Survey about child (asked of parent/guardian) and parent/guardian's presence during direct Child Assessment

OMB Clearance Number: 2528-0337

Expires: XX/XX/XXXX

Attachment H.1: The Child Assessment Survey about Child Baseline - Questions Asked of Parent or Guardian

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This collection of information is voluntary and will be used to evaluate the US Department of Housing and Urban Development’s Community Choice Demonstration. Public reporting burden for this collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, 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. The OMB number for this collection is OMB 2528-0337 which expires on XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to NAME at XXXX@XXXXX.XXX or call XXX-XXX-XXXX. 

Privacy Act Statement  

Authority:  Section 502 of the Housing and Urban Development Act of 1970 (Public Law 91-609) (12 U.S.C. §§ 1701z-1; 1701z-2(d) and (g)).  

Purpose:  Evaluation of the Community Choice Demonstration (CCD).  

Routine Use:  The information will be used for the purpose set forth above and may be provided to Congress or other Federal, state, and local agencies, when determined necessary.  

Disclosure:  Records will be used for research and statistical analysis and will not be used to make decisions that affect the rights, benefits, or privileges of specific individuals. 

SORN ID:  Community Choice Demonstration Evaluation Data Files, HUD/PDR-09  

CONTENTS

Module A. Home Environment and Parenting 1

Module B. Child Behavioral, Educational, and Social Functioning 5

Module C. Child Physical Health, Diet, and Nutrition 15

1. Home Environment and Parenting

First, I am going to ask you a few questions about your housing unit and neighborhood environment.

1. Overall, how would you describe the condition of your current house/apartment/living space? Would you say it is in:

[Source: HUD Rent Reform Demonstration]

☐ Excellent condition

☐ Good condition

☐ Fair condition

☐ Poor condition

☐ Don’t know

☐ Prefer not to answer

1. What aspects of your housing unit work well for you and your family? Please tell us whether you agree or disagree with each of the following statements.

[Source: New questions that need piloting; informed by Evenson et al., (2006); Johns Hopkins question]

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Prefer not to answer
There is enough space to prepare meals.	☐	☐	☐	☐	☐	☐
There is enough space to have meals as a family.	☐	☐	☐	☐	☐	☐
There is enough space to store food.	☐	☐	☐	☐	☐	☐
The appliances work well for cooking food.	☐	☐	☐	☐	☐	☐

3. These are some statements about your living situation. For each statement that I read to you, please tell me whether the statement is True or False for you and your household. For some statements you may feel that they are True some of the time but not always. Determine whether the statement is True or False more than half of the time and answer accordingly.

[Source: Fragile Families Study, validated in Evans et al. (2005); A3a-A3f summed into a composite score; Johns Hopkins question]

	True	False	Don’t know	Prefer not to answer
There is very little commotion where we live.	☐	☐	☐	☐
We can usually find things when we need them.	☐	☐	☐	☐
We are usually able to “stay on top of things.”	☐	☐	☐	☐
It’s a real “zoo” where we live.	☐	☐	☐	☐
You can’t hear yourself think where we live.	☐	☐	☐	☐
The atmosphere where we live is calm.	☐	☐	☐	☐

1. How many days of the week do your family sit at a table and eat dinner together? This includes when it is just you and your child(ren)?

[Source: Comprehensive Home Environment Survey (CHES); validated by Pinard et al. (2014); Johns Hopkins question]

☐ 1 day or less

☐ 2 days

☐ 3 days

☐ 4 days

☐ 5 days

☐ 6 days

☐ 7 days

☐Prefer not to answer

Now I have some questions about parenting practices.

5. [ASK IF CHILD AGE IS >= 5 YEARS] The following are a number of statements about your family. Please rate each item as to how often it typically occurs in your home. Possible answers are: Never (1), Almost Never (2), Sometimes (3), Often (4), Always (5).

[Source: Alabama Parenting Scale-9, validated in Elgar et al. (2007); A1a-A1i summed into a composite score, with sub-scores for positive parenting, discipline, and supervision]

	Never  (1)	Almost Never (2)	Sometimes (3)	Often (4)	Always (5)	Don’t know	Prefer not to answer
You let your child know when they are doing a good job with something	☐	☐	☐	☐	☐	☐	☐
You threaten to punish your child and then do not actually punish them	☐	☐	☐	☐	☐	☐	☐
Your child fails to leave a note or to let you know where they are going	☐	☐	☐	☐	☐	☐	☐
Your child talks you out of being punished after they have done something wrong	☐	☐	☐	☐	☐	☐	☐
Your child stays out in the evening after the time they are supposed to be home	☐	☐	☐	☐	☐	☐	☐
You compliment your child after they have done something well	☐	☐	☐	☐	☐	☐	☐
You praise your child if they behave well	☐	☐	☐	☐	☐	☐	☐
Your child is out with friends you don’t know	☐	☐	☐	☐	☐	☐	☐
You let your child out of a punishment early (like lift restrictions earlier than you originally said)	☐	☐	☐	☐	☐	☐	☐

6. [ASK IF CHILD AGE IS 2 TO 4 YEARS] This set of questions asks about how often you were able to engage in certain parenting practices in the past month. Please rate how often you were able to engage in each practice on a scale of 1 (Not at All) to 7 (Most of the time).

