Form Approved
OMB No.
Exp. Date:
Attachment 24
Stress and Coping Questionnaires
<<Adolescent Health Questionnaire>>
Public reporting burden of this collection of information is estimated to average 20 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. 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 an other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)
Adolescent Health Questionnaire
Affix Case ID Label Here
Participant's ID Number
Interviewer Name _____________________________________________________
Date ____________/____________
month year
Start Time: I__I__I : I__I__I End Time: I__I__I : I__I__I
Public reporting burden of this collection of information is estimated to average 10 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. 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, Project Clearance Officer, 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0401). Do not send the completed form to this address.
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HEALTH PERCEPTIONS
1. I’d like to ask you some general questions about your health.
Would you say that in general your health is excellent, very good, good, fair, or poor?
EXCELLENT 1
VERY GOOD 2
GOOD 3
FAIR 4
POOR 5
DON’T KNOW 8
REFUSED 7
2. Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?
NUMBER OF DAYS: ___ ____
DON'T KNOW -1
REFUSED -2
3. Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?
NUMBER OF DAYS: ___ ____
DON'T KNOW -1
REFUSED -2
4. During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, school or recreation?
NUMBER OF DAYS: ___ ____
DON'T KNOW -1
REFUSED -2
5. Compared to other people your age, would you say your health is much better, better, the same, worse, or much worse?
MUCH BETTER 1
BETTER 2
THE SAME 3
WORSE 4
MUCH WORSE 5
DON’T KNOW 8
REFUSED 7
6. How would you rate your overall quality of life at the present time? Would you say excellent, very good, good, fair, or poor? By overall quality of life, we mean your well-being in general.
EXCELLENT 1
VERY GOOD 2
GOOD 3
FAIR 4
POOR 5
DON’T KNOW 8
REFUSED 7
7. In general, how satisfied are you with your life? Would you say very satisfied, satisfied, dissatisfied, or very dissatisfied?
VERY SATISFIED 1
SATISFIED 2
DISSATISFIED 3
VERY DISSATISFIED 4
DON’T KNOW 8
REFUSED 7
These next questions are about physical activity such as running, walking fast, biking, dancing and playing soccer and other sports. Physical activity is any activity that makes your heart beat faster and also makes you breathe faster.
8. Over a typical 7-day week, on how many days were you physically active for at least 60 minutes total per day, not including school PE (physical education) class?
In a typical 7-day week, on how many days do you do exercises to strengthen or tone your muscles, such as push-ups, sit-ups, or weight-training?
During the past 12 months, have you been a member of any sports teams at school or outside of school? Dance teams and cheerleading can be included here.
YES 1
NO 2
The next question is about classes you may have taken at school or outside of school. During the past 12 months, have you taken any physically active classes or lessons like dance, karate, gymnastics, swimming, or tennis?
YES 1
NO 2
During the school year, have you walked, bicycled, skateboarded or roller bladed to school?
YES 1
NO 2 SKIP TO QUESTION 13
12a. During the school year, on how many days during a typical week do you walk, bicycle, or skateboard, roller blade to school?
12b. About how many minutes does it take to walk, bicycle, skateboard or roller blade to school?
Minutes: ___ ___ ___
During the school year, have you walked, bicycled, skateboarded or roller bladed from school?
YES 1
NO 2 SKIP TO QUESTION 14
13a. During the school year, on how many days during a typical week do you walk, bicycle, or skateboard, roller blade from school?
13b. About how many minutes does it take to walk, bicycle, skateboard or roller blade from school?
Minutes: ___ ___ ___
Please think about your free time on weekdays (Mondays through Fridays). On a typical weekday, about how many hours do you usually watch TV or play video games?
Weekday hours watching TV or playing video: ______
About how many hours per day on weekdays do you use a computer for fun, not schoolwork?
Weekday hours using the computer for fun: ______
Now, thinking about weekends (Saturdays and Sundays), about how many hours per day do you usually watch TV or play video games?
Weekend hours watching TV or playing video: ______
And about how many hours per day on weekends do you use a computer for fun, not schoolwork?
Weekend hours using the computer for fun: ______
PERCEIVED STRESS
Now I’m going to ask you about your feelings and thoughts during the last month. In each case, please indicate how often you felt or thought a certain way.
