0920- 0222-23EQ Questions

Attachment 1: Questions to be cognitively tested

Form Approved

OMB No. 0920-0222

Exp. Date: 01/31/2026

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I. Questions for Adults (18+) reporting on their child’s experiences

Children 0-17 years old

1. 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

   1. Yes

   2. No

2. 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

   1. Yes

   2. No

3. 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

   1. Yes

   2. No

4. When your family faces problems, how often are you likely to do each of the following: Talk together about what to do

   1. All of the time

   2. Most of the time

   3. Some of the time

   4. None of the time

5. When your family faces problems, how often are you likely to do each of the following: Work together to solve our problems

   1. All of the time

   2. Most of the time

   3. Some of the time

   4. None of the time

6. When your family faces problems, how often are you likely to do each of the following: Know we have strengths to draw on

   1. All of the time

   2. Most of the time

   3. Some of the time

   4. None of the time

7. When your family faces problems, how often are you likely to do each of the following: Stay hopeful even in difficult times

   1. All of the time

   2. Most of the time

   3. Some of the time

   4. None of the time

8. 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?

   1. Never

   2. Rarely

   3. Sometimes

   4. Usually

   5. Always

9. During the past month, how often have you felt that this child does things that really bother you a lot?

   1. Never

   2. Rarely

   3. Sometimes

   4. Usually

   5. Always

10. During the past 12 months, was there someone that you could turn to for day-to-day emotional support with parenting or raising children?

1. Yes

2. No

11. Which of these statements best describes your household’s ability to afford the food you need during the past 12 months (select one):

    1. We can always afford to eat good nutritious meals

    2. We could always afford enough to eat but not always the kinds of foods we should eat

    3. Sometimes we could not afford enough to eat

    4. Often we could not afford enough to eat

12. To what extent do you agree or disagree with these statements about your neighborhood or community? People in the neighborhood help each other out

    1. Definitely agree

    2. Somewhat agree

    3. Somewhat disagree

    4. Definitely disagree

13. 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

    1. Definitely agree

    2. Somewhat agree

    3. Somewhat disagree

    4. Definitely disagree

14. 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

    1. Definitely agree

    2. Somewhat agree

    3. Somewhat disagree

    4. Definitely disagree

15. To what extent do you agree or disagree with these statements about your neighborhood or community? This child is safe in our neighborhood

    1. Definitely agree

    2. Somewhat agree

    3. Somewhat disagree

    4. Definitely disagree

16. To what extent do you agree or disagree with these statements about your neighborhood or community? This child is safe at school

    1. Definitely agree

    2. Somewhat agree

    3. Somewhat disagree

    4. Definitely disagree

Children 6 months to 5 years

17. How often is this child affectionate and tender with you?

    1. Always

    2. Usually

    3. Sometimes

    4. Never

18. How often does this child bounce back quickly when things do not go his or her way?

    1. Always

    2. Usually

    3. Sometimes

    4. Never

19. How often does this child show interest and curiosity in learning new things?

    1. Always

    2. Usually

    3. Sometimes

    4. Never

20. How often does this child smile and laugh?

    1. Always

    2. Usually

    3. Sometimes

    4. Never

Children 3-17 years

21. Compared to other children his or her age, how much difficulty does this child have making or keeping friends?

    1. No difficulty

    2. A little difficulty

    3. A lot of difficulty

Children 6-17 years

22. How well can you and this child share ideas or talk about things that really matter?

    1. Very well

    2. Somewhat well

    3. Not very well

    4. Not well at all

23. 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?

    1. Yes

    2. No

24. How often does this child do all required homework?

    1. Always

    2. Usually

    3. Sometimes

    4. Never

25. How often does this child care about doing well in school?

    1. Always

    2. Usually

    3. Sometimes

    4. Never

26. How often does this child show interest and curiosity in learning new things?

    1. Always

    2. Usually

    3. Sometimes

    4. Never

27. How often does this child work to finish tasks he or she starts?

    1. Always

    2. Usually

    3. Sometimes

    4. Never

28. How often does this child stay calm and in control when faced with a challenge?

    1. Always

    2. Usually

    3. Sometimes

    4. Never

II. Questions for Adults (18+) reporting on their own experiences

These questions refer to the time before you were 18 years of age.

