8 Pain Assessment Ages 8-12

Attachment 8

Pain Assessment - Ages 8-12

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

Name of test: Pain Assessment Ages 8-12
Estimated time burden: 3 minutes
PROXY
On the next screens, you will see questions about your child’s pain. Read each question
carefully and answer as best you can. 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 previous question and then choose a different answer.
On the next screens, you will see questions about your child's pain. 1
Click on the CONTINUE button when you are ready to begin.

ID
PSPR8-12-9

Context/Stem
In the past 7 days, how would you rate
your child's pain on average?

PSPR8-12-01

In the past 7 days, my child was angry
when he or she had pain.

Responses
Don't know
0 No pain
1
2
3
4
5
6
7
8
9
10 Worst imaginable
pain
I don't know
Never
Almost Never
Sometimes
Often
Almost Always

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

ID
PSPR8-12-02

Context/Stem
In the past 7 days, my child had trouble
doing schoolwork because of pain.

PSPR8-12-03

In the past 7 days, my child had trouble
sleeping because of pain.

PSPR8-12-04

In the past 7 days, it was hard for my child
to pay attention because of pain.

PSPR8-12-05

In the past 7 days, it was hard for my child
to run because of pain.

PSPR8-12-06

In the past 7 days, it was hard for my child
to walk one block because of pain.

PSPR8-12-07

In the past 7 days, it was hard for my child
to have fun because of pain.

PSPR8-12-08

In the past 7 days, it was hard for my child
to stay standing because of pain.

Responses
I don't know
Never
Almost Never
Sometimes
Often
Almost Always
I don't know
Never
Almost Never
Sometimes
Often
Almost Always
I don't know
Never
Almost Never
Sometimes
Often
Almost Always
I don't know
Never
Almost Never
Sometimes
Often
Almost Always
I don't know
Never
Almost Never
Sometimes
Often
Almost Always
I don't know
Never
Almost Never
Sometimes
Often
Almost Always
I don't know
Never
Almost Never
Sometimes
Often
Almost Always

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

Self
ID
PSSR8-12-00

Context/Stem
On the next screens, we will ask you
questions about pain. Please think about
each question by itself and give your best
answer. 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 earlier question and then
choose a different answer.

Responses

Click on the CONTINUE button when
you are ready to begin.

PSSR8-12-01

How would you rate your pain right now?

PSSR8-12-10

In the past 7 days, how would you rate
your pain on average?

0 No pain
1
2
3
4
5
6
7
8
9
10 Worst imaginable
pain
0 No pain
1
2
3
4
5
6
7
8
9
10 Worst imaginable
pain

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

ID
PSSR8-12-02

Context/Stem
In the past 7 days, I felt angry when I had
pain.

PSSR8-12-03

In the past 7 days, I had trouble doing
schoolwork when I had pain.

PSSR8-12-04

In the past 7 days, I had trouble sleeping
when I had pain.

PSSR8-12-05

In the past 7 days, it was hard for me to
pay attention when I had pain.

PSSR8-12-06

In the past 7 days, it was hard for me to
run when I had pain.

PSSR8-12-07

In the past 7 days, it was hard for me to
walk one block when I had pain.

PSSR8-12-08

In the past 7 days, it was hard to have fun
when I had pain.

PSSR8-12-09

In the past 7 days, it was hard to stay
standing when I had pain.

Responses
Never
Almost Never
Sometimes
Often
Almost Always
Never
Almost Never
Sometimes
Often
Almost Always
Never
Almost Never
Sometimes
Often
Almost Always
Never
Almost Never
Sometimes
Often
Almost Always
Never
Almost Never
Sometimes
Often
Almost Always
Never
Almost Never
Sometimes
Often
Almost Always
Never
Almost Never
Sometimes
Often
Almost Always
Never
Almost Never
Sometimes
Often
Almost Always