35.5 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

48M Questionnaire – Child, Phase 2g

OMB Specification

48M Questionnaire - Child

Event Category:	Time-Based
Event:	48M
Administration:	N/A
Instrument Target:	Child
Instrument Respondent:	Primary Caregiver
Domain:	Questionnaire
Document Category:	Questionnaire
Method:	Data Collector Administered
Mode (for this instrument*):	In-Person, CAI; Phone, CAI
OMB Approved Modes:	In-Person, CAI; Phone, CAI; Web-Based, CAI
Estimated Administration Time:	8 minutes
Multiple Child/Sibling Consideration:	Per Child
Special Considerations:	N/A
Version:	1.0
MDES Release:	4.0

*This instrument is OMB-approved for multi-mode administration but this version of the instrument is designed for administration in this/these mode(s) only.

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48M Questionnaire - Child

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

PARENTING 3

PHYSICAL ACTIVITY 12

SUN EXPOSURE 20

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48M Questionnaire - Child

GENERAL PROGRAMMER INSTRUCTIONS:

WHEN PROGRAMMING INSTRUMENTS, VALIDATE FIELD LENGTHS AND TYPES AGAINST THE MDES TO ENSURE DATA COLLECTION RESPONSES DO NOT EXCEED THOSE OF THE MDES. SOME GENERAL ITEM LIMITS USED ARE AS FOLLOWS:

DATA ELEMENT FIELDS	MAXIMUM CHARACTERS PERMITTED	DATA TYPE	PROGRAMMER INSTRUCTIONS
ADDRESS AND EMAIL FIELDS	100	CHARACTER
UNIT AND PHONE FIELDS	10	CHARACTER
_OTH AND COMMENT FIELDS	255	CHARACTER	Limit text to 255 characters
FIRST NAME AND LAST NAME	30	CHARACTER	Limit text to 30 characters
ALL ID FIELDS	36	CHARACTER
ZIP CODE	5	NUMERIC
ZIP CODE LAST FOUR	4	NUMERIC
CITY	50	CHARACTER
DOB AND ALL OTHER DATE FIELDS (E.G., DT, DATE, ETC.)	10	NUMERIC CHARACTER	DISPLAY AS MM/DD/YYYY STORE AS YYYY-MM-DD HARD EDITS: MM MUST EQUAL 01 TO 12 DD MUST EQUAL 01 TO 31 YYYY MUST BE BETWEEN 1900 AND CURRENT YEAR.
TIME VARIABLES	TWO-DIGIT HOUR AND TWO-DIGIT MINUTE, AM/PM DESIGNATION	NUMERIC	HARD EDITS: HOURS MUST BE BETWEEN 00 AND 12; MINUTES MUST BE BETWEEN 00 AND 59

Instrument Guidelines for Participant and Respondent IDs:

PRENATALLY, THE P_ID IN THE MDES HEADER IS THAT OF THE PARTICIPANT (E.G. THE NON-PREGNANT WOMAN, PREGNANT WOMAN, OR THE FATHER).

POSTNATALLY, A RESPONDENT ID WILL BE USED IN ADDITION TO THE PARTICIPANT ID BECAUSE SOMEBODY OTHER THAN THE PARTICIPANT MAY BE COMPLETING THE INTERVIEW. FOR EXAMPLE, THE PARTICIPANT MAY BE THE CHILD AND THE RESPONDENT MAY BE THE MOTHER, FATHER, OR ANOTHER CAREGIVER. THEREFORE, MDES VERSION 2.2 AND ALL FUTURE VERSIONS CONTAIN A R_P_ID (RESPONDENT PARTICIPANT ID) HEADER FIELD FOR EACH POST-BIRTH INSTRUMENT. THIS WILL ALLOW ROCs TO INDICATE WHETHER THE RESPONDENT IS SOMEBODY OTHER THAN THE PARTICIPANT ABOUT WHOM THE QUESTIONS ARE BEING ASKED.

