OMB Clearance Number: 2528-0337
Expires: XX/XX/XXXX
Attachment I.1: The Child Assessment Direct Child Assessment Baseline
If you require information to be presented in an accessible format or reasonable accommodations to participate in this study, please contact us with any specific requests by calling XXX-XXX-XXXX or emailing [email protected]. If you require language assistance to participate in this study, please contact us with any specific language assistance requests or needs.
Paperwork Reduction Act Burden Statement
This collection of information is voluntary and will be used to evaluate the US Department of Housing and Urban Development’s Community Choice Demonstration. Public reporting burden for this collection of information is estimated to average 32 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, 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. The OMB number for this collection is OMB 2528-0337 which expires on XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to NAME at [email protected] or call XXX-XXX-XXXX.
Privacy Act Statement
Authority: Section 502 of the Housing and Urban Development Act of 1970 (Public Law 91-609) (12 U.S.C. §§ 1701z-1; 1701z-2(d) and (g)).
Purpose: Evaluation of the Community Choice Demonstration (CCD).
Routine Use: The information will be used for the purpose set forth above and may be provided to Congress or other Federal, state, and local agencies, when determined necessary.
Disclosure: Records will be used for research and statistical analysis and will not be used to make decisions that affect the rights, benefits, or privileges of specific individuals.
SORN ID: Community Choice Demonstration Evaluation Data Files, HUD/PDR-09
CONTENTS
Module A. Child-Reported Behavioral, Educational, and Social Functioning (Age 8-17 Years) ……………………………………………………………………………………1
Module B. Child-Reported Health, Diet, and Nutrition (Age 10-17 Years)………..6
I have some questions for you so I can learn a little about you and your life. These questions will include things about school, friends, your health, social media habits, and more. If you don’t know how to answer one of the questions, please just give me your best guess. You can choose to skip any questions you don’t want to answer, and we can stop at any time. None of the choices for these questions are wrong. Do you have any questions for me before we get started?
First, we are going to ask you some questions about your school and relationships. We know that sometimes kids do not like to talk about school very much. Please remember you can choose not to answer a question. We can also pause the interview for a bit if you need to.
Please rate how much you agree or disagree with the following statements.
[Fragile Families, The Panel Study of Income Dynamics, Child Development Supplement; Responses to A.4a-c summed into a composite score; Johns Hopkins questions. Note: For children ages 2-9, parents report on a version of these questions.]
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Strongly disagree |
Disagree |
Neither agree nor disagree |
Agree |
Strongly agree |
Don’t know |
Prefer not to answer |
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Now I am going to ask about your friendships.
[ASK IF CHILD IS 10+ YEARS OLD] Please let me know if the following describe all, most, some, or none of your friendships.
[Source: New question, wording needs to be tested – based on Murayama et al. (2013); Johns Hopkins questions.]
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Some |
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[Source: NHIS Teen Survey https://www.cdc.gov/nchs/nhis/teen.htm; Johns Hopkins questions]
How much can you rely on your friends for help if you have a serious problem? Would you say:
☐ A lot
☐ Some
☐ A little
☐ Not at all
☐ Don’t Know
☐ Prefer not to answer
How much can you open up to your friends if you need to talk about your worries?
☐ A lot
☐ Some
☐ A little
☐ Not at all
☐ Don’t Know
We want to know about your thoughts and possible plans for the future. If you haven’t thought about this yet, that’s okay. We just want to know what you think at this time.
A.3 [ASK IF CHILD AGE 10+ YEARS OLD] How likely do you think it is that you will do each of the following things? [If you have already graduated high school, answer “Definitely will”]
[Source: NIDA Monitoring the Future (2020), Johns Hopkins questions]
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Probably won’t |
Probably will |
Definitely will |
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Prefer not to answer |
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Now we are going to ask some questions about your use of electronic devices and social media
A.4 [ASK IF CHILD AGE 10+ YEARS OLD] On an average school day, how many hours do you spend in front of a TV, computer, smart phone, or other electronic device watching shows or videos, playing games, accessing the Internet, or using social media (also called "screen time")? Do not count time spent doing schoolwork.
[Source: CDC Youth Risk Behavior Survey (YRBS) - 2023, Johns Hopkins question]
☐ I do not use screens on school days
☐ Less than 1 hour per day
☐ 1 hour per day
☐ 2 hours per day
☐ 3 hours per day
☐ 4 hours per day
☐ 5 or more hours per day
☐ Don’t know
☐ Prefer not to answer
A.5 [ASK IF CHILD AGE 10+ YEARS OLD] About how often do you use social media? [INTERVIEWER INSTRUCTION: By social media, we mean TikTok, Instagram, YouTube, Facebook, Twitter, Tumblr, Snapchat, Reddit, Twitch, Threads, and the like].