How often were you able to…?

[Source: Parenting Young Children Scale, validated in McEachern et al. (2012); A2a-A2u are summed into a composite score with sub-scores for supportive positive behavior, proactive parenting, and setting limits]

	1 (Not at All)	2	3	4	5	6	7 (Most of the time)	Prefer not to answer
Invite your child to play a game with you or share an enjoyable activity?	☐	☐	☐	☐	☐	☐	☐	☐
Reward your child when they did something well or showed a new skill?	☐	☐	☐	☐	☐	☐	☐	☐
Teach your child new skills (such as tying their shoes)?	☐	☐	☐	☐	☐	☐	☐	☐
Play with your child in a way that was fun for both of you?	☐	☐	☐	☐	☐	☐	☐	☐
Notice and praise your child’s good behavior (such as, “Good job putting away your toys.”)	☐	☐	☐	☐	☐	☐	☐	☐
Involve your child in household chores?	☐	☐	☐	☐	☐	☐	☐	☐
Stand back and let your child work through problems they might be able to solve (such as putting a puzzle together)?	☐	☐	☐	☐	☐	☐	☐	☐
Avoid struggles with your child by giving clear choices (such as offering toast or cereal for breakfast)?	☐	☐	☐	☐	☐	☐	☐	☐
Warn your child before a change of activity was required (such as a 5 min warning before leaving the house in the morning)?	☐	☐	☐	☐	☐	☐	☐	☐
Plan ways to prevent problem behavior (such as feeding your child before going to the store)?	☐	☐	☐	☐	☐	☐	☐	☐
Give reasons for your requests (such as picking up toys) so your child followed through?	☐	☐	☐	☐	☐	☐	☐	☐
Make a game out of everyday tasks (such as picking up toys) so your child followed through?	☐	☐	☐	☐	☐	☐	☐	☐
Break a task into small steps (such as “Put your shoes on first and then get your coat.” instead of “Get ready to go.”)	☐	☐	☐	☐	☐	☐	☐	☐
Prepare your child for a challenging situation (such as going to a toy store or starting a new school)?	☐	☐	☐	☐	☐	☐	☐	☐
Speak calmly with your child when you were upset with them?	☐	☐	☐	☐	☐	☐	☐	☐
Stick to your rules and not change your mind?	☐	☐	☐	☐	☐	☐	☐	☐
Explain what you wanted your child to do in clear and simple ways?	☐	☐	☐	☐	☐	☐	☐	☐
Make sure your child followed the rules you set all or most of the time?	☐	☐	☐	☐	☐	☐	☐	☐
Tell your child what you wanted them to do rather than tell them to stop doing something?	☐	☐	☐	☐	☐	☐	☐	☐
Set rules on your child’s problem behavior that you were willing/able to enforce?	☐	☐	☐	☐	☐	☐	☐	☐
Tell your child how you expected them to behave (such as in the grocery store)?	☐	☐	☐	☐	☐	☐	☐	☐

2. Child Behavioral, Educational, and Social Functioning

1. [ASK IF CHILD AGE < 5 YEARS] Is your child in regular childcare or school at least 10 hours per week?

[Source: MTO Interim Evaluation]

☐ Yes

☐ No (SKIP TO B.20)

☐ Don’t know (SKIP TO B.20)

☐ Prefer not to answer (SKIP TO B.20)

2. [ASK IF CHILD AGE < 5 YEARS AND B.1=YES] How many different childcare arrangements or schools has your child been in for at least 10 hours a week in the past year? Please include all types of childcare arrangements.

[Source: SAMHSA MOMS and Family Options study]

________# childcare arrangements (SKIP TO B.10)

☐ Don’t know (SKIP TO B.10)

☐ Prefer not to answer (SKIP TO B.10)

3. [ASK IF CHILD AGE >= 5 YEARS] Now I have some questions about the schools [CHILD NAME] has attended. How many different schools has [CHILD NAME] attended in the past two years?

[Source: SAMHSA MOMS and Family Options study]

______# schools

☐ Don’t know (SKIP TO B.5)

☐ Prefer not to answer (SKIP TO B.5)

4. [ASK IF CHILD AGE >= 5 YEARS AND B.3>1] Did [CHILD NAME] ever have to change schools in the middle of a school year in the past two years?

[Source: Family Options Study 12-Year Follow-Up]

☐ Yes

☐ No

☐ Don’t know

☐ Prefer not to answer

5. [ASK IF CHILD AGE >= 5 YEARS] Has [CHILD NAME] ever repeated a grade or been prevented from moving on to the next grade or level in school?

[Source: SAMHSA MOMS and Family Options study]

☐ Yes

☐ No

☐ Don’t know

☐ Prefer not to answer

6. [ASK IF CHILD AGE >= 5 YEARS] How many days in the past month has your child missed school?

