Attachment 1: Questions to be cognitively tested
Form Approved
OMB No. 0920-0222
Exp. Date: 01/31/2026
Notice - CDC estimates the average public reporting burden for this collection of information as 60 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0222).
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I. Questions for Adults (18+) reporting on their child’s experiences
Children 0-17 years old
To the best of your knowledge, has this child EVER experienced any of the following? Was regularly sworn at, insulted, or put down by an adult
Yes
No
To the best of your knowledge, has this child EVER experienced any of the following? Was hit, beat, kicked, or physically hurt by an adult
Yes
No
To the best of your knowledge, has this child EVER experienced any of the following? Was forced to have sexual intercourse, forced to touch someone in a sexual way, or forced to be touched by someone in a sexual way when the child did not want to
Yes
No
When your family faces problems, how often are you likely to do each of the following: Talk together about what to do
All of the time
Most of the time
Some of the time
None of the time
When your family faces problems, how often are you likely to do each of the following: Work together to solve our problems
All of the time
Most of the time
Some of the time
None of the time
When your family faces problems, how often are you likely to do each of the following: Know we have strengths to draw on
All of the time
Most of the time
Some of the time
None of the time
When your family faces problems, how often are you likely to do each of the following: Stay hopeful even in difficult times
All of the time
Most of the time
Some of the time
None of the time
During the past month, how often have you felt that this child is much harder to care for than most children his or her age?
Never
Rarely
Sometimes
Usually
Always
During the past month, how often have you felt that this child does things that really bother you a lot?
Never
Rarely
Sometimes
Usually
Always
During the past 12 months, was there someone that you could turn to for day-to-day emotional support with parenting or raising children?
Yes
No
Which of these statements best describes your household’s ability to afford the food you need during the past 12 months (select one):
We can always afford to eat good nutritious meals
We could always afford enough to eat but not always the kinds of foods we should eat
Sometimes we could not afford enough to eat
Often we could not afford enough to eat
To what extent do you agree or disagree with these statements about your neighborhood or community? People in the neighborhood help each other out
Definitely agree
Somewhat agree
Somewhat disagree
Definitely disagree
To what extent do you agree or disagree with these statements about your neighborhood or community? We watch out for each others’ children in this neighborhood
Definitely agree
Somewhat agree
Somewhat disagree
Definitely disagree
To what extent do you agree or disagree with these statements about your neighborhood or community? When we encounter difficulties, we know where to go for help in our community
Definitely agree
Somewhat agree
Somewhat disagree
Definitely disagree
To what extent do you agree or disagree with these statements about your neighborhood or community? This child is safe in our neighborhood
Definitely agree
Somewhat agree
Somewhat disagree
Definitely disagree
To what extent do you agree or disagree with these statements about your neighborhood or community? This child is safe at school
Definitely agree
Somewhat agree
Somewhat disagree
Definitely disagree
Children 6 months to 5 years
How often is this child affectionate and tender with you?
Always
Usually
Sometimes
Never
How often does this child bounce back quickly when things do not go his or her way?
Always
Usually
Sometimes
Never
How often does this child show interest and curiosity in learning new things?
Always
Usually
Sometimes
Never
How often does this child smile and laugh?
Always
Usually
Sometimes
Never
Children 3-17 years
Compared to other children his or her age, how much difficulty does this child have making or keeping friends?
No difficulty
A little difficulty
A lot of difficulty
Children 6-17 years
How well can you and this child share ideas or talk about things that really matter?
Very well
Somewhat well
Not very well
Not well at all
Other than you or other adults in your home, is there at least one other adult in this child’s school, neighborhood, or community who knows this child well and who he or she can rely on for advice or guidance?
Yes
No
How often does this child do all required homework?
Always
Usually
Sometimes
Never
How often does this child care about doing well in school?
Always
Usually
Sometimes
Never
How often does this child show interest and curiosity in learning new things?
Always
Usually
Sometimes
Never
How often does this child work to finish tasks he or she starts?
