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Attachment I.1: The Child Assessment Direct Child Assessment Baseline
If you require information to be presented in an accessible format or reasonable accommodations to
participate in this study, please contact us with any specific requests by calling XXX-XXX-XXXX or
emailing XXXX@XXXX.XXX. If you require language assistance to participate in this study, please contact us
with any specific language assistance requests or needs.
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and Urban Development’s Community Choice Demonstration. Public reporting burden for this collection
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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.
8-17 Years)
Child-Reported Behavioral, Educational, and Social Functioning (Age
……………………………………………………………………………………1
Module B.
Child-Reported Health, Diet, and Nutrition (Age 10-17 Years)………..76
ii
Module A. Child-Reported Behavioral, Educational, and
Social Functioning (Age 8-17 Years)
I have some questions for you so I can learn a little about you and your life. These questions will include things
about school, friends, your health, social media habits, and more. If you don’t know how to answer one of the
questions, please just give me your best guess. You can choose to skip any questions you don’t want to answer, and
we can stop at any time. None of the choices for these questions are wrong. Do you have any questions for me
before we get started?
First, we are going to ask you some questions about your school and relationships. We know that sometimes kids
do not like to talk about school very much. Please remember you can choose not to answer a question. We can also
pause the interview for a bit if you need to.
A.1 Please rate how much you agree or disagree with the following statements.
[Fragile Families, The Panel Study of Income Dynamics, Child Development Supplement; Responses to
A.4a-c summed into a composite score; Johns Hopkins questions. Note: For children ages 2-9, parents report
on a version of these questions.]
Strongly
disagree Disagree
Neither
agree nor
disagree
Agree
Strongly
agree
Don’t
know
Prefer
not to
answer
a.
You feel close to people at school
☐
☐
☐
☐
☐
☐
☐
b.
You feel like a part of the school
☐
☐
☐
☐
☐
☐
☐
c.
You are happy to be at school
☐
☐
☐
☐
☐
☐
☐
Now I am going to ask about your friendships.
A.2 [ASK IF CHILD IS 10+ YEARS OLD] Please let me know if the following describe all, most, some, or none
of your friendships.
[Source: New question, wording needs to be tested – based on Murayama et al. (2013); Johns Hopkins
questions.]
a.
b.
c.
My friends live in the
neighborhood
[ASK IF CHILD IS 12+
YEARS OLD] My friends’
parents have graduated
from college
My friends are different
racial or ethnic groups
than me
All
Most
Some
None
Don’t know
Prefer not to
answer
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
[Source: NHIS Teen Survey https://www.cdc.gov/nchs/nhis/teen.htm; Johns Hopkins questions]
d. How much can you rely on your friends for help if you have a serious problem? Would you say:
1
☐ A lot
☐ Some
☐ A little
☐ Not at all
☐ Don’t Know
☐ Prefer not to answer
e. How much can you open up to your friends if you need to talk about your worries?
☐ A lot
☐ Some
☐ A little
☐ Not at all
☐ Don’t Know
☐ Prefer not to answer
We want to know about your thoughts and possible plans for the future. If you haven’t thought about this yet, that’s
okay. We just want to know what you think at this time.
A.3 [ASK IF CHILD AGE 10+ YEARS OLD] How likely do you think it is that you will do each of the following
things? [If you have already graduated high school, answer “Definitely will”]
[Source: NIDA Monitoring the Future (2020), Johns Hopkins questions]
a.
Graduate high school…
b.
Go to a technical or vocational school
after high school…
Graduate from a two-year college
program…
Graduate from college (four-year
program) ...
c.
d.
