Form 2 Family Household Visit Protocol Overview

The Healthy Communities Study: How Communities Shape Childrens Health (NHLBI)

FINAL_HCS_SSA_ATTACH 6_PARENT PROTOCOL_Jan 2013 v2

Parents/Caregivers

OMB: 0925-0649

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0925-0649 can be found here:

2013-07-24 - Revision of a currently approved collection

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SSA ATTACHMENT 6

HEALTHY COMMUNITIES STUDY

FAMILY HOUSEHOLD VISIT PROTOCOL OVERVIEW

FOR PARENTS/CAREGIVER PARTICIPANTS

This document provides an overview of the protocol for the family household visit for the parent/caregiver participant. Protocol materials include the recruitment script, consent and medical record release authorization forms, the anthropometric measurement recording form, and the Home Visit Interview survey instrument (sections that may be completed by the parent/caregiver are highlighted). These data collection materials will be used for the household visit in every community.

Recruitment of Households with an Eligible Child and Adult Guardian

If the selected family is found to be eligible during the screening call (see SSA Attachment 5 for the screening script) and is willing to participate in the study, the Battelle telephone interview will continue the call with the recruitment and scheduling script to provide further detail on the study, record basic contact information, enroll the family into the study, and schedule the date and time for the household visit. At the time of enrollment, 1 in 9 (approximately 11%) of the families within each community will be randomly selected to participate in the Enhanced Protocol, which involves a more detailed first visit, a second home visit 8-10 days later, and the use of an accelerometer by the child during the time between the two visits.

Consent of Parents/Caregivers

Once a potential adult participant has completed the eligibility screening and recruitment on the phone and scheduled a home visit, a trained field interviewer will go to their home. The field interviewer will explain the study to the parent/caregiver and child in their home, review the consent documents, and answer any questions the parent/caregiver may have. At this time, the parent/caregiver will be asked to sign the informed consent form, which will indicate their consent to participate. If other parents/caregivers are living in the home and available to be measured, they will also be asked to sign the form indicating their agreement to be measured. Field interviewers will be trained to explain the study thoroughly and answer questions fully. They will be instructed to proceed only if the participants have provided their voluntary, informed consent. Field interviewers will be trained in Human Subjects Research, and will therefore know the guidelines regarding what qualifies as “informed” consent.

The data collection requirements for Standard and Enhanced Protocol participants are very different and every community will have families taking part in both protocol models. Therefore, the study will need to utilize 2 different consent forms. A master version of the adult consent form is provided with the shaded wording under Procedures and Compensation indicating where sentences or phrases will differ as appropriate to the 2 conditions.

Home Visit Data Collection

As described earlier, every participating family will be administered at least one in-person home visit (home visit 1). Enhanced Protocol families have a second home visit (home visit 2) 8 to 10 days later. All of the questions to be asked of both Standard and Enhanced Protocol parent/caregivers during home visit 1 and home visit 2 using the study designed computer assisted interview (CAI) are provided. In addition to asking these computer-assisted questions, other data collection activities will take place in the home following consent.

Home Visit 1

While in the home, anthropometric measurements will be taken and recorded either directly on the computer or onto a paper form; the measurements on the paper form will be entered into the computer at the earliest opportunity before leaving the house. A medical record release form will also be completed and signed by the parent/caregiver. Data from this form will be entered into the study database by the field interviewer following the home visit. At this time the incentive will also be distributed.

If the family is participating in the Enhanced Protocol, during the first home visit the children’s version of the National Cancer Institute (NCI) Automated Self-Administered 24-hour Dietary Recall (ASA24-Kids) will be completed for the previous day by using the study computer and its broadband card to access the online instrument. The dietary recall will be self-administered. The field interviewer will log on and enter the child’s ID, note the date and time the interview commences, and then turn over the computer to the primary respondent. The primary respondent, along with the secondary respondent, will use the computer to enter the information prompted by the online mascot. The field interviewer will be trained to give a neutral introduction and clear instructions to the parent/caregiver and child regarding who is to respond and to encourage interchange to obtain the most accurate information about the child's food intake on the previous day. The ASA24-Kids dietary recall will take approximately 30 minutes. Data collected through this web instrument will later be downloaded following the NCI’s procedures for data retrieval. Enhanced Protocol families will also be shown how to attach and detach the accelerometer during this first home visit, this demonstration is anticipated to take 2.5 minutes.

Home Visit 2

At the second home visit, the accelerometer will be retrieved and the data from the device will be downloaded into the study database. The ASA24-Kids dietary recall will be administered for the previous day by using the study computer and its broadband card to access the online instrument and a Physical Behavior Activity Recall instrument will also be administered (this instrument is provided as part of the home visit questionnaire instrument under the Enhanced Protocol section). The second incentive will be distributed during this visit.

HEALTHY COMMUNITIES STUDY

HOUSEHOLD RECRUITMENT AND HOME VISIT SCHEDULING SCRIPT

[CONTINUED FROM SCREENING SCRIPT FOR ELIGIBLE RESPONDENTS]

Public reporting burden for this collection of information is estimated to average 11 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0649). Do not return the completed form to this address.

	Next I'm going to give you a brief summary of what we'll be doing during your home visit(s).
	IF CHILD IS IN KINDERGARTEN THROUGH 5TH GRADE AND WAS SELECTED FOR STANDARD PROTOCOL: Your home visit will last about 1 hour and 15 minutes. Both (CHILD NAME) and you will need to be present during the whole visit. During the home visit, the study team member will measure (CHILD NAME)’s height, weight and waist circumference and ask you to answer some survey questions. Children are also asked questions that vary based on their age, which you may need to help them answer. At the end of this visit, you will receive a gift worth $25 and your child will receive a small toy as a thank you for finishing the visit.
	IF CHILD IS IN KINDERGARTEN THROUGH 5TH GRADE AND WAS SELECTED FOR ENHANCED PROTOCOL: You will have two home visits – the first one will last about 1 hour and 35 minutes and the second one will last about 50 minutes. Both (CHILD NAME) and you will need to be there for both visits for the whole visit. During the first home visit, the study team member will measure (CHILD NAME)’s height, weight and waist, ask you to answer some survey questions, and work with you to fill out a survey online where you report what foods your child ate on the day before the visit. Children are asked questions based on their age. You may need to help (CHILD NAME) answer some of the questions. The study team member will give you an activity monitor for your child to wear and show you how to use it. Your child will be asked to wear the monitor for approximately 8 days while (HE/SHE) is awake. At the end of this first visit, you will receive a gift worth $25 and your child will receive a small toy as a thank you for finishing the visit. A week after your first home visit, the study team member will return to your home. During the second home visit, the study team member will collect the activity monitor, ask you some additional questions, and do the food recall task again. Your family will get an additional $50 money order at the end of this second visit.
	IF CHILD IS IN 6TH THROUGH 8TH GRADE AND WAS SELECTED FOR STANDARD PROTOCOL: Your home visit will last about 1 hour and 15 minutes. Both (CHILD NAME) and you will need to be present during the whole visit. During the home visit, the study team member will measure (CHILD NAME)’s height, weight and waist circumference and ask you to answer some survey questions. Children are also asked questions that vary based on their age, which you may need to help them answer. At the end of the visit, you will each receive a gift worth $15 as a thank you for finishing the visit.
	IF CHILD IS IN 6TH THROUGH 8TH GRADE AND WAS SELECTED FOR ENHANCED PROTOCOL: You will have two home visits – the first one will last about 1 hour and 35 minutes and the second one will last about 50 minutes. Both (CHILD NAME) and you will need to be there for both visits for the whole visit. During the first home visit, the study team member will measure (CHILD NAME)’s height, weight and waist, ask you to answer some survey questions, and work with you to fill out a survey online where you report what foods your child ate on the day before the visit. Children are asked questions based on their age. You may need to help (CHILD NAME) answer some of the questions. The study team member will give you an activity monitor for your child to wear and show you how to use it. Your child will be asked to wear the monitor for approximately 8 days while (HE/SHE) is awake. At the end of this first visit, you will each get a gift worth $15 as a thank you for finishing the visit. Eight days after your first home visit, the study team member will return to your home. During the second home visit, the study team member will collect the activity monitor, ask you some additional questions, and do the food recall task again. Your family will get an additional $50 money order at the end of this second visit.
	Now I need to ask you a few questions to see which adults in your household we would like to be present during the visit.
Q1.	Are you a legal guardian of (CHILD NAME), such that you can sign study related forms, including medical record release forms?
	IF YES PROCEED. IF NO: May I please have the first name of (CHILD NAME)'s legal guardian?
Q2.	Are you (CHILD NAME)'s biological parent?
	IF YES PROCEED. IF NO SKIP TO Q4.
Q3.	Since you are (CHILD NAME)'s biological parent, we will want to measure you. Could (CHILD NAME)'s other biological parent also be available to be measured during our visit?
	IF YES: Ok, great. What is (HIS/HER) name? SKIP TO Q5.
	IF NO: Ok -- does (CHILD NAME) have another adult caregiver who would be available to be measured during the visit?
	IF YES: Great, could you please tell me his or her name and relationship to (CHILD NAME)?
Q4.	IF ADULT RESPONDENT IS NOT A BIOLOGICAL PARENT: Are (CHILD NAME)'s biological parents available to be measured during the home visit?
	IF YES: What is (CHILD NAME)'s biological mother's name? What about (HIS/HER) biological father? IF NO SKIP TO Q5.
	IF BIOLOGICAL PARENTS UNABLE TO BE MEASURED: Ok - does (CHILD NAME) have any other adult caregivers who would be available to be measured during the home visit?
	IF YES: Could you please tell me the names and relationships of the other adult caregivers to (CHILD NAME)?
Q5.	I would now like to schedule your home visit(s). We would like you and (CHILD NAME) to be there for the whole visit. We only need (NAME OF OTHER ADULT(S) BEING MEASURED) to be there for about 10 minutes at any time during the visit. ([IF ADULT RESPONDENT IS NOT LEGAL GUARDIAN]: Please make sure that (LEGAL GUARDIAN NAME) is there at the beginning of the visit to sign a form saying that (CHILD NAME) can be in the study.) What day of the week and what time works best for you?
	IF CHILD IS 12-15 YEARS OLD: Please let (CHILD NAME) know that (HE/SHE) will be actively involved during the majority of the appointment time.
	Ok, so I have you scheduled for [DAY OF WEEK], [MONTH DAY] at [XX:XX AM/PM].
	ENHANCED HOUSEHOLDS: And your second appointment is scheduled for [DAY OF WEEK], [MONTH DAY] at [XX:XX AM/PM].
Q6.	In order for us to give your information to the study team member so that a home visit can be scheduled, I need to get your full contact information. -Please tell me your full name. -And what is (CHILD NAME)’s full name? -What language(s) do you and (CHILD NAME) speak? -I'd like to confirm the best phone number to reach you that you listed on the interest form. I have (###-###-####). Is that correct? [IF NOT, RECORD BEST NUMBER]. -I have (###-###-####) listed as another number to reach you. Is that correct? [IF NOT, RECORD ALTERNATE NUMBER]. ([IF NO ALTERNATIVE NUMBER PROVIDED]: I did not see any other numbers where we can reach you. Do you have another phone number we can call to try to reach you?) -Is there a family member or friend we can call if we have trouble reaching you at the numbers you just gave me?
	IF YES: Ok, may I please have the full name, relationship, and phone number for that person? IF NO: Ok, that’s fine.
	We would like you to have your child’s birth certificate available at the time of your home visit so that we can record the birth weight and length of your child and how far along you were in your pregnancy when you gave birth.
	The study team member will call you to confirm your visit one to two days before the visit. If, at that time, your schedule changed, let the interviewer know and we can get your visit rescheduled. Thank you so much for your time today. Please call us at ###-###-#### if you have any questions or if your schedule changes. Have a great day!

HEALTHY COMMUNITIES STUDY

MASTER ADULT CONSENT FORM FOR WAVE 2¹

Public reporting burden for 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0649). Do not return the completed form to this address.

PURPOSE

The purpose of the Healthy Communities Study is to see what programs and policies in communities across the United States help children lead healthy lives. This study is being conducted by a research company, Battelle Memorial Institute. It is funded by the National Institutes of Health (NIH).

PROCEDURES – STANDARD PROTOCOL

If you agree to have you and your child participate in this study, a trained interviewer will come to your home one time. He or she will ask you and your child questions about nutrition and physical activity. The interviewer will also ask questions about your home and your community and will record the precise location of your home. This information will allow researchers to look at the specific resources and environment around the homes of study participants to understand where community programs have an impact.

Your answers will be recorded on a computer and some answers will be entered into the computer directly by you and your child. If your child is aged 12 or older when we come to your home, we will ask him or her to answer many of the questions without your help.

The interviewer will take measurements of your child including your child’s height, weight, and waist circumference. A cosmetic pencil will be used to place a small mark on your child’s hip in order to accurately place the tape measure for the waist measurement.The interviewer will also record current height and weight measurements for the child’s parents/caregivers. If you are a parent/caregiver, the interviewer will measure your height and weight today, and measure the height and weight of the other parent/caregiver, if he or she lives here, is available today, and consents to being measured. If you are not the parent/caregiver, the interviewer will measure the height and weight of the parents/caregivers if either/both live here, are available today, and consent to being measured. If any parent/caregiver is not available or willing to be measured, we will ask you to report their latest known height and weight, if you know that information. All measurements will be repeated for accuracy. Finally, the interviewer will ask you to sign a form to let us look at your child’s past medical records on file at your child’s doctor’s office to collect information on how your child has been growing. The entire visit today by the interviewer should take about 75 minutes.

We may also contact you again in the future when similar studies take place in your community. At that time you will be given the choice to participate in that new study or not.

PROCEDURES – ENHANCED PROTOCOL

If you agree to have you and your child participate in this study, a trained interviewer will come to your home two times. During the first visit, he or she will ask you and your child questions about nutrition and physical activity. The interviewer will also ask questions about your home and your community and will record the precise location of your home. This information will allow researchers to look at the specific resources and environment around the homes of study participants to understand where community programs have an impact.

The interviewer will take measurements of your child including your child’s height, weight, and waist circumference. A cosmetic pencil will be used to place a small mark on your child’s hip in order to accurately place the tape measure for the waist measurement.The interviewer will also record current height and weight measurements for the child’s parents/caregivers. If you are a parent/caregiver, the interviewer will measure your height and weight today, and measure the height and weight of the other parent/caregiver, if he or she lives here, is available today, and consents to being measured. If you are not the parent/caregiver, the interviewer will measure the height and weight of the parents/caregivers if either/both live here, are available today, and consent to being measured. If any parent/careiver is not available or willing to be measured, we will ask you to report their latest known height and weight, if you know that information. All measurements will be repeated for accuracy.

Your child will be asked to wear an activity monitor for the next week. The monitor measures movement. It should be worn at all times except while sleeping or when in water, such as while bathing or swimming. The interviewer will show you how to put the monitor on (and take it off) your child.

You and your child will also be asked to recall what your child ate yesterday. Finally, the interviewer will ask you to sign a form to let us look at your child’s past medical records on file at your child’s doctor’s office to collect information on how your child has been growing. The entire first visit by the interviewer should take about 95 minutes.

One week after the first visit, the interviewer will come back to your house to collect the activity monitor and repeat the food recall and the measurements. At this time, they will also ask you questions about what activities your child did yesterday. This second visit will take approximately 50 minutes.

We may also contact you again in the future when similar studies take place in your community. At that time you will be given the choice to participate in that new study or not.

HOW YOU WERE SELECTED

You are eligible to be in the study because you have a child in kindergarten through eighth grade living in your household and your household is located within one of the 264 communities we are studying. Approximately 21,000 children and their parents will eventually participate in this study.

DATA SECURITY

The study team will do everything they can to make sure your information stays private and secure. All study staff members are required to complete trainings on keeping your information safe. Study laptops and equipment are password protected. They also have programs to protect your information. Your information will be stored in a locked building with access limited to authorized study team members only.

Any forms with your name (or your child’s name) will be kept separate from any papers that might be used to collect information about your child. Study data forms will only have your study identification number on it.

The only reasons we would have to reveal your study participation, as required by law, are:

if a case of child abuse is discovered during the study, or
if the Institutional Review Board (IRB), the body which oversees the protection of study participants, needs to review records.

If you let us look at your child’s medical records, your doctor will know that you are in the study, but he or she will not have access to the information we collect during this study.

Final study results will be published on groups only. No individual information will be included. No individual in this study will be able to be identified.

RISKS/DISCOMFORTS

There are few known risks to participation in this study. Some of the questions we ask may be sensitive. Because the study is voluntary, you do not need to answer any question you do not feel comfortable answering. There is also a risk of your data being revealed. Every effort will be made to keep your information safe and secure.

BENEFITS

This study has no known individual benefits for participation. However, it is important for you and your child to participate because it will help researchers understand what programs and policies in the community help children to stay healthy. The results of this study could help improve existing and future programs/policies for children across the United States.

COSTS AND COMPENSATION

There is no cost to you for being in this study. In appreciation of your participation, after the [first] home visit if your child is in kindergarten through fifth grade, you will get a gift worth $25 and a small age-appropriate toy for your child. If your child is in sixth through eighth grade and helps answer more of the study questions directly, you will each get a gift worth $15.

At the end of yoursecond home visit, when the interviewer collects the activity monitor, your family will get an additional $50 money order.

As an additional thank you for your participation in this study, at the end of the study, you will get a summary report of the study results for all participants as a group.

VOLUNTARY

Participation by you, your child, and any other parents/caregivers in this study is voluntary. You may ask questions at any time. You may refuse to answer any survey question. You may also drop out at any time without penalty to you or your child. If your child is aged 8 or older today, we will also ask your child to sign a form indicating his or her agreement to be in the study before we begin any data collection.

CONTACT INFORMATION

For questions about your rights as a study participant, contact:

Battelle Institutional Review Board

1-877-810-9530

For questions or concerns about the study:

Dr. Howard Fishbein

Battelle Memorial Institute

703-248-1647

I have read this consent form and the study staff have answered my questions.

I, ____________________________________, parent/guardian of __________________________,

^{Printed
Parent/Guardian Full Name
Printed Child Full Name}

agree for myself and my child to participate in the “HEALTHY COMMUNITIES STUDY.”

____________________________________________ __________________

^{Parent/Guardian
Signature
Date}

________________________________

^{Witness
Signature}

COMPLETE THE FOLLOWING FOR ANY PARENT/CAREGIVER NOT PARTICIPATING IN THE INTERVIEW WHO CONSENTS TO HAVE THEIR MEASUREMENTS TAKEN.

I agree to have my height and weight measured for the “HEALTHY COMMUNITIES STUDY.”

_________________________________________ _____________________________________ ^{Parent/Caregiver
Signature
Parent/Caregiver Signature}

HIPAA COMPLIANT AUTHORIZATION TO RELEASE CONFIDENTIAL MEDICAL INFORMATION

Public reporting burden for this collection of information is estimated to average 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. 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0649). Do not return the completed form to this address.

