF
RTYPE=02)?

> PROBE: By this kind of care we mean: changing bandages, taking care of
> medical equipment, giving medications, and things like that. Do not
> include routine care for a (Fill "CHILD" if \<17; Fill " young person"
> if 17+) of (FILL "HIS/HER" IF RTYPE=01, 03; "YOUR" IF RTYPE=02) age.
>
> PROBE: Por este tipo de servicio queremos decir: cambiar vendas,
> mantener equipo medico, dar medicinas, y cosas así. No incluya cuidado
> de rutina para un (Fill "NIno" if \<17; Fill " joven" if 17+) de su
> edad.

\|\_\_\|\_\_\|\_\_\| HOURS PER WEEK (0-168)

CP, YP, YA, YX (living with family)

NHIS-D Child Followback (modified)

B54. How are these family members related to (FILL "NAME" IF RTYPE=01,
03; "YOU" IF RTYPE=02)?

¿Cuál es la relación o el parentesco que tienen estos miembros de
familia con (FILL "NAME" IF RTYPE=01, 03; "UD." IF RTYPE=02)?

*Do not read list, code all that apply*

MOTHER (BIOLOGICAL OR ADOPTIVE) 02

FATHER (BIOLOGICAL OR ADOPTIVE) 03

STEP-PARENT OF (NAME) 04

FOSTER PARENT OF (NAME) 05

GRANDPARENT 07

BROTHER/SISTER OF (NAME) 08

AUNT/UNCLE OF (NAME) 09

(NAME'S) SPOUSE 10

OTHER RELATIVE OF (NAME)

(SPECIFY IN QUESTION) 15

DON\'T KNOW d

REFUSED r

CP, YP, YA, YX

NHIS-D Child Followback (modified)

B55. Last week, how many hours, if any, did (FILL "NAME" IF RTYPE=01,
03; "YOU" IF RTYPE=02) receive health care where (FILL "NAME LIVES" IF
RTYPE=01, 03; "YOU LIVE" IF RTYPE=02) from people **other than** family
members?

La semana pasada, ¿cuántas horas, si las hay, recibió (FILL "NAME" IF
RTYPE=01, 03; " UD." IF RTYPE=02) en el hogar servicios de salud de
personas además de miembros de la familia?

\|\_\_\|\_\_\|\_\_\| HOURS PER WEEK (1-168)  *If "00," go to Part C*

CP, YP, YA, YX

Created

B56. Did (FILL "YOU AND YOUR FAMILY" IF RTYPE=01, 02; "NAME AND HIS/HER
FAMILY" IF RTYPE=03) pay for any of this health care that (FILL "NAME"
IF RTYPE=01, 03; "YOU" IF RTYPE=02) received last week? Do not count
money that has been or will be reimbursed by insurance or any other
source.

> ¿Pagó (FILL "Ud. y su familia IF RTYPE=01, 02; "NAME" y su familia IF
> RTYPE=03) por cualquiera de estos servicios de salud que (FILL "NAME"
> IF RTYPE=01, 03; "UD." IF RTYPE=02) recibió la semana pasada? Por
> favor no cuente dinero que ya ha sido, o que será reembolsado por el
> seguro o por cualquier otra fuente.

YES 01

![](media/image16.wmf) NO 00

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

Created

B57. About how much did (FILL "YOU AND YOUR FAMILY" IF RTYPE=01, 02;
"NAME AND HIS/HER FAMILY" IF RTYPE=03) pay for the health care (FILL
"NAME" IF RTYPE=01, 03; "YOU" IF RTYPE=02) received last week? Again,
don't count money that has been or will be reimbursed by insurance or
any other source.

Más o menos, ¿cuánto pagó (FILL "UD." IF RTYPE=01, 02 "NAME IF RTYPE=03)
y su familia por los servicios de salud que (FILL "NAME" IF RTYPE=01,
03; " UD." IF RTYPE=02) recibió la semana pasada? Otra vez, por favor no
cuente dinero que ya ha sido, o que será reembolsado por el seguro o por
cualquier otra fuente.

\$\_\_\_\_.00 AMOUNT PAID FOR LAST WEEK'S CARE (0-9,999)

DON'T KNOW d

REFUSED r