FINAL_HCS_SSA_ATTACH 14_MOD WINDSHIELD SURVEY_Jan 2013

SSA ATTACHMENT 14

HEALTHY COMMUNITIES STUDY

HEALTHY COMMUNITIES STUDY

MODIFIED WINDSHEILD SURVEY PROTOCOL

In all 264 Wave 2 communities, at the time of the home visit (or the first home visit in the Enhanced Protocol), the field interviewers will complete a five-item modified windshield survey prior to entering the home. The field interviewers will rate features of the social and physical environment on the street segment associated with each child’s home address. A street segment is defined as the street in front of the home, from intersection to intersection, not to exceed 0.5 miles. In the instances where the street segment exceeds 0.5 miles, the field interviewers will be instructed to consider the street segment that is contained within 0.25 miles from the home in either direction or to the nearest intersection, whichever is closer.

A paper form of the modified five-item windshield survey, included in this attachment, will be completed when the field interviewer arrives at the child’s home and entered into the study database following the home visit. GPS coordinates will also be obtained for each participant’s household to match to GIS data.

HEALTHY COMMUNITIES STUDY

MODIFIED WINDSHIELD SURVEY

There is little to no public reporting burden of this collection of information as it is completed by research staff. 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.

	HOUSEHOLD ID#:		DATE:
To be completed by the Field Interviewers: COMPLETE THE FOLLOWING FORM ON THE STREET SEGMENT ASSOCIATED WITH THE CHILD’S HOME ADDRESS. A STREET SEGMENT IS DEFINED AS THE STREET IN FRONT OF THE HOME, FROM INTERSECTION TO INTERSECTION, NOT TO EXCEED 0.5 MILES. OBSERVE THE STREET SEGMENT WHILE DRIVING TO THE HOME. FILL OUT THIS FORM WHILE PARKED OUTSIDE OF THE PARTICIPANT’S HOME.
1.	OVERALL CONDITION OF MOST RESIDENTIAL UNITS				EXCELLENT 1 GOOD CONDITION/WELL KEPT 2 FAIR CONDITION 3 POOR/DETERIORATED CONDITION 4 MIXED CONDITION 5
2.	ANY BURNED, BOARDED UP, OR ABANDONED RESIDENTIAL UNITS?				YES 1 NO 2
3.	AMOUNT OF LITTER				NONE…(SKIP TO Q4) 0 A LITTLE 1 A MODERATE AMOUNT 2 A CONSIDERABLE AMOUNT 3
	TYPE OF LITTER (CODE ALL THAT APPLY)				NONALCOHOLIC CANS/BOTTLES/PAPER 1 ALCOHOLIC CANS/BOTTLES 2 LARGE ITEMS (TIRES, FURNITURE, APPLIANCES, CARS) 3 OTHER LITTER 4
4.	TYPE OF STREET SEGMENT (CODE ALL THAT APPLY)				MAJOR THOROUGHFARE/BUSY STREET 1 MODERATELY BUSY THOROUGHFARE 2 SIDE STREET 3 DEAD-END STREET 4 ONE WAY STREET 5 CUL-DE-SAC STREET 6
5.	PRESENCE OF SIDEWALKS				NONE…(END SURVEY) 0 SOME OF THE SEGMENT 1 ALL OF THE SEGMENT 2
	IS THE SIDEWALK CONDUCIVE TO BEING ACTIVE (RIDING A BIKE, SKATEBOARDING)?				YES 1 IN MOST PLACES 2 IN SOME BUT NOT ALL PLACES 3