Records and information obtained will be disclosed to: Examination Management Services, Inc. (EMSI), a subcontractor of Battelle Memorial Institute.

The purpose of this disclosure is to contribute to an ongoing research study. I, ____________________, (Name of Parent/Guardian) hereby authorize you to release all medical records and information within your possession, custody, or control regarding my child, _________________________ (Name of Child) pursuant to this Authorization. All records and information regarding diagnosis, testing, treatment, and prognosis of my child’s physical or mental condition are to be released. Such records and information to be released may include, but not be limited to, the following: age at observation, length/height and weight, and any indication of nutritional, physical activity, or sedentary activity counseling in the medical record.

I, the undersigned, hereby authorize all medical practitioners, physicians, pharmacists, hospitals, clinics, nurses, records custodians, or anyone else located at:

Medical Record Number	Facility Name (i.e. hospital or clinic name)	Provider Name (i.e. name of doctor or nurse)	Provider Address	Provider Phone #	Please check all of the ages, in years, that the child saw this provider.			How many times do you think this provider measured this child’s height and weight?	Will child continue to see this provider?
				(__ __ __) __ __ __- __ __ __ __	<1 1 2 3 4 5	6 7 8 9 10	11 12 13 14 15		Yes No
				(__ __ __) __ __ __- __ __ __ __	<1 1 2 3 4 5	6 7 8 9 10	11 12 13 14 15		Yes No
				(__ __ __) __ __ __- __ __ __ __	<1 1 2 3 4 5	6 7 8 9 10	11 12 13 14 15		Yes No

to release all records and information regarding my child.

Patient (Child)’s Name: __________________________________________

^{First
Middle Last}

Other Names Used: __________________________________________

Date of Birth: ___/___/_______ Social Security Number: _____-___-_____

Specifics to be released: Medical Records

To be released to and exchanged between Examination Management Services, Inc. (EMSI), a subcontractor of Battelle Memorial Institute and their agents, contractors, employees, representatives, affiliates, and assigns as necessary to fulfill the purpose of this disclosure.

I understand when my child’s medical records are disclosed pursuant to this Authorization, my child’s medical records and the information contained in those records may become subject to further disclosure by Examination Management Services, Inc. (EMSI), a subcontractor of Battelle Memorial Institute. For example, Examination Management Services, Inc. (EMSI), a subcontractor of Battelle Memorial Institute may be required to provide it to the Institutional Review Board (IRB) (governing body that protects the rights of study participants). In this case, the information may no longer be protected by the rules governing this Authorization. This Authorization will remain in effect for three years from my date of signature below. I understand I may revoke this Authorization at any time by requesting such of EMSI in writing as its address stated above, unless action has already been taken in reliance upon it, or during a contestability period under applicable law. A photocopy of this Authorization will be treated in the same manner as the original.

I understand that if I refuse to sign this authorization to release my child’s complete medical records, he/she may not be able to participate in the research study.

Signature of patient/guardian/

personal representative: __________________________________________ Date: ___/___/______

Legal relationship to applicant: ______________________

(only if signed above by guardian or personal representative)

HEALTHY COMMUNITIES STUDY

ANTHROPOMETRIC MEASUREMENT RECORDING FORM FOR PARENT/CAREGIVER


FOR ALL HEIGHT AND WAIST CIRCUMFERENCE MEASUREMENTS, RECORD MEASUREMENT IN CENTIMETERS TO THE NEAREST .1 CM. FOR ALL WEIGHT MEASUREMENTS, RECORD MEASUREMENT IN KILOGRAMS TO THE NEAREST .1 KG. IF PARENT/CAREGIVER REFUSES TO BE MEASURED OR IS NOT AVAILABLE, ASK FOR SELF-REPORT OR PROXY-REPORT HEIGHT AND WEIGHT.
	Person Measured:	Child	ADULT1 ID#: __________________	ADULT2 ID#: __________________
	Birth Date	____/____/________ mm/ dd / yyyy	____/____/________ mm/ dd / yyyy	____/____/________ mm/ dd / yyyy
	Height values (Select only one)	measured cm self-reported feet and inches self-reported centimeters proxy reported feet and inches proxy reported centimeters refused don't know	measured cm self-reported feet and inches self-reported centimeters proxy reported feet and inches proxy reported centimeters refused don't know	measured cm self-reported feet and inches self-reported centimeters proxy reported feet and inches proxy reported centimeters refused don't know
	Height 1	___ ___ ___ . ___	___ ___ ___ . ___	___ ___ ___ . ___
	Height 2	___ ___ ___ . ___	___ ___ ___ . ___	___ ___ ___ . ___
	Height 3*	___ ___ ___ . ___	___ ___ ___ . ___	___ ___ ___ . ___
	Hair correction factor (cm)	___ ___ ___ . ___ Not applicable	___ ___ ___ . ___ Not applicable	___ ___ ___ . ___ Not applicable
	Weight values (Select only one)	measured kgs self-reported pounds self-reported kgs proxy-reported pounds proxy-reported kgs refused don't know	measured kgs self-reported pounds self-reported kgs proxy-reported pounds proxy-reported kgs refused don't know	measured kgs self-reported pounds self-reported kgs proxy-reported pounds proxy-reported kgs refused don't know
	Weight 1	___ ___ ___ . ___	___ ___ ___ . ___	___ ___ ___ . ___
	Weight 2	___ ___ ___ . ___	___ ___ ___ . ___	___ ___ ___ . ___
	Weight 3*	___ ___ ___ . ___	___ ___ ___ . ___	___ ___ ___ . ___

Cast or prosthesis (Select only one)	no yes not applicable…(SKIP TO WAIST CIRCUMFERENCE 1)	no yes not applicable…(SKIP TO CLOTHING ITEMS WORN)		no yes not applicable…(SKIP TO CLOTHING ITEMS WORN)
Cast or prosthesis (specify)
Waist Circumference 1 (cm)	___ ___ ___ . ___
Waist Circumference 2 (cm)	___ ___ ___ . ___
*Waist Circumference 3 (cm)**	___ ___ ___ . ___
Clothing items worn (check all that apply)	T-shirt	T-shirt	T-shirt
	Sleeveless top	Sleeveless top	Sleeveless top
	3/4 length shirt	3/4 length shirt	3/4 length shirt
	Long-sleeved t-shirt	Long-sleeved t-shirt	Long-sleeved t-shirt
	Sweater	Sweater	Sweater
	Sweatshirt	Sweatshirt	Sweatshirt

	Shorts	Shorts	Shorts
	Short skirt	Short skirt	Short skirt
	Capris	Capris	Capris
	Long skirt	Long skirt	Long skirt
	Jeans	Jeans	Jeans
	Slacks	Slacks	Slacks
	Sweatpants	Sweatpants	Sweatpants

	Dress/Jumper	Dress/Jumper	Dress/Jumper
Measurement Comments

*A third measurement will be taken if:

Height 1 and Height 2 are more than 0.5 centimeters different from one another
Weight 1 and Weight 2 are more than 0.1 kilograms different from one another
Waist Circumference 1 and Waist Circumference 2 are more than 2 centimeters different from one another

HOME VISIT COMPUTER-ASSISTED INTERVIEW CONTENT

Public reporting burden for this collection of information is estimated to average 31 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0649). Do not return the completed form to this address.

HOME VISIT 1

NOTE: The following questions will be asked during the first home visit for all Standard and Enhanced Protocol families. These questions will be programmed into a computer-assisted interview (CAI) and asked of the adult and/or child respondent as indicated. They will be asked by the interviewer or self-administered as indicated. These questions are in addition to other home visit data collection activities (modified windshield survey, anthropometric measurements, obtaining signed medical record release, instructing on use of the accelerometer) which will be completed on paper and in addition to completing the ASA24-Kids dietary recall through a website (for Enhanced Protocol families). No interviewer prompts, wording probes, or other question-by-question specifications are captured in this document. Those additional details will be provided in an annotated version to be used during interviewer training and will be programmed into the CAI. The ORDER of the questions in this version may be revised to adjust for the changes made to the instrument. Consideration will still be given to issues of child fatigue, need for privacy, etc., and when appropriate, simultaneous activities will be planned (for example, measuring the adult respondent while an older child respondent is self-completing sensitive questions).

SECTION A: COMMUNITY EXPOSURE

Interviewer administered

Child aged 4 – 5: Adult respondent

Child aged 6 – 11 Adult respondent/child present to assist

Child aged 12 – 15: Child respondent/adult present to assist

The first questions ask about your community or neighborhood. A community has many different things including schools, after school programs, childcare centers, work places, businesses, food stores, and markets, restaurants, places for sports, places for entertainment, churches, and other locations for community activities, and billboards with advertising. HAND SHOW CARD A.

A1.

During the past six months, how often (have you/has your child) participated in or used any community or neighborhood programs or places that encourage healthy eating or make healthy eating easier? Would you say (READ ANSWERS)?

Never (SKIP TO A2) 1

Rarely 2

Sometimes 3

Often 4

Very Often 5

REFUSED (SKIP TO A2) -1

DON’T KNOW (SKIP TO A2) -2

What were the names of the programs or places that encouraged healthy eating or made it easier?

PROGRAM 1:____________________________________

PROGRAM 2:____________________________________

PROGRAM 3:____________________________________

REFUSED -1

DON’T KNOW -2

A2.

During the past six months, how often (have you/has your child) participated in or used any community or neighborhood programs or places that encourage physical activity or make physical activity easier? Would you say (READ ANSWERS)?

Never (END SECTION) 1

Rarely 2

Sometimes 3

Often 4

Very Often 5

REFUSED (END SECTION) -1

DON’T KNOW (END SECTION) -2

What were the names of the programs or places that encouraged physical activity or made it easier?

PROGRAM 1:____________________________________

PROGRAM 2:____________________________________

PROGRAM 3:____________________________________

REFUSED -1

DON’T KNOW -2

SECTION J: NUTRITION QUESTIONS (PIECE 1)

Domain 1: Food and Beverage Intake

Interviewer administered

Child aged 4 – 5: Adult respondent

Child aged 6 – 8: Adult respondent/child present to assist

Child aged 9 – 15: Child respondent/adult present to assist

These questions are about the different kinds of foods (you/your child) ate or drank during the past month, that is, the past 30 days. When answering, please include meals and snacks eaten at home, at school, in restaurants, and anyplace else. HAND SHOW CARD B.

J1.

During the past month, how often did (you/your child) eat hot or cold cereals? You can answer per day, per week or per month.

PER DAY 1

PER WEEK 2

PER MONTH 3

# OF TIMES Shape1

NEVER (SKIP TO J3) 0

REFUSED (SKIP TO J3) -1

DON’T KNOW (SKIP TO J3) -2

IF J1 RESPONSE > 1 AND UNIT RESPONSE = 1 (DAY), OR

IF J1 RESPONSE > 14 AND UNIT RESPONSE = 2 (WEEK), OR

IF J1 RESPONSE > 60 AND UNIT RESPONSE = 3 (MONTH),

ASK A.

A. You said (DISPLAY NUMBER FROM ABOVE) times per (DISPLAY UNIT FROM ABOVE). Is that correct?

YES (CONTINUE) 1

NO (RETURN TO J1) 2

REFUSED (CONTINUE) -1

DON’T KNOW (CONTINUE) -2

J2.

During the past month, what kinds of cereal did (you/your child) usually eat?

CEREAL1: (SELECT CEREAL FROM DROP DOWN LIST)

CEREAL2: (SELECT CEREAL FROM DROP DOWN LIST)

REFUSED -1

DON’T KNOW -2

J3.

During the past month, how often did (you/your child) have milk either to drink or on cereal? Do not include soy milk or small amounts of milk in coffee or tea. You can answer per day, per week or per month.

INCLUDE: SKIM, NO-FAT, LOW-FAT, WHOLE MILK, BUTTERMILK, AND LACTOSE-FREE MILK. ALSO INCLUDE CHOCOLATE OR OTHER FLAVORED MILKS.

DO NOT INCLUDE: CREAM.

PER DAY 1

PER WEEK 2

PER MONTH 3

# OF TIMES

NEVER (SKIP TO J5) 0

REFUSED (SKIP TO J5) -1

DON’T KNOW (SKIP TO J5) -2

IFJ3 RESPONSE > 2 AND UNIT RESPONSE = 1 (DAY), (Does not apply for participants 4-11 years old) OR,

IF J3 RESPONSE > 14 AND UNIT RESPONSE = 2 (WEEK), OR

IF J3 RESPONSE > 60 AND UNIT RESPONSE = 3 (MONTH),

ASK A.

You said (DISPLAY NUMBER FROM ABOVE) times per (DISPLAY UNIT FROM ABOVE). Is that correct?

YES (CONTINUE) 1

NO (RETURN TO J3) 2

REFUSED (CONTINUE) -1

DON’T KNOW (CONTINUE) -2

J4.

During the past month, what kind of milk did (you/your child) usually drink?

WHOLE OR REGULAR MILK 1

2% FAT OR REDUCED-FAT MILK 2

1%, 1/2%, OR LOW-FAT MILK 3

FAT-FREE, SKIM OR NONFAT MILK 4

SOY MILK 5

OTHER 6

REFUSED ....................................................................-1

DON'T KNOW -2

J5.

During the past month, how often did (you/your child) drink the following beverages? You can answer per day, per week or per month.

PER DAY

PER WEEK

PER MONTH

# OF TIMES

NEVER

a. Regular soda or pop that contains sugar? Do not include diet soda

INCLUDE: MANZANITA AND PEÑAFIEL SODAS.

DO NOT INCLUDE: DIET OR SUGAR-FREE FRUIT DRINKS. DO NOT INCLUDE JUICES OR TEA IN CANS.

-1

-2

IF J5a. RESPONSE > 2 AND UNIT =RESPONSE = 1 (DAY), OR

IF J5a.RESPONSE > 14 AND UNIT RESPONSE = 2 (WEEK), OR

IF J5a.RESPONSE > 60 AND UNIT RESPONSE = 3 (MONTH),

ASK J5a1

You said (DISPLAY NUMBER FROM ABOVE) times per (DISPLAY UNIT FROM ABOVE). Is that correct?

YES (CONTINUE) 1

NO (RETURN TO J5a) 2

REFUSED (CONTINUE) -1

DON’T KNOW (CONTINUE) -2

b. 100% pure fruit juice such as orange, mango, apple, grape, and pineapple juices? Do not include fruit-flavored drinks with added sugar or fruit juice you made at home and added sugar to.

INCLUDE: ONLY 100% PURE JUICES.

DO NOT INCLUDE: FRUIT-FLAVORED DRINKS WITH ADDED SUGAR, LIKE CRANBERRY COCKTAIL, HI-C, LEMONADE, KOOL-AID, GATORADE, TAMPICO, AND SUNNY DELIGHT.

-1

-2

IF J5b. RESPONSE > 1 AND UNIT RESPONSE = 1 (DAY) (Does not apply for participants 4-11 years old) OR,

IF J5b. RESPONSE > 14 AND UNIT RESPONSE = 2 (WEEK), OR

IF J5b. RESPONSE > 60 AND UNIT RESPONSE = 3 (MONTH),

ASK J5b1

You said (DISPLAY NUMBER FROM ABOVE) times per (DISPLAY UNIT FROM ABOVE). Is that correct?

YES (CONTINUE) 1

NO (RETURN TO J5b) 2

REFUSED (CONTINUE) -1

DON’T KNOW (CONTINUE) -2

IF AGE 4-11 YEARS OLD, SKIP TO J5d.

c. Coffee or tea that had sugar or honey added to it? Include coffee and tea you sweetened yourself and presweetened tea and coffee drinks such as Arizona Iced Tea and Frappuccino. Do not include artificially sweetened coffee or diet tea.

-1

-2

IF J5c. RESPONSE > 1 AND UNIT RESPONSE = 1 (DAY), OR

IF J5c. RESPONSE > 14 AND UNIT RESPONSE = 2 (WEEK), OR

IF J5c. RESPONSE > 60 AND UNIT RESPONSE = 3 (MONTH),

ASK J5c1

You said (DISPLAY NUMBER FROM ABOVE) times per (DISPLAY UNIT FROM ABOVE). Is that correct?

YES (CONTINUE) 1

NO (RETURN TO J5c) 2

REFUSED (CONTINUE) -1

DON’T KNOW (CONTINUE) -2

d. Sports or energy drinks, such as Gatorade, Red Bull, or Vitamin Water?

-1

-2

IF J5d. RESPONSE > 1 AND UNIT RESPONSE = 1 (DAY) (Does not apply for participants 4-11 years old) OR,

IF J5d. RESPONSE > 14 AND UNIT RESPONSE = 2 (WEEK), OR

IF J5d. RESPONSE > 60 AND UNIT RESPONSE = 3 (MONTH),

ASK J5d1

You said (DISPLAY NUMBER FROM ABOVE) times per (DISPLAY UNIT FROM ABOVE). Is that correct?

YES (CONTINUE) 1

NO (RETURN TO J5d) 2

REFUSED (CONTINUE) -1

DON’T KNOW (CONTINUE) -2

e. Sweetened fruit drinks, such as Kool-Aid, cranberry drink, Hi-C or lemonade? Include fruit drinks you made at home and added sugar to. Do not include diet drinks or artificially sweetened drinks.

INCLUDE: DRINKS WITH ADDED SUGAR, TAMPICO, SUNNY DELIGHT, AND TWISTER.

DO NOT INCLUDE: 100% FRUIT JUICES OR SODA, YOGURT DRINKS, CARBONATED WATER OR FRUIT-FLAVORED TEAS.

-1

-2

IF J5e. RESPONSE > 1 AND UNIT RESPONSE = 1 (DAY) (Does not apply for participants 4-11 years old) OR,

IF J5e. RESPONSE > 14 AND UNIT RESPONSE = 2 (WEEK), OR

IF J5e. RESPONSE > 60 AND UNIT RESPONSE = 3 (MONTH),

ASK J5e1

You said (DISPLAY NUMBER FROM ABOVE) times per (DISPLAY UNIT FROM ABOVE). Is that correct?

YES (CONTINUE) 1

NO (RETURN TO J5e) 2

REFUSED (CONTINUE) -1

DON’T KNOW (CONTINUE) -2

During the past month, how often did (you/your child) eat the following foods? You can answer per day, per week or per month.

f. Fruit? Include fresh, frozen, or canned fruit. Do not include juices

DO NOT INCLUDE: DRIED FRUITS.

-1

-2

IF J5f. RESPONSE > 2 AND UNIT RESPONSE = 1 (DAY), OR

IF J5f. RESPONSE > 14 AND UNIT RESPONSE = 2 (WEEK), OR

IF J5f. RESPONSE > 60 AND UNIT RESPONSE = 3 (MONTH),

ASK J5f1

You said (DISPLAY NUMBER FROM ABOVE) times per (DISPLAY UNIT FROM ABOVE). Is that correct?

YES (CONTINUE) 1

NO (RETURN TO J5f) 2

REFUSED (CONTINUE) -1

DON’T KNOW (CONTINUE) -2

g. A green leafy or lettuce salad, with or without other vegetables?

