Form 10 Child Protocol
The Healthy Communities Study: How Communities Shape Children?s Health (NHLBI)
HCS_SSA_ATTACH 10_CHILD PROTOCOL_ SEPTEMBER FINAL for OMB
Children
OMB: 0925-0649
HEALTHY COMMUNITIES STUDY |
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HEALTHY COMMUNITIES STUDY
FAMILY HOUSEHOLD VISIT PROTOCOL OVERVIEW
FOR CHILD PARTICIPANTS
This document provides an overview of the protocol for the family household visit for the child participant. Protocol materials include the assent form for children aged 8 and older, the anthropometric measurement recording form, and the Home Visit Interview survey instrument. 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
After the parent/caregiver has completed the screening and recruitment and the household has been enrolled in the study, Examination Management Services, Inc. (EMSI), will contact the parent/caregiver to schedule the home visit at a date and time convenient for both the adult and child. An EMSI trained field interviewer will then conduct the home visit to administer the interview with both the parent/caregiver and child, and collect anthropometric measurements.
Assent of Child Aged 8 or Older
Once in the home, the EMSI field interviewer will explain the study, review the assent document with children aged 8 or older, and answer any questions the child may have. At this time, the child (if aged 8 or older) will be asked to sign the informed assent form, which will indicate their assent to participate. EMSI field interviewers will be trained to explain the study thoroughly and answer questions fully. They will be instructed to proceed only if both the parent/caregiver and (where appropriate) the child participants have respectively provided their voluntary, informed consent and assent. EMSI field interviewers will be trained in Human Subjects Research, and will therefore know the guidelines regarding what qualifies as “informed” consent/assent.
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 assent forms (4 community models by 2 protocol models). A master version of the child assent 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 children 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 children during remote follow-up data collection.
In addition to asking these computer-assisted questions, other data collection activities will take place in the home with the child (as well as completing the child assent form where appropriate).
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. Additionally, the incentive will be distributed while at the home.
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, on average, 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 also 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
MASTER CHILD ASSENT FORM1 (for children aged 8 or older)
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]
WHY?
We are doing a study to see what activities in your neighborhood help children lead healthy lives.
WHAT? – STANDARD PROTOCOL
If you agree to be in this study, a person from the study called an 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 parent questions about what you eat, what things you do in school and for play, and where you go in your neighborhood. The interviewer will put some answers into a computer and you and your parent may put some answers in the computer. The interviewer will also measure your height and waist and see how much you weigh.
The interviewer will ask your parent to sign a form to let us look at your medical records at your doctor’s office to see how you are growing. The visit to your home today by the interviewer should take about 75 minutes.
[One year/Two years] from now, we will contact you and your parent again and ask you both to answer about 35 minutes worth of questions through the computer or over the telephone. The questions will be similar to those you answered today.
WHAT? – ENHANCED PROTOCOL
If you agree to be in this study, a person from the study called an 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 parent questions about what you eat, what things you do in school and for play, and where you go in your neighborhood. The interviewer will put some answers into a computer and you and your parent may put some answers in the computer. The interviewer will also measure your height and waist and see how much you weigh.
You will be asked to wear an activity monitor for the next week. The monitor is a small machine that can tell when you are moving. It should be worn at all times except while sleeping or when in water like while in the bath or while swimming. The interviewer will show you how to put the monitor on and take it off. We will also ask you to tell us what you ate yesterday and we will audio record what you say so that we can check that we entered the correct information in the computer. Finally, the interviewer will ask your parent to sign a form to let us look at your medical records at your doctor’s office to see how you are 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 ask you again what you ate yesterday. At this time, they will also ask you about what you have been doing in the past week. This second visit will take approximately 50 minutes.
[One year/Two years] from now, we will contact you and your parent again and ask you both to answer about 35 minutes worth of questions through the computer or over the telephone. The questions will be similar to those you answered today.
WHO?
You can be in this study because you are between 3 and 15 years old and you live in one of the 279 neighborhoods we are studying.
IS THIS SAFE?
We will never use your name in any reports so what you tell us will not appear with your name. We will keep everything you tell us locked up and protected by passwords.
WILL ANYTHING HURT?
Nothing should hurt and if you do not like any of the questions we ask, you do not have to answer.
WHO WILL THIS HELP?
This study will help researchers understand how communities can help children stay healthy.
WILL I GET ANYTHING?
Yes, after [the/each] [first] home visit if you are between 8 and 11 years old, you will get a small toy. If you are 12 or older, you will get a gift worth $15. Your parent will also get a gift.
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 and your parent complete the follow-up web or telephone questions in a few years, we will mail your family a gift worth $10.
DO I HAVE TO DO THIS?
No, you can choose to join or not. You may ask questions at any time. You may refuse to answer any survey question. You may also drop out at any time.
I have read this form and the study staff have answered my questions.
I, _________________________________, agree to be in the “HEALTHY COMMUNITIES STUDY.”
Printed Child Full Name
Please check one of the following boxes
I agree to let you audio record the part where I tell you what foods I ate yesterday.
I do NOT agree to let you audio record the part where I tell you what foods I ate yesterday.
_______________________________________________ __________________
Child Signature Date
________________________________
Witness Signature
HEALTHY COMMUNITIES STUDY
ANTHROPOMETRIC MEASUREMENT RECORDING FORM FOR CHILD PARTICIPANT
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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 BIOLOGICAL PARENT REFUSES TO BE MEASURED OR IS NOT AVAILABLE, ASK FOR SELF-REPORTED OR PROXY-REPORT HEIGHT IN FEET AND INCHES AND WEIGHT IN POUNDS. |
CHILD MEASUREMENTS |
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1. |
CHILD ID NUMBER |
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ID |
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2. |
CHILD HEIGHT #1 |
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MEASURED
CM . RF 9997 |
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3. |
CHILD HEIGHT #2 (ONLY DO IF ENHANCED PROTOCOL) |
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MEASURED
CM . RF 9997 |
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4. |
CHILD WEIGHT #1 |
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MEASURED
KG.. . RF 9997 |
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5. |
CHILD WEIGHT #2 (ONLY DO IF ENHANCED PROTOCOL) |
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MEASURED
KG . RF 9997 |
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6. |
CHILD WAIST CIRCUMFERENCE #1 |
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MEASURED
CM.. . RF 9997 |
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7. |
CHILD WAIST CIRCUMFERENCE #2 (ONLY DO IF ENHANCED PROTOCOL) |
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MEASURED
CM . RF 9997 |
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HEALTHY COMMUNITIES STUDY HOME VISIT COMPUTER-ASSISTED INTERVIEW CONTENT |
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HOME VISIT 1 |
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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 CHILD 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). |
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SECTION A: COMMUNITY EXPOSURE |
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Interviewer administered |
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Child aged 3 – 5: Adult respondentChild aged 6 – 8: Adult respondent/child present to assistChild aged 9 – 11: Child respondent/adult present to assistChild aged 12 – 15: Child respondent |
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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. |
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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 |
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* |
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PROGRAM 1:____________________________________ PROGRAM 2:____________________________________ PROGRAM 3:____________________________________ REFUSED 7 DON’T KNOW 8 |
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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 |
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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 |
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*
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PROGRAM 1:____________________________________ PROGRAM 2:____________________________________ PROGRAM 3:____________________________________ REFUSED 7 DON’T KNOW 8 |
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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 |
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SECTION B: DEMOGRAPHIC AND SOCIO-ECONOMIC INFORMATION |
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Interviewer administered |
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Child aged 3 – 15: Adult respondent |
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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. |
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B1. |
How are you related to (CHILD)? |
BIOLOGICAL MOTHER (SKIP TO B3) 1BIOLOGICAL FATHER (SKIP TO B3) 2ADOPTIVE/STEP/FOSTERMOTHER (SKIP TO B3) 3ADOPTIVE/STEP/FOSTERFATHER (SKIP TO B3) 4PARTNER OF CHILD’S MOTHER OR FATHER 5GRANDPARENT 6BROTHER/SISTER (BIOLOGICAL/ADOPTIVE/ STEP/IN-LAW/FOSTER) 7AUNT/UNCLE 8OTHER RELATIVE 9OTHER NONRELATIVE 10LEGAL GUARDIAN (SKIP TO B3) 11CHILD IS WARD OF STATE ORCOURT (SKIP TO B3) 12 REFUSED 97DON’T KNOW 98 |
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B2. |
Are you (CHILD)’s guardian? |
Yes 1 no 2 refused 7 don’t know 8 |
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B3. |
How old are you? |
Age REFUSED 97 DON’T KNOW 98 |
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B4. |
RECORD GENDER WITHOUT ASKING |
MALE 1 FEMALE 2 |
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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 |
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B6. |
Do you consider yourself Hispanic/Latin(o/a)?
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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 |
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B7. |
(In addition to being Hispanic, what/What) race do you consider yourself to be? CODE ALL THAT APPLY
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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 |
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SPECIFY: |
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IF B7 = 16 ONLY, ASK A. ELSE SKIP TO B8 |
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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
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SPECIFY: |
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B8. |
Where were you born?
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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
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SPECIFY: |
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YEAR REFUSED 9997 DON’T KNOW 9998 |
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Now I am going to ask you about language use. |
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IF B6=1, SKIP TO B10 |
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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
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SKIP TO B11 |
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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 |
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Now, I have some questions about educational history to ask you. |
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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 |
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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 |
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SPECIFY: |
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B13. |
How many nights a week does (CHILD) usually sleep in this house? |
nights REFUSED 97 DON’T KNOW 98 |
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IF B1>02, SKIP TO B25 |
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You said that you are (CHILD)’S biological (mother/father). I would like to ask some questions now about (his/her) other biological parent. |
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B14. |
Does (CHILD)’s biological (father/mother) also live in this household? |
YES 1 NO 2 REFUSED 7 DON’T KNOW 8 |
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B15. |
How old is (he/she)? |
Age REFUSED 97 DON’T KNOW 98 |
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B16. |
RECORD GENDER OF OTHER BIOLOGICAL PARENT WITHOUT ASKING |
MALE 1 FEMALE 2 |
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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 |
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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 |
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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 |
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B19. |
(In addition to being Hispanic, what/What) race do you consider (him/her) to be? CODE ALL THAT APPLY
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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 |
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SPECIFY: |
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IF B19 = 16 ONLY, ASK A. ELSE SKIP TO B20 |
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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 |
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SPECIFY: |
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B20. |
Where was (he/she) born?
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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 |
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SPECIFY: |
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YEAR REFUSED 9997 DON’T KNOW 9998 |
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Now I am going to ask you about (his/her) language use. |
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IF B18=1, SKIP TO B22 |
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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 |
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SKIP TO B23 |
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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 |
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Now, I have some questions about (his/her) educational history to ask you. |
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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 |
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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 |
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SPECIFY: |
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SKIP TO B45 |
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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. |
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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 |
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B26. |
How old is (his/her) biological mother? |
Age REFUSED 97 DON’T KNOW 98 |
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B27.
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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 |
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B28. |
Do you consider her Hispanic/ Latina?
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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 |
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B29. |
(In addition to being Hispanic, what/What) race do you consider her to be? CODE ALL THAT APPLY
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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 |
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SPECIFY: |
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IF B29 = 16 ONLY, ASK A. ELSE SKIP TO B30 |
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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 |
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SPECIFY: |
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B30. |
Where was she born?
