Attachment 7a - 2021-2022 Adolescent Follow-back Survey (AFS)
Content Summary and Field Dates
(DRAFT – September 14, 2020 – 94 questions)
General health and well-being
Self-assessed health status ‡‡
Satisfaction with life §§
Height and weight
Self-reported height ‡
Self-reported weight ‡
Perception of weight status
Concern about weight
Physical activity
(Past 12 months) Played on sports teams, took sports lesson in school/community ‡
(Past 12 months) Took PE or gym class ‡
(Typical school week) How often physically active for a total of at least 60 minutes per day ‡
(Typical school week) How often muscle strengthening activities ‡
(Typical school week) How often walks for at least 10 minutes ‡
(Typical school week) How often rides a bike for at least 10 minutes ‡
Sleep
(Typical school week) How often do you wake up well-rested ‡
(Typical school week) How often do you have difficulty getting out of bed in morning ‡
(Typical school week) How often do you complain about being tired ‡
(Typical school week) How often do you fall asleep during day ‡
(Typical school week) How often do you go to bed at same time ‡
(Typical school week) How often do you wake up at the same time ‡
Screen time
(Typical weekday) Number of hours in front of TV, computer, cellphone, or other electronic device ‡
Concussions
As a result of a blow or jolt to the head, ever knocked out or lost consciousness ‡§
If no:
As a result of a blow or jolt to the head, ever been dazed or had a gap in your memory ‡§
As a result of a blow or jolt to the head, ever had headaches, vomiting, blurred vision, changes in mood or behavior ‡§
Ever been checked for a concussion or brain injury ‡§
If yes:
Ever been diagnosed with a concussion or brain injury ‡§
Health care utilization
Time since last seen doctor or health professional ‡‡
If not never:
Time alone with doctor or health professional at last visit §§
Was most recent visit a wellness visit, physical, or general-purpose check-up ‡‡
If no:
Time since last wellness visit, physical, or general-purpose check-up ‡‡
If not never:
Time alone with doctor or health professional at last wellness visit §§
(Ever) Had visit with doctor or health professional that parents did not know about
If yes:
Type of visit (mental health, women’s health, other - specify)
Content of care in past year (or at last wellness visit)
Talked about understanding the changes in health care that happen at age 18
Talked about gaining skills to manage your health and health care
Talked about tobacco products or smoking
Talked about your mental or emotional health
Talked about puberty (e.g., changes to your body) or sexual health (e.g., safe sex practices)
Health care access
Has a usual place for care when sick ‡‡
If yes or more than one place:
Type of place (or type of place visited most often) ‡‡
Has a personal doctor or nurse §§
Complementary and alternative health
(Past 12 months) Use of meditation ‡
(Past 12 months) Practice yoga ‡
(Past 12 months) Visit a chiropractor ‡
Mental health care use and unmet need
(Past 12 months) Any prescription medication taken to help with emotions, concentration, behavior, or mental health §‡
(Past 12 months) Received counseling or therapy from a mental health professional §‡
(Past 12 months) Any counseling or therapy needed but didn’t get due to cost ‡
(Past 12 months) Any counseling or therapy needed but didn’t get due to fear of what others would think of you
(Past 12 months) Any counseling or therapy needed but didn’t get due to not knowing where to go or how to get help
Social support
How often do you receive the social and emotional support you need §§
How much can you rely on friends if you have a serious problem
How much can you open up to friends if you need to talk about your worries
How much can you rely on your parents/guardians if you have a serious problem
How much can you open up to your parents/guardians if you need to talk about your worries
Is there an adult in school, neighborhood, or community who makes a positive and meaningful difference in your life §§
Cognition
Compared with people of same age, level of difficulty learning things ‡‡
Compared with people of same age, level of difficulty remembering things ‡‡
Behavior
Compared with people of same age, level of difficulty controlling behavior ‡‡
Level of difficulty focusing on activity you enjoy ‡‡
Level of difficulty accepting changes in routine ‡‡
Level of difficulty making friends ‡‡
Depression and anxiety (PHQ-2 and GAD-2)
(Past 2 weeks) Frequency of…little interest or pleasure in doing things
(Past 2 weeks) Frequency of…feeling down, depressed, hopeless
(Past 2 weeks) Frequency of…feeling nervous, anxious, or on edge
(Past 2 weeks) Frequency of…not being able to stop or control worrying
Stressful life events / adverse childhood experiences
Ever victim of violence or witness any violence in neighborhood ‡§
Ever been separated from a parent or guardian because they went to jail, prison, or detention center ‡§
Ever live with anyone who was mentally ill or severely depressed ‡§
Ever live with anyone who had a problem with alcohol or drugs ‡§
Ever had a parent or guardian die
Ever had a parent or guardian divorce or separate
Ever lived with parent or guardian who frequently swore at you, insulted you, or put you down ‡§
Ever been a time when your basic needs were not met ‡§
Ever been treated or judged unfairly because of your race or ethnic group §§
Ever been treated or judged unfairly because of your sexual orientation or gender identity §§
Bullying
(Past 12 months) How often were you bullied, picked on, or excluded by others §§
(Past 12 months) Been electronically bullied §§
(Past 12 months) How often did you bully others, pick on them, or exclude them §§
(Past 12 months) Electronically bulled others
Everyday discrimination
How often are you treated with less courtesy or respect than other people your age
At restaurants or stores, how often do you receive poorer service than other people your age
How often do people act as if they think you are not smart
Demographics
Hispanic origin ‡‡
Race ‡‡
Sexual orientation
Sex at birth
Gender identity
School enrollment
Survey environment
Type of device used to complete the survey
Was survey completed at home
Did anyone help you answer questions in the survey
Was anyone else in the room when you completed the survey
Experience with survey
How burdensome was this survey
How easy or difficult was the survey
How sensitive were the questions
How would you describe the length of the survey
‡ = Question already included in NHIS annual core or rotating core, sponsored, or emerging core in 2021
‡ = Question already included in NHIS annual core or rotating core, sponsored, or emerging core in 2022
§ = New question to be added to the NHIS sample child interview in 2021 and/or 2022
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Blumberg, Stephen J. (CDC/DDPHSS/NCHS/DHIS) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-13 |