INCLUDE: SPINACH SALADS.

-1

-2

IF J5g RESPONSE > 1 AND UNIT RESPONSE = 1 (DAY) , OR

IF J5g RESPONSE > 14 AND UNIT RESPONSE = 2 (WEEK), OR

IF J5g RESPONSE > 60 AND UNIT RESPONSE = 3 (MONTH),

ASK J5g1

You said (DISPLAY NUMBER FROM ABOVE) times per (DISPLAY UNIT FROM ABOVE). Is that correct?

YES (CONTINUE) 1

NO (RETURN TO J5g) 2

REFUSED (CONTINUE) -1

DON’T KNOW (CONTINUE) -2

h. Any kind of fried potatoes, including french fries, home fries, or hash brown potatoes?

DO NOT INCLUDE: POTATO CHIPS.

-1

-2

IF J5h RESPONSE > 1 AND UNIT RESPONSE = 1 (DAY) , OR

IF J5h RESPONSE > 14 AND UNIT RESPONSE = 2 (WEEK), OR

IF J5h RESPONSE > 60 AND UNIT RESPONSE = 3 (MONTH),

ASK J5h1

You said (DISPLAY NUMBER FROM ABOVE) times per (DISPLAY UNIT FROM ABOVE). Is that correct?

YES (CONTINUE) 1

NO (RETURN TO J5h) 2

REFUSED (CONTINUE) -1

DON’T KNOW (CONTINUE) -2

i. Any other kind of potatoes, such as baked, boiled, mashed potatoes, sweet potatoes, or potato salad?

INCLUDE: ALL TYPES OF POTATOES EXCEPT FRIED. INCLUDE POTATOES AU GRATIN, SCALLOPED POTATOES.

-1

-2

IF J5i RESPONSE > 1 AND UNIT RESPONSE = 1 (DAY) , OR

IF J5i RESPONSE > 14 AND UNIT RESPONSE = 2 (WEEK), OR

IF J5i RESPONSE > 60 AND UNIT RESPONSE = 3 (MONTH),

ASK J5i1

You said (DISPLAY NUMBER FROM ABOVE) times per (DISPLAY UNIT FROM ABOVE). Is that correct?

YES (CONTINUE) 1

NO (RETURN TO J5i) 2

REFUSED (CONTINUE) -1

DON’T KNOW (CONTINUE) -2

j. Refried beans, baked beans, beans in soup, pork and beans or any other type of cooked dried beans? Do not include green beans.

INCLUDE: SOYBEANS, KIDNEY, PINTO, GARBANZO, LENTILS, BLACK, BLACK-EYED PEAS, COW PEAS, AND LIMA BEANS.

-1

-2

IF J5j RESPONSE > 1 AND UNIT RESPONSE = 1 (DAY) , OR

IF J5j RESPONSE > 14 AND UNIT RESPONSE = 2 (WEEK), OR

IF J5j RESPONSE > 60 AND UNIT RESPONSE = 3 (MONTH),

ASK J5j1

You said (DISPLAY NUMBER FROM ABOVE) times per (DISPLAY UNIT FROM ABOVE). Is that correct?

YES (CONTINUE) 1

NO (RETURN TO J5j) 2

REFUSED (CONTINUE) -1

DON’T KNOW (CONTINUE) -2

k. Not including what you just told me about lettuce salads, potatoes, cooked dried beans and not including rice, how often did (you/your child) eat other vegetables?

DO NOT INCLUDE: RICE

EXAMPLES OF OTHER VEGETABLES INCLUDE: TOMATOES, GREEN BEANS, CARROTS, CORN, CABBAGE, BEAN SPROUTS, COLLARD GREENS, AND BROCCOLI. INCLUDE ANY FORM OF THE VEGETABLE (RAW, COOKED, CANNED, OR FROZEN).

-1

-2

IF J5k RESPONSE > 2 AND UNIT RESPONSE = 1 (DAY) , OR

IF J5k RESPONSE > 14 AND UNIT RESPONSE = 2 (WEEK), OR

IF J5k RESPONSE > 60 AND UNIT RESPONSE = 3 (MONTH),

ASK J5k1

You said (DISPLAY NUMBER FROM ABOVE) times per (DISPLAY UNIT FROM ABOVE). Is that correct?

YES (CONTINUE) 1

NO (RETURN TO J5k) 2

REFUSED (CONTINUE) -1

DON’T KNOW (CONTINUE) -2

During the past month, how often did (you/your child) eat the following foods? You can answer per day, per week or per month.

l. Pizza? Include frozen pizza, fast food pizza, and homemade pizza

-1

-2

IF J5l RESPONSE > 1 AND UNIT RESPONSE = 1 (DAY) , OR

IF J5l RESPONSE > 14 AND UNIT RESPONSE = 2 (WEEK), OR

IF J5l RESPONSE > 60 AND UNIT RESPONSE = 3 (MONTH),

ASK J5l1

You said (DISPLAY NUMBER FROM ABOVE) times per (DISPLAY UNIT FROM ABOVE). Is that correct?

YES (CONTINUE) 1

NO (RETURN TO J5l) 2

REFUSED (CONTINUE) -1

DON’T KNOW (CONTINUE) -2

m. Mexican-type salsa made with tomato?

INCLUDE: ALL TOMATO-BASED SALSAS.

-1

-2

IF J5m RESPONSE > 1 AND UNIT RESPONSE = 1 (DAY) , OR

IF J5m RESPONSE > 14 AND UNIT RESPONSE = 2 (WEEK), OR

IF J5m RESPONSE > 60 AND UNIT RESPONSE = 3 (MONTH),

ASK J5m1

You said (DISPLAY NUMBER FROM ABOVE) times per (DISPLAY UNIT FROM ABOVE). Is that correct?

YES (CONTINUE) 1

NO (RETURN TO J5m) 2

REFUSED (CONTINUE) -1

DON’T KNOW (CONTINUE) -2

n. Tomato sauces such as with spaghetti, noodles, or mixed into foods such as lasagna? Please do not count tomato sauce on pizza.

-1

-2

IF J5n RESPONSE > 1 AND UNIT RESPONSE = 1 (DAY) , OR

IF J5n RESPONSE > 14 AND UNIT RESPONSE = 2 (WEEK), OR

IF J5n RESPONSE > 60 AND UNIT RESPONSE = 3 (MONTH),

ASK J5n1

You said (DISPLAY NUMBER FROM ABOVE) times per (DISPLAY UNIT FROM ABOVE). Is that correct?

YES (CONTINUE) 1

NO (RETURN TO J5n) 2

REFUSED (CONTINUE) -1

DON’T KNOW (CONTINUE) -2

o. Cheese? Include cheese as a snack, cheese on burgers, sandwiches, and cheese in foods such as lasagna, quesadillas, or casseroles. Please do not count cheese on pizza

INCLUDE: MACARONI AND CHEESE, ENCHILADAS.

DO NOT INCLUDE: CREAM CHEESE OR CHEESES MADE FROM NON-DAIRY FOODS, SUCH AS SOY OR RICE, OR CHEESE ON PIZZA.

-1

-2

IF J5o RESPONSE > 1 AND UNIT RESPONSE = 1 (DAY) , OR

IF J5o RESPONSE > 14 AND UNIT RESPONSE = 2 (WEEK), OR

IF J5o RESPONSE > 60 AND UNIT RESPONSE = 3 (MONTH),

ASK J5o1

You said (DISPLAY NUMBER FROM ABOVE) times per (DISPLAY UNIT FROM ABOVE). Is that correct?

YES (CONTINUE) 1

NO (RETURN TO J5o) 2

REFUSED (CONTINUE) -1

DON’T KNOW (CONTINUE) -2

p. Whole grain bread including toast, rolls and in sandwiches? Whole grain breads include whole wheat, rye, oatmeal, and pumpernickel. Do not include white bread.

INCLUDE: CRACKED WHEAT, MULTI-GRAIN, BRAN BREADS, WHOLE GRAIN WHITE BREAD.

-1

-2

IF J5p RESPONSE > 1 AND UNIT RESPONSE = 1 (DAY) , OR

IF J5p RESPONSE > 14 AND UNIT RESPONSE = 2 (WEEK), OR

IF J5p RESPONSE > 60 AND UNIT RESPONSE = 3 (MONTH),

ASK J5p1

You said (DISPLAY NUMBER FROM ABOVE) times per (DISPLAY UNIT FROM ABOVE). Is that correct?

YES (CONTINUE) 1

NO (RETURN TO J5p) 2

REFUSED (CONTINUE) -1

DON’T KNOW (CONTINUE) -2

q. Brown rice or other cooked whole grains, such as bulgur, cracked wheat, or millet? Do not include white rice.

BROWN RICE IS A TYPE OF WHOLE GRAIN. IT IS BROWN IN COLOR AND TAKES LONGER TO COOK THAN WHITE RICE. IT CONTAINS ALMOST ALL OF THE RICE GRAIN AND IS NOT AS PROCESSED AS WHITE RICE. COMPARED TO WHITE RICE IT ALSO CONTAINS MORE FIBER AND MORE OF SOME VITAMINS AND MINERALS THAT ARE LOST DURING THE PROCESSING OF RICE.

-1

-2

IF J5q RESPONSE > 1 AND UNIT RESPONSE = 1 (DAY) , OR

IF J5q RESPONSE > 14 AND UNIT RESPONSE = 2 (WEEK), OR

IF J5q RESPONSE > 60 AND UNIT RESPONSE = 3 (MONTH),

ASK J5q1

You said (DISPLAY NUMBER FROM ABOVE) times per (DISPLAY UNIT FROM ABOVE). Is that correct?

YES (CONTINUE) 1

NO (RETURN TO J5q) 2

REFUSED (CONTINUE) -1

DON’T KNOW (CONTINUE) -2

During the past month, how often did (you/your child) eat the following foods? You can answer per day, per week or per month.

r. Chocolate or any other types of candy? Do not include sugar-free candy.

-1

-2

IF J5r RESPONSE > 1 AND UNIT RESPONSE = 1 (DAY) , OR

IF J5r RESPONSE > 14 AND UNIT RESPONSE = 2 (WEEK), OR

IF J5r RESPONSE > 60 AND UNIT RESPONSE = 3 (MONTH),

ASK J5r1

You said (DISPLAY NUMBER FROM ABOVE) times per (DISPLAY UNIT FROM ABOVE). Is that correct?

YES (CONTINUE) 1

NO (RETURN TO J5r) 2

REFUSED (CONTINUE) -1

DON’T KNOW (CONTINUE) -2

s. Doughnuts, sweet rolls, Danish, muffins, pan dulce, or pop-tarts? Do not include sugar-free items.

INCLUDE: LOW-FAT KINDS.

DO NOT INCLUDE: PANCAKES, WAFFLES, FRENCH TOAST, CAKE, ICE CREAM AND OTHER FROZEN DESSERTS OR CANDY.

-1

-2

IF J5s RESPONSE > 1 AND UNIT RESPONSE = 1 (DAY) , OR

IF J5s RESPONSE > 14 AND UNIT RESPONSE = 2 (WEEK), OR

IF J5s RESPONSE > 60 AND UNIT RESPONSE = 3 (MONTH),

ASK J5s1

You said (DISPLAY NUMBER FROM ABOVE) times per (DISPLAY UNIT FROM ABOVE). Is that correct?

YES (CONTINUE) 1

NO (RETURN TO J5s) 2

REFUSED (CONTINUE) -1

DON’T KNOW (CONTINUE) -2

t. Cookies, cake, pie or brownies? Do not include sugar-free kinds.

INCLUDE: LOW-FAT KINDS, TWINKIES AND HOSTESS CUPCAKES.

DO NOT INCLUDE: ICE CREAM AND OTHER FROZEN DESSERTS OR CANDY.

-1

-2

IF J5t RESPONSE > 1 AND UNIT RESPONSE = 1 (DAY) , OR

IF J5t RESPONSE > 14 AND UNIT RESPONSE = 2 (WEEK), OR

IF J5t RESPONSE > 60 AND UNIT RESPONSE = 3 (MONTH),

ASK J5t1

You said (DISPLAY NUMBER FROM ABOVE) times per (DISPLAY UNIT FROM ABOVE). Is that correct?

YES (CONTINUE) 1

NO (RETURN TO J5t) 2

REFUSED (CONTINUE) -1

DON’T KNOW (CONTINUE) -2

u. Ice cream or other frozen desserts? Do not include sugar-free kinds, popsicles, or sno-cones.

INCLUDE: LOW-FAT KINDS. ALSO INCLUDE FROZEN YOGURT AND SHERBET.

DO NOT INCLUDE: NON-DAIRY FROZEN DESSERTS, SUCH AS SORBET, SNO-CONES, POPSICLES.

-1

-2

IF J5u RESPONSE > 1 AND UNIT RESPONSE = 1 (DAY) , OR

IF J5u RESPONSE > 14 AND UNIT RESPONSE = 2 (WEEK), OR

IF J5u RESPONSE > 60 AND UNIT RESPONSE = 3 (MONTH),

ASK J5u1

You said (DISPLAY NUMBER FROM ABOVE) times per (DISPLAY UNIT FROM ABOVE). Is that correct?

YES (CONTINUE) 1

NO (RETURN TO J5u) 2

REFUSED (CONTINUE) -1

DON’T KNOW (CONTINUE) -2

v. Popcorn?

INCLUDE: LOW-FAT POPCORN.

-1

-2

IF J5v RESPONSE > 1 AND UNIT RESPONSE = 1 (DAY) , OR

IF J5v RESPONSE > 14 AND UNIT RESPONSE = 2 (WEEK), OR

IF J5v RESPONSE > 60 AND UNIT RESPONSE = 3 (MONTH),

ASK J5v1

You said (DISPLAY NUMBER FROM ABOVE) times per (DISPLAY UNIT FROM ABOVE). Is that correct?

YES (CONTINUE) 1

NO (RETURN TO J5v) 2

REFUSED (CONTINUE) -1

DON’T KNOW (CONTINUE) -2

w. Potato chips, corn chips, or crackers?

INCLUDE: LOW-FAT KINDS.

-1

-2

IF J5w RESPONSE > 1 AND UNIT RESPONSE = 1 (DAY) , OR

IF J5w RESPONSE > 14 AND UNIT RESPONSE = 2 (WEEK), OR

IF J5w RESPONSE > 60 AND UNIT RESPONSE = 3 (MONTH),

ASK J5w1

You said (DISPLAY NUMBER FROM ABOVE) times per (DISPLAY UNIT FROM ABOVE). Is that correct?

YES (CONTINUE) 1

NO (RETURN TO J5w) 2

REFUSED (CONTINUE) -1

DON’T KNOW (CONTINUE) -2

Domain 2: Food Patterns and Behaviors

Interviewer administered

Child aged 4 – 5: Adult respondent

Child aged 6 – 8: Adult respondent/child present to assist

Child aged 9 – 11: Child respondent/adult present to assist

Child aged 12 – 15: Child respondent

These next questions are about meals during the past week, that is, the past 7 days.

J6.

During the past 7 days, on how many days did (you/your child) eat breakfast or a morning meal?

DAYS

REFUSED -1

DON’T KNOW -2

J7.

HAND SHOW CARD A. When (you eat/your child eats) at home, how often is a television on while you are eating? Would you say (READ ANSWERS)?

Never 1

Rarely 2

Sometimes 3

Often 4

Very Often 5

REFUSED -1

DON'T KNOW -2

J8.

During the past 7 days, on how many days did (you/your child) eat or drink anything from a fast food restaurant such as McDonald's, Taco Bell, or KFC?

DAYS

REFUSED -1

DON’T KNOW -2

J9.

During the past 7 days, on how many days did (you/your child) and all or most of your family sit down and eat dinners or suppers together?

DAYS

REFUSED -1

DON’T KNOW -2

Domain 3: Perceived Social Support Regarding Healthy Eating and Peer Influence

Interviewer administered

Child aged 4 – 5: Adult respondent – Family ratings only

Child aged 6 – 8: Adult respondent/child present to assist – Family ratings only

Child aged 9 – 11: Child respondent/adult present to assist – Family ratings only

Child aged 12 – 15: Child respondent – Ratings of both Family and Friends

I am next going to read a list of things people might do or say to someone who is trying to improve their eating habits. (Please rate each question twice.) (For family, rate/Rate) how often anyone living in your household has said or done what is described during the last month. (For friends, rate how often your friends have said or done what is described, during the last month.) HAND SHOW CARD A.

J10.

Complimented (you/your child) on eating habits, for example “Keep it up,” “We are proud of you”.

Never

Rarely

Sometimes

Often

Very Often

Would you say your family has done this (READ ANSWERS)?

-1

-2

Would you say your friends have done this (READ ANSWERS)?

-1

-2

J11.

Encouraged (you/your child) to eat fruits and vegetables when tempted not to.

Never

Rarely

Sometimes

Often

Very Often

Would you say your family has done this (READ ANSWERS)?

-1

-2

Would you say your friends have done this (READ ANSWERS)?

-1

-2

Domain 5: Perceived School Environment Regarding Healthy Eating

Interviewer administered

Child aged 4 – 8: Adult respondent/child present to assist

Child aged 9 – 11: Child respondent/adult present to assist

Child aged 12 – 15: Child respondent

I’m going to read you statements about foods at school during this school year. How often are these statements true in your opinion? HAND SHOW CARD A. Would you say never, rarely, sometimes, often, or very often?

J12.

The school lunch is healthy.

NEVER 1

RARELY 2

SOMETIMES 3

OFTEN 4

VERY OFTEN 5

DOES NOT APPLY/NO SCHOOL LUNCH 6

REFUSED -1

DON’T KNOW -2

J13.

The foods and beverages that are sold in places like vending machines, snack bars, carts, or stores at my (child’s) school are healthy.

NEVER 1

RARELY 2

SOMETIMES 3

OFTEN 4

VERY OFTEN 5

DOES NOT APPLY/NO FOODS OR BEVERAGES SOLD AT SCHOOL VENDING MACHINES, SNACK BARS, CARTS, OR STORES 6

REFUSED -1

DON’T KNOW -2

Think about this school year, when you answer the following questions.

J14.

How many days a week (does your child/do you) usually eat the school breakfast?

DAYS

DOES NOT APPLY/NO SCHOOL BREAKFAST -3

REFUSED -1

DON’T KNOW -2

J15.

How many days a week (does your child/do you) usually eat the school lunch?

DAYS

DOES NOT APPLY/NO SCHOOL LUNCH -3

REFUSED -1

DON’T KNOW -2

SECTION G: PHYSICAL ACTIVITY BEHAVIORS RECALL

Self administered

Child aged 4 – 8: Adult respondent/child present to assist

Child aged 9 – 15: Child respondent/ adult present to assist

Now we have a few questions that we would like (CHILD/you) to answer on the computer with (your/ CHILD’s) help. I can show you how to get started with the questions. DEMONSTRATE COMPUTER USAGE TO CHILD & ADULT AND PROVIDE AGE AND GENDER APPROPRIATE INTENSITY SHOW CARD. MAKE SURE BOTH ADULT AND CHILD KNOW HOW TO ANSWER QUESTIONS ON THE TABLET BECAUSE BOTH WILL NEED TO COMPLETE SELF-ADMINISTERED SECTIONS LATER IN THE INTERVIEW.