A REMINDER:

ALL RESPONDENTS MUST BE CONSENTED AND HAVE RECORDS IN THE PERSON, PARTICIPANT, PARTICIPANT_CONSENT AND LINK_PERSON_PARTICIPANT TABLES, WHICH CAN BE PRELOADED INTO EACH INSTRUMENT. ADDITIONALLY, IN POST-BIRTH QUESTIONNAIRES WHERE THERE IS THE ABILITY TO LOOP THROUGH A SET OF QUESTIONS FOR MULTIPLE CHILDREN, IT IS IMPORTANT TO CAPTURE AND STORE THE CORRECT CHILD P_ID ALONG WITH THE LOOP INFORMATION. IN THE MDES VARIABLE LABEL/DEFINITION COLUMN, THIS IS INDICATED AS FOLLOWS: EXTERNAL IDENTIFIER: PARTICIPANT ID FOR CHILD DETAIL.

PARENTING

(TIME_STAMP_PAR_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

• PRELOAD PARTICIPANT ID (P_ID) FOR CHILD AND RESPONDENT ID (R_P_ID) FOR ADULT CAREGIVER.

• PRELOAD FIRST NAME OF CHILD (C_FNAME) FROM  PARTICIPANT VERIFICATION, SCHEDULING, & TRACING QUESTIONNAIRE (INSTRUMENT_ID = XX) AND DISPLAY APPROPRIATE NAME IN “C_FNAME” THROUGHOUT THE INSTRUMENT.

• OTHERWISE, IF C_FNAME = -1 OR -2, DISPLAY “the child” IN APPROPRIATE FIELDS THROUGHOUT THE INSTRUMENT.

• PRELOAD CHILD_SEX FROM PARTICIPANT VERIFICATION, SCHEDULING, & TRACING QUESTIONNAIRE (INSTRUMENT_ID = XX).

• IF CHILD_SEX = 1, DISPLAY “his”, “he”, OR “himself” IN APPROPRIATE FIELDS THROUGHOUT INSTRUMENT.

• IF CHILD_SEX = 2, DISPLAY “her”, “she”, OR “herself” IN APPROPRIATE FIELDS THROUGHOUT INSTRUMENT.

PAR01000. Now I would like to ask you some questions about things you may do with {C_FNAME/the child}.  Please tell me how many days you do each of these activities in a typical week.  How many days a week do you….

SOURCE

The Fragile Families and Child Wellbeing Study (Mother’s 3-Year Follow-Up Survey) Public Use Version, May 2008

Current: National Children’s Study, Vanguard Phase (30M)

PAR02000/(SING). Sing songs or nursery rhymes with {C_FNAME/the child}?

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

• RE-READ INTRODUCTORY STATEMENT (How many days a week do you…) AS NEEDED.

Label	Code	Go To
NEVER/LESS THAN ONE DAY PER WEEK	0
1 DAY PER WEEK	1
2 DAYS PER WEEK	2
3 DAYS PER WEEK	3
4 DAYS PER WEEK	4
5 DAYS PER WEEK	5
6 DAYS PER WEEK	6
7 DAYS PER WEEK	7
REFUSED	-1
DON'T KNOW	-2

SOURCE

The Fragile Families and Child Wellbeing Study (Mother’s 3-Year Follow-Up Survey) Public Use Version, May 2008 (modified)

Current: National Children’s Study, Vanguard Phase (30M)

PAR03000/(HUG). Hug or show physical affection to {C_FNAME/the child}?

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

• RE-READ INTRODUCTORY STATEMENT (How many days a week do you…) AS NEEDED.

Label	Code	Go To
NEVER/LESS THAN ONE DAY PER WEEK	0
1 DAY PER WEEK	1
2 DAYS PER WEEK	2
3 DAYS PER WEEK	3
4 DAYS PER WEEK	4
5 DAYS PER WEEK	5
6 DAYS PER WEEK	6
7 DAYS PER WEEK	7
REFUSED	-1
DON'T KNOW	-2

SOURCE

The Fragile Families and Child Wellbeing Study (Mother’s 3-Year Follow-Up Survey) Public Use Version, May 2008 (modified)

Current: National Children’s Study, Vanguard Phase (30M)

PAR04000/(TELL_LOVE). Tell {C_FNAME/the child} that you love {him/her}?

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

• RE-READ INTRODUCTORY STATEMENT (How many days a week do you…) AS NEEDED.

