32 Supplemental Emotional Health Questionaire

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Overview

Title Page
Overview
18+ NA (SELF)
18+ PA (SELF)
18+ SR (SELF)
8-17 SR (SELF)
3-12 SR (PROXY)

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Sheet 1: Title Page

Attachment 32

Emotional Health Questionnaires for Toolshed

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Sheet 2: Overview

	Attach 32 Supplemental Emotional Health Questionnaires
SUPPLEMENTAL EMOTIONAL HEALTH QUESTIONNAIRES , OVERVIEW
Subdomain	Concept	Measure	Item Count	Measure	Item Count	Measure	Item Count	Measure	Item Count	Measure	Item Count
		ADULT SELF-REPORT (18+)		PEDS SELF-REPORT (13-17)		PEDS SELF-REPORT (8-12)		PEDS PROXY REPORT (8-12)		PEDS PROXY-REPORT (3-7)
Negative Affect
	Apathy	AES SF	7
		Subdomain Total	7	Subdomain Total	0	Subdomain Total	0	Subdomain Total	0	Subdomain Total	0
Positive Affect
	Life Satisfaction	Domain-Specific Life Satisfaction Bank (CDC)	13
		Subdomain Total	13		0	Subdomain Total	0	Subdomain Total	0	Subdomain Total	0
Social Relationships
	Social Network Integration	Revised Social Network Index (SNI)	30	Revised Peds SNI	39	Revised Peds SNI	39	Revised Peds Proxy SNI	30	Revised Peds Proxy SNI	30
		Subdomain Total	30	Subdomain Total	39	Subdomain Total	39	Subdomain Total	30	Subdomain Total	30
		OVERALL TOTAL	50	OVERALL TOTAL	39	OVERALL TOTAL	39	OVERALL TOTAL	30	OVERALL TOTAL	30
		Estimated Total Time	11 min.	Estimated Total Time	9 min.	Estimated Total Time	9 min.	Estimated Total Time	8 min.	Estimated Total Time	8 min.
Public reporting burden for this collection of information is estimated to average 2 1/2 hours 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx*) EXP: (xx/xxxx). Do not return the completed form to this address.

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Sheet 3: 18+ NA (SELF)

SUPPLEMENTAL EMOTIONAL HEALTH QUESTIONNAIRE, 18+ NA (SELF)
Item Count	ID #	Item Context	Item Stem	Response	Scale
Apathy
53	Apathy01	For each question, select the answer that best describes your thoughts, feelings, and actions during the past 4 weeks.	I am interested in things.	1-Not at all true 2-Slightly true 3-Somewhat true 4-Very true	Apathy Evaluation Scale SF
54	Apathy02	For each question, select the answer that best describes your thoughts, feelings, and actions during the past 4 weeks.	I get things done during the day.	1-Not at all true 2-Slightly true 3-Somewhat true 4-Very true	Apathy Evaluation Scale SF
55	Apathy03	For each question, select the answer that best describes your thoughts, feelings, and actions during the past 4 weeks.	Getting things started on my own is important to me.	1-Not at all true 2-Slightly true 3-Somewhat true 4-Very true	Apathy Evaluation Scale SF
56	Apathy08	For each question, select the answer that best describes your thoughts, feelings, and actions during the past 4 weeks.	Seeing a job through to the end is important to me.	1-Not at all true 2-Slightly true 3-Somewhat true 4-Very true	Apathy Evaluation Scale SF
57	Apathy09	For each question, select the answer that best describes your thoughts, feelings, and actions during the past 4 weeks.	I spend time doing things that interest me.	1-Not at all true 2-Slightly true 3-Somewhat true 4-Very true	Apathy Evaluation Scale SF
58	Apathy16	For each question, select the answer that best describes your thoughts, feelings, and actions during the past 4 weeks.	Getting things done during the day is important to me.	1-Not at all true 2-Slightly true 3-Somewhat true 4-Very true	Apathy Evaluation Scale SF
59	Apathy18	For each question, select the answer that best describes your thoughts, feelings, and actions during the past 4 weeks.	I have motivation.	1-Not at all true 2-Slightly true 3-Somewhat true 4-Very true	Apathy Evaluation Scale SF
Public reporting burden for this collection of information is estimated to average 2 1/2 hours 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx*) EXP: (xx/xxxx). Do not return the completed form to this address.

