Questionnaire

Attachment 1a: Questions to be asked directly to teens ages 12-17

The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

Public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0222).

OMB #0920-0222; Expiration Date: 06/30/2015

Interviewer administered questions

T1. I would like to ask you some questions about difficulties you may have in doing certain activities. Do you wear glasses or contact lenses?	Yes 1 No 2	2T3
T2. When wearing your glasses, Do you HAVE difficulty seeing? Would you say you have: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4	1T4 2T4 3T4 4T4
T3. Do you have difficulty seeing? Would you say you have: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4
T4. Do you use a hearing aid?	Yes 1 No 2	2T6
T5. When using your hearing aid(s), Do you have difficulty hearing sounds like peoples’ voices or music? Would you say you have: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4	1T7 2T7 3T7 4T7
T6. Do you have difficulty hearing sounds like peoples’ voices or music? Would you say you have: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4
T7. Do you use any equipment or receive assistance for walking?	Yes 1 No 2	2T12
T8. Without using your equipment or assistance, do you have difficulty walking 100 yards/meters on level ground?  That would be about the length of 1 football field. Would you say you have: some difficulty, a lot of difficulty or cannot do at all?	Some difficulty 1 A lot of difficulty 2 Cannot do at all 3
T9. when using your equipment or assistance, Do you have difficulty walking 100 yards/meters on level ground?  That would be about the length of 1 football field. Would you say you have: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4	1T10 2T14 3T14
T10. Without using your equipment or assistance, Do you have difficulty walking 500 yards/meters on level ground?   That would be about the length of 5 football fields? Would you say you have: some difficulty, a lot of difficulty or cannot do at all?	Some difficulty 1 A lot of difficulty 2 Cannot do at all 3
T11. Do you have difficulty walking 100 yards/meters on level ground?  That would be about the length of 1 football field. Would you say you have: some difficulty, a lot of difficulty or cannot do at all?	Some difficulty 1 A lot of difficulty 2 Cannot do at all 3
T12. Do you have difficulty walking 500 yards/meters on level ground? That would be about the length of 5 football fields. Would you say you have: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4	1T13 2T13 3T13 4T13
T13. Do you have difficulty with self-care such as feeding or dressing yourself? Would you say you have: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4
T14. When you speak, do you have difficulty being understood by people inside of your household? Would you say you have: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4
T15. When you speak, do you have difficulty being understood by people outside of your household? Would you say you have: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4
T16. Do you have difficulty learning things? Would you say you have: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4
T17. Do you have difficulty remembering things? Would you say you have: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4
T18. How often Do you feel anxious, nervous or worried? Would you say: daily, weekly, monthly, a few times a year or never?	Daily 1 Weekly 2 Monthly 3 A few times a year 4 Never 5
T19. How often Do you feel sad or depressed? Would you say: daily, weekly, monthly, a few times a year or never?	Daily 1 Weekly 2 Monthly 3 A few times a year 4 Never 5
T20.Compared to children of the same age, how much difficulty do you have controlling your behaviour? Would you say: none, the same or less, more or a lot more?	None 1 The same or less 2 More 3 A lot more 4
T21. Do you have difficulty focusing on an activity that you enjoy doing? Would you say you have: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4
T22. Do you have difficulty accepting changes in your routine? Would you say you have: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4
T23. Do you have difficulty making friends? Would you say you have: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4
T24. Have you suffered a serious accident or injury in the last 3 months?	Yes 1 No 2 [If yes] What type of accident or injury? (Open Ended)

Self-Administered Questions

D1. What is Your age?	12-17: _____________________
D2. Are you male or female?	Male Female
D3. Are you Hispanic or Latino?	Yes No
D4. What is your race? You may indicate one or more races that you consider yourself to be.	American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White
D5. In what grade are you?	7th 8th 9th 10th 11th 12th Ungraded or other
To be asked only of 15-17 Year Olds
D6. Which of the following best describes you?	Heterosexual (straight) Gay or lesbian Bisexual Not sure

Attachment 1b: Questions to be asked to parents/guardians of teens ages 12-17

The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

Public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0222).

OMB #0920-0222; Expiration Date: 06/30/2015

Interviewer administered questions

CFD1. I would like to ask you some questions about difficulties your child may have Does (name) wear glasses?	Yes 1 No 2	2CFD3
CFD2. When wearing his/her glasses, does (name) have difficulty seeing? Would you say (name) has: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4	1CFD4 2CFD4 3CFD4 4CFD4
CFD3. Does (name) have difficulty seeing? Would you say (name) has: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4
CFD4. Does (name) use a hearing aid?	Yes 1 No 2	2CFD6
CFD5. When using his/her hearing aid(s), does (name) have difficulty hearing noises like peoples’ voices or music? Would you say (name) has: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4	1CFD7 2CFD7 3CFD7 4CFD7
CFD6. Does (name) have difficulty hearing noises like peoples’ voices or music? Would you say (name) has: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4
CFD7. Does (name) use any equipment or receive assistance for walking?	Yes 1 No 2	2CFD10
CFD8. When using his/her equipment or assistance, does (name) have difficulty walking? Would you say (name) has: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4
CFD9. Without using his/her equipment or assistance, does (name) have difficulty walking? Would you say (name) has: some difficulty, a lot of difficulty or cannot do at all?	Some difficulty 1 A lot of difficulty 2 Cannot do at all 3	1CFD11 2CFD11 3CFD11
CFD10. Compared with children of the same age, does (name) have difficulty walking? Would you say (name) has: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4
CFD11. Does (name) have difficulty with self-care such as feeding or dressing him/herself? Would you say (name) has: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4
CFD12. When (name) speaks, does he/she have difficulty being understood by people inside of this household? Would you say (name) has: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4
CFD13. When (name) speaks, does he/she have difficulty being understood by people outside of this household? Would you say (name) has: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4
CFD14. Compared with children of the same age, does (name) have difficulty learning things? Would you say (name) has: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4
CFD15. Compared with children of the same age, does (name) have difficulty remembering things? Would you say (name) has: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4
CFD16. How often does (name) seem anxious, nervous or worried? Would you say: daily, weekly, monthly, a few times a year or never?	Daily 1 Weekly 2 Monthly 3 A few times a year 4 Never 5
CFD17. How often does (name) seem sad or depressed? Would you say: daily, weekly, monthly, a few times a year or never?	Daily 1 Weekly 2 Monthly 3 A few times a year 4 Never 5
CFD18. Compared with children of the same age, how much difficulty does (name) have controlling his/her behaviour? Would you say: none, the same or less, more or a lot more?	None 1 The same or less 2 More 3 A lot more 4
CFD19. Does (name) have difficulty focusing on an activity that he/she enjoys doing? Would you say (name) has: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4
CFD20. Does (name) have difficulty accepting changes in his/her routine? Would you say (name) has: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4
CFD21. Does (name) have difficulty making friends? Would you say (name) has: no difficulty, some difficulty, a lot of difficulty or cannot do at all?	No difficulty 1 Some difficulty 2 A lot of difficulty 3 Cannot do at all 4
T24. Has your child suffered a serious accident or injury in the last 3 months?	Yes 1 No 2 [If yes] What type of accident or injury? (Open Ended)

10 | Page