Form 8 Parent In-Home Survey

NEXT Plus Parent In-Home Survey

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 (####-####). Do not return the completed form to this address.

INSTRUCTIONS FOR COMPLETING THE SURVEY
•

Read each question carefully.

•

Please write or mark your answer clearly.

•

Mark the answer that best fits your situation.

NEXT Plus Parent In-Home Survey1
1. Has a doctor, nurse or other health provider told you that your teen has any of the following conditions? Please circle “yes” or
“not” for each item. If the answer is “yes” indicate which medications, if any, your teen takes for this condition.
CIRCLE ONE
Health Condition

NO
My teen does not
have this health
condition now

Yes
My teen has
this health
condition now

a. Cancer or lymphoma or leukemia. Don’t include skin cancer,
except melanoma
b. High blood cholesterol or triglycerides or lipids

1

2

1

2

c. High blood pressure or hypertension (when not pregnant)

1

2

d. High blood pressure or hypertension (when not pregnant)

1

2

e. High blood sugar or diabetes (when not pregnant)

1

2

f. High blood sugar or diabetes (when pregnant only)

1

2

g. Heart disease

1

2

h. Asthma, chronic bronchitis or emphysema

1

2

i. Migraine headaches

1

2

j. Depression

1

2

k. Post-traumatic stress disorder or PTSD

1

2

l. Anxiety or panic disorder

1

2

m. Epilepsy or another seizure disorder

1

2

n. Attention problems or ADD or ADHD

1

2

o. HIV/AIDS

1

2

p. Hepatitis C

1

2

q. Allergies

1

2

r. Celiac disease

1

2

s. Sleep disorders

1

2

t. Other (specify) __________________________________

1

2

1

From TAGG

If Applicable
My teen takes the following
medication(s) for this
condition

2. What is your relationship to TEEN? Please circle ONE response.

Relationship
a. Mother
b. Father
c. Stepmother
d. Stepfather
e. Foster mother
f. Foster father
g. Grandmother
h. Grandfather
i. Parent’s Partner (female)
j. Parent’s Partner (male)
k. Other

Circle ONE
1
2
3
4
5
6
7
8
9
10
11

NEXT Plus Student In-Home Survey

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 (####-####). Do not return the completed form to
this address.

INSTRUCTIONS FOR COMPLETING THE SURVEY
•

Read each question carefully.

•

Please write or mark your answer clearly.

•

Mark the answer that best fits your situation.

NEXT Plus Student In-Home Survey1
Please think about the medicines you are using now.
1. In the past 24 hours, have you taken aspirin or aspirin containing medications including cold and allergy
medications or headache powders? Some examples of those include:
Anacin
Aspirin
B.C.
Backache Relief Extra Strength
Bayer

Excedrin
Goody’s
Pain Relief
Pain Reliever Added Strength
Vanquish

… Yes
… No
2. In the past 24 hours, have you taken other anti-inflammatory medications? Some examples of those include:
Advil
166
Aleve
Nuprin

Ibuprofen
Motrin
Naproxen

… Yes
… No
3. In the past 24 hours, have you used any prescription medications whether or not they were prescribed for
you?

… Yes
… No (skip to the paragraph preceding question 5)

1

From TAGG

4. How many different prescription medications have you used in the past 24 hours? _________
What is the name of the medication?
(write in name below)

At what time did you last take this medication?
Hour/Minute
(example: 7:30)

AM or PM
(circle one)

a.

AM / PM

b.

AM / PM

c.

AM / PM

d.

AM / PM

e.

AM / PM

f.

AM / PM

g.

AM / PM

h.

AM / PM

i.

AM / PM

j.

AM / PM

k.

AM / PM

l.

AM / PM

m.

AM / PM

n.

AM / PM

o.

AM / PM

p.

AM / PM

q.

AM / PM

r.

AM / PM

s.

AM / PM

t.

AM / PM

Now, for the next questions, please think about the different facilities in and around your neighborhood. By this we
mean the area ALL around your home that you could walk to in 10-15 minutes. Please check only one answer
for each question.
5.

What is the main type of housing in your neighborhood?
1

Detached single-family housing

2

Townhouses, row houses, apartments, or condos of 2-3 stories

3

Mix of single-family residences and townhouses, row houses, apartments or condos

4

Apartments or condos of 4-12 stories

5

Apartments or condos of more than 12 stories

77

Don’t know/Not sure

The next items are statements about your neighborhood related to walking and bicycling. Fill in the circle completely
and chose only one answer for each statement. There are no right or wrong answers – chose the answer that is best
for you.
Strongly
Disagree

Somewhat
Disagree

Somewhat
Agree

Strongly
Agree

Don’t know/
not sure

6. Many shops, stores, markets or other places to buy things
I need are within easy walking distance of my home.

c

d

e

f

g

7. It is within a 10-15 minutes walk to a transit stop (such as
a bus, train, trolley, or subway) from my home.

c

d

e

f

g

c

d

e

f

g

c

d

e

f

g

c

d

e

f

g

c

d

e

f

g

c

d

e

f

g

8. My neighborhood has several free or low cost recreation
facilities, such as parks, walking trails, bike paths, recreation
centers, play grounds public swimming pools, etc
.
9. The crime rate in my neighborhood makes it unsafe to go
on walks at night.
10. I see many people being physically active in my
neighborhood doing things like walking, jogging, cycling, or
playing sports and active games
.
11. There are many interesting things to look at while
walking in my neighborhood
.
12. The sidewalks in my neighborhood are well maintained
(paved, with few cracks) and not obstructed.

Strongly
Disagree

Somewhat
Disagree

Somewhat
Agree

Strongly
Agree

Don’t know/
not sure

13. Places for bicycling (such as bike paths) in and around
my neighborhood are well maintained and not obstructed.

c

d

e

f

g

14. There is so much traffic on the streets that it makes it
difficult or unpleasant to ride a bicycle in my neighborhood.

c

d

e

f

g

15. The crime rate in my neighborhood makes it unsafe to
go on walks during the day.

c

d

e

f

g

16.

There are sidewalks on most of the streets in my neighborhood. Would you say that you…
1

Strongly disagree

2

Somewhat disagree

3

Somewhat agree

4

Strongly agree

88

Does not apply to my neighborhood

77

Don’t know/Not sure

17.

There are facilities to bicycle in or near my neighborhood, such as special lanes, separate
paths or trails, shared use paths for cycles and pedestrians. Would you say that you…
1

Strongly disagree

2

Somewhat disagree

3

Somewhat agree

4

Strongly agree

88

Does not apply to my neighborhood

77

Don’t know/Not sure

18.

There is so much traffic on the streets that it makes it difficult or unpleasant to walk in my
neighborhood. Would you say that you…
1

Strongly disagree

2

Somewhat disagree

3

Somewhat agree

4

Strongly agree

88

There are no streets or roads in my neighborhood

77

Don’t know/Not sure

19.

How many motor vehicles in working order (e.g., cars, trucks, motorcycles) are there at your
household?
____ Motor Vehicles
77

20.

Don’t know/Not sure

There are many four-way intersections in my neighborhood. Would you say that you…
1

Strongly disagree

2

Somewhat disagree

3

Somewhat agree

4

Strongly agree

88

There are no streets or roads in my neighborhood

77

Don’t know/Not sure