Form 7 Parent Protocol

SSA Attachment 7

HEALTHY COMMUNITIES STUDY

HEALTHY COMMUNITIES STUDY

FAMILY HOUSEHOLD VISIT PROTOCOL OVERVIEW

FOR PARENTS/CAREGIVER PARTICIPANTS

This document provides an overview of the protocol for the family household visit for the parent/caregiver participant. Protocol materials include the recruitment script, consent and medical record release authorization forms, the anthropometric measurement recording form, and the Home Visit Interview survey instrument (sections that may be completed by the /parent/cergiver are highlighted). These data collection materials will be used for the household visit in every community, for the remote follow-up data collection in the first 200 Wave 2 communities one or two years following the initial visit, and for the repeat in-person household visit three years after the initial visit for the Repeat In Person Assessment (RIPA) communities.

Recruitment of Households with an Eligible Child and Adult Guardian

If the selected family is found to be eligible during the screening call and is willing to participate in the study, the Battelle telephone interview will continue the call with the recruitment script to provide further detail on the study, record basic contact information, and enroll the family into the study. At the time of enrollment, 1 in 6 (approximately 17%) of the families within each community will be randomly selected to participate in the Enhanced Protocol, which involves a more detailed first visit, a second home visit approximately one week later, and the use of an accelerometer by the child during the time between the two visits.

Once enrolled, the household contact information will be provided to Examination Management Services, Inc. (EMSI), a company specializing in conducting home data collection across the country, so that home visits can be scheduled. EMSI will then contact the parent/caregiver to schedule the home visit at a date and time convenient for the family.

Consent of Parents/Caregivers

Once a potential adult participant has completed the eligibility screening and recruitment on the phone and scheduled a home visit, a trained field interviewer from EMSI will go to their home. The EMSI field interviewer will explain the study to the parent/caregiver and child in their home, review the consent documents, and answer any questions the parent/caregiver may have.  At this time, the parent/caregiver will be asked to sign the informed consent form, which will indicate their consent to participate. If other parents/caregivers are living in the home and available to be measured, they will also be asked to sign the form indicating their agreement to be measured. EMSI field interviewers will be trained to explain the study thoroughly and answer questions fully. They will be instructed to proceed only if the participants have provided their voluntary, informed consent.  EMSI field interviewers will be trained in Human Subjects Research, and will therefore know the guidelines regarding what qualifies as “informed” consent.

What defines “study participation” for a family differs across different communities and by intensity of data collection. The families in the 40 Repeat In-Person Assessment (RIPA) communities will have a follow-up home visit three years later to repeat the baseline assessments. The families in the first 200 Wave 2 communities (including the 40 RIPA communities) will be asked to answer questions by web or telephone one or two years after their baseline home visit. Families in other communities (the 4 Wave 1 communities and last 75 Wave 2 communities) will only have the one assessment. The table below describes these four different community data collection models for the entire 3.5 years of data collection.

Community Type	Number of Communities	Timing of Remote Follow-up	# of in-person Assessments
Wave 1*	4	N/A	1
Wave 2 RIPA	40	2 years	2
Wave 2 Non-RIPA	60	2 years	1
Wave 2 Non-RIPA	100	1 year	1
Wave 2 Non-RIPA*	75	N/A	1

*NOTE: these communities follow the same model

The data collection requirements for Standard and Enhanced Protocol participants are very different and every community will have families taking part in both protocol models. Therefore, the study will need to utilize 8 different consent forms (4 community models by 2 protocol models). A master version of the adult consent form is provided with the shaded wording under Procedures and Compensation indicating where sentences or phrases will differ as appropriate to the 8 conditions.

Home Visit Data Collection

As described earlier, every participating family will be administered at least one in-person home visit (home visit 1). Enhanced Protocol families have a second home visit (home visit 2) approximately one week later. Families in the RIPA communities have these in-person visits repeated three years later. In the first 200 Wave 2 communities, the families will also answer questions by web or telephone one or two years after their baseline home visit.

All of the questions to be asked of both Standard and Enhanced Protocol parent/caregivers during home visit 1 and home visit 2 using the study designed computer assisted interview (CAI) are provided. The interview instrument also indicates which questions will be asked of the parent/caregivers during remote follow-up data collection.

In addition to asking these computer-assisted questions, other data collection activities will take place in the home following consent.

Home Visit 1

While in the home, anthropometric measurements will be taken and recorded onto a paper form; the measurements on the paper form will be entered into the computer at the earliest opportunity before leaving the house. A medical record release form will also be completed and signed by the parent/caregiver. Data from this form will be entered into the study database by the EMSI field interviewer following the home visit. At this time the incentive will also be distributed.

If the family is participating in the Enhanced Protocol, during the first home visit the National Cancer Institute (NCI) Automated Self-Administered 24-hour Dietary Recall (ASA24) will be completed for the previous day by using the study computer and its broadband card to access the online instrument. Although the ASA24 was intended for self-administration, the dietary recall will be interviewer-administered. Respondents will sit alongside the EMSI field interviewer at the computer to view and respond to pre-programmed onscreen questions and portion size prompts as they report their intakes from the previous day. The interview will take approximately 30 minutes. Data collected through this web instrument will later be downloaded following the NCI’s procedures for data retrieval. Enhanced Protocol families will also be shown how to attach and detach the accelerometer during this first home visit, this demonstration is anticipated to take five minutes..

Home Visit 2

At the second home visit, the accelerometer will be retrieved and the data from the device will be downloaded into the study database. The ASA24 dietary recall will be administered for the previous day by using the study computer and its broadband card to access the online instrument and a Physical Behavior Activity Recall instrument will also be administered (this instrument is provided as part of the home visit questionnaire instrument under the Enhanced Protocol section). The second incentive will be distributed during this visit.

Remote Follow-up Data Collection

Respondents in the first 200 Wave 2 communities will be requested to participate in a remote questionnaire-based follow-up data collection that will occur via web or computer-assisted telephone interviews (CATI). The same questionnaire as used for the Standard Protocol baseline visit will be utilized for the remote follow-up, although certain questions will not be repeated for this interview. Questions to be included in the remote follow-up are identified in the home visit questionnaire instrument with an asterix.

HEALTHY COMMUNITIES STUDY

HOUSEHOLD RECRUITMENT SCRIPT

[CONTINUED FROM SCREENING SCRIPT FOR ELIGIBLE RESPONDENTS]

Public reporting burden of this collection of information is estimated at 6 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining 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 S. Sonia Arteaga, Ph.D., project officer at [email protected]

Now that we selected (name of child) to participate, I will tell you a little more about the study.

If child is 3-11 years old:

Standard Protocol: A data collector will call you to schedule a home visit that will last approximately 75 minutes. Both (name of child) and (name of adult) will need to be present during this entire visit time. During the home visit, the data collector will measure (name of child)’s height, weight and waist circumference and ask you to answer some survey questions. Children are also asked questions that vary based on their age, which you may need to help them answer. At the end of this visit, you will receive a gift worth $25 card and your child will receive a small toy as a thank you for your participation.

Enhanced Protocol: A data collector will call you to schedule two home visits – the first one will last approximately 95 minutes and the second one will last approximately 50 minutes. Both (name of child) and (name of adult) will need to be present during these entire visit times. During the first home visit, the data collector will measure (name of child)’s height, weight and waist circumference, ask you to answer some survey questions, and work with you to complete a task online that indicates what foods your child ate on the previous day. Children are also asked questions that vary based on their age, which you may need to help them answer. The data collector will give you an activity monitor for your child to wear and show you how to use it. Your child will be asked to wear the monitor for up to 8 days during waking hours. At the end of this first visit, you will receive

a gift worth $25 and your child will receive a small toy as a thank you for your participation. A week after your first home visit, the data collector will return to your home. During the second home visit, the data collector will collect the activity monitor lent to you, ask you some additional questions, and repeat the food recall task. Your family will receive an additional $50 money order at the end of this second visit.

If child is 12 or older:

Standard Protocol: A data collector will call you to schedule a home visit that will last approximately 75 minutes. Both (name of child) and (name of adult) will need to be present during this entire visit time. During the home visit, the data collector will measure (name of child)’s height, weight and waist circumference and ask you to answer some survey questions. Your child will also be asked to answer questions on his/her own. At the end of this visit, you will each receive a gift worth $15 as a thank you for your participation.

Enhanced Protocol: A data collector will call you to schedule a home visit – the first one will last approximately 95 minutes and the second one will last approximately 50 minutes. Both (name of child) and (name of adult) will need to be present during these entire visit times. During the first home visit, the data collector will measure (name of child)’s height, weight and waist circumference and ask you to answer some survey questions. Your child will also be asked to answer questions on their own and the data collector will work with your child to complete a task online that indicates what foods (he/she) ate on the previous day. The data collector will give you an activity monitor for your child to wear and show you both how to use it. Your child will be asked to wear the monitor for up to 8 days during waking hours. At the end of this first visit, you will each receive a gift worth $15 as a thank you for your participation. A week after your first home visit, the data collector will return to your home. During the second home visit, the data collector will collect the activity monitor lent to you, ask you and your child some additional questions, and repeat the food recall task. Your family will receive an additional $50 money order at the end of this second visit.

We would like you to have your child’s birth certificate available at the time of your home visit so that we can record the birth weight and length of your child and how far along you were in your pregnancy when you gave birth.

In order for us to give your information to the data collector so that a home visit can be scheduled, I need to get your full contact information.

Please tell me [name of adult]’s full name.

And what is [name of child]’s full name?

What language(s) does [name of child] speak?

Could you please give me the phone number that is best for us to call to reach you?

And what is an alternative number we can try if we have difficulty reaching you at that number?

Is there a family member or friend we can call if we have trouble reaching you at the numbers you just gave me?

If yes, Ok, may I please have the full name, relationship, and phone number for that person?

If no, Ok, that’s fine.

If address not verified earlier, Can you please give me your full address?

Feel free to call [phone number] with any questions or concerns.

Thank you so much for agreeing to participate in The Healthy Communities Study! We are very excited to meet you and will be in touch to schedule a home visit soon. Have a wonderful day!

HEALTHY COMMUNITIES STUDY

MASTER ADULT CONSENT FORM¹

Public reporting burden of this collection of information is estimated at 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining 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 S. Sonia Arteaga, Ph.D., project officer at [email protected]

PURPOSE

The purpose of the Healthy Communities Study is to see what programs and policies in communities across the United States help children lead healthy lives. This study is being conducted by a research company, Battelle Centers for Public Health Research and Evaluation. It is funded by the National Institutes of Health (NIH).

PROCEDURES – STANDARD PROTOCOL

If you agree to have you and your child participate in this study, a trained interviewer will come to your home [one time/two times, now and again three years from now]. [He or she/Each time he or she] will ask you and your child questions about nutrition and physical activity. The interviewer will also ask questions about your home and your community and will record the precise location of your home. This information will allow researchers to look at the specific resources and environment around the homes of study participants to understand where community programs have an impact.

Your answers will be recorded on a computer and some answers will be entered into the computer directly by you and your child. If your child was aged 12 or older when we first asked you to join the study, we will ask him or her to answer many of the questions without your help.

The interviewer will take measurements of your child including your child’s height, weight, and waist circumference. The interviewer will also record current height and weight measurements for the child’s parents/caregivers. If you are a parent/caregivers, the interviewer will measure your height and weight today, and measure the height and weight of the other parent/caregiver, if he or she lives here, is available today, and consents to being measured. If you are not the parentcaregiver, the interviewer will measure the height and weight of the parents/caregivers if either/both live here, are available today, and consent to being measured. If any parent/caregiver is not available or willing to be measured, we will ask you to report their latest known height and weight, if you know that information. Finally, the interviewer will ask you to sign a form to let us look at your child’s past medical records on file at your child’s doctor’s office to collect information on how your child has been growing. The entire visit today by the interviewer should take about 75 minutes.

[One year/Two years] from now, we will contact you again and ask you to answer about 35 minutes worth of questions through a web or telephone survey. The questions will be similar to those you are answering during today’s visit.

We may also contact you again in the future when similar studies take place in your community. At that time you will be given the choice to participate in that new study or not.

PROCEDURES – ENHANCED PROTOCOL

If you agree to have you and your child participate in this study, a trained interviewer will come to your home [two times/four times, twice now and twice again three years from now]. During the first visit [each year], he or she will ask you and your child questions about nutrition and physical activity. The interviewer will also ask questions about your home and your community and will record the precise location of your home. This information will allow researchers to look at the specific resources and environment around the homes of study participants to understand where community programs have an impact.

Your answers will be recorded on a computer and some answers will be entered into the computer directly by you and your child. If your child was aged 12 or older when we first asked you to join the study, we will ask him or her to answer many of the questions without your help.

The interviewer will take measurements of your child including your child’s height, weight, and waist circumference. The interviewer will also record current height and weight measurements for the child’s parents/caregivers. If you are a parent/caregiver, the interviewer will measure your height and weight today, and measure the height and weight of the other parent/caregiver, if he or she lives here, is available today, and consents to being measured. If you are not the parent/caregiver, the interviewer will measure the height and weight of the parents/caregivers if either/both live here, are available today, and consent to being measured. If any parent/careiver is not available or willing to be measured, we will ask you to report their latest known height and weight, if you know that information.

Your child will be asked to wear an activity monitor for the next week. The monitor measures movement. It should be worn at all times except while sleeping or when in water, such as while bathing or swimming. The interviewer will show you how to put the monitor on (and take it off) your child.

You and your child will also be asked to recall what your child ate yesterday. We would like to audio record the discussions as this food recall is being completed so that we can check that we entered the correct information in the computer. Finally, the interviewer will ask you to sign a form to let us look at your child’s past medical records on file at your child’s doctor’s office to collect information on how your child has been growing. The entire first visit by the interviewer should take about 95 minutes.

One week after the first visit [each year], the interviewer will come back to your house to collect the activity monitor and repeat the food recall. At this time, they will also ask you questions about what activities your child has done in the past week. This second visit will take approximately 50 minutes.

[One year/Two years] from now, we will contact you again and ask you to answer about 35 minutes worth of questions through a web or telephone survey. The questions will be similar to those you are answering during today’s visit.

We may also contact you again in the future when similar studies take place in your community. At that time you will be given the choice to participate in that new study or not.

HOW YOU WERE SELECTED

You are eligible to be in the study because you have a child between 3 and 15 years old living in your household and your household is located within one of the 279 communities we are studying. Approximately 23,000 children and their parents will eventually participate in this study.

CONFIDENTIALITY

The study team will do everything they can to make sure your information stays private and secure. All study staff members are required to complete trainings on keeping your information safe. Study laptops and equipment are password protected. They also have programs to protect your information. Your information will be stored in a locked building with access limited to authorized study team members only.

Any forms with your name (or your child’s name) will be kept separate from any papers that might be used to collect information about your child. Study data forms will only have your study identification number on it.

The only reasons we would have to break confidentiality, as required by law, are:

1. if a case of child abuse is discovered during the study, or

2. if the Institutional Review Board (IRB), the body which oversees the protection of study participants, needs to review records.

If you let us look at your child’s medical records, your doctor will know that you are in the study, but he or she will not have access to the information we collect during this study.

Final study results will be published on groups only. No individual information will be included. No individual in this study will be able to be identified.

RISKS/DISCOMFORTS

There are few known risks to participation in this study. Some of the questions we ask may be sensitive. Because the study is voluntary, you do not need to answer any question you do not feel comfortable answering. There is also a risk of loss of confidentiality. Every effort will be made to keep your information safe and secure.

BENEFITS

This study has no known individual benefits for participation. However, it is important for you and your child to participate because it will help researchers understand what programs and policies in the community help children to stay healthy. The results of this study could help improve existing and future programs/policies for children across the United States.

COSTS AND COMPENSATION

There is no cost to you for being in this study. In appreciation of your participation, after [the/each] [first] home visit if your child was between 3 and 11 years old when we first invited you to join the study, you will get a gift worth $25 and a small age-appropriate toy for your child. If your child was 12 or older when you agreed to join the study and today your child helps answer more of the study questions directly, you will each get a gift worth $15.

At the end of [your/each] second home visit, when the interviewer collects the activity monitor, your family will get an additional $50 money order.

If you complete the follow-up web or telephone questions in a few years, we will mail you another gift worth $10. As an additional thank you for your participation in this study, at the end of the study, you will get a summary report of the study results for all participants as a group.

VOLUNTARY

Participation by you, your child, and any other parents/caregivers in this study is voluntary. You may ask questions at any time. You may refuse to answer any survey question. You may also drop out at any time without penalty to you or your child. If your child is aged 8 or older today, we will also ask your child to sign a form indicating his or her agreement to be in the study before we begin any data collection.

CONTACT INFORMATION

For questions about your rights as a study participant, contact:

Battelle Institutional Review Board

1-877-810-9530

For questions or concerns about the study:

Dr. Howard Fishbein

Battelle Centers for Public Health Research and Evaluation

703-248-1647

I have read this consent form and the study staff have answered my questions.

I, ____________________________________, parent/guardian of __________________________,

^{Printed Parent/Guardian Full Name Printed Child Full Name}

agree for myself and my child to participate in the “HEALTHY COMMUNITIES STUDY.”

Please check one of the following boxes

I agree to allow audio recording of the food recall part of the interview.

I do NOT agree to allow audio recording of the food recall part of the interview.

____________________________________________ __________________

^{Parent/Guardian Signature Date}

________________________________

^{Witness Signature}

COMPLETE THE FOLLOWING FOR ANY BIOLOGIC PARENT NOT PARTICIPATING IN THE INTERVIEW WHO CONSENTS TO HAVE THEIR MEASUREMENTS TAKEN.

I agree to have my height and weight measured for the “HEALTHY COMMUNITIES STUDY.”

_________________________________________ _____________________________________ ^{Parent Signature Parent Signature}

HEALTHY COMMUNITIES STUDY

HIPAA COMPLIANT AUTHORIZATION TO RELEASE CONFIDENTIAL MEDICAL INFORMATION

Public reporting burden of this collection of information is estimated at 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining 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 S. Sonia Arteaga, Ph.D., project officer at [email protected]

Records and information obtained will be disclosed to: Examination Management Services, Inc. (EMSI), a subcontractor of Battelle Memorial Institute.

The purpose of this disclosure is to contribute to an ongoing research study. I, ____________________, (Name of Parent/Guardian) hereby authorize you to release all medical records and information within your possession, custody, or control regarding my child, _________________________ (Name of Child) pursuant to this Authorization. All records and information regarding diagnosis, testing, treatment, and prognosis of my child’s physical or mental condition are to be released. Such records and information to be released may include, but not be limited to, the following: age at observation, length/height and weight, and any indication of nutritional, physical activity, or sedentary activity counseling in the medical record.

I, the undersigned, hereby authorize all medical practitioners, physicians, pharmacists, hospitals, clinics, nurses, records custodians, or anyone else located at:

Facility Name	Medical Record Number	Provider Name	Address	Phone #	Ages when child saw provider	Approximate # times height & weight measured	Will child continue to see this provider?
				(__ __ __) __ __ __- __ __ __ __			Yes No
				(__ __ __) __ __ __- __ __ __ __			Yes No
				(__ __ __) __ __ __- __ __ __ __			Yes No
				(__ __ __) __ __ __- __ __ __ __			Yes No
				(__ __ __) __ __ __- __ __ __ __			Yes No
				(__ __ __) __ __ __- __ __ __ __			Yes No

to release all records and information regarding my child:

Patient (Child)’s Name: __________________________________________

^{First Middle Last}

Other Names Used: __________________________________________

Date of Birth: ___/___/_______ Social Security Number: _____-___-_____

Specifics to be released: __________________________________________

To be released to and exchanged between Examination Management Services, Inc. (EMSI), a subcontractor of Battelle Memorial Institute and their agents, contractors, employees, representatives, affiliates, and assigns as necessary to fulfill the purpose of this disclosure.

I understand when my child’s medical records are disclosed pursuant to this Authorization, my child’s medical records and the information contained in those records may become subject to further disclosure by Examination Management Services, Inc. (EMSI), a subcontractor of Battelle Memorial Institute. For example, Examination Management Services, Inc. (EMSI), a subcontractor of Battelle Memorial Institute may be required to provide it to the Institutional Review Board (IRB) (governing body that protects the rights of study participants). In this case, the information may no longer be protected by the rules governing this Authorization. This Authorization will remain in effect for three years from my date of signature below. I understand I may revoke this Authorization at any time by requesting such of EMSI in writing as its address stated above, unless action has already been taken in reliance upon it, or during a contestability period under applicable law. A photocopy of this Authorization will be treated in the same manner as the original.

I understand that if I refuse to sign this authorization to release my child’s complete medical records, he/she may not be able to participate in the research study.

