Health Risk Behavior Survey (elementary)

OMB No: ??: Exp Date: ???

Health Risk Behavior Survey

HEALTH AND HEALTH RISK BEHAVIOR QUESTIONNAIRE: PARENT Elementary School Version TABLE OF CONTENTS General Information 1 Injury 2 Tobacco/Alcohol/Drug Use 3 Physical Activity 3 Dietary Behavior 6 Prevention Behavior 6 Sleep Behavior 7 School Performance 7

I. General Information 1. How tall is your child without shoes on (in feet and inches)? feet inches 2. When was this measurement taken? month day year 3. How much does your child weigh without shoes on (in pounds)? pounds 4. When was this measurement taken? month day year 5. Relative to other children, do you consider your child overweight? Yes No 6. Relative to other children, do you consider your child underweight? Yes No

Public reporting burden of this collection of information is estimated to average 16 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Clearance Officer; 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (???).

II. Injury The following questions ask about significant injuries that your child experienced in the past year. Injuries should be included if they required medical attention, resulted in limitations in the child’s day-to-day activities (including play), or that the child considered bothersome for more than a day. Examples of such injuries include a broken bone or a cut that required stitches. 7 . How many times was your child injured in the past 12 months? 8. In the past twelve months, has your child suffered any of the following injuries? (Fill in all that apply). A. An injury related to a recreational activity (for example, while playing on a bicycle or skateboard)? Yes No B. A burn or scald? Yes No C. A broken or fractured bone? Yes No D. An animal bite? Yes No E. A poison related injury? Yes No F. A cut or pierce that required stitches? Yes No

G. An injury caused by a piece of machinery? Yes No 9. How often does your child refuse to wear a seat belt when riding in a car? Never Rarely Sometimes Most of the time Always 10. How often does your child cross the street or run out into the street without checking for cars? Never Rarely Sometimes Most of the time Always 11. How often does your child do dangerous things like jumping off high places? Never Rarely Sometimes Most of the time Always 12. When your child rides a bicycle, how often does he/she wear a helmet? He/she does not ride a bicycle Never Rarely Sometimes Most of the time Always

13. When your child roller blades or rides a skateboard, how often does he/she wear protective gear such as a helmet, wrist guards, or knee pads? He/she does not roller blade or ride a skateboard Never Rarely Sometimes Most of the time Always 14. In the past 12 months, have you been called into school because your child was caught carrying a weapon, such as a gun, knife, or club? Yes No 15. To the best of your knowledge, has your child ever tried to intentionally hurt him or herself? Yes No 16. If your child takes prescription medication for ADHD (attention deficit/hyperactivity disorder): In the past 12 months, did he/she ever give or sell his/her medication to others? Yes No My child does not take medication for ADHD

III. Tobacco/Alcohol/Drug Use 17. To the best of your knowledge, how old was your child when he/she tried cigarette smoking, even one or two puffs? He/she has never tried cigarette smoking 5 years old or younger 6 years old 7 years old 8 years old 9 years old 10 years old 18. To the best of your knowledge, does your child currently smoke on a regular basis (at least once per week)? Yes No 19. To the best of your knowledge, has your child ever used chewing tobacco, snuff, or dip, such as Redman, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen? Yes No VI. Physical Activity 20. On how many of the past 7 days did your child exercise or participate in physical activity for at least 20 minutes that made him/her sweat and breathe hard, such as basketball, soccer, running, swimming laps, fast bicycling, fast dancing, or similar aerobic activities? 0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days

21. On how many of the past 7 days did your child exercise or participate in physical activity for at least 20 minutes that did not make him/her sweat and breathe hard, such as fast walking, slow bicycling, skating, pushing a lawn mower, or mopping floors? 0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days 22. On how many of the past 7 days did your child do exercises to strengthen or tone his/her muscles, such as push-ups, sit-ups, or weight lifting? 0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days 23. On an average school day, how many hours does your child usually spend reading for pleasure (books/magazines/ newspapers)? My child does not read for pleasure on an average school day Less than 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 hours per day 5 or more hours per day 24. Do you limit the amount of time that your child spends watching television? Yes No

25. On an average school day, how many hours does your child watch TV or DVD/videos? My child does not watch TV on an average school day Less than 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 hours per day 5 or more hours per day 26. On an average school day, how many hours does your child listen to music (radio, tapes, CDs, MP3s)? My child does not listen to music on an average school day Less than 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 hours per day 5 or more hours per day 27. On an average school day, how many hours does your child play with video or handheld games? My child does not play with video games on an average school day Less than 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 hours per day 5 or more hours per day