Interviewer: if conducting interview during the summer, ask parent to remember the last month of school. If needed, remind parent that there are usually 22 school days in a typical month.

[Source: SAMHSA MOMS and Family Options study]

# of days: ________________

☐ Don’t know

☐ Prefer not to answer

7. [ASK IF CHILD AGE >= 5 YEARS] Think about the last completed school year. Was your child absent from in-person or remote school for 15 or more days in the entire school year?

[Source: Family Options 12-Year Follow-Up Study]

☐ Yes

☐ No

☐ Don’t know

☐ Prefer not to answer

8. [ASK IF CHILD AGE >= 5 YEARS] What is the most common way that [CHILD’S NAME] gets to school?

[Source: Johns Hopkins team member Sabriya Linton’s adolescent survey, Johns Hopkins question]

☐ Car

☐ School bus

☐ Public transportation

☐ Walk

☐ Bike

☐ Other: ____________

☐ Prefer not to answer

9. [ASK IF CHILD AGE >= 5 YEARS] About how long does it usually take [CHILD’S NAME] to get to school?

[Source: Johns Hopkins team member Sabriya Linton’s adolescent survey, Johns Hopkins question]

☐ ENTER TIME: ____ hours, _____ minutes

☐ Don’t know

☐ Prefer not to answer

10. The next set of questions asks about how you are currently feeling about several aspects of [CHILD NAME]’s life. For each question, please tell me how you feel. The options are completely satisfied, very satisfied, slightly satisfied, neutral, slightly dissatisfied, very dissatisfied, or completely dissatisfied.

How satisfied are you with…?

[Source: NIDA Monitoring the Future Survey (2020), B10a-c wording from questions on nationally representative survey allowing for direct comparison with national norms.]

	Completely satisfied	Very satisfied	A little satisfied	Neutral	A little dissatisfied	Very dissatisfied	Completely dissatisfied	Prefer not to answer
Your child’s educational experiences?	☐	☐	☐	☐	☐	☐	☐	☐
[IF CHILD AGE 5+] Your child’s safety at school?	☐	☐	☐	☐	☐	☐	☐	☐
Your child’s safety in your neighborhood?	☐	☐	☐	☐	☐	☐	☐	☐

11. [ASK IF CHILD AGE 5-9 YEARS OLD] How likely do you think it is that your child will do each of the following things? [If your child has already graduated high school, answer “Definitely will”]

	Definitely won’t	Probably won’t	Probably will	Definitely will	Don’t know	Prefer not to answer
Graduate high school…	☐	☐	☐	☐	☐	☐
Graduate from college (four-year program) ...	☐	☐	☐	☐	☐	☐

12. [ASK IF CHILD AGE IS 2–9 YEARS OLD] Please rate how much you agree or disagree with the following statements. The options are strongly disagree, disagree, neither agree nor disagree, agree, strongly agree.

[Source: Fragile Families, The Panel Study of Income Dynamics, Child Development Supplement; Responses to B.12a-c summed into a composite score; Johns Hopkins questions. Note: Children ages 10+ answer a self-reported version of these questions.]

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Prefer not to answer
Your child feels close to people at [IF AGE 5-9: school; IF AGE 2-4: preschool or childcare]	☐	☐	☐	☐	☐	☐
Your child feels like a part of [IF AGE 5-9: the school; IF AGE 2-4: preschool or childcare]	☐	☐	☐	☐	☐	☐
Your child is happy to be at [IF AGE 5-9: school; IF AGE 2-4: their preschool or childcare]	☐	☐	☐	☐	☐	☐

13. Please let me know if the following describe nearly all, most, some, a few, or none of your child’s friendships.

[Source: New question, wording needs to be tested – based on Murayama et al. (2013); Johns Hopkins questions.]

	Nearly all	Most	Some	A few	None	Don’t know	Prefer not to answer
His/her friends live in the neighborhood	☐	☐	☐	☐	☐	☐	☐
The parents of his/her friends have graduated from college	☐	☐	☐	☐	☐	☐	☐
His/her friends are different racial or ethnic groups than my child	☐	☐	☐	☐	☐	☐	☐

14. [ASK IF CHILD AGE >= 5 YEARS OR B.1=YES] How much does [CHILD’S NAME] currently like [IF CHILD AGE >= 5 YEARS: school; IF CHILD AGE 2-4 YEARS: childcare or preschool]? Would you say:

[Source: Shinn et al. (2008) and Family Options Study]

☐ Not at all

☐ Not very much

☐ Some

☐ Pretty much

☐ Very much

☐ Don’t know

☐ Prefer not to answer

Now for the next few questions I’d like you to think about the past 12 months. That would be from [MONTH YEAR 12 MONTHS PRIOR TO INTERVIEW] to today.