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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 |
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SPECIFY: |
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YEAR REFUSED 9997 DON’T KNOW 9998 |
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Now I am going to ask you about her language use. |
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IF B28=1, SKIP TO B32 |
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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 |
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SKIP TO B33 |
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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 |
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Now, I have some questions about her educational history to ask you. |
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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 |
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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 |
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Now I would like to ask the same questions about (CHILD)’s biological father. |
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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 |
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B36. |
How old is (his/her) biological father? |
Age REFUSED 97 DON’T KNOW 98 |
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B37.
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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 |
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B38. |
Do you consider him Hispanic/ Latino?
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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 |
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B39. |
(In addition to being Hispanic, what/What) race do you consider him to be? CODE ALL THAT APPLY
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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 |
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||
SPECIFY: |
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IF B39 = 16 ONLY, ASK A. ELSE SKIP TO B40 |
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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 |
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SPECIFY: |
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B40. |
Where was he born?
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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 |
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YEAR REFUSED 9997 DON’T KNOW 9998 |
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Now I am going to ask you about his language use. |
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IF B38=1, SKIP TO B42 |
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B41. |
What languages does he speak at home? CODE ALL THAT APPLY |
ENGLISH 1 SPANISH 2 OTHER 3 REFUSED 7 DON’T KNOW 8 |
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SKIP TO B43 |
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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 |
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Now, I have some questions about his educational history to ask you. |
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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 |
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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 |
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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. |
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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 |
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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 |
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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 |
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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 |
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SKIP TO B51 |
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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 |
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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 |
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|||||
B51. |
Does (CHILD) consider (himself/ herself) Hispanic/Latin(o/a)?
|
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 |
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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 |
|||||
|
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: |
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|||||
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: |
|||||
|
YEAR REFUSED 9997 DON’T KNOW 9998 |
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|
||||
Now I am going to ask you about (CHILD)’s language use. |
|||||
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|||||
IF B51=1, SKIP TO B55 |
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|||||
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 |
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|
SKIP TO B56 |
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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 |
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|
||||
Now, I have some questions about (CHILD)’s educational history to ask you. |
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|
|||||
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: |
|||||
|
|||||
* |
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NAME:__________________________________________ REFUSED 7 DON’T KNOW 8 |
|||
SECTION C: DETAILS OF CHILD’S BIRTH |
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Interviewer administered |
|||||
Child aged 3 – 15: Adult respondent |
|||||
We now want to ask some questions about (CHILD)’s birth. |
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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 |
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POUNDS OUNCES |
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SKIP TO C2 |
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GRAMS |
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SKIP TO C2 |
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YES 1 NO (SKIP TO C2) 2 REFUSED (SKIP TO C2) 7 DON’T KNOW (SKIP TO C2) 8
|
||||
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||||
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YES 1 NO 2 REFUSED 7 DON’T KNOW 8 |
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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 |
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INCHES |
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SKIP TO C3 |
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CENTIMETERS |
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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 |
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|||||
|
WEEKS (SKIP TO SECTION D) REFUSED 97 DON’T KNOW 98 |
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|||||
|
WEEKS REFUSED 97 DON’T KNOW 98 |
||||
SECTION D: HEALTH INSURANCE |
|||||
Interviewer administered |
|||||
Child aged 3 – 15: Adult respondent |
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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. |
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D1. * |
Are you currently covered by medical insurance or some other kind of health care plan?
|
YES 1NO (SKIP TO D4) 2 REFUSED (SKIP TO D4) 7 DON’T KNOW (SKIP TO D4) 8 |
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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 1MEDICARE 2MEDI-GAP 3MEDICAID/STATE PLAN NAME 4SCHIP/CHIP/CHILDREN’S HEALTH INSURANCE PROGRAM 5MILITARY HEALTH CARE/TRICARE/VA/CHAMP-VA 6INDIAN HEALTH SERVICES 7STATE-SPONSORED HEALTH PLAN/STATE PLAN NAME 8OTHER GOVERNMENT PROGRAM 9SINGLE SERVICE PLAN (DENTAL, VISION, PRESCRIPTION) 10NO COVERAGE OF ANY TYPE 11REFUSED 97DON’T KNOW 98 |
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D3.* |
In the past 12 months, was there any time when you did not have health insurance coverage? |
YES 1NO 2REFUSED 7DON'T KNOW 8 |
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D4. * |
Is (CHILD) currently covered by medical insurance or some other kind of health care plan? |
YES 1 1NO (SKIP TO D7) 2 REFUSED (SKIP TO D7) 7 DON’T KNOW (SKIP TO D7) 8 |
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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 1MEDICARE 2MEDI-GAP 3MEDICAID/STATE PLAN NAME 4SCHIP/CHIP/CHILDREN’S HEALTH INSURANCE PROGRAM 5MILITARY HEALTH CARE/TRICARE/VA/CHAMP-VA 6INDIAN HEALTH SERVICES 7STATE-SPONSORED HEALTH PLAN/STATE PLAN NAME 8OTHER GOVERNMENT PROGRAM 9SINGLE SERVICE PLAN (DENTAL, VISION, PRESCRIPTION) 10NO COVERAGE OF ANY TYPE 11REFUSED 97DON’T KNOW 98 |
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D6.* |
In the past 12 months, was there any time when (CHILD) did not have health insurance coverage? |
YES 1NO 2REFUSED 7DON’T KNOW 8 |
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Now I am going to ask some questions about (CHILD)’s health. |
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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) 1NO (SKIP TO D8) 2 REFUSED (SKIP TO D8) 7 DON’T KNOW (SKIP TO D8) 8 |
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SPECIFY CONDITION: |
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* |
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YES (SPECIFY) 1NO 2REFUSED 7DON'T KNOW 8
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|
SPECIFY MEDICATION: |
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|||||
D8. * |
Has a doctor or other health professional ever referred (CHILD) to a pediatric endocrinologist?
|
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YES 1NO (SKIP TO D9) 2 REFUSED (SKIP TO D9) 7 DON’T KNOW (SKIP TO D9) 8 |
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|||||
* |
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YES 1NO 2REFUSED 7DON'T KNOW 8 |
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D9. * |
Is (CHILD) currently enrolled in a structured program that targets weight, diet, or physical activity? Please do not include organized sports programs. |
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YES 1NO 2REFUSED 7DON'T KNOW 8 |
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D10.* |
Does (CHILD) have an impairment or health problem that limits (his/her) ability to walk, run or play? |
YES 1NO (SKIP TO SECTION E) 2 REFUSED (SKIP TO SECTION E) 7 DON’T KNOW (SKIP TO SECTION E) 8 |
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D11. * |
Is this an impairment or health problem that has lasted, or is expected to last, 12 months or longer? |
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YES 1NO (SKIP TO SECTION E) 2 REFUSED (SKIP TO SECTION E) 7 DON’T KNOW (SKIP TO SECTION E) 8 |
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D12. * |
Would you please describe this impairment or health problem? |
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YES (SPECIFY) 1NO (SKIP TO SECTION E) 2 REFUSED (SKIP TO SECTION E) 7 DON’T KNOW (SKIP TO SECTION E) 8 |
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SPECIFY: |
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SECTION E: CHILD SELF-REPORTED BEHAVIORS |
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Self administered |
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Child aged 3 – 11: NOT ADMINISTEREDChild aged 12 – 15: Child respondent |
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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. |
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E1. * |
We first want you to answer some questions about smoking. Have you smoked at least one cigarette within the last 30 days? |
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YES 1NO (SKIP TO E2) 2 REFUSED 7 DON’T KNOW 8 |
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* |
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YES 1NO 2I DO NOT SMOKE 3REFUSED 7 DON’T KNOW 8 |
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||
IF CHILD IS MALE, SKIP TO SECTION F |
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E2.* |
Have your periods or menstrual cycles started yet? |
YES 1NO (SKIP TO E4) 2 REFUSED (SKIP TO E4) 7 DON’T KNOW (SKIP TO E4) 8 |
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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 |
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||
* |
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. |
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Younger than 10 110 to 12 213 to 15, or 316 or older 4REFUSED 7 DON’T KNOW 8 |
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E4. * |
Are you pregnant now?
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YES 1NO 2REFUSED 7DON'T KNOW 8 |
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||
SECTION F: PHYSICAL ACTIVITY BEHAVIORS RECALL (FOR 3 – 5 YEAR OLDS) |
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Self administered |
|||||
Child aged 3 – 5: Adult respondentChild aged 6 – 15: NOT ADMINISTERED |
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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. |
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||
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? |
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YES 1NO (SKIP TO f2) 2 REFUSED (SKIP TO f2) 7 DON’T KNOW (SKIP TO f2) 8 |
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* |
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SUNDAY 1MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6SATURDAY 7REFUSED 97DON’T KNOW 98 |
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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? |
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YES 1NO (SKIP TO f3) 2 REFUSED (SKIP TO f3) 7 DON’T KNOW (SKIP TO f3) 8 |
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||
* |
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SUNDAY 1MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6SATURDAY 7REFUSED 97DON’T KNOW 98 |
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||
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)? |
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YES 1NO (SKIP TO f4) 2 REFUSED (SKIP TO f4) 7 DON’T KNOW (SKIP TO f4) 8 |
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||
* |
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SUNDAY 1MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6SATURDAY 7REFUSED 97DON’T KNOW 98 |
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||
F4. * |
Did your child use a computer for playing games or playing on the internet in the past 7 days? |
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YES 1NO (SKIP TO f5) 2 REFUSED (SKIP TO f5) 7 DON’T KNOW (SKIP TO f5) 8 |
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||
* |
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SUNDAY 1MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6SATURDAY 7REFUSED 97DON’T KNOW 98 |
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F5. * |
Did your child watch TV or videos in the past 7 days? |
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YES 1NO (SKIP TO f6) 2 REFUSED (SKIP TO f6) 7 DON’T KNOW (SKIP TO f6) 8 |
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||
* |
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SUNDAY 1MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6SATURDAY 7REFUSED 97DON’T KNOW 98 |
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F6. * |
Did your child play non-active video games in the past 7 days? |
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YES 1NO (SKIP TO f7) 2 REFUSED (SKIP TO f7) 7 DON’T KNOW (SKIP TO f7) 8 |
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* |
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SUNDAY 1MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6SATURDAY 7REFUSED 97DON’T KNOW 98 |
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F7. * |
Did your child play physically active video games (Wii, DDR, Xbox Kinect, Playstation Move, etc.) in the past 7 days? |
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YES 1NO (SKIP TO f8) 2 REFUSED (SKIP TO f8) 7 DON’T KNOW (SKIP TO f8) 8 |
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||
* |
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SUNDAY 1MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6SATURDAY 7REFUSED 97DON’T KNOW 98 |
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||
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. |
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F8. * |
Did your child play an organized sport in the past 7 days? |
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YES 1NO (SKIP TO f9) 2 REFUSED (SKIP TO f9) 7 DON’T KNOW (SKIP TO f9) 8 |
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* |
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SUNDAY 1MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6SATURDAY 7REFUSED 97DON’T KNOW 98 |
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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? |
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YES 1NO (SKIP TO f10) 2 REFUSED (SKIP TO f10) 7 DON’T KNOW (SKIP TO f10) 8 |
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* |
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SUNDAY 1MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6SATURDAY 7REFUSED 97DON’T KNOW 98 |
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F10. * |
Did your child participate in any physically active classes or lessons in the past 7 days? |
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YES 1NO (SKIP TO f11) 2 REFUSED (SKIP TO f11) 7 DON’T KNOW (SKIP TO f11) 8 |
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* |
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SUNDAY 1MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6SATURDAY 7REFUSED 97DON’T KNOW 98 |
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F11. * |
Did your child participate in any activities in the water (swim lessons, swimming, pool/water games) in the past 7 days? |
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YES 1NO (SKIP TO f12) 2 REFUSED (SKIP TO f12) 7 DON’T KNOW (SKIP TO f12) 8 |
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* |
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SUNDAY 1MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6SATURDAY 7REFUSED 97DON’T KNOW 98 |
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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). |
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F12. * |
Does your child attend a structured childcare or school? |
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YES 1NO (SKIP TO f18) 2 REFUSED (SKIP TO f18) 7 DON’T KNOW (SKIP TO f18) 8 |
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* |
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DAYS REFUSED 97 DON’T KNOW 98 |
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* |
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HOURS REFUSED 97 DON’T KNOW 98 |
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F13. * |
Which of the following best describes the school or childcare center that your child attends? |
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RELIGIOUS-AFFILIATED CHILDCARE FACILITY 1COMMERCIAL CHILDCARE FACILITY 2PUBLIC SCHOOL DISTRICT SPONSORED FACILITY 3OTHER 4REFUSED 7DON’T KNOW 8 |
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F14. * |
During a typical week, does your child attend physical education (PE) classes at school/childcare?