Label	Code	Go To
NEVER/LESS THAN ONE DAY PER WEEK	0
1 DAY PER WEEK	1
2 DAYS PER WEEK	2
3 DAYS PER WEEK	3
4 DAYS PER WEEK	4
5 DAYS PER WEEK	5
6 DAYS PER WEEK	6
7 DAYS PER WEEK	7
REFUSED	-1
DON'T KNOW	-2

SOURCE

The Fragile Families and Child Wellbeing Study (Mother’s 3-Year Follow-Up Survey) Public Use Version, May 2008 (modified)

Current: National Children’s Study, Vanguard Phase (30M)

PAR05000/(HELP_CHORES). Let {C_FNAME/the child} help you with simple household chores?

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

• RE-READ INTRODUCTORY STATEMENT (How many days a week do you…) AS NEEDED.

Label	Code	Go To
NEVER/LESS THAN ONE DAY PER WEEK	0
1 DAY PER WEEK	1
2 DAYS PER WEEK	2
3 DAYS PER WEEK	3
4 DAYS PER WEEK	4
5 DAYS PER WEEK	5
6 DAYS PER WEEK	6
7 DAYS PER WEEK	7
REFUSED	-1
DON'T KNOW	-2

SOURCE

The Fragile Families and Child Wellbeing Study (Mother’s 3-Year Follow-Up Survey) Public Use Version, May 2008 (modified)

Current: National Children’s Study, Vanguard Phase (30M)

PAR06000/(PLAY_GAMES). Play imaginary games with {C_FNAME/the child}?

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

• RE-READ INTRODUCTORY STATEMENT (How many days a week do you…) AS NEEDED.

Label	Code	Go To
NEVER/LESS THAN ONE DAY PER WEEK	0
1 DAY PER WEEK	1
2 DAYS PER WEEK	2
3 DAYS PER WEEK	3
4 DAYS PER WEEK	4
5 DAYS PER WEEK	5
6 DAYS PER WEEK	6
7 DAYS PER WEEK	7
REFUSED	-1
DON'T KNOW	-2

SOURCE

The Fragile Families and Child Wellbeing Study (Mother’s 3-Year Follow-Up Survey) Public Use Version, May 2008 (modified)

Current: National Children’s Study, Vanguard Phase (30M)

PAR07000/(READ_STORIES). Read stories to {C_FNAME/the child}?

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

• RE-READ INTRODUCTORY STATEMENT (How many days a week do you…) AS NEEDED.

Label	Code	Go To
NEVER/LESS THAN ONE DAY PER WEEK	0
1 DAY PER WEEK	1
2 DAYS PER WEEK	2
3 DAYS PER WEEK	3
4 DAYS PER WEEK	4
5 DAYS PER WEEK	5
6 DAYS PER WEEK	6
7 DAYS PER WEEK	7
REFUSED	-1
DON'T KNOW	-2

SOURCE

The Fragile Families and Child Wellbeing Study (Mother’s 3-Year Follow-Up Survey) Public Use Version, May 2008 (modified)

Current: National Children’s Study, Vanguard Phase (30M)

PAR08000/(TELL_STORIES). Tell stories to {C_FNAME/the child}?

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

• RE-READ INTRODUCTORY STATEMENT (How many days a week do you…) AS NEEDED.

Label	Code	Go To
NEVER/LESS THAN ONE DAY PER WEEK	0
1 DAY PER WEEK	1
2 DAYS PER WEEK	2
3 DAYS PER WEEK	3
4 DAYS PER WEEK	4
5 DAYS PER WEEK	5
6 DAYS PER WEEK	6
7 DAYS PER WEEK	7
REFUSED	-1
DON'T KNOW	-2

SOURCE

The Fragile Families and Child Wellbeing Study (Mother’s 3-Year Follow-Up Survey) Public Use Version, May 2008 (modified)

Current: National Children’s Study, Vanguard Phase (30M)

PAR09000/(PLAY_TOYS). Play inside with toys such as blocks or legos with {C_FNAME/the child}?

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

• RE-READ INTRODUCTORY STATEMENT (How many days a week do you…) AS NEEDED.