15. [ASK IF CHILD AGE >= 5 YEARS OR B.1=YES] Overall, how would you rate [CHILD NAME]’s experiences at [IF CHILD AGE 5+ YEARS: school; IF CHILD AGE 2-4 YEARS: their preschool or childcare arrangement] in the past year? Would you say that [CHILD NAME] has had:

[Source: Shinn et al. (2008) and Family Options Study]

☐ Mostly positive experiences

☐ Both positive and negative experiences

☐ Mostly negative experiences

☐ Don’t know

☐ Prefer not to answer

16. [ASK IF CHILD AGE >= 5 YEARS OR B.1=YES] During the past 12 months, has [CHILD] been suspended or expelled from [IF CHILD AGE >= 5 YEARS: school; IF CHILD AGE 2 TO 4 YEARS: their preschool or childcare arrangement]?

[Source: MTO Interim Evaluation]

☐ Yes

☐ No

☐ Don’t know

☐ Prefer not to answer

I would like to ask you about [CHILD NAME]’s involvement in various activities in the past 12 months.

17. [ASK IF CHILD AGE >= 5 YEARS] During the past 12 months, in how many kinds of school-based activities, such as team sports, cheerleading, choir, band, student government, or clubs, has [CHILD NAME] participated?

[Source: National Survey of Drug Use and Behavior]

☐ None

☐ 1

☐ 2

☐ 3 or more

☐ Don’t know

☐ Prefer not to answer

18. [ASK IF CHILD AGE >= 5 YEARS] During the past 12 months, in how many different kinds of community-based activities, such as volunteer activities, sports, clubs, or groups has [CHILD NAME] participated?

[Source: National Survey of Drug Use and Behavior]

☐ None

☐ 1

☐ 2

☐ 3 or more

☐ Don’t know

☐ Prefer not to answer

19. [ASK IF CHILD AGE >= 5 YEARS] During the past 12 months, in how many kinds of church or faith-based activities, such as clubs, youth groups, Saturday or Sunday school, prayer groups, youth trips, service or volunteer activities has [CHILD NAME] participated?

[Source: National Survey of Drug Use and Behavior]

☐ None

☐ 1

☐ 2

☐ 3 or more

☐ Don’t know

☐ Prefer not to answer

20. [ASK IF CHILD AGE IS 2 TO 4 YEARS] For each of the following items I read, please tell me if it is Not True, Sometimes True, or Certainly True for your child. Would you say that your child is…

[Source: Strengths and Difficulties Questionnaire, age 2-4 version; responses to questions B20a-y are summed into two overall composite scores – one on total behavioral problems and one on pro-social behavior. The total behavioral problems scale includes four sub-scales with composite scores for emotional symptoms, peer relationship problems, conduct problems, and hyperactivity/inattention. The measure has been validated in nationally representative samples in the U.S. and 9 other countries and used to assess behavioral strengths and difficulties in over 100 countries.]

	Not true	Sometimes true	Certainly true	Don’t know	Prefer not to answer
Considerate of other people’s feelings	☐	☐	☐	☐	☐
Restless, overactive, cannot stay still for long	☐	☐	☐	☐	☐
Often complains of headaches, stomach-aches, or sickness	☐	☐	☐	☐	☐
Shares readily with other youth, for example toys, treats, pencils	☐	☐	☐	☐	☐
Often loses temper	☐	☐	☐	☐	☐
Rather solitary, prefers to play alone	☐	☐	☐	☐	☐
Generally, well behaved, usually does what adults request	☐	☐	☐	☐	☐
Many worries or often seems worried	☐	☐	☐	☐	☐
Helpful if someone is hurt, upset, or feeling ill	☐	☐	☐	☐	☐
Constantly fidgeting or squirming	☐	☐	☐	☐	☐
Has at least one good friend	☐	☐	☐	☐	☐
Often fights with other children or bullies them	☐	☐	☐	☐	☐
Often unhappy, depressed, or tearful	☐	☐	☐	☐	☐
Generally liked by other children	☐	☐	☐	☐	☐
Easily distracted, concentration wanders	☐	☐	☐	☐	☐
Nervous in new situations, easily loses confidence	☐	☐	☐	☐	☐
Kind to younger children	☐	☐	☐	☐	☐
Often argumentative with adults	☐	☐	☐	☐	☐
Picked on or bullied by other children	☐	☐	☐	☐	☐
Often offers to help others (parents, teachers, other children)	☐	☐	☐	☐	☐
Can stop and think things out before acting	☐	☐	☐	☐	☐
Can be spiteful to others	☐	☐	☐	☐	☐
Gets along better with adults than with other children	☐	☐	☐	☐	☐
Many fears, easily scared	☐	☐	☐	☐	☐
Good attention span, sees work through to the end	☐	☐	☐	☐	☐

21. [ASK IF CHILD AGE IS 5 TO 10 YEARS] For each of the following items I read, please tell me if it is Not True, Sometimes True, or Certainly True for your child. Would you say that your child is…

[Source: Strengths and Difficulties Questionnaire, age 5-10 version; responses to questions B21a-y are summed into two overall composite scores – one on total behavioral problems and one on pro-social behavior. The total behavioral problems scale includes four sub-scales with composite scores for emotional symptoms, peer relationship problems, conduct problems, and hyperactivity/inattention. The measure has been validated in nationally representative samples in the U.S. and 9 other countries and used to assess behavioral strengths and difficulties in over 100 countries.]