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YES 1NO 2REFUSED 7 DON’T KNOW 8 |
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F15. * |
During a typical week, does your child have recess on most days while at school?
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YES 1NO 2REFUSED 7 DON’T KNOW 8 |
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F16. * |
During a typical week, does your child attend dance or other physically active classes at school/childcare (other than PE class)? |
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YES 1NO 2REFUSED 7 DON’T KNOW 8 |
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F17. * |
During a typical week, does your child participate in any kind of physical activity (structured or unstructured) during an afterschool program? |
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YES 1NO 2REFUSED 7 DON’T KNOW 8 |
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IF F1A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO F19 |
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F18. * |
You said that your child played physically active games at home or in the neighborhood yesterday. Is this correct? |
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YES 1NO (SKIP TO f19) 2 REFUSED (SKIP TO f19) 7 DON’T KNOW (SKIP TO f19) 8 |
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* |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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* |
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TAG 1RED ROVER/DUCK DUCK GOOSE/ETC. 2HOPSCOTCH 3OTHER (SPECIFY) 4REFUSED 97DON’T KNOW 98 |
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IF F2A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO F20 |
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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? |
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YES 1NO (SKIP TO f20) 2 REFUSED (SKIP TO f20) 7 DON’T KNOW (SKIP TO f20) 8 |
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* |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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* |
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RIDING A TRICYCLE/BICYCLE 1RIDING ON A SCOOTER 2RIDING MOTORIZED TOYS (POWERWHEELS, ETC.) 3RIDING ON A SKATEBOARD/SKATES 4OTHER (SPECIFY) 5REFUSED 97DON’T KNOW 98 |
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IF F3A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO F21 |
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F20. * |
You said that your child participated in physically active play yesterday. Is this correct? |
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YES 1NO (SKIP TO f21) 2 REFUSED (SKIP TO f21) 7 DON’T KNOW (SKIP TO f21) 8 |
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* |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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* |
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PLAYING WITH BALLS/OTHER EQUIPMENT 1PLAYING ON FIXED EQUIPMENT (TREE HOUSE, MONKEY BARS, SLIDES, SWINGS, ETC) 2JUMPROPE/HULA HOOP 3OTHER (SPECIFY) 4REFUSED 97DON’T KNOW 98 |
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IF F4A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO F22 |
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F21. * |
You said that your child used a computer for gaming or playing on the internet yesterday. Is this correct? |
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YES 1NO (SKIP TO f22) 2 REFUSED (SKIP TO f22) 7 DON’T KNOW (SKIP TO f22) 8 |
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* |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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* |
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PLAYING EDUCATIONAL GAMES 1PLAYING NON-EDUCATION GAMES 2REFUSED 97DON’T KNOW 98 |
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IF F5A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO F23 |
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F22. * |
You said that your child watched TV or videos yesterday. Is this correct? |
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YES 1NO (SKIP TO f23) 2 REFUSED (SKIP TO f23) 7 DON’T KNOW (SKIP TO f23) 8 |
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* |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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* |
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WATCHING EDUCATIONAL TV OR VIDEOS 1WATCHING NON-EDUCATIONAL TV OR VIDEOS 2REFUSED 97DON’T KNOW 98 |
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IF F6A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO F24 |
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F23. * |
You said that your child played non-active video games yesterday. Is this correct? |
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YES 1NO (SKIP TO f24) 2 REFUSED (SKIP TO f24) 7 DON’T KNOW (SKIP TO f24) 8 |
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* |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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* |
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PLAYING GAMES ON A GAME CONSOLE 1PLAYING GAMES ON A HANDHELD GAMING DEVICE 2REFUSED 97DON’T KNOW 98 |
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IF F7A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO F25 |
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F24. * |
You said that your child played physically active video games yesterday. Is this correct? |
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YES 1NO (SKIP TO f25) 2 REFUSED (SKIP TO f25) 7 DON’T KNOW (SKIP TO f25) 8 |
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* |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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* |
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PLAYING WII/KINECT/MOVE, ETC 1REFUSED 97DON’T KNOW 98 |
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IF F8A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO F26 |
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F25. * |
You said that your child played an organized sport yesterday. Is this correct? |
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YES 1NO (SKIP TO f26) 2 REFUSED (SKIP TO f26) 7 DON’T KNOW (SKIP TO f26) 8 |
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* |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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* |
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PLAYING BASEBALL/SOFTBALL 1PLAYING SOCCER/FOOTBALL 2PLAYING BASKETBALL 3PLAYING TENNIS 4SWIM TEAM 5OTHER (SPECIFY) 6REFUSED 97DON’T KNOW 98 |
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IF F9A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO F27 |
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F26. * |
You said that your child participated in a program to improve (his/her) movement skills yesterday. Is this correct? |
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YES 1NO (SKIP TO f27) 2 REFUSED (SKIP TO f27) 7 DON’T KNOW (SKIP TO f27) 8 |
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* |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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* |
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PARTICIPATING IN GYMBOREE OR LITTLE GYM (OR OTHER FACILITY) CLASSES 1PLAYING AT A BOUNCE HOUSE (MONKEY JOE’S, ETC.) 2PLAYING AT A TRAMPOLINE GYM 3OTHER (SPECIFY) 4REFUSED 97DON’T KNOW 98 |
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IF F10A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO F28 |
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F27. * |
You said that your child participated in any physically active classes or lessons yesterday. Is this correct? |
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YES 1NO (SKIP TO f28) 2 REFUSED (SKIP TO f28) 7 DON’T KNOW (SKIP TO f28) 8 |
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* |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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* |
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DANCE/ CHEER 1TUMBLING OR GYMNASTICS CLASSES 2SPORT LESSONS (TENNIS, BASEBALL, BASKETBALL, ETC.) 3KARATE OR OTHER MARTIAL ARTS CLASSES 4OTHER (SPECIFY) 5REFUSED 97DON’T KNOW 98 |
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IF F11A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO F29 |
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F28. * |
You said that your child participated in any activities in the water yesterday. Is this correct? |
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YES 1NO (SKIP TO f29) 2 REFUSED (SKIP TO f29) 7 DON’T KNOW (SKIP TO f29) 8 |
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* |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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* |
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SWIM LESSONS 1SWIMMING 2PLAYING POOL/WATER GAMES 3OTHER (SPECIFY) 4REFUSED 97DON’T KNOW 98 |
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F29. * |
Did your child do any other physical activities yesterday that were not already mentioned? |
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YES 1NO (SKIP TO section h) 2 REFUSED (SKIP TO section h) 7 DON’T KNOW (SKIP TO section h) 8 |
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* |
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ACTIVITY 1:_____________________________________ ACTIVITY 2:_____________________________________ ACTIVITY 3:_____________________________________ ACTIVITY 4:_____________________________________ REFUSED 7 DON’T KNOW 8 |
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* |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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SECTION G: PHYSICAL ACTIVITY BEHAVIORS RECALL (FOR 6 – 15 YEAR OLDS) |
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Self administered |
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Child aged 3 – 5: NOT ADMINISTEREDChild aged 6 – 11: Child respondent/adult present to assistChild aged 12 – 15: Child respondent |
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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
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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
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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
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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. |
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G1. * |
Did you have physical education (PE) class in school in the past 7 days? |
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YES 1NO (SKIP TO G2) 2 REFUSED (SKIP TO G2) 7 DON’T KNOW (SKIP TO G2) 8 |
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* |
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MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6REFUSED 97DON’T KNOW 98 |
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* |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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G2. * |
Did you have recess or other free-play at school in the past 7 days? |
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YES 1NO (SKIP TO G3) 2 REFUSED (SKIP TO G3) 7 DON’T KNOW (SKIP TO G3) 8 |
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* |
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MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6REFUSED 97DON’T KNOW 98 |
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* |
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* |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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G3. * |
Did you have dance or other physically active classes at school (other than PE class) in the past 7 days? |
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YES 1NO (SKIP TO G4) 2 REFUSED (SKIP TO G4) 7 DON’T KNOW (SKIP TO G4) 8 |
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* |
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MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6REFUSED 97DON’T KNOW 98 |
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* |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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G4. * |
Did you participate in physical activity breaks during classes at school in the past 7 days? |
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YES 1NO (SKIP TO G5) 2 REFUSED (SKIP TO G5) 7 DON’T KNOW (SKIP TO G5) 8 |
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* |
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MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6REFUSED 97DON’T KNOW 98 |
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* |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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G5. * |
Did you practice or play with a school sports team in the past 7 days? |
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YES 1NO (SKIP TO G6) 2 REFUSED (SKIP TO G6) 7 DON’T KNOW (SKIP TO G6) 8 |
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* |
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SUNDAY 1MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6SATURDAY 7REFUSED 97DON’T KNOW 98 |
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* |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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G6. * |
Did you practice or play with a non-school sports team in the past 7 days? |
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YES 1NO (SKIP TO G7) 2 REFUSED (SKIP TO G7) 7 DON’T KNOW (SKIP TO G7) 8 |
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* |
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SUNDAY 1MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6SATURDAY 7REFUSED 97DON’T KNOW 98 |
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* |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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G7. * |
Did you participate in pick-up sports (basketball, football, baseball/softball, etc.) in the past 7 days? |
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YES 1NO (SKIP TO G8) 2 REFUSED (SKIP TO G8) 7 DON’T KNOW (SKIP TO G8) 8 |
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* |
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SUNDAY 1MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6SATURDAY 7REFUSED 97DON’T KNOW 98 |
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* |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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G8. * |
Did you participate in physical activity during an afterschool program in the past 7 days? |
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YES 1NO (SKIP TO G9) 2 REFUSED (SKIP TO G9) 7 DON’T KNOW (SKIP TO G9) 8 |
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* |
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MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6REFUSED 97DON’T KNOW 98 |
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* |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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G9. * |
Did you play any physically active games (hopscotch, red rover, tag, jumping rope, etc.) in the past 7 days? |