Signature of patient/guardian/

personal representative: __________________________________________ Date: ___/___/______

Legal relationship to applicant: ______________________

(only if signed above by guardian or personal representative)

HEALTHY COMMUNITIES STUDY

ANTHROPOMETRIC MEASUREMENT RECORDING FORM FOR PARENT/CAREGIVER

To be completed by EMSI research staff: FOR ALL HEIGHT AND WAIST CIRCUMFERENCE MEASUREMENTS, RECORD MEASUREMENT IN CENTIMETERS TO THE NEAREST .1 CM. FOR ALL WEIGHT MEASUREMENTS, RECORD MEASUREMENT IN KILOGRAMS TO THE NEAREST .1 KG. IF PARENT/CAREGIVER REFUSES TO BE MEASURED OR IS NOT AVAILABLE, ASK FOR SELF-REPORTED OR PROXY-REPORT HEIGHT IN FEET AND INCHES AND WEIGHT IN POUNDS.
SECTION A: MOTHER/CAREGIVER MEASUREMENTS
A1.	MOTHER/CAREGIVER ID NUMBER		ID - - MOTHER/CAREGIVER UNKNOWN. (SKIP TO SECTION B) 9
A2.	MOTHER/CAREGIVER HEIGHT #1		MEASURED CM . OR SELF REPORT FT SELF REPORT INCHES OR PROXY REPORT FT PROXY REPORT INCHES OR RF 9997 DK 9998
A3.	MOTHER/CAREGIVER HEIGHT #2 (ONLY DO IF ENHANCED PROTOCOL)		MEASURED CM . RF 9997
A4.	MOTHER/CAREGIVER WEIGHT #1		MEASURED KG.. . OR SELF REPORT LBS . OR PROXY REPORT LBS . OR RF 9997 DK 9998
A5.	MOTHER/CAREGIVER WEIGHT #2 (ONLY DO IF ENHANCED PROTOCOL)		MEASURED KG . RF 9997

SECTION B: FATHER/CAREGIVER MEASUREMENTS
B1.	FATHER/CARGEIVER ID NUMBER		ID - - FATHER/CAREGIVER UNKNOWN.. (SKIP TO SECTION C) 9
B2.	FATHER/CAREGIVER HEIGHT #1		MEASURED CM.. . OR SELF REPORT FT SELF REPORT INCHES OR PROXY REPORT FT PROXY REPORT INCHES OR RF 9997 DK 9998
B3.	FATHER/CAREGIVER HEIGHT #2 (ONLY DO IF ENHANCED PROTOCOL)		MEASURED CM . RF 9997
B4.	FATHER/CAREGIVER WEIGHT #1		MEASURED KG . OR SELF REPORT LBS . OR PROXY REPORT LBS . OR RF 9997 DK 9998
B5.	FATHER/CAREGIVER WEIGHT #2 (ONLY DO IF ENHANCED PROTOCOL)		MEASURED KG . RF 9997