18. In the last month, how often have you been upset because of something that happened unexpectedly?
Never 0
Almost never 1
Sometimes 2
Fairly often 3
Very often 4
DON'T KNOW 8
REFUSED 7
19. In the last month, how often have you felt that you were unable to control the important things in your life?
Never 0
Almost never 1
Sometimes 2
Fairly often 3
Very often 4
DON'T KNOW 8
REFUSED 7
20. In the last month, how often have you felt nervous and "stressed"?
Never 0
Almost never 1
Sometimes 2
Fairly often 3
Very often 4
DON'T KNOW 8
REFUSED 7
In the last month, how often have you felt confident about your ability to handle your personal problems?
Never 0
Almost never 1
Sometimes 2
Fairly often 3
Very often 4
DON'T KNOW 8
REFUSED 7
22. In the last month, how often have you felt that things were going your way?
Never 0
Almost never 1
Sometimes 2
Fairly often 3
Very often 4
DON'T KNOW 8
REFUSED 7
23. In the last month, how often have you found that you could not cope with all the things that you had to do?
Never 0
Almost never 1
Sometimes 2
Fairly often 3
Very often 4
DON'T KNOW 8
REFUSED 7
24. In the last month, how often have you been able to control irritations in your life?
Never 0
Almost never 1
Sometimes 2
Fairly often 3
Very often 4
DON'T KNOW 8
REFUSED 7
25. In the last month, how often have you felt that you were on top of things?
Never 0
Almost never 1
Sometimes 2
Fairly often 3
Very often 4
DON'T KNOW 8
REFUSED 7
In the last month, how often have you been angered because of things that were outside of your control?
Never 0
Almost never 1
Sometimes 2
Fairly often 3
Very often 4
DON'T KNOW 8
REFUSED 7
In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?
Never 0
Almost never 1
Sometimes 2
Fairly often 3
Very often 4
DON'T KNOW 8
REFUSED 7
SENSE OF COMMUNITY
The next part of this survey includes statements that people might make about their neighborhood.
If you live in a city or town, your neighborhood is your block. It includes all the buildings or houses on your street with numbers in the same range of 100. For example, if your address is 109 Maple Avenue, your neighborhood includes all the buildings and houses with an address between 100 and 199 Maple Avenue.
If you live in the country, your neighborhood is a 1-mile block.
For each statement, please mark whether it is mostly true or mostly false about your neighborhood.
|
|
Mostly True |
Mostly False |
28. I think my neighborhood is a good place for me to live. |
1 |
2 |
29. People in this neighborhood do not share the same values. |
1 |
2 |
30. My neighbors and I want the same things from the neighborhood. |
1 |
2 |
31. I can recognize most of the people who live in my neighborhood. |
1 |
2 |
32. I feel at home in this neighborhood. |
1 |
2 |
33. Very few of my neighbors know me. |
1 |
2 |
34. I care about what my neighbors think of my actions. |
1 |
2 |
35. I have no influence over what this neighborhood is like. |
1 |
2 |
36. If there is a problem in this neighborhood, people who live here can get it solved. |
1 |
2 |
37. It is very important to me to live in this particular neighborhood. |
1 |
2 |
38. People in this neighborhood generally don't get along with each other. |
1 |
2 |
39. I expect to live in this neighborhood for a long time. |
1 |
2 |
40. How long have you lived in your current neighborhood? _____________Years
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TOBACCO USE
41. Have you ever smoked cigarettes, smoked cigars, chewed tobacco, or used snuff?
1 Yes
2 No → END OF QUESTIONNAIRE – THANK YOU!
42. Have you ever smoked cigarettes regularly, that is, as least one per day for six months or longer?
1 Yes
2 No → IF NO, GO TO QUESTION 43
42a. How old were you when you started smoking cigarettes regularly?
Age: _________
42b. How many cigarettes would you say you smoke(d) per day?
Cigarettes per day: _________
42c. Do you currently smoke cigarettes?
1 Yes → IF YES, GO TO QUESTION 42e
2 No
42d. How old were you when you quit smoking cigarettes?
Age: _________
42e. Between the time when you started smoking cigarettes and the time that you quit or now, was there ever a period of one year or longer when you did not smoke cigarettes?
1 Yes
2 No → IF NO, GO TO QUESTION 43
42f. How many years did you not smoke cigarettes?
Number of years: _________
Do you currently smoke cigars regularly, that is, as least one per week ?
1 Yes
2 No
Do you currently chew at least one pouch or plug of tobacco per week?
1 Yes
2 No
45 . Do you currently use snuff?
1 Yes
2 No
Thank you. |
| File Type | application/msword |
| File Title | Health and Stress Questionnaire |
| Author | Abt Associates Inc. |
| Last Modified By | evm3 |
| File Modified | 2007-11-21 |
| File Created | 2007-06-01 |