Individuals and Households Respondents

H15. Child Height and Weight Form

This page has been left blank for double-sided copying.

OMB Number: 0584-xxxx

Expiration Date: xx/xx/20xx

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

Standing Height and Weight Form – Ages 2 and Up

Child ID #: | | | | | | / | | | / 2023 Month Day

Field Interviewer ID #: | | | | | | | | |

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 0.2 lbs, TAKE 3RD MEASUREMENT. Lbs
2nd measurement								.				Lbs
3rd measurement								.				Lbs

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 or boots	6	£	Other (Specify) _______________________________
3	£	Wearing cast or brace

Comments: _____________________________________________________________________________________

The Food and Nutrition Service (FNS) is collecting this information to understand the nutritional quality of CACFP meals and snacks, the cost to produce them, and dietary intakes and activity levels of CACFP participants. This is a voluntary collection and FNS will use the information to examine CACFP operations. The collection does request personally identifiable information under the Privacy Act of 1974. Responses will be kept private to the extent provided by law and FNS regulations. 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 0.0835 hours (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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Service, Office of Policy Support, 1320 Braddock Place, 5th Floor, Alexandria, VA 22314. ATTN: PRA (0584-xxxx). Do not return the completed form to this address.

Standing and Holding Weight Form – Ages 12 to 23 Months and Older Children Unable to Stand Unassisted

Child ID #: | | | | | | / | | | / 2023 Month Day

Field Interviewer ID #: | | | | | | | | |

REMOVE SHOES, HATS, HEAVY CLOTHING, AND REMOVE HAIR PIECES AND EMPTY POCKETS.

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

If child is unable to stand on scale unassisted, use the following procedure:

1. Have adult caregiver step on scale.

2. Zero (tare) the scale so that it now reads 0 lbs.

3. Have the caregiver pick up the child and step back onto the scale.

4. Obtain reading.

1. Weight
1st measurement				.		IF DIFFERENCE BETWEEN 1ST & 2ND MEASUREMENT IS GREATER THAN 0.2 lbs, TAKE 3RD MEASUREMENT. Lbs
2nd measurement				.		Lbs
3rd measurement				.		Lbs

2. 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 or boots	6	£	Other (Specify) _______________________________
3	£	Wearing cast or brace

Comments: _____________________________________________________________________________________