HEALTHY COMMUNITIES STUDY HOME VISIT COMPUTER-ASSISTED INTERVIEW CONTENT
Public reporting burden of this collection of information has an estimated average of 31 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining 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 S. Sonia Arteaga, Ph.D., project officer at [email protected]
HOME VISIT 1
NOTE: The following questions will be asked during the first home visit for all Standard and Enhanced Protocol families at baseline, and at in-person follow-up when applicable. These questions will be programmed into a computer-assisted interview (CAI) and asked of the adult and/or child respondent as indicated. Subsections of questions where the PARENT/CAREGIVER is the respondent have been highlighted for easier identification. They will be asked by the interviewer or self-administered as indicated. These questions are in addition to other home visit data collection activities (anthropmetric measurements, obtaining signed medical record release, teaching about use of the accelerometer) which will be completed on paper and in addition to completing the ASA-24 dietary recall through a website (for Enhanced Protocol families). The questions with an asterisk (*) will also be asked during the remote follow-up interviews. No interviewer prompts, wording probes, or other question-by-question specifications are captured in this document. Those additional details will be provided in an annotated version to be used during interviewer training and will be programmed into the CAI. In addition, the ORDER of the specific question sections will be modified for each age group, depending on how much of the questions the child needs to be present for. Consideration will be given to issues of child fatigue, need for privacy, etc., and when appropriate, simultaneous activities will be planned (for example, measuring the adult respondent while an older child respondent is self-completing sensitive questions).
SECTION A: COMMUNITY EXPOSURE
Interviewer administered
Child aged 3 – 5: Adult respondent Child aged 6 – 8: Adult respondent/child present to assist Child aged 9 – 11: Child respondent/adult present to assist Child aged 12 – 15: Child respondent
The first questions ask about your community or neighborhood. A community has many different things including schools, after school programs, childcare centers, work places, businesses, food stores, and markets, restaurants, places for sports, places for entertainment, churches, and other locations for community activities, and billboards with advertising.
A1. *	During the past six months, (have you/has your child) participated in or used any programs, services, facilities, or events in your community that encourage healthy eating or make healthy eating easier?		YES 1 NO (SKIP TO A3) 2 REFUSED (SKIP TO A3) 7 DON’T KNOW (SKIP TO A3) 8
*	What were the programs, services, facilities, events, promotions or something else in your community or neighborhood that encouraged healthy eating or made healthy eating easier?		PROGRAM 1:____________________________________ PROGRAM 2:____________________________________ PROGRAM 3:____________________________________ REFUSED 7 DON’T KNOW 8
A2. *	During the past six months, how often (have you/has your child) participated in or used any community programs, services, facilities, or events that encourage healthy eating? Would you say (READ ANSWERS)?		Rarely 1 Sometimes 2 Often 3 Very Often 4 REFUSED 7 DON’T KNOW 8
A3. *	During the past six months, (have you/has your child) participated in or used any programs, services, facilities, or events in your community that encourage or make physical activity easier?		YES 1 NO (SKIP TO SECTION B) 2 REFUSED (SKIP TO SECTION B) 7 DON’T KNOW (SKIP TO SECTION B) 8
*	What were the programs, services, facilities, events, or something else in your community that encouraged physical activity or made it easier?		PROGRAM 1:____________________________________ PROGRAM 2:____________________________________ PROGRAM 3:____________________________________ REFUSED 7 DON’T KNOW 8
A4. *	During the past six months, how often (have you/has your child) participated in or used any community programs, services, facilities, or events that encourage or make physical activity easier? Would you say (READ ANSWERS)?		Rarely 1 Sometimes 2 Often 3 Very Often 4 REFUSED 7 DON’T KNOW 8
SECTION B: DEMOGRAPHIC AND SOCIO-ECONOMIC INFORMATION
Interviewer administered
Child aged 3 – 15: Adult respondent
Now we have some basic background and demographic information to ask you. These questions are simple, straightforward, and will be kept strictly confidential. Your name will not be on your questionnaire.
B1.	How are you related to (CHILD)?		BIOLOGICAL MOTHER (SKIP TO B3) 1 BIOLOGICAL FATHER (SKIP TO B3) 2 ADOPTIVE/STEP/FOSTER MOTHER (SKIP TO B3) 3 ADOPTIVE/STEP/FOSTER FATHER (SKIP TO B3) 4 PARTNER OF CHILD’S MOTHER OR FATHER 5 GRANDPARENT 6 BROTHER/SISTER (BIOLOGICAL/ADOPTIVE/ STEP/IN-LAW/FOSTER) 7 AUNT/UNCLE 8 OTHER RELATIVE 9 OTHER NONRELATIVE 10 LEGAL GUARDIAN (SKIP TO B3) 11 CHILD IS WARD OF STATE OR COURT (SKIP TO B3) 12 REFUSED 97 DON’T KNOW 98
B2.	Are you (CHILD)’s guardian?		Yes 1 no 2 refused 7 don’t know 8
B3.	How old are you?		Age REFUSED 97 DON’T KNOW 98
B4.	RECORD GENDER WITHOUT ASKING		MALE 1 FEMALE 2
B5.	Are you now married, widowed, divorced separated, never married or living with a partner?		MARRIED 1 WIDOWED 2 DIVORCED 3 SEPARATED 4 NEVER MARRIED 5 LIVING WITH PARTNER 6 REFUSED 7 DON’T KNOW 8
B6.	Do you consider yourself Hispanic/Latin(o/a)? Which of the following represent your Hispanic origin or ancestry? READ ANSWERS AND CODE ALL THAT APPLY		YES 1 NO (SKIP TO B7) 2 REFUSED (SKIP TO B7) 7 DON’T KNOW (SKIP TO B7) 8 Puerto Rican 1 Dominican (Republic) 2 Mexican/Mexican American 3 Cuban/Cuban American 4 Central/South American 5 Other Latin American 6 Other Hispanic or Latin(o/a) 7 REFUSED 97 DON’T KNOW 98
B7.	(In addition to being Hispanic, what/What) race do you consider yourself to be? CODE ALL THAT APPLY		WHITE 1 BLACK/ AFRICAN AMERICAN 2 AMERICAN INDIAN/NATIVE AMERICAN 3 ALASKAN NATIVE 4 NATIVE HAWAIIAN 5 GUAMANIAN 6 SAMOAN 7 OTHER PACIFIC ISLANDER (SPECIFY) 8 ASIAN INDIAN 9 CHINESE 10 FILIPINO 11 JAPANESE 12 KOREAN 13 VIETNAMESE 14 OTHER ASIAN (SPECIFY) 15 AMERICAN 16 SOME OTHER RACE (SPECIFY) 17 REFUSED 97 DON’T KNOW 98
SPECIFY:
IF B7 = 16 ONLY, ASK A. ELSE SKIP TO B8
	In addition to being an American, what do you consider your main ethnic or national group to be?		WHITE 1 BLACK/ AFRICAN AMERICAN 2 AMERICAN INDIAN/NATIVE AMERICAN 3 ALASKAN NATIVE 4 NATIVE HAWAIIAN 5 GUAMANIAN 6 SAMOAN 7 OTHER PACIFIC ISLANDER (SPECIFY) 8 ASIAN INDIAN 9 CHINESE 10 FILIPINO 11 JAPANESE 12 KOREAN 13 VIETNAMESE 14 OTHER ASIAN (SPECIFY) 15 AMERICAN 16 SOME OTHER RACE (SPECIFY) 17 REFUSED 97 DON’T KNOW 98
SPECIFY:
B8.	Where were you born?		US STATE (SPECIFY) (SKIP TO B9) 1 US TERRITORY OR FOREIGN COUNTRY(SPECIFY) 2 REFUSED (SKIP TO B9) 7 DON’T KNOW (SKIP TO B9) 8
SPECIFY:
	What year did you come to live in the United States?		YEAR REFUSED 9997 DON’T KNOW 9998
Now I am going to ask you about language use.
IF B6=1, SKIP TO B10
B9.	What languages do you usually speak at home? CODE ALL THAT APPLY		ENGLISH 1 SPANISH 2 OTHER 3 REFUSED 7 DON’T KNOW 8
			SKIP TO B11
B10.	What languages do you usually speak at home? Would you say (READ ANSWERS)?		Only Spanish 1 More Spanish than English 2 Both Equally 3 More English than Spanish 4 Only English 5 REFUSED 7 DON’T KNOW 8
Now, I have some questions about educational history to ask you.
B11.	What is the highest grade or year of school you have completed or the highest degree you have received?		never attended/kindergarten only 1 1st grade 2 2nd grade 3 3rd grade 4 4th grade 5 5th grade 6 6th grade 7 7th grade 8 8th grade 9 9th grade 10 10th grade 11 11th grade 12 12th grade 13 12th grade, NO DIPLOMA 14 high school graduate 15 ged or equivalent 16 some college, no degree 17 associate degree: occupational, technical, or vocational program 18 associate degree: academic program 19 bachelor’s degree (ba, ab, bs, bba) 20 master’s Degree (ma, ms, meng, med, mba) 21 professional school degree (MD, DDS, DVM, JD) 22 doctoral degree (PHD, EDD) 23 refused 97 don’t know 98
B12.	We would like to know about what you do – are you working full-time for pay now, working part-time for pay, looking for work, retired, keeping house, a student, or what? CODE ALL THAT APPLY		WORKING FULL-TIME FOR PAY NOW 1 WORKING PART-TIME FOR PAY NOW 2 ONLY TEMPORARILY LAID OFF, on SICK LEAVE OR MATERNITY LEAVE 3 LOOKING FOR WORK, UNEMPLOYED 4 RETIRED 5 DISABLED, PERMANENTLY OR TEMPORARILY 6 KEEPING HOUSE 7 STUDENT 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98
SPECIFY:
B13.	How many nights a week does (CHILD) usually sleep in this house?		nights REFUSED 97 DON’T KNOW 98
IF B1>02, SKIP TO B25
You said that you are (CHILD)’S parent/caregiver. I would like to ask some questions now about (his/her) other parent/caregiver.
B14.	Does (CHILD)’s biological (father/mother) also live in this household?		YES 1 NO 2 REFUSED 7 DON’T KNOW 8
B15.	How old is (he/she)?		Age REFUSED 97 DON’T KNOW 98
B16.	RECORD GENDER OF OTHER PARENT/CAREGIVER WITHOUT ASKING		MALE 1 FEMALE 2
B17.	Is (he/she) now married, widowed, divorced, separated, never married, or living with a partner?		MARRIED 1 WIDOWED 2 DIVORCED 3 separated 4 never married 5 living with partner 6 refused 7 don’t know 8
B18.	Do you consider (him/her) Hispanic/Latin(o/a)?		YES 1 NO (SKIP TO B19) 2 REFUSED (SKIP TO B19) 7 DON’T KNOW (SKIP TO B19) 8
	Which of the following represent (his/her) Hispanic origin or ancestry? READ ANSWERS AND CODE ALL THAT APPLY		Puerto Rican 1 Dominican (Republic) 2 Mexican/Mexican American 3 Cuban/Cuban American 4 Central/South American 5 Other Latin American 6 Other Hispanic or Latin(o/a) 7 REFUSED 97 DON’T KNOW 98
B19.	(In addition to being Hispanic, what/What) race do you consider (him/her) to be? CODE ALL THAT APPLY		WHITE 1 BLACK/ AFRICAN AMERICAN 2 AMERICAN INDIAN/NATIVE AMERICAN 3 ALASKAN NATIVE 4 NATIVE HAWAIIAN 5 GUAMANIAN 6 SAMOAN 7 OTHER PACIFIC ISLANDER (SPECIFY) 8 ASIAN INDIAN 9 CHINESE 10 FILIPINO 11 JAPANESE 12 KOREAN 13 VIETNAMESE 14 OTHER ASIAN (SPECIFY) 15 AMERICAN 16 SOME OTHER RACE (SPECIFY) 17 REFUSED 97 DON’T KNOW 98
SPECIFY:
IF B19 = 16 ONLY, ASK A. ELSE SKIP TO B20
	In addition to being an American, what do you consider (his/her) main ethnic or national group to be?		WHITE 1 BLACK/ AFRICAN AMERICAN 2 AMERICAN INDIAN/NATIVE AMERICAN 3 ALASKAN NATIVE 4 NATIVE HAWAIIAN 5 GUAMANIAN 6 SAMOAN 7 OTHER PACIFIC ISLANDER (SPECIFY) 8 ASIAN INDIAN 9 CHINESE 10 FILIPINO 11 JAPANESE 12 KOREAN 13 VIETNAMESE 14 OTHER ASIAN (SPECIFY) 15 AMERICAN 16 SOME OTHER RACE (SPECIFY) 17 REFUSED 97 DON’T KNOW 98
SPECIFY:
B20.	Where was (he/she) born?		US STATE (SPECIFY) (SKIP TO B21) 1 US TERRITORY OR FOREIGN COUNTRY(SPECIFY) 2 REFUSED (SKIP TO B21) 7 DON’T KNOW (SKIP TO B21) 8
SPECIFY:
	What year did (he/she) come to live in the United States?		YEAR REFUSED 9997 DON’T KNOW 9998
Now I am going to ask you about (his/her) language use.
IF B18=1, SKIP TO B22
B21.	What languages does (he/she) usually speak at home? CODE ALL THAT APPLY		ENGLISH 1 SPANISH 2 OTHER 3 REFUSED 7 DON’T KNOW 8
			SKIP TO B23
B22.	What languages does (he/she) usually speak at home? Would you say (READ ANSWERS)?		Only Spanish 1 More Spanish than English 2 Both Equally 3 More English than Spanish 4 Only English 5 Other 6 REFUSED 7 DON’T KNOW 8
Now, I have some questions about (his/her) educational history to ask you.
B23.	What is the highest grade or year of school (he/she) has completed or the highest degree (he/she) has received?		never attended/kindergarten only 1 1st grade 2 2nd grade 3 3rd grade 4 4th grade 5 5th grade 6 6th grade 7 7th grade 8 8th grade 9 9th grade 10 10th grade 11 11th grade 12 12th grade 13 12th grade, NO DIPLOMA 14 high school graduate 15 ged or equivalent 16 some college, no degree 17 associate degree: occupational, technical, or vocational program 18 associate degree: academic program 19 bachelor’s degree (ba, ab, bs, bba) 20 master’s Degree (ma, ms, meng, med, mba) 21 professional school degree (MD, DDS, DVM, JD) 22 doctoral degree (PHD, EDD) 23 refused 97 don’t know 98
B24.	We would like to know about what (he/she) does- is (he/ she) working full-time for pay now, working part-time for pay, looking for work, retired, keeping house, a student, or what? CODE ALL THAT APPLY		WORKING FULL-TIME FOR PAY NOW 1 WORKING PART-TIME FOR PAY NOW 2 ONLY TEMPORARILY LAID OFF, on SICK LEAVE OR MATERNITY LEAVE 3 LOOKING FOR WORK, UNEMPLOYED 4 RETIRED 5 DISABLED, PERMANENTLY OR TEMPORARILY 6 KEEPING HOUSE 7 STUDENT 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98
SPECIFY:
			SKIP TO B45
You said that you are not (CHILD)’s biological parent. I would like to ask some questions now about (his/her) biological mother and father.
B25.	Does (CHILD)’s biological mother live in the household?		YES 1 NO 2 KNOWS NOTHING ABOUT BIOLOGICAL MOTHER (SKIP TO B35) 3 REFUSED 7 don’t KNOW 8
B26.	How old is (his/her) biological mother?		Age REFUSED 97 DON’T KNOW 98
B27.	Is she now married, widowed, divorced, separated, never married, or living with a partner?		MARRIED 1 WIDOWED 2 DIVORCED 3 separated 4 never married 5 living with partner 6 refused 7 don’t know 8
B28.	Do you consider her Hispanic/ Latina? Which of the following represent her Hispanic origin or ancestry? READ ANSWERS AND CODE ALL THAT APPLY		YES 1 NO (SKIP TO B29) 2 REFUSED (SKIP TO B29) 7 DON’T KNOW (SKIP TO B29) 8 Puerto Rican 1 Dominican (Republic) 2 Mexican/Mexican American 3 Cuban/Cuban American 4 Central/South American 5 Other Latin American 6 Other Hispanic or Latin(o/a) 7 REFUSED 97 DON’T KNOW 98
B29.	(In addition to being Hispanic, what/What) race do you consider her to be? CODE ALL THAT APPLY		WHITE 1 BLACK/ AFRICAN AMERICAN 2 AMERICAN INDIAN/NATIVE AMERICAN 3 ALASKAN NATIVE 4 NATIVE HAWAIIAN 5 GUAMANIAN 6 SAMOAN 7 OTHER PACIFIC ISLANDER (SPECIFY) 8 ASIAN INDIAN 9 CHINESE 10 FILIPINO 11 JAPANESE 12 KOREAN 13 VIETNAMESE 14 OTHER ASIAN (SPECIFY) 15 AMERICAN 16 SOME OTHER RACE (SPECIFY) 17 REFUSED 97 DON’T KNOW 98
SPECIFY:
IF B29 = 16 ONLY, ASK A. ELSE SKIP TO B30
	In addition to being an American, what do you consider her main ethnic or national group to be?		WHITE 1 BLACK/ AFRICAN AMERICAN 2 AMERICAN INDIAN/NATIVE AMERICAN 3 ALASKAN NATIVE 4 NATIVE HAWAIIAN 5 GUAMANIAN 6 SAMOAN 7 OTHER PACIFIC ISLANDER (SPECIFY) 8 ASIAN INDIAN 9 CHINESE 10 FILIPINO 11 JAPANESE 12 KOREAN 13 VIETNAMESE 14 OTHER ASIAN (SPECIFY) 15 AMERICAN 16 SOME OTHER RACE (SPECIFY) 17 REFUSED 97 DON’T KNOW 98
SPECIFY:
B30.	Where was she born?		US STATE (SPECIFY) (SKIP TO B31) 1 US TERRITORY OR FOREIGN COUNTRY(SPECIFY) 2 REFUSED (SKIP TO B31) 7 don’t know (skip to B31) 8
SPECIFY:
	What year did she come to live in the United States?		YEAR REFUSED 9997 DON’T KNOW 9998
Now I am going to ask you about her language use.
IF B28=1, SKIP TO B32
B31.	What languages does she usually speak at home? CODE ALL THAT APPLY		ENGLISH 1 SPANISH 2 OTHER 3 REFUSED 7 DON’T KNOW 8
			SKIP TO B33
B32.	What languages does she usually speak at home? Would you say (READ ANSWERS)?		Only Spanish 1 More Spanish than English 2 Both Equally 3 More English than Spanish 4 Only English 5 Other 6 REFUSED 7 DON’T KNOW 8
Now, I have some questions about her educational history to ask you.
B33.	What is the highest grade or year of school she has completed or the highest degree she has received?		never attended/kindergarten only 1 1st grade 2 2nd grade 3 3rd grade 4 4th grade 5 5th grade 6 6th grade 7 7th grade 8 8th grade 9 9th grade 10 10th grade 11 11th grade 12 12th grade 13 12th grade, NO DIPLOMA 14 high school graduate 15 ged or equivalent 16 some college, no degree 17 associate degree: occupational, technical, or vocational program 18 associate degree: academic program 19 bachelor’s degree (ba, ab, bs, bba) 20 master’s Degree (ma, ms, meng, med, mba) 21 professional school degree (MD, DDS, DVM, JD) 22 doctoral degree (PHD, EDD) 23 refused 97 don’t know 98
B34.	We would like to know about what she does – is she working full-time for pay now, working part-time for pay, looking for work, retired, keeping house, a student, or what? CODE ALL THAT APPLY		WORKING FULL-TIME FOR PAY NOW 1 WORKING PART-TIME FOR PAY NOW 2 ONLY TEMPORARILY LAID OFF, on SICK LEAVE OR MATERNITY LEAVE 3 LOOKING FOR WORK, UNEMPLOYED 4 RETIRED 5 DISABLED, PERMANENTLY OR TEMPORARILY 6 KEEPING HOUSE 7 STUDENT 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98
Now I would like to ask the same questions about (CHILD)’s biological father.
B35.	Does (CHILD)’s biological father live in this household?		YES 1 NO 2 KNOWS NOTHING ABOUT BIOLOGICAL FATHER (SKIP TO B45) 3 REFUSED 7 don’t KNOW 8
B36.	How old is (his/her) biological father?		Age REFUSED 97 DON’T KNOW 98
B37.	Is he now married, widowed, divorced, separated, never married, or living with a partner?		MARRIED 1 WIDOWED 2 DIVORCED 3 separated 4 never married 5 living with partner 6 refused 7 don’t know 8
B38.	Do you consider him Hispanic/ Latino? Which of the following represent his Hispanic origin or ancestry? READ ANSWERS AND CODE ALL THAT APPLY		YES 1 NO (SKIP TO B39) 2 REFUSED (SKIP TO B39) 7 DON’T KNOW (SKIP TO B39) 8 Puerto Rican 1 Dominican (Republic) 2 Mexican/Mexican American 3 Cuban/Cuban American 4 Central/South American 5 Other Latin American 6 Other Hispanic or Latin(o/a) 7 REFUSED 97 DON’T KNOW 98
B39.	(In addition to being Hispanic, what/What) race do you consider him to be? CODE ALL THAT APPLY		WHITE 1 BLACK/ AFRICAN AMERICAN 2 AMERICAN INDIAN/NATIVE AMERICAN 3 ALASKAN NATIVE 4 NATIVE HAWAIIAN 5 GUAMANIAN 6 SAMOAN 7 OTHER PACIFIC ISLANDER (SPECIFY) 8 ASIAN INDIAN 9 CHINESE 10 FILIPINO 11 JAPANESE 12 KOREAN 13 VIETNAMESE 14 OTHER ASIAN (SPECIFY) 15 AMERICAN 16 SOME OTHER RACE (SPECIFY) 17 REFUSED 97 DON’T KNOW 98
SPECIFY:
IF B39 = 16 ONLY, ASK A. ELSE SKIP TO B40
	In addition to being an American, what do you consider his main ethnic or national group to be?		WHITE 1 BLACK/ AFRICAN AMERICAN 2 AMERICAN INDIAN/NATIVE AMERICAN 3 ALASKAN NATIVE 4 NATIVE HAWAIIAN 5 GUAMANIAN 6 SAMOAN 7 OTHER PACIFIC ISLANDER (SPECIFY) 8 ASIAN INDIAN 9 CHINESE 10 FILIPINO 11 JAPANESE 12 KOREAN 13 VIETNAMESE 14 OTHER ASIAN (SPECIFY) 15 AMERICAN 16 SOME OTHER RACE (SPECIFY) 17 REFUSED 97 DON’T KNOW 98
SPECIFY:
B40.	Where was he born?		US STATE (SPECIFY) (SKIP TO B41) 1 US TERRITORY OR FOREIGN COUNTRY(SPECIFY) 2 REFUSED (SKIP TO B41) 7 don’t know (skip to B41) 8
	What year did he come to live in the United States?		YEAR REFUSED 9997 DON’T KNOW 9998
Now I am going to ask you about his language use.
IF B38=1, SKIP TO B42
B41.	What languages does he speak at home? CODE ALL THAT APPLY		ENGLISH 1 SPANISH 2 OTHER 3 REFUSED 7 DON’T KNOW 8
			SKIP TO B43
B42.	What languages does he usually speak at home? Would you say (READ ANSWERS)?		Only Spanish 1 More Spanish than English 2 Both Equally 3 More English than Spanish 4 Only English 5 Other 6 REFUSED 7 DON’T KNOW 8
Now, I have some questions about his educational history to ask you.
B43.	What is the highest grade or year of school he has completed or the highest degree he has received?		never attended/kindergarten only 1 1st grade 2 2nd grade 3 3rd grade 4 4th grade 5 5th grade 6 6th grade 7 7th grade 8 8th grade 9 9th grade 10 10th grade 11 11th grade 12 12th grade 13 12th grade, NO DIPLOMA 14 high school graduate 15 ged or equivalent 16 some college, no degree 17 associate degree: occupational, technical, or vocational program 18 associate degree: academic program 19 bachelor’s degree (ba, ab, bs, bba) 20 master’s Degree (ma, ms, meng, med, mba) 21 professional school degree (MD, DDS, DVM, JD) 22 doctoral degree (PHD, EDD) 23 refused 97 don’t know 98
B44.	We would like to know about what he does – is he working full-time for pay now, part-time for pay looking for work, retired, keeping house, a student, or what?		WORKING FULL-TIME FOR PAY NOW 1 WORKING PART-TIME FOR PAY NOW 2 ONLY TEMPORARILY LAID OFF, on SICK LEAVE OR MATERNITY LEAVE 3 LOOKING FOR WORK, UNEMPLOYED 4 RETIRED 5 DISABLED, PERMANENTLY OR TEMPORARILY 6 KEEPING HOUSE 7 STUDENT 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98
The next questions are about your total family income in (LAST CALENDAR YEAR IN 4-DIGIT FORMAT) before taxes. Income is important in understanding the health information we collect. For example, with this information, we can learn how income is related to children’s health. These answers will be kept strictly confidential like all the other information you provide When answering these questions, please remember that by “combined family income” I mean your income plus the income of all family members and partners living in the household. Please include income from jobs, government assistance, social security, disability, unemployment insurance, investments, and any other income that your family has.
B45. *	What is your best estimate of the total income of all family members from all sources, before taxes were taken out, in (LAST CALENDAR YEAR IN 4-DIGIT FORMAT)?		INCOME (SKIP TO B51) $ , , REFUSED 9999997 DON’T KNOW 9999998
B46. *	Was your total family income from all sources less than $50,000 or $50,000 or more?		LESS THAN $50,000 1 $50,000 OR MORE (SKIP TO B49) 2 REFUSED 7 DON’T KNOW 8
B47. *	Was your total family income from all sources less than $35,000 or $35,000 or more?		LESS THAN $35,000 1 $35,000 OR MORE (SKIP TO B51) 2 REFUSED 7 DON’T KNOW 8
B48. *	Was your total family income from all sources less than $20,000 or $20,000 or more?		LESS THAN $20,000 1 $20,000 OR MORE. 2 REFUSED 7 DON’T KNOW 8
			SKIP TO B51
B49. *	Was your total family income from all sources less than $100,000 or $100,000 or more?		LESS THAN $100,000 1 $100,000 OR MORE (SKIP TO B51) 2 REFUSED 7 DON’T KNOW 8
B50. *	Was your total family income from all sources less than $75,000 or $75,000 or more?		LESS THAN $75,000 1 $75,000 OR MORE 2 REFUSED 7 DON’T KNOW 8
B51.	Does (CHILD) consider (himself/ herself) Hispanic/Latin(o/a)? Which of the following represent (CHILD)’s Hispanic origin or ancestry? READ ANSWERS AND CODE ALL THAT APPLY		YES 1 NO (SKIP TO B52) 2 REFUSED (SKIP TO B52) 7 DON’T KNOW (SKIP TO B52) 8 Puerto Rican 1 Dominican (Republic) 2 Mexican/Mexican American 3 Cuban/Cuban American 4 Central/South American 5 Other Latin American 6 Other Hispanic or Latin(o/a) 7 REFUSED 97 DON’T KNOW 98
B52.	(In addition to being Hispanic, what/What) race does (CHILD) consider (himself/ herself) to be? CODE ALL THAT APPLY		WHITE 1 BLACK/ AFRICAN AMERICAN 2 AMERICAN INDIAN/NATIVE AMERICAN 3 ALASKAN NATIVE 4 NATIVE HAWAIIAN 5 GUAMANIAN 6 SAMOAN 7 OTHER PACIFIC ISLANDER (SPECIFY) 8 ASIAN INDIAN 9 CHINESE 10 FILIPINO 11 JAPANESE 12 KOREAN 13 VIETNAMESE 14 OTHER ASIAN (SPECIFY) 15 AMERICAN 16 SOME OTHER RACE (SPECIFY) 17 REFUSED 97 DON’T KNOW 98
SPECIFY:
IF B52 = 16 ONLY, ASK A. ELSE SKIP TO B53
	In addition to being an American, what does (CHILD) consider (his/her) main ethnic or national group to be?		WHITE 1 BLACK/ AFRICAN AMERICAN 2 AMERICAN INDIAN/NATIVE AMERICAN 3 ALASKAN NATIVE 4 NATIVE HAWAIIAN 5 GUAMANIAN 6 SAMOAN 7 OTHER PACIFIC ISLANDER (SPECIFY) 8 ASIAN INDIAN 9 CHINESE 10 FILIPINO 11 JAPANESE 12 KOREAN 13 VIETNAMESE 14 OTHER ASIAN (SPECIFY) 15 AMERICAN 16 SOME OTHER RACE (SPECIFY) 17 REFUSED 97 DON’T KNOW 98
SPECIFY:
B53.	Where was (CHILD) born?		US STATE (SPECIFY) (SKIP TO B54) 1 US TERRITORY OR FOREIGN COUNTRY(SPECIFY) 2 REFUSED (SKIP TO B54) 7 don’t know (skip to B54) 8
SPECIFY:
	What year did (CHILD) come to live in the United States?		YEAR REFUSED 9997 DON’T KNOW 9998
Now I am going to ask you about (CHILD)’s language use.
IF B51=1, SKIP TO B55
B54.	What languages does (CHILD) usually speak at home? CODE ALL THAT APPLY		ENGLISH 1 SPANISH 2 OTHER 3 REFUSED 7 DON’T KNOW 8
			SKIP TO B56
B55.	What languages does (CHILD) usually speak at home? Would you say (READ ANSWERS)?		Only Spanish 1 More Spanish than English 2 Both Equally 3 More English than Spanish 4 Only English 5 Other 6 REFUSED 7 DON’T KNOW 8
Now, I have some questions about (CHILD)’s educational history to ask you.
B56. *	What grade or year of school (is [he/ she] currently attending/will [he/she] be attending in the coming school year)?		nOT attendING/kindergarten only 1 1st grade 2 2nd grade 3 3rd grade 4 4th grade 5 5th grade 6 6th grade 7 7th grade 8 8th grade 9 9th grade 10 10th grade 11 11th grade 12 12th grade 13 OTHER (SPECIFY) 14 refused 97 don’t know 98
SPECIFY:
*	What is the name of the school (CHILD) (is currently attending/will be attending in the coming school year)?		NAME:__________________________________________ REFUSED 7 DON’T KNOW 8
SECTION C: DETAILS OF CHILD’S BIRTH
Interviewer administered
Child aged 3 – 15: Adult respondent
We now want to ask some questions about (CHILD)’s birth.
C1.	How much did (CHILD) weigh at birth?		ANSWER IN POUNDS 1 ANSWER IN GRAMS (SKIP TO B) 2 REFUSED (SKIP TO C) 7 DON’T KNOW (SKIP TO C) 8
	RECORD BIRTH WEIGHT IN POUNDS AND OUNCES		POUNDS OUNCES
			SKIP TO C2
	RECORD BIRTH WEIGHT IN GRAMS (1 KILOGRAM = 1000 GRAMS)		GRAMS
			SKIP TO C2
	Did (CHILD) weigh more than 5 ½ pounds or 2500 grams?		YES 1 NO (SKIP TO C2) 2 REFUSED (SKIP TO C2) 7 DON’T KNOW (SKIP TO C2) 8
	Did (CHILD) weigh more than 9 pounds or 4100 grams?		YES 1 NO 2 REFUSED 7 DON’T KNOW 8
C2.	What was (CHILD)’s length at birth?		ANSWER IN INCHES 1 ANSWER IN CENTIMETERS (SKIP TO B) 2 REFUSED (SKIP TO C3) 7 DON’T KNOW (SKIP TO C3) 8
	RECORD BIRTH LENGTH IN INCHES		INCHES
			SKIP TO C3
	RECORD BIRTH LENGTH IN CENTIMETERS		CENTIMETERS
C3.	Was (CHILD) born early or preterm? A preterm delivery is one that occurs at 36 weeks or earlier in pregnancy (more than 3 weeks before the baby’s due date).		YES 1 NO (SKIP TO SECTION D) 2 REFUSED (SKIP TO SECTION D) 7 DON’T KNOW (SKIP TO SECTION D) 8
	How many weeks early was (CHILD) born?		WEEKS (SKIP TO SECTION D) REFUSED 97 DON’T KNOW 98
	How many weeks along was (CHILD) at birth?		WEEKS REFUSED 97 DON’T KNOW 98
SECTION D: HEALTH INSURANCE
Interviewer administered
Child aged 3 – 15: Adult respondent
The next questions are about health insurance coverage for you and for (CHILD). When answering these questions, please include health insurance obtained through employment or purchased directly as well as government programs like Medicare and Medicaid that provide medical care or help pay medical bills.
D1. *	Are you currently covered by medical insurance or some other kind of health care plan?		YES 1 NO (SKIP TO D4) 2 REFUSED (SKIP TO D4) 7 DON’T KNOW (SKIP TO D4) 8
D2. *	What kind of health insurance or health care coverage do you have? Include those plans that only pay for one kind of service such as nursing home care, accidents or dental care. Exclude private plans that only provide extra cash when hospitalized. If you have more than one kind of health insurance, please tell me all the plans that you have. CODE ALL THAT APPLY		PRIVATE HEALTH INSURANCE 1 MEDICARE 2 MEDI-GAP 3 MEDICAID/STATE PLAN NAME 4 SCHIP/CHIP/CHILDREN’S HEALTH INSURANCE PROGRAM 5 MILITARY HEALTH CARE/TRICARE/VA/CHAMP-VA 6 INDIAN HEALTH SERVICES 7 STATE-SPONSORED HEALTH PLAN/STATE PLAN NAME 8 OTHER GOVERNMENT PROGRAM 9 SINGLE SERVICE PLAN (DENTAL, VISION, PRESCRIPTION) 10 NO COVERAGE OF ANY TYPE 11 REFUSED 97 DON’T KNOW 98
D3. *	In the past 12 months, was there any time when you did not have health insurance coverage?		YES 1 NO 2 REFUSED 7 DON'T KNOW 8
D4. *	Is (CHILD) currently covered by medical insurance or some other kind of health care plan?		YES 1 1 NO (SKIP TO D7) 2 REFUSED (SKIP TO D7) 7 DON’T KNOW (SKIP TO D7) 8
D5. *	What kind of health insurance or health care coverage does (he/she) have? Include those plans that only pay for one kind of service such as nursing home care, accidents or dental care. Exclude private plans that only provide extra cash when hospitalized. If (CHILD) has more than one kind of health insurance, please tell me all the plans that (he/she) has. CODE ALL THAT APPLY		PRIVATE HEALTH INSURANCE 1 MEDICARE 2 MEDI-GAP 3 MEDICAID/STATE PLAN NAME 4 SCHIP/CHIP/CHILDREN’S HEALTH INSURANCE PROGRAM 5 MILITARY HEALTH CARE/TRICARE/VA/CHAMP-VA 6 INDIAN HEALTH SERVICES 7 STATE-SPONSORED HEALTH PLAN/STATE PLAN NAME 8 OTHER GOVERNMENT PROGRAM 9 SINGLE SERVICE PLAN (DENTAL, VISION, PRESCRIPTION) 10 NO COVERAGE OF ANY TYPE 11 REFUSED 97 DON’T KNOW 98
D6. *	In the past 12 months, was there any time when (CHILD) did not have health insurance coverage?		YES 1 NO 2 REFUSED 7 DON’T KNOW 8
Now I am going to ask some questions about (CHILD)’s health.
D7. *	Has a doctor or other health professional ever told you that (CHILD) has a long-term or chronic disease like diabetes, asthma or any other condition?		YES (SPECIFY) 1 NO (SKIP TO D8) 2 REFUSED (SKIP TO D8) 7 DON’T KNOW (SKIP TO D8) 8
SPECIFY CONDITION:
*	Has a doctor or other health professional ever prescribed medication for (CHILD) for this chronic medical condition?		YES (SPECIFY) 1 NO 2 REFUSED 7 DON'T KNOW 8
SPECIFY MEDICATION:
D8. *	Has a doctor or other health professional ever referred (CHILD) to a pediatric endocrinologist?		YES 1 NO (SKIP TO D9) 2 REFUSED (SKIP TO D9) 7 DON’T KNOW (SKIP TO D9) 8
*	Was this visit related to (CHILD)’s weight?		YES 1 NO 2 REFUSED 7 DON'T KNOW 8
D9. *	Is (CHILD) currently enrolled in a structured program that targets weight, diet, or physical activity? Please do not include organized sports programs.		YES 1 NO 2 REFUSED 7 DON'T KNOW 8
D10. *	Does (CHILD) have an impairment or health problem that limits (his/her) ability to walk, run or play?		YES 1 NO (SKIP TO SECTION E) 2 REFUSED (SKIP TO SECTION E) 7 DON’T KNOW (SKIP TO SECTION E) 8
D11. *	Is this an impairment or health problem that has lasted, or is expected to last, 12 months or longer?		YES 1 NO (SKIP TO SECTION E) 2 REFUSED (SKIP TO SECTION E) 7 DON’T KNOW (SKIP TO SECTION E) 8
D12. *	Would you please describe this impairment or health problem?		YES (SPECIFY) 1 NO (SKIP TO SECTION E) 2 REFUSED (SKIP TO SECTION E) 7 DON’T KNOW (SKIP TO SECTION E) 8
SPECIFY:
SECTION E: CHILD SELF-REPORTED BEHAVIORS
Self administered
Child aged 3 – 11: NOT ADMINISTERED Child aged 12 – 15: Child respondent
Now we have a few questions for (CHILD) that we would like (him/her) to answer by (himself/herself) on the computer. These questions ask about behaviors and perceptions that are linked to children’s health. I can show (CHILD) how to get started with the questions. AFTER DEMONSTRATING COMPUTER USAGE TO (CHILD), REMIND (HIM/HER) THAT NO ONE IN THE HOME WILL SEE THE ANSWERS.
E1. *	We first want you to answer some questions about smoking. Have you smoked at least one cigarette within the last 30 days?		YES 1 NO (SKIP TO E2) 2 REFUSED 7 DON’T KNOW 8
*	During the past 30 days, did you smoke cigarettes to help you lose weight or to keep you from gaining weight?		YES 1 NO 2 I DO NOT SMOKE 3 REFUSED 7 DON’T KNOW 8
IF CHILD IS MALE, SKIP TO SECTION F
E2. *	Have your periods or menstrual cycles started yet?		YES 1 NO (SKIP TO E4) 2 REFUSED (SKIP TO E4) 7 DON’T KNOW (SKIP TO E4) 8
E3. *	How old were you when you had your first menstrual period?		Age (SKIP TO E4) REFUSED (SKIP TO E4) 97 DON’T KNOW 98
*	Were you (SHOW ANSWERS)? If you are having trouble remembering your age, try to think of what grade you were in and when during the school year you first started your period.		Younger than 10 1 10 to 12 2 13 to 15, or 3 16 or older 4 REFUSED 7 DON’T KNOW 8
E4. *	Are you pregnant now?		YES 1 NO 2 REFUSED 7 DON'T KNOW 8
SECTION F: PHYSICAL ACTIVITY BEHAVIORS RECALL (FOR 3 – 5 YEAR OLDS)
Self administered
Child aged 3 – 5: Adult respondent Child aged 6 – 15: NOT ADMINISTERED
The next questions are going to ask you about the activities that your child has done over the past week. Please only think about the activities that were done between last (DAY OF WEEK) and today. For each activity tell us whether or not (CHILD) did the activity in the past 7 days (one week). For those activities that you mark yes, please select the days on which the activity was done. The following questions are about activities done around the home or in the neighborhood (including parks and playgrounds). Please consider activities done only in these locations.
F1. *	Did your child play any physically active games (hopscotch, red rover, tag, etc.) at home or in the neighborhood in the past 7 days?		YES 1 NO (SKIP TO f2) 2 REFUSED (SKIP TO f2) 7 DON’T KNOW (SKIP TO f2) 8
*	Which days did (he/she) play any physically active games at home or in the neighborhood? Choose all the days that apply.		SUNDAY 1 MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 SATURDAY 7 REFUSED 97 DON’T KNOW 98
F2. *	Did your child ride a bike or tricycle or use other wheeled toys (scooter, skates, etc) at home or in the neighborhood in the past 7 days?		YES 1 NO (SKIP TO f3) 2 REFUSED (SKIP TO f3) 7 DON’T KNOW (SKIP TO f3) 8
*	Which days did (he/she) ride (his/her) bike or use other wheeled toys like a scooter or skates at home or in the neighborhood? Choose all the days that apply.		SUNDAY 1 MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 SATURDAY 7 REFUSED 97 DON’T KNOW 98
F3. *	Did your child participate in physically active play in the past 7 days (running around the yard, using fixed equipment [jungle gym/swings/monkey bars], playing with balls)?		YES 1 NO (SKIP TO f4) 2 REFUSED (SKIP TO f4) 7 DON’T KNOW (SKIP TO f4) 8
*	Which days did (he/she) participate in physically active play? Choose all the days that apply.		SUNDAY 1 MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 SATURDAY 7 REFUSED 97 DON’T KNOW 98
F4. *	Did your child use a computer for playing games or playing on the internet in the past 7 days?		YES 1 NO (SKIP TO f5) 2 REFUSED (SKIP TO f5) 7 DON’T KNOW (SKIP TO f5) 8
*	Which days did (he/she) use a computer for playing games or playing on the internet? Choose all the days that apply.		SUNDAY 1 MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 SATURDAY 7 REFUSED 97 DON’T KNOW 98
F5. *	Did your child watch TV or videos in the past 7 days?		YES 1 NO (SKIP TO f6) 2 REFUSED (SKIP TO f6) 7 DON’T KNOW (SKIP TO f6) 8
*	Which days did (he/she) watch TV or videos? Choose all the days that apply.		SUNDAY 1 MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 SATURDAY 7 REFUSED 97 DON’T KNOW 98
F6. *	Did your child play non-active video games in the past 7 days?		YES 1 NO (SKIP TO f7) 2 REFUSED (SKIP TO f7) 7 DON’T KNOW (SKIP TO f7) 8
*	Which days did (he/she) play non-active video games? Choose all the days that apply.		SUNDAY 1 MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 SATURDAY 7 REFUSED 97 DON’T KNOW 98
F7. *	Did your child play physically active video games (Wii, DDR, Xbox Kinect, Playstation Move, etc.) in the past 7 days?		YES 1 NO (SKIP TO f8) 2 REFUSED (SKIP TO f8) 7 DON’T KNOW (SKIP TO f8) 8
*	Which days did (he/she) play physically active video games? Choose all the days that apply.		SUNDAY 1 MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 SATURDAY 7 REFUSED 97 DON’T KNOW 98
The following questions refer to activities done as part of community programs or organized recreational opportunities in community settings. Please consider activities done in community settings when answering these questions.
F8. *	Did your child play an organized sport in the past 7 days?		YES 1 NO (SKIP TO f9) 2 REFUSED (SKIP TO f9) 7 DON’T KNOW (SKIP TO f9) 8
*	Which days did (he/she) play an organized sport? Choose all the days that apply.		SUNDAY 1 MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 SATURDAY 7 REFUSED 97 DON’T KNOW 98
F9. *	Did your child participate in a program to improve (his/her) movement skills (Gymboree, Little Gym, Monkey Joe’s, BounceORama, trampoline gyms, etc.) in the past 7 days?		YES 1 NO (SKIP TO f10) 2 REFUSED (SKIP TO f10) 7 DON’T KNOW (SKIP TO f10) 8
*	Which days did (he/she) participate in a program to improve (his/her) movement skills? Choose all the days that apply.		SUNDAY 1 MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 SATURDAY 7 REFUSED 97 DON’T KNOW 98
F10. *	Did your child participate in any physically active classes or lessons in the past 7 days?		YES 1 NO (SKIP TO f11) 2 REFUSED (SKIP TO f11) 7 DON’T KNOW (SKIP TO f11) 8
*	Which days did (he/she) participate in any physically active classes or lessons? Choose all the days that apply.		SUNDAY 1 MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 SATURDAY 7 REFUSED 97 DON’T KNOW 98