The next questions are going to ask you about the activities that (you have/your child has) done over the past week. Please only think about the activities (you have/your child has) done between last (DAY OF WEEK) and today, not activities that (you like/your child likes) or would like to do. For each activity, answer whether or not (you/your child) did the activity in the past 7 days (one week). For those activities that you mark yes, then select the days on which (you/your child) did the activity. Then, using the word and picture descriptions on the card as a guide, select how physically hard or intense the activity was. Remember, these pictures are just a guide, and not the activities you are answering questions about.

Once you have finished this part, you will be asked some additional questions about the activities that (you/your child) did yesterday.

INTENSITY RATINGS FOR BOYS AGED 4 – 11:

Light Moderate

slow, easy movement medium pace movement

Hard Very hard

fast pace movement very fast pace movement

INTENSITY RATINGS FOR GIRLS AGED 4 – 11:

Light Moderate

slow, easy movement medium pace movement

Hard Very hard

fast pace movement very fast pace movement

INTENSITY RATINGS FOR BOYS AGED 12 – 15:

Light Moderate

slow, easy movement medium pace movement

Hard Very hard

fast pace movement very fast pace movement

INTENSITY RATINGS FOR GIRLS AGED 12 – 15:

Light Moderate

slow, easy movement medium pace movement

Hard Very hard

fast pace movement very fast pace movement

G1.

Did (you/your child) have physical education (PE) class in school in the past 7 days?

YES 1

NO (SKIP TO G2) 2

REFUSED (SKIP TO G2) -1

DON’T KNOW (SKIP TO G2) -2

Which days did (you/your child) have PE? Choose all the days that apply.

MONDAY 2

TUESDAY 3

WEDNESDAY 4

THURSDAY 5

FRIDAY 6

REFUSED -1

DON’T KNOW -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

G2.

Did (you/your child) have recess or other free-play at school in the past 7 days?

YES 1

NO (SKIP TO G3) 2

REFUSED (SKIP TO G3) -1

DON’T KNOW (SKIP TO G3) -2

Which days did (you/your child) have recess or other free-play at school? Choose all the days that apply.

MONDAY 2

TUESDAY 3

WEDNESDAY 4

THURSDAY 5

FRIDAY 6

REFUSED -1

DON’T KNOW -2

(Were you/Was your child) physically active during recess or free play?

YES 1

NO (SKIP TO G3) 2

REFUSED (SKIP TO G3) -1

DON’T KNOW (SKIP TO G3) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

G3.

Did (you/your child) have dance or other physically active classes at school (other than PE class) in the past 7 days?

YES 1

NO (SKIP TO G4) 2

REFUSED (SKIP TO G4) -1

DON’T KNOW (SKIP TO G4) -2

Which days did (you/your child) have dance or other physically active classes at school (other than PE class)? Choose all the days that apply.

MONDAY 2

TUESDAY 3

WEDNESDAY 4

THURSDAY 5

FRIDAY 6

REFUSED -1

DON’T KNOW -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

G4.

Did (you/your child) participate in physical activity breaks during classes at school in the past 7 days?

YES 1

NO (SKIP TO G5) 2

REFUSED (SKIP TO G5) -1

DON’T KNOW (SKIP TO G5) -2

Which days did (you/your child) participate in physical activity breaks during classes at school? Choose all the days that apply.

MONDAY 2

TUESDAY 3

WEDNESDAY 4

THURSDAY 5

FRIDAY 6

REFUSED -1

DON’T KNOW -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

G5.

Did (you/your child) practice or play with a school sports team in the past 7 days?

YES 1

NO (SKIP TO G6) 2

REFUSED (SKIP TO G6) -1

DON’T KNOW (SKIP TO G6) -2

Which days did (you/your child) practice or play with a school sports team? Choose all the days that apply.

SUNDAY 1

MONDAY 2

TUESDAY 3

WEDNESDAY 4

THURSDAY 5

FRIDAY 6

SATURDAY 7

REFUSED -1

DON’T KNOW -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

G6.

Did (you/your child) practice or play with a non-school sports team in the past 7 days?

YES 1

NO (SKIP TO G7) 2

REFUSED (SKIP TO G7) -1

DON’T KNOW (SKIP TO G7) -2

Which days did (you/your child) practice or play with a non-school sports team? Choose all the days that apply.

SUNDAY 1

MONDAY 2

TUESDAY 3

WEDNESDAY 4

THURSDAY 5

FRIDAY 6

SATURDAY 7

REFUSED -1

DON’T KNOW -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

G7.

Did (you/your child) participate in pick-up sports (basketball, football, baseball/softball, etc.) in the past 7 days?

YES 1

NO (SKIP TO G8) 2

REFUSED (SKIP TO G8) -1

DON’T KNOW (SKIP TO G8) -2

Which days did (you/your child) participate in pick-up sports? Choose all the days that apply.

SUNDAY 1

MONDAY 2

TUESDAY 3

WEDNESDAY 4

THURSDAY 5

FRIDAY 6

SATURDAY 7

REFUSED -1

DON’T KNOW -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

G8.

Did (you/your child) participate in physical activity during an afterschool program in the past 7 days?

YES 1

NO (SKIP TO G9) 2

REFUSED (SKIP TO G9) -1

DON’T KNOW (SKIP TO G9) -2

Which days did (you/your child) participate in physical activity during an afterschool program? Choose all the days that apply.

MONDAY 2

TUESDAY 3

WEDNESDAY 4

THURSDAY 5

FRIDAY 6

REFUSED -1

DON’T KNOW -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

G9.

Did (you/your child) play any physically active games (hopscotch, red rover, tag, jumping rope, skating, etc.) in the past 7 days?

YES 1

NO (SKIP TO G10) 2

REFUSED (SKIP TO G10) -1

DON’T KNOW (SKIP TO G10) -2

Which days did (you/your child) play any physically active games? Choose all the days that apply.

SUNDAY 1

MONDAY 2

TUESDAY 3

WEDNESDAY 4

THURSDAY 5

FRIDAY 6

SATURDAY 7

REFUSED -1

DON’T KNOW -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

G10.

Did (you/your child) swim or play games in a pool, lake, or ocean in the past 7 days?

YES 1

NO (SKIP TO G11) 2

REFUSED (SKIP TO G11) -1

DON’T KNOW (SKIP TO G11) -2

Which days did (you/your child) swim or play games in a pool, lake, or ocean? Choose all the days that apply.

SUNDAY 1

MONDAY 2

TUESDAY 3

WEDNESDAY 4

THURSDAY 5

FRIDAY 6

SATURDAY 7

REFUSED -1

DON’T KNOW -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

G11.

Did (you/your child) do any outdoor or adventure sports (hiking, kayaking, rock climbing, surfing, skiing, etc.) in the past 7 days?

YES 1

NO (SKIP TO G12) 2

REFUSED (SKIP TO G12) -1

DON’T KNOW (SKIP TO G12) -2

Which days did (you/your child) do any outdoor or adventure sports? Choose all the days that apply.

SUNDAY 1

MONDAY 2

TUESDAY 3

WEDNESDAY 4

THURSDAY 5

FRIDAY 6

SATURDAY 7

REFUSED -1

DON’T KNOW -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

G12.

Did (you/your child) walk or bike to or from school in the past 7 days?

YES 1

NO (SKIP TO G13) 2

REFUSED (SKIP TO G13) -1

DON’T KNOW (SKIP TO G13) -2

Which days did (you/your child) walk or bike to or from school? Choose all the days that apply.

MONDAY 2

TUESDAY 3

WEDNESDAY 4

THURSDAY 5

FRIDAY 6

REFUSED -1

DON’T KNOW -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

G13.

Did (you/your child) walk or bike to or from a store, park, or playground or a friend’s house in the past 7 days?

YES 1

NO (SKIP TO G14) 2

REFUSED (SKIP TO G14) -1

DON’T KNOW (SKIP TO G14) -2

Which days did (you/your child) walk or bike to or from a store, park, or playground or a friend’s house? Choose all the days that apply.

SUNDAY 1

MONDAY 2

TUESDAY 3

WEDNESDAY 4

THURSDAY 5

FRIDAY 6

SATURDAY 7

REFUSED -1

DON’T KNOW -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

G14.

Did (you/your child) walk or ride a bike, scooter, skateboard, or skates for fun or exercise in the past 7 days?

YES 1

NO (SKIP TO G15) 2

REFUSED (SKIP TO G15) -1

DON’T KNOW (SKIP TO G15) -2

Which days did (you/your child) walk or ride a bike, scooter, skateboard or skates for fun or exercise? Choose all the days that apply.

SUNDAY 1

MONDAY 2

TUESDAY 3

WEDNESDAY 4

THURSDAY 5

FRIDAY 6

SATURDAY 7

REFUSED -1

DON’T KNOW -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

G15.

Did (you/your child) use a computer for games or playing on the internet (not for schoolwork or social networks) in the past 7 days?

YES 1

NO (SKIP TO G16) 2

REFUSED (SKIP TO G16) -1

DON’T KNOW (SKIP TO G16) -2

Which days did (you/your child) use a computer for games or playing on the internet? Choose all the days that apply.

SUNDAY 1

MONDAY 2

TUESDAY 3

WEDNESDAY 4

THURSDAY 5

FRIDAY 6

SATURDAY 7

REFUSED -1

DON’T KNOW -2

G16.

Did (you/your child) use a computer or phone for social networking (Facebook, MySpace, Twitter, IM, texting, etc.) in the past 7 days?

YES 1

NO (SKIP TO G17) 2

REFUSED (SKIP TO G17) -1

DON’T KNOW (SKIP TO G17) -2

Which days did (you/your child) use a computer or phone for social networking? Choose all the days that apply.

SUNDAY 1

MONDAY 2

TUESDAY 3

WEDNESDAY 4

THURSDAY 5

FRIDAY 6

SATURDAY 7

REFUSED -1

DON’T KNOW -2

G17.

Did (you/your child) watch TV in the past 7 days?

YES 1

NO (SKIP TO G18) 2

REFUSED (SKIP TO G18) -1

DON’T KNOW (SKIP TO G18) -2

Which days did (you/your child) watch TV? Choose all the days that apply.

SUNDAY 1

MONDAY 2

TUESDAY 3

WEDNESDAY 4

THURSDAY 5

FRIDAY 6

SATURDAY 7

REFUSED -1

DON’T KNOW -2

G18.

Did (you/your child) play non-active video games in the past 7 days?

YES 1

NO (SKIP TO G19) 2

REFUSED (SKIP TO G19) -1

DON’T KNOW (SKIP TO G19) -2

Which days did (you/your child) play non-active video games? Choose all the days that apply.

SUNDAY 1

MONDAY 2

TUESDAY 3

WEDNESDAY 4

THURSDAY 5

FRIDAY 6

SATURDAY 7

REFUSED -1

DON’T KNOW -2

G19.

Did (you/your child) play physically active video games (Wii, DDR, Xbox Kinect, PlayStation Move, etc.) in the past 7 days? A physically active video game is one where some physical effort is involved in playing the game.

YES 1

NO (SKIP TO G20) 2

REFUSED (SKIP TO G20) -1

DON’T KNOW (SKIP TO G20) -2

Which days did (you/your child) play physically active video games? Choose all the days that apply.

SUNDAY 1

MONDAY 2

TUESDAY 3

WEDNESDAY 4

THURSDAY 5

FRIDAY 6

SATURDAY 7

REFUSED -1

DON’T KNOW -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

IF G1A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G21

G20.

You answered that (you/your child) had physical education (PE) class in school yesterday. Is this correct?

YES 1

NO (SKIP TO G21) 2

REFUSED (SKIP TO G21) -1

DON’T KNOW (SKIP TO G21) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) have PE class in school yesterday?

MINUTES

REFUSED -1

DON’T KNOW -2

When (you/your child) had PE class in school, what exactly (were you/was your child) doing?

TEAM SPORT SKILLS 1

INDIVIDUAL SPORT SKILLS 2

DANCE/TUMBLING SKILLS 3

WATER ACTIVITY SKILLS 4

CARDIOVASCULAR MACHINES OR CONDITIONING (RUNNING, CYCLING, STAIRCLIMBER, ROWERS, ETC.) 5

CLIMBING WALL ACTIVITIES 6

EXERCISES/CALISTHENICS 7

FRISBEE OR FRISBEE GOLF 8

JUMPROPE/PLYOMETRICS/CONDITIONING 9

WEIGHT TRAINING 10

YOGA/PILATES 11

OTHER (SPECIFY) 12

REFUSED -1

DON’T KNOW -2

SPECIFY:

IF G2A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G22

G21.

You answered that (you/your child) had recess or other free-play at school yesterday. Is this correct?

YES 1

NO (SKIP TO G22) 2

REFUSED (SKIP TO G22) -1

DON’T KNOW (SKIP TO G22) -2

(Were you/Was your child) physically active when (you/your child) had recess or other free-play yesterday?

YES 1

NO (SKIP TO G22) 2

REFUSED (SKIP TO G22) -1

DON’T KNOW (SKIP TO G22) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) have recess or other free-play at school yesterday?

MINUTES

REFUSED -1

DON’T KNOW -2

When (you/your child) had recess or other free-play at school, what exactly (were you/was your child) doing?

PLAYGROUND GAME (KICKBALL, FOUR SQUARE, DODGEBALL, ETC.) 1

ORGANIZED SPORT GAME (BASEBALL, BASKETBALL, FOOTBALL, ETC.) 2

TAG/CAPTURE THE FLAG/RED ROVER/ETC. 3

FIXED EQUIPMENT (MONKEY BARS, SLIDES, SWINGS, ETC.) 4

HANGING OUT WITH FRIENDS 5

DOING SCHOOL WORK 6

OTHER (SPECIFY) 7

REFUSED -1

DON’T KNOW -2

SPECIFY:

IF G3A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G23

G22.

You answered that (you/your child) had dance or other physically active classes at school (other than PE class) yesterday. Is this correct?

YES 1

NO (SKIP TO G23) 2

REFUSED (SKIP TO G23) -1

DON’T KNOW (SKIP TO G23) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) have dance or other physically active classes at school (other than PE class) yesterday?

MINUTES

REFUSED -1

DON’T KNOW -2

When (you/your child) had dance or other physically active classes at school (other than PE class), what exactly (were you/was your child) doing?

DANCE 1

WEIGHTLIFTING 2

OTHER (SPECIFY) 3

REFUSED -1

DON’T KNOW -2

SPECIFY:

IF G4A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G24

G23.

You answered that (you/your child) participated in physical activity breaks during classes at school yesterday. Is this correct?

YES 1

NO (SKIP TO G24) 2

REFUSED (SKIP TO G24) -1

DON’T KNOW (SKIP TO G24) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) participate in physical activity breaks during classes at school yesterday?

MINUTES

REFUSED -1

DON’T KNOW -2

When (you/your child) participated in physical activity breaks during classes at school, what exactly (were you/was your child) doing?

IN-CLASS PHYSICAL ACTIVITY 1

VIDEO/STRUCTURED ACTIVITY IN HOMEROOM/ANNOUNCEMENTS 2

WALKING LAPS 3

OTHER (SPECIFY) 4

REFUSED -1

DON’T KNOW -2

SPECIFY:

IF G5A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G25

G24.

You answered that (you/your child) practiced or played with a school sports team yesterday. Is this correct?

YES 1

NO (SKIP TO G25) 2

REFUSED (SKIP TO G25) -1

DON’T KNOW (SKIP TO G25) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) practice or play with a school sports team yesterday?

MINUTES

REFUSED -1

DON’T KNOW -2

When (you/your child) practiced or played with a school sports team, what exactly (were you/was your child) doing?

BASEBALL/SOFTBALL 1

FOOTBALL/SOCCER/LACROSSE/HOCKEY/

BASKETBALL 2

SWIM TEAM/DIVING/WATER POLO 3

GOLF/TENNIS 4

TRACK AND FIELD/CROSS COUNTRY 5

CHEER/DANCE TEAM 6

WRESTLING 7

VOLLEYBALL 8

MARTIAL ARTS 9

ROWING/CANOE/KAYAK 10

BOWLING 11

SKIING 12

OTHER (SPECIFY) 13

REFUSED -1

DON’T KNOW -2

SPECIFY:

IF G6A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G26

G25.

You answered that (you/your child) practiced or played with a non-school sports team yesterday. Is this correct?

YES 1

NO (SKIP TO G26) 2

REFUSED (SKIP TO G26) -1

DON’T KNOW (SKIP TO G26) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) practice or play with a non-school sports team yesterday?

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) practice or play with a non-school sports team? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

When (you/your child) practiced or played with a non-school sports team, what exactly (were you/was your child) doing?

BASEBALL/SOFTBALL 1

FOOTBALL/SOCCER/LACROSSE/HOCKEY/

BASKETBALL 2

SWIM TEAM/DIVING/WATER POLO 3

GOLF/TENNIS 4

TRACK AND FIELD/CROSS COUNTRY 5

CHEER/DANCE TEAM 6

WRESTLING 7

VOLLEYBALL 8

MARTIAL ARTS 9

ROWING/CANOE/KAYAK 10

BOWLING 11

SKIING 12

OTHER (SPECIFY) 13

REFUSED -1

DON’T KNOW -2

SPECIFY:

IF G7A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G27

G26.

You answered that (you/your child) participated in pick-up sports yesterday. Is this correct?

YES 1

NO (SKIP TO G27) 2

REFUSED (SKIP TO G27) -1

DON’T KNOW (SKIP TO G27) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) participate in pick-up sports yesterday?

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) participate in pick-up sports? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Who did (you/your child) participate in pick-up sports with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

When (you/your child) participated in pick-up sports, what exactly (were you/was your child) doing?

BASEBALL/SOFTBALL 1

FOOTBALL/SOCCER/LACROSSE/HOCKEY/

BASKETBALL 2

SWIM TEAM/DIVING/WATER POLO 3

OTHER (SPECIFY) 4

REFUSED -1

DON’T KNOW -2

SPECIFY:

IF G8A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G28

G27.

You answered that (you/your child) participated in physical activity during an afterschool program yesterday. Is this correct?

YES 1

NO (SKIP TO G28) 2

REFUSED (SKIP TO G28) -1

DON’T KNOW (SKIP TO G28) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes (were you/was your child) physically active during (your/his/her) afterschool program yesterday?

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) participate in physical activity during an afterschool program? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Who did (you/your child) participate in physical activity during an afterschool program with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

When (you/your child) participated in physical activity during an afterschool program, what exactly (were you/was your child) doing?

PLAYGROUND GAME (KICKBALL, FOUR SQUARE, DODGEBALL, ETC.) 1

ORGANIZED SPORT GAME (BASEBALL, BASKETBALL, FOOTBALL, ETC.) 2

TAG/CAPTURE THE FLAG/RED ROVER/ETC. 3

FIXED EQUIPMENT (MONKEY BARS, SLIDES, SWINGS, ETC.) 4

DANCE/STEP TEAM 5

DOUBLE-DUTCH 6

OTHER (SPECIFY) 7

REFUSED -1

DON’T KNOW -2

SPECIFY:

IF G9A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G29

G28.