Label	Code	Go To
NEVER/LESS THAN ONE DAY PER WEEK	0
1 DAY PER WEEK	1
2 DAYS PER WEEK	2
3 DAYS PER WEEK	3
4 DAYS PER WEEK	4
5 DAYS PER WEEK	5
6 DAYS PER WEEK	6
7 DAYS PER WEEK	7
REFUSED	-1
DON'T KNOW	-2

SOURCE

The Fragile Families and Child Wellbeing Study (Mother’s 3-Year Follow-Up Survey) Public Use Version, May 2008 (modified)

Current: National Children’s Study, Vanguard Phase (30M)

PAR10000/(TELL_APPREC). Tell {C_FNAME/the child} that you appreciated something {he/she} did?

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

• RE-READ INTRODUCTORY STATEMENT (How many days a week do you…) AS NEEDED.

Label	Code	Go To
NEVER/LESS THAN ONE DAY PER WEEK	0
1 DAY PER WEEK	1
2 DAYS PER WEEK	2
3 DAYS PER WEEK	3
4 DAYS PER WEEK	4
5 DAYS PER WEEK	5
6 DAYS PER WEEK	6
7 DAYS PER WEEK	7
REFUSED	-1
DON'T KNOW	-2

SOURCE

The Fragile Families and Child Wellbeing Study (Mother’s 3-Year Follow-Up Survey) Public Use Version, May 2008 (modified)

Current: National Children’s Study, Vanguard Phase (30M)

PAR11000/(VISIT_RELATIVES). Take {C_FNAME/the child} to visit relatives?

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

• RE-READ INTRODUCTORY STATEMENT (How many days a week do you…) AS NEEDED.

Label	Code	Go To
NEVER/LESS THAN ONE DAY PER WEEK	0
1 DAY PER WEEK	1
2 DAYS PER WEEK	2
3 DAYS PER WEEK	3
4 DAYS PER WEEK	4
5 DAYS PER WEEK	5
6 DAYS PER WEEK	6
7 DAYS PER WEEK	7
REFUSED	-1
DON'T KNOW	-2

SOURCE

The Fragile Families and Child Wellbeing Study (Mother’s 3-Year Follow-Up Survey) Public Use Version, May 2008 (modified)

Current: National Children’s Study, Vanguard Phase (30M)

PAR12000/(EAT_OUT). Go to a restaurant or out to eat with {C_FNAME/the child}?

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

• RE-READ INTRODUCTORY STATEMENT (How many days a week do you…) AS NEEDED.

Label	Code	Go To
NEVER/LESS THAN ONE DAY PER WEEK	0
1 DAY PER WEEK	1
2 DAYS PER WEEK	2
3 DAYS PER WEEK	3
4 DAYS PER WEEK	4
5 DAYS PER WEEK	5
6 DAYS PER WEEK	6
7 DAYS PER WEEK	7
REFUSED	-1
DON'T KNOW	-2

SOURCE

The Fragile Families and Child Wellbeing Study (Mother’s 3-Year Follow-Up Survey) Public Use Version, May 2008 (modified)

Current: National Children’s Study, Vanguard Phase (30M)

PAR12100/(ASSIST_EAT). Assist {C_FNAME/the child} with eating?

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

• RE-READ INTRODUCTORY STATEMENT (How many days a week do you…) AS NEEDED.

Label	Code	Go To
NEVER/LESS THAN ONE DAY PER WEEK	0
1 DAY PER WEEK	1
2 DAYS PER WEEK	2
3 DAYS PER WEEK	3
4 DAYS PER WEEK	4
5 DAYS PER WEEK	5
6 DAYS PER WEEK	6
7 DAYS PER WEEK	7
REFUSED	-1
DON'T KNOW	-2

SOURCE

The Fragile Families and Child Wellbeing Study (Mother’s 3-Year Follow-Up Survey) Public Use Version, May 2008 (modified)

Current: National Children’s Study, Vanguard Phase (30M)

PAR13000/(PUT_BED). Put {C_FNAME/the child} to bed?

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

• RE-READ INTRODUCTORY STATEMENT (How many days a week do you…) AS NEEDED.