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Sheet 4: 18+ PA (SELF)

SUPPLEMENTAL EMOTIONAL HEALTH QUESTIONNAIRE , 18+ PA (SELF)
Item Count	ID #	Item Context	Item Stem	Response	Scale
LIFE SATISFACTION
			For the next set of questions, please indicate how much you agree or disagree with each statement.
1	PA077	Indicate how much you agree or disagree:	I am satisfied with my education.	1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much	CDC Domain-Specific Life Satisfaction Items
2	PA078	Indicate how much you agree or disagree:	I am satisfied with my present job or work.	1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much	CDC Domain-Specific Life Satisfaction Items
3	PA079	Indicate how much you agree or disagree:	I am satisfied with my well-being from spiritual, religious or philosophical beliefs.	1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much	CDC Domain-Specific Life Satisfaction Items
4	PA080	Indicate how much you agree or disagree:	I am satisfied with my housing.	1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much	CDC Domain-Specific Life Satisfaction Items
5	PA081	Indicate how much you agree or disagree:	I am satisfied with my family life.	1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much	CDC Domain-Specific Life Satisfaction Items
6	PA082	Indicate how much you agree or disagree:	I am satisfied with my health.	1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much	CDC Domain-Specific Life Satisfaction Items
7	PA083	Indicate how much you agree or disagree:	I am satisfied with my friends and social life.	1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much	CDC Domain-Specific Life Satisfaction Items
8	PA084	Indicate how much you agree or disagree:	I am satisfied with my neighborhood overall.	1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much	CDC Domain-Specific Life Satisfaction Items
9	PA085	Indicate how much you agree or disagree:	I am satisfied with my ability to help others.	1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much	CDC Domain-Specific Life Satisfaction Items
10	PA086	Indicate how much you agree or disagree:	I am satisfied with my achievement of my goals.	1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much	CDC Domain-Specific Life Satisfaction Items
11	PA087	Indicate how much you agree or disagree:	I am satisfied with my leisure.	1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much	CDC Domain-Specific Life Satisfaction Items
12	PA088	Indicate how much you agree or disagree:	I am satisfied with my physical safety.	1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much	CDC Domain-Specific Life Satisfaction Items
13	PA089	Indicate how much you agree or disagree:	I am satisfied with my energy level.	1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much	CDC Domain-Specific Life Satisfaction Items
Public reporting burden for this collection of information is estimated to average 2 1/2 hours 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx*) EXP: (xx/xxxx). Do not return the completed form to this address.

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Sheet 5: 18+ SR (SELF)