Always
Usually
Sometimes
Never
How often does this child stay calm and in control when faced with a challenge?
Always
Usually
Sometimes
Never
II. Questions for Adults (18+) reporting on their own experiences
These questions refer to the time before you were 18 years of age.
How often did you feel your family stood by you during difficult times?
Never
Rarely
Sometimes
Often
Very often
How often did you feel that you were able to talk to your family about your feelings?
Never
Rarely
Sometimes
Often
Very often
For how much of your childhood was there an adult in your household who made you feel safe and protected?
Never
Rarely
Sometimes
Often
Very often
How often did you enjoy participating in your community’s traditions?
Never
Rarely
Sometimes
Often
Very often
How often did you feel supported by your friends?
Never
Rarely
Sometimes
Often
Very often
How often did you feel that you belonged at your high school?
Never
Rarely
Sometimes
Often
Very often
How often were there at least two adults, other than your parents, who took a genuine interest in you?
Never
Rarely
Sometimes
Often
Very often
For how much of your childhood did you have beliefs that gave you comfort?
Never
Rarely
Sometimes
Often
Very often
For how much of your childhood did you have at least one teacher who cared about you?
Never
Rarely
Sometimes
Often
Very often
How often did you have opportunities to have a good time?
Never
Rarely
Sometimes
Often
Very often
How often did you have a predictable home routine, like regular meals and a regular bedtime?
Never
Rarely
Sometimes
Often
Very often
How often did you and your parent/caregiver share ideas or talk about things that really matter?
Never
Rarely
Sometimes
Often
Very often
In general, how was your parents’/caregivers’ mental or emotional health?
Excellent
Very Good
Good
Fair
Poor
Which of these statements best describes your household’s ability to afford the food you needed when you were growing up:
We could always afford to eat good nutritious meals
We could always afford enough to eat but not always the kinds of foods we should eat
Sometimes we could not afford enough to eat
Often we could not afford enough to eat
Looking back on the neighborhood or community where you grew up (before you were 18 years of age), how often did people in the neighborhood help each other out?
Never
Rarely
Sometimes
Often
Very often
Looking back on the neighborhood or community where you grew up (before you were 18 years of age), how often did families watch out for each others’ children in your neighborhood?
Never
Rarely
Sometimes
Often
Very often
Looking back on the neighborhood or community where you grew up (before you were 18 years of age), how often did you feel safe in your neighborhood?
Never
Rarely
Sometimes
Often
Very often
How often did you care about doing well in school?
Never
Rarely
Sometimes
Often
Very often
How often did you get along with people around you?
Never
Rarely
Sometimes
Often
Very often
How important was getting an education to you?
Not at all important
A little important
Somewhat important
Very important
How often did you feel that your parents/caregivers really looked out for you?
Never
Rarely
Sometimes
Often
Very often
How often did you feel that your parents/caregivers knew a lot about you (for example, who your friends were, what you liked to do)?
Never
Rarely
Sometimes
Often
Very often
How often did you feel that people liked to spend time with you?
Never
Rarely
Sometimes
Often
Very often
How often were you able to talk to your family/caregiver(s) about your feelings (for example, when you were hurt or sad)?
Never
Rarely
Sometimes
Often
Very often
How often did you feel supported by your friends?
Never
Rarely
Sometimes
Often
Very often
How often did you feel that you belonged at your high school?
Never
Rarely
Sometimes
Often
Very often
How often did you feel that your family/caregiver(s) cared about you when times were hard (for example, when you were sick or had done something wrong)?
Never
Rarely
Sometimes
Often
Very often
How often did you feel that your friends cared about you when times were hard (for example if you were sick or had done something wrong)?
Never
Rarely
Sometimes
Often
Very often
How often did you feel treated fairly in your community?
Never
Rarely
Sometimes
Often
Very often
How often did you have chances to show others that you were growing up and could do things by yourself?
Never
Rarely
Sometimes
Often
Very often
How often did you feel safe when you were with your family/caregivers?