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YES 1NO (SKIP TO G10) 2 REFUSED (SKIP TO G10) 7 DON’T KNOW (SKIP TO G10) 8 |
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* |
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SUNDAY 1MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6SATURDAY 7REFUSED 97DON’T KNOW 98 |
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* |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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G10. * |
Did you swim or play games in a pool, lake, or ocean in the past 7 days? |
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YES 1NO (SKIP TO G11) 2 REFUSED (SKIP TO G11) 7 DON’T KNOW (SKIP TO G11) 8 |
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* |
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SUNDAY 1MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6SATURDAY 7REFUSED 97DON’T KNOW 98 |
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* |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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G11. * |
Did you do any outdoor or adventure sports (hiking, kayaking, rock climbing, surfing, skiing, etc.) in the past 7 days? |
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YES 1NO (SKIP TO G12) 2 REFUSED (SKIP TO G12) 7 DON’T KNOW (SKIP TO G12) 8 |
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* |
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SUNDAY 1MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6SATURDAY 7REFUSED 97DON’T KNOW 98 |
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* |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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G12. * |
Did you walk or bike to or from school in the past 7 days? |
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YES 1NO (SKIP TO G13) 2 REFUSED (SKIP TO G13) 7 DON’T KNOW (SKIP TO G13) 8 |
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* |
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MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6REFUSED 97DON’T KNOW 98 |
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* |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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G13. * |
Did you walk or bike to or from a store, park, or playground or a friend’s house in the past 7 days? |
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YES 1NO (SKIP TO G14) 2 REFUSED (SKIP TO G14) 7 DON’T KNOW (SKIP TO G14) 8 |
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* |
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SUNDAY 1MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6SATURDAY 7REFUSED 97DON’T KNOW 98 |
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* |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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G14. * |
Did you walk or ride your bike, scooter, skateboard, or skates for fun or exercise in the past 7 days? |
|
YES 1NO (SKIP TO G15) 2 REFUSED (SKIP TO G15) 7 DON’T KNOW (SKIP TO G15) 8 |
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* |
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SUNDAY 1MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6SATURDAY 7REFUSED 97DON’T KNOW 98 |
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* |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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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 1NO (SKIP TO G16) 2 REFUSED (SKIP TO G16) 7 DON’T KNOW (SKIP TO G16) 8 |
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* |
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SUNDAY 1MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6SATURDAY 7REFUSED 97DON’T KNOW 98 |
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G16. * |
Did you use a computer or phone for social networking (Facebook, MySpace, Twitter, IM, texting, etc.) in the past 7 days? |
|
YES 1NO (SKIP TO G17) 2 REFUSED (SKIP TO G17) 7 DON’T KNOW (SKIP TO G17) 8 |
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* |
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SUNDAY 1MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6SATURDAY 7REFUSED 97DON’T KNOW 98 |
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G17. * |
Did you watch TV in the past 7 days? |
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YES 1NO (SKIP TO G18) 2 REFUSED (SKIP TO G18) 7 DON’T KNOW (SKIP TO G18) 8 |
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* |
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SUNDAY 1MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6SATURDAY 7REFUSED 97DON’T KNOW 98 |
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G18. * |
Did you play non-active video games in the past 7 days? |
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YES 1NO (SKIP TO G19) 2 REFUSED (SKIP TO G19) 7 DON’T KNOW (SKIP TO G19) 8 |
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* |
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SUNDAY 1MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6SATURDAY 7REFUSED 97DON’T KNOW 98 |
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G19. * |
Did you play physically active video games (Wii, DDR, Xbox Kinect, Playstation Move, etc.) in the past 7 days? |
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YES 1NO (SKIP TO G20) 2 REFUSED (SKIP TO G20) 7 DON’T KNOW (SKIP TO G20) 8 |
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* |
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SUNDAY 1MONDAY 2TUESDAY 3WEDNESDAY 4THURSDAY 5FRIDAY 6SATURDAY 7REFUSED 97DON’T KNOW 98 |
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* |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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IF G1A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G21 |
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G20. * |
You said that you had physical education (PE) class in school yesterday. Is this correct? |
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YES 1NO (SKIP TO G21) 2 REFUSED (SKIP TO G21) 7 DON’T KNOW (SKIP TO G21) 8 |
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* |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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* |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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* |
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TEAM SPORT SKILLS 1INDIVIDUAL SPORT SKILLS 2DANCE/TUMBLING SKILLS 3WATER ACTIVITY SKILLS 4CARDIOVASCULAR MACHINES OR CONDITIONING (RUNNING, CYCLING, STAIRCLIMBER, ROWERS, ETC.) 5CLIMBING WALL ACTIVITIES 6EXERCISES/CALISTHENICS 7FRISBEE OR FRISBEE GOLF 8JUMPROPE/PLYOMETRICS/CONDITIONING 9WEIGHT TRAINING 10YOGA/PILATES 11OTHER (SPECIFY) 12REFUSED 97DON’T KNOW 98 |
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IF G2A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G22 |
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G21. * |
You said that you had recess or other free-play at school yesterday. Is this correct? |
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YES 1NO (SKIP TO G22) 2 REFUSED (SKIP TO G22) 7 DON’T KNOW (SKIP TO G22) 8 |
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* |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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* |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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* |
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PLAYGROUND GAME (KICKBALL, FOUR SQUARE, DODGEBALL, ETC.) 1ORGANIZED SPORT GAME (BASEBALL, BASKETBALL, FOOTBALL, ETC.) 2TAG/CAPTURE THE FLAG/RED ROVER/ETC. 3FIXED EQUIPMENT (MONKEY BARS, SLIDES, SWINGS, ETC.) 4HANGING OUT WITH FRIENDS 5DOING SCHOOL WORK 6OTHER (SPECIFY) 7REFUSED 97DON’T KNOW 98 |
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IF G3A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G23 |
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G22. * |
You said that you had dance or other physically active classes at school (other than PE class) yesterday. Is this correct? |
|
YES 1NO (SKIP TO G23) 2 REFUSED (SKIP TO G23) 7 DON’T KNOW (SKIP TO G23) 8 |
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* |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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* |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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* |
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DANCE 1WEIGHTLIFTING 2OTHER (SPECIFY) 3REFUSED 97DON’T KNOW 98 |
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IF G4A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G24 |
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G23. * |
You said that you participated in physical activity breaks during classes at school yesterday. Is this correct? |
|
YES 1NO (SKIP TO G24) 2 REFUSED (SKIP TO G24) 7 DON’T KNOW (SKIP TO G24) 8 |
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* |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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* |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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* |
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IN-CLASS PHYSICAL ACTIVITY 1VIDEO/STRUCTURED ACTIVITY IN HOMEROOM/ANNOUNCEMENTS 2WALKING LAPS 3OTHER (SPECIFY) 4REFUSED 97DON’T KNOW 98 |
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IF G5A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G25 |
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G24. * |
You said that you practiced or played with a school sports team yesterday. Is this correct? |
|
YES 1NO (SKIP TO G25) 2 REFUSED (SKIP TO G25) 7 DON’T KNOW (SKIP TO G25) 8 |
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* |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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||
* |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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||
* |
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BASEBALL/SOFTBALL 1FOOTBALL/SOCCER/LACROSSE/HOCKEY BASKETBALL 2SWIM TEAM/DIVING/WATER POLO 3GOLF/TENNIS 4TRACK AND FIELD/CROSS COUNTRY 5CHEER/DANCE TEAM 6WRESTLING 7VOLLEYBALL 8MARTIAL ARTS 9ROWING/CANOE/KAYAK 10BOWLING 11SKIING 12OTHER (SPECIFY) 13REFUSED 97DON’T KNOW 98 |
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IF G6A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G26 |
|||||
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||
G25. * |
You said that you practiced or played with a non-school sports team yesterday. Is this correct? |
|
YES 1NO (SKIP TO G26) 2 REFUSED (SKIP TO G26) 7 DON’T KNOW (SKIP TO G26) 8 |
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||
* |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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||
* |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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||
* |
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|
BASEBALL/SOFTBALL 1FOOTBALL/SOCCER/LACROSSE/HOCKEY BASKETBALL 2SWIM TEAM/DIVING/WATER POLO 3GOLF/TENNIS 4TRACK AND FIELD/CROSS COUNTRY 5CHEER/DANCE TEAM 6WRESTLING 7VOLLEYBALL 8MARTIAL ARTS 9ROWING/CANOE/KAYAK 10BOWLING 11SKIING 12OTHER (SPECIFY) 13REFUSED 97DON’T KNOW 98REFUSED 97DON’T KNOW 98 |
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||
IF G7A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G27 |
|||||
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||
G26. * |
You said that you participated in pick-up sports yesterday. Is this correct? |
|
YES 1NO (SKIP TO G27) 2 REFUSED (SKIP TO G27) 7 DON’T KNOW (SKIP TO G27) 8 |
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||
* |
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|
LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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||
* |
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|
MINUTES REFUSED 997 DON’T KNOW 998 |
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||
* |
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|
AT SCHOOL 1AT HOME 2AT A REC CENTER 3AT A PARK/PLAYGROUND 4IN MY NEIGHBORHOOD 5ON MY STREET 6AT CHURCH 7AT A FRIEND’S HOUSE 8OTHER (SPECIFY) 9REFUSED 97DON’T KNOW 98 |
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|
SPECIFY: |
|||||
* |
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|
BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
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||
* |
|
|
BASEBALL/SOFTBALL 1FOOTBALL/SOCCER/LACROSSE/HOCKEY BASKETBALL 2SWIM TEAM/DIVING/WATER POLO 3OTHER (SPECIFY) 4REFUSED 97DON’T KNOW 98 |
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||
IF G8A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G28 |
|||||
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|
||
G27. * |
You said that you participated in physical activity during an afterschool program yesterday. Is this correct? |
|
YES 1NO (SKIP TO G28) 2 REFUSED (SKIP TO G28) 7 DON’T KNOW (SKIP TO G28) 8 |
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||
* |
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|
LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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||
* |
|
|
MINUTES REFUSED 997 DON’T KNOW 998 |
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||
* |
|
|
AT SCHOOL 1AT HOME 2AT A REC CENTER 3AT A PARK/PLAYGROUND 4IN MY NEIGHBORHOOD 5ON MY STREET 6AT CHURCH 7AT A FRIEND’S HOUSE 8OTHER (SPECIFY) 9REFUSED 97DON’T KNOW 98 |
|
|
SPECIFY: |
|||||
* |
|
|
BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
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|
||
* |
|
|
PLAYGROUND GAME (KICKBALL, FOUR SQUARE, DODGEBALL, ETC.) 1ORGANIZED SPORT GAME (BASEBALL, BASKETBALL, FOOTBALL, ETC.) 2TAG/CAPTURE THE FLAG/RED ROVER/ETC. 3FIXED EQUIPMENT (MONKEY BARS, SLIDES, SWINGS, ETC.) 4DANCE/STEP TEAM 5DOUBLE-DUTCH 6OTHER (SPECIFY) 7REFUSED 97DON’T KNOW 98 |
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|
||
IF G9A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G29 |
|||||
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|
||
G28. * |
You said that you played physically active games yesterday. Is this correct? |
|
YES 1NO (SKIP TO G29) 2 REFUSED (SKIP TO G29) 7 DON’T KNOW (SKIP TO G29) 8 |
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||
* |
|
|
LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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||
* |
|
|
MINUTES REFUSED 997 DON’T KNOW 998 |
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||
* |
|
|
AT SCHOOL 1AT HOME 2AT A REC CENTER 3AT A PARK/PLAYGROUND 4IN MY NEIGHBORHOOD 5ON MY STREET 6AT CHURCH 7AT A FRIEND’S HOUSE 8OTHER (SPECIFY) 9REFUSED 97DON’T KNOW 98 |
|
|
SPECIFY: |
|||||
* |
|
|
BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
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||
* |
|
|
TAG 1RED ROVER/DUCK DUCK GOOSE/ETC. 2HOPSCOTCH 3OTHER (SPECIFY) 4REFUSED 97DON’T KNOW 98 |
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|
||
IF G10A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G30 |
|||||
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|
||
G29. * |
You said that you swam or played games in a pool, lake, or ocean yesterday. Is this correct? |
|
YES 1NO (SKIP TO G30) 2 REFUSED (SKIP TO G30) 7 DON’T KNOW (SKIP TO G30) 8 |