	Not true	Sometimes true	Certainly true	Don’t know	Prefer not to answer
Considerate of other people’s feelings	☐	☐	☐	☐	☐
Restless, overactive, cannot stay still for long	☐	☐	☐	☐	☐
Often complains of headaches, stomach-aches, or sickness	☐	☐	☐	☐	☐
Shares readily with other youth, for example toys, treats, pencils	☐	☐	☐	☐	☐
Often loses temper	☐	☐	☐	☐	☐
Rather solitary, prefers to play alone	☐	☐	☐	☐	☐
Generally, well behaved, usually does what adults request	☐	☐	☐	☐	☐
Many worries or often seems worried	☐	☐	☐	☐	☐
Helpful if someone is hurt, upset, or feeling ill	☐	☐	☐	☐	☐
Constantly fidgeting or squirming	☐	☐	☐	☐	☐
Has at least one good friend	☐	☐	☐	☐	☐
Often fights with other children or bullies them	☐	☐	☐	☐	☐
Often unhappy, depressed, or tearful	☐	☐	☐	☐	☐
Generally liked by other children	☐	☐	☐	☐	☐
Easily distracted, concentration wanders	☐	☐	☐	☐	☐
Nervous in new situations, easily loses confidence	☐	☐	☐	☐	☐
Kind to younger children	☐	☐	☐	☐	☐
Often lies or cheats	☐	☐	☐	☐	☐
Picked on or bullied by other children	☐	☐	☐	☐	☐
Often offers to help others (parents, teachers, other children)	☐	☐	☐	☐	☐
Thinks things out before acting	☐	☐	☐	☐	☐
Steals from home, school, or elsewhere	☐	☐	☐	☐	☐
Gets along better with adults than with other children	☐	☐	☐	☐	☐
Many fears, easily scared	☐	☐	☐	☐	☐
Good attention span, sees work through to the end	☐	☐	☐	☐	☐

22. [ASK IF CHILD AGE IS 11 TO 17 YEARS] For each of the following items I read, please tell me if it is Not True, Sometimes True, or Certainly True for your child. Would you say that your child is…

[Source: Strengths and Difficulties Questionnaire, age 11-17 version; responses to questions B22a-y are summed into two overall composite scores – one on total behavioral problems and one on pro-social behavior. The total behavioral problems scale includes four sub-scales with composite scores for emotional symptoms, peer relationship problems, conduct problems, and hyperactivity/inattention. The measure has been validated in nationally representative samples in the U.S. and 9 other countries and used to assess behavioral strengths and difficulties in over 100 countries.]

	Not true	Sometimes true	Certainly true	Don’t know	Prefer not to answer
Considerate of other people’s feelings	☐	☐	☐	☐	☐
Restless, overactive, cannot stay still for long	☐	☐	☐	☐	☐
Often complains of headaches, stomach-aches, or sickness	☐	☐	☐	☐	☐
Shares readily with other youth, for example books, games, food	☐	☐	☐	☐	☐
Often loses temper	☐	☐	☐	☐	☐
Would rather be alone than with other youth	☐	☐	☐	☐	☐
Generally, well behaved, usually does what adults request	☐	☐	☐	☐	☐
Many worries or often seems worried	☐	☐	☐	☐	☐
Helpful if someone is hurt, upset, or feeling ill	☐	☐	☐	☐	☐
Constantly fidgeting or squirming	☐	☐	☐	☐	☐
Has at least one good friend	☐	☐	☐	☐	☐
Often fights with other youth or bullies them	☐	☐	☐	☐	☐
Often unhappy, depressed, or tearful	☐	☐	☐	☐	☐
Generally liked by other youth	☐	☐	☐	☐	☐
Easily distracted, concentration wanders	☐	☐	☐	☐	☐
Nervous in new situations, easily loses confidence	☐	☐	☐	☐	☐
Kind to younger children	☐	☐	☐	☐	☐
Often lies or cheats	☐	☐	☐	☐	☐
Picked on or bullied by other youth	☐	☐	☐	☐	☐
Often offers to help others (parents, teachers, other children)	☐	☐	☐	☐	☐
Thinks things out before acting	☐	☐	☐	☐	☐
Steals from home, school, or elsewhere	☐	☐	☐	☐	☐
Gets along better with adults than with other children	☐	☐	☐	☐	☐
Many fears, easily scared	☐	☐	☐	☐	☐
Good attention span, sees work through to the end	☐	☐	☐	☐	☐

23. [ASK IF CHILD AGE 2 TO 7] For each of the following items I read, please tell me if it is Not True or Hardly Ever True, Somewhat True or Sometimes True, or Very True or Often True for [CHILD NAME]. [CHILD NAME]…

[Source: Screen for Child Anxiety-Related Emotional Disorders-Brief (SCARED-5; initially validated in Birmaher et al., 1999); questions are summed into a composite score]