F11. *	Did your child participate in any activities in the water (swim lessons, swimming, pool/water games) in the past 7 days?		YES 1 NO (SKIP TO f12) 2 REFUSED (SKIP TO f12) 7 DON’T KNOW (SKIP TO f12) 8
*	Which days did (he/she) participate in any activities in the water? Choose all the days that apply.		SUNDAY 1 MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 SATURDAY 7 REFUSED 97 DON’T KNOW 98
The following questions refer to activities done at school. Please answer the questions regarding your child’s school attendance and activities done at school (if they do attend school).
F12. *	Does your child attend a structured childcare or school?		YES 1 NO (SKIP TO f18) 2 REFUSED (SKIP TO f18) 7 DON’T KNOW (SKIP TO f18) 8
*	For how many days per week does your child attend school or daycare?		DAYS REFUSED 97 DON’T KNOW 98
*	For how many hours per day does your child attend school or daycare?		HOURS REFUSED 97 DON’T KNOW 98
F13. *	Which of the following best describes the school or childcare center that your child attends?		RELIGIOUS-AFFILIATED CHILDCARE FACILITY 1 COMMERCIAL CHILDCARE FACILITY 2 PUBLIC SCHOOL DISTRICT SPONSORED FACILITY 3 OTHER 4 REFUSED 7 DON’T KNOW 8
F14. *	During a typical week, does your child attend physical education (PE) classes at school/childcare?		YES 1 NO 2 REFUSED 7 DON’T KNOW 8
F15. *	During a typical week, does your child have recess on most days while at school?		YES 1 NO 2 REFUSED 7 DON’T KNOW 8
F16. *	During a typical week, does your child attend dance or other physically active classes at school/childcare (other than PE class)?		YES 1 NO 2 REFUSED 7 DON’T KNOW 8
F17. *	During a typical week, does your child participate in any kind of physical activity (structured or unstructured) during an afterschool program?		YES 1 NO 2 REFUSED 7 DON’T KNOW 8
IF F1A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO F19
F18. *	You said that your child played physically active games at home or in the neighborhood yesterday. Is this correct?		YES 1 NO (SKIP TO f19) 2 REFUSED (SKIP TO f19) 7 DON’T KNOW (SKIP TO f19) 8
*	For how many minutes did (he/she) play physically active games at home or in the neighborhood yesterday?		MINUTES REFUSED 997 DON’T KNOW 998
*	When your child played physically active games at home or in the neighborhood, what exactly was (he/she) doing?		TAG 1 RED ROVER/DUCK DUCK GOOSE/ETC. 2 HOPSCOTCH 3 OTHER (SPECIFY) 4 REFUSED 97 DON’T KNOW 98
IF F2A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO F20
F19. *	You said that your child rode (his/her) bike or rode on other wheeled toys at home or in the neighborhood yesterday. Is this correct?		YES 1 NO (SKIP TO f20) 2 REFUSED (SKIP TO f20) 7 DON’T KNOW (SKIP TO f20) 8
*	For how many minutes did (he/she) ride (his/her) bike or use other wheeled toys at home or in the neighborhood yesterday?		MINUTES REFUSED 997 DON’T KNOW 998
*	When your child rode (his/her) bike or used other wheeled toys like skates or a scooter at home or in the neighborhood, what exactly was (he/she) doing?		RIDING A TRICYCLE/BICYCLE 1 RIDING ON A SCOOTER 2 RIDING MOTORIZED TOYS (POWERWHEELS, ETC.) 3 RIDING ON A SKATEBOARD/SKATES 4 OTHER (SPECIFY) 5 REFUSED 97 DON’T KNOW 98
IF F3A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO F21
F20. *	You said that your child participated in physically active play yesterday. Is this correct?		YES 1 NO (SKIP TO f21) 2 REFUSED (SKIP TO f21) 7 DON’T KNOW (SKIP TO f21) 8
*	For how many minutes did (he/she) participate in physically active play yesterday?		MINUTES REFUSED 997 DON’T KNOW 998
*	When your child participated in physically active play, what exactly was (he/she) doing?		PLAYING WITH BALLS/OTHER EQUIPMENT 1 PLAYING ON FIXED EQUIPMENT (TREE HOUSE, MONKEY BARS, SLIDES, SWINGS, ETC) 2 JUMPROPE/HULA HOOP 3 OTHER (SPECIFY) 4 REFUSED 97 DON’T KNOW 98
IF F4A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO F22
F21. *	You said that your child used a computer for gaming or playing on the internet yesterday. Is this correct?		YES 1 NO (SKIP TO f22) 2 REFUSED (SKIP TO f22) 7 DON’T KNOW (SKIP TO f22) 8
*	For how many minutes did (he/she) use a computer for gaming or playing on the internet yesterday?		MINUTES REFUSED 997 DON’T KNOW 998
*	When your child used a computer for gaming or playing on the internet, what exactly was (he/she) doing?		PLAYING EDUCATIONAL GAMES 1 PLAYING NON-EDUCATION GAMES 2 REFUSED 97 DON’T KNOW 98
IF F5A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO F23
F22. *	You said that your child watched TV or videos yesterday. Is this correct?		YES 1 NO (SKIP TO f23) 2 REFUSED (SKIP TO f23) 7 DON’T KNOW (SKIP TO f23) 8
*	For how many minutes did (he/she) watch TV or videos yesterday?		MINUTES REFUSED 997 DON’T KNOW 998
*	When your child watched TV or videos, what exactly was (he/she) doing?		WATCHING EDUCATIONAL TV OR VIDEOS 1 WATCHING NON-EDUCATIONAL TV OR VIDEOS 2 REFUSED 97 DON’T KNOW 98
IF F6A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO F24
F23. *	You said that your child played non-active video games yesterday. Is this correct?		YES 1 NO (SKIP TO f24) 2 REFUSED (SKIP TO f24) 7 DON’T KNOW (SKIP TO f24) 8
*	For how many minutes did (he/she) play non-active video games yesterday?		MINUTES REFUSED 997 DON’T KNOW 998
*	When your child played non-active video games, what exactly was (he/she) doing?		PLAYING GAMES ON A GAME CONSOLE 1 PLAYING GAMES ON A HANDHELD GAMING DEVICE 2 REFUSED 97 DON’T KNOW 98
IF F7A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO F25
F24. *	You said that your child played physically active video games yesterday. Is this correct?		YES 1 NO (SKIP TO f25) 2 REFUSED (SKIP TO f25) 7 DON’T KNOW (SKIP TO f25) 8
*	For how many minutes did (he/she) play physically active video games yesterday?		MINUTES REFUSED 997 DON’T KNOW 998
*	When your child played physically active video games, what exactly was (he/she) doing?		PLAYING WII/KINECT/MOVE, ETC 1 REFUSED 97 DON’T KNOW 98
IF F8A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO F26
F25. *	You said that your child played an organized sport yesterday. Is this correct?		YES 1 NO (SKIP TO f26) 2 REFUSED (SKIP TO f26) 7 DON’T KNOW (SKIP TO f26) 8
*	For how many minutes did (he/she) play an organized sport yesterday?		MINUTES REFUSED 997 DON’T KNOW 998
*	When your child played an organized sport, what exactly was (he/she) doing?		PLAYING BASEBALL/SOFTBALL 1 PLAYING SOCCER/FOOTBALL 2 PLAYING BASKETBALL 3 PLAYING TENNIS 4 SWIM TEAM 5 OTHER (SPECIFY) 6 REFUSED 97 DON’T KNOW 98
IF F9A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO F27
F26. *	You said that your child participated in a program to improve (his/her) movement skills yesterday. Is this correct?		YES 1 NO (SKIP TO f27) 2 REFUSED (SKIP TO f27) 7 DON’T KNOW (SKIP TO f27) 8
*	For how many minutes did (he/she) participate in a program to improve (his/her) movement skills yesterday?		MINUTES REFUSED 997 DON’T KNOW 998
*	When your child participated in a program to improve (his/her) movement skills, what exactly was (he/she) doing?		PARTICIPATING IN GYMBOREE OR LITTLE GYM (OR OTHER FACILITY) CLASSES 1 PLAYING AT A BOUNCE HOUSE (MONKEY JOE’S, ETC.) 2 PLAYING AT A TRAMPOLINE GYM 3 OTHER (SPECIFY) 4 REFUSED 97 DON’T KNOW 98
IF F10A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO F28
F27. *	You said that your child participated in any physically active classes or lessons yesterday. Is this correct?		YES 1 NO (SKIP TO f28) 2 REFUSED (SKIP TO f28) 7 DON’T KNOW (SKIP TO f28) 8
*	For how many minutes did (he/she) participate in any physically active classes or lessons yesterday?		MINUTES REFUSED 997 DON’T KNOW 998
*	When your child participated in any physically active classes or lessons, what exactly was (he/she) doing?		DANCE/ CHEER 1 TUMBLING OR GYMNASTICS CLASSES 2 SPORT LESSONS (TENNIS, BASEBALL, BASKETBALL, ETC.) 3 KARATE OR OTHER MARTIAL ARTS CLASSES 4 OTHER (SPECIFY) 5 REFUSED 97 DON’T KNOW 98
IF F11A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO F29
F28. *	You said that your child participated in any activities in the water yesterday. Is this correct?		YES 1 NO (SKIP TO f29) 2 REFUSED (SKIP TO f29) 7 DON’T KNOW (SKIP TO f29) 8
*	For how many minutes did (he/she) participate in any water activities yesterday?		MINUTES REFUSED 997 DON’T KNOW 998
*	When your child participated in any water activities, what exactly was (he/she) doing?		SWIM LESSONS 1 SWIMMING 2 PLAYING POOL/WATER GAMES 3 OTHER (SPECIFY) 4 REFUSED 97 DON’T KNOW 98
F29. *	Did your child do any other physical activities yesterday that were not already mentioned?		YES 1 NO (SKIP TO section h) 2 REFUSED (SKIP TO section h) 7 DON’T KNOW (SKIP TO section h) 8
*	What were the other activities?		ACTIVITY 1:_____________________________________ ACTIVITY 2:_____________________________________ ACTIVITY 3:_____________________________________ ACTIVITY 4:_____________________________________ REFUSED 7 DON’T KNOW 8
*	For how many minutes did (he/she) participate in these other activities?		MINUTES REFUSED 997 DON’T KNOW 998
SECTION G: PHYSICAL ACTIVITY BEHAVIORS RECALL (FOR 6 – 15 YEAR OLDS)
Self administered
Child aged 3 – 5: NOT ADMINISTERED Child aged 6 – 11: Child respondent/adult present to assist Child aged 12 – 15: Child respondent
The next questions are going to ask you about the activities that you have done over the past week. Please only think about the activities you have done between last (DAY OF WEEK) and today, not activities that you like or would like to do. For each activity, tell us whether or not you did the activity in the past 7 days (one week). For those activities that you mark yes, then select the days on which you did the activity. Then, using the following word and picture descriptions as a guide, select how physically hard or intense the activity was. Remember, these pictures are just a guide, and not the activities you are answering questions about. INTENSITY RATINGS FOR BOYS AGED 6 – 11: Light Moderate slow, easy movement medium pace movement Hard Very hard fast pace movement very fast pace movement
INTENSITY RATINGS FOR GIRLS AGED 6 – 11: Light Moderate slow, easy movement medium pace movement Hard Very hard fast pace movement very fast pace movement
INTENSITY RATINGS FOR BOYS AGED 12 – 15: Light Moderate slow, easy movement medium pace movement Hard Very hard fast pace movement very fast pace movement
INTENSITY RATINGS FOR GIRLS AGED 12 – 15: Light Moderate slow, easy movement medium pace movement Hard Very hard fast pace movement very fast pace movement Once you have finished this part, you will be asked some additional questions about the activities that you did yesterday.
G1. *	Did you have physical education (PE) class in school in the past 7 days?		YES 1 NO (SKIP TO G2) 2 REFUSED (SKIP TO G2) 7 DON’T KNOW (SKIP TO G2) 8
*	Which days did you have PE? Choose all the days that apply.		MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 REFUSED 97 DON’T KNOW 98
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
G2. *	Did you have recess or other free-play at school in the past 7 days?		YES 1 NO (SKIP TO G3) 2 REFUSED (SKIP TO G3) 7 DON’T KNOW (SKIP TO G3) 8
*	Which days did you have recess or other free-play at school? Choose all the days that apply.		MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 REFUSED 97 DON’T KNOW 98
*	Were you physically active during recess or free play?		YES……………………………………………………… …..1 NO ……………………….(SKIP TO G3)……………………2
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
G3. *	Did you have dance or other physically active classes at school (other than PE class) in the past 7 days?		YES 1 NO (SKIP TO G4) 2 REFUSED (SKIP TO G4) 7 DON’T KNOW (SKIP TO G4) 8
*	Which days did you have dance or other physically active classes at school (other than PE class)? Choose all the days that apply.		MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 REFUSED 97 DON’T KNOW 98
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
G4. *	Did you participate in physical activity breaks during classes at school in the past 7 days?		YES 1 NO (SKIP TO G5) 2 REFUSED (SKIP TO G5) 7 DON’T KNOW (SKIP TO G5) 8
*	Which days did you participate in physical activity breaks during classes at school? Choose all the days that apply.		MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 REFUSED 97 DON’T KNOW 98
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
G5. *	Did you practice or play with a school sports team in the past 7 days?		YES 1 NO (SKIP TO G6) 2 REFUSED (SKIP TO G6) 7 DON’T KNOW (SKIP TO G6) 8
*	Which days did you practice or play with a school sports team? Choose all the days that apply.		SUNDAY 1 MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 SATURDAY 7 REFUSED 97 DON’T KNOW 98
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
G6. *	Did you practice or play with a non-school sports team in the past 7 days?		YES 1 NO (SKIP TO G7) 2 REFUSED (SKIP TO G7) 7 DON’T KNOW (SKIP TO G7) 8
*	Which days did you practice or play with a non-school sports team? Choose all the days that apply.		SUNDAY 1 MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 SATURDAY 7 REFUSED 97 DON’T KNOW 98
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
G7. *	Did you participate in pick-up sports (basketball, football, baseball/softball, etc.) in the past 7 days?		YES 1 NO (SKIP TO G8) 2 REFUSED (SKIP TO G8) 7 DON’T KNOW (SKIP TO G8) 8
*	Which days did you participate in pick-up sports? Choose all the days that apply.		SUNDAY 1 MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 SATURDAY 7 REFUSED 97 DON’T KNOW 98
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
G8. *	Did you participate in physical activity during an afterschool program in the past 7 days?		YES 1 NO (SKIP TO G9) 2 REFUSED (SKIP TO G9) 7 DON’T KNOW (SKIP TO G9) 8
*	Which days did you participate in physical activity during an afterschool program? Choose all the days that apply.		MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 REFUSED 97 DON’T KNOW 98
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
G9. *	Did you play any physically active games (hopscotch, red rover, tag, jumping rope, etc.) in the past 7 days?		YES 1 NO (SKIP TO G10) 2 REFUSED (SKIP TO G10) 7 DON’T KNOW (SKIP TO G10) 8
*	Which days did you play any physically active games? Choose all the days that apply.		SUNDAY 1 MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 SATURDAY 7 REFUSED 97 DON’T KNOW 98
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
G10. *	Did you swim or play games in a pool, lake, or ocean in the past 7 days?		YES 1 NO (SKIP TO G11) 2 REFUSED (SKIP TO G11) 7 DON’T KNOW (SKIP TO G11) 8
*	Which days did you swim or play games in a pool, lake, or ocean? Choose all the days that apply.		SUNDAY 1 MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 SATURDAY 7 REFUSED 97 DON’T KNOW 98
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
G11. *	Did you do any outdoor or adventure sports (hiking, kayaking, rock climbing, surfing, skiing, etc.) in the past 7 days?		YES 1 NO (SKIP TO G12) 2 REFUSED (SKIP TO G12) 7 DON’T KNOW (SKIP TO G12) 8
*	Which days did you do any outdoor or adventure sports? Choose all the days that apply.		SUNDAY 1 MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 SATURDAY 7 REFUSED 97 DON’T KNOW 98
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
G12. *	Did you walk or bike to or from school in the past 7 days?		YES 1 NO (SKIP TO G13) 2 REFUSED (SKIP TO G13) 7 DON’T KNOW (SKIP TO G13) 8
*	Which days did you walk or bike to or from school? Choose all the days that apply.		MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 REFUSED 97 DON’T KNOW 98
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
G13. *	Did you walk or bike to or from a store, park, or playground or a friend’s house in the past 7 days?		YES 1 NO (SKIP TO G14) 2 REFUSED (SKIP TO G14) 7 DON’T KNOW (SKIP TO G14) 8
*	Which days did you walk or bike to or from a store, park, or playground or a friend’s house? Choose all the days that apply.		SUNDAY 1 MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 SATURDAY 7 REFUSED 97 DON’T KNOW 98
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
G14. *	Did you walk or ride your bike, scooter, skateboard, or skates for fun or exercise in the past 7 days?		YES 1 NO (SKIP TO G15) 2 REFUSED (SKIP TO G15) 7 DON’T KNOW (SKIP TO G15) 8
*	Which days did you walk or ride your bike, scooter, skateboard or skates for fun or exercise? Choose all the days that apply.		SUNDAY 1 MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 SATURDAY 7 REFUSED 97 DON’T KNOW 98
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
G15. *	Did you use a computer for games or playing on the internet (not for schoolwork or social networks) in the past 7 days?		YES 1 NO (SKIP TO G16) 2 REFUSED (SKIP TO G16) 7 DON’T KNOW (SKIP TO G16) 8
*	Which days did you use a computer for gaming or playing on the internet? Choose all the days that apply.		SUNDAY 1 MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 SATURDAY 7 REFUSED 97 DON’T KNOW 98
G16. *	Did you use a computer or phone for social networking (Facebook, MySpace, Twitter, IM, texting, etc.) in the past 7 days?		YES 1 NO (SKIP TO G17) 2 REFUSED (SKIP TO G17) 7 DON’T KNOW (SKIP TO G17) 8
*	Which days did you use a computer or phone for social networking? Choose all the days that apply.		SUNDAY 1 MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 SATURDAY 7 REFUSED 97 DON’T KNOW 98
G17. *	Did you watch TV in the past 7 days?		YES 1 NO (SKIP TO G18) 2 REFUSED (SKIP TO G18) 7 DON’T KNOW (SKIP TO G18) 8
*	Which days did you watch TV? Choose all the days that apply.		SUNDAY 1 MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 SATURDAY 7 REFUSED 97 DON’T KNOW 98
G18. *	Did you play non-active video games in the past 7 days?		YES 1 NO (SKIP TO G19) 2 REFUSED (SKIP TO G19) 7 DON’T KNOW (SKIP TO G19) 8
*	Which days did you play non-active video games? Choose all the days that apply.		SUNDAY 1 MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 SATURDAY 7 REFUSED 97 DON’T KNOW 98
G19. *	Did you play physically active video games (Wii, DDR, Xbox Kinect, Playstation Move, etc.) in the past 7 days?		YES 1 NO (SKIP TO G20) 2 REFUSED (SKIP TO G20) 7 DON’T KNOW (SKIP TO G20) 8
*	Which days did you play physically active video games? Choose all the days that apply.		SUNDAY 1 MONDAY 2 TUESDAY 3 WEDNESDAY 4 THURSDAY 5 FRIDAY 6 SATURDAY 7 REFUSED 97 DON’T KNOW 98
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
IF G1A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G21
G20. *	You said that you had physical education (PE) class in school yesterday. Is this correct?		YES 1 NO (SKIP TO G21) 2 REFUSED (SKIP TO G21) 7 DON’T KNOW (SKIP TO G21) 8
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
*	For how many minutes did you have PE class in school?		MINUTES REFUSED 997 DON’T KNOW 998
*	When you had PE class in school, what exactly were you doing?		TEAM SPORT SKILLS 1 INDIVIDUAL SPORT SKILLS 2 DANCE/TUMBLING SKILLS 3 WATER ACTIVITY SKILLS 4 CARDIOVASCULAR MACHINES OR CONDITIONING (RUNNING, CYCLING, STAIRCLIMBER, ROWERS, ETC.) 5 CLIMBING WALL ACTIVITIES 6 EXERCISES/CALISTHENICS 7 FRISBEE OR FRISBEE GOLF 8 JUMPROPE/PLYOMETRICS/CONDITIONING 9 WEIGHT TRAINING 10 YOGA/PILATES 11 OTHER (SPECIFY) 12 REFUSED 97 DON’T KNOW 98
IF G2A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G22
G21. *	You said that you had recess or other free-play at school yesterday. Is this correct?		YES 1 NO (SKIP TO G22) 2 REFUSED (SKIP TO G22) 7 DON’T KNOW (SKIP TO G22) 8
*	How physically hard were your activities during recess or free play yesterday?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
*	For how many minutes did you have recess or other free-play at school?		MINUTES REFUSED 997 DON’T KNOW 998
*	When you had recess or other free-play at school, what exactly were you doing?		PLAYGROUND GAME (KICKBALL, FOUR SQUARE, DODGEBALL, ETC.) 1 ORGANIZED SPORT GAME (BASEBALL, BASKETBALL, FOOTBALL, ETC.) 2 TAG/CAPTURE THE FLAG/RED ROVER/ETC. 3 FIXED EQUIPMENT (MONKEY BARS, SLIDES, SWINGS, ETC.) 4 HANGING OUT WITH FRIENDS 5 DOING SCHOOL WORK 6 OTHER (SPECIFY) 7 REFUSED 97 DON’T KNOW 98
IF G3A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G23
G22. *	You said that you had dance or other physically active classes at school (other than PE class) yesterday. Is this correct?		YES 1 NO (SKIP TO G23) 2 REFUSED (SKIP TO G23) 7 DON’T KNOW (SKIP TO G23) 8
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
*	For how many minutes did you have dance or other physically active classes at school (other than PE class)?		MINUTES REFUSED 997 DON’T KNOW 998
*	When you had dance or other physically active classes at school (other than PE class), what exactly were you doing?		DANCE 1 WEIGHTLIFTING 2 OTHER (SPECIFY) 3 REFUSED 97 DON’T KNOW 98
IF G4A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G24
G23. *	You said that you participated in physical activity breaks during classes at school yesterday. Is this correct?		YES 1 NO (SKIP TO G24) 2 REFUSED (SKIP TO G24) 7 DON’T KNOW (SKIP TO G24) 8
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
*	For how many minutes did you participate in physical activity breaks during classes at school?		MINUTES REFUSED 997 DON’T KNOW 998
*	When you participated in physical activity breaks during classes at school, what exactly were you doing?		IN-CLASS PHYSICAL ACTIVITY 1 VIDEO/STRUCTURED ACTIVITY IN HOMEROOM/ANNOUNCEMENTS 2 WALKING LAPS 3 OTHER (SPECIFY) 4 REFUSED 97 DON’T KNOW 98
IF G5A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G25
G24. *	You said that you practiced or played with a school sports team yesterday. Is this correct?		YES 1 NO (SKIP TO G25) 2 REFUSED (SKIP TO G25) 7 DON’T KNOW (SKIP TO G25) 8
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
*	For how many minutes did you practice or play with a school sports team?		MINUTES REFUSED 997 DON’T KNOW 998
*	When you practiced or played with a school sports team, what exactly were you doing?		BASEBALL/SOFTBALL 1 FOOTBALL/SOCCER/LACROSSE/HOCKEY BASKETBALL 2 SWIM TEAM/DIVING/WATER POLO 3 GOLF/TENNIS 4 TRACK AND FIELD/CROSS COUNTRY 5 CHEER/DANCE TEAM 6 WRESTLING 7 VOLLEYBALL 8 MARTIAL ARTS 9 ROWING/CANOE/KAYAK 10 BOWLING 11 SKIING 12 OTHER (SPECIFY) 13 REFUSED 97 DON’T KNOW 98
IF G6A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G26
G25. *	You said that you practiced or played with a non-school sports team yesterday. Is this correct?		YES 1 NO (SKIP TO G26) 2 REFUSED (SKIP TO G26) 7 DON’T KNOW (SKIP TO G26) 8
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
*	For how many minutes did you practice or play with a non-school sports team?		MINUTES REFUSED 997 DON’T KNOW 998
*	When you practiced or played with a non-school sports team, what exactly were you doing?		BASEBALL/SOFTBALL 1 FOOTBALL/SOCCER/LACROSSE/HOCKEY BASKETBALL 2 SWIM TEAM/DIVING/WATER POLO 3 GOLF/TENNIS 4 TRACK AND FIELD/CROSS COUNTRY 5 CHEER/DANCE TEAM 6 WRESTLING 7 VOLLEYBALL 8 MARTIAL ARTS 9 ROWING/CANOE/KAYAK 10 BOWLING 11 SKIING 12 OTHER (SPECIFY) 13 REFUSED 97 DON’T KNOW 98 REFUSED 97 DON’T KNOW 98
IF G7A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G27
G26. *	You said that you participated in pick-up sports yesterday. Is this correct?		YES 1 NO (SKIP TO G27) 2 REFUSED (SKIP TO G27) 7 DON’T KNOW (SKIP TO G27) 8
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
*	For how many minutes did you participate in pick-up sports?		MINUTES REFUSED 997 DON’T KNOW 998
*	Where did you participate in pick-up sports? CODE ALL THAT APPLY		AT SCHOOL 1 AT HOME 2 AT A REC CENTER 3 AT A PARK/PLAYGROUND 4 IN MY NEIGHBORHOOD 5 ON MY STREET 6 AT CHURCH 7 AT A FRIEND’S HOUSE 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98
SPECIFY:
*	Who did you participate in pick-up sports with?		BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8
*	When you participated in pick-up sports, what exactly were you doing?		BASEBALL/SOFTBALL 1 FOOTBALL/SOCCER/LACROSSE/HOCKEY BASKETBALL 2 SWIM TEAM/DIVING/WATER POLO 3 OTHER (SPECIFY) 4 REFUSED 97 DON’T KNOW 98
IF G8A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G28
G27. *	You said that you participated in physical activity during an afterschool program yesterday. Is this correct?		YES 1 NO (SKIP TO G28) 2 REFUSED (SKIP TO G28) 7 DON’T KNOW (SKIP TO G28) 8
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
*	For how many minutes did you participate in physical activity during an afterschool program?		MINUTES REFUSED 997 DON’T KNOW 998
*	Where did you participate in physical activity during an afterschool program? CODE ALL THAT APPLY		AT SCHOOL 1 AT HOME 2 AT A REC CENTER 3 AT A PARK/PLAYGROUND 4 IN MY NEIGHBORHOOD 5 ON MY STREET 6 AT CHURCH 7 AT A FRIEND’S HOUSE 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98
SPECIFY:
*	Who did you participate in physical activity during an afterschool program with?		BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8
*	When you participated in physical activity during an afterschool program, what exactly were you doing?		PLAYGROUND GAME (KICKBALL, FOUR SQUARE, DODGEBALL, ETC.) 1 ORGANIZED SPORT GAME (BASEBALL, BASKETBALL, FOOTBALL, ETC.) 2 TAG/CAPTURE THE FLAG/RED ROVER/ETC. 3 FIXED EQUIPMENT (MONKEY BARS, SLIDES, SWINGS, ETC.) 4 DANCE/STEP TEAM 5 DOUBLE-DUTCH 6 OTHER (SPECIFY) 7 REFUSED 97 DON’T KNOW 98
IF G9A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G29
G28. *	You said that you played physically active games yesterday. Is this correct?		YES 1 NO (SKIP TO G29) 2 REFUSED (SKIP TO G29) 7 DON’T KNOW (SKIP TO G29) 8
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
*	For how many minutes did you play any physically active games?		MINUTES REFUSED 997 DON’T KNOW 998
*	Where did you play any physically active games? CODE ALL THAT APPLY		AT SCHOOL 1 AT HOME 2 AT A REC CENTER 3 AT A PARK/PLAYGROUND 4 IN MY NEIGHBORHOOD 5 ON MY STREET 6 AT CHURCH 7 AT A FRIEND’S HOUSE 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98
SPECIFY:
*	Who did you play any physically active games with?		BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8
*	When you played physically active games, what exactly were you doing?		TAG 1 RED ROVER/DUCK DUCK GOOSE/ETC. 2 HOPSCOTCH 3 OTHER (SPECIFY) 4 REFUSED 97 DON’T KNOW 98
IF G10A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G30
G29. *	You said that you swam or played games in a pool, lake, or ocean yesterday. Is this correct?		YES 1 NO (SKIP TO G30) 2 REFUSED (SKIP TO G30) 7 DON’T KNOW (SKIP TO G30) 8
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
*	For how many minutes did you swim or play games in a pool, lake, or ocean?		MINUTES REFUSED 997 DON’T KNOW 998
*	Where did you swim or play games in a pool, lake, or ocean? CODE ALL THAT APPLY		AT SCHOOL 1 AT HOME 2 AT A REC CENTER 3 AT A PARK/PLAYGROUND 4 IN MY NEIGHBORHOOD 5 ON MY STREET 6 AT CHURCH 7 AT A FRIEND’S HOUSE 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98
SPECIFY:
*	Who did you swim or play games in a pool, lake, or ocean with?		BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8
*	When you swam or played games in a pool, lake, or ocean, what exactly were you doing?		SWIMMING 1 WATER GAMES (MARCO POLO, SHARK AND MINNOWS, ETC.) 2 WATERPLAY 3 OTHER (SPECIFY) 4 REFUSED 97 DON’T KNOW 98
IF G11A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G31
G30. *	You said that you did outdoor or adventure sports yesterday. Is this correct?		YES 1 NO (SKIP TO G31) 2 REFUSED (SKIP TO G31) 7 DON’T KNOW (SKIP TO G31) 8
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
*	For how many minutes did you do any outdoor or adventure sports?		MINUTES REFUSED 997 DON’T KNOW 998
*	Who did you do outdoor or adventure sports with?		BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8
*	Where did you do outdoor or adventure sports? CODE ALL THAT APPLY		AT SCHOOL 1 AT HOME 2 AT A REC CENTER 3 AT A PARK/PLAYGROUND 4 IN MY NEIGHBORHOOD 5 ON MY STREET 6 AT CHURCH 7 AT A FRIEND’S HOUSE 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98
SPECIFY:
*	When you did outdoor or adventure sports, what exactly were you doing?		HIKING 1 ROCK CLIMBING 2 SURFING/SKIMBOARDING/BODYBOARDING 3 SNOW SKIING/SNOWBOARDING 4 WATER SKIING/WAKEBOARDING 5 KAYAKING 6 OTHER (SPECIFY) 7 REFUSED 97 DON’T KNOW 98
IF G12A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G32
G31. *	You said that you walked or biked to or from school yesterday. Is this correct?		YES 1 NO (SKIP TO G32) 2 REFUSED (SKIP TO G32) 7 DON’T KNOW (SKIP TO G32) 8
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
*	For how many minutes did you walk or bike to or from school?		MINUTES REFUSED 997 DON’T KNOW 998
*	Who did you walk or bike to or from school with?		BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8
*	When you walked or biked to or from school, what exactly were you doing?		WALK 1 BIKE 2 REFUSED 97 DON’T KNOW 98
IF G13A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G33
G32. *	You said that you walked or biked to or from a store, park, or playground or a friend’s house yesterday. Is this correct?		YES 1 NO (SKIP TO G33) 2 REFUSED (SKIP TO G33) 7 DON’T KNOW (SKIP TO G33) 8
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
*	For how many minutes did you walk or bike to or from a store, park, or playground or a friend’s house?		MINUTES REFUSED 997 DON’T KNOW 998
*	Where did you walk or bike to or from a store, park, or playground or a friend’s house? CODE ALL THAT APPLY		AT SCHOOL 1 AT HOME 2 AT A REC CENTER 3 AT A PARK/PLAYGROUND 4 IN MY NEIGHBORHOOD 5 ON MY STREET 6 AT CHURCH 7 AT A FRIEND’S HOUSE 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98
SPECIFY:
*	Who did you walk or bike to or from a store, park, or playground or a friend’s house with?		BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8
*	When you walked or biked to or from a store, park, or playground or a friend’s house, what exactly were you doing?		WALK 1 BIKE 2 REFUSED 97 DON’T KNOW 98
IF G14A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G34
G33. *	You said that you walked or rode your bike, scooter, skateboard, or skates for fun or exercise yesterday. Is this correct?		YES 1 NO (SKIP TO G34) 2 REFUSED (SKIP TO G34) 7 DON’T KNOW (SKIP TO G34) 8
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
*	For how many minutes did you walk or ride your bike, scooter, skateboard, or skates for fun or exercise?		MINUTES REFUSED 997 DON’T KNOW 998
*	Where did you walk or ride your bike, scooter, skateboard, or skates for fun or exercise? CODE ALL THAT APPLY		AT SCHOOL 1 AT HOME 2 AT A REC CENTER 3 AT A PARK/PLAYGROUND 4 IN MY NEIGHBORHOOD 5 ON MY STREET 6 AT CHURCH 7 AT A FRIEND’S HOUSE 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98
SPECIFY:
*	Who did you walk or ride your bike, scooter, skateboard, or skates for fun or exercise with?		BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8
*	When you walked or rode your bike, scooter, skateboard, or skates for fun or exercise, what exactly were you doing?		WALK 1 BIKE 2 SCOOTER 3 SKATEBOARD 4 SKATES/ROLLERBLADES 5 OTHER (SPECIFY) 6 REFUSED 97 DON’T KNOW 98
IF G15A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G35
G34. *	You said that you used a computer for gaming or playing on the internet (not for schoolwork or social networks) yesterday. Is this correct?		YES 1 NO (SKIP TO G35) 2 REFUSED (SKIP TO G35) 7 DON’T KNOW (SKIP TO G35) 8
*	For how many minutes did you use a computer for gaming or playing on the internet?		MINUTES REFUSED 997 DON’T KNOW 998
*	Where did you use a computer for gaming or playing on the internet? CODE ALL THAT APPLY		AT SCHOOL 1 AT HOME 2 AT A REC CENTER 3 AT A PARK/PLAYGROUND 4 IN MY NEIGHBORHOOD 5 ON MY STREET 6 AT CHURCH 7 AT A FRIEND’S HOUSE 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98
SPECIFY:
*	Who did you use a computer for gaming or playing on the internet with?		BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8
*	When you used a computer for gaming or playing on the internet, what exactly were you doing?		GAMING 1 SURFING THE INTERNET 2 OTHER (SPECIFY) 3 REFUSED 97 DON’T KNOW 98
IF G16A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G36
G35. *	You said that you used a computer or phone for social networking yesterday. Is this correct?		YES 1 NO (SKIP TO G36) 2 REFUSED (SKIP TO G36) 7 DON’T KNOW (SKIP TO G36) 8
*	For how many minutes did you use a computer or phone for social networking?		MINUTES REFUSED 997 DON’T KNOW 998
*	Where did you use a computer or phone for social networking? CODE ALL THAT APPLY		AT SCHOOL 1 AT HOME 2 AT A REC CENTER 3 AT A PARK/PLAYGROUND 4 IN MY NEIGHBORHOOD 5 ON MY STREET 6 AT CHURCH 7 AT A FRIEND’S HOUSE 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98
SPECIFY:
*	Who did you use a computer or phone for social networking with?		BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8
*	When you used a computer or phone for social networking, what exactly were you doing?		IM/CHAT/TWITTER 1 1 SOCIAL NETWORKING ON THE COMPUTER 2 TEXTING 3 OTHER (SPECIFY) 4 REFUSED 97 DON’T KNOW 98
IF G17A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G37
G36. *	You said that you watched TV yesterday. Is this correct?		YES 1 NO (SKIP TO G37) 2 REFUSED (SKIP TO G37) 7 DON’T KNOW (SKIP TO G37) 8
*	For how many minutes did you watch TV?		MINUTES REFUSED 997 DON’T KNOW 998
*	Where did you watch TV? CODE ALL THAT APPLY		AT SCHOOL 1 AT HOME 2 AT A REC CENTER 3 AT A PARK/PLAYGROUND 4 IN MY NEIGHBORHOOD 5 ON MY STREET 6 AT CHURCH 7 AT A FRIEND’S HOUSE 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98
SPECIFY:
*	Who did you watch TV with?		BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8
*	When you watched TV, what exactly were you doing?		WATCHING TV/VIDEOS 1 REFUSED 97 DON’T KNOW 98
IF G18A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G38
G37. *	You said that you played non-active video games yesterday. Is this correct?		YES 1 NO (SKIP TO G38) 2 REFUSED (SKIP TO G38) 7 DON’T KNOW (SKIP TO G38) 8
*	For how many minutes did you play non-active video games?		MINUTES REFUSED 997 DON’T KNOW 998
*	Where did you play non-active video games? CODE ALL THAT APPLY		AT SCHOOL 1 AT HOME 2 AT A REC CENTER 3 AT A PARK/PLAYGROUND 4 IN MY NEIGHBORHOOD 5 ON MY STREET 6 AT CHURCH 7 AT A FRIEND’S HOUSE 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98
SPECIFY:
*	Who did you play non-active video games with?		BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8
*	When you played non-active video games, what exactly were you doing?		PLAYING GAMES ON A GAME CONSOLE 1 PLAYING GAMES ON A HANDHELD GAMING DEVICE 2 REFUSED 97 DON’T KNOW 98
IF G19A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G39
G38. *	You said that you played physically active video games yesterday. Is this correct?		YES 1 NO (SKIP TO G39) 2 REFUSED (SKIP TO G39) 7 DON’T KNOW (SKIP TO G39) 8
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
*	For how many minutes did you play physically active video games?		MINUTES REFUSED 997 DON’T KNOW 998
*	Where did you play physically active video games? CODE ALL THAT APPLY		AT SCHOOL 1 AT HOME 2 AT A REC CENTER 3 AT A PARK/PLAYGROUND 4 IN MY NEIGHBORHOOD 5 ON MY STREET 6 AT CHURCH 7 AT A FRIEND’S HOUSE 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98
SPECIFY:
*	Who did you play physically active video games with?		BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8
*	When you played physically active video games, what exactly were you doing?		PLAYING WII/KINECT/MOVE, ETC. 1 REFUSED 97 DON’T KNOW 98
G39. *	Did you do any other physical activity yesterday that was not already mentioned?		YES 1 NO (SKIP TO section h) 2 REFUSED (SKIP TO section h) 7 DON’T KNOW (SKIP TO section h) 8
*	What was the other activity?		ACTIVITY:______________________________________ REFUSED 7 DON’T KNOW 8
*	How physically hard was this activity?		LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8
*	For how many minutes did you do this other activity?		MINUTES REFUSED 997 DON’T KNOW 998
*	Where did you do this other activity? CODE ALL THAT APPLY		AT SCHOOL 1 AT HOME 2 AT A REC CENTER 3 AT A PARK/PLAYGROUND 4 IN MY NEIGHBORHOOD 5 ON MY STREET 6 AT CHURCH 7 AT A FRIEND’S HOUSE 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98
SPECIFY:
*	Who did you do this other activity with?		BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8