Label	Code	Go To
NEVER/LESS THAN ONE DAY PER WEEK	0
1 DAY PER WEEK	1
2 DAYS PER WEEK	2
3 DAYS PER WEEK	3
4 DAYS PER WEEK	4
5 DAYS PER WEEK	5
6 DAYS PER WEEK	6
7 DAYS PER WEEK	7
REFUSED	-1
DON'T KNOW	-2

SOURCE

The Fragile Families and Child Wellbeing Study (Mother’s 3-Year Follow-Up Survey) Public Use Version, May 2008 (modified)

Current: National Children’s Study, Vanguard Phase (30M)

(TIME_STAMP_PAR_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

PHYSICAL ACTIVITY

(TIME_STAMP_PA_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

PA01000. These next questions are about {C_FNAME/the child}’s physical activity.

PA02000/(MED_LIMIT_PA). Does {C_FNAME/the child} have any physical or medical condition that affects {his/her} ability to play and be physically active?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (modified)

PA03000/(COMPARE_AGE). How active would you say {C_FNAME/the child} is compared with other {girls/boys} {C_FNAME/the child}’s age?  Would you say:

Label	Code	Go To
A lot less active	1
Less active	2
The same	3
More active	4
A lot more active	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (modified)

PROGRAMMER INSTRUCTIONS

• IF CHILD_SEX = 1, DISPLAY "boys".

• IF CHILD_SEX = 2, DISPLAY "girls".

• OTHERWISE, DISPLAY “girls/boys”

PA04000. Thinking about yesterday (or the most recent day you were home with child), how much time did {C_FNAME/the child} spend outdoors in active play?

INTERVIEWER INSTRUCTIONS

• ENTER "0 HOURS" AND "00 MINUTES" IF CHILD DID NOT SPEND ANYTIME OUTDOORS IN ACTIVE PLAY YESTERDAY.

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (modified)

(OUTDOOR_YEST_HRS) |___|

HOURS

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(OUTDOOR_YEST_MIN) |___|___|

MINUTES

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

PA05000/(WEATHER_THATDAY). Thinking about that day, what was the weather like?  Would you say it was…

Label	Code	Go To
Fine to play outdoors	1	BACKYARD_TYPE
Too wet to play outdoors	2	BACKYARD_TYPE
Too hot or humid to play outdoors	3	BACKYARD_TYPE
Too cold to play outdoors	4	BACKYARD_TYPE
Another reason it was not suitable to play outdoors, for example, bad air quality	-5
REFUSED	-1	BACKYARD_TYPE
DON'T KNOW	-2	BACKYARD_TYPE

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (modified)

PA06000/(WEATHER_THATDAY_OTH). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (modified)

PA07000/(BACKYARD_TYPE). What best describes your backyard or grassy play area in your complex?  Would you say you have

Label	Code	Go To
No yard or outside area where your children can play	1	PA09000
A yard or play area that you share with other residents	2
A private yard where your children can play	3
REFUSED	-1
DON'T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (modified)

PA08000/(BACKYARD_SIZE). What best describes the size of your backyard or grassy play area in your complex? Would you say you have a small, medium or large yard or play area?

Label	Code	Go To
A SMALL YARD OR PLAY AREA (UP TO 1/8 ACRE)	1
A MEDIUM-SIZED YARD OR PLAY AREA (1/8 TO ¼ ACRE)	2
A LARGE YARD OR PLAY AREA (GREATER THAN ¼ ACRE)	3
REFUSED	-1
DON'T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (modified)

PA09000. Do you have access to any of the following facilities within your backyard or home environment?

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) 

PA10000/(PLAY_EQUIP_BACKYARD). Play equipment like a swing set, slide, or climbing gym?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (modified)

PA11000/(POOL_BACKYARD). Pool or spa? 

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) 

PA12000/(BIKE_AREA_BACKYARD). Area suitable to ride a tricycle, bike or scooter?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (modified)

PA14000. I am going to read several statements.  Please tell me how often the statement applies to you or {C_FNAME/the child}.

PA15000/(OUTDOOR_PLAY_OFTEN). {C_FNAME/The child} plays outside when the weather is suitable.  

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NEVER	1
RARELY	2
SOMETIMES	3
OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Family Health Behavior Scale (modified)

PA16000/(PART_OFTEN_CAREGIVERS). {C_FNAME/The child} participates in physical activity with parents and caregivers.  