	Not True or Hardly Ever True	Somewhat True or Sometimes True	Very True or Very Often True	Don’t know	Prefer not to answer	NA
Gets really frightened for no reason at all	☐	☐	☐	☐	☐	☐
Is afraid to be alone in the house	☐	☐	☐	☐	☐	☐
Worries too much	☐	☐	☐	☐	☐	☐
Is shy	☐	☐	☐	☐	☐	☐
[IF CHILD AGE >= 5 YEARS] Is scared to go to school	☐	☐	☐	☐	☐	☐
[IF CHILD AGE < 5 YEARS] Is scared to go to preschool or childcare	☐	☐	☐	☐	☐	☐

24. [ASK IF CHILD AGE >= 12 YEARS OLD] In the past 6 months, has [CHILD NAME] had any problems that involved the police contacting you (the parent/guardian)?

[Source: Effects of Housing Choice Vouchers on Welfare Families]

☐ Yes

☐ No

☐ Don’t know

☐ Prefer not to answer

25. [ASK IF CHILD AGE >= 12 YEARS OLD] Has [CHILD NAME] been arrested in the past 2 years?

[Source: Effects of Housing Choice Vouchers on Welfare Families]

☐ Yes

☐ No

☐ Don’t know

☐ Prefer not to answer

26. Now I have some questions about [CHILD NAME]’s sleep. I will read a list of items. Please tell me how often the following occur: Almost always; Most days; Sometimes; Rarely; or Almost Never.

[Source: Sleep Disorder Questionnaire – Adapted and Family Options Study; questions are summed into a composite score.]

Would you say that [READ ITEM]…	Almost always	Most days	Sometimes	Rarely	Almost never	Prefer not to answer
[ASK IF CHILD AGE 2 TO 7] [CHILD NAME] has difficulty waking up in the morning	☐	☐	☐	☐	☐	☐
[ASK IF CHILD AGE 8 TO 17] [CHILD NAME] has difficulty waking up on school days	☐	☐	☐	☐	☐	☐
[CHILD NAME] is tired during the day	☐	☐	☐	☐	☐	☐

3. Child Physical Health, Diet, and Nutrition

Now we would like to talk about [CHILD NAME]’s health.

1. Would you say [CHILD NAME]’s health in general is excellent, very good, good, fair, or poor?

[Source: Short-Form 12 and MTO Interim Evaluation]

☐ Excellent

☐ Very good

☐ Good

☐ Fair

☐ Poor

☐ Don’t know

☐ Prefer not to answer

2. During the past 12 months, how many times has [CHILD NAME] gone to a hospital emergency room?

[Source: CDC National Health Interview Survey; Johns Hopkins question]

☐ [NUMBER OF TIMES] _____

☐ None

☐ Don’t know

☐ Prefer not to answer

3. During the past 12 months, how many times has [CHILD NAME] been hospitalized overnight?

[Source: CDC National Health Interview Survey; Johns Hopkins question]

☐ [NUMBER OF TIMES] _____

☐ None

☐ Don’t know

☐ Prefer not to answer

4. Has a doctor or other health professional EVER told you that [CHILD NAME] has asthma?

[Source: CDC National Health Interview Survey; Johns Hopkins question]

☐ Yes

☐ No (SKIP TO C.6)

☐ Don’t know (SKIP TO C.6)

☐ Prefer not to answer (SKIP TO C.6)

5. [IF C.4. = YES, ASK:] Does [CHILD NAME] still have asthma?

[Source: CDC National Health Interview Survey; Johns Hopkins question]

☐ Yes

☐ No

☐ Don’t know

☐ Prefer not to answer

6. [IF C.3. = NO, DON’T KNOW, or PREFER NOT TO ANSWER, ASK:] Has [CHILD NAME] had at least two illnesses in their life that have been associated with their chest (such as pneumonia or bronchitis)?

[Source: Mobility Asthma Project (MAP) Survey, Johns Hopkins question]

☐ Yes

☐ No

☐ Don’t know

☐ Prefer not to answer

7. [IF C.5. OR C.6 = YES, ASK:] During the past 12 months, did [CHILD NAME] have to visit an emergency room or urgent care center because of their asthma or wheezing?

[Source: CDC National Health Interview Survey; Johns Hopkins question]

☐ Yes

☐ No

☐ Don’t know

☐ Prefer not to answer

8. [IF C.7 = YES, ASK:] How many times did [CHILD NAME] have to visit an emergency room or urgent care center because of their asthma or wheezing?

[Source: CDC National Health Interview Survey; Johns Hopkins question]

☐ [NUMBER OF TIMES] _____

☐ None

☐ Don’t know

☐ Prefer not to answer

9. About how long has it been since [CHILD NAME] last saw a doctor or other health professional for a well-visit, physical, or general-purpose check-up?