[Source: 2022 Pew Research Center’s Teens Survey, Johns Hopkins question]
☐ Almost constantly
☐ Several times a day
☐ About once a day
☐ Several times a week
☐ Once a week or less often
☐ Never
☐ Don’t know
☐ Prefer not to answer
A.6 [ASK IF CHILD AGE 10+ YEARS OLD] Overall, would you say the amount of time you spend on social media is...
[Source: 2022 Pew Research Center’s Teens Survey, Johns Hopkins question]
☐ Too much
☐ Too little
☐ About right
☐ I do not use social media
☐ Don’t know
☐ Prefer not to answer
[ASK IF CHILD AGE 10+ YEARS] The next set of questions asks about how you are currently feeling about several aspects of your life. For each question, please tell me how you feel. The options are completely satisfied, very satisfied, slightly satisfied, neutral, slightly dissatisfied, very dissatisfied, or completely dissatisfied.
How satisfied are you with…?
[Source: NIDA Monitoring the Future Survey (2020), A7a-d wording from questions on nationally representative survey allowing for direct comparison with national norms]
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Completely satisfied |
Very satisfied |
Slightly satisfied |
Neutral |
Slightly dissatisfied |
Very dissatisfied |
Completely dissatisfied |
DK |
Prefer not to answer |
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I will now read a list of sentences that describe how people feel. For each of the following items I read, please tell me if it is Not True or Hardly Ever True, Somewhat True or Sometimes True, or Very True or Often True for you.
[Source: Screen for Child Anxiety-Related Emotional Disorders-Brief (SCARED-5; initially validated in Birmaher et al., 1999); questions are summed into a composite score]
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Not True or Hardly Ever True |
Somewhat True or Sometimes True |
Very True or Very Often True |
NA |
Don’t know |
Prefer not to Answer |
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Now we would like to ask you some questions about how safe you think your neighborhood is.
A.9 [ASK IF CHILD AGE 8+ YEARS OLD] How safe do you feel on the streets near your home during the day?
[Source: MTO Interim Evaluation, Johns Hopkins question]
☐ Very safe
☐ Safe
☐ Unsafe
☐ Very unsafe
☐ Don’t know
☐ Prefer not to answer
A.10 [ASK IF CHILD AGE 10+ YEARS OLD] How safe do you feel on the streets near your home at night?
[Source: MTO Interim Evaluation, Johns Hopkins question]
☐ Very safe
☐ Safe
☐ Unsafe
☐ Very unsafe
☐ Don’t know
☐ Prefer not to answer
Please remember that we will not share your answers with your parents or anyone else. You can choose not to answer a question.
A.11 [ASK IF CHILD AGE 12+ YEARS OLD] Have you seen people using or selling illegal drugs in your neighborhood during the past 30 days?
[Source: MTO Interim Evaluation, Johns Hopkins question]
☐ Yes
☐ No
☐ Don’t know
☐ Prefer not to answer
A.12 [ASK IF CHILD AGE 10+ YEARS OLD]
[Source: NHIS Teen Survey, Johns Hopkins questions]
Next I would like to ask you about how other people treat you.
During the past 12 months, how often were you bullied, picked on, or excluded by other children or teenagers?
☐ Never in the past 12 months
☐ 1-2 times in the past 12 months
☐ 1-2 times per month
☐ 1-2 times per week
☐ Almost every day
☐ Don’t know
☐ Prefer not to answer
During the past 12 months, have you ever been electronically bullied? Count being bullied through texting, Instagram, Snapchat, Facebook, or other social media.
☐ Yes
☐ No
☐ Don’t know
☐ Prefer not to answer
A.13 [ASK IF CHILD AGE 12+ YEARS] In your day-to-day life, how often have any of the following things happened to you?
[Source: Everyday Discrimination Scale, Short Form, Johns Hopkins question]
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Almost every day |
At least once a week |
A few times a month |
A few times a year |
Less than once a year |
Never |
Don’t know |
Prefer not to answer |
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A.14 [ASK IF CHILD 12+ & ANSWERED “A FEW TIMES A YEAR” OR MORE FREQUENTLY TO AT LEAST ONE OF THE ABOVE] What do you think is the main reason for these experiences? (Interviewer instruction: Check more than one if volunteered. This question is asked only once and not for each type of discrimination reported in A.13)
[Source: Everyday Discrimination Scale, Short Form; Johns Hopkins question]
☐ Your ancestry or national origins
☐ Your gender
☐ Your race
☐ Your age
☐ Your religion
☐ Your height
☐ Your weight
☐ Some other aspect of your physical appearance
☐ Your sexual orientation
☐ The amount of money your family has
☐ Other (Specify): ______________________________
☐ Don’t know
☐ Prefer not to answer
Now we would like to talk about your health, diet, and physical activity.