You answered that (you/your child) played physically active games yesterday. Is this correct?

YES 1

NO (SKIP TO G29) 2

REFUSED (SKIP TO G29) -1

DON’T KNOW (SKIP TO G29) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) play any physically active games yesterday?

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) play any physically active games? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Who did (you/your child) play any physically active games with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

When (you/your child) played physically active games, what exactly (were you/was your child) doing?

TAG 1

RED ROVER/DUCK DUCK GOOSE/ETC. 2

HOPSCOTCH 3

OTHER (SPECIFY) 4

REFUSED -1

DON’T KNOW -2

SPECIFY:

IF G10A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G30

G29.

You answered that (you/your child) swam or played games in a pool, lake, or ocean yesterday. Is this correct?

YES 1

NO (SKIP TO G30) 2

REFUSED (SKIP TO G30) -1

DON’T KNOW (SKIP TO G30) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) swim or play games in a pool, lake, or ocean yesterday?

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) swim or play games in a pool, lake, or ocean? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Who did (you/your child) swim or play games in a pool, lake, or ocean with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

When (you/your child) swam or played games in a pool, lake, or ocean, what exactly (were you/was your child) doing?

SWIMMING 1

WATER GAMES (MARCO POLO, SHARK AND MINNOWS, ETC.) 2

WATERPLAY 3

OTHER (SPECIFY) 4

REFUSED -1

DON’T KNOW -2

SPECIFY:

IF G11A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G31

G30.

You answered that (you/your child) did outdoor or adventure sports yesterday. Is this correct?

YES 1

NO (SKIP TO G31) 2

REFUSED (SKIP TO G31) -1

DON’T KNOW (SKIP TO G31) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) do any outdoor or adventure sports yesterday?

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) do outdoor or adventure sports? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Who did (you/your child) do outdoor or adventure sports with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

When (you/your child) did outdoor or adventure sports, what exactly (were you/was your child) doing?

HIKING 1

ROCK CLIMBING 2

SURFING/SKIMBOARDING/BODYBOARDING 3

SNOW SKIING/SNOWBOARDING 4

WATER SKIING/WAKEBOARDING 5

KAYAKING 6

OTHER (SPECIFY) 7

REFUSED -1

DON’T KNOW -2

SPECIFY:

IF G12A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G32

G31.

You answered that (you/your child) walked or biked to or from school yesterday. Is this correct?

YES 1

NO (SKIP TO G32) 2

REFUSED (SKIP TO G32) -1

DON’T KNOW (SKIP TO G32) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) walk or bike to or from school yesterday?

MINUTES

REFUSED -1

DON’T KNOW -2

Who did (you/your child) walk or bike to or from school with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

When (you/your child) walked or biked to or from school, what exactly (were you/was your child) doing?

WALK 1

BIKE 2

REFUSED -1

DON’T KNOW -2

IF G13A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G33

G32.

You answered that (you/your child) walked or biked to or from a store, park, or playground or a friend’s house yesterday. Is this correct?

YES 1

NO (SKIP TO G33) 2

REFUSED (SKIP TO G33) -1

DON’T KNOW (SKIP TO G33) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) walk or bike to or from a store, park, or playground or a friend’s house yesterday?

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) walk or bike to or from a store, park, or playground or a friend’s house? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Who did (you/your child) walk or bike to or from a store, park, or playground or a friend’s house with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

When (you/your child) walked or biked to or from a store, park, or playground or a friend’s house, what exactly (were you/was your child) doing?

WALK 1

BIKE 2

REFUSED -1

DON’T KNOW -2

IF G14A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G34

G33.

You answered that (you/your child) walked or rode a bike, scooter, skateboard, or skates for fun or exercise yesterday. Is this correct?

YES 1

NO (SKIP TO G34) 2

REFUSED (SKIP TO G34) -1

DON’T KNOW (SKIP TO G34) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) walk or ride a bike, scooter, skateboard, or skates for fun or exercise yesterday?

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) walk or ride a bike, scooter, skateboard, or skates for fun or exercise? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Who did (you/your child) walk or ride a bike, scooter, skateboard, or skates for fun or exercise with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

When (you/your child) walked or rode a bike, scooter, skateboard, or skates for fun or exercise, what exactly (were you/was your child) doing?

WALK 1

BIKE 2

SCOOTER 3

SKATEBOARD 4

SKATES/ROLLERBLADES 5

OTHER (SPECIFY) 6

REFUSED -1

DON’T KNOW -2

SPECIFY:

IF G15A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G35

G34.

You answered that (you/your child) used a computer for games or playing on the internet (not for schoolwork or social networks) yesterday. Is this correct?

YES 1

NO (SKIP TO G35) 2

REFUSED (SKIP TO G35) -1

DON’T KNOW (SKIP TO G35) -2

For how many minutes did (you/your child) use a computer for games or playing on the internet yesterday?

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) use a computer for games or playing on the internet? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Who did (you/your child) use a computer for games or playing on the internet with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

When (you/your child) used a computer for games or playing on the internet, what exactly (were you/was your child) doing?

PLAYING GAMES 1

SURFING THE INTERNET 2

OTHER (SPECIFY) 3

REFUSED -1

DON’T KNOW -2

SPECIFY:

IF G16A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G36

G35.

You answered that (you/your child) used a computer or phone for social networking yesterday. Is this correct?

YES 1

NO (SKIP TO G36) 2

REFUSED (SKIP TO G36) -1

DON’T KNOW (SKIP TO G36) -2

For how many minutes did (you/your child) use a computer or phone for social networking yesterday?

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) use a computer or phone for social networking? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Who did (you/your child) use a computer or phone for social networking with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

When (you/your child) used a computer or phone for social networking, what exactly (were you/was your child) doing?

IM/CHAT/TWITTER 1

SOCIAL NETWORKING ON THE COMPUTER 2

TEXTING 3

OTHER (SPECIFY) 4

REFUSED -1

DON’T KNOW -2

SPECIFY:

IF G17A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G37

G36.

You answered that (you/your child) watched TV yesterday. Is this correct?

YES 1

NO (SKIP TO G37) 2

REFUSED (SKIP TO G37) -1

DON’T KNOW (SKIP TO G37) -2

For how many minutes did (you/your child) watch TV yesterday?

1 Hour = 60 Minutes

2 Hours = 120 Minutes

3 Hours = 180 Minutes

4 Hours = 240 Minutes

5 Hours = 300 Minutes

6 Hours = 360 Minutes

7 Hours = 420 Minutes

8 Hours = 480 Minutes

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) watch TV? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Who did (you/your child) watch TV with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

When (you/your child) watched TV, what exactly (were you/was your child) doing?

WATCHING EDUCATIONAL TV OR VIDEOS 1

WATCHING NON-EDUCATIONAL TV OR VIDEOS 2

OTHER (SPECIFY) 3

REFUSED -1

DON’T KNOW -2

SPECIFY:

IF G18A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G38

G37.

You answered that (you/your child) played non-active video games yesterday. Is this correct?

YES 1

NO (SKIP TO G38) 2

REFUSED (SKIP TO G38) -1

DON’T KNOW (SKIP TO G38) -2

For how many minutes did (you/your child) play non-active video games yesterday?

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) play non-active video games? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Who did (you/your child) play non-active video games with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

When (you/your child) played non-active video games, what exactly (were you/was your child) doing?

PLAYING GAMES ON A GAME CONSOLE 1

PLAYING GAMES ON A HANDHELD GAMING DEVICE 2

OTHER (SPECIFY) 3

REFUSED -1

DON’T KNOW -2

SPECIFY:

IF G19A DOES NOT INCLUDE PREVIOUS DAY OF WEEK, SKIP TO G39

G38.

You answered that (you/your child) played physically active video games yesterday. A physically active video game is one where some physical effort is involved in playing the game. Is this correct?

YES 1

NO (SKIP TO G39) 2

REFUSED (SKIP TO G39) -1

DON’T KNOW (SKIP TO G39) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) play physically active video games yesterday?

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) play physically active video games? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Who did (you/your child) play physically active video games with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

When (you/your child) played physically active video games, what exactly (were you/was your child) doing?

PLAYING WII/KINECT/MOVE, ETC. 1

DANCE, DANCE REVOLUTION 2

OTHER (SPECIFY) 3

REFUSED -1

DON’T KNOW -2

SPECIFY:

G39.

Did (you/your child) do any other physical activities yesterday that were not already mentioned?

YES 1

NO (SKIP TO section h) 2

REFUSED (SKIP TO section h) -1

DON’T KNOW (SKIP TO section h) -2

What were the other activities?

ACTIVITY 1:_____________________________________

ACTIVITY 2:_____________________________________

ACTIVITY 3:_____________________________________

ACTIVITY 4:_____________________________________

REFUSED -1

DON’T KNOW -2

How physically hard or intense were these activities?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) do these other activities?

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) do these other activities? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Who did (you/your child) do these other activities with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

SECTION H: PHYSICAL ACTIVITY CHILD SURVEY

Self administered

Child aged 4 – 11: Child respondent/adult present to assist

Child aged 12 – 15: Child respondent

H1.

How much do you agree or disagree with the following statements?

Disagree A Lot

Disagree A Little

Agree A Little

Agree A Lot

REFUSED

DON’T KNOW

There are many places I like to go within easy walking distance of my home.

-1

-2

There are sidewalks on most of the streets in my neighborhood.

-1

-2

There are bicycle or walking trails in my neighborhood.

-1

-2

It is safe to walk or jog in my neighborhood during the day.

-1

-2

People in my neighborhood can easily see walkers and bikers on the streets from their homes.

-1

-2

There is so much traffic that it makes it hard to walk in my neighborhood.

-1

-2

There is a lot of crime in my neighborhood.

-1

-2

I often see other girls or boys playing outdoors in my neighborhood.

-1

-2

There are many interesting things to look at while walking in my neighborhood.

-1

-2

My neighborhood streets are well lit at night.

-1

-2

There are lots of loose or scary dogs in my neighborhood.

-1

-2

There is enough equipment (like balls, bikes, etc.) for me to use at home.

-1

-2

H2.

How much do you agree or disagree with the following statements?

Disagree A Lot

Disagree A Little

Agree A Little

Agree A Lot

REFUSED

DON’T KNOW

My closest friends are physically active on most days

-1

-2

My school has non-sports programs for students to be physically active (step team, dance, walk/run club, etc.)

-1

-2

My school has sports teams that you have to try out for

-1

-2

My school has sports teams where everyone can participate (no try-outs)

-1

-2

H3.

How much do you agree or disagree with the following statement?

Disagree A Lot

Disagree A Little

Agree A Little

Agree A Lot

Does Not Apply To Me

REFUSED

I enjoy physical education classes at my school

-1

-2

H4.

How do you rate your physical activity level compared to others of the same age and gender?

Much Less Than Others 1

Somewhat Less Than Others 2

About The Same 3

Somewhat More Than Others 4

Much More Than Others 5

REFUSED -1

DON’T KNOW -2

Domain 9: Dieting Behaviors (FOR 12 – 15 YEAR OLDS)

Self-administered

Child aged 4 – 11: NOT ADMINISTERED IN THIS FORMAT OR POINT IN THE SURVEY

Child aged 12 – 15: Child respondent

J16.

At this time do you feel that you are?

Underweight 1

About the right weight 2

Overweight 3

REFUSED -1

DON'T KNOW -2

J17.

Which of the following are you trying to do about your weight?

Lose weight.................................................... 1

Gain weight ........................................... 2

Stay the same weight ........................................ 3

Not trying to do anything about weight 4

REFUSED ......................................................................-1

DON'T KNOW ...............................................................-2

J18.

Thinking about the past year, how often has someone said something to you about your weight or your eating that made you feel bad?

Never 1

Less than once a year 2

A few times a year 3

A few times a month 4

At least once a week 5

REFUSED -1

DON'T KNOW -2

J19.

Some people skip meals to keep from gaining weight or to try to lose weight. During the past 7 days, on how many days did you skip meals to keep from gaining weight or to try to lose weight?

NONE 1

1 DAY 2

2 DAYS 3

3 DAYS 4

4 DAYS 5

5 DAYS 6

6 DAYS 7

7 DAYS 8

REFUSED -1

DON’T KNOW -2

J20.

At this time how satisfied are you with your weight? Please choose a number between 1 and 5 with 1 being very satisfied and 5 being not at all satisfied.

VERY SATISFIED NOT AT ALL

SATISFIED

				
1	2	3	4	5

REFUSED -1

DON'T KNOW -2

SECTION E: CHILD SELF-REPORTED BEHAVIORS

Self administered

Child aged 4 – 11: NOT ADMINISTERED

Child aged 12 – 15: Child respondent

These next questions ask about behaviors and perceptions that are linked to children’s health. Remember that no one else in your home will see your answers.

E1.

We first want you to answer some questions about smoking. Have you smoked at least one cigarette within the last 30 days?

YES 1

NO (SKIP TO E2) 2

REFUSED -1

DON’T KNOW -2

During the past 30 days, did you smoke cigarettes to help you lose weight or to keep you from gaining weight?

YES 1

NO 2

I DO NOT SMOKE 3

REFUSED -1

DON’T KNOW -2

IF CHILD IS MALE, END SECTION

E2.

Have your periods or menstrual cycles started yet?

YES 1

NO (SKIP TO E4) 2

REFUSED (SKIP TO E4) -1

DON’T KNOW (SKIP TO E4) -2

E3.

How old were you when you had your first menstrual period?

Age (SKIP TO E4)

REFUSED (SKIP TO E4) -1

DON’T KNOW -2

Were you (SHOW ANSWERS)?

If you are having trouble remembering your age, try to think of what grade you were in and when during the school year you first started your period.

YOUNGER THAN 10 1

10 TO 12 2

13 TO 15, OR 3

16 OR OLDER 4

REFUSED -1

DON’T KNOW -2

E4.

Are you pregnant now?

YES 1

NO 2

REFUSED -1

DON'T KNOW -2

SECTION I: PHYSICAL ACTIVITY PARENT SURVEY

Self administered

Child aged 4 – 15: Adult respondent

Now we have a few questions that we would like you to answer on the computer. If you have any questions about using the computer, please let me know.

I1.

In my home or yard, my child has access to the following. Choose all that apply.

BASKETBALL HOOP/SPORTS GOALS (SOCCER) 1

BICYCLE 2

BIG YARD/EMPTY FIELD 3

ACTIVE VIDEO GAME SYSTEMS (WII, PLAYSTATION MOVE, XBOX KINECT) OR EXERCISE VIDEO TAPES 4

INDOOR PLAY SPACE (PLAYROOM, EMPTY GARAGE) 5

CARDIO OR WEIGHT LIFTING EQUIPMENT (TREADMILL, STATIONARY BICYCLE, STEP CLIMBER, ELLIPTICAL MACHINE, ROWING MACHINE, FREE WEIGHTS, NAUTILUS) 6

JUNGLE GYM/TREE HOUSE/SWINGS/SLIDES 7

WHEELED TOYS (SCOOTER, SKATEBOARD, INLINE SKATES, ROLLER SKATES, ETC.) 8

ACTIVE EQUIPMENT (BALLS, JUMPROPES FRISBEES, RACQUETS, BATS, ETC.) 9

SWIMMING POOL 10

OTHER, PLEASE SPECIFY 11

REFUSED -1

DON’T KNOW -2

SPECIFY:

I2.

In my community or neighborhood, my child has access to the following. Choose all that apply.

BASKETBALL HOOP/SPORTS GOALS (SOCCER) 12

BIG YARD/EMPTY FIELD 13

INDOOR PLAY SPACE (CLUBHOUSE) 14

CARDIO OR WEIGHT LIFTING EQUIPMENT (TREADMILL, STATIONARY BICYCLE, STEP CLIMBER, ELLIPTICAL MACHINE, ROWING MACHINE, FREE WEIGHTS, NAUTILUS) 15

LAKE OR OCEAN 16

PLAYGROUND (JUNGLE GYM, SLIDES, SWINGS, ETC.) 17

SWIMMING POOL 18

TENNIS COURT 19

PARK 20

WALKING OR BIKING PATH/TRAIL 21

YMCA/BOYS AND GIRLS CLUB/ETC. 22

SKATE PARK/PLACE FOR SKATEBOARDING 23

OTHER, PLEASE SPECIFY 24

REFUSED -1

DON’T KNOW -2

SPECIFY:

Please read each of the following statements and select the response that best indicates how much you agree or disagree with the statement.

I3.

I allow my child to play video games or computer games as much as (he/she) wants.

STRONGLY DISAGREE 1

DISAGREE 2

AGREE 3

STRONGLY AGREE 4

REFUSED -1

DON’T KNOW -2

I4.

I allow my child to watch as much TV as (he/she) wants.

STRONGLY DISAGREE 1

DISAGREE 2

AGREE 3

STRONGLY AGREE 4

REFUSED -1

DON’T KNOW -2

I5.

If my child has been occupied for a long time with inside activities and the weather is nice, I encourage (him/her) to play outside.

STRONGLY DISAGREE 1

DISAGREE 2

AGREE 3

STRONGLY AGREE 4

REFUSED -1

DON’T KNOW -2

I6.

My child is allowed to play outside without adult supervision. Would you say yes or no?

YES 1

NO 2

REFUSED -1

DON'T KNOW -2

I7.

How often does a member of your household take (CHILD) to a place where (he/she) can participate in physical activities?

0 DAYS PER WEEK 1

1-2 DAYS PER WEEK 2

3-4 DAYS PER WEEK 3

5-6 DAYS PER WEEK 4

7 DAYS PER WEEK 5

REFUSED -1

DON’T KNOW -2

I8.

How do you rate your child’s level of physical activity, compared to others of the same age and gender?

MUCH LESS THAN OTHERS 1

SOMEWHAT LESS THAN OTHERS 2

ABOUT THE SAME 3

SOMEWHAT MORE THAN OTHERS 4

MUCH MORE THAN OTHERS 5

REFUSED -1

DON’T KNOW -2

Thank you for answering those questions. Please give the tablet back to the interviewer now.

SECTION J: NUTRITION QUESTIONS (PIECE 2)

Domain 4: Perceived Home Environment Regarding Healthy Eating

Interviewer administered

Child aged 4 – 15: Adult respondent

The next questions ask how often you have certain types of food available at home. HAND SHOW CARD A.

J21.

How often do you have fruits available at home? Would you say (READ ANSWERS)?

Never 1

Rarely 2

Sometimes 3

Often 4

Very Often 5

REFUSED -1

DON’T KNOW -2

J22.

How often do you have any of these dark green vegetables available at home? Broccoli; spinach and other greens like collard, mustard, and turnip greens; and dark green leafy lettuce like romaine. Would you say (READ ANSWERS)?

Never 1

Rarely 2

Sometimes 3

Often 4

Very Often 5

REFUSED -1

DON’T KNOW -2

J23.

