Children (baseline only + retest)

Attachment 30
Instructions for Emotional Health Questionnaire

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX

Instructions for Emotional Health Questionnaire

This domain is administered on the computer. Each participant is presented with
a series of self-report questions that tap into four sub-domains of emotional wellbeing: Positive Affect, Negative Affect, Stress and Self-Efficacy, and Social
Relationships. These sub-domains are further divided into more precise aspects
as illustrated in the table below:1
General Aspect
Positive Affect

Precise Aspects
Life satisfaction & meaning
Positive feeling states

Sadness
Fear
Anger
Self-efficacy
Stress and Self-Efficacy
Perceived stress
Social support
Social Relationships
Companionship
Social distress
Negative Affect

If a participant (adult, child or proxy) has difficulty using the mouse, he/she may
point and the examiner may operate the mouse. The examiner should say
something like the following to the participant: “You can point to your choice
and then I will use the mouse to click on it for you.”
Completion time will vary from one age group to another but will be less than 30
minutes for 90th percentile of participants. Adults, children, and child proxies
each receive slightly different instructions on the screen; these are given below:
For Adults (ages 18-85):
On the next screens, we will ask you questions about your
thoughts, feelings and behaviors. Read each question
carefully and answer as well as you can. There is no right or
wrong answer, only what is true for you and describes your
thoughts, feelings, and behaviors. Some questions may seem
similar to ones you have already answered. This is intentional.
Please consider each question by itself and choose an
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.

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
answer that shows how you behave or what you really feel or
believe.
After you make your choice, the computer will automatically
go on to the next question. If you want to change your
answer, click on the GO BACK button to return to the
question, then choose a different answer.
Click on the CONTINUE button when you are ready to begin.
For Children (ages 8-17):
On the next screens, we will ask you questions about your
thoughts, feelings and behaviors. Read each question
carefully and answer as well as you can. There is no right or
wrong answer, only what is true for you and describes your
thoughts, feelings, and behaviors. Some questions may seem
like ones you have already answered. This is on purpose.
Please think about each question by itself and choose the
answer that shows how you behave or what you really feel or
believe.
After you make your choice, the computer will automatically
go on to the next question. If you want to change your
answer, click on the GO BACK button to return to the
question, then choose a different answer.
Click on the CONTINUE button when you are ready to begin.

For Child Proxies (ages 3-12):
On the next screens, you will see questions about your child’s
feelings and behaviors. Read each question carefully and
answer as best you can. There is no right or wrong answer, just
answer what you believe accurately describes your child’s
feelings and behaviors. Some questions may seem similar to
ones you have already answered. This is intentional. Please
consider each question by itself and choose an answer that
shows what you really feel or believe about your child.
After you make your choice, the computer will automatically
go on to the next question. If you want to change your
answer, click on the GO BACK button to return to the
question, then choose a different answer.
Click on the CONTINUE button when you are ready to begin.