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NEVER	1
RARELY	2
SOMETIMES	3
OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Family Health Behavior Scale (modified )

PA17000/(ACTIVE_DAILY_30MIN). {C_FNAME/The child} is physically active for at least 30 minutes a day.  

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NEVER	1
RARELY	2
SOMETIMES	3
OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Family Health Behavior Scale (modified )

PA18000/(PART_ORG_SPORTS). {C_FNAME/The child} participates in organized sports.  

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NEVER	1
RARELY	2
SOMETIMES	3
OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Family Health Behavior Scale (modified)

PA19000/(PREFER_INDOOR). {C_FNAME/The child} prefers indoor activities over outdoor activities.  

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NEVER	1
RARELY	2
SOMETIMES	3
OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Family Health Behavior Scale (modified)

PA20000/(PART_WITH_CHILD). I participate in physical activity with {C_FNAME/the child}.  

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NEVER	1
RARELY	2
SOMETIMES	3
OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Family Health Behavior Scale (modified)

PA21000/(OBSERVE_PHYS_ACT). {C_FNAME/The child} observes me being physically active. 

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NEVER	1
RARELY	2
SOMETIMES	3
OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (modified)

PA22000/(WORRY_CHILD_INJURE). When {C_FNAME/the child} plays I worry that {he/she} may injure {himself/herself}.  

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NEVER	1
RARELY	2
SOMETIMES	3
OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (modified)

PA23000/(BASIC_LEARNING_FOC). I focus upon {C_NAME/the child} developing {his/her} basic learning skills such as numbers and letters. 

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NEVER	1
RARELY	2
SOMETIMES	3
OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (modified)

PA24000/(WORK_LIMIT_PLAY). My work schedule or other commitments limit the time I have to play with {C_FNAME/the child}.  

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NEVER	1
RARELY	2
SOMETIMES	3
OFTEN	4
VERY OFTEN	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Preschool-Aged Children’s Physical Activity Questionnaire (Pre-PAQ) (modified)

(TIME_STAMP_PA_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

SUN EXPOSURE

(TIME_STAMP_SE_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

SE01000. These next questions asks about you, {C_FNAME/the child}, and your views and habits when out in the sun.

SOURCE

Sun Habits Survey

SE02000/(HOURS_SUN_WEEKDAY). On average, how long was {C_FNAME/the child} outdoors in the sun on weekdays between 10 a.m. and 4 p.m. last summer?  

Label	Code	Go To
1 HOUR OR LESS	1
2 HOURS	2
3 HOURS	3
4 HOURS	4
5 HOURS	5
6 HOURS	6
REFUSED	-1
DON'T KNOW	-2

SOURCE

Sun Habits Survey (modified)

SE03000/(HOURS_SUN_WEEKEND). On average, how long was {C_FNAME/the child} outdoors in the sun on weekends between 10 a.m. and 4 p.m. last summer?  

Label	Code	Go To
1 HOUR OR LESS	1
2 HOURS	2
3 HOURS	3
4 HOURS	4
5 HOURS	5
6 HOURS	6
REFUSED	-1
DON'T KNOW	-2

SOURCE

Sun Habits Survey (modified)

SE04000. When {C_FNAME/the child} is outdoors in the sun, how often do you have {C_FNAME/the child} do each of the following?

SOURCE

Sun Habits Survey (modified)

SE05000/(SUN_SHIRT_SLEEVES). Wear a shirt with sleeves?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT (“When {C_FNAME/the child} is outdoors in the sun, how often do you have {C_FNAME/the child}  …”) AS NEEDED.

Label	Code	Go To
RARELY OR NEVER	1
SOMETIMES	2
USUALLY	3
ALWAYS	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Sun Habits Survey

SE06000/(SUN_SHADE). Stay in the shade or under an umbrella?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT (“When {C_FNAME/the child} is outdoors in the sun, how often do you have {C_FNAME/the child}  …”) AS NEEDED.

Label	Code	Go To
RARELY OR NEVER	1
SOMETIMES	2
USUALLY	3
ALWAYS	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Sun Habits Survey

SE07000/(SUN_SUNSCREEN). Wear sunscreen?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT (“When {C_FNAME/the child} is outdoors in the sun, how often do you have {C_FNAME/the child}  …”) AS NEEDED.