How often do you have salty snacks such as chips and crackers available at home? Do not include nuts. Would you say (READ ANSWERS)?

Never 1

Rarely 2

Sometimes 3

Often 4

Very Often 5

REFUSED -1

DON’T KNOW -2

J24.

How often do you have 1% fat, skim, or fat-free milk available at home? Do not include 2% milk. Would you say (READ ANSWERS)?

Never 1

Rarely 2

Sometimes 3

Often 4

Very Often 5

REFUSED -1

DON’T KNOW -2

J25.

How often do you have soft drinks, fruit-flavored drinks, or fruit punch available at home? Do not include diet drinks, 100% juice or sports drinks. Would you say (READ ANSWERS)?

Never 1

Rarely 2

Sometimes 3

Often 4

Very Often 5

REFUSED -1

DON’T KNOW -2

Domain 6: Perceived Community Environment Regarding Healthy Eating

Interviewer administered

Child aged 4 – 15: Adult respondent

In the next question, I am going to ask you about obtaining food.

J26.

When shopping for food, how often does the main food shopper in your household go to each of the following places? HAND SHOW CARD A.

Would you say (READ ANSWERS)?

Never

Rarely

Sometimes

Often

Very Often

Large chain grocery store or supermarket?

-1

-2

Natural or organic supermarket such as Whole Foods Market?

-1

-2

Small local store or corner store?

-1

-2

Convenience store such as 7-Eleven, Quick Stop, mini market?

-1

-2

Warehouse club store such as Sam’s Club or Costco?

-1

-2

Discount superstore such as Wal-Mart or Target?

-1

-2

Online delivery such as Peapod or Fresh Direct?

-1

-2

Ethnic market?

-1

-2

Farmer’s market/co-op?

-1

-2

The next question is about eating prepared food, including when you eat at restaurants, go through the drive-thru, carry out, or have it delivered.

J27.

When you eat out or get take out food, how often do you go to each of the following places? HAND SHOW CARD A. Would you say (READ ANSWERS)?

Never

Rarely

Sometimes

Often

Very Often

Restaurant with waiter or waitress service?

-1

-2

Buffet or cafeteria?

-1

-2

Fast food restaurant?

-1

-2

Deli, stand alone or in a shop?

-1

-2

Convenience stores such as 7-Eleven, Quick Stop, mini market?

-1

-2

Bar, tavern, or lounge?

-1

-2

Coffee shop?

-1

-2

In this next set of questions, I am going to ask you about the availability, cost, and quality of food in your community. Remember, community is defined as the place where you live, including your neighborhood and the neighborhoods that you are easily able to get to. HAND SHOW CARD C.

J28.

Please tell me how much you agree or disagree with the following statements. Do you disagree a lot, disagree a little, agree a little, or agree a lot?

DISAGREE A LOT

DISAGREE A LITTLE

AGREE A LITTLE

AGREE A LOT

It is easy to buy fresh fruits and vegetables in my community.

-1

-2

There is a large selection of fresh fruits and vegetables in my community.

-1

-2

The produce, fresh fruits and vegetables, in my community is of high quality. REMOVE SHOW CARD C.

-1

-2

Domain 7: Infant Feeding History

Interviewer administered

Child aged 4 – 15: Adult respondent

The next questions are about breastfeeding your child.

J29.

Was your child ever breastfed or fed breast milk?

YES 1

NO (SKIP TO J31) 2

REFUSED (SKIP TO J31) -1

DON’T KNOW (SKIP TO J31) -2

J30.

How old was your child when (he/she) completely stopped breastfeeding or being fed breast milk?

WEEKS

MONTHS

YEARS

REFUSED -1

DON'T KNOW -2

Domain 8: Household Food Insecurity

Interviewer administered

Child aged 4 – 15: Adult respondent

Now I’m going to read you several statements that people have made about their food situation. For these statements, please tell me whether the statement was often true, sometimes true, or never true for your household in the last 12 months – that is, since last (CURRENT MONTH).

J31.

We worried whether our food would run out before we got money to buy more. Was that often true, sometimes true, or never true for your household in the last 12 months?

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

REFUSED -1

DON'T KNOW -2

J32.

The food that we bought just didn’t last, and we didn’t have money to get more. Was that often, sometimes, or never true for your household in the last 12 months?

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

REFUSED -1

DON'T KNOW -2

Domain 9: Dieting Behaviors (FOR 4 – 11 YEAR OLDS)

Interviewer administered

Child aged 4 – 11:Adult respondent

Child aged 12 – 15: NOT ADMINISTERED IN THIS FORMAT OR POINT IN THE SURVEY

J33.

At this time do you feel that your child is (READ ANSWERS)?

Underweight 1

About the right weight 2

Overweight 3

REFUSED -1

DON'T KNOW -2

J34.

At this time how satisfied are you with your child’s weight? Please choose a number between 1 and 5 with 1 being very satisfied and 5 being not at all satisfied.

VERY SATISFIED NOT AT ALL

SATISFIED

				
1	2	3	4	5

REFUSED -1

DON'T KNOW -2

SECTION B: DEMOGRAPHIC AND SOCIO-ECONOMIC INFORMATION

Interviewer administered

Child aged 4 – 15: Adult respondent

Now we have some basic background and demographic information to ask you. These questions are simple, straightforward, and will be kept private under the Privacy Act. Your name will not be on your questionnaire.

For the following questions, please consider the other people who live in your household as they relate to (CHILD).

B1.

HAND SHOW CARD D. Who lives in this household? Please select all the numbers that apply. Please remember not to include anyone who usually lives somewhere else. CODE ALL THAT APPLY

STUDY CHILD’S BIOLOGICAL MOTHER 1

STUDY CHILD’S BIOLOGICAL FATHER 2

OTHER ADULTS AGED 18 AND OLDER, NOT INCLUDING THE STUDY CHILD’S BIOLOGICAL PARENTS 3

OTHER CHILDREN UNDER THE AGE OF 18, NOT INCLUDING THE STUDY CHILD 4

REFUSED -1

DON’T KNOW -2

IF B1 RESPONSE INCLUDES 3, ASK A.

HAND SHOW CARD E. Please indicate the number of each type of adult who lives in this household. Please only include adults 18 years old or older. ASK FOR COUNT FOR EACH TYPE BY LETTER.

A: NON-BIOLOGICAL PARENTS ( ADOPTIVE, STEP OR FOSTER)

B: PARENT’S UNMARRIED PARTNER

C: GRANDPARENT(S)

D: AUNT(S)/UNCLE(S)

E: OTHER ADULT RELATIVES

F: OTHER ADULT NON-RELATIVES

REFUSED -1

DON’T KNOW -2

IF B1 RESPONSE INCLUDES 4, ASK B.

HAND SHOW CARD F. Please indicate the number of each type of child, other than (CHILD) who lives in this household. Please only include children less than 18 years old. ASK FOR COUNT FOR EACH TYPE BY LETTER.

G: BROTHER/SISTER(S) (BIOLOGICAL/ADOPTIVE/

STEP/FOSTER)

H: COUSINS

I: NIECE(S)/NEPHEWS(S)

J: STUDY CHILD’S CHILD(REN)

K: OTHER RELATIVE CHILD(REN)

L: OTHER NON-RELATIVE CHILD(REN)

REFUSED -1

DON’T KNOW -2

B2.

HAND SHOW CARD G. How are you related to (CHILD)? Please tell me the number of your answer. REMOVE SHOW CARD G.

BIOLOGICAL MOTHER (SKIP TO B4) 1

BIOLOGICAL FATHER (SKIP TO B4) 2

ADOPTIVE/STEP/FOSTER

MOTHER (SKIP TO B4) 3

ADOPTIVE/STEP/FOSTER

FATHER (SKIP TO B4) 4

PARTNER OF STUDY CHILD’S MOTHER

OR FATHER 5

GRANDPARENT 6

BROTHER/SISTER (BIOLOGICAL/ADOPTIVE/

STEP/IN-LAW/FOSTER) 7

AUNT/UNCLE 8

OTHER RELATIVE 9

OTHER NONRELATIVE 10

LEGAL GUARDIAN (SKIP TO B4) 11

STUDY CHILD IS WARD OF STATE OR

COURT (SKIP TO B4) 12

REFUSED -1

DON’T KNOW -2

B3.

Are you (CHILD)’s guardian?

Yes 1

no 2

refused -1

don’t know -2

B4.

How old are you?

Age

REFUSED -1

DON’T KNOW -2

B5.

RECORD GENDER WITHOUT ASKING

MALE 1

FEMALE 2

B6.

Are you now married, widowed, divorced separated, never married or living with a partner?

MARRIED 1

WIDOWED 2

DIVORCED 3

SEPARATED 4

NEVER MARRIED 5

LIVING WITH PARTNER 6

REFUSED -1

DON’T KNOW -2

B7.

Do you consider yourself Hispanic/Latin(o/a)?

Which of the following represent your Hispanic origin or ancestry? READ ANSWERS AND CODE ALL THAT APPLY

YES 1

NO (SKIP TO B8) 2

REFUSED (SKIP TO B8) -1

DON’T KNOW (SKIP TO B8) -2

Puerto Rican 1

Dominican (Republic) 2

Mexican/Mexican American 3

Cuban/Cuban American 4

Central/South American 5

Other Latin American 6

Other Hispanic Or Latin(o/a) 7

REFUSED -1

DON’T KNOW -2

B8.

(In addition to being Hispanic, what/What) race do you consider yourself to be? CODE ALL THAT APPLY

WHITE 1

BLACK/ AFRICAN AMERICAN 2

AMERICAN INDIAN/ALASKA NATIVE 3

NATIVE HAWAIIAN/PACIFIC ISLANDER 4

ASIAN 5

REFUSED -1

DON’T KNOW -2

IF B8 RESPONSE INCLUDES 4, ASK A

Which Native Hawaiian and/or Pacific Islander group? CODE ALL THAT APPLY

NATIVE HAWAIIAN 1

GUAMANIAN 2

SAMOAN 3

OTHER PACIFIC ISLANDER (SPECIFY) 4

REFUSED -1

DON’T KNOW -2

SPECIFY:

IF B8 RESPONSE INCLUDES 5, ASK B

Which Asian group? CODE ALL THAT APPLY

ASIAN INDIAN 1

CHINESE 2

FILIPINO 3

JAPANESE 4

KOREAN 5

VIETNAMESE 6

OTHER ASIAN (SPECIFY) 7

REFUSED -1

DON’T KNOW -2

SPECIFY:

B9.

Where were you born?

US STATE (SPECIFY) (SKIP TO B10) 1

US TERRITORY OR FOREIGN COUNTRY(SPECIFY) 2

REFUSED (SKIP TO B10) -1

DON’T KNOW (SKIP TO B10) -2

SPECIFY:

What year did you come to live in the United States?

YEAR

REFUSED -1

DON’T KNOW -2

Now I am going to ask you about language use.

IF B7=1, SKIP TO B11

B10.

What languages do you usually speak at home? CODE ALL THAT APPLY

ENGLISH 1

SPANISH 2

OTHER 3

REFUSED -1

DON’T KNOW -2

SKIP TO B12

B11.

What languages do you usually speak at home? Would you say (READ ANSWERS)?

Only Spanish 1

More Spanish Than English 2

Both Equally 3

More English Than Spanish 4

Only English 5

Other 6

REFUSED -1

DON’T KNOW -2

Now, I have some questions about educational history to ask you.

B12.

What is the highest grade or year of school you have completed or the highest degree you have received?

never attended/kindergarten only 1

1^st grade 2

2^nd grade 3

3^rd grade 4

4^th grade 5

5^th grade 6

6^th grade 7

7^th grade 8

8^th grade 9

9^th grade 10

10^th grade 11

11^th grade 12

12^th grade 13

12^th grade, NO DIPLOMA 14

high school graduate 15

ged or equivalent 16

some college, no degree 17

associate degree: occupational, technical, or vocational program 18

associate degree: academic program 19

bachelor’s degree (ba, ab, bs, bba) 20

master’s Degree (ma, ms, meng, med, mba) 21

professional school degree (MD,

DDS, DVM, JD) 22

doctoral degree (PHD, EDD) 23

refused -1

don’t know -2

B13.

We would like to know about what you do – are you working full-time for pay now, working part-time for pay, looking for work, retired, keeping house, a student, or what? CODE ALL THAT APPLY

WORKING FULL-TIME FOR PAY NOW 1

WORKING PART-TIME FOR PAY NOW 2

ONLY TEMPORARILY LAID OFF, on SICK LEAVE OR MATERNITY LEAVE 3

LOOKING FOR WORK, UNEMPLOYED 4

RETIRED 5

DISABLED, PERMANENTLY OR TEMPORARILY 6

KEEPING HOUSE 7

STUDENT 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

B14.

How many nights a week does (CHILD) usually sleep in this house?

nights

REFUSED -1

DON’T KNOW -2

IF B2>02, SKIP TO B25

You said that you are (CHILD)’s biological (mother/father). I would like to ask some questions now about (his/her) other biological parent.

B15.

How old is (he/she)?

Age

DECEASED 95

KNOW NOTHING ABOUT THIS PERSON 96

REFUSED -1

DON’T KNOW -2

B16.

RECORD GENDER OF OTHER BIOLOGICAL PARENT WITHOUT ASKING

MALE 1

FEMALE 2

IF B15 = 96, SKIP TO B43

IF B15 = 95 SKIP TO B18

IF B2=1 AND B1 DOES NOT INCLUDE 2 [RESPONDENT= BIO MOTHER, BIO FATHER DOES NOT LIVE IN HH] OR B2=2 AND B1 DOES NOT INCLUDE 1 [RESPONDENT=BIO FATHER, BIO MOTHER DOES NOT LIVE IN HH] SKIP TO B18

B17.

Is (he/she) now married, widowed, divorced, separated, never married, or living with a partner?

MARRIED 1

WIDOWED 2

DIVORCED 3

separated 4

never married 5

living with partner 6

refused -1

don’t know -2

B18.

(IF B15 = 95, READ: I am sorry to hear that. I would still like to ask a few questions about (him/her) at the time of (his/her) death.)

Do you consider (him/her) Hispanic/Latin(o/a)?

YES 1

NO (SKIP TO B19) 2

REFUSED (SKIP TO B19) -1

DON’T KNOW (SKIP TO B19) -2

Which of the following represent (his/her) Hispanic origin or ancestry? READ ANSWERS AND CODE ALL THAT APPLY

Puerto Rican 1

Dominican (Republic) 2

Mexican/Mexican American 3

Cuban/Cuban American 4

Central/South American 5

Other Latin American 6

Other Hispanic Or Latin(o/a) 7

REFUSED -1

DON’T KNOW -2

B19.

(In addition to being Hispanic, what/What) race do you consider (him/her) to be? CODE ALL THAT APPLY

WHITE 1

BLACK/ AFRICAN AMERICAN 2

AMERICAN INDIAN/ALASKA NATIVE 3

NATIVE HAWAIIAN/PACIFIC ISLANDER 4

ASIAN 5

REFUSED -1

DON’T KNOW -2

IF B19 RESPONSE INCLUDES 4, ASK A

Which Native Hawaiian and/or Pacific Islander group? CODE ALL THAT APPLY

NATIVE HAWAIIAN 1

GUAMANIAN 2

SAMOAN 3

OTHER PACIFIC ISLANDER (SPECIFY) 4

REFUSED -1

DON’T KNOW -2

SPECIFY:

IF B19 RESPONSE INCLUDES 5, ASK B

Which Asian group? CODE ALL THAT APPLY

ASIAN INDIAN 1

CHINESE 2

FILIPINO 3

JAPANESE 4

KOREAN 5

VIETNAMESE 6

OTHER ASIAN (SPECIFY) 7

REFUSED -1

DON’T KNOW -2

SPECIFY:

IF B15 = 95 SKIP TO B23

IF B2=1 AND B1 DOES NOT INCLUDE 2 [RESPONDENT= BIO MOTHER, BIO FATHER DOES NOT LIVE IN HH] OR B2=2 AND B1 DOES NOT INCLUDE 1 [RESPONDENT=BIO FATHER, BIO MOTHER DOES NOT LIVE IN HH] SKIP TO B23

B20.

Where was (he/she) born?

US STATE (SPECIFY) (SKIP TO B21) 1

US TERRITORY OR FOREIGN COUNTRY(SPECIFY) 2

REFUSED (SKIP TO B21) -1

DON’T KNOW (SKIP TO B21) -2

SPECIFY:

What year did (he/she) come to live in the United States?

YEAR

REFUSED -1

DON’T KNOW -2

Now I am going to ask you about (his/her) language use.

IF B18=1, SKIP TO B22

B21.

What languages (does/did) (he/she) usually speak at home? CODE ALL THAT APPLY

ENGLISH 1

SPANISH 2

OTHER 3

REFUSED -1

DON’T KNOW -2

SKIP TO B23

B22.

What languages (does/did) (he/she) usually speak at home? Would you say (READ ANSWERS)?

Only Spanish 1

More Spanish Than English 2

Both Equally 3

More English Than Spanish 4

Only English 5

Other 6

REFUSED -1

DON’T KNOW -2

Now, I have some questions about (his/her) educational history to ask you.

B23.

What is the highest grade or year of school (he/she) (has/had) completed or the highest degree (he/she) (has/had) received?

never attended/kindergarten only 1

1^st grade 2

2^nd grade 3

3^rd grade 4

4^th grade 5

5^th grade 6

6^th grade 7

7^th grade 8

8^th grade 9

9^th grade 10

10^th grade 11

11^th grade 12

12^th grade 13

12^th grade, NO DIPLOMA 14

high school graduate 15

ged or equivalent 16

some college, no degree 17

associate degree: occupational, technical, or vocational program 18

associate degree: academic program 19

bachelor’s degree (ba, ab, bs, bba) 20

master’s Degree (ma, ms, meng, med, mba) 21

professional school degree (MD,

DDS, DVM, JD) 22

doctoral degree (PHD, EDD) 23

refused -1

don’t know -2

IF B15 = 95, SKIP TO B43

IF B2=1 AND B1 DOES NOT INCLUDE 2 [RESPONDENT= BIO MOTHER, BIO FATHER DOES NOT LIVE IN HH] OR B2=2 AND B1 DOES NOT INCLUDE 1 [RESPONDENT=BIO FATHER, BIO MOTHER DOES NOT LIVE IN HH] SKIP TO B43

B24.

We would like to know about what (he/she) does- is (he/ she) working full-time for pay now, working part-time for pay, looking for work, retired, keeping house, a student, or what? CODE ALL THAT APPLY

WORKING FULL-TIME FOR PAY NOW 1

WORKING PART-TIME FOR PAY NOW 2

ONLY TEMPORARILY LAID OFF, on SICK LEAVE OR MATERNITY LEAVE 3

LOOKING FOR WORK, UNEMPLOYED 4

RETIRED 5

DISABLED, PERMANENTLY OR TEMPORARILY 6

KEEPING HOUSE 7

STUDENT 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

SKIP TO B43

You said that you are not (CHILD)’s biological parent. I would like to ask some questions now about (his/her) biological mother and father.