SUPPLEMENTAL EMOTIONAL HEALTH QUESTIONNAIRE , 18+ SR (SELF)
Item Count	ID #	Item Context	Item Stem	Responses	Scale
Social Network Integration
			The next set of questions are about your family, friends, activities and community.
1	SNI001		Which of the following best describes your current marital status?	0 - Currently married and living together, or living with someone in a marital-like relationship 1 - Never married and never lived with someone in a marital-like relationship 2 - Separated 3 - Divorced or formerly lived with someone in a marital-like relationship 4 - Widowed (and not now living with someone in a marital-like relationship)	Modified SNI
2	SNI002		How many children do you have?	0 - No children 1 - 1 child 2 - 2 children 3 - 3 children 4 - 4 children 5 - 5 children 6 - 6 children 7 - 7 or more children	Modified SNI
3	SNI002a	BRANCH - Answer only if response to 2 is NOT 0	How many children do you see or talk to at least once every 2 weeks?	0 - No children 1 - 1 child 2 - 2 children 3 - 3 children 4 - 4 children 5 - 5 children 6 - 6 children 7 - 7 or more children	Modified SNI
4	SNI003		Are either of your parents living?	0 - No, neither 1 - Mother only 2 - Father only 3 - Both parents are living	Modified SNI
5	SNI003a	BRANCH - Answer only if response to 3 is NOT 0	Do you see or talk to either of your parents at least once every 2 weeks?	0 - No, neither 1 - Mother only 2 - Father only 3 - Both parents	Modified SNI
6	SNI004		Are either of your in-laws (or partner's parents) living?	0 - No, neither 1 - Mother only 2 - Father only 3 - Both parents are living	Modified SNI
7	SNI004a	BRANCH - Answer only if response to 4 is NOT 0	Do you see or talk to either of your in-laws (or partner's parents) at least once every 2 weeks?	0 - No, neither 1 - Mother only 2 - Father only 3 - Both parents	Modified SNI
8	SNI005		How many other relatives (other than your spouse, parents, and children) do you feel close to?	0 - None 1 - 1 relative 2 - 2 relatives 3 - 3 relatives 4 - 4 relatives 5 - 5 relatives 6 - 6 relatives 7 - 7 or more relatives	Modified SNI
9	SNI005a	BRANCH - Answer only if response to 5 is NOT 0	How many of these other relatives do you see or talk to at least once every 2 weeks?	0 - None 1 - 1 relative 2 - 2 relatives 3 - 3 relatives 4 - 4 relatives 5 - 5 relatives 6 - 6 relatives 7 - 7 or more relatives	Modified SNI
Public reporting burden for this collection of information is estimated to average 2 1/2 hours 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx*) EXP: (xx/xxxx). Do not return the completed form to this address.
10	SNI006		All together, with how many family members do you feel comfortable enough to talk about personal problems?	0 - None 1 - 1 family member 2 - 2 family members 3 - 3 family members 4 - 4 family members 5 - 5 family members 6 - 6 family members 7 - 7 or more family members	Modified SNI
11	SNI007		All together, with how many family members do you feel close enough that you could ask them for help?	0 - None 1 - 1 family member 2 - 2 family members 3 - 3 family members 4 - 4 family members 5 - 5 family members 6 - 6 family members 7 - 7 or more family members	Modified SNI
12	SNI008		All together, how many family members are available to you to talk to when you have an important decision to make?	0 - None 1 - 1 family member 2 - 2 family members 3 - 3 family members 4 - 4 family members 5 - 5 family members 6 - 6 family members 7 - 7 or more family members	Modified SNI
13	SNI009		How many close friends do you have? (meaning people that you feel comfortable with, can talk to about personal problems, and can call on for help)	0 - None 1 - 1 friend 2 - 2 friends 3 - 3 friends 4 - 4 friends 5 - 5 friends 6 - 6 friends 7 - 7 or more friends	Modified SNI
