Pediatric Quality of Life (teen)

P

Public reporting burden of this collection of information is estimated to average 5 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 (???).

ediatric Quality of Life

(Teen Report Ages 13-18)

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

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On the following page is a list of things that might be a problem for you. Please tell us how much of a problem each one has been for you during the past ONE month by filling in the circle for never a problem, almost never a problem, sometimes a problem, often a problem, or almost always a problem. There are no right or wrong answers. If you do not understand a question, please ask for help. Please begin now. Thank you.

In the past ONE month, how much of a problem has this been for you . . .

About My Health and Activities (problems with…)	Never	Almost Never	Some-times	Often	Almost Always
It is hard for me to walk more than one block	O	O	O	O	O
It is hard for me to run	O	O	O	O	O
It is hard for me to do a sports activity or exercise	O	O	O	O	O
It is hard for me to lift something heavy	O	O	O	O	O
It is hard for me to take a bath or shower by myself	O	O	O	O	O
It is hard for me to do chores around the house	O	O	O	O	O
I hurt or ache	O	O	O	O	O
I have low energy	O	O	O	O	O

About My Feelings (problems with…)	Never	Almost Never	Some-times	Often	Almost Always
I feel afraid or scared	O	O	O	O	O
I feel sad or blue	O	O	O	O	O
I feel angry	O	O	O	O	O
I have trouble sleeping	O	O	O	O	O
I worry about what will happen to me	O	O	O	O	O

How I Get Along with Others (problems with…)	Never	Almost Never	Some-times	Often	Almost Always
I have trouble getting along with other teens	O	O	O	O	O
Other teens do not want to be my friend	O	O	O	O	O
Other teens tease me	O	O	O	O	O
I cannot do things that other teens my age can do	O	O	O	O	O
It is hard to keep up with my peers	O	O	O	O	O

P

Public reporting burden of this collection of information is estimated to average 5 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 (???).

lease turn over and answer questions on back of page.

FOR STUDY USE ONLY
ID Number
Date Interviewed	Month Day Year	Interviewed by

About School (problems with…)	Never	Almost Never	Some-times	Often	Almost Always
It is hard to pay attention in class	O	O	O	O	O
I forget things	O	O	O	O	O
I have trouble keeping up with my schoolwork	O	O	O	O	O
I miss school because of not feeling well	O	O	O	O	O
I miss school to go to the doctor or hospital	O	O	O	O	O

The End.

February 3, 2021 16011001 Page 1 of 2