B25.

How old is (his/her) biological mother?

Age

DECEASED 95

KNOW NOTHING ABOUT THIS PERSON 96

REFUSED -1

DON’T KNOW -2

IF B25 = 96, SKIP TO B34

IF B25 = 95, SKIP TO B27

IF B1 DOES NOT INCLUDE 1, SKIP TO B27

B26.

Is she now married, widowed, divorced, separated, never married, or living with a partner?

MARRIED 1

WIDOWED 2

DIVORCED 3

separated 4

never married 5

living with partner 6

refused -1

don’t know -2

B27.

(IF B25 = 95, READ: I am sorry to hear that. I would still like to ask a few questions about her at the time of her death.)

Do you consider her Hispanic/ Latina?

YES 1

NO (SKIP TO B28) 2

REFUSED (SKIP TO B28) -1

DON’T KNOW (SKIP TO B28) -2

Which of the following represent her Hispanic origin or ancestry? READ ANSWERS AND CODE ALL THAT APPLY

Puerto Rican 1

Dominican (Republic) 2

Mexican/Mexican American 3

Cuban/Cuban American 4

Central/South American 5

Other Latin American 6

Other Hispanic Or Latin(o/a) 7

REFUSED -1

DON’T KNOW -2

B28.

(In addition to being Hispanic, what/What) race do you consider her to be? CODE ALL THAT APPLY

WHITE 1

BLACK/ AFRICAN AMERICAN 2

AMERICAN INDIAN/ALASKA NATIVE 3

NATIVE HAWAIIAN/PACIFIC ISLANDER 4

ASIAN 5

REFUSED -1

DON’T KNOW -2

IF B28 RESPONSE INCLUDES 4, ASK A

Which Native Hawaiian and/or Pacific Islander group? CODE ALL THAT APPLY

NATIVE HAWAIIAN 1

GUAMANIAN 2

SAMOAN 3

OTHER PACIFIC ISLANDER (SPECIFY) 4

REFUSED -1

DON’T KNOW -2

SPECIFY:

IF B28 RESPONSE INCLUDES 5, ASK B

Which Asian group? CODE ALL THAT APPLY

ASIAN INDIAN 1

CHINESE 2

FILIPINO 3

JAPANESE 4

KOREAN 5

VIETNAMESE 6

OTHER ASIAN (SPECIFY) 7

REFUSED -1

DON’T KNOW -2

SPECIFY:

IF B25 = 95, SKIP TO B32

IF B1 DOES NOT INCLUDE 1, SKIP TO B32

B29.

Where was she born?

US STATE (SPECIFY) (SKIP TO B30) 1

US TERRITORY OR FOREIGN COUNTRY(SPECIFY) 2

REFUSED (SKIP TO B30) -1

don’t know (skip to B30) -2

SPECIFY:

What year did she come to live in the United States?

YEAR

REFUSED -1

DON’T KNOW -2

Now I am going to ask you about her language use.

IF B27=1, SKIP TO B31

B30.

What languages (does/did) she usually speak at home? CODE ALL THAT APPLY

ENGLISH 1

SPANISH 2

OTHER 3

REFUSED -1

DON’T KNOW -2

SKIP TO B32

B31.

What languages (does/did) she usually speak at home? Would you say (READ ANSWERS)?

Only Spanish 1

More Spanish Than English 2

Both Equally 3

More English Than Spanish 4

Only English 5

Other 6

REFUSED -1

DON’T KNOW -2

Now, I have some questions about her educational history to ask you.

B32.

What is the highest grade or year of school she (has/had) completed or the highest degree she (has/had) received?

never attended/kindergarten only 1

1^st grade 2

2^nd grade 3

3^rd grade 4

4^th grade 5

5^th grade 6

6^th grade 7

7^th grade 8

8^th grade 9

9^th grade 10

10^th grade 11

11^th grade 12

12^th grade 13

12^th grade, NO DIPLOMA 14

high school graduate 15

ged or equivalent 16

some college, no degree 17

associate degree: occupational, technical, or vocational program 18

associate degree: academic program 19

bachelor’s degree (ba, ab, bs, bba) 20

master’s Degree (ma, ms, meng, med, mba) 21

professional school degree (MD,

DDS, DVM, JD) 22

doctoral degree (PHD, EDD) 23

refused -1

don’t know -2

IF B25 = 95, SKIP TO B34

IF B1 DOES NOT INCLUDE 1, SKIP TO B34

B33.

We would like to know about what she does – is she working full-time for pay now, working part-time for pay, looking for work, retired, keeping house, a student, or what? CODE ALL THAT APPLY

WORKING FULL-TIME FOR PAY NOW 1

WORKING PART-TIME FOR PAY NOW 2

ONLY TEMPORARILY LAID OFF, on SICK LEAVE OR MATERNITY LEAVE 3

LOOKING FOR WORK, UNEMPLOYED 4

RETIRED 5

DISABLED, PERMANENTLY OR TEMPORARILY 6

KEEPING HOUSE 7

STUDENT 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Now I would like to ask the same questions about (CHILD)’s biological father.

B34.

How old is (his/her) biological father?

Age

DECEASED 95

KNOW NOTHING ABOUT THIS PERSON 96

REFUSED -1

DON’T KNOW -2

IF B34 = 96, SKIP TO B43

IF B34 = 95, SKIP TO B36

IF B1 DOES NOT INCLUDE 2, SKIP TO B36

B35.

Is he now married, widowed, divorced, separated, never married, or living with a partner?

MARRIED 1

WIDOWED 2

DIVORCED 3

separated 4

never married 5

living with partner 6

refused -1

don’t know -2

B36.

(IF B34 = 95, READ: I am sorry to hear that. I would still like to ask a few questions about him at the time of his death.)

Do you consider him Hispanic/ Latino?

YES 1

NO (SKIP TO B37) 2

REFUSED (SKIP TO B37) -1

DON’T KNOW (SKIP TO B37) -2

Which of the following represent his Hispanic origin or ancestry? READ ANSWERS AND CODE ALL THAT APPLY

Puerto Rican 1

Dominican (Republic) 2

Mexican/Mexican American 3

Cuban/Cuban American 4

Central/South American 5

Other Latin American 6

Other Hispanic Or Latin(o/a) 7

REFUSED -1

DON’T KNOW -2

B37.

(In addition to being Hispanic, what/What) race do you consider him to be? CODE ALL THAT APPLY

WHITE 1

BLACK/ AFRICAN AMERICAN 2

AMERICAN INDIAN/ALASKA NATIVE 3

NATIVE HAWAIIAN/PACIFIC ISLANDER 4

ASIAN 5

REFUSED -1

DON’T KNOW -2

IF B37 RESPONSE INCLUDES 4, ASK A

Which Native Hawaiian and/or Pacific Islander group? CODE ALL THAT APPLY

NATIVE HAWAIIAN 1

GUAMANIAN 2

SAMOAN 3

OTHER PACIFIC ISLANDER (SPECIFY) 4

REFUSED -1

DON’T KNOW -2

SPECIFY:

IF B37 RESPONSE INCLUDES 5, ASK B

Which Asian group? CODE ALL THAT APPLY

ASIAN INDIAN 1

CHINESE 2

FILIPINO 3

JAPANESE 4

KOREAN 5

VIETNAMESE 6

OTHER ASIAN (SPECIFY) 7

REFUSED -1

DON’T KNOW -2

SPECIFY:

IF B34 = 95, SKIP TO B41

IF B1 DOES NOT INCLUDE 2, SKIP TO B41

B38.

Where was he born?

US STATE (SPECIFY) (SKIP TO B39) 1

US TERRITORY OR FOREIGN COUNTRY(SPECIFY) 2

REFUSED (SKIP TO B39) -1

don’t know (skip to B39) -2

SPECIFY:

What year did he come to live in the United States?

YEAR

REFUSED -1

DON’T KNOW -2

Now I am going to ask you about his language use.

IF B36=1, SKIP TO B40

B39.

What languages (does/did) he speak at home? CODE ALL THAT APPLY

ENGLISH 1

SPANISH 2

OTHER 3

REFUSED -1

DON’T KNOW -2

SKIP TO B41

B40.

What languages (does/did) he usually speak at home? Would you say (READ ANSWERS)?

Only Spanish 1

More Spanish Than English 2

Both Equally 3

More English Than Spanish 4

Only English 5

Other 6

REFUSED -1

DON’T KNOW -2

Now, I have some questions about his educational history to ask you.

B41.

What is the highest grade or year of school he (has/had) completed or the highest degree he (has/had) received?

never attended/kindergarten only 1

1^st grade 2

2^nd grade 3

3^rd grade 4

4^th grade 5

5^th grade 6

6^th grade 7

7^th grade 8

8^th grade 9

9^th grade 10

10^th grade 11

11^th grade 12

12^th grade 13

12^th grade, NO DIPLOMA 14

high school graduate 15

ged or equivalent 16

some college, no degree 17

associate degree: occupational, technical, or vocational program 18

associate degree: academic program 19

bachelor’s degree (ba, ab, bs, bba) 20

master’s Degree (ma, ms, meng, med, mba) 21

professional school degree (MD,

DDS, DVM, JD) 22

doctoral degree (PHD, EDD) 23

refused -1

don’t know -2

IF B34 = 95, SKIP TO B43

IF B1 DOES NOT INCLUDE 2, SKIP TO B43

B42.

We would like to know about what he does – is he working full-time for pay now, part-time for pay looking for work, retired, keeping house, a student, or what?

WORKING FULL-TIME FOR PAY NOW 1

WORKING PART-TIME FOR PAY NOW 2

ONLY TEMPORARILY LAID OFF, on SICK LEAVE OR MATERNITY LEAVE 3

LOOKING FOR WORK, UNEMPLOYED 4

RETIRED 5

DISABLED, PERMANENTLY OR TEMPORARILY 6

KEEPING HOUSE 7

STUDENT 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

The next questions are about your total family income in (LAST CALENDAR YEAR IN 4-DIGIT FORMAT) before taxes. Income is important in understanding the health information we collect. For example, with this information, we can learn how income is related to children’s health. These answers will be kept private under the Privacy Act. like all the other information you provide

When answering these questions, please remember that by “combined family income” I mean your income plus the income of all family members and partners living in the household. Please include income from jobs, government assistance, social security, disability, unemployment insurance, investments, and any other income that your family has.

B43.

What is your best estimate of the total income of all family members from all sources, before taxes were taken out, in (LAST CALENDAR YEAR IN 4-DIGIT FORMAT)?

INCOME (SKIP TO B49) $ , ,

REFUSED -1

DON’T KNOW -2

B44.

Was your total family income from all sources less than $50,000 or $50,000 or more?

LESS THAN $50,000 1

$50,000 OR MORE (SKIP TO B47) 2

REFUSED -1

DON’T KNOW -2

B45.

Was your total family income from all sources less than $35,000 or $35,000 or more?

LESS THAN $35,000 1

$35,000 OR MORE (SKIP TO B49) 2

REFUSED -1

DON’T KNOW -2

B46.

Was your total family income from all sources less than $20,000 or $20,000 or more?

LESS THAN $20,000 1

$20,000 OR MORE. 2

REFUSED -1

DON’T KNOW -2

SKIP TO B49

B47.

Was your total family income from all sources less than $100,000 or $100,000 or more?

LESS THAN $100,000 1

$100,000 OR MORE (SKIP TO B49) 2

REFUSED -1

DON’T KNOW -2

B48.

Was your total family income from all sources less than $75,000 or $75,000 or more?

LESS THAN $75,000 1

$75,000 OR MORE 2

REFUSED -1

DON’T KNOW -2

B49.

Does (CHILD) consider (himself/ herself) Hispanic/Latin(o/a)?

Which of the following represent (CHILD)’s Hispanic origin or ancestry? READ ANSWERS AND CODE ALL THAT APPLY

YES 1

NO (SKIP TO B50) 2

REFUSED (SKIP TO B50) -1

DON’T KNOW (SKIP TO B50) -2

Puerto Rican 1

Dominican (Republic) 2

Mexican/Mexican American 3

Cuban/Cuban American 4

Central/South American 5

Other Latin American 6

Other Hispanic Or Latin(o/a) 7

REFUSED -1

DON’T KNOW -2

B50.

(In addition to being Hispanic, what/What) race does (CHILD) consider (himself/ herself) to be? CODE ALL THAT APPLY

WHITE 1

BLACK/ AFRICAN AMERICAN 2

AMERICAN INDIAN/ALASKA NATIVE 3

NATIVE HAWAIIAN/PACIFIC ISLANDER 4

ASIAN 5

REFUSED -1

DON’T KNOW -2

IF B50 RESPONSE INCLUDES 4, ASK A

Which Native Hawaiian and/or Pacific Islander group? CODE ALL THAT APPLY

NATIVE HAWAIIAN 1

GUAMANIAN 2

SAMOAN 3

OTHER PACIFIC ISLANDER (SPECIFY) 4

REFUSED -1

DON’T KNOW -2

SPECIFY:

IF B50 RESPONSE INCLUDES 5, ASK B

Which Asian group? CODE ALL THAT APPLY

ASIAN INDIAN 1

CHINESE 2

FILIPINO 3

JAPANESE 4

KOREAN 5

VIETNAMESE 6

OTHER ASIAN (SPECIFY) 7

REFUSED -1

DON’T KNOW -2

SPECIFY:

B51.

Where was (CHILD) born?

US STATE (SPECIFY) (SKIP TO B52) 1

US TERRITORY OR FOREIGN COUNTRY(SPECIFY) 2

REFUSED (SKIP TO B52) -1

don’t know (skip to B52) -2

SPECIFY:

What year did (CHILD) come to live in the United States?

YEAR

REFUSED -1

DON’T KNOW -2

Now I am going to ask you about (CHILD)’s language use.

IF B49=1, SKIP TO B53

B52.

What languages does (CHILD) usually speak at home? CODE ALL THAT APPLY

ENGLISH 1

SPANISH 2

OTHER 3

REFUSED -1

DON’T KNOW -2

SKIP TO B54

B53.

What languages does (CHILD) usually speak at home? Would you say (READ ANSWERS)?

Only Spanish 1

More Spanish Than English 2

Both Equally 3

More English Than Spanish 4

Only English 5

Other 6

REFUSED -1

DON’T KNOW -2

Now, I have some questions about (CHILD)’s educational history to ask you.

B54.

What grade or year of school (is [he/ she] currently attending/will [he/she] be attending in the coming school year)?

kindergarten 1

1^st grade 2

2^nd grade 3

3^rd grade 4

4^th grade 5

5^th grade 6

6^th grade 7

7^th grade 8

8^th grade 9

9^th grade 10

OTHER (SPECIFY) 11

refused -1

don’t know -2

SPECIFY:

B55.

In the past month, has anyone in your household received assistance from any of the following:

A. Supplemental Nutrition Assistance benefits, sometimes called SNAP or Food Stamps?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

B. Supplemental nutrition program for Women, Infants or Children, sometimes called WIC?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

SECTION C: DETAILS OF CHILD’S BIRTH

Interviewer administered

Child aged 4 – 15: Adult respondent

We now want to ask some questions about (CHILD)’s birth.

C1.

What is (CHILD)’s birthdate?

birth date: / /

MONTH DAY YEAR

REFUSED (SKIP TO C2) -1

DON’T KNOW (SKIP TO C2) -2

RECORD SOURCE OF BIRTH DATE DATA.

BIRTH CERTIFICATE 1

BABY BOOK/RECORD 2

ADULT REPORT 3

OTHER (specify) 4

SPECIFY:

C2.

How much did (CHILD) weigh at birth?

ANSWER IN POUNDS 1

ANSWER IN GRAMS (SKIP TO C2B) 2

REFUSED (SKIP TO C2C) -1

DON’T KNOW (SKIP TO C2C) -2

RECORD BIRTH WEIGHT IN POUNDS AND OUNCES

POUNDS

OUNCES

SKIP TO C2E

RECORD BIRTH WEIGHT IN GRAMS (1 KILOGRAM = 1000 GRAMS)

GRAMS

SKIP TO C2E

Did (CHILD) weigh more than 5 ½ pounds or 2500 grams?

YES 1

NO (SKIP TO C3) 2

REFUSED (SKIP TO C3) -1

DON’T KNOW (SKIP TO C3) -2

Did (CHILD) weigh more than 9 pounds or 4100 grams?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

SKIP TO C3

RECORD SOURCE OF BIRTH WEIGHT DATA.

BIRTH CERTIFICATE 1

BABY BOOK/RECORD 2

ADULT REPORT 3

OTHER (specify) 4

SPECIFY:

C3.

What was (CHILD)’s length at birth?

ANSWER IN INCHES 1

ANSWER IN CENTIMETERS (SKIP TO C3B) 2

REFUSED (SKIP TO C4) -1

DON’T KNOW (SKIP TO C4) -2

RECORD BIRTH LENGTH IN INCHES

INCHES

SKIP TO C3C

RECORD BIRTH LENGTH IN CENTIMETERS

CENTIMETERS

RECORD SOURCE OF BIRTH LENGTH DATA.

BIRTH CERTIFICATE 1

BABY BOOK/RECORD 2

ADULT REPORT 3

OTHER (specify) 4

SPECIFY:

C4.

Was (CHILD) born early or preterm? A preterm delivery is one that occurs at 36 weeks or earlier in pregnancy, that is more than 3 weeks before the baby’s due date.

YES 1

NO (SKIP TO C5) 2

REFUSED (SKIP TO C5) -1

DON’T KNOW (SKIP TO C5) -2

How many weeks early was (CHILD) born?

WEEKS (SKIP TO C5)

REFUSED -1

DON’T KNOW -2

How many weeks along was (CHILD) at birth?

WEEKS

REFUSED -1

DON’T KNOW -2

C5.

How many years has (CHILD) lived at this address?

YEARS

REFUSED -1

DON’T KNOW -2

C6.

How many years has (CHILD) lived in the area around (NAME OF HIGH SCHOOL)?

YEARS

REFUSED -1

DON’T KNOW -2

SECTION D: HEALTH INSURANCE

Interviewer administered

Child aged 4 – 15: Adult respondent

The next questions are about health insurance coverage for you and for (CHILD). When answering these questions, please include health insurance obtained through employment or purchased directly as well as government programs like Medicare and Medicaid that provide medical care or help pay medical bills.

D1.

Are you currently covered by medical insurance or some other kind of health care plan?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

D2.

In the past 12 months, was there any time when you did not have health insurance coverage?

YES 1

NO 2

REFUSED -1

DON'T KNOW -2

D3.

Is (CHILD) currently covered by medical insurance or some other kind of health care plan?

YES 1 1

NO 2

REFUSED -1

DON’T KNOW -2

D4.

In the past 12 months, was there any time when (CHILD) did not have health insurance coverage?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

D5.

Does your child get free or reduced-price lunches at school?

YES 1

NO 2

NOT APPLICABLE 6

REFUSED -1

DON’T KNOW -2

Now I am going to ask some questions about (CHILD)’s health.

D6.