14	SNI009a	BRANCH - Answer only if response to 9 is NOT 0	How many of these friends do you see or talk to at least once every 2 weeks?	0 - None 1 - 1 friend 2 - 2 friends 3 - 3 friends 4 - 4 friends 5 - 5 friends 6 - 6 friends 7 - 7 or more friends	Modified SNI
15	SNI010		Do you belong to a church, temple, mosque, or other religious group?	0 - No 1 - Yes	Modified SNI
16	SNI010a	BRANCH - Answer only if response to 10 is 1	How many members of your church or religious group do you talk to at least once every 2 weeks?	0 - None 1 - 1 member 2 - 2 members 3 - 3 members 4 - 4 members 5 - 5 members 6 - 6 members 7 - 7 or more members	Modified SNI
17	SNI011		Do you attend any classes (school, university, technical training, or adult education) on a regular basis?	0 - No 1 - Yes	Modified SNI
18	SNI011a	BRANCH - Answer only if response to 11 is 1	How many fellow students or teachers do you talk to at least once every 2 weeks? (this includes at class meetings)	0 - None 1 - 1 person 2 - 2 people 3 - 3 people 4 - 4 people 5 - 5 people 6 - 6 people 7 - 7 or more people	Modified SNI
19	SNI012		Are you currently employed either full or part-time?	0 - No 1 - Yes	Modified SNI
20	SNI012a	BRANCH - Answer only if response to 12 is 1	How many people at work do you talk to at least once every 2 weeks?	0 - None 1 - 1 person 2 - 2 people 3 - 3 people 4 - 4 people 5 - 5 people 6 - 6 people 7 - 7 or more people	Modified SNI
21	SNI013		How many neighbors do you visit or talk to at least once every 2 weeks?	0 - None 1 - 1 person 2 - 2 people 3 - 3 people 4 - 4 people 5 - 5 people 6 - 6 people 7 - 7 or more people	Modified SNI
22	SNI014		Are you currently involved in regular volunteer work?	0 - No 1 - Yes	Modified SNI
23	SNI014a	BRANCH - Answer only if response to 14 is 1	How many people involved in this volunteer work do you talk to about volunteer-related issues at least once every 2 weeks?	0 - None 1 - 1 person 2 - 2 people 3 - 3 people 4 - 4 people 5 - 5 people 6 - 6 people 7 - 7 or more people	Modified SNI
24	SNI015		Do you currently belong to any social clubs, recreational groups, or sports teams?	0 - No 1 - Yes	Modified SNI
25	SNI016		Do you currently belong to any trade unions, commercial groups, or professional organizations?	0 - No 1 - Yes	Modified SNI
26	SNI017		Do you currently belong to any groups concerned with children, like the PTA (parent-teacher association), boy scouts or girl scouts?	0 - No 1 - Yes	Modified SNI
27	SNI018	BRANCH - Answer only if response to either 15, 16 or 17 is 1	How many people involved in these social, recreational, professional, or child-related groups do you see or talk to about group-related activities at least once every 2 weeks?	0 - None 1 - 1 person 2 - 2 people 3 - 3 people 4 - 4 people 5 - 5 people 6 - 6 people 7 - 7 or more people	Modified SNI
28	SNI019		All together, with how many friends or other people (who are not a part of your family) do you feel comfortable enough to talk about personal problems?	0 - None 1 - 1 person 2 - 2 people 3 - 3 people 4 - 4 people 5 - 5 people 6 - 6 people 7 - 7 or more people	Modified SNI
29	SNI020		All together, with how many friends or other people (who are not a part of your family) do you feel close enough that you could ask them for help?	0 - None 1 - 1 person 2 - 2 people 3 - 3 people 4 - 4 people 5 - 5 people 6 - 6 people 7 - 7 or more people	Modified SNI
30	SNI021		All together, how many friends or other people (who are not a part of your family) can you talk to when you have an important decision to make?	0 - None 1 - 1 person 2 - 2 people 3 - 3 people 4 - 4 people 5 - 5 people 6 - 6 people 7 - 7 or more people	Modified SNI