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||
* |
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|
LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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||
* |
|
|
MINUTES REFUSED 997 DON’T KNOW 998 |
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|
||
* |
|
|
AT SCHOOL 1AT HOME 2AT A REC CENTER 3AT A PARK/PLAYGROUND 4IN MY NEIGHBORHOOD 5ON MY STREET 6AT CHURCH 7AT A FRIEND’S HOUSE 8OTHER (SPECIFY) 9REFUSED 97DON’T KNOW 98 |
|
|
SPECIFY: |
|||||
* |
|
|
BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
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||
* |
|
|
SWIMMING 1WATER GAMES (MARCO POLO, SHARK AND MINNOWS, ETC.) 2WATERPLAY 3OTHER (SPECIFY) 4REFUSED 97DON’T KNOW 98 |
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||
IF G11A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G31 |
|||||
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|
||
G30. * |
You said that you did outdoor or adventure sports yesterday. Is this correct? |
|
YES 1NO (SKIP TO G31) 2 REFUSED (SKIP TO G31) 7 DON’T KNOW (SKIP TO G31) 8 |
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||
* |
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|
LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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||
* |
|
|
MINUTES REFUSED 997 DON’T KNOW 998 |
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||
* |
|
|
BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
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|
||
* |
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|
AT SCHOOL 1AT HOME 2AT A REC CENTER 3AT A PARK/PLAYGROUND 4IN MY NEIGHBORHOOD 5ON MY STREET 6AT CHURCH 7AT A FRIEND’S HOUSE 8OTHER (SPECIFY) 9REFUSED 97DON’T KNOW 98 |
|
|
SPECIFY: |
|||||
* |
|
|
HIKING 1ROCK CLIMBING 2SURFING/SKIMBOARDING/BODYBOARDING 3SNOW SKIING/SNOWBOARDING 4WATER SKIING/WAKEBOARDING 5KAYAKING 6OTHER (SPECIFY) 7REFUSED 97DON’T KNOW 98 |
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||
IF G12A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G32 |
|||||
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|
||
G31. * |
You said that you walked or biked to or from school yesterday. Is this correct? |
|
YES 1NO (SKIP TO G32) 2 REFUSED (SKIP TO G32) 7 DON’T KNOW (SKIP TO G32) 8 |
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||
* |
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|
LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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||
* |
|
|
MINUTES REFUSED 997 DON’T KNOW 998 |
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||
* |
|
|
BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
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|
||
* |
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|
WALK 1BIKE 2REFUSED 97DON’T KNOW 98 |
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||
IF G13A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G33 |
|||||
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|
||
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 1NO (SKIP TO G33) 2 REFUSED (SKIP TO G33) 7 DON’T KNOW (SKIP TO G33) 8 |
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||
* |
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|
LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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||
* |
|
|
MINUTES REFUSED 997 DON’T KNOW 998 |
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||
* |
|
|
AT SCHOOL 1AT HOME 2AT A REC CENTER 3AT A PARK/PLAYGROUND 4IN MY NEIGHBORHOOD 5ON MY STREET 6AT CHURCH 7AT A FRIEND’S HOUSE 8OTHER (SPECIFY) 9REFUSED 97DON’T KNOW 98 |
|
|
SPECIFY: |
|||||
* |
|
|
BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
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||
* |
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|
WALK 1BIKE 2REFUSED 97DON’T KNOW 98 |
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|
||
IF G14A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G34 |
|||||
|
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|
||
G33. * |
You said that you walked or rode your bike, scooter, skateboard, or skates for fun or exercise yesterday. Is this correct? |
|
YES 1NO (SKIP TO G34) 2 REFUSED (SKIP TO G34) 7 DON’T KNOW (SKIP TO G34) 8 |
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||
* |
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|
LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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||
* |
|
|
MINUTES REFUSED 997 DON’T KNOW 998 |
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||
* |
|
|
AT SCHOOL 1AT HOME 2AT A REC CENTER 3AT A PARK/PLAYGROUND 4IN MY NEIGHBORHOOD 5ON MY STREET 6AT CHURCH 7AT A FRIEND’S HOUSE 8OTHER (SPECIFY) 9REFUSED 97DON’T KNOW 98 |
|
|
SPECIFY: |
|||||
* |
|
|
BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
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||
* |
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|
WALK 1BIKE 2SCOOTER 3SKATEBOARD 4SKATES/ROLLERBLADES 5OTHER (SPECIFY) 6REFUSED 97DON’T KNOW 98 |
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|
||
IF G15A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G35 |
|||||
|
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|
||
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 1NO (SKIP TO G35) 2 REFUSED (SKIP TO G35) 7 DON’T KNOW (SKIP TO G35) 8 |
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||
* |
|
|
MINUTES REFUSED 997 DON’T KNOW 998 |
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||
* |
|
|
AT SCHOOL 1AT HOME 2AT A REC CENTER 3AT A PARK/PLAYGROUND 4IN MY NEIGHBORHOOD 5ON MY STREET 6AT CHURCH 7AT A FRIEND’S HOUSE 8OTHER (SPECIFY) 9REFUSED 97DON’T KNOW 98 |
|
|
SPECIFY: |
|||||
* |
|
|
BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
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||
* |
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|
GAMING 1SURFING THE INTERNET 2OTHER (SPECIFY) 3REFUSED 97DON’T KNOW 98 |
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|
||
IF G16A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G36 |
|||||
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|
||
G35. * |
You said that you used a computer or phone for social networking yesterday. Is this correct? |
|
YES 1NO (SKIP TO G36) 2 REFUSED (SKIP TO G36) 7 DON’T KNOW (SKIP TO G36) 8 |
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||
* |
|
|
MINUTES REFUSED 997 DON’T KNOW 998 |
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||
* |
|
|
AT SCHOOL 1AT HOME 2AT A REC CENTER 3AT A PARK/PLAYGROUND 4IN MY NEIGHBORHOOD 5ON MY STREET 6AT CHURCH 7AT A FRIEND’S HOUSE 8OTHER (SPECIFY) 9REFUSED 97DON’T KNOW 98 |
|
|
SPECIFY: |
|||||
* |
|
|
BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
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|
||
* |
|
|
IM/CHAT/TWITTER 1 1SOCIAL NETWORKING ON THE COMPUTER 2TEXTING 3OTHER (SPECIFY) 4REFUSED 97DON’T KNOW 98 |
|
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|
||
IF G17A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G37 |
|||||
|
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|
||
G36. * |
You said that you watched TV yesterday. Is this correct? |
|
YES 1NO (SKIP TO G37) 2 REFUSED (SKIP TO G37) 7 DON’T KNOW (SKIP TO G37) 8 |
|
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|
||
* |
|
|
MINUTES REFUSED 997 DON’T KNOW 998 |
|
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|
||
* |
|
|
AT SCHOOL 1AT HOME 2AT A REC CENTER 3AT A PARK/PLAYGROUND 4IN MY NEIGHBORHOOD 5ON MY STREET 6AT CHURCH 7AT A FRIEND’S HOUSE 8OTHER (SPECIFY) 9REFUSED 97DON’T KNOW 98 |
|
|
SPECIFY: |
|||||
* |
|
|
BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
|
|
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||
* |
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WATCHING TV/VIDEOS 1REFUSED 97DON’T KNOW 98 |
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||
IF G18A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G38 |
|||||
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||
G37. * |
You said that you played non-active video games yesterday. Is this correct? |
|
YES 1NO (SKIP TO G38) 2 REFUSED (SKIP TO G38) 7 DON’T KNOW (SKIP TO G38) 8 |
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||
* |
|
|
MINUTES REFUSED 997 DON’T KNOW 998 |
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||
* |
|
|
AT SCHOOL 1AT HOME 2AT A REC CENTER 3AT A PARK/PLAYGROUND 4IN MY NEIGHBORHOOD 5ON MY STREET 6AT CHURCH 7AT A FRIEND’S HOUSE 8OTHER (SPECIFY) 9REFUSED 97DON’T KNOW 98 |
|
|
SPECIFY: |
|||||
* |
|
|
BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
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||
* |
|
|
PLAYING GAMES ON A GAME CONSOLE 1PLAYING GAMES ON A HANDHELD GAMING DEVICE 2REFUSED 97DON’T KNOW 98 |
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|
||
IF G19A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G39 |
|||||
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||
G38. * |
You said that you played physically active video games yesterday. Is this correct? |
|
YES 1NO (SKIP TO G39) 2 REFUSED (SKIP TO G39) 7 DON’T KNOW (SKIP TO G39) 8 |
|
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||
* |
|
|
LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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||
* |
|
|
MINUTES REFUSED 997 DON’T KNOW 998 |
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||
* |
|
|
AT SCHOOL 1AT HOME 2AT A REC CENTER 3AT A PARK/PLAYGROUND 4IN MY NEIGHBORHOOD 5ON MY STREET 6AT CHURCH 7AT A FRIEND’S HOUSE 8OTHER (SPECIFY) 9REFUSED 97DON’T KNOW 98 |
|
|
SPECIFY: |
|||||
* |
|
|
BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
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||
* |
|
|
PLAYING WII/KINECT/MOVE, ETC. 1REFUSED 97DON’T KNOW 98 |
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|
||
G39. * |
Did you do any other physical activity yesterday that was not already mentioned? |
|
YES 1NO (SKIP TO section h) 2 REFUSED (SKIP TO section h) 7 DON’T KNOW (SKIP TO section h) 8 |
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||
* |
|
|
ACTIVITY:______________________________________ REFUSED 7 DON’T KNOW 8 |
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||
* |
|
|
LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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|
||
* |
|
|
MINUTES REFUSED 997 DON’T KNOW 998 |
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||
* |
|
|
AT SCHOOL 1AT HOME 2AT A REC CENTER 3AT A PARK/PLAYGROUND 4IN MY NEIGHBORHOOD 5ON MY STREET 6AT CHURCH 7AT A FRIEND’S HOUSE 8OTHER (SPECIFY) 9REFUSED 97DON’T KNOW 98 |
|
|
SPECIFY: |
|||||
* |
|
|
BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
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||
SECTION H: PHYSICAL ACTIVITY CHILD SURVEY |
|||||||||||
Self administered |
|||||||||||
Child aged 3 – 5: NOT COMPLETEDChild aged 6 – 11: Child respondent/adult present to assistChild 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 |
|
|||||||||||||||||||||||||||||||||||
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|
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|
||||||||||||||||||||||||||||||||||||||||
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 |
|
|||||||||||||||||||||||||||||||||||
|
|
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|
|
||||||||||||||||||||||||||||||||||||||||
H7. |
How much is each of the following statements true for you? |
|
||||||||||||||||||||||||||||||||||||||||||
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|
||||||||||||||||||||||||||||||||||||
|
|
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) 1Bicycle 2Big yard/Empty Field 3Exercise Video tapes 4Active Video game systems (Wii, Playstation Move, Xbox Kinect) 5Indoor Playspace (playroom, empty garage) 6Cardio Equipment (Treadmill, stationary bicycle, step climber, elliptical machine, rowing machine) 7Jungle Gym/Tree House 8Swings/Slides 9Wheeled Toys (scooter, skateboard, inline skates, roller skates, etc.) 10Active Equipment (balls, jumpropes Frisbees, racquets, bats, etc.) 11Swimming Pool 12Trampoline 13Weight lifting equipment 14Other, please specify 15Refused 97Don’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) 16Big yard/Empty Field 17Indoor Playspace (clubhouse) 18Cardio Equipment (Treadmill, stationary bicycle, step climber, elliptical machine, rowing machine) 19Lake or Ocean 20Playground (jungle gym, slides, swings, etc.) 21Swimming Pool 22Tennis Court 23Weight lifting equipment 24Park 25Walking Trail 26Bike Path/Trail 27YMCA/Boys and Girls Club/etc. 28Skate park/place for skateboarding 29Other, please specify 30Refused 97Don’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 1Disagree 2Agree 3Strongly Agree 4Refused 7Don’t Know 8 |
|
|||||||||||||||||||||||||||||||||||||||||
|
|
|
||||||||||||||||||||||||||||||||||||||||||
I4.* |
I allow my child to watch as much TV as (he/she) wants. |
Strongly disagree 1Disagree 2Agree 3Strongly Agree 4Refused 7Don’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 1Disagree 2Agree 3Strongly Agree 4Refused 7Don’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 1NO 2REFUSED 7DON'T KNOW 8 |
|
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|
|
|
|
||||||||||||||||||||||||||||||||||||||||
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 1NO 2DON’T HAVE A YARD ………………………………………3REFUSED 7DON'T KNOW 8 |
|
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|
|
|
||||||||||||||||||||||||||||||||||||||||
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 1NO 2REFUSED 7DON'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 11-2 DAYS PER WEEK 23-4 DAYS PER WEEK 35-6 DAYS PER WEEK 47 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 1Somewhat less than others 2About the same 3Somewhat more than others 4Much more than others 5Refused 7Don’t Know 8 |
|
|
|
||||||||||||||||||||||||||||||||||||||
|
|
|
|
|
||||||||||||||||||||||||||||||||||||||||
SECTION J: NUTRITION QUESTIONS |
|
|||||||||||||||||||||||||||||||||||||||||||
Interviewer administered |
|
|||||||||||||||||||||||||||||||||||||||||||
Domain 1: Food and Beverage Intake |
|
|
||||||||||||||||||||||||||||||||||||||||||
Child aged 3 – 5: Adult respondentChild aged 6 – 8: Adult respondent/child present to assistChild aged 9 – 11: Child respondent/adult present to assistChild 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.................................. 12% FAT OR REDUCED-FAT MILK 21%, 1/2%, OR LOW-FAT MILK 3FAT-FREE, SKIM OR NONFAT MILK 4SOY MILK 5OTHER 6REFUSED ....................................................................7DON'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 respondentChild aged 6 – 8: Adult respondent/child present to assistChild aged 9 – 11: Child respondent/adult present to assistChild 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 1RARELY 2SOMETIMES 3MOST OF THE TIME 4REFUSED 7DON'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 ADMINISTEREDChild 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 1A LITTLE LIKE ME 2A LOT LIKE ME 3REFUSED 7DON'T KNOW 8 |
|
|
||||||||||||||||||||||||||||||||||||||||
|
|
|
||||||||||||||||||||||||||||||||||||||||||
J11.* |
I make sure I get plenty of healthy foods on each day. |
NOT LIKE ME 1A LITTLE LIKE ME 2A LOT LIKE ME 3REFUSED 7DON'T KNOW 8 |
|
|
||||||||||||||||||||||||||||||||||||||||
|
|
|||||||||||||||||||||||||||||||||||||||||||
J12.* |
I get excited about eating healthy every day.