[ASK IF CHILD AGE 10+ YEARS OLD] During the school year, about how many times a week do you usually get breakfast at school?
[Source: CDC National Health and Nutrition Examination Survey, 2017-2020 (NHANES), Johns Hopkins question]
☐ [ENTER NUMBER OF TIMES] _____
☐ None
☐ Don’t know
☐ Prefer not to answer
[ASK IF CHILD AGE 10+ YEARS OLD] During the school year, about how many times a week do you usually get lunch at school?
[Source: CDC National Health and Nutrition Examination Survey, 2017-2020 (NHANES), Johns Hopkins question]
☐ [ENTER NUMBER OF TIMES] _____
☐ None
☐ Don’t know
☐ Prefer not to answer
[ASK IF CHILD AGE 10+ YEARS OLD] In the past month please indicate your response for each beverage type you drink.
-Indicate how often you drank the following beverages, for example, if you drank 5 glasses of water per week, respond with 4-6 times per week for "HOW OFTEN"
-Indicate the approximate amount of beverage you drank each time, for example, if you drank 1 cup of water each time, respond with 1 cup for "HOW MUCH EACH TIME"
-Do not count beverages used in cooking or other preparations, such as milk in cereal.
[Source: Beverage Intake Questionnaire (BEVQ), Johns Hopkins question]
Type of Beverage |
How often? |
How much? |
Don’t know |
Prefer not to answer |
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Never or less than 1 time per week |
1 time per week |
2-3 times per week |
4-5 times per week |
1 time per day |
2 times per day |
3 or more times per day |
Less than ¾ cup (6 fl. oz.)
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1 cup (8 fl. oz.) |
1 ½ cups (12 fl. oz.)
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2 cups (16 fl. oz.)
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2 ½ cups (20 fl. oz.) |
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*Sweetened fruit drinks DO NOT include 100% fruit juice.
[ASK IF CHILD AGE 10+ YEARS OLD] Next, I'm going to ask you about meals. By meal, I mean breakfast, lunch, and dinner. During the past 7 days, how many meals did you get that were prepared away from home in places such as restaurants, fast food places, food stands, grocery stores, or from vending machines? (Please do not include meals provided as part of the school lunch or school breakfast).
[Source: CDC National Health and Nutrition Examination Survey, 2017-2020 (NHANES), Johns Hopkins question]
☐ [ENTER NUMBER OF MEALS 1-21]
☐ None
☐ More than 21 meals per week
☐ Don’t know
☐ Prefer not to answer
[ASK IF CHILD AGE 10+ YEARS OLD; SKIP IF B.4 IS NOT “None”, “Prefer not to answer”, or “Don’t Know”, ASK] How many of those meals did you get from a fast-food or pizza place?
[Source: CDC National Health and Nutrition Examination Survey, 2017-2020 (NHANES), Johns Hopkins question]
☐ [ENTER NUMBER OF MEALS 1-21]
☐ None
☐ More than 21 meals per week
☐ Don’t know
☐ Prefer not to answer
[ASK IF CHILD AGE 10+ YEARS OLD] During the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day? (Add up all the time you spent in any kind of physical activity that increased your heart rate and made you breathe hard some of the time.)
[Source: CDC Youth Risk Behavior Survey (YRBS) - 2023, validated national survey question, Johns Hopkins question]
☐ [ENTER NUMBER OF DAYS] _____
☐ None
☐ Don’t know
☐ Prefer not to answer
[ASK IF CHILD AGE 10+ YEARS OLD] During the past 12 months, on how many sports teams did you play? (Count any teams run by your school or community groups.)
[Source: CDC Youth Risk Behavior Survey (YRBS) - 2023, validated national survey question, Johns Hopkins question]
☐ 0 teams
☐ 1 team
☐ 2 teams
☐ 3 or more teams
☐ Don’t know
☐ Prefer not to answer
Now I am going to ask a few questions about how you feel about your body. Please remember that we will not share this information with your parents or anyone else. You can choose not to answer any question.