1. How often did you feel your family stood by you during difficult times?

   1. Never

   2. Rarely

   3. Sometimes

   4. Often

   5. Very often

2. How often did you feel that you were able to talk to your family about your feelings?

   1. Never

   2. Rarely

   3. Sometimes

   4. Often

   5. Very often

3. For how much of your childhood was there an adult in your household who made you feel safe and protected?

   1. Never

   2. Rarely

   3. Sometimes

   4. Often

   5. Very often

4. How often did you enjoy participating in your community’s traditions?

   1. Never

   2. Rarely

   3. Sometimes

   4. Often

   5. Very often

5. How often did you feel supported by your friends?

   1. Never

   2. Rarely

   3. Sometimes

   4. Often

   5. Very often

6. How often did you feel that you belonged at your high school?

   1. Never

   2. Rarely

   3. Sometimes

   4. Often

   5. Very often

7. How often were there at least two adults, other than your parents, who took a genuine interest in you?

   1. Never

   2. Rarely

   3. Sometimes

   4. Often

   5. Very often

8. For how much of your childhood did you have beliefs that gave you comfort?

   1. Never

   2. Rarely

   3. Sometimes

   4. Often

   5. Very often

9. For how much of your childhood did you have at least one teacher who cared about you?

   1. Never

   2. Rarely

   3. Sometimes

   4. Often

   5. Very often

10. How often did you have opportunities to have a good time?

    1. Never

    2. Rarely

    3. Sometimes

    4. Often

    5. Very often

11. How often did you have a predictable home routine, like regular meals and a regular bedtime?

    1. Never

    2. Rarely

    3. Sometimes

    4. Often

    5. Very often

12. How often did you and your parent/caregiver share ideas or talk about things that really matter?

    1. Never

    2. Rarely

    3. Sometimes

    4. Often

    5. Very often

13. In general, how was your parents’/caregivers’ mental or emotional health?

    1. Excellent

    2. Very Good

    3. Good

    4. Fair

    5. Poor

14. Which of these statements best describes your household’s ability to afford the food you needed when you were growing up:

    1. We could always afford to eat good nutritious meals

    2. We could always afford enough to eat but not always the kinds of foods we should eat

    3. Sometimes we could not afford enough to eat

    4. Often we could not afford enough to eat

15. 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?

    1. Never

    2. Rarely

    3. Sometimes

    4. Often

    5. Very often

16. 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?

    1. Never

    2. Rarely

    3. Sometimes

    4. Often

    5. Very often

17. 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?

    1. Never

    2. Rarely

    3. Sometimes

    4. Often

    5. Very often

18. How often did you care about doing well in school?

    1. Never

    2. Rarely

    3. Sometimes

    4. Often

    5. Very often

19. How often did you get along with people around you?

    1. Never

    2. Rarely

    3. Sometimes

    4. Often

    5. Very often

20. How important was getting an education to you?

    1. Not at all important

    2. A little important

    3. Somewhat important

    4. Very important

21. How often did you feel that your parents/caregivers really looked out for you?

    1. Never

    2. Rarely

    3. Sometimes

    4. Often

    5. Very often

22. 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)?

    1. Never

    2. Rarely

    3. Sometimes

    4. Often

    5. Very often

23. How often did you feel that people liked to spend time with you?

    1. Never

    2. Rarely

    3. Sometimes

    4. Often

    5. Very often

24. How often were you able to talk to your family/caregiver(s) about your feelings (for example, when you were hurt or sad)?

    1. Never

    2. Rarely

    3. Sometimes

    4. Often

    5. Very often

25. How often did you feel supported by your friends?

    1. Never

    2. Rarely

    3. Sometimes

    4. Often

    5. Very often

26. How often did you feel that you belonged at your high school?

    1. Never

    2. Rarely

    3. Sometimes

    4. Often

    5. Very often

27. 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)?

    1. Never

    2. Rarely

    3. Sometimes

    4. Often

    5. Very often

28. 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)?

    1. Never

    2. Rarely

    3. Sometimes

    4. Often

    5. Very often

29. How often did you feel treated fairly in your community?

    1. Never

    2. Rarely

    3. Sometimes

    4. Often

    5. Very often

30. How often did you have chances to show others that you were growing up and could do things by yourself?

    1. Never

    2. Rarely

    3. Sometimes

    4. Often

    5. Very often

31. How often did you feel safe when you were with your family/caregivers?

    1. Never

    2. Rarely

    3. Sometimes

    4. Often

    5. Very often

32. How often did you have chances to learn things that would be useful when you were older (like cooking, working, and helping others)?