|
NOT LIKE ME 1A LITTLE LIKE ME 2A LOT LIKE ME 3REFUSED 7DON'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 1SURE 2VERY SURE 3REFUSED 7DON'T KNOW 8 |
|
|
||||||||||||||||||||||||||||||||||||||||
|
|
|
||||||||||||||||||||||||||||||||||||||||||
J14. * |
Stick to eating healthy when eating with friends. |
A LITTLE SURE 1SURE 2VERY SURE 3REFUSED 7DON'T KNOW 8 |
|
|
||||||||||||||||||||||||||||||||||||||||
|
|
|
||||||||||||||||||||||||||||||||||||||||||
J15. * |
Choose healthy foods when I eat at school. |
A LITTLE SURE 1SURE 2VERY SURE 3REFUSED 7DON'T KNOW 8 |
|
|
||||||||||||||||||||||||||||||||||||||||
|
|
|||||||||||||||||||||||||||||||||||||||||||
Domain 4: Perceived Social Support Regarding Healthy Eating and Peer Influence |
|
|
||||||||||||||||||||||||||||||||||||||||||
Child aged 3 – 5: Adult respondent – Family ratings onlyChild aged 6 – 8: Adult respondent/child present to assist – Family ratings onlyChild aged 9 – 11: Child respondent/adult present to assist – Family ratings onlyChild 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 1MOST OF THE TIME 2SOMETIMES 3RARELY 4NEVER 5REFUSED 7DON’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 1MOST OF THE TIME 2SOMETIMES 3RARELY 4NEVER 5REFUSED 7DON’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 1MOST OF THE TIME 2SOMETIMES 3RARELY 4NEVER 5REFUSED 7DON’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 1MOST OF THE TIME 2SOMETIMES 3RARELY 4NEVER 5REFUSED 7DON’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 1MOST OF THE TIME 2SOMETIMES 3RARELY 4NEVER 5REFUSED 7DON’T KNOW 8 |
|
|
||||||||||||||||||||||||||||||||||||||||
|
|
|
||||||||||||||||||||||||||||||||||||||||||
Domain 6: Perceived School Environment Regarding Healthy Eating |
|
|
||||||||||||||||||||||||||||||||||||||||||
Child aged 3 – 5: NOT ADMINISTEREDChild aged 6 – 8: Adult respondent/child present to assistChild aged 9 – 11: Child respondent/adult present to assistChild 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 1MOST OF THE TIME 2SOMETIMES 3RARELY 4NEVER 5REFUSED 7DON’T KNOW 8 |
|
|
|||||||||||||||||||||||||||||||||||||||
|
|
|||||||||||||||||||||||||||||||||||||||||||
J25. * |
The school lunch tastes good.
|
|
ALWAYS 1MOST OF THE TIME 2SOMETIMES 3RARELY 4NEVER 5REFUSED 7DON’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 1MOST OF THE TIME 2SOMETIMES 3RARELY 4NEVER 5REFUSED 7DON’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 1MOST OF THE TIME 2SOMETIMES 3RARELY 4NEVER 5REFUSED 7DON’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 |
|
|
|||||||||||||||||||||||||||||||||||
* |
|
1 |
2 |
3 |
4 |
7 |
8 |
|
|
|||||||||||||||||||||||||||||||||||
* |
|
1 |
2 |
3 |
4 |
7 |
8 |
|
|
|||||||||||||||||||||||||||||||||||
* |
|
1 |
2 |
3 |
4 |
7 |
8 |
|
|
|||||||||||||||||||||||||||||||||||
* |
|
1 |
2 |
3 |
4 |
7 |
8 |
|
|
|||||||||||||||||||||||||||||||||||
* |
|
1 |
2 |
3 |
4 |
7 |
8 |
|
|
|||||||||||||||||||||||||||||||||||
* |
|
1 |
2 |
3 |
4 |
7 |
8 |
|
|
|||||||||||||||||||||||||||||||||||
* |
|
1 |
2 |
3 |
4 |
7 |
8 |
|
|
|||||||||||||||||||||||||||||||||||
* |
|
1 |
2 |
3 |
4 |
7 |
8 |
|
|
|||||||||||||||||||||||||||||||||||
* |
|
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 |
|
|
|||||||||||||||||||||||||||||||||||
* |
|
1 |
2 |
3 |
4 |
7 |
8 |
|
|
|||||||||||||||||||||||||||||||||||
* |
|
1 |
2 |
3 |
4 |
7 |
8 |
|
|
|||||||||||||||||||||||||||||||||||
* |
|
1 |
2 |
3 |
4 |
7 |
8 |
|
|
|||||||||||||||||||||||||||||||||||
* |
|
1 |
2 |
3 |
4 |
7 |
8 |
|
|
|||||||||||||||||||||||||||||||||||
* |
|
1 |
2 |
3 |
4 |
7 |
8 |
|
|
|||||||||||||||||||||||||||||||||||
* |
|
1 |
2 |
3 |
4 |
7 |
8 |
|
|
|||||||||||||||||||||||||||||||||||
* |
|
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. |
|
|
|
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|
STRONGLY AGREE |
AGREE |
NEITHER AGREE NOR DISAGREE |
DIS-AGREE |
STRONGLY DISAGREE |
RF |
DK |
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* |
|
1 |
2 |
3 |
4 |
5 |
7 |
8 |
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* |
|
1 |
2 |
3 |
4 |
5 |
7 |
8 |
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* |
|
1 |
2 |
3 |
4 |
5 |
7 |
8 |
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* |
|
1 |
2 |
3 |
4 |
5 |
7 |
8 |
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|
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* |
|
1 |
2 |
3 |
4 |
5 |
7 |
8 |
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* |
|
1 |
2 |
3 |
4 |
5 |
7 |
8 |
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J33. * |
Has the cost of fresh fruits and vegetables where you shop ever kept you from buying them? |
|
YES 1NO 2REFUSED 7DON'T KNOW 8
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|
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Domain 8: Infant Feeding History |
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|
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Child aged 3 – 15: Adult respondent |
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The next questions are about breastfeeding your child. |
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J34. * |
Was your child ever breastfed or fed breast milk? |
|
YES 1NO (SKIP TO J36) 2 REFUSED (SKIP TO J36) 7 DON’T KNOW (SKIP TO J36) 8 |
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J35. * |
How old was your child when (he/she) completely stopped breastfeeding or being fed breast milk? |
|
MONTHS YEARS |
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Domain 9: Household Food Insecurity |
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|
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Child aged 3 – 15: Adult respondent |
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|
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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). |
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|
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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 1SOMETIMES TRUE 2NEVER TRUE 3REFUSED 7DON'T KNOW 8
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|
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|
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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 1SOMETIMES TRUE 2NEVER TRUE 3REFUSED 7DON'T KNOW 8
|
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|
||||||||||||||||||||||||||||||||||||||
|
|
|||||||||||||||||||||||||||||||||||||||||||
Domain 10: Dieting Behaviors |
|
|
||||||||||||||||||||||||||||||||||||||||||
Child aged 3 – 11: NOT ADMINISTEREDChild aged 12 – 15: Child respondent |
|
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|
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J38. * |
How do you describe your weight?
|
|
VERY UNDERWEIGHT.................................................... 1SLIGHTLY UNDERWEIGHT ........................................... 2ABOUT THE RIGHT WEIGHT ........................................ 3SLIGHTLY OVERWEIGHT 4VERY OVERWEIGHT ...................................................... 5REFUSED ......................................................................7DON'T KNOW ...............................................................8 |
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|
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|
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J39. * |
Which of the following are you trying to do about your weight?