Never
Rarely
Sometimes
Often
Very often
How often did you have chances to learn things that would be useful when you were older (like cooking, working, and helping others)?
Never
Rarely
Sometimes
Often
Very often
III. Questions for Adolescents (14-18) reporting on their own experiences
The next 4 questions ask about bullying. Bullying is when 1 or more students tease, threaten, spread rumors about, hit, shove, or hurt another student over and over again. It is not bullying when 2 students of about the same strength or power argue or fight or tease each other in a friendly way.
During the past 12 months, have you ever been bullied on school property?
Yes
No
During the past 12 months, have you ever been electronically bullied? (Count being bullied through texting, Instagram, Facebook, or other social media.)
Yes
No
During the past 12 months, have you ever bullied someone on school property?
Yes
No
During the past 12 months, have you ever electronically bullied someone?
Yes
No
During the past 12 months, did you ever force anyone to do sexual things that they did not want to do?
Yes
No
Do you have at least one caregiver with whom you feel safe?
Yes
No
Do you have at least one good friend?
Yes
No
Do you have beliefs that give you comfort?
Yes
No
Do you have at least one teacher who cares about you?
Yes
No
How often is there an adult, other than your parents or caregivers, who could provide you with support or advice?
Yes
No
Do you have opportunities to have a good time?
Yes
No
Do you have a predictable home routine, like regular meals and a regular bedtime?
Yes
No
How often do you and your parent/caregiver share ideas or talk about things that really matter?
Never
Rarely
Sometimes
Often
Very often
In general, how is your parents’/caregivers’ mental or emotional health?
Excellent
Very Good
Good
Fair
Poor
Which of these statements best describes your household’s ability to afford the food you needed:
We can always afford to eat good nutritious meals
We can always afford enough to eat but not always the kinds of foods we should eat
Sometimes we cannot afford enough to eat
Often we cannot afford enough to eat
Thinking about the neighborhood or community where you live, how often do people in the neighborhood help each other out?
Never
Rarely
Sometimes
Often
Very often
Thinking about the neighborhood or community where you live, how often do families watch out for each others’ children in your neighborhood?
Never
Rarely
Sometimes
Often
Very often
Thinking about the neighborhood or community where you live, how often do you feel safe in your neighborhood?
Never
Rarely
Sometimes
Often
Very often
Has there ever been a time when you needed health care but it was not received? By health care, we mean medical care as well as other kinds of care like dental care, vision care, and mental health services.
Yes
No
Do you get along with people around you?
Not at all
A little
Somewhat
Quite a bit
A lot
Is doing well in school important to you?
Not at all
A little
Somewhat
Quite a bit
A lot
Do you feel that your parents/caregivers really look out for you?
Not at all
A little
Somewhat
Quite a bit
A lot
Do you feel that your parents/caregivers know a lot about you (for example, who your friends are, what you like to do)?
Not at all
A little
Somewhat
Quite a bit
A lot
Do you talk to your family/caregiver(s) about your feelings (for example, when you are hurt or sad)?
Not at all
A little
Somewhat
Quite a bit
A lot
Do you feel treated fairly in your community?
Not at all
A little
Somewhat
Quite a bit
A lot
Do you have chances to show others that you are growing up and can do things by yourself?
Not at all
A little
Somewhat
Quite a bit
A lot
Do you feel safe when you are with your family/caregivers?
Not at all
A little
Somewhat
Quite a bit
A lot
Do you have chances to learn things that will be useful when you are older (like cooking, working, and helping others)?
Not at all
A little
Somewhat
Quite a bit
A lot
Do you like the way your family/caregiver(s) celebrates things (like holidays or learning about your culture)?
Not at all
A little
Somewhat
Quite a bit
A lot
During your life, how often has there been an adult in your household who made you feel safe and protected?
Never
Rarely
Sometimes
Often
Very often
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Virkar, Saarika (CDC/DDPHSS/NCHS/DRM) |
File Modified | 0000-00-00 |
File Created | 2025-05-19 |