Label	Code	Go To
RARELY OR NEVER	1
SOMETIMES	2
USUALLY	3
ALWAYS	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Sun Habits Survey

SE08000/(APPLY_SUNSCREEN_FREQ). How often do you or {C_FNAME/the child} apply sunscreen on {him/her} before {he/she} goes to outdoor activities?

Label	Code	Go To
RARELY OR NEVER	1
SOMETIMES	2
USUALLY	3
ALWAYS	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Sun Habits Survey (modified)

SE09000/(APPLY_SUNSCREEN_TIME). When do you (or {C_FNAME/the child}) usually first put sunscreen on?

Label	Code	Go To
First thing in the morning	1
Before going outside	2
After being outside	3
DO NOT APPLY SUNSCREEN	-7
REFUSED	-1
DON'T KNOW	-2

SOURCE

Sun Habits Survey (modified)

SE10000/(CHILD_NAT_HAIR_COLOR). What is {C_FNAME/the child}’s natural hair color?

Label	Code	Go To
RED	1	CHILD_EYE_COLOR
BLONDE	2	CHILD_EYE_COLOR
BROWN	3	CHILD_EYE_COLOR
BLACK	4	CHILD_EYE_COLOR
REFUSED	-1	CHILD_EYE_COLOR
DON'T KNOW	-2	CHILD_EYE_COLOR
OTHER	-5

SOURCE

Sun Habits Survey (modified)

SE10100/(CHILD_NAT_HAIR_COLOR_OTH). SPECIFY: _____________________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

​Sun Habits Survey (modified)

SE11000/(CHILD_EYE_COLOR). What is the color of {C_FNAME/the child}’s eyes?

Label	Code	Go To
GREEN	1	CHILD_SKIN_COLOR
BLUE	2	CHILD_SKIN_COLOR
HAZEL	3	CHILD_SKIN_COLOR
BROWN	4	CHILD_SKIN_COLOR
BLACK	5	CHILD_SKIN_COLOR
OTHER	-5
REFUSED	-1	CHILD_SKIN_COLOR
DON'T KNOW	-2	CHILD_SKIN_COLOR

SOURCE

Sun Habits Survey (modified)

SE12000/(CHILD_EYE_COLOR_OTH). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

Sun Habits Survey (modified)

SE13000/(CHILD_SKIN_COLOR). What is the color of {C_FNAME/the child}’s untanned skin?

Label	Code	Go To
Very fair	1	TAN_30MIN_SUN
Fair	2	TAN_30MIN_SUN
Olive	3	TAN_30MIN_SUN
Dark	4	TAN_30MIN_SUN
Very dark	5	TAN_30MIN_SUN
OTHER	-5
REFUSED	-1	TAN_30MIN_SUN
DON'T KNOW	-2	TAN_30MIN_SUN

SOURCE

Sun Habits Survey (modified)

SE14000/(CHILD_SKIN_COLOR_OTH). SPECIFY: _____________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

Sun Habits Survey (modified)

SE15000/(TAN_30MIN_SUN). After being in direct sunlight for more than 30 minutes, does {C_FNAME/the child} get: 

Label	Code	Go To
A severe burn with blistering	1
A severe burn without blistering	2
A mild burn, but then tan or darken	3
Tanned easily	4
Tanned slowly	5
IS NEVER IN DIRECT SUNLIGHT FOR MORE THAN 30 MINUTES	-7
REFUSED	-1
DON'T KNOW	-2

SOURCE

Sun Habits Survey (modified)

SE16000/(EVER_SUNBURN). Has {C_FNAME/the child} ever had a sunburn?

Label	Code	Go To
YES	1
NO	2	TIME_STAMP_SE_ET
REFUSED	-1	TIME_STAMP_SE_ET
DON'T KNOW	-2	TIME_STAMP_SE_ET

SOURCE

Sun Habits Survey (modified)

SE17000/(NUM_SUNBURNS_PREV_SUMMER). How many times last summer did {C_FNAME/the child} get a sunburn?

Label	Code	Go To
NONE	0
ONE	1
TWO	2
THREE	3
FOUR	4
FIVE OR MORE	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Sun Habits Survey

(TIME_STAMP_SE_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 8 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 (0925-0593*).  Do not return the completed form to this address.