|
|
LOSE WEIGHT.................................................... 1GAIN WEIGHT ........................................... 2STAY THE SAME WEIGHT ........................................ 3NOT TRYING TO DO ANYTHING ABOUT WEIGHT 4REFUSED ......................................................................7DON'T KNOW ...............................................................8 |
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|
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|
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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 1NO 2REFUSED 7DON'T KNOW 8 |
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|
||||||||||||||||||||||||||||||||||||||
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|
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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 1NO 2REFUSED 7DON'T KNOW 8
|
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|
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|
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J42. * |
Have you ever vomited or taken laxatives to lose weight or to keep from gaining weight? |
|
YES 1NO 2REFUSED 7DON'T KNOW 8 |
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|
||||||||||||||||||||||||||||||||||||||
|
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HOME VISIT 2 (Enhanced Protocol ONLY) |
|
|||||||||||||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||||||||||
SECTION K: PHYSICAL ACTIVITY BEHAVIORS RECALL (FOR 3 – 5 YEAR OLDS) |
|
|||||||||||||||||||||||||||||||||||||||||||
Self administered |
|
|||||||||||||||||||||||||||||||||||||||||||
Child aged 3 – 5: Adult respondentChild 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. |
|
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|
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K1.
|
Did your child play any physically active games (hopscotch, red rover, tag, etc.) at home or in the neighborhood yesterday? |
|
YES 1NO (SKIP TO K2) 2 REFUSED (SKIP TO K2) 7 DON’T KNOW (SKIP TO K2) 8 |
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|
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|
||||||||||||||||||||||||||||||||||||||||
|
|
|
MINUTES REFUSED 997 DON’T KNOW 998 |
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|
|||||||||||||||||||||||||||||||||||||||
|
|
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|
||||||||||||||||||||||||||||||||||||||||
|
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|
TAG 1RED ROVER/DUCK DUCK GOOSE/ETC. 2HOPSCOTCH 3OTHER (SPECIFY) 4REFUSED 97DON’T KNOW 98 |
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|
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|
||||||||||||||||||||||||||||||||||||||||
K2.
|
Did your child ride (his/her) bike or use other wheeled toys (scooter, skates, etc) at home or in the neighborhood yesterday? |
|
YES 1NO (SKIP TO K3) 2 REFUSED (SKIP TO K3) 7 DON’T KNOW (SKIP TO K3) 8 |
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|
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|
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|
MINUTES REFUSED 997 DON’T KNOW 998 |
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|
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|
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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 1NO (SKIP TO K4) 2 REFUSED (SKIP TO K4) 7 DON’T KNOW (SKIP TO K4) 8 |
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|
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|
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|
MINUTES REFUSED 997 DON’T KNOW 998 |
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|
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|
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|
PLAYING WITH BALLS/OTHER EQUIPMENT 1PLAYING ON FIXED EQUIPMENT (TREE HOUSE, MONKEY BARS, SLIDES, SWINGS, ETC) 2JUMPROPE/HULA HOOP 3OTHER (SPECIFY) 4REFUSED 97DON’T KNOW 98 |
|
|
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|
|
|
|
|
||||||||||||||||||||||||||||||||||||||||
K4.
|
Did your child use a computer for playing games on the internet yesterday? |
|
YES 1NO (SKIP TO K5) 2 REFUSED (SKIP TO K5) 7 DON’T KNOW (SKIP TO K5) 8 |
|
|
|||||||||||||||||||||||||||||||||||||||
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|
||||||||||||||||||||||||||||||||||||||||
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|
MINUTES REFUSED 997 DON’T KNOW 998 |
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|
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|
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|
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K5.
|
Did your child watch TV or videos yesterday? |
|
YES 1NO (SKIP TO K6) 2 REFUSED (SKIP TO K6) 7 DON’T KNOW (SKIP TO K6) 8 |
|
|
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|
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|
MINUTES REFUSED 997 DON’T KNOW 998 |
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|
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|
||||||||||||||||||||||||||||||||||||||||
K6.
|
Did your child play non-active video games yesterday? |
|
YES 1NO (SKIP TO K7) 2 REFUSED (SKIP TO K7) 7 DON’T KNOW (SKIP TO K7) 8 |
|
|
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|
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|
MINUTES REFUSED 997 DON’T KNOW 998 |
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|
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|
||||||||||||||||||||||||||||||||||||||||
K7.
|
Did your child play physically active video games (Wii, DDR, Xbox Kinect, Playstation Move, etc.) yesterday? |
|
YES 1NO (SKIP TO K8) 2 REFUSED (SKIP TO K8) 7 DON’T KNOW (SKIP TO K8) 8 |
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|
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|
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|
MINUTES REFUSED 997 DON’T KNOW 998 |
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|
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|
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|
PLAYING WII/KINECT/MOVE, ETC 1REFUSED 97DON’T KNOW 98 |
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|
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|
|
||||||||||||||||||||||||||||||||||||||||
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. |
|
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|
||||||||||||||||||||||||||||||||||||||||
K8.
|
Did your child play an organized sport yesterday? |
|
YES 1NO (SKIP TO K9) 2 REFUSED (SKIP TO K9) 7 DON’T KNOW (SKIP TO K9) 8 |
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|
|||||||||||||||||||||||||||||||||||||||
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|
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|
MINUTES REFUSED 997 DON’T KNOW 998 |
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|
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|
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|
PLAYING BASEBALL/SOFTBALL 1PLAYING SOCCER/FOOTBALL 2PLAYING BASKETBALL 3PLAYING TENNIS 4SWIM TEAM 5OTHER (SPECIFY) 4REFUSED 97DON’T KNOW 98 |
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|
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|
||||||||||||||||||||||||||||||||||||||||
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 1NO (SKIP TO K10) 2 REFUSED (SKIP TO K10) 7 DON’T KNOW (SKIP TO K10) 8 |
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|
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|
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|
MINUTES REFUSED 997 DON’T KNOW 998 |
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|
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|
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|
PARTICIPATING IN GYMBOREE OR LITTLE GYM (OR OTHER FACILITY) CLASSES 1PLAYING AT A BOUNCE HOUSE (MONKEY JOE’S, ETC.) 2PLAYING AT A TRAMPOLINE GYM 3 |
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|
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|
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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 1NO (SKIP TO K11) 2 REFUSED (SKIP TO K11) 7 DON’T KNOW (SKIP TO K11) 8 |
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|
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|
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|
MINUTES REFUSED 997 DON’T KNOW 998 |
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|
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|
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|
DANCE/ CHEER 1TUMBLING OR GYMNASTICS CLASSES 2SPORT LESSONS (TENNIS, BASEBALL, BASKETBALL, ETC.) 3KARATE OR OTHER MARTIAL ARTS CLASSES 4OTHER (SPECIFY) 4REFUSED 97DON’T KNOW 98 |
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|
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|
||||||||||||||||||||||||||||||||||||||||
K11.
|
Did your child participate in any activities in the water (swim lessons, swimming, pool/water games) yesterday? |
|
YES 1NO (SKIP TO K12) 2 REFUSED (SKIP TO K12) 7 DON’T KNOW (SKIP TO K12) 8 |
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|
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|
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|
MINUTES REFUSED 997 DON’T KNOW 998 |
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|
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|
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|
SWIM LESSONS 1SWIMMING 2PLAYING POOL/WATER GAMES 3OTHER (SPECIFY) 4REFUSED 97DON’T KNOW 98 |
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|
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|
||||||||||||||||||||||||||||||||||||||||
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). |
|
|||||||||||||||||||||||||||||||||||||||||||
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|
||||||||||||||||||||||||||||||||||||||||
K12.
|
Did your child attend a structured childcare or school yesterday? |
|
YES 1NO (END SURVEY) 2 REFUSED (END SURVEY) 7 DON’T KNOW (END SURVEY) 8 |
|
|
|||||||||||||||||||||||||||||||||||||||
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|
||||||||||||||||||||||||||||||||||||||||
|
Yes 1 no 2 refused 7 don’t know 8 |
|
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|
||||||||||||||||||||||||||||||||||||||||
|
Yes 1 no 2 refused 7 don’t know 8 |
|
||||||||||||||||||||||||||||||||||||||||||
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|
||||||||||||||||||||||||||||||||||||||||
|
Yes 1 no 2 refused 7 don’t know 8 |
|
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|
||||||||||||||||||||||||||||||||||||||||
|
Yes 1 no 2 refused 7 don’t know 8 |
|
||||||||||||||||||||||||||||||||||||||||||
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|
||||||||||||||||||||||||||||||||||||||||
SECTION L: PHYSICAL ACTIVITY BEHAVIORS RECALL (FOR 6 – 15 YEAR OLDS) |
|
|||||||||||||||||||||||||||||||||||||||||||
Self administered |
|
|||||||||||||||||||||||||||||||||||||||||||
Child aged 3 – 5: NOT ADMINISTEREDChild aged 6 – 11: Child respondent/adult present to assistChild 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. |
|
|
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|
||||||||||||||||||||||||||||||||||||||||
L1.
|
Did you have physical education (PE) class in school yesterday? |
|
YES 1NO (SKIP TO L2) 2 REFUSED (SKIP TO L2) 7 DON’T KNOW (SKIP TO L2) 8 |
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|
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|
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|
LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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|
MINUTES REFUSED 997 DON’T KNOW 998 |
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|
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|
TEAM SPORT SKILLS 1INDIVIDUAL SPORT SKILLS 2DANCE/TUMBLING SKILLS 3WATER ACTIVITY SKILLS 4CARDIOVASCULAR MACHINES OR CONDITIONING (RUNNING, CYCLING, STAIRCLIMBER, ROWERS, ETC.) 5CLIMBING WALL ACTIVITIES 6EXERCISES/CALISTHENICS 7FRISBEE OR FRISBEE GOLF 8JUMPROPE/PLYOMETRICS/CONDITIONING 9WEIGHT TRAINING 10YOGA/PILATES 11OTHER (SPECIFY) 12REFUSED 97DON’T KNOW 98 |
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|
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|
||||||||||||||||||||||||||||||||||||||||
L2.
|
Did you have recess or other free-play at school yesterday? |
|
YES 1NO (SKIP TO L3) 2 REFUSED (SKIP TO L3) 7 DON’T KNOW (SKIP TO L3) 8 |
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|
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|
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|
LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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|
MINUTES REFUSED 997 DON’T KNOW 998 |
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PLAYGROUND GAME (KICKBALL, FOUR SQUARE, DODGEBALL, ETC.) 1ORGANIZED SPORT GAME (BASEBALL, BASKETBALL, FOOTBALL, ETC.) 2TAG/CAPTURE THE FLAG/RED ROVER/ETC. 3FIXED EQUIPMENT (MONKEY BARS, SLIDES, SWINGS, ETC.) 4HANGING OUT WITH FRIENDS 5DOING SCHOOL WORK 6OTHER (SPECIFY) 7REFUSED 97DON’T KNOW 98 |
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L3.
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Did you have dance or other physically active classes at school (other than PE class) yesterday? |
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YES 1NO (SKIP TO L4) 2 REFUSED (SKIP TO L4) 7 DON’T KNOW (SKIP TO L4) 8 |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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DANCE 1WEIGHTLIFTING 2OTHER (SPECIFY) 3REFUSED 97DON’T KNOW 98 |
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L4.
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Did you participate in physical activity breaks during classes at school yesterday? |
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YES 1NO (SKIP TO L5) 2 REFUSED (SKIP TO L5) 7 DON’T KNOW (SKIP TO L5) 8 |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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IN-CLASS PHYSICAL ACTIVITY 1VIDEO/STRUCTURED ACTIVITY IN HOMEROOM/ANNOUNCEMENTS 2WALKING LAPS 3OTHER (SPECIFY) 4REFUSED 97DON’T KNOW 98 |
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L5.