28. On an average school day, how many hours does your child use a computer for something that is not school work? My child does not use a computer for something that is not school work on an average school day Less than 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 hours per day 5 or more hours per day 29. On an average school day, how many hours does your child use more than one type of media at the same time (like music and computer, or TV and reading)? My child does not use more than one type of media on an average school day Less than 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 hours per day 5 or more hours per day 30. Do you use internet filters or other methods of parental supervision when your child is on the Internet or watching television? Yes No 31. Does your child have access to R-rated movies and videos or mature rated video games? Yes No 32. Are there family rules about what TV programs your child is allowed to watch? Yes No

33. In an average week when your child is in school, on how many days does your child go to physical education (PE) classes? 0 days 1 day 2 days 3 days 4 days 5 days 34. How often does your child participate in organized or team sports? My child does not participate in organized sports Daily Twice a week Weekly Every other week Once a month Less than once a month 35. Relative to other children his/her age, do you consider your child: Much more active than other children Somewhat more active than other children About as active as other children Less active than other children Much less active than other children

V. Dietary Behavior 36. During the past 7 days, how many times did your family eat a meal together? Never Once Twice 3 times 4 times 5 times 6 times 7 or more times 37. Is your child on a special diet? My child is not on a special diet Feingold diet Lactose-restricted Sugar-restricted Oligoantigenic Other, (Specify): ______________________ VI. Prevention Behavior 38. How often does your child brush his/her teeth? Daily 5-6 days a week 3-4 days a week 1-2 days a week Less than once per week Never 39. About how long has it been since anyone in the family last saw or talked to a doctor or other health care professional about your child’s health? 6 months ago or less More than 6 months, but not more than 1 year ago More than 1 year, but not more than 3 years ago More than 3 years ago Never

40. When was the last time your child saw a doctor or nurse for a check-up or physical exam when he/she was not sick or injured? 6 months ago or less More than 6 months, but not more than 1 year ago More than 1 year, but not more than 3 years ago More than 3 years ago Never 41. During the past 12 months, how many times has your child gone to a hospital emergency room about his/her health? None 1 time 2-3 times 4-9 times 10-12 times 13 or more times 42. During the past 12 months, have you seen or talked to a mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker about your child’s health? Yes No 43. During the past 12 months, have you seen or talked to a minister or member of the clergy about your child’s health? Yes No 44. During the past 12 months, have you seen or talked to a chiropractor about your child’s health? Yes No

45. During the past 12 months, have you seen or talked to a physical therapist, speech therapist, respiratory therapist, audiologist, or occupational therapist about your child’s health? Yes No VII. Sleep Behavior 46. On an average night, does your child have difficulty sleeping? Yes No 47. Does your child snore? Yes No 48. Is your child a restless sleeper? Yes No 49. Does your child awaken during the night? Yes No 50. How many hours of sleep does your child get on an average night? More than 8 hours 6-8 hours 4-5 hours Less than 4 hours 51. Is your child sleepy during the day? Yes No VIII. School Performance 52. Has a representative from a school or a health professional ever told you that your child has a learning disability? Yes No

53. Do you consider your child an: A student B student C student D student F student 54. Do you have concerns about your child’s current and future school performance? Yes No 55. During the last year, did your child get poor grades? Yes No 56. During the last year, did your child get in trouble with a teacher or principal at school? Yes No 57. During the last year, did your family move to a new home or apartment? Yes No 58. During the last year, has your family had a new baby come into the family? Yes No 59. During the last year, has anyone moved out of your home? Yes No 60. During the last year, did a family member die? Yes No

61. During the last year, did another relative or friend who was close to your child die? Yes No 62. During the last year, has a family member become seriously ill, injured badly, and/or had to stay at the hospital? Yes No 63. During the last year, has someone else your child knows, other than a member of your family, been beaten, attacked, or really hurt by others? Yes No

64. During the last year, has your child been afraid to go outside and play, or have you made your child stay inside because of gangs or drugs in your neighborhood? Yes No 65. During the last year, has your child had to hide someplace because of shootings in your neighborhood? Yes No

FOR STUDY USE ONLY
Date Interviewed	Month Day Year	Interviewed by