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Sheet 6: 8-17 SR (SELF)

SUPPLEMENTAL EMOTIONAL HEALTH QUESTIONNAIRE, 8-17 SR (SELF)
Item Count	ID #	Item Context	Item Stem	Responses	Scale
Social Network Integration
			The next set of questions are about your family, friends, activities and community.
1	PedsSNI01		Which of the following best describes your current living arrangement? (Note: Parents may include biological or adoptive parents.)	0 - Live in a home with both parents 1 - Live with mother most (or all) of the time 2 - Live with father most (or all) of the time 3 - Split time equally between mother's and father's homes 4 - Don't live with either parent	Modified SNI
2	PedsSNI01a	BRANCH - Answer only if response to 1 is 1	How often you see or talk to your father?	0 - Have no contact with father 1 - Visit or talk to father on occasion 2 - Visit or talk to father at least once every 2 weeks	Modified SNI
3	PedsSNI01b	BRANCH - Answer only if response to 1 is 2	How often you see or talk to your mother?	0 - Have no contact with mother 1 - Visit or talk to mother on occasion 2 - Visit or talk to mother at least once every 2 weeks	Modified SNI
4	PedsSNI01c	BRANCH - Answer only if response to 1 is 4	With whom do you currently live?	0 - Live with other family members 1 - Live in a foster home 2 - Live with friends or neighbors	Modified SNI
5	PedsSNI02		Do you have any step-parents?	0 - No step-parents 1 - Step-mother only 2 - Step-father only 3 - Both step-mother and step-father	Modified SNI
6	PedsSNI02a	BRANCH - Answer only if response to 2 is NOT 0	How many step-parents do you see or talk to at least once every 2 weeks?	0 - No step-parents 1 - 1 step-parent 2 - 2 or more step-parents	Modified SNI
7	PedsSNI02b	BRANCH - Answer only if response to 2a is NOT 0	Do you live with any of these step-parents?	0 - No, I do not live with step-parents 1 - I live with step-father (part or full time) 2 - I live with step-mother (part or full time) 3 - I live with both step-mother and step-father at least part time
8	PedsSNI03		How many brothers and sisters do you have? (Please include step-brothers and sisters or half-brothers and sisters.)	0 - No brothers or sisters 1 - 1 brother or sister 2 - 2 brothers or sisters 3 - 3 brothers or sisters 4 - 4 brothers or sisters 5 - 5 brothers or sisters 6 - 6 brothers or sisters 7 - 7 or more brothers or sisters	Modified SNI
Public reporting burden for this collection of information is estimated to average 2 1/2 hours 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx*) EXP: (xx/xxxx). Do not return the completed form to this address.
9	PedsSNI03a	BRANCH - Answer only if response to 3 is NOT 0	How many brothers and sisters do you see or talk to at least once every 2 weeks? (Please include step-brothers and sisters or half-brothers and sisters.)	0 - No brothers or sisters 1 - 1 brother or sister 2 - 2 brothers or sisters 3 - 3 brothers or sisters 4 - 4 brothers or sisters 5 - 5 brothers or sisters 6 - 6 brothers or sisters 7 - 7 or more brothers or sisters	Modified SNI
10	PedsSNI04		Are any of your grandparents living? (Please include step-grandparents.)	0 - No grandparents currently living 1 - 1 grandparent currently living 2 - 2 grandparents living 3 - 3 grandparents living 4 - 4 or more grandparents living	Modified SNI
11	PedsSNI04a	BRANCH - Answer only if response to 4 is NOT 0	How many grandparents do you see or talk to at least once every 2 weeks? (Please include step-grandparents.)	0 - None 1 - 1 grandparent 2 - 2 grandparents 3 - 3 grandparents 4 - 4 grandparents 5 - 5 grandparents 6 - 6 grandparents 7 - 7 or more grandparents	Modified SNI
12	PedsSNI05		How many other relatives (not including parents, grandparents, brothers or sisters) do you feel close to?	0 - None 1 - 1 relative 2 - 2 relatives 3 - 3 relatives 4 - 4 relatives 5 - 5 relatives 6 - 6 relatives 7 - 7 or more relatives	Modified SNI
13	PedsSNI05a	BRANCH - Answer only if response to 5 is NOT 0	How many of these other relatives do you see or talk to at least once every 2 weeks?	0 - None 1 - 1 relative 2 - 2 relatives 3 - 3 relatives 4 - 4 relatives 5 - 5 relatives 6 - 6 relatives 7 - 7 or more relatives	Modified SNI
14	PedsSNI06		All together, with how many family members do you feel comfortable enough to talk about personal problems?	0 - None 1 - 1 family member 2 - 2 family members 3 - 3 family members 4 - 4 family members 5 - 5 family members 6 - 6 family members 7 - 7 or more family members	Modified SNI
15	PedsSNI07		All together, with how many family members do you feel close enough that you could ask them for help?	0 - None 1 - 1 family member 2 - 2 family members 3 - 3 family members 4 - 4 family members 5 - 5 family members 6 - 6 family members 7 - 7 or more family members	Modified SNI
16	PedsSNI08		All together, how many family members are available to you to talk to when you have an important decision to make?	0 - None 1 - 1 family member 2 - 2 family members 3 - 3 family members 4 - 4 family members 5 - 5 family members 6 - 6 family members 7 - 7 or more family members	Modified SNI
17	PedsSNI09		How many close friends do you have?	0 - None 1 - 1 friend 2 - 2 friends 3 - 3 friends 4 - 4 friends 5 - 5 friends 6 - 6 friends 7 - 7 or more friends	Modified SNI
