Child Disability Topical Module

-CDIN-

The questions in this section ask about any physical or mental conditions which your children may have.

-CDQ1A-

Does ... have a serious physical or mental condition or a developmental delay that limits ordinary activities?

(1) Yes

(2) No

-CDQ1B-

Does ... have a long-lasting condition that limits his/her ability to move his/her arms or legs?

(1) Yes

(2) No

-CDQ1C-

Does ... have a long-lasting condition that limits his/her ability to walk, run, or play?

(1) Yes

(2) No

-CDQ3-

Because of a physical, learning, or mental condition, does ... have any limitations in his/her ability to do regular school work?

(1) Yes

(2) No

-CDQ4-

Has ... ever received special education services?

(1) Yes

(2) No

-CDQ5-

Is ... currently receiving special education services?

(1) Yes

(2) No

-CDQ6-

Does ... have:

(1) Yes (2) No

a. A learning disability such as dyslexia?

b. Mental retardation?

c. A developmental disability such as autism or cerebral palsy?

d. Attention Deficit Hyperactivity Disorder (ADHD)

e. Any other developmental condition for which he/she has received therapy or diagnostic services?

-CDQ6a-

Does ... take medication or receive treatment for this condition?

(1) Yes

(2) No

-CDQ7-

MARK BY OBSERVATION IF APPARENT:

Does ... use any of the following aids?

(1) Yes (2) No

a. A cane, crutches, or a walker?

b. A wheelchair or an electric scooter?

c. A hearing aid?

-CDQ8-

Has ... used a cane, crutches, or a walker for six months or longer?

(1) Yes

(2) No

-CDQ9-

Does ... have difficulty seeing the words and letters in ordinary newspaper print, even when wearing glasses or contact lenses if he/she usually wears them?

(1) Yes

(2) No

(3) Person is Blind

-CDQ10-

Is ... able to see the words and letters in ordinary newspaper print at all?

(1) Yes

(2) No

-CDQ11-

Does ... have difficulty hearing what is said in a normal conversation with another person even when wearing his/her hearing aid?

(1) Yes

(2) No

(3) Person is Deaf

CDQ12-

Is ... able to hear what is said in a normal conversation at all?

(1) Yes

(2) No

-CDQ13-

Does ... have any difficulty having his/her speech understood?

(1) Yes

(2) No

-CDQ14-

In general, are people able to understand ... speech at all?

(1) Yes

(2) No

-CDQ15-

Does ... have a long-lasting condition that limits his/her ability to walk, run, or take part in sports and games?

(1) Yes

(2) No

-CDQ16-

Because of a long-lasting physical or mental condition does ... have any difficulty getting around INSIDE the home by himself/herself?

(1) Yes

(2) No

-CDQ17-

Does ... need the help of another person with getting around inside the home?

(1) Yes

(2) No

-CDQ18-

Does ... have any difficulty getting in and out of bed or a chair by himself/herself?

(1) Yes

(2) No

-CDQ19-

Does ... need the help of another person with getting in and out of bed or a chair?

(1) Yes

(2) No

-CDQ20-

Does ... have any difficulty taking a bath or shower by himself/herself?

(1) Yes

(2) No

-CDQ21-

Does ... need the help of another person with taking a bath or shower?

(1) Yes

(2) No

-CDQ22-

Because of a long-lasting condition does ... have any difficulty putting on his/her clothing by himself/herself?

(1) Yes

(2) No

-CDQ23-

Does ... need the help of another person with putting on his/her clothing?

(1) Yes

(2) No

-CDQ24-

Does ... have any difficulty eating food by himself/herself?

(1) Yes

(2) No

-CDQ25-

Does ... need the help of another person with eating food?

(1) Yes

(2) No

-CDQ26-

Does ... have any difficulty using or getting to the toilet by himself/herself?

(1) Yes

(2) No

-CDQ27-

Does ... need the help of another person with using or getting to the toilet?

(1) Yes

(2) No

-CDQ28-

Does ... have an emotional or mental condition that makes it difficult to play with or get along with other children of the same age?

(1) Yes

(2) No

-CDQ29-

SHOW FLASHCARD CC FOR PERSONAL VISIT INTERVIEWS.

I have recorded that ... has difficulty with certain activities. Which condition or conditions cause this difficulty?

Any others?

Enter (N) for None or No More.

Enter (H) for list of health conditions.

01- Asthma

02- Autism

03- ADHD

04- Blindness or vision problems

05- Cancer

06- Cerebral palsy

07- Deafness or hearing problems

08- Diabetes

09- Drug or alcohol problem or disorder

10- Epilepsy or seizure disorder

11- Hay fever or other respiratory allergies

12- Head or spinal cord injury

13- Heart trouble

14- Impairment or deformity of back, foot, or leg

15- Impairment or deformity of arm, hand, or finger

16- Learning disability

17- Mental or emotional problem or disorder

18- Mental retardation

19- Missing legs, feet, arms, hands, or fingers

20- Paralysis of any kind

21- Speech problems

22- Tonsillitis or repeated ear infections

23- Other

FR NOTE: If the person reports more than three conditions enter the appropriate code for the first three conditions the respondent identified.

-CDQ30-

Is this condition the result of a motor vehicle accident?

(1) Yes

(2) No

End of Child Disability Topical Module

Page Last Modified: May 12, 2006

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