    1. Never

    2. Rarely

    3. Sometimes

    4. Often

    5. 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.

1. During the past 12 months, have you ever been bullied on school property?

1. Yes

2. No

2. During the past 12 months, have you ever been electronically bullied? (Count being bullied through texting, Instagram, Facebook, or other social media.)

1. Yes

2. No

3. During the past 12 months, have you ever bullied someone on school property?

1. Yes

2. No

4. During the past 12 months, have you ever electronically bullied someone?

1. Yes

2. No

5. During the past 12 months, did you ever force anyone to do sexual things that they did not want to do?

1. Yes

2. No

6. Do you have at least one caregiver with whom you feel safe?

1. Yes

2. No

7. Do you have at least one good friend?

1. Yes

2. No

8. Do you have beliefs that give you comfort?

1. Yes

2. No

9. Do you have at least one teacher who cares about you?

1. Yes

2. No

10. How often is there an adult, other than your parents or caregivers, who could provide you with support or advice?

1. Yes

2. No

11. Do you have opportunities to have a good time?

1. Yes

2. No

12. Do you have a predictable home routine, like regular meals and a regular bedtime?

1. Yes

2. No

13. How often do you and your parent/caregiver share ideas or talk about things that really matter?

1. Never

2. Rarely

3. Sometimes

4. Often

5. Very often

14. In general, how is your parents’/caregivers’ mental or emotional health?

1. Excellent

2. Very Good

3. Good

4. Fair

5. Poor

15. Which of these statements best describes your household’s ability to afford the food you needed:

1. We can always afford to eat good nutritious meals

2. We can always afford enough to eat but not always the kinds of foods we should eat

3. Sometimes we cannot afford enough to eat

4. Often we cannot afford enough to eat

16. Thinking about the neighborhood or community where you live, how often do people in the neighborhood help each other out?

1. Never

2. Rarely

3. Sometimes

4. Often

5. Very often

17. Thinking about the neighborhood or community where you live, how often do families watch out for each others’ children in your neighborhood?

1. Never

2. Rarely

3. Sometimes

4. Often

5. Very often

18. Thinking about the neighborhood or community where you live, how often do you feel safe in your neighborhood?

1. Never

2. Rarely

3. Sometimes

4. Often

5. Very often

19. 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.

1. Yes

2. No

20. Do you get along with people around you?

1. Not at all

2. A little

3. Somewhat

4. Quite a bit

5. A lot

21. Is doing well in school important to you?

1. Not at all

2. A little

3. Somewhat

4. Quite a bit

5. A lot

22. Do you feel that your parents/caregivers really look out for you?

1. Not at all

2. A little

3. Somewhat

4. Quite a bit

5. A lot

23. Do you feel that your parents/caregivers know a lot about you (for example, who your friends are, what you like to do)?

1. Not at all

2. A little

3. Somewhat

4. Quite a bit

5. A lot

24. Do you talk to your family/caregiver(s) about your feelings (for example, when you are hurt or sad)?

1. Not at all

2. A little

3. Somewhat

4. Quite a bit

5. A lot

25. Do you feel treated fairly in your community?

1. Not at all

2. A little

3. Somewhat

4. Quite a bit

5. A lot

26. Do you have chances to show others that you are growing up and can do things by yourself?

1. Not at all

2. A little

3. Somewhat

4. Quite a bit

5. A lot

27. Do you feel safe when you are with your family/caregivers?

1. Not at all

2. A little

3. Somewhat

4. Quite a bit

5. A lot

28. Do you have chances to learn things that will be useful when you are older (like cooking, working, and helping others)?

1. Not at all

2. A little

3. Somewhat

4. Quite a bit

5. A lot

29. Do you like the way your family/caregiver(s) celebrates things (like holidays or learning about your culture)?

1. Not at all

2. A little

3. Somewhat

4. Quite a bit

5. A lot

30. During your life, how often has there been an adult in your household who made you feel safe and protected?

    1. Never

    2. Rarely

    3. Sometimes

    4. Often

    5. Very often