Has a doctor or other health professional ever told you that (CHILD) has a long-term or chronic disease like diabetes, asthma or any other condition?

YES (SPECIFY) 1

NO (SKIP TO D7) 2

REFUSED (SKIP TO D7) -1

DON’T KNOW (SKIP TO D7) -2

SPECIFY CONDITION:

Has a doctor or other health professional ever prescribed medication for (CHILD) for this chronic medical condition?

YES (SPECIFY) 1

NO 2

REFUSED -1

DON'T KNOW -2

SPECIFY MEDICATION:

D7.

Is (CHILD) currently enrolled in a structured program that targets weight, diet, or physical activity? Please do not include organized sports programs.

YES 1

NO 2

REFUSED -1

DON'T KNOW -2

D8.

Does (CHILD) have an impairment or health problem that limits (his/her) ability to walk, run or play?

YES 1

NO (END SECTION) 2

REFUSED (END SECTION) -1

DON’T KNOW (END SECTION) -2

D9.

Is this an impairment or health problem that has lasted, or is expected to last, 12 months or longer?

YES 1

NO (END SECTION) 2

REFUSED (END SECTION) -1

DON’T KNOW (END SECTION) -2

D10.

Would you please describe this impairment or health problem?

YES (SPECIFY) 1

NO (END SECTION) 2

REFUSED (END SECTION) -1

DON’T KNOW (END SECTION) -2

SPECIFY:

HOME VISIT 2 (Enhanced Protocol ONLY)

SECTION L: PHYSICAL ACTIVITY BEHAVIORS RECALL (FOR 4 – 15 YEAR OLDS)

Self administered

Child aged 4 – 8: Adult respondent/child present to assist

Child aged 9 – 15: Child respondent/ adult present to assist

The next questions are going to ask you about the activities that (you/your child) did yesterday. Please only think about the activities (you/your child) did yesterday, not activities that (you like/your child likes) or would like to do. For each activity, answer whether or not (you/your child) did the activity yesterday. For those activities that (you/your child) did, mark yes and answer the remaining questions for that activity. Use the word and picture descriptions on the card as a guide to select how physically hard or intense the activity was. Remember, these pictures are just a guide, and not the activities you are answering questions about.

L1.

Did (you/your child) have physical education (PE) class in school yesterday?

YES 1

NO (SKIP TO L2) 2

REFUSED (SKIP TO L2) -1

DON’T KNOW (SKIP TO L2) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) have PE?

MINUTES

REFUSED -1

DON’T KNOW -2

When (you/ yourchild) were in PE, what exactly (were you/was your child) doing?

TEAM SPORT SKILLS 1

INDIVIDUAL SPORT SKILLS 2

DANCE/TUMBLING SKILLS 3

WATER ACTIVITY SKILLS 4

CARDIOVASCULAR MACHINES OR CONDITIONING (RUNNING, CYCLING, STAIRCLIMBER, ROWERS, ETC.) 5

CLIMBING WALL ACTIVITIES 6

EXERCISES/CALISTHENICS 7

FRISBEE OR FRISBEE GOLF 8

JUMPROPE/PLYOMETRICS/CONDITIONING 9

WEIGHT TRAINING 10

YOGA/PILATES 11

OTHER (SPECIFY) 12

REFUSED -1

DON’T KNOW -2

SPECIFY:

L2.

Did (you/your child) have recess or other free-play at school yesterday?

YES 1

NO (SKIP TO L3) 2

REFUSED (SKIP TO L3) -1

DON’T KNOW (SKIP TO L3) -2

Were (you/your child) physically active when (you/your child) had recess or other free-play?

YES 1

NO (SKIP TO L3) 2

REFUSED (SKIP TO L3) -1

DON’T KNOW (SKIP TO L3) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) have recess or other free-play time?

MINUTES

REFUSED -1

DON’T KNOW -2

When (you/your child) were in recess or other free-play, what exactly (were you/was your child) doing?

PLAYGROUND GAME (KICKBALL, FOUR SQUARE, DODGEBALL, ETC.) 1

ORGANIZED SPORT GAME (BASEBALL, BASKETBALL, FOOTBALL, ETC.) 2

TAG/CAPTURE THE FLAG/RED ROVER/ETC. 3

FIXED EQUIPMENT (MONKEY BARS, SLIDES, SWINGS, ETC.) 4

HANGING OUT WITH FRIENDS 5

DOING SCHOOL WORK 6

OTHER (SPECIFY) 7

REFUSED -1

DON’T KNOW -2

SPECIFY:

L3.

Did (you/your child) have dance or other physically active classes at school (other than PE class) yesterday?

YES 1

NO (SKIP TO L4) 2

REFUSED (SKIP TO L4) -1

DON’T KNOW (SKIP TO L4) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) have dance or the physically active class?

MINUTES

REFUSED -1

DON’T KNOW -2

When (you/your child) were in dance or the physically active class, what exactly (were you/was your child) doing?

DANCE 1

WEIGHTLIFTING 2

OTHER (SPECIFY) 3

REFUSED -1

DON’T KNOW -2

SPECIFY:

L4.

Did (you/your child) participate in physical activity breaks during classes at school yesterday?

YES 1

NO (SKIP TO L5) 2

REFUSED (SKIP TO L5) -1

DON’T KNOW (SKIP TO L5) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes were the physical activity breaks?

MINUTES

REFUSED -1

DON’T KNOW -2

During the physical activity breaks during class, what exactly (were you/was your child) doing?

IN-CLASS PHYSICAL ACTIVITY 1

VIDEO/STRUCTURED ACTIVITY IN HOMEROOM/ANNOUNCEMENTS 2

WALKING LAPS 3

OTHER (SPECIFY) 4

REFUSED -1

DON’T KNOW -2

SPECIFY:

L5.

Did (you/your child) practice or play with a school sports team yesterday?

YES 1

NO (SKIP TO L6) 2

REFUSED (SKIP TO L6) -1

DON’T KNOW (SKIP TO L6) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) practice or play with a school sports team?

MINUTES

REFUSED -1

DON’T KNOW -2

When (you/your child) practiced or played with a school sports team, what exactly (were you/was your child) doing?

BASEBALL/SOFTBALL 1

FOOTBALL/SOCCER/LACROSSE/HOCKEY/

BASKETBALL 2

SWIM TEAM/DIVING/WATER POLO 3

GOLF/TENNIS 4

TRACK AND FIELD/CROSS COUNTRY 5

CHEER/DANCE TEAM 6

WRESTLING 7

VOLLEYBALL 8

MARTIAL ARTS 9

ROWING/CANOE/KAYAK 10

BOWLING 11

SKIING 12

OTHER (SPECIFY) 13

REFUSED -1

DON’T KNOW -2

SPECIFY:

L6.

Did (you/your child) practice or play with a non-school sports team yesterday?

YES 1

NO (SKIP TO L7) 2

REFUSED (SKIP TO L7) -1

DON’T KNOW (SKIP TO L7) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) practice or play with a non-school sports team?

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) practice or play with a non-school sports team? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

When (you/your child) practiced or played with a non-school sports team, what exactly (were you/was your child) doing?

BASEBALL/SOFTBALL 1

FOOTBALL/SOCCER/LACROSSE/HOCKEY/

BASKETBALL 2

SWIM TEAM/DIVING/WATER POLO 3

GOLF/TENNIS 4

TRACK AND FIELD/CROSS COUNTRY 5

CHEER/DANCE TEAM 6

WRESTLING 7

VOLLEYBALL 8

MARTIAL ARTS 9

ROWING/CANOE/KAYAK 10

BOWLING 11

SKIING 12

OTHER (SPECIFY) 13

REFUSED -1

DON’T KNOW -2

SPECIFY:

L7.

Did (you/your child) participate in any pick-up sports (basketball, football, baseball/softball, etc.) yesterday?

YES 1

NO (SKIP TO L8) 2

REFUSED (SKIP TO L8) -1

DON’T KNOW (SKIP TO L8) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) play pick-up sports?

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) play pick-up sports? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Who did (you/your child) play pick-up sports with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

When (you/your child) played pick-up sports, what exactly (were you/was your child) doing?

BASEBALL/SOFTBALL 1

FOOTBALL/SOCCER/LACROSSE/HOCKEY/

BASKETBALL 2

SWIM TEAM/DIVING/WATER POLO 3

OTHER (SPECIFY) 4

REFUSED -1

DON’T KNOW -2

SPECIFY:

L8.

Did (you/your child) participate in physical activity during an afterschool program yesterday?

YES 1

NO (SKIP TO L9) 2

REFUSED (SKIP TO L9) -1

DON’T KNOW (SKIP TO L9) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes (were you/was your child) physically active during (your/his/her) afterschool program?

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) do physical activity during (your/your child’s) afterschool program? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Who did (you/your child) do physical activity during (your/your child’s) afterschool program with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

When (you/your child) did physical activity during (your/your child’s) afterschool program, what exactly (were you/was your child) doing?

PLAYGROUND GAME (KICKBALL, FOUR SQUARE, DODGEBALL, ETC.) 1

ORGANIZED SPORT GAME (BASEBALL, BASKETBALL, FOOTBALL, ETC.) 2

TAG/CAPTURE THE FLAG/RED ROVER/ETC. 3

FIXED EQUIPMENT (MONKEY BARS, SLIDES, SWINGS, ETC.) 4

DANCE/STEP TEAM 5

DOUBLE-DUTCH 6

OTHER (SPECIFY) 7

REFUSED -1

DON’T KNOW -2

SPECIFY:

L9.

Did (you/your child) play any physically active games (hopscotch, red rover, tag, jumping rope, skating, etc.) yesterday?

YES 1

NO (SKIP TO L10) 2

REFUSED (SKIP TO L10) -1

DON’T KNOW (SKIP TO L10) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) play physically active games?

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) play physically active games? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Who did (you/your child) play physically active games with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

When (you/your child) played physically active games, what exactly (were you/was your child) doing?

TAG 1

RED ROVER/DUCK DUCK GOOSE/ETC. 2

HOPSCOTCH 3

OTHER (SPECIFY) 4

REFUSED -1

DON’T KNOW -2

SPECIFY:

L10.

Did (you/your child) swim or play games in a pool, lake, or ocean yesterday?

YES 1

NO (SKIP TO L11) 2

REFUSED (SKIP TO L11) -1

DON’T KNOW (SKIP TO L11) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) swim or play games in a pool, lake or ocean?

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) swim or play games in a pool, lake, or ocean? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Who did (you/your child) swim or play games in a pool, lake, or ocean with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

When (you/your child) swam or played games in a pool, lake, or ocean, what exactly (were you/was your child) doing?

SWIMMING 1

WATER GAMES (MARCO POLO, SHARK AND MINNOWS, ETC.) 2

WATERPLAY 3

OTHER (SPECIFY) 4

REFUSED -1

DON’T KNOW -2

SPECIFY:

L11.

Did (you/your child) do any outdoor or adventure sports (hiking, kayaking, rock climbing, surfing, skiing, etc.) yesterday?

YES 1

NO (SKIP TO L12) 2

REFUSED (SKIP TO L12) -1

DON’T KNOW (SKIP TO L12) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) do outdoor or adventure sports?

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) do outdoor or adventure sports? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Who did (you/your child) do outdoor or adventure sports with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

When (you/your child) did outdoor or adventure sports, what exactly (were you/was your child) doing?

HIKING 1

ROCK CLIMBING 2

SURFING/SKIMBOARDING/BODYBOARDING 3

SNOW SKIING/SNOWBOARDING 4

WATER SKIING/WAKEBOARDING 5

KAYAKING 6

OTHER (SPECIFY) 7

REFUSED -1

DON’T KNOW -2

SPECIFY:

L12.

Did (you/your child) walk or bike to or from school yesterday?

YES 1

NO (SKIP TO L13) 2

REFUSED (SKIP TO L13) -1

DON’T KNOW (SKIP TO L13) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) walk or bike to or from school?

MINUTES

REFUSED -1

DON’T KNOW -2

Who did (you/your child) walk or bike to or from school with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

When (you/your child) walked or biked to or from school, what exactly (were you/was your child) doing?

WALK 1

BIKE 2

REFUSED -1

DON’T KNOW -2

L13.

Did (you/your child) walk or bike to or from a store, park, or playground or a friend’s house yesterday?

YES 1

NO (SKIP TO L14) 2

REFUSED (SKIP TO L14) -1

DON’T KNOW (SKIP TO L14) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) walk or bike to or from a store, park, or playground or a friend’s house?

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) walk or bike to or from a store, park, or playground or a friend’s house? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Who did (you/your child) walk or bike to or from a store, park, or playground or a friend’s house with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

When (you/your child) walked or biked to or from a store, park, or playground or a friend’s house, what exactly (were you/was your child) doing?

WALK 1

BIKE 2

REFUSED -1

DON’T KNOW -2

L14.

Did (you/your child) walk or ride a bike, scooter, skateboard, or skates for fun or exercise yesterday?

YES 1

NO (SKIP TO L15) 2

REFUSED (SKIP TO L15) -1

DON’T KNOW (SKIP TO L15) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) walk or ride a bike, scooter, skateboard, or skates for fun or exercise?

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) walk or ride a bike, scooter, skateboard, or skates for fun or exercise? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Who did (you/your child) walk or ride a bike, scooter, skateboard, or skates for fun or exercise with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

When (you/your child) walked or rode a bike, scooter, skateboard, or skates for fun or exercise, what exactly (were you/was your child) doing?

WALK 1

BIKE 2

SCOOTER 3

SKATEBOARD 4

SKATES/ROLLERBLADES 5

OTHER (SPECIFY) 6

REFUSED -1

DON’T KNOW -2

SPECIFY:

L15.

Did (you/your child) use a computer for games or playing on the internet (not for schoolwork or social networks) yesterday?

YES 1

NO (SKIP TO L16) 2

REFUSED (SKIP TO L16) -1

DON’T KNOW (SKIP TO L16) -2

For how many minutes did (you/your child) use a computer for games or playing on the internet?

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) use a computer for games or playing on the internet? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Who did (you/your child) use a computer for games or playing on the internet with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

When (you/your child) used a computer for games or playing on the internet, what exactly (were you/was your child) doing?

PLAYING GAMES 1

SURFING THE INTERNET 2

OTHER (SPECIFY) 3

REFUSED -1

DON’T KNOW -2

SPECIFY:

L16.

Did (you/your child) use a computer or phone for social networking (Facebook, MySpace, Twitter, IM, texting, etc.) yesterday?

YES 1

NO (SKIP TO L17) 2

REFUSED (SKIP TO L17) -1

DON’T KNOW (SKIP TO L17) -2

For how many minutes did (you/your child) use a computer or phone for social networking?

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) use a computer or phone for social networking? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Who did (you/your child) use a computer or phone for social networking with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

When (you/your child) used a computer or phone for social networking, what exactly (were you/ was your child) doing?

IM/CHAT/TWITTER 1

SOCIAL NETWORKING ON THE COMPUTER 2

TEXTING 3

OTHER (SPECIFY) 4

REFUSED -1

DON’T KNOW -2

SPECIFY:

L17.

Did (you/your child) watch TV yesterday?

YES 1

NO (SKIP TO L18) 2

REFUSED (SKIP TO L18) -1

DON’T KNOW (SKIP TO L18) -2

For how many minutes did (you/your child) watch TV?

1 Hour = 60 Minutes

2 Hours = 120 Minutes

3 Hours = 180 Minutes

4 Hours = 240 Minutes

5 Hours = 300 Minutes

6 Hours = 360 Minutes

7 Hours = 420 Minutes

8 Hours = 480 Minutes

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) watch TV? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Who did (you/your child) watch TV with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

When (you/your child) watched TV, what exactly (were you/was your child) doing?

WATCHING EDUCATIONAL TV OR VIDEOS 1

WATCHING NON-EDUCATIONAL TV OR VIDEOS 2

OTHER (SPECIFY) 3

REFUSED -1

DON’T KNOW -2

SPECIFY:

L18.

Did (you/your child) play non-active video games yesterday?

YES 1

NO (SKIP TO L19) 2

REFUSED (SKIP TO L19) -1

DON’T KNOW (SKIP TO L19) -2

For how many minutes did (you/your child) play non-active video games?

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) play non-active video games? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Who did (you/your child) play non-active video games with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

When (you/your child) played non-active video games, what exactly (were you/was your child) doing?

PLAYING GAMES ON A GAME CONSOLE 1

PLAYING GAMES ON A HANDHELD GAMING DEVICE 2

OTHER (SPECIFY) 3

REFUSED -1

DON’T KNOW -2

SPECIFY:

L19.

Did (you/your child) play physically active video games (Wii, DDR, Xbox Kinect, PlayStation Move, etc.) yesterday? A physically active video game is one where some physical effort is involved in playing the game.

YES 1

NO (SKIP TO L20) 2

REFUSED (SKIP TO L20) -1

DON’T KNOW (SKIP TO L20) -2

How physically hard or intense was this activity?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) play physically active video games?

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) play physically active video games? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Who did (you/your child) play physically active video games with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

When (you/your child) played physically active video games, what exactly (were you/ was your child) doing?

PLAYING WII/KINECT/MOVE, ETC. 1

DANCE, DANCE REVOLUTION 2

OTHER (SPECIFY) 3

REFUSED -1

DON’T KNOW -2

SPECIFY:

L20.

Did (you/your child) do any other physical activities yesterday that were not already mentioned?

YES 1

NO (end section) 2

REFUSED (end section) -1

DON’T KNOW (end section) -2

What were the other activities?

ACTIVITY 1:_____________________________________

ACTIVITY 2:_____________________________________

ACTIVITY 3:_____________________________________

ACTIVITY 4:_____________________________________

REFUSED -1

DON’T KNOW -2

How physically hard or intense were these activities?

LIGHT 1

MODERATE 2

HARD 3

VERY HARD 4

REFUSED -1

DON’T KNOW -2

For how many minutes did (you/your child) do these other activities?

MINUTES

REFUSED -1

DON’T KNOW -2

Where did (you/your child) do these other activities? CODE ALL THAT APPLY

AT SCHOOL 1

AT HOME 2

AT A REC CENTER 3

AT A PARK/PLAYGROUND 4

IN MY NEIGHBORHOOD 5

ON MY STREET 6

AT CHURCH 7

AT A FRIEND’S HOUSE 8

OTHER (SPECIFY) 9

REFUSED -1

DON’T KNOW -2

SPECIFY:

Who did (you/your child) do these other activities with?

BY (MYSELF/HIS SELF/HERSELF) 1

WITH 1 OTHER FRIEND 2

WITH SEVERAL FRIENDS 3

WITH (MY/HIS/HER) TEAM OR CLASS 4

WITH (MY/HIS/HER) PARENT(S) OR OTHER FAMILY MEMBER(S) 5

REFUSED -1

DON’T KNOW -2

1 This master version of the adult consent form contains shaded wording under Procedures and Compensation indicating where sentences or phrases will differ as appropriate according to the type of protocol.

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	REC 01
Author	Marcia P. Treece
File Modified	0000-00-00
File Created	2021-01-29