32 Supplemental Emotional Health Questionaire

NIH Toolbox for Assessment of Neurological and Behavioral Function (NIA)

Attach 32 Supplemental Emotional Health Questionnaires.xls

Children (baseline only + retest)

OMB: 0925-0638

Document [xlsx]
Download: xlsx | pdf

Overview

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


Sheet 1: Title Page

Attachment 32


Emotional Health Questionnaires for Toolshed

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.






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.

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.

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

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

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
File Typeapplication/vnd.ms-excel
AuthorNicholas Zill
Last Modified Bywagsterm
File Modified2011-04-11
File Created2009-09-14

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