SECTION H: PHYSICAL ACTIVITY CHILD SURVEY
Self administered
Child aged 3 – 5: NOT COMPLETED Child aged 6 – 11: Child respondent/adult present to assist Child aged 12 – 15: Child respondent
H1.	How much do you agree or disagree with the following statements?
		Disagree a lot			Disagree a little	Agree a little	Agree a lot	Refused	Don’t Know
*	There are many places I like to go within easy walking distance of my home.	1			2	3	4	7	8
*	There are sidewalks on most of the streets in (our/my) neighborhood.	1			2	3	4	7	8
*	There are bicycle or walking trails in my neighborhood.	1			2	3	4	7	8
*	It is safe to walk or jog in my neighborhood during the day.	1			2	3	4	7	8
*	People in my neighborhood can easily see walkers and bikers on the streets from their homes.	1			2	3	4	7	8
*	There is so much traffic that it makes it hard to walk in my neighborhood.	1			2	3	4	7	8
*	There is a lot of crime in my neighborhood.	1			2	3	4	7	8
*	I often see other girls or boys playing outdoors in my neighborhood.	1			2	3	4	7	8
*	There are many interesting things to look at while walking in my neighborhood.	1			2	3	4	7	8
*	My neighborhood streets are well lit at night.	1			2	3	4	7	8
*	There are lots of loose or scary dogs in my neighborhood.	1			2	3	4	7	8
*	There is enough equipment (like balls, bikes, etc.) for me to use at home.	1			2	3	4	7	8
H2. *	About how often does your mother or female guardian exercise, like jogging, running, playing sports, or taking long walks?			Never or almost never 1 Once or Twice a Week 2 Three or more times a week 3 Does not apply to me 4 REFUSED 7 DON’T KNOW 8
H3. *	About how often does your father or male guardian exercise, like jogging, running, playing sports, or taking long walks?			Never or almost never 1 Once or Twice a Week 2 Three or more times a week 3 Does not apply to me 4 REFUSED 7 DON’T KNOW 8

