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 | NHIS | As a result of a blow or jolt to the head, has [CHILD’S NAME] ever been knocked out or lost consciousness? | 2019 |
| NHIS | As a result of a blow or jolt to the head, has [CHILD’S NAME] ever been dazed or had a gap in his/her memory? | 2019 |
| NHIS | As a result of a blow or jolt to the head, has [CHILD’S NAME] ever had headaches, vomiting, blurred vision, or changes in mood or behavior? | 2019 |
| NHIS | Has [CHILD’S NAME] ever been checked for a concussion or brain injury by a doctor, nurse, athletic trainer, or other health care professional? | 2019 |
| NHIS | Did a doctor, nurse, athletic trainer, or other health care provider ever say that [CHILD’S NAME] had a concussion or brain injury? | 2019 |
| Not Applicable | Other than those you have already reported to me, in the last year, that is since one year ago from today, did [you/your child] experience any other injuries to [your/their] head or neck? | 2016 |
| Not Applicable | In the least year, that is since one year ago from today, how many head or neck injuries did [you/your child] experience, not counting the injuries you have already mentioned? | 2016 |
| Not Applicable | "Were you dazed, foggy, confused, or disoriented?" /PROXY: "Did your child act or appear mentally foggy?" /DIRECT: "Did you feel mentally foggy?" | 2016 |
| Not Applicable | Which of the following best describes how the injury happened? Would you say that: someone else injured [you/your child] on purpose, you/your child] tried to injure [yourself/him or herself], it was an accident—no one intended to injure [you/your child], or something else happened? | 2016 |
| Not Applicable | Did [you/your child] experience this injury while on a bicycle or a self-propelled wheeled vehicle? | 2016 |
| Not Applicable | Which of the following best describes how the injury occurred? Did [you/your child] collide with another motor vehicle, a stationary object, an animal (e.g. a deer), or something else? | 2016 |
| Not Applicable | Why [Were you/ was your child] riding or driving at the time of the injury? [Were you/was your child] | 2016 |
| Not Applicable | Would you say that the injury occurred because you fell without being struck or pushed, were hit by an object or person, or were pushed against something? | 2016 |
| Not Applicable | Did [you/your child] fall...from the floor or from ground level, like a trip or slip, down the stairs, from a height less than or equal to 10 feet, or from a height greater than 10 feet | 2016 |
| Not Applicable | Did this injury occur...at your home, on a street, at a school, park or recreational area, at a sports field or complex, or somewhere else? | 2016 |
| Not Applicable | What initially caused the injury? For example, if two individuals collided, and then made contact with the ground, the initial contact would be another person. Was the injury initially due to contact with...another person, the ground, an object that was part of the activity like a ball or a goal,
an object that was not part of the activity like the bleachers or a tree, or something else? | 2016 |
| Not Applicable | Following this injury, did a medical professional diagnose [you/your child] with a concussion or traumatic brain injury? | 2016 |
| Not Applicable | Did the injury cause you to miss or stop work that you do for pay? | 2016 |
| Not Applicable | Did the injury cause you to miss or stop other responsibilities you have, like taking care of your family or volunteer work? | 2016 |
| Not Applicable | Thinking across [your/ your child's entire life], has a doctor, nurse, or other medical professional ever told you [you/your child] that [you/he or she] had a concussion or any other type of brain injury caused by a blow to the head? | 2016 |
| Not Applicable | How many conclusions, or other types of brain injury caused by a blow to the head, [Have you/has your child] had in [your/his or her] lifetime? | 2016 |
| Not Applicable | If there was an injury in the last 12 months: “Other than what you have already reported in the last 12 months” In [your/ your child’s] lifetime, do you believe that [you have/ your child has] ever had a concussion or other type of brain injury other than those diagnosed by a medical professional? | 2016 |
| Not Applicable | How many non-diagnosed concussions, or other type of brain injury [have you/has your child] had in [your/his or her] lifetime? | 2016 |
| Not Applicable | [Was this/were any of these] concussions experienced while participating in sports or a recreational activity for fun or competition? | 2016 |
| Not Applicable | How old were you at the time of [this/the first] brain injury or concussion? | 2016 |