18	PedsSNI09a	BRANCH - Answer only if response to 9 is NOT 0	How many close friends do you see or talk to at least once every 2 weeks?	0 - None 1 - 1 friend 2 - 2 friends 3 - 3 friends 4 - 4 friends 5 - 5 friends 6 - 6 friends 7 - 7 or more friends	Modified SNI
19	PedsSNI10		Do you belong to a church, temple, mosque or other religious group?	0 - No 1 - Yes	Modified SNI
20	PedsSNI10a	BRANCH - Answer only if response to 10 is 1	How many members of the church or religious group do you talk to at least once every 2 weeks?	0 - None 1 - 1 member 2 - 2 members 3 - 3 members 4 - 4 members 5 - 5 members 6 - 6 members 7 - 7 or more members	Modified SNI
21	PedsSNI11		Do you go to school?	0 - No 1 - Yes	Modified SNI
22	PedsSNI11a	BRANCH - Answer only if response to 11 is 1	How many fellow students or teachers do you talk to at least once every 2 weeks?	0 - None 1 - 1 person 2 - 2 people 3 - 3 people 4 - 4 people 5 - 5 people 6 - 6 people 7 - 7 or more people	Modified SNI
23	PedsSNI12		Do you currently have a full or part-time job?	0 - No 1 - Yes	Modified SNI
24	PedsSNI12a	BRANCH - Answer only if response to 12 is 1	How many people at work do you talk to at least once every 2 weeks?	0 - None 1 - 1 person 2 - 2 people 3 - 3 people 4 - 4 people 5 - 5 people 6 - 6 people 7 - 7 or more people	Modified SNI
25	PedsSNI13		How many neighbors do you visit or talk to at least once every 2 weeks?	0 - None 1 - 1 person 2 - 2 people 3 - 3 people 4 - 4 people 5 - 5 people 6 - 6 people 7 - 7 or more people	Modified SNI
26	PedsSNI14		Are you currently involved in regular volunteer work?	0 - No 1 - Yes	Modified SNI
27	PedsSNI14a	BRANCH - Answer only if response to 14 is 1	How many people involved in this volunteer work do you talk to about volunteer-related issues at least once every 2 weeks?	0 - None 1 - 1 person 2 - 2 people 3 - 3 people 4 - 4 people 5 - 5 people 6 - 6 people 7 - 7 or more people	Modified SNI
28	PedsHBQ15	Please indicate which best describes your activities during the past year	Outside of gym classes in school, did you take part in any sports (with adult coaches) during the past year?	0 - No 1 - Yes	HBQ - MacArthur Health and Behavior Questionnaire: Recreational Activities
29	PedsHBQ15a	BRANCH - Answer only if response to 15 is 1	How many sports did you play?		HBQ - MacArthur Health and Behavior Questionnaire: Recreational Activities
30	PedsHBQ15b	BRANCH - Answer only if response to 15 is 1	While playing these sports, how many times a week did you have practices or games?	0 - Less than once a week 1 - 1-3 times a week 2 - 4 or more times a week	HBQ - MacArthur Health and Behavior Questionnaire: Recreational Activities
31	PedsHBQ16	Please indicate which best describes your activities during the past year	Outside of regular classes in school, did you take any lessons during the past year in music, dance, art or other activities (not sports)?	0 - No 1 - Yes	HBQ - MacArthur Health and Behavior Questionnaire: Recreational Activities
32	PedsHBQ16a	BRANCH - Answer only if response to 16 is Yes	In how many non-sport activities did you take lessons or classes?		HBQ - MacArthur Health and Behavior Questionnaire: Recreational Activities
33	PedsHBQ16b	BRANCH - Answer only if response to 16 is Yes	How many times a week did you participate in any of these: music, dance, art, or other non-sport activities?	0 - Less than once a week 1 - 1-3 times a week 2 - 4 or more times a week	HBQ - MacArthur Health and Behavior Questionnaire: Recreational Activities
34	PedsHBQ17	Please indicate which best describes your activities during the past year	Did you belong to any clubs or groups with adult leaders, such as Scouts, or any religious or community programs?	0 - No 1 - Yes	HBQ - MacArthur Health and Behavior Questionnaire: Recreational Activities
35	PedsHBQ17a	BRANCH - Answer only if response to 17 is Yes	To how many such clubs or groups did you belong?		HBQ - MacArthur Health and Behavior Questionnaire: Recreational Activities
36	PedsHBQ17b	BRANCH - Answer only if response to 17 is Yes	How many times a week did you attend meetings of these clubs or groups?	0 - Less than once a week 1 - 1-3 times a week 2 - 4 or more times a week	HBQ - MacArthur Health and Behavior Questionnaire: Recreational Activities
37	PedsSNI15		How many different people involved in these groups do you see or talk to about group-related activities at least once every 2 weeks?	0 - None 1 - 1 person 2 - 2 people 3 - 3 people 4 - 4 people 5 - 5 people 6 - 6 people 7 - 7 or more people	Modified SNI
38	PedsSNI16		All together, with how many friends or other people (who are not a part of your family) do you feel comfortable enough to talk about personal problems?	0 - None 1 - 1 person 2 - 2 people 3 - 3 people 4 - 4 people 5 - 5 people 6 - 6 people 7 - 7 or more people	Modified SNI
39	PedsSNI17		All together, with how many friends or other people (who are not a part of your family) do you feel close enough that you could ask them for help?	0 - None 1 - 1 person 2 - 2 people 3 - 3 people 4 - 4 people 5 - 5 people 6 - 6 people 7 - 7 or more people	Modified SNI
40	PedsSNI18		All together, how many friends or other people (who are not a part of your family) you talk to when you have an important decision to make?	0 - None 1 - 1 person 2 - 2 people 3 - 3 people 4 - 4 people 5 - 5 people 6 - 6 people 7 - 7 or more people	Modified SNI