H4.

How much do you agree or disagree with the following statements?

Disagree a lot

Disagree a little

Agree a little

Agree a lot

Does not apply to me

Refused

Don’t Know

*

I see teachers and staff at my school playing sports or doing physical activities

1

2

3

4

5

7

8

*

Teachers and staff at my school talk to students about being active and playing sports

1

2

3

4

5

7

8

*

My closest friends are often physically active

1

2

3

4

5

7

8

*

My school has non-sports programs for students to be physically active (step team, dance, walk/run club, etc.)

1

2

3

4

5

7

8

*

My school has sports teams that you have to try out for

1

2

3

4

5

7

8

*

My school has sports teams where everyone can participate (no try-outs)

1

2

3

4

5

7

8

H5.

How much do you agree or disagree with the following statements?

Disagree a lot

Disagree a little

Agree a little

Agree a lot

Does not apply to me

Refused

Don’t Know

*

There is enough equipment for me to do the activities I want during recess

1

2

3

4

5

7

8

*

There is equipment for resistance training/weight lifting at my school

1

2

3

4

5

7

8

*

There are outdoor facilities at my school where I can be active (track, fields, playground, etc.)

1

2

3

4

5

7

8

*

There are indoor facilities at my school where I can be active (gym, weight room, multipurpose room, etc.)

1

2

3

4

5

7

8

*

I can use the outdoor facilities at my school during non-school time (nights and weekends) to be active

1

2

3

4

5

7

8

*

I can use the indoor facilities at my school during non-school time (nights and weekends) to be active

1

2

3

4

5

7

8

*

The facilities and equipment at my school for sports are of good quality

1

2

3

4

5

7

8

H6.

How much do you agree or disagree with the following statements?

Disagree a lot

Disagree a little

Agree a little

Agree a lot

Does not apply to me

Refused

Don’t Know

*

There is enough equipment for everyone in my class to use during PE

1

2

3

4

5

7

8

*

My PE teacher is physically active

1

2

3

4

5

7

8

*

I enjoy physical education classes at my school

1

2

3

4

5

7

8

H7.

How much is each of the following statements true for you?

Not at all true for me

A little untrue for me

A little true for me

Very true for me

Refused

Don’t Know

*

I am someone who exercises regularly

1

2

3

4

7

8

*

It is important to m) to be someone who exercises regularly

1

2

3

4

7

8

*

I am someone who keeps physically fit

1

2

3

4

7

8

*

It is important to me to be someone who keeps physically fit

1

2

3

4

7

8

*

I am physically active

1

2

3

4

7

8

*

It is important to me to be someone who is physically active

1

2

3

4

7

8

H8. *

Compared to others of the same age and gender, how good are you at sports?

Much worse 1 Somewhat worse 2 About the same 3 Somewhat better 4 Much better 5 refused 7 don’t know 8

H9. *

How do you rate your physical activity level compared to others of the same age and gender?

Much less than others 1 Somewhat Less than Others 2 About the same 3 Somewhat More than others 4 Much more than others 5 refused 7 don’t know 8

SECTION I: PHYSICAL ACTIVITY PARENT SURVEY

Self administered

Child aged 3 – 15: Adult respondent

I1. *

In my home or yard, my child has access to the following. Choose all that apply.

Basketball Hoop/Sports Goals (soccer) 1 Bicycle 2 Big yard/Empty Field 3 Exercise Video tapes 4 Active Video game systems (Wii, Playstation Move, Xbox Kinect) 5 Indoor Playspace (playroom, empty garage) 6 Cardio Equipment (Treadmill, stationary bicycle, step climber, elliptical machine, rowing machine) 7 Jungle Gym/Tree House 8 Swings/Slides 9 Wheeled Toys (scooter, skateboard, inline skates, roller skates, etc.) 10 Active Equipment (balls, jumpropes Frisbees, racquets, bats, etc.) 11 Swimming Pool 12 Trampoline 13 Weight lifting equipment 14 Other, please specify 15 Refused 97 Don’t Know 98

SPECIFY:

I2. *

In my community or neighborhood, my child has access to the following. Choose all that apply.

Basketball Hoop/Sports Goals (soccer) 16 Big yard/Empty Field 17 Indoor Playspace (clubhouse) 18 Cardio Equipment (Treadmill, stationary bicycle, step climber, elliptical machine, rowing machine) 19 Lake or Ocean 20 Playground (jungle gym, slides, swings, etc.) 21 Swimming Pool 22 Tennis Court 23 Weight lifting equipment 24 Park 25 Walking Trail 26 Bike Path/Trail 27 YMCA/Boys and Girls Club/etc. 28 Skate park/place for skateboarding 29 Other, please specify 30 Refused 97 Don’t Know 98

SPECIFY:

Please read each of the following statements and select the response that best indicates how much you agree or disagree with the statement.

I3. *

I allow my child to play video games or computer games as much as he/she wants.

Strongly disagree 1 Disagree 2 Agree 3 Strongly Agree 4 Refused 7 Don’t Know 8

I4. *

I allow my child to watch as much TV as (he/she) wants.

Strongly disagree 1 Disagree 2 Agree 3 Strongly Agree 4 Refused 7 Don’t Know 8

I5. *

If my child has been occupied for a long time with inside activities and the weather is nice, I encourage (him/her) to play outside.

Strongly disagree 1 Disagree 2 Agree 3 Strongly Agree 4 Refused 7 Don’t Know 8

I6. *

My child is allowed to play outside without an adult as long as (he/she) stays within the neighborhood. Would you say yes or no?

YES 1 NO 2 REFUSED 7 DON'T KNOW 8

I7. *

My child is allowed to play outside without an adult as long as (he/she) stays in the yard. Would you say yes or no?

YES 1 NO 2 DON’T HAVE A YARD ………………………………………3 REFUSED 7 DON'T KNOW 8

I8. *

My child is allowed to play outside without an adult as long as (he/she) stays within sight of our home. Would you say yes or no?

YES 1 NO 2 REFUSED 7 DON'T KNOW 8

I9. *

How often does a member of your household take (CHILD) to a place where (he/she) can participate in physical activities?

0 DAYS PER WEEK 1 1-2 DAYS PER WEEK 2 3-4 DAYS PER WEEK 3 5-6 DAYS PER WEEK 4 7 DAYS PER WEEK 5 REFUSED 7 DON’T KNOW 8

I10. *

How do you rate your child’s level of physical activity, compared to others of the same age and gender?

Much less than others 1 Somewhat less than others 2 About the same 3 Somewhat more than others 4 Much more than others 5 Refused 7 Don’t Know 8

SECTION J: NUTRITION QUESTIONS

Interviewer administered

Domain 1: Food and Beverage Intake

Child aged 3 – 5: Adult respondent Child aged 6 – 8: Adult respondent/child present to assist Child aged 9 – 11: Child respondent/adult present to assist Child aged 12 – 15: Child respondent

These questions are about the different kinds of foods (you/your child) ate or drank during the past month, that is, the past 30 days. When answering, please include meals and snacks eaten at home, at school, in restaurants, and anyplace else.

J1. *

During the past month, how often did (you/your child) eat hot or cold cereals? You can answer per day, per week or per month.

PER DAY 1 PER WEEK 2 PER MONTH 3 # OF TIMES NEVER (SKIP TO J3) 0 REFUSED (SKIP TO J3) 7 DON’T KNOW (SKIP TO J3) 8

J2. *

During the past month, what kinds of cereal did (you/your child) usually eat?

CEREAL1:_______________________________________ CEREAL2:_______________________________________ REFUSED 7 DON’T KNOW 8

J3. *

During the past month, how often did (you/your child) have milk either to drink or on cereal? Do not include soymilk or small amounts of milk in coffee or tea. You can answer per day, per week or per month.

PER DAY 1 PER WEEK 2 PER MONTH 3 # OF TIMES NEVER (SKIP TO J5) 0 REFUSED (SKIP TO J5) 7 DON’T KNOW (SKIP TO J5) 8

J4. *

During the past month, what kind of milk did (you/your child) usually drink?

WHOLE OR REGULAR MILK.................................. 1 2% FAT OR REDUCED-FAT MILK 2 1%, 1/2%, OR LOW-FAT MILK 3 FAT-FREE, SKIM OR NONFAT MILK 4 SOY MILK 5 OTHER 6 REFUSED ....................................................................7 DON'T KNOW 8

J5. *

During the past month, how often did (you/your child) eat or drink the following foods? You can answer per day, per week or per month.

PER DAY

PER WEEK

PER MONTH

# OF TIMES

NEVER

RF

DK

*

a. Regular soda or pop that contains sugar? Do not include diet soda

1

2

3

0

7

8

*

b. 100% pure fruit juice such as orange, mango, apple, grape, and pineapple juices? Do not include fruit-flavored drinks with added sugar or fruit juice you made at home and added sugar to

1

2

3

0

7

8

*

c. Coffee or tea that had sugar or honey added to it? Include coffee and tea you sweetened yourself and presweetened tea and coffee drinks such as Arizona Iced Tea and Frappuccino. Do not include artificially sweetened coffee or diet tea

1

2

3

0

7

8

*

d. Sports or energy drinks, such as Gatorade, Red Bull, or Vitamin Water?

1

2

3

0

7

8

*

e. Sweetened fruit drinks, such as Kool-aid, cranberry, or lemonade? Include fruit drinks you made at home and added sugar to

1

2

3

0

7

8

*

f. Fruit? Include fresh, frozen, dried, or canned fruit. Do not include juices

1

2

3

0

7

8

*

g. A green leafy or lettuce salad, with or without other vegetables?

1

2

3

0

7

8

*

h. Any kind of fried potatoes, including french fries, home fries, or hash brown potatoes.

1

2

3

0

7

8

*

i. Any other kind of potatoes, such as baked, boiled, mashed potatoes, sweet potatoes, or potato salad?

1

2

3

0

7

8

*

j. Refried beans, baked beans, beans in soup, pork and beans or any other type of cooked dried beans? Do not include green beans....

1

2

3

0

7

8

*

k. Not including what you just told me about lettuce salads, potatoes, cooked dried beans and not including rice, how often did (you/your child) eat other vegetables?

1

2

3

0

7

8

*

l. Pizza? Include frozen pizza, fast food pizza, and homemade pizza

1

2

3

0

7

8

*

m. Mexican-type salsa made with tomato?...

1

2

3

0

7

8

*

n. Tomato sauces such as with spaghetti, noodles, or mixed into foods such as lasagna? Please do not count tomato sauce on pizza.....

1

2

3

0

7

8

*

o. Cheese? Include cheese as a snack, cheese on burgers, sandwiches, and cheese in foods such as lasagna, quesadillas, or casseroles. Please do not count cheese on pizza

1

2

3

0

7

8

*

p. Whole grain bread including toast, rolls and in sandwiches? Whole grain breads include whole wheat, rye, oatmeal, and pumpernickel. Do not include white bread

1

2

3

0

7

8

*

q. Brown rice or other cooked whole grains, such as bulgur, cracked wheat, or millet? Do not include white rice

1

2

3

0

7

8

*

r. Chocolate or any other types of candy? Do not include sugar-free candy

1

2

3

0

7

8

*

s. Doughnuts, sweet rolls, Danish, muffins, pan dulce, or pop-tarts? Do not include sugar-free items.

1

2

3

0

7

8

*

t. Cookies, cake, pie or brownies? Do not include sugar-free kinds.

1

2

3

0

7

8

*

u. Ice cream or other frozen desserts? Do not include sugar-free kinds.

1

2

3

0

7

8

*

v. Popcorn?

1

2

3

0

7

8

*

w. potato chips, corn chips, or crackers?.

1

2

3

0

7

8

Domain 2: Food Patterns and Behaviors

Child aged 3 – 5: Adult respondent Child aged 6 – 8: Adult respondent/child present to assist Child aged 9 – 11: Child respondent/adult present to assist Child aged 12 – 15: Child respondent

These next questions are about meals during the past week, that is, the past 7 days.

J6. *

During the past 7 days, on how many days did (you/your child) eat breakfast or a morning meal?

DAYS REFUSED 97 DON’T KNOW 98

J7. *

When (you/your child) eat at home, how often is a television on while you are eating?

NEVER 1 RARELY 2 SOMETIMES 3 MOST OF THE TIME 4 REFUSED 7 DON'T KNOW 8

J8. *

During the past 7 days, on how many days did (you/your child) eat or drink anything from a fast food restaurant such as McDonald's, Taco Bell, or KFC?

DAYS REFUSED 97 DON’T KNOW 98

J9. *

During the past 7 days, how many dinners, or suppers did all or most of your family sit down and eat together?

DAYS REFUSED 97 DON’T KNOW 98

Domain 3: Self-Efficacy and Intentions Regarding Healthy Eating

Child aged 3 – 11: NOT ADMINISTERED Child aged 12 – 15: Child respondent

Read each sentence. Select the answer that describes YOU. Eating healthy means you eat fruits and vegetables, lean meats like chicken, low fat dairy products, and a limited amount of sugary or salty snacks, junk foods, and sodas.

J10. *

It is important to eat healthy every day.

NOT LIKE ME 1 A LITTLE LIKE ME 2 A LOT LIKE ME 3 REFUSED 7 DON'T KNOW 8

J11. *

I make sure I get plenty of healthy foods on each day.

NOT LIKE ME 1 A LITTLE LIKE ME 2 A LOT LIKE ME 3 REFUSED 7 DON'T KNOW 8

J12. *

I get excited about eating healthy every day.

NOT LIKE ME 1 A LITTLE LIKE ME 2 A LOT LIKE ME 3 REFUSED 7 DON'T KNOW 8

Below is a list of things people might do while trying to change their eating habits. Whether you are trying to change your eating habits or not, please rate how confident you are that you could really motivate yourself to do things like this consistently for, at least six months. How sure are you that you can do these things?

J13. *

Stick to eating healthy when eating with family.

A LITTLE SURE 1 SURE 2 VERY SURE 3 REFUSED 7 DON'T KNOW 8

J14. *

Stick to eating healthy when eating with friends.

A LITTLE SURE 1 SURE 2 VERY SURE 3 REFUSED 7 DON'T KNOW 8

J15. *

Choose healthy foods when I eat at school.

A LITTLE SURE 1 SURE 2 VERY SURE 3 REFUSED 7 DON'T KNOW 8

Domain 4: Perceived Social Support Regarding Healthy Eating and Peer Influence

Child aged 3 – 5: Adult respondent – Family ratings only Child aged 6 – 8: Adult respondent/child present to assist – Family ratings only Child aged 9 – 11: Child respondent/adult present to assist – Family ratings only Child aged 12 – 15: Child respondent – Ratings of both Family and Friends

Below is a list of things people might do or say to someone who is trying to improve their eating habits. (Please rate each question twice.) (For family, rate/Rate) how often anyone living in your household has said or done what is described during the last month. (For friends, rate how often your friends have said or done what is described, during the last month.)

J16. *

Complimented (you/your child) on eating habits (“Keep it up,” “We are proud of you”).

None

Rarely

A Few Times

Often

Very Often

RF

DK

a. FAMILY

1

2

3

4

5

7

8

b. FRIENDS

1

2

3

4

5

7

8

J17. *

Encouraged (you/your child) to eat fruits and vegetables when tempted not to.

None

Rarely

A Few Times

Often

Very Often

RF

DK

a. FAMILY

1

2

3

4

5

7

8

b. FRIENDS

1

2

3

4

5

7

8

J18. *

Discussed (your/your child's) eating habits with (you/your child) (asked how doing with eating healthier).

None

Rarely

A Few Times

Often

Very Often

RF

DK

a. FAMILY

1

2

3

4

5

7

8

b. FRIENDS

1

2

3

4

5

7

8

Domain 5: Perceived Home Environment Regarding Healthy Eating

Child aged 3 – 15: Adult respondent

The next questions ask how often you have certain types of food available at home.

J19. *

How often do you have fruits available at home? This includes fresh, dried, canned, and frozen fruits. Would you say always, most of the time, sometimes, rarely, or never?

ALWAYS 1 MOST OF THE TIME 2 SOMETIMES 3 RARELY 4 NEVER 5 REFUSED 7 DON’T KNOW 8

J20. *

How often do you have any of these dark green vegetables available at home? This includes fresh, dried, canned, and frozen vegetables. Bok Choy; Broccoli; Collard greens; Dark green leafy lettuce; Kale; Mesclun; Mustard greens; Romaine lettuce; Turnip greens; Spinach; Watercress. (Would you say always, most of the time, sometimes, rarely, or never?)

ALWAYS 1 MOST OF THE TIME 2 SOMETIMES 3 RARELY 4 NEVER 5 REFUSED 7 DON’T KNOW 8

J21. *

How often do you have salty snacks such as chips and crackers available at home? Do not include nuts. (Would you say always, most of the time, sometimes, rarely, or never?)

ALWAYS 1 MOST OF THE TIME 2 SOMETIMES 3 RARELY 4 NEVER 5 REFUSED 7 DON’T KNOW 8

J22. *

How often do you have 1% fat, skim, or fat-free milk available at home? Do not include 2% milk. (Would you say always, most of the time, sometimes, rarely, or never?)

ALWAYS 1 MOST OF THE TIME 2 SOMETIMES 3 RARELY 4 NEVER 5 REFUSED 7 DON’T KNOW 8

J23. *

How often do you have soft drinks, fruit-flavored drinks, or fruit punch available at home? Do not include diet drinks, 100% juice or sports drinks. (Would you say always, most of the time, sometimes, rarely, or never?)

ALWAYS 1 MOST OF THE TIME 2 SOMETIMES 3 RARELY 4 NEVER 5 REFUSED 7 DON’T KNOW 8

Domain 6: Perceived School Environment Regarding Healthy Eating

Child aged 3 – 5: NOT ADMINISTERED Child aged 6 – 8: Adult respondent/child present to assist Child aged 9 – 11: Child respondent/adult present to assist Child aged 12 – 15: Child respondent

I’m going to read you statements about foods at school during this school year. How often are these statements true in your opinion? Would you say always, most of the time, sometimes, rarely, or never?

J24. *

The school lunch is healthy.

ALWAYS 1 MOST OF THE TIME 2 SOMETIMES 3 RARELY 4 NEVER 5 REFUSED 7 DON’T KNOW 8

J25. *

The school lunch tastes good.

ALWAYS 1 MOST OF THE TIME 2 SOMETIMES 3 RARELY 4 NEVER 5 REFUSED 7 DON’T KNOW 8

J26. *

The foods that are sold in places like vending machines, snack bars, carts, or stores at my (child’s) school are healthy.

ALWAYS 1 MOST OF THE TIME 2 SOMETIMES 3 RARELY 4 NEVER 5 REFUSED 7 DON’T KNOW 8

J27. *

The foods that are sold in places like vending machines, snack bars, carts, or stores at my (child’s) school taste good.

ALWAYS 1 MOST OF THE TIME 2 SOMETIMES 3 RARELY 4 NEVER 5 REFUSED 7 DON’T KNOW 8

Think about this school year, when you answer the following questions.

J28. *

How many days a week (does your child/do you) usually eat the school breakfast?

DAYS REFUSED 7 DON’T KNOW 8

J29. *

How many days a week (does your child/do you) usually eat the school lunch?

DAYS REFUSED 7 DON’T KNOW 8

Domain 7: Perceived Community Environment Regarding Healthy Eating

Child aged 3 – 15: Adult respondent

In the next question, I am going to ask you about obtaining food.

J30.

When shopping for food, how often does the main food shopper in your household go to each of the following places? Would you say often, sometimes, rarely or never?

OFTEN

SOMETIMES

RARELY

NEVER

RF

DK

*

Large chain grocery store or supermarket?

1

2

3

4

7

8

*

Natural or organic supermarket (such as Whole Foods Market)?