[ASK IF CHILD IS 12+] Please tell me on a scale of 1 to 10, where 1 is “Extremely Unsatisfied” and 10 is “Extremely Satisfied” how you rate the following questions.
[Source: Neumark-Sztainer et al. (2006), Johns Hopkins question]
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Satisfaction |
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1 Extremely Unsatisfied |
2 |
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5 |
6 |
7 |
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9 |
10 Extremely Satisfied |
DK |
Prefer not to answer |
a. How satisfied are you with your weight? |
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[ASK IF CHILD AGE 12+ YEARS OLD] How often have you gone on a diet in the past year?
[Source: Neumark-Sztainer et al. (2006), Johns Hopkins question]
☐ Never
☐ One to four times
☐ Five to ten times
☐ More than ten times
☐ I am always dieting
☐ Don’t know
☐ Prefer not to answer
[ASK IF CHILD AGE 12+ YEARS OLD] Have you done any of the following things in order to lose weight or keep from gaining weight during the past year including fasting, ate very little food, took diet pills, made yourself vomit, used laxatives, used diuretics (water pills), used food substitute (powder or special drinks), skipped meals, or smoked more cigarettes?
[Source: EAT Gen2 Adolescent Study, Johns Hopkins question]
☐ Yes
☐ No
☐ Don’t know
☐ Prefer not to answer
[ASK IF CHILD AGE 12+ YEARS OLD] In the past year, have you ever eaten so much food in a short period of time that you would be embarrassed if others saw you (binge-eating)?
[Source: EAT Gen2 Preadolescent Survey; Johns Hopkins question]
☐ Yes
☐ No
☐ Don’t know
☐ Prefer not to answer
[IF YES TO B.10 AND CHILD AGE 12+ YEARS OLD] During the times when you ate this way, did you feel like you couldn’t stop eating or control what or how much you were eating?
☐ Yes
☐ No
☐ Don’t know
☐ Prefer not to answer
[IF CHILD AGE 12+ YEARS OLD] [INTERVIEWER INSTRUCTIONS: Hand the child the tablet to complete questions B.13 through B.17]
The following questions are about how you feel. Over the last 2 weeks, how often have you been bothered by the following problems:
[Source: Patient Health Questionnaire-2; questions B12a and B12b are summed into a composite score; Johns Hopkins questions]
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Not at all |
Several days |
More than half of days |
Nearly every day |
Don’t Know |
Prefer not to answer |
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Now we are going to ask a question about smoking. I want to remind you that we will not tell your parent/guardian your answers to any questions.
[ASK IF CHILD AGE 12+ YEARS OLD] Have you ever tried cigarette smoking, vaping, or other tobacco products (such as e-cigarettes, cigars, cigarillos, little cigars, or chewing tobacco)? E-cigarettes are battery powered devices that usually contain a nicotine-based liquid that is vaporized and inhaled. You may also know them as e-cigs, vape-pens, e-hookahs, or mods.
[Source: EAT Gen2 Adolescent Survey, Johns Hopkins question]
☐ Yes
☐ No
☐ Don’t know
☐ Prefer not to answer
[ASK IF CHILD AGE 12+ YEARS OLD AND B.13=YES] During the past 30 days, on how many days did you smoke cigarettes, vape, or use other tobacco products?
[Source: EAT Gen2 Adolescent Survey; Johns Hopkins question]
☐ 0 days
☐ 1 or 2 days
☐ 3 to 5 days
☐ 6 to 9 days
☐ 10 to 19 days
☐ 20 to 29 days
☐ All 30 days
☐ Don’t know
☐ Prefer not to answer
Lastly, we are going to ask questions about how you describe yourself.
[ASK IF CHILD AGE 12+ YEARS OLD] Are you (select all that apply):
[Source: National Center for Health Statistics, Johns Hopkins question]
☐ Male
☐ Female
☐ Transgender, non-binary, or another gender
☐ Don’t know
☐ Prefer not to answer
[ASK IF CHILD IS AGE 12+ YEARS OLD] Which of the following best describes you?
[Source: CDC Youth Risk Behavior Survey (YRBS) – 2023, Johns Hopkins question]
☐ Heterosexual (straight)
☐ Gay or lesbian
☐ Bisexual
☐ I describe my sexual identity some other way
☐ I am not sure about my sexual identity (questioning)
☐ I do not know what this question is asking
☐ Prefer not to answer
That is all the questions we have at this time. Thank you very much for taking the time to talk with us today.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Abt Single-Sided Body Template |
| Author | Charmayne Walker |
| File Modified | 0000-00-00 |
| File Created | 2024-10-27 |