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Sheet 7: 3-12 SR (PROXY)

SUPPLEMENTAL EMOTIONAL HEALTH QUESTIONNAIRE, 3-12 SR (PROXY)
Item Count	ID #	Item Context	Item Stem	Responses	Scale
Social Network Integration
			The next set of questions are about your child's family, friends, activities and community.
1	PedPxySNI01		Which of the following best describes the child's current living arrangement? (Note: Parents may include biological or adoptive parents.)	0 - The child currently lives in a home with both parents. 1 - The child lives with mother most (or all) of the time. 2 - The child lives with father most (or all) of the time. 3 - The child splits time equally between mother's and father's homes. 4 - The child doesn't live with either parent.	Modified SNI
2	PedPxySNI01a	BRANCH - Answer only if response to 1 is 1	How often does the child see or talk to his/her father?	0 - The child has no contact with father. 1 - The child visits or talks to father on occasion. 2 - The child visits or talks to father at least once every 2 weeks.	Modified SNI
3	PedPxySNI01b	BRANCH - Answer only if response to 1 is 2	How often does the child see or talk to his/her mother?	0 - The child has no contact with mother. 1 - The child visits or talks to mother on occasion. 2 - The child visits or talks to mother at least once every 2 weeks.	Modified SNI
4	PedPxySNI01c	BRANCH - Answer only if response to 1 is 4	With whom does the child live?	0 - The child lives with other family members. 1 - The child lives in a foster home. 2 - The child lives with friends or neighbors.	Modified SNI
5	PedPxySNI02		Does the child have any step-parents?	0 - No step-parents 1 - Step-mother only 2 - Step-father only 3 - Both step-mother and step-father	Modified SNI
6	PedPxySNI02a	BRANCH - Answer only if response to 2 is: 1,2 or 3	How many step-parents does the child see or talk to at least once every 2 weeks?	0 - No step-parents 1 - 1 step-parent 2 - 2 or more step-parents	Modified SNI
7	PedPxySNI02b	BRANCH - Answer only if response to 2a is: 1 or 2	Does the child live with any of these step-parents?	0 - No, the child does not live with step-parents 1 - Child lives with step-father (part or full time) 2 - Child lives with step-mother (part or full time) 3 - Child lives with both step-mother and step-father at least part time
8	PedPxySNI03		How many brothers and sisters does the child have? (Please include step-brothers and sisters or half-brothers and sisters.)	0 - No brothers or sisters 1 - 1 brother or sister 2 - 2 brothers or sisters 3 - 3 brothers or sisters 4 - 4 brothers or sisters 5 - 5 brothers or sisters 6 - 6 brothers or sisters 7 - 7 or more brothers or sisters	Modified SNI
9	PedPxySNI03a	BRANCH - Answer only if response to 3 is NOT 0	How many brothers and sisters does the child see or talk to at least once every 2 weeks? (Please include step-brothers and sisters or half-brothers and sisters.)	0 - No brothers or sisters 1 - 1 brother or sister 2 - 2 brothers or sisters 3 - 3 brothers or sisters 4 - 4 brothers or sisters 5 - 5 brothers or sisters 6 - 6 brothers or sisters 7 - 7 or more brothers or sisters	Modified SNI
10	PedPxySNI04		Are the child's grandparents living? (Please include step-grandparents.)	0 - No grandparents currently living 1 - 1 grandparent currently living 2 - 2 grandparents living 3 - 3 grandparents living 4 - 4 or more grandparents living	Modified SNI
11	PedPxySNI04a	BRANCH - Answer only if response to 4 is NOT 0	How many grandparents does the child see or talk to at least once every 2 weeks? (Please include step-grandparents.)	0 - None 1 - 1 grandparent 2 - 2 grandparents 3 - 3 grandparents 4 - 4 grandparents 5 - 5 grandparents 6 - 6 grandparents 7 - 7 or more grandparents	Modified SNI
12	PedPxySNI05		How many other relatives (not including parents, grandparents, brothers or sisters) is the child close to?	0 - None 1 - 1 relative 2 - 2 relatives 3 - 3 relatives 4 - 4 relatives 5 - 5 relatives 6 - 6 relatives 7 - 7 or more relatives	Modified SNI
13	PedPxySNI05a	BRANCH - Answer only if response to 5 is NOT 0	How many of these relatives does the child see or talk to at least once every 2 weeks?	0 - None 1 - 1 relative 2 - 2 relatives 3 - 3 relatives 4 - 4 relatives 5 - 5 relatives 6 - 6 relatives 7 - 7 or more relatives	Modified SNI