1

2

3

4

7

8

*

Small local store or corner store?

1

2

3

4

7

8

*

Convenience store (such as 7-Eleven, Quick Stop, mini market)?

1

2

3

4

7

8

*

Warehouse club store (such as Sam’s Club or Costco)?

1

2

3

4

7

8

*

Discount superstore (such as Wal-Mart or Target)?

1

2

3

4

7

8

*

Online delivery (such as Peapod or Fresh Direct)?

1

2

3

4

7

8

*

Ethnic market?

1

2

3

4

7

8

*

Farmer’s market/co-op?

1

2

3

4

7

8

The next question is about eating prepared food, including when you eat at restaurants, go through the drive-thru, carry out, or have it delivered.

J31.

When you eat out or get take out food, how often do you go to each of the following places? Would you say often, sometimes, rarely or never?

OFTEN

SOMETIMES

RARELY

NEVER

RF

DK

*

Restaurant with waiter or waitress service?

1

2

3

4

7

8

*

Buffet or cafeteria?

1

2

3

4

7

8

*

Fast food restaurant?

1

2

3

4

7

8

*

Deli (stand alone or in a shop)?

1

2

3

4

7

8

*

Convenience stores (such as 7-Eleven, Quick Stop, mini market)?

1

2

3

4

7

8

*

Bar, tavern, or lounge?

1

2

3

4

7

8

*

Coffee shop?

1

2

3

4

7

8

In this next set of questions, I am going to ask you about the availability, cost, and quality of food in your community. This includes the stores or markets where you shop for food. Remember, community is defined as the place where you live, including your neighborhood and the neighborhoods that you are easily able to get to.

J32.

Please tell us how much you agree or disagree with the following statements. Do you strongly agree, agree, neither agree nor disagree, disagree, or strongly disagree.

STRONGLY AGREE

AGREE

NEITHER AGREE NOR DISAGREE

DIS-AGREE

STRONGLY DISAGREE

RF

DK

*

It is easy to buy fresh fruits and vegetables in my community.

1

2

3

4

5

7

8

*

There is a large selection of fresh fruits and vegetables in my community.

1

2

3

4

5

7

8

*

The produce (fresh fruits and vegetables) in my community is of high quality.

1

2

3

4

5

7

8

*

It is easy to purchase low-fat products (such as low fat milk or lean meats) in my community.

1

2

3

4

5

7

8

*

There is a large selection of low-fat products available in my community.

1

2

3

4

5

7

8

*

The low-fat products in my community are of high quality.

1

2

3

4

5

7

8

J33. *

Has the cost of fresh fruits and vegetables where you shop ever kept you from buying them?

YES 1 NO 2 REFUSED 7 DON'T KNOW 8

Domain 8: Infant Feeding History

Child aged 3 – 15: Adult respondent

The next questions are about breastfeeding your child.

J34. *

Was your child ever breastfed or fed breast milk?

YES 1 NO (SKIP TO J36) 2 REFUSED (SKIP TO J36) 7 DON’T KNOW (SKIP TO J36) 8

J35. *

How old was your child when (he/she) completely stopped breastfeeding or being fed breast milk?

MONTHS YEARS

Domain 9: Household Food Insecurity

Child aged 3 – 15: Adult respondent

Now I’m going to read you several statements that people have made about their food situation. For these statements, please tell me whether the statement was often true, sometimes true, or never true for your household in the last 12 months – that is, since last (CURRENT MONTH).

J36. *

We worried whether our food would run out before we got money to buy more. Was that often true, sometimes true, or never true for your household in the last 12 months?

OFTEN TRUE 1 SOMETIMES TRUE 2 NEVER TRUE 3 REFUSED 7 DON'T KNOW 8

J37. *

The food that we bought just didn’t last, and we didn’t have money to get more. Was that often, sometimes, or never true for your household in the last 12 months?

OFTEN TRUE 1 SOMETIMES TRUE 2 NEVER TRUE 3 REFUSED 7 DON'T KNOW 8

Domain 10: Dieting Behaviors

Child aged 3 – 11: NOT ADMINISTERED Child aged 12 – 15: Child respondent

J38. *

How do you describe your weight?

VERY UNDERWEIGHT.................................................... 1 SLIGHTLY UNDERWEIGHT ........................................... 2 ABOUT THE RIGHT WEIGHT ........................................ 3 SLIGHTLY OVERWEIGHT 4 VERY OVERWEIGHT ...................................................... 5 REFUSED ......................................................................7 DON'T KNOW ...............................................................8

J39. *

Which of the following are you trying to do about your weight?

LOSE WEIGHT.................................................... 1 GAIN WEIGHT ........................................... 2 STAY THE SAME WEIGHT ........................................ 3 NOT TRYING TO DO ANYTHING ABOUT WEIGHT 4 REFUSED ......................................................................7 DON'T KNOW ...............................................................8

J40. *

Have you ever gone without eating for 24 hours or more (also called fasting) to lose weight or to keep from gaining weight?

YES 1 NO 2 REFUSED 7 DON'T KNOW 8

J41. *

Have you ever taken any diet pills, powders, or liquids without a doctor's advice to lose weight or to keep from gaining weight? Do not include meal replacement products such as Slim Fast.

YES 1 NO 2 REFUSED 7 DON'T KNOW 8

J42. *

Have you ever vomited or taken laxatives to lose weight or to keep from gaining weight?

YES 1 NO 2 REFUSED 7 DON'T KNOW 8

HOME VISIT 2 (Enhanced Protocol ONLY)

SECTION K: PHYSICAL ACTIVITY BEHAVIORS RECALL (FOR 3 – 5 YEAR OLDS)

Self administered

Child aged 3 – 5: Adult respondent Child aged 6 – 15: NOT ADMINISTERED

The next questions are going to ask you about the activities that your child did yesterday. Please only think about the activities that were done yesterday. For each activity, indicate whether or not the child did the activity yesterday. For those activities that you mark yes, please indicate how long your child did the activity and the specific activity done. The following questions refer to activities done around the home or in the neighborhood (including parks and playgrounds). Please consider activities done only in these locations.

K1.

Did your child play any physically active games (hopscotch, red rover, tag, etc.) at home or in the neighborhood yesterday?

YES 1 NO (SKIP TO K2) 2 REFUSED (SKIP TO K2) 7 DON’T KNOW (SKIP TO K2) 8

For how many minutes did (he/she) play physically active games at home or in the neighborhood?

MINUTES REFUSED 997 DON’T KNOW 998

When your child played physically active games at home or in the neighborhood, what exactly was (he/she) doing?

TAG 1 RED ROVER/DUCK DUCK GOOSE/ETC. 2 HOPSCOTCH 3 OTHER (SPECIFY) 4 REFUSED 97 DON’T KNOW 98

K2.

Did your child ride (his/her) bike or use other wheeled toys (scooter, skates, etc) at home or in the neighborhood yesterday?

YES 1 NO (SKIP TO K3) 2 REFUSED (SKIP TO K3) 7 DON’T KNOW (SKIP TO K3) 8

For how many minutes did (he/she) ride (his/her) bike or use other wheeled toys at home or in the neighborhood?

MINUTES REFUSED 997 DON’T KNOW 998

K3. *

Did your child participate in physically active play yesterday (running around the yard, using fixed equipment [jungle gym/swings/monkey bars], playing with balls)?

YES 1 NO (SKIP TO K4) 2 REFUSED (SKIP TO K4) 7 DON’T KNOW (SKIP TO K4) 8

For how many minutes did (he/she) participate in physically active play?

MINUTES REFUSED 997 DON’T KNOW 998

When your child participated in physically active play, what exactly was (he/she) doing?

PLAYING WITH BALLS/OTHER EQUIPMENT 1 PLAYING ON FIXED EQUIPMENT (TREE HOUSE, MONKEY BARS, SLIDES, SWINGS, ETC) 2 JUMPROPE/HULA HOOP 3 OTHER (SPECIFY) 4 REFUSED 97 DON’T KNOW 98

K4.

Did your child use a computer for playing games on the internet yesterday?

YES 1 NO (SKIP TO K5) 2 REFUSED (SKIP TO K5) 7 DON’T KNOW (SKIP TO K5) 8

For how many minutes did (he/she) use a computer for playing games on the internet?

MINUTES REFUSED 997 DON’T KNOW 998

K5.

Did your child watch TV or videos yesterday?

YES 1 NO (SKIP TO K6) 2 REFUSED (SKIP TO K6) 7 DON’T KNOW (SKIP TO K6) 8

For how many minutes did (he/she) watch TV or videos?

MINUTES REFUSED 997 DON’T KNOW 998

K6.

Did your child play non-active video games yesterday?

YES 1 NO (SKIP TO K7) 2 REFUSED (SKIP TO K7) 7 DON’T KNOW (SKIP TO K7) 8

For how many minutes did (he/she) play non-active video games?

MINUTES REFUSED 997 DON’T KNOW 998

K7.

Did your child play physically active video games (Wii, DDR, Xbox Kinect, Playstation Move, etc.) yesterday?

YES 1 NO (SKIP TO K8) 2 REFUSED (SKIP TO K8) 7 DON’T KNOW (SKIP TO K8) 8

For how many minutes did (he/she) play physically active video games?

MINUTES REFUSED 997 DON’T KNOW 998

When your child played physically active video games, what exactly was (he/she) doing?

PLAYING WII/KINECT/MOVE, ETC 1 REFUSED 97 DON’T KNOW 98

The following questions refer to activities done as part of community programs or organized recreational opportunities in community settings. Please consider activities done in community settings when answering these questions.

K8.

Did your child play an organized sport yesterday?

YES 1 NO (SKIP TO K9) 2 REFUSED (SKIP TO K9) 7 DON’T KNOW (SKIP TO K9) 8

For how many minutes did (he/she) play an organized sport?

MINUTES REFUSED 997 DON’T KNOW 998

When your child played an organized sport, what exactly was (he/she) doing?

PLAYING BASEBALL/SOFTBALL 1 PLAYING SOCCER/FOOTBALL 2 PLAYING BASKETBALL 3 PLAYING TENNIS 4 SWIM TEAM 5 OTHER (SPECIFY) 4 REFUSED 97 DON’T KNOW 98

K9.

Did your child participate in a program to improve (his/her) movement skills (Gymboree, Little Gym, Monkey Joe’s, BounceORama, trampoline gyms, etc.) yesterday?

YES 1 NO (SKIP TO K10) 2 REFUSED (SKIP TO K10) 7 DON’T KNOW (SKIP TO K10) 8

For how many minutes did (he/she) participate in a program to improve (his/her) movement skills?

MINUTES REFUSED 997 DON’T KNOW 998

When your child participated in a program to improve (his/her) movement skills, what exactly was (he/she) doing?

PARTICIPATING IN GYMBOREE OR LITTLE GYM (OR OTHER FACILITY) CLASSES 1 PLAYING AT A BOUNCE HOUSE (MONKEY JOE’S, ETC.) 2 PLAYING AT A TRAMPOLINE GYM 3 OTHER (SPECIFY) 4 REFUSED 97 DON’T KNOW 98

K10.

Did your child participate in any physically active classes or lessons (not including swimming or activities done at school) such as dance, karate, tennis, gymnastics, etc. yesterday?

YES 1 NO (SKIP TO K11) 2 REFUSED (SKIP TO K11) 7 DON’T KNOW (SKIP TO K11) 8

For how many minutes did (he/she) participate in any physically active classes or lessons?

MINUTES REFUSED 997 DON’T KNOW 998

When your child participated in any physically active classes or lessons, what exactly was (he/she) doing?

DANCE/ CHEER 1 TUMBLING OR GYMNASTICS CLASSES 2 SPORT LESSONS (TENNIS, BASEBALL, BASKETBALL, ETC.) 3 KARATE OR OTHER MARTIAL ARTS CLASSES 4 OTHER (SPECIFY) 4 REFUSED 97 DON’T KNOW 98

K11.

Did your child participate in any activities in the water (swim lessons, swimming, pool/water games) yesterday?

YES 1 NO (SKIP TO K12) 2 REFUSED (SKIP TO K12) 7 DON’T KNOW (SKIP TO K12) 8

For how many minutes did (he/she) participate in any water activities?

MINUTES REFUSED 997 DON’T KNOW 998

When your child participated in any water activities, what exactly was (he/she) doing?

SWIM LESSONS 1 SWIMMING 2 PLAYING POOL/WATER GAMES 3 OTHER (SPECIFY) 4 REFUSED 97 DON’T KNOW 98

The following questions refer to activities done at school. Please answer the questions regarding your child’s school attendance and activities done at school (if they do attend school).

K12.

Did your child attend a structured childcare or school yesterday?

YES 1 NO (END SURVEY) 2 REFUSED (END SURVEY) 7 DON’T KNOW (END SURVEY) 8

Yesterday, did your child attend physical education classes at school/childcare?

Yes 1 no 2 refused 7 don’t know 8

Yesterday, did your child have recess on most days while at school?

Yes 1 no 2 refused 7 don’t know 8

Yesterday, did your child attend dance or other physically active classes at school/childcare (other than PE class)?

Yes 1 no 2 refused 7 don’t know 8

Yesterday, did your child participate in physical activity (structured or unstructured) during an afterschool program?

Yes 1 no 2 refused 7 don’t know 8

SECTION L: PHYSICAL ACTIVITY BEHAVIORS RECALL (FOR 6 – 15 YEAR OLDS)

Self administered

Child aged 3 – 5: NOT ADMINISTERED Child aged 6 – 11: Child respondent/adult present to assist Child aged 12 – 15: Child respondent

The next questions are going to ask you about the activities that you did yesterday. Please only think about the activities you did yesterday, not activities that you like or would like to do. For each activity, indicate whether or not you did the activity yesterday. For those activities that you did, mark yes and answer the remaining questions for that activity. Then, using the following word and picture description as a guide, select how physically hard or intense the activity was. Remember, these pictures are just a guide and not the activities you are answering questions about. For those that you did not do yesterday, mark NO and skip to the next activity. APPROPRIATE AGE AND GENDER PHOTOS FOR INTENSITY RATINGS WILL BE SHOWN AS INDICATED PREVIOUSLY IN SECTION G.

L1.

Did you have physical education (PE) class in school yesterday?

YES 1 NO (SKIP TO L2) 2 REFUSED (SKIP TO L2) 7 DON’T KNOW (SKIP TO L2) 8

How physically hard was this activity?

LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8

For how many minutes was PE?

MINUTES REFUSED 997 DON’T KNOW 998

When you were in PE, what exactly were you doing?

TEAM SPORT SKILLS 1 INDIVIDUAL SPORT SKILLS 2 DANCE/TUMBLING SKILLS 3 WATER ACTIVITY SKILLS 4 CARDIOVASCULAR MACHINES OR CONDITIONING (RUNNING, CYCLING, STAIRCLIMBER, ROWERS, ETC.) 5 CLIMBING WALL ACTIVITIES 6 EXERCISES/CALISTHENICS 7 FRISBEE OR FRISBEE GOLF 8 JUMPROPE/PLYOMETRICS/CONDITIONING 9 WEIGHT TRAINING 10 YOGA/PILATES 11 OTHER (SPECIFY) 12 REFUSED 97 DON’T KNOW 98

L2.

Did you have recess or other free-play at school yesterday?

YES 1 NO (SKIP TO L3) 2 REFUSED (SKIP TO L3) 7 DON’T KNOW (SKIP TO L3) 8

How physically hard was this activity?

LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8

For how many minutes was recess or other free-play time?

MINUTES REFUSED 997 DON’T KNOW 998

When you were in recess or other free-play, what exactly were you doing?

PLAYGROUND GAME (KICKBALL, FOUR SQUARE, DODGEBALL, ETC.) 1 ORGANIZED SPORT GAME (BASEBALL, BASKETBALL, FOOTBALL, ETC.) 2 TAG/CAPTURE THE FLAG/RED ROVER/ETC. 3 FIXED EQUIPMENT (MONKEY BARS, SLIDES, SWINGS, ETC.) 4 HANGING OUT WITH FRIENDS 5 DOING SCHOOL WORK 6 OTHER (SPECIFY) 7 REFUSED 97 DON’T KNOW 98

L3.

Did you have dance or other physically active classes at school (other than PE class) yesterday?

YES 1 NO (SKIP TO L4) 2 REFUSED (SKIP TO L4) 7 DON’T KNOW (SKIP TO L4) 8

How physically hard was this activity?

LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8

For how many minutes was dance or the physically active class?

MINUTES REFUSED 997 DON’T KNOW 998

When you were in dance or the physically active class, what exactly were you doing?

DANCE 1 WEIGHTLIFTING 2 OTHER (SPECIFY) 3 REFUSED 97 DON’T KNOW 98

L4.

Did you participate in physical activity breaks during classes at school yesterday?

YES 1 NO (SKIP TO L5) 2 REFUSED (SKIP TO L5) 7 DON’T KNOW (SKIP TO L5) 8

How physically hard was this activity?

LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8

For how many minutes were the physical activity breaks?

MINUTES REFUSED 997 DON’T KNOW 998

During the physical activity breaks during class, what exactly were you doing?

IN-CLASS PHYSICAL ACTIVITY 1 VIDEO/STRUCTURED ACTIVITY IN HOMEROOM/ANNOUNCEMENTS 2 WALKING LAPS 3 OTHER (SPECIFY) 4 REFUSED 97 DON’T KNOW 98

L5.

Did you practice or play with a school sports team yesterday?

YES 1 NO (SKIP TO L6) 2 REFUSED (SKIP TO L6) 7 DON’T KNOW (SKIP TO L6) 8

How physically hard was this activity?

LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8

For how many minutes did you practice or play with a school sports team?

MINUTES REFUSED 997 DON’T KNOW 998

When you practiced or played with a school sports team, what exactly were you doing?

BASEBALL/SOFTBALL 1 FOOTBALL/SOCCER/LACROSSE/HOCKEY BASKETBALL 2 SWIM TEAM/DIVING/WATER POLO 3 GOLF/TENNIS 4 TRACK AND FIELD/CROSS COUNTRY 5 CHEER/DANCE TEAM 6 WRESTLING 7 VOLLEYBALL 8 MARTIAL ARTS 9 ROWING/CANOE/KAYAK 10 BOWLING 11 SKIING 12 OTHER (SPECIFY) 13 REFUSED 97 DON’T KNOW 98

L6.

Did you practice or play with a non-school sports team yesterday?

YES 1 NO (SKIP TO L7) 2 REFUSED (SKIP TO L7) 7 DON’T KNOW (SKIP TO L7) 8

How physically hard was this activity?

LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8

For how many minutes did you practice or play with a non-school sports team?

MINUTES REFUSED 997 DON’T KNOW 998

Where did you practice or play with a non-school sports team? CODE ALL THAT APPLY

AT SCHOOL 1 AT HOME 2 AT A REC CENTER 3 AT A PARK/PLAYGROUND 4 IN MY NEIGHBORHOOD 5 ON MY STREET 6 AT CHURCH 7 AT A FRIEND’S HOUSE 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98

SPECIFY:

When you practiced or played with a non-school sports team, what exactly were you doing?

BASEBALL/SOFTBALL 1 FOOTBALL/SOCCER/LACROSSE/HOCKEY BASKETBALL 2 SWIM TEAM/DIVING/WATER POLO 3 GOLF/TENNIS 4 TRACK AND FIELD/CROSS COUNTRY 5 CHEER/DANCE TEAM 6 WRESTLING 7 VOLLEYBALL 8 MARTIAL ARTS 9 ROWING/CANOE/KAYAK 10 BOWLING 11 SKIING 12 OTHER (SPECIFY) 13 REFUSED 97 DON’T KNOW 98

L7.

Did you participate in any pick-up sports (basketball, football, baseball/softball, etc.) yesterday?

YES 1 NO (SKIP TO L8) 2 REFUSED (SKIP TO L8) 7 DON’T KNOW (SKIP TO L8) 8

How physically hard was this activity?

LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8

For how many minutes did you play pick-up sports?

MINUTES REFUSED 997 DON’T KNOW 998

Where did you play pick-up sports? CODE ALL THAT APPLY

AT SCHOOL 1 AT HOME 2 AT A REC CENTER 3 AT A PARK/PLAYGROUND 4 IN MY NEIGHBORHOOD 5 ON MY STREET 6 AT CHURCH 7 AT A FRIEND’S HOUSE 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98

SPECIFY:

Who did you play pick-up sports with?

BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8

When you played pick-up sports, what exactly were you doing?

BASEBALL/SOFTBALL 1 FOOTBALL/SOCCER/LACROSSE/HOCKEY BASKETBALL 2 SWIM TEAM/DIVING/WATER POLO 3 OTHER (SPECIFY) 4 REFUSED 97 DON’T KNOW 98

L8.

Did you participate in physical activity during an afterschool program yesterday?

YES 1 NO (SKIP TO L9) 2 REFUSED (SKIP TO L9) 7 DON’T KNOW (SKIP TO L9) 8

How physically hard was this activity?

LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8

For how many minutes did you do physical activity during your afterschool program?

MINUTES REFUSED 997 DON’T KNOW 998

Where did you do physical activity during your afterschool program? CODE ALL THAT APPLY

AT SCHOOL 1 AT HOME 2 AT A REC CENTER 3 AT A PARK/PLAYGROUND 4 IN MY NEIGHBORHOOD 5 ON MY STREET 6 AT CHURCH 7 AT A FRIEND’S HOUSE 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98

SPECIFY:

Who did you do physical activity during your afterschool program with?

BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8

When you did physical activity during your afterschool program, what exactly were you doing?

PLAYGROUND GAME (KICKBALL, FOUR SQUARE, DODGEBALL, ETC.) 1 ORGANIZED SPORT GAME (BASEBALL, BASKETBALL, FOOTBALL, ETC.) 2 TAG/CAPTURE THE FLAG/RED ROVER/ETC. 3 FIXED EQUIPMENT (MONKEY BARS, SLIDES, SWINGS, ETC.) 4 DANCE/STEP TEAM 5 DOUBLE-DUTCH 6 OTHER (SPECIFY) 7 REFUSED 97 DON’T KNOW 98

L9.

Did you play any physically active games (hopscotch, red rover, tag, etc.) yesterday?

YES 1 NO (SKIP TO L10) 2 REFUSED (SKIP TO L10) 7 DON’T KNOW (SKIP TO L10) 8

How physically hard was this activity?

LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8

For how many minutes did you play physically active games?

MINUTES REFUSED 997 DON’T KNOW 998

Where did you play physically active games? CODE ALL THAT APPLY

AT SCHOOL 1 AT HOME 2 AT A REC CENTER 3 AT A PARK/PLAYGROUND 4 IN MY NEIGHBORHOOD 5 ON MY STREET 6 AT CHURCH 7 AT A FRIEND’S HOUSE 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98

SPECIFY:

Who did you play physically active games with?

BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8

When you played physically active games, what exactly were you doing?

TAG 1 RED ROVER/DUCK DUCK GOOSE/ETC. 2 HOPSCOTCH 3 OTHER (SPECIFY) 4 REFUSED 97 DON’T KNOW 98

L10.

Did you swim or play games in a pool, lake, or ocean yesterday?

YES 1 NO (SKIP TO L11) 2 REFUSED (SKIP TO L11) 7 DON’T KNOW (SKIP TO L11) 8

How physically hard was this activity?

LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8

For how many minutes did you swim or play games in a pool, lake or ocean?

MINUTES REFUSED 997 DON’T KNOW 998

Where did you swim or play games in a pool, lake, or ocean? CODE ALL THAT APPLY

AT SCHOOL 1 AT HOME 2 AT A REC CENTER 3 AT A PARK/PLAYGROUND 4 IN MY NEIGHBORHOOD 5 ON MY STREET 6 AT CHURCH 7 AT A FRIEND’S HOUSE 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98

SPECIFY:

Who did you swim or play games in a pool, lake, or ocean with?

BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8

When you swam or played games in a pool, lake, or ocean, what exactly were you doing?

SWIMMING 1 WATER GAMES (MARCO POLO, SHARK AND MINNOWS, ETC.) 2 WATERPLAY 3 OTHER (SPECIFY) 4 REFUSED 97 DON’T KNOW 98

L11.

Did you do any outdoor or adventure sports (hiking, kayaking, rock climbing, surfing, skiing, etc.) yesterday?

YES 1 NO (SKIP TO L12) 2 REFUSED (SKIP TO L12) 7 DON’T KNOW (SKIP TO L12) 8

How physically hard was this activity?

LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8

For how many minutes did you do outdoor or adventure sports?

MINUTES REFUSED 997 DON’T KNOW 998

Where did you do outdoor or adventure sports? CODE ALL THAT APPLY

AT SCHOOL 1 AT HOME 2 AT A REC CENTER 3 AT A PARK/PLAYGROUND 4 IN MY NEIGHBORHOOD 5 ON MY STREET 6 AT CHURCH 7 AT A FRIEND’S HOUSE 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98

SPECIFY:

Who did you do outdoor or adventure sports with?

BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8

When you did outdoor or adventure sports, what exactly were you doing?

HIKING 1 ROCK CLIMBING 2 SURFING/SKIMBOARDING/BODYBOARDING 3 SNOW SKIING/SNOWBOARDING 4 WATER SKIING/WAKEBOARDING 5 KAYAKING 6 OTHER (SPECIFY) 7 REFUSED 97 DON’T KNOW 98

L12.

Did you walk or bike to or from school yesterday?

YES 1 NO (SKIP TO L13) 2 REFUSED (SKIP TO L13) 7 DON’T KNOW (SKIP TO L13) 8

How physically hard was this activity?

LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8

For how many minutes did you walk or bike to or from school?

MINUTES REFUSED 997 DON’T KNOW 998

Who did you walk or bike to or from school with?

BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8

L13.

Did you walk or bike to or from a store, park, or playground or a friend’s house yesterday?

YES 1 NO (SKIP TO L14) 2 REFUSED (SKIP TO L14) 7 DON’T KNOW (SKIP TO L14) 8

How physically hard was this activity?

LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8

For how many minutes did you walk or bike to or from a store, park, or playground or a friend’s house?

MINUTES REFUSED 997 DON’T KNOW 998

Where did you walk or bike to or from a store, park, or playground or a friend’s house? CODE ALL THAT APPLY

AT SCHOOL 1 AT HOME 2 AT A REC CENTER 3 AT A PARK/PLAYGROUND 4 IN MY NEIGHBORHOOD 5 ON MY STREET 6 AT CHURCH 7 AT A FRIEND’S HOUSE 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98

SPECIFY:

Who did you walk or bike to or from a store, park, or playground or a friend’s house with?

BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8

L14.

Did you walk or ride your bike, scooter, skateboard, or skates for fun or exercise yesterday?

YES 1 NO (SKIP TO L15) 2 REFUSED (SKIP TO L15) 7 DON’T KNOW (SKIP TO L15) 8

How physically hard was this activity?

LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8

For how many minutes did you walk or ride your bike, scooter, skateboard, or skates for fun or exercise?

MINUTES REFUSED 997 DON’T KNOW 998

Where did you walk or ride your bike, scooter, skateboard, or skates for fun or exercise? CODE ALL THAT APPLY

AT SCHOOL 1 AT HOME 2 AT A REC CENTER 3 AT A PARK/PLAYGROUND 4 IN MY NEIGHBORHOOD 5 ON MY STREET 6 AT CHURCH 7 AT A FRIEND’S HOUSE 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98

SPECIFY:

Who did you walk or ride your bike, scooter, skateboard, or skates for fun or exercise with?

BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8

L15.

Did you use a computer for gaming or playing on the internet (not for schoolwork or social networks) yesterday?

YES 1 NO (SKIP TO L16) 2 REFUSED (SKIP TO L16) 7 DON’T KNOW (SKIP TO L16) 8

For how many minutes did you use a computer for gaming or playing on the internet?

MINUTES REFUSED 997 DON’T KNOW 998

Where did you use a computer for gaming or playing on the internet? CODE ALL THAT APPLY

AT SCHOOL 1 AT HOME 2 AT A REC CENTER 3 AT A PARK/PLAYGROUND 4 IN MY NEIGHBORHOOD 5 ON MY STREET 6 AT CHURCH 7 AT A FRIEND’S HOUSE 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98

SPECIFY:

Who did you use a computer for gaming or playing on the internet with?

BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8

When you used a computer for gaming or playing on the internet, what exactly were you doing?

GAMING 1 SURFING THE INTERNET 2 REFUSED 97 DON’T KNOW 98

L16.

Did you use a computer or phone for social networking (Facebook, MySpace, Twitter, IM, texting, etc.) yesterday?

YES 1 NO (SKIP TO L17) 2 REFUSED (SKIP TO L17) 7 DON’T KNOW (SKIP TO L17) 8

For how many minutes did you use a computer or phone for social networking?

MINUTES REFUSED 997 DON’T KNOW 998

Where did you use a computer or phone for social networking? CODE ALL THAT APPLY

AT SCHOOL 1 AT HOME 2 AT A REC CENTER 3 AT A PARK/PLAYGROUND 4 IN MY NEIGHBORHOOD 5 ON MY STREET 6 AT CHURCH 7 AT A FRIEND’S HOUSE 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98

SPECIFY:

Who did you use a computer or phone for social networking with?

BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8

When you used a computer or phone for social networking, what exactly were you doing?

IM/CHAT/TWITTER 1 1 SOCIAL NETWORKING ON THE COMPUTER 2 TEXTING 3 REFUSED 97 DON’T KNOW 98

L17.

Did you watch TV yesterday?

YES 1 NO (SKIP TO L18) 2 REFUSED (SKIP TO L18) 7 DON’T KNOW (SKIP TO L18) 8

For how many minutes did you watch TV?

MINUTES REFUSED 997 DON’T KNOW 998

Where did you watch TV? CODE ALL THAT APPLY

AT SCHOOL 1 AT HOME 2 AT A REC CENTER 3 AT A PARK/PLAYGROUND 4 IN MY NEIGHBORHOOD 5 ON MY STREET 6 AT CHURCH 7 AT A FRIEND’S HOUSE 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98

SPECIFY:

Who did you watch TV with?

BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8

L18.

Did you play non-active video games yesterday?

YES 1 NO (SKIP TO L19) 2 REFUSED (SKIP TO L19) 7 DON’T KNOW (SKIP TO L19) 8

For how many minutes did you play non-active video games?

MINUTES REFUSED 997 DON’T KNOW 998

Where did you play non-active video games? CODE ALL THAT APPLY

AT SCHOOL 1 AT HOME 2 AT A REC CENTER 3 AT A PARK/PLAYGROUND 4 IN MY NEIGHBORHOOD 5 ON MY STREET 6 AT CHURCH 7 AT A FRIEND’S HOUSE 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98

SPECIFY:

Who did you play non-active video games with?

BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8

When you played non-active video games, what exactly were you doing?

PLAYING GAMES ON A GAME CONSOLE 1 PLAYING GAMES ON A HANDHELD GAMING DEVICE 2 REFUSED 97 DON’T KNOW 98

L19.

Did you play physically active video games (Wii, DDR, Xbox Kinect, Playstation Move, etc.) yesterday?

YES 1 NO (SKIP TO L20) 2 REFUSED (SKIP TO L20) 7 DON’T KNOW (SKIP TO L20) 8

How physically hard was this activity?

LIGHT 1 MODERATE 2 HARD 3 VERY HARD 4 REFUSED 7 DON’T KNOW 8

For how many minutes did you play physically active video games?

MINUTES REFUSED 997 DON’T KNOW 998

Where did you play physically active video games? CODE ALL THAT APPLY

AT SCHOOL 1 AT HOME 2 AT A REC CENTER 3 AT A PARK/PLAYGROUND 4 IN MY NEIGHBORHOOD 5 ON MY STREET 6 AT CHURCH 7 AT A FRIEND’S HOUSE 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98

SPECIFY:

Who did you play physically active video games with?

BY MYSELF 1 WITH 1 OTHER FRIEND 2 WITH SEVERAL FRIENDS 3 WITH MY TEAM OR CLASS 4 WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5 REFUSED 7 DON’T KNOW 8

When you played physically active video games, what specifically were you doing?

PLAYING WII/KINECT/MOVE, ETC. 1 REFUSED 97 DON’T KNOW 98

Sources and References

SECTION A: COMMUNITY EXPOSURE

Community Exposure/participation questions-New

SECTION B: DEMOGRAPHIC AND SOCIO-ECONOMIC INFORMATION

• Panel Study of Income Dynamics (PSID), 2007

• American Community Survey (ACS), 2008
  U.S. Census Bureau. 2008

• National Health and Nutrition Examination Survey (NHANES), 2009-2010, Demographic Background/Occupation (DMQ-FAM)

• NHANES, 2009-2010, Demographics Information (DMQ-SP)
  NHANES, 2009-2010, Acculturation (ACQ)

SECTION C: DETAILS OF CHILD’S BIRTH

• NHANES, 2009-2010, Early Childhood (ECQ)

SECTION D: HEALTH INSURANCE

• NHANES, 2009-2010, Health Insurance (HIQ)

• NHANES, 2009-2010, Physical Functioning (PFQ)

SECTION E: CHILD SELF-REPORTED BEHAVIORS

• 2008 National Survey on Drug Use and Health; November 2007.

• NHANES, 2009-2010, Reproductive Health (RHQ)

• NHANES, 2009-2010, Medical Conditions (MCQ)

• CDC, 2010 National Youth Physical Activity and Nutrition Survey

SECTION F: PHYSICAL ACTIVITY BEHAVIORS RECALL (FOR 3 – 5 YEAR OLDS)

• Self-reported physical activity behavior recall –Standard Protocol (New)

SECTION G: PHYSICAL ACTIVITY BEHAVIORS RECALL (FOR 6 – 15 YEAR OLDS)

• Self-reported physical activity behavior recall –Standard Protocol (New)

SECTION H: PHYSICAL ACTIVITY CHILD SURVEY

• Perceived Home/Neighborhood Environment (TAAG)

References : Evenson et al., 2006, Sallis et al., 2002

• Perceived Parent Participation in PA (NYPANS)

• Perceived School Environment (New)

• Self –schema (Self-schemata; Amherst Survey)

References: Kendzierski, 1988; Sallis et al., 2002

References

Sallis JF, Taylor WC, Dowda M, Freedson PS, Pate RR. Correlates of vigorous physical activity for children in grades 1 through 12: Comparing parent-reported and objectively measured physical activity. Pediatr Exerc Sci 2002; 14:30-44

Evenson KR, Birnbaum AS, Bedimo-Rung AL et al. Girls’ Perception of physical environmental factors and transportation: Reliability and association with physical activity and active transport to school. Int J Behav Nutr Phys Act 2006; 3:28.

Kendzierski D. Self-Schemata and Exercise. Basic and Applied Social Psychology1988 March; 9(1): 45-59.

SECTION I: PHYSICAL ACTIVITY PARENT SURVEY

• Perceived Home/Neighborhood Environment (Amherst Survey)

References : Evenson et al., 2006, Sallis et al., 2002

• Rules (Amherst Survey; New)

References: Sallis et al., 2002

• Social Support (Amherst Survey)

References: Sallis et al., 2002

• Parent perception of child PA (Amherst Survey)

References: Sallis et al., 2002

References

Sallis JF, Taylor WC, Dowda M, Freedson PS, Pate RR. Correlates of vigorous physical activity for children in grades 1 through 12: Comparing parent-reported and objectively measured physical activity. Pediatr Exerc Sci 2002; 14:30-44

Evenson KR, Birnbaum AS, Bedimo-Rung AL et al. Girls’ Perception of physical environmental factors and transportation: Reliability and association with physical activity and active transport to school. Int J Behav Nutr Phys Act 2006; 3:28.

SECTION J: NUTRITION QUESTIONS

Domain 1: Food and Beverage Intake

• NHANES Dietary Screener 2009-2010

References: Thompson, 2004, 2005, 2009; Zimmerman, 2010; Woodward-Lopez, 2006

Domain 2: Food Patterns and Behaviors

• CDC 2010 Youth Physical Activity and Nutrition Survey

• NHANES Flexible Consumer Behavior Survey (CBQ) 2009-2010

References: YPANS (not yet publicly available); Woodward-Lopez, 2006

Domain 3: Self-Efficacy and Intentions Regarding Healthy Eating

References: Wilson, 2002 (also unpublished work); Sallis, 1988

Domain 4: Perceived Social Support Regarding Healthy Eating and Peer Influence

References: Sallis, 1987, 1988; Wilson et al 2010

Domain 5: Perceived Home Environment Regarding Healthy Eating

• NHANES Flexible Consumer Behavior Survey (CBQ) 2009-2010

References: NHANES CBQ; Story, 2008

Domain 6: Perceived School Environment Regarding Healthy Eating

• CA HEAC Youth Nutrition Survey

• SNDA III

References: Samuels, 2010; Fox, 2009; Story, 2008

Domain 7: Perceived Community Environment Regarding Healthy Eating

• Boehmer/ Brownson et. al.

References: Casey, 2008; Boehmer, 2006; Story, 2008

Domain 8: Infant Feeding History

• NHANES Diet Behavior and Nutrition Questionnaire 2009-2010

References: NHANES 2009-2010 DBNQ; Li, 2005; Harder, 2005; Monasta, 2010

Domain 9: Household Food Insecurity

• USDA Food Security Module subscale

References: Hager, 2010; Nord, 2009

Domain 10: Dieting Behaviors

• CDC Youth Risk Behavior Surveillance System Questionnaire

References: CDC YRBSS; Rosen, 2010

References

Boehmer TK, Lovegreen SL, Haire-Joshu D, Brownson RC. What Constitutes an Obesogenic Environment in Rural Communities? (2006). Am J Health Promot. Jul-Aug; 20(6):411-421.

Casey AA, et. al. Impact of the Food Environment and Physical Activity Environment on Behaviors and Weight Status in Rural U.S. Communities (2008). Prev Med. 47:600-604.

CDC. Youth Risk Behavior Surveillance System Questionnaire. Retrieved on January 24, 2011 from http://www.cdc.gov/HealthyYouth/yrbs/index.htm

Fox MK, Dodd AH, Wilson A, Gleason PM. Association between School Food Environment and Practices and Body Mass Index of US Public School Children (2009). J Am Diet Assoc. 109:S108-S117.

Hager ER, et. al. Development and Validity of a 2-Item Screen to Identify Families at Risk for Food Insecurity (2010). Pediatrics. 126:e26-e32.

Harder T, Bergmann R, Kallischnigg G, Plagemann A. Duration of breastfeeding and risk of overweight: a meta-analysis (2005). Am J Epidemiol. 162:397-403.

Li R, Scanlon KS, Serdula MK. The validity and reliability of maternal recall of breastfeeding practice. (2005) Nutr Rev. 63:103-10.

Monasta L, Batty GD, Cattaneo A, Lutje V, Ronfani L, Van Lenthe FJ, Brug J. Early-life determinants of overweight and obesity: a review of systematic reviews (2010). Obes Rev. 11:695-708.

National Health and Nutrition Examination Survey (NHANES) 2009-2010. Flexible Consumer Behavior Survey (FCBS) Module. June 2009. Retrieved on November 18, 2010 from: http://www.cdc.gov/nchs/data/nhanes/nhanes_09_10/FCBS_f.pdf.

National Health and Nutrition Examination Survey (NHANES) 2009-2010. Diet Behavior and Nutrition Questionnaire. July 2008. Retrieved on November 18, 2010 from: http://www.cdc.gov/nchs/nhanes/nhanes2009-2010/questexam09_10.htm

Nord M, Andrews M and Carlson S. Household Food Security in the United States, 2008. Washington, DC: U.S. Department of Agriculture, Economic Research Service (2009). www.ers.usda.gov/Publications/ERR83/ERR83.pdf.

Rosen DS; American Academy of Pediatrics Committee on Adolescence. Identification and management of eating disorders in children and adolescents (2010). Pediatrics. 126:1240-53.

Sallis IF, Pinski RB, Grossman RM, Patterson TL, Nader P. The development of self-efficacy scales for health-related diet and exercise behaviors (1988). Health Ed Res Theory Pract. 3:283-292.1

Sallis, J.F., Grossman, R.M., Pinski, R.B., Patterson, T.L., and Nader, P.R. The development of scales to measure social support for diet and exercise behaviors (1987). Prev Med. 16:825-836.

Samuels SE et al. The California Endowment’s Healthy Eating, Active Communities Program: A midpoint review (2010). Am J Public Health. 100:2114-2123.

Story M, Kaphingst KM, Robinson-O'Brien R, Glanz K. Creating healthy food and eating environments: policy and environmental approaches (2008). Annu Rev Public Health. 29:253-72.

Thompson FE et al. Dietary intake estimates in the National Health Interview Survey, 2000: Methodology, results, and interpretation (2005). J Am Diet Assoc. 105: 352-363.

Thompson FE et al. Interrelationships of added sugar intake, socioeconomic status, and race/ethnicity in adults in the U.S.: National Health Interview Survey 2005 (2009). J Am Diet Assoc. 109:1376-83.

Thompson FE et al. Performance of a short tool to assess dietary intakes of fruits and vegetables, percentage energy from fat, and fibre (2004). Pub Health Nutr. 7:1097-1106.

Wilson DK, Ampey-Thornhill G: The role of gender and family support on dietary compliance in an African American adolescent hypertension prevention study (2001). Ann Behav Med. 23:59-67.

Wilson DK, Teasley N, Friend R, Green S, Sica, DA. Motivational versus social cognitive interventions for promoting healthy diet and physical activity habits in African-American adolescents (2002). Ann Behav Med. 24:310-319.

Woodward-Lopez G, Ritchie LD, Gerstein D, Crawford PB. Obesity: Dietary and Developmental Influences. Boca Raton: CRC Press. 2006.

Zimmerman TP, Hull SG, McNutt S, Mittl B, Islam N, Guenther PM, Thompson FE, Potischman NA, Subar AF. Challenges in converting an interviewer-administered food probe database to self-administration in the National Cancer Institute Automated Self-administered 24-Hour Recall (ASA24). (2010). J Food Compos Anal. 22(Suppl 1): S48–S51

HOME VISIT 2 (Enhanced Protocol ONLY)

SECTION K: PHYSICAL ACTIVITY BEHAVIORS RECALL (FOR 3 – 5 YEAR OLDS)

Self-reported physical activity behavior recall – Enhanced Protocol (New)

SECTION L: PHYSICAL ACTIVITY BEHAVIORS RECALL (FOR 6 – 15 YEAR OLDS)

Self-reported physical activity behavior recall – Enhanced Protocol (New)

1 This master version of the adult consent form contains shaded wording under Procedures and Compensation indicating where sentences or phrases will differ as appropriate according to the type of community and type of protocol.

1