[Source: CDC National Health Interview Survey; Johns Hopkins question]

☐ Within past 6 months

☐ Within past 12 months

☐ Within past 2 years

☐ Within the last 3 years [ASK RESPONSE OPTION IF CHILD AGE 3+ YEARS]

☐ Within the last 4 years [ASK RESPONSE OPTION IF CHILD AGE 4+ YEARS]

☐ 5 or more years [ASK RESPONSE OPTION IF CHILD AGE 5+ YEARS]

☐ Never

☐ Don’t know

☐ Prefer not to answer

10. Do you have one or more persons you think of as [CHILD NAME]’s personal doctor or nurse? [INTERVIEWER INSTRUCTION: Read if necessary: A personal doctor or nurse is a health professional who knows [CHILD NAME] well and is familiar with his/her health history. This can be a general doctor, a pediatrician, a specialist doctor, a nurse practitioner, or a physician assistant.]

[Source: Derived from Mobility Asthma Project, Johns Hopkins question]

☐ Yes

☐ No

☐ Don’t know

☐ Prefer not to answer

11. Has a doctor or other health professional EVER told you that [CHILD NAME] has diabetes?

[Source: CDC National Health Interview Survey; Johns Hopkins question]

☐ Yes

☐ No

☐ Don’t know

☐ Prefer not to answer

[ASK C12-C20 IF CHILD AGE 2–9. IF CHILD AGE 5-9, INTERVIEW SHOULD HAVE PARENT LOCATE CHILD TO ASSIST WITH RESPONSES]

12. [ASK IF CHILD AGE 2-4] Now I am going to ask you questions about your child’s diet. In the past month please indicate your response for each beverage type your child may drink.

-Indicate how often your child drank the following beverages, for example, if your child drank 5 glasses of water per week, respond with 4-6 times per week for "HOW OFTEN"

-Indicate the approximate amount of beverage your child drank each time, for example, if your child drank 1 cup of water each time, respond with 1 cup for "HOW MUCH EACH TIME"

-Do not count beverages used in cooking or other preparations, such as milk in cereal.

[INTERVIEWER INSTRUCTIONS: Ask the parent how often their child has each beverage type by reading the response options in the table. Select the box with the response from the parent. Read the options for “How much” next and mark the correct response. The response options are the same for each beverage type and might not need to be read each time with each beverage.]

[Source: Beverage Intake Questionnaire - Preschool (BEVQPS); Johns Hopkins question]

Type of Beverage

How often?

How much?

Don’t know

Prefer not to answer

Never or less than 1 time per week

1 time per week

2-3 times per week

4-5 times per week

1 time per day

2 times per day

3 or more times per day

1/3 cup or less (1-3 fl. oz.)

1/2 cup or ¾ cup (4-6 fl. oz.)

About 1 cup (7-8 fl. oz)

About 1 ¼ cups (9-10 fl. oz.)

About 1 ½ cups per day (12 fl. oz. or more)

Water

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

Sweetened carbonated soft drinks or regular sodas

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

100% Fruit Juice

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

Whole Milk

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

Reduced fat milk (2%)

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

Low fat/fat free milk (Skim, 1%, Buttermilk, Soymilk)

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

Flavored milk (chocolate, strawberry)

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

Sports drinks (e.g., Gatorade, Powerade)

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

Sweetened juice beverages/drinks* (e.g., lemonade, fruit punch)

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

Sweetened tea

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

*Sweetened fruit drinks DO NOT include 100% fruit juice.

13. [ASK IF CHILD AGE 5-9] Now I am going to ask you questions about your child’s diet. In the past month please indicate your response for each beverage type your child may drink.

-Indicate how often your child drank the following beverages, for example, if your child drank 5 glasses of water per week, respond with 4-6 times per week for "HOW OFTEN"

-Indicate the approximate amount of beverage your child drank each time, for example, if your child drank 1 cup of water each time, respond with 1 cup for "HOW MUCH EACH TIME"

-Do not count beverages used in cooking or other preparations, such as milk in cereal.

[INTERVIEWER INSTRUCTIONS: Ask the parent how often their child has each beverage type by reading the response options in the table. Select the box with the response from the parent. Read the options for “How much” next and mark the correct response. The response options are the same for each beverage type and might not need to be read each time with each beverage. Since the child is there to assist, please confirm the frequency and amount of each beverage that the parent responds with the child.

[Source: Beverage Intake Questionnaire (BEVQ), Johns Hopkins question]

Type of Beverage

How often?

How much?

Don’t know

Prefer not to answer

Never or less than 1 time per week

1 time per week

2-3 times per week

4-5 times per week

1 time per day

2 times per day

3 or more times per day

Less than ¾ cup (6 fl. oz.)

1 cup (8 fl. oz.)

1 ½ cups (12 fl. oz.)

2 cups (16 fl. oz.)

2 ½ cups (20 fl. oz.)

Water

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

Soft drinks [INTERVIEWER INSTRUCTION: e.g., Coca-Cola, Pepsi]

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

100% Fruit Juice

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

Whole Milk

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

Reduced fat milk (2%)

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

Low fat/fat free milk (Skim, 1%, Buttermilk, Soymilk)

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

Energy & Sports Drinks (e.g., Red Bull, Rockstar, Gatorade, Powerade, etc.)

