Individuals/Households - Parents & Children

E.2a Standing Height and Weight Form

OMB Control No: 0584-XXXX

OMB Approval Expiration Date: XX/XX/XXXX

LOGO

Study of Nutrition and Activity in Child Care Settings (SNACS)

Child ID Label

Standing Height and Weight Form – Ages 2 and Up

Interviewer ID #: | | | | | | | | | | | | / | | | / 2016 Month Day

ASK CHILD TO REMOVE SHOES, HATS, HEAVY CLOTHING, REMOVABLE HAIR PIECES AND EMPTY POCKETS.

ENSURE THAT THE CHILD IS NOT HOLDING ANYTHING DURING THE MEASUREMENT.

1. Standing Height
1st measurement				.		IF DIFFERENCE BETWEEN 1ST & 2ND MEASUREMENT IS GREATER THAN 0.5 CM, TAKE 3RD MEASUREMENT. Centimeters
2nd measurement				.		Centimeters
3rd measurement				.		Centimeters

2. Check all concerns you have regarding the measurement above. If none, check “no concerns”.

	0	£	No concerns				3		£		Difficulty obtaining measurement (Describe in Comments)
	1	£	Wearing shoes or boots				4		£		Refusal (no measurement or report)
	2	£	Hair, hair piece, or hat interfered				5		£		Other (Specify) ______________________________________
3. Weight
1st measurement								.				IF DIFFERENCE BETWEEN 1ST & 2ND MEASUREMENT IS GREATER THAN 0.1 KG, TAKE 3RD MEASUREMENT. Kilograms
2nd measurement								.				Kilograms
3rd measurement								.				Kilograms

4. Check all concerns you have regarding the measurement below. If none, check “no concerns”.

0	£	No concerns	4	£	Difficulty obtaining measurement (Describe in Comments)
1	£	Wearing heavy clothing	5	£	Refusal (no measurement or report)
2	£	Wearing shoes	6	£	Other (Specify) _______________________________
3	£	Wearing cast or brace

Comments: ______________________________________________________________________________________

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-XXXX. The time required to complete this information collection is estimated to average 5 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.

Adapted from the Student Height and Weight Measurement Form from the School Nutrition and Meal Cost Study and the Height and Weight Measurement Form from the Evaluation off the School Breakfast Pilot Project.

Standing Height and Weight Form, p. 1