Form 23 ATTACHMENT C24: Social Inventory (High School, 14 plus y

5

S

OMB No: 0920-0747: Exp Date: ???

ocial Networking

Check the box that best describes your answer.

Family: Considering the people to whom you are related either by birth or marriage ... How many relatives do you…	None	One	Two	Three or Four	Five thru Eight	Nine or More
See or hear from at least once a month?
Feel close to such that you could call on them for help?
Feel at ease with that you can talk about private matters?

Friendships: Considering all of your friends How many of your friends do you…	None	One	Two	Three or Four	Five thru Eight	Nine or More
See or hear from at least once a month?
Feel close to such that you could call on them for help?
Feel at ease with that you can talk about private matters?

Public reporting burden of this collection of information is estimated to average 10 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 (??).

Social Relationships

2. How long have you lived in your local community?

• Less than a year

• More than a year, but less than 5 years

• 5 to10 years

• More than 10 years

• Basically, my whole life

3. Are you involved in any teams, clubs, or other groups either at school or in your community?

• Yes

• No

4. Check the types of groups you have been involved in during the past year.

• I get together regularly with my friends, but it is not a formal group

• Sports team

• Academic team

• Special interest club

• Band

• Church group

• Community volunteer group

• Newspaper or yearbook

• Chorus

• Cheerleading

• Scouts

• Other religious group

• Other boys or girls club

• Other (please explain) ________________________________________________

5. About how many of these teams, clubs, or other groups do you belong to?

_____________________

Pick one team, club, or group that is the most important to you – it could be an organized group or just groups of your friends who get together regularly to do an activity or talk about things.

6. How often do you take part in this group?

• Never

• A few times a year

• Once or twice a month

• Once a week

• A few times a week

• Every day

Social Competence Scale

Some teenagers find it easy to talk and deal with people, others find it hard. The questions below deal with how you communicated with people in the past 6 months. Can you indicate how easy or difficult each of the situations below has been for you in the past 6 months? If you haven’t experienced one or more of the situations below, please imagine how easy or difficult each of the situations would have been for you. How easy or difficult was it in the past six months to. . .	Very Difficult	Difficult	Not Difficult, Not Easy	Easy	Very Easy
Start a conversation with someone you did not know very well?
Introduce yourself for the first time to someone?
Start a new friendship?
Call someone whom you wanted to get to know better?
Ask someone to get together and do something?
Stand up for your rights when someone wronged you?
Stand up for yourself when someone made a fool of you?
Stand up for yourself when someone accused you of something you did not do?
Stand up for someone else who was made a fool of?

Self-Efficacy

Please read the following questions. After each question, fill in the circle to show how much you believe you can or cannot do what is asked now. If something doesn’t apply (if you don’t take medication for example) fill in that circle.

How much do you believe you can or cannot do the following?	Doesn’t Apply	Very Sure I Can’t	Sure I Can’t	Probably I Can’t	Probably I Can	Sure I Can	Very Sure I Can
Talk to my doctor myself and ask for the things I need	O	O	O	O	O	O	O
Take responsibility for getting my homework and chores done	O	O	O	O	O	O	O
Change my doctor if I don’t like him/her	O	O	O	O	O	O	O
Make a teacher see my point of view	O	O	O	O	O	O	O

Self-Efficacy for ADHD

Do you currently have ADHD, or have you ever been told by a doctor or other health professional that you have ADHD?

• Yes

• No

If you answered no, you may continue with the next survey

If you answered yes, please complete the following questions:

How much do you believe you can or cannot do the following?	Doesn’t Apply	Very Sure I Can’t	Sure I Can’t	Probably I Can’t	Probably I Can	Sure I Can	Very Sure I Can
Keep track of my medication	O	O	O	O	O	O	O
Follow my doctor’s orders for taking care of my ADHD	O	O	O	O	O	O	O
Tell a friend I have ADHD	O	O	O	O	O	O	O
Tell my boyfriend or girlfriend I have ADHD	O	O	O	O	O	O	O
Suggest to my parents changes in my medication dose	O	O	O	O	O	O	O
Believe that I have the ability to have control over my ADHD	O	O	O	O	O	O	O
Run my life the same as I would if I didn’t have ADHD	O	O	O	O	O	O	O

Coping with ADHD

There are many things that people with ADHD may have to learn and do. Here is a list of important things. Fill in the circle to show how hard each thing has been for you.

		I Don't Do this	Not that Hard to Do	A Little Hard to Do	Very Hard to Do
Giving myself medication		O	O	O	O
Remembering to take my medication		O	O	O	O
Taking medication on time		O	O	O	O
Going for clinic/doctor visits		O	O	O	O
Telling my friends about my ADHD		O	O	O	O
Telling teachers and grown-ups about my ADHD		O	O	O	O
Now, fill in the circle to show how much the rest of these things have upset you recently. Pick the answer that describes you best.
	Does Not Apply to Me		Not very Upsetting	A Little Upsetting	Very Upsetting
Being "different" from other people	O		O	O	O
My parents telling me what to do about ADHD	O		O	O	O
Thinking about why I got ADHD	O		O	O	O
Other people knowing that I have ADHD	O		O	O	O
Reading or seeing stuff on TV about ADHD	O		O	O	O
Having to take pills for my ADHD	O		O	O	O