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

Sweetened juice beverages/drinks* (e.g., lemonade, fruit punch)

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

Sweetened tea

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

*Sweetened fruit drinks DO NOT include 100% fruit juice.

14. Next, I'm going to ask you about meals your child ate. By meal, I mean breakfast, lunch, and dinner. During the past 7 days, how many meals did [CHILD NAME] get that were prepared away from home in places such as restaurants, fast food places, food stands, grocery stores, or from vending machines? (Please do not include meals provided as part of the school lunch or school breakfast).

[Source: CDC National Health and Nutrition Examination Survey, 2017-2020, validated national survey question, Johns Hopkins question]

☐ [ENTER NUMBER OF MEALS 1-21]

☐ None

☐ More than 21 meals per week

☐ Don’t know

☐ Prefer not to answer

[INTERVIEWER INSTRUCTION: IF CHILD AGE 5-9, ASK CHILD TO CONFIRM ANSWER]

15. [IF C14 IS NOT “None”, “Prefer not to answer”, or “Don’t Know”, ASK] How many of those meals did [CHILD NAME] get from a fast-food or pizza place?

[Source CDC National Health and Nutrition Examination Survey, 2017-2020, validated national survey question, Johns Hopkins question]

☐ [ENTER NUMBER OF MEALS 1-21] [INTERVIEWER INSTRUCTIONS: This number should not be higher than the number provided above]

☐ None

☐ More than 21 meals per week

☐ Don’t know

☐ Prefer not to answer

[INTERVIEWER INSTRUCTION: IF CHILD AGE 5-9, ASK CHILD TO CONFIRM ANSWER]

16. [ASK IF CHILD AGE 5-9, WITH CHILD CONFIRMING ANSWER] During the school year, about how many times a week does [CHILD NAME] usually get breakfast at school?

[Source: CDC National Health and Nutrition Examination Survey, 2017-2020, validated national survey question, Johns Hopkins question]

☐ [ENTER NUMBER OF TIMES] _____

☐ None

☐ Don’t know

☐ Prefer not to answer

17. [ASK IF CHILD AGE 5-9, WITH CHILD CONFIRMING ANSWER] During the school year, about how many times a week does [CHILD NAME] usually get lunch at school?

[Source: CDC National Health and Nutrition Examination Survey, 2017-2020, validated national survey question, Johns Hopkins question]

☐ [ENTER NUMBER OF TIMES] _____

☐ None

☐ Don’t know

☐ Prefer not to answer

18. [ASK IF CHILD AGE 5-9, WITH CHILD CONFIRMING ANSWER] During the past 7 days, on how many days was [CHILD NAME] physically active for a total of at least 60 minutes per day? (Add up all the time spent in any kind of physical activity that increased their heart rate and made them breathe hard some of the time.)

[Source: CDC Youth Risk Behavior Survey (YRBS) - 2023, validated national survey question, Johns Hopkins question]

☐ 0 days

☐ 1 day

☐ 2 days

☐ 3 days

☐ 4 days

☐ 5 days

☐ 6 days

☐ 7 days

☐ Prefer not to answer

19. [ASK IF CHILD AGE 5-9, WITH CHILD CONFIRMING ANSWER] During the past 12 months, on how many sports teams did [CHILD NAME] play? (Count any teams run by their school or community groups.)

[Source: CDC Youth Risk Behavior Survey (YRBS) - 2023, validated national survey question, Johns Hopkins question]

☐ 0 teams

☐ 1 team

☐ 2 teams

☐ 3 or more teams

☐ Don’t know

☐ Prefer not to answer

20. Does your child currently have a health problem that would interfere with their participation in physical activity?

[Source: Maron et al. (2007) – American Heart Association Scientific Statement, Johns Hopkins Question]

☐ Yes

☐ No

☐ Unsure

☐ Prefer not to answer

21. Now I am going to ask you about your child’s screen time.

[IF AGE 2-4, DISPLAY:] On an average weekday how many hours does [CHILD NAME] spend in front of a TV, computer, smart phone, or other electronic device watching shows or videos, playing games, or accessing the Internet?

[IF AGE 5-9, DISPLAY AND CONFIRM ANSWER WITH CHILD:] On an average school day, how many hours does [CHILD NAME] spend in front of a TV, computer, smart phone, or other electronic device watching shows or videos, playing games, accessing the Internet, or using social media (also called "screen time")? Do not count time spent doing schoolwork.

[Source: CDC Youth Risk Behavior Survey (YRBS) - 2023, validated national survey question, Johns Hopkins question]

☐ My child does not use screens on [AGE 2-4: weekdays; AGE 5-9: school days]

☐ Less than 1 hour per day

☐ 1 hour per day

☐ 2 hours per day

☐ 3 hours per day

☐ 4 hours per day

☐ 5 or more hours per day

☐ Prefer not to answer

Thank you very much for your time, that’s the end of this questionnaire.