14	PedPxySNI06		How many good friends does the child have?	0 - None 1 - 1 friend 2 - 2 friends 3 - 3 friends 4 - 4 friends 5 - 5 friends 6 - 6 friends 7 - 7 or more friends	Modified SNI
15	PedPxySNI06a	BRANCH - Answer only if response to 6 is NOT 0	How many good friends does the child see or talk to at least once every 2 weeks?	0 - None 1 - 1 friend 2 - 2 friends 3 - 3 friends 4 - 4 friends 5 - 5 friends 6 - 6 friends 7 - 7 or more friends	Modified SNI
16	PedPxySNI07		Does the child's family belong to a church, temple, mosque, or other religious group?	0 - No 1 - Yes	Modified SNI
17	PedPxySNI07a	BRANCH - Answer only if response to 7 is 1	How many members of the church or religious group does the child have close, personal interactions with on a regular basis?	0 - None 1 - 1 member 2 - 2 members 3 - 3 members 4 - 4 members 5 - 5 members 6 - 6 members 7 - 7 or more members	Modified SNI
18	PedPxySNI08		Does the child go to school or daycare?	0 - No 1 - Yes	Modified SNI
19	PedPxySNI08a	BRANCH - Answer only if response to 8 is 1	How many children or teachers at school/daycare does the child have close, personal interactions with at least once every 2 weeks?	0 - None 1 - 1 person 2 - 2 people 3 - 3 people 4 - 4 people 5 - 5 people 6 - 6 people 7 - 7 or more people	Modified SNI
20	PedPxySNI09		How many neighbors does the child visit, talk to, or play with at least once every 2 weeks?	0 - None 1 - 1 person 2 - 2 people 3 - 3 people 4 - 4 people 5 - 5 people 6 - 6 people 7 - 7 or more people	Modified SNI
21	PedPxySNI10		Outside of physical education classes in school, did the child take part in any regular sport activities during the past year that involved adult coaching or instruction?	0 - No 1 - Yes	HBQ - MacArthur Health and Behavior Questionnaire: Recreational Activities
22	PedPxySNI10a	BRANCH - Answer only if response to 10 is 1	How many sports did he/she take part in?		HBQ - MacArthur Health and Behavior Questionnaire: Recreational Activities
23	PedPxySNI10b	BRANCH - Answer only if response to 10 is 1	While playing these sports, how many times a week did he/she participate (on average)?	0 - Less than once a week 1 - 1-3 times a week 2 - 4 or more times a week	HBQ - MacArthur Health and Behavior Questionnaire: Recreational Activities
24	PedPxySNI11		Outside of regular classes in school, did the child take any lessons or instruction during the past year in music, dance, art or other non-sport activities?	0 - No 1 - Yes	HBQ - MacArthur Health and Behavior Questionnaire: Recreational Activities
25	PedPxySNI11a	BRANCH - Answer only if response to 11 is 1	In how many non-sport activities did he/she take lessons or instruction?		HBQ - MacArthur Health and Behavior Questionnaire: Recreational Activities
26	PedPxySNI11b	BRANCH - Answer only if response to 11 is 1	During the past year, how many times a week did he/she attend any of these: music, dance, art, or other non-sport activities?	0 - Less than once a week 1 - 1-3 times a week 2 - 4 or more times a week	HBQ - MacArthur Health and Behavior Questionnaire: Recreational Activities
27	PedPxySNI12		During the past year, did the child belong to any clubs or groups with adult leadership, such as Scouts, Brownies, or any community programs?	0 - No 1 - Yes	HBQ - MacArthur Health and Behavior Questionnaire: Recreational Activities
28	PedPxySNI12a	BRANCH - Answer only if response to 12 is 1	To how many such clubs or groups did he/she belong?		HBQ - MacArthur Health and Behavior Questionnaire: Recreational Activities
29	PedPxySNI12b	BRANCH - Answer only if response to 12 is 1	During the past year, how many times a week did the child attend meetings of these clubs or groups?	0 - Less than once a week 1 - 1-3 times a week 2 - 4 or more times a week	HBQ - MacArthur Health and Behavior Questionnaire: Recreational Activities
30	PedPxySNI13		How many different people involved in these groups does the child see or interact with about group-related activities at least once every 2 weeks?	0 - None 1 - 1 person 2 - 2 people 3 - 3 people 4 - 4 people 5 - 5 people 6 - 6 people 7 - 7 or more people	Modified SNI