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Did you practice or play with a school sports team yesterday? |
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YES 1NO (SKIP TO L6) 2 REFUSED (SKIP TO L6) 7 DON’T KNOW (SKIP TO L6) 8 |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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BASEBALL/SOFTBALL 1FOOTBALL/SOCCER/LACROSSE/HOCKEY BASKETBALL 2SWIM TEAM/DIVING/WATER POLO 3GOLF/TENNIS 4TRACK AND FIELD/CROSS COUNTRY 5CHEER/DANCE TEAM 6WRESTLING 7VOLLEYBALL 8MARTIAL ARTS 9ROWING/CANOE/KAYAK 10BOWLING 11SKIING 12OTHER (SPECIFY) 13REFUSED 97DON’T KNOW 98 |
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L6.
|
Did you practice or play with a non-school sports team yesterday? |
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YES 1NO (SKIP TO L7) 2 REFUSED (SKIP TO L7) 7 DON’T KNOW (SKIP TO L7) 8 |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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AT SCHOOL 1AT HOME 2AT A REC CENTER 3AT A PARK/PLAYGROUND 4IN MY NEIGHBORHOOD 5ON MY STREET 6AT CHURCH 7AT A FRIEND’S HOUSE 8OTHER (SPECIFY) 9REFUSED 97DON’T KNOW 98 |
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SPECIFY: |
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BASEBALL/SOFTBALL 1FOOTBALL/SOCCER/LACROSSE/HOCKEY BASKETBALL 2SWIM TEAM/DIVING/WATER POLO 3GOLF/TENNIS 4TRACK AND FIELD/CROSS COUNTRY 5CHEER/DANCE TEAM 6WRESTLING 7VOLLEYBALL 8MARTIAL ARTS 9ROWING/CANOE/KAYAK 10BOWLING 11SKIING 12OTHER (SPECIFY) 13REFUSED 97DON’T KNOW 98 |
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L7.
|
Did you participate in any pick-up sports (basketball, football, baseball/softball, etc.) yesterday? |
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YES 1NO (SKIP TO L8) 2 REFUSED (SKIP TO L8) 7 DON’T KNOW (SKIP TO L8) 8 |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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AT SCHOOL 1AT HOME 2AT A REC CENTER 3AT A PARK/PLAYGROUND 4IN MY NEIGHBORHOOD 5ON MY STREET 6AT CHURCH 7AT A FRIEND’S HOUSE 8OTHER (SPECIFY) 9REFUSED 97DON’T KNOW 98 |
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SPECIFY: |
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BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
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BASEBALL/SOFTBALL 1FOOTBALL/SOCCER/LACROSSE/HOCKEY BASKETBALL 2SWIM TEAM/DIVING/WATER POLO 3OTHER (SPECIFY) 4REFUSED 97DON’T KNOW 98 |
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L8.
|
Did you participate in physical activity during an afterschool program yesterday? |
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YES 1NO (SKIP TO L9) 2 REFUSED (SKIP TO L9) 7 DON’T KNOW (SKIP TO L9) 8 |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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AT SCHOOL 1AT HOME 2AT A REC CENTER 3AT A PARK/PLAYGROUND 4IN MY NEIGHBORHOOD 5ON MY STREET 6AT CHURCH 7AT A FRIEND’S HOUSE 8OTHER (SPECIFY) 9REFUSED 97DON’T KNOW 98 |
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SPECIFY: |
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BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
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PLAYGROUND GAME (KICKBALL, FOUR SQUARE, DODGEBALL, ETC.) 1ORGANIZED SPORT GAME (BASEBALL, BASKETBALL, FOOTBALL, ETC.) 2TAG/CAPTURE THE FLAG/RED ROVER/ETC. 3FIXED EQUIPMENT (MONKEY BARS, SLIDES, SWINGS, ETC.) 4DANCE/STEP TEAM 5DOUBLE-DUTCH 6OTHER (SPECIFY) 7REFUSED 97DON’T KNOW 98 |
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L9.
|
Did you play any physically active games (hopscotch, red rover, tag, etc.) yesterday? |
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YES 1NO (SKIP TO L10) 2 REFUSED (SKIP TO L10) 7 DON’T KNOW (SKIP TO L10) 8 |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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AT SCHOOL 1AT HOME 2AT A REC CENTER 3AT A PARK/PLAYGROUND 4IN MY NEIGHBORHOOD 5ON MY STREET 6AT CHURCH 7AT A FRIEND’S HOUSE 8OTHER (SPECIFY) 9REFUSED 97DON’T KNOW 98 |
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SPECIFY: |
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BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
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TAG 1RED ROVER/DUCK DUCK GOOSE/ETC. 2HOPSCOTCH 3OTHER (SPECIFY) 4REFUSED 97DON’T KNOW 98 |
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L10.
|
Did you swim or play games in a pool, lake, or ocean yesterday? |
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YES 1NO (SKIP TO L11) 2 REFUSED (SKIP TO L11) 7 DON’T KNOW (SKIP TO L11) 8 |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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AT SCHOOL 1AT HOME 2AT A REC CENTER 3AT A PARK/PLAYGROUND 4IN MY NEIGHBORHOOD 5ON MY STREET 6AT CHURCH 7AT A FRIEND’S HOUSE 8OTHER (SPECIFY) 9REFUSED 97DON’T KNOW 98 |
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SPECIFY: |
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BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
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SWIMMING 1WATER GAMES (MARCO POLO, SHARK AND MINNOWS, ETC.) 2WATERPLAY 3OTHER (SPECIFY) 4REFUSED 97DON’T KNOW 98 |
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L11.
|
Did you do any outdoor or adventure sports (hiking, kayaking, rock climbing, surfing, skiing, etc.) yesterday? |
|
YES 1NO (SKIP TO L12) 2 REFUSED (SKIP TO L12) 7 DON’T KNOW (SKIP TO L12) 8 |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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AT SCHOOL 1AT HOME 2AT A REC CENTER 3AT A PARK/PLAYGROUND 4IN MY NEIGHBORHOOD 5ON MY STREET 6AT CHURCH 7AT A FRIEND’S HOUSE 8OTHER (SPECIFY) 9REFUSED 97DON’T KNOW 98 |
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SPECIFY: |
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BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
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HIKING 1ROCK CLIMBING 2SURFING/SKIMBOARDING/BODYBOARDING 3SNOW SKIING/SNOWBOARDING 4WATER SKIING/WAKEBOARDING 5KAYAKING 6OTHER (SPECIFY) 7REFUSED 97DON’T KNOW 98 |
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L12.
|
Did you walk or bike to or from school yesterday? |
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YES 1NO (SKIP TO L13) 2 REFUSED (SKIP TO L13) 7 DON’T KNOW (SKIP TO L13) 8 |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
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L13.
|
Did you walk or bike to or from a store, park, or playground or a friend’s house yesterday? |
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YES 1NO (SKIP TO L14) 2 REFUSED (SKIP TO L14) 7 DON’T KNOW (SKIP TO L14) 8 |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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AT SCHOOL 1AT HOME 2AT A REC CENTER 3AT A PARK/PLAYGROUND 4IN MY NEIGHBORHOOD 5ON MY STREET 6AT CHURCH 7AT A FRIEND’S HOUSE 8OTHER (SPECIFY) 9REFUSED 97DON’T KNOW 98 |
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SPECIFY: |
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BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
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L14.
|
Did you walk or ride your bike, scooter, skateboard, or skates for fun or exercise yesterday? |
|
YES 1NO (SKIP TO L15) 2 REFUSED (SKIP TO L15) 7 DON’T KNOW (SKIP TO L15) 8 |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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AT SCHOOL 1AT HOME 2AT A REC CENTER 3AT A PARK/PLAYGROUND 4IN MY NEIGHBORHOOD 5ON MY STREET 6AT CHURCH 7AT A FRIEND’S HOUSE 8OTHER (SPECIFY) 9REFUSED 97DON’T KNOW 98 |
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SPECIFY: |
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BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
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L15.
|
Did you use a computer for gaming or playing on the internet (not for schoolwork or social networks) yesterday? |
|
YES 1NO (SKIP TO L16) 2 REFUSED (SKIP TO L16) 7 DON’T KNOW (SKIP TO L16) 8 |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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AT SCHOOL 1AT HOME 2AT A REC CENTER 3AT A PARK/PLAYGROUND 4IN MY NEIGHBORHOOD 5ON MY STREET 6AT CHURCH 7AT A FRIEND’S HOUSE 8OTHER (SPECIFY) 9REFUSED 97DON’T KNOW 98 |
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BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
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GAMING 1SURFING THE INTERNET 2REFUSED 97DON’T KNOW 98 |
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L16.
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Did you use a computer or phone for social networking (Facebook, MySpace, Twitter, IM, texting, etc.) yesterday? |
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YES 1NO (SKIP TO L17) 2 REFUSED (SKIP TO L17) 7 DON’T KNOW (SKIP TO L17) 8 |
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MINUTES REFUSED 997 DON’T KNOW 998 |
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AT SCHOOL 1AT HOME 2AT A REC CENTER 3AT A PARK/PLAYGROUND 4IN MY NEIGHBORHOOD 5ON MY STREET 6AT CHURCH 7AT A FRIEND’S HOUSE 8OTHER (SPECIFY) 9REFUSED 97DON’T KNOW 98 |
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BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
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IM/CHAT/TWITTER 1 1SOCIAL NETWORKING ON THE COMPUTER 2TEXTING 3REFUSED 97DON’T KNOW 98 |
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L17.
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Did you watch TV yesterday? |
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YES 1NO (SKIP TO L18) 2 REFUSED (SKIP TO L18) 7 DON’T KNOW (SKIP TO L18) 8 |
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AT SCHOOL 1AT HOME 2AT A REC CENTER 3AT A PARK/PLAYGROUND 4IN MY NEIGHBORHOOD 5ON MY STREET 6AT CHURCH 7AT A FRIEND’S HOUSE 8OTHER (SPECIFY) 9REFUSED 97DON’T KNOW 98 |
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BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
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L18.
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Did you play non-active video games yesterday? |
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YES 1NO (SKIP TO L19) 2 REFUSED (SKIP TO L19) 7 DON’T KNOW (SKIP TO L19) 8 |
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AT SCHOOL 1AT HOME 2AT A REC CENTER 3AT A PARK/PLAYGROUND 4IN MY NEIGHBORHOOD 5ON MY STREET 6AT CHURCH 7AT A FRIEND’S HOUSE 8OTHER (SPECIFY) 9REFUSED 97DON’T KNOW 98 |
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BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
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PLAYING GAMES ON A GAME CONSOLE 1PLAYING GAMES ON A HANDHELD GAMING DEVICE 2REFUSED 97DON’T KNOW 98 |
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L19.
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Did you play physically active video games (Wii, DDR, Xbox Kinect, Playstation Move, etc.) yesterday? |
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YES 1NO (SKIP TO L20) 2 REFUSED (SKIP TO L20) 7 DON’T KNOW (SKIP TO L20) 8 |
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LIGHT 1MODERATE 2HARD 3VERY HARD 4REFUSED 7DON’T KNOW 8 |
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AT SCHOOL 1AT HOME 2AT A REC CENTER 3AT A PARK/PLAYGROUND 4IN MY NEIGHBORHOOD 5ON MY STREET 6AT CHURCH 7AT A FRIEND’S HOUSE 8OTHER (SPECIFY) 9REFUSED 97DON’T KNOW 98 |
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BY MYSELF 1WITH 1 OTHER FRIEND 2WITH SEVERAL FRIENDS 3WITH MY TEAM OR CLASS 4WITH MY PARENT(S) OR OTHER FAMILY MEMBER(S) 5REFUSED 7DON’T KNOW 8 |
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PLAYING WII/KINECT/MOVE, ETC. 1REFUSED 97DON’T KNOW 98 |
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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. 2008National 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 child assent 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.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Battelle |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |
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