Definitely
won’t
Probably
won’t
Probably
will
Definitely
will
DK
Prefer not
to answer
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Now we are going to ask some questions about your use of electronic devices and social media
A.4 [ASK IF CHILD AGE 10+ YEARS OLD] On an average school day, how many hours do you 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, Johns Hopkins question]
☐ I do not use screens on school days
☐ Less than 1 hour per day
☐ 1 hour per day
☐ 2 hours per day
2
☐ 3 hours per day
☐ 4 hours per day
☐ 5 or more hours per day
☐ Don’t know
☐ Prefer not to answer
A.5 [ASK IF CHILD AGE 10+ YEARS OLD] About how often do you use social media? [INTERVIEWER
INSTRUCTION: By social media, we mean TikTok, Instagram, YouTube, Facebook, Twitter, Tumblr, Snapchat,
Reddit, Twitch, Threads, and the like].
[Source: 2022 Pew Research Center’s Teens Survey, Johns Hopkins question]
☐ Almost constantly
☐ Several times a day
☐ About once a day
☐ Several times a week
☐ Once a week or less often
☐ Never
☐ Don’t know
☐ Prefer not to answer
A.6 [ASK IF CHILD AGE 10+ YEARS OLD] Overall, would you say the amount of time you spend on social
media is...
[Source: 2022 Pew Research Center’s Teens Survey, Johns Hopkins question]
☐ Too much
☐ Too little
☐ About right
☐ I do not use social media
☐ Don’t know
☐ Prefer not to answer
A.7 [ASK IF CHILD AGE 10+ YEARS] The next set of questions asks about how you are currently feeling about
several aspects of your 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), A7a-d wording from questions on nationally
representative survey allowing for direct comparison with national norms]
a.
b.
Your safety at school?
Your educational
experiences?
Completely
satisfied
Very
satisfied
Slightly
satisfied Neutral
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
3
Slightly
Very
Completely DK Prefer not to
dissatisfied dissatisfied dissatisfied
answer
c.
d.
Completely
satisfied
Very
satisfied
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Your safety in your
neighborhood?
Your friends and other
people you spend time
with?
Slightly
satisfied Neutral
Slightly
Very
Completely DK Prefer not to
dissatisfied dissatisfied dissatisfied
answer
A.8 I will now read a list of sentences that describe how people feel. 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
you.
[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 Somewhat True
Hardly Ever or Sometimes
Very True or
True
True
Very Often True
NA
Don’t
know
Prefer
not to
Answer
a.
I get really frightened for no reason at all
☐
☐
☐
☐
☐
☐
b.
[IF AGE 10+ YEARS OLD] I am afraid to be alone
in the house
☐
☐
☐
☐
☐
☐
c.
People tell me that I worry too much
☐
☐
☐
☐
☐
☐
d.
I am shy
☐
☐
☐
☐
☐
☐
e.
I am scared to go to school
☐
☐
☐
☐
☐
☐
Now we would like to ask you some questions about how safe you think your neighborhood is.
A.9 [ASK IF CHILD AGE 8+ YEARS OLD] How safe do you feel on the streets near your home during the day?
[Source: MTO Interim Evaluation, Johns Hopkins question]
☐ Very safe
☐ Safe
☐ Unsafe
☐ Very unsafe
☐ Don’t know
☐ Prefer not to answer
A.10 [ASK IF CHILD AGE 10+ YEARS OLD] How safe do you feel on the streets near your home at night?
[Source: MTO Interim Evaluation, Johns Hopkins question]
☐ Very safe
☐ Safe
☐ Unsafe
4
☐ Very unsafe
☐ Don’t know
☐ Prefer not to answer
Please remember that we will not share your answers with your parents or anyone else. You can choose not to
answer a question.
A.11 [ASK IF CHILD AGE 12+ YEARS OLD] Have you seen people using or selling illegal drugs in your
neighborhood during the past 30 days?
[Source: MTO Interim Evaluation, Johns Hopkins question]
☐ Yes
☐ No
☐ Don’t know
☐ Prefer not to answer
A.12 [ASK IF CHILD AGE 10+ YEARS OLD]
[Source: NHIS Teen Survey, Johns Hopkins questions]
Next I would like to ask you about how other people treat you.
a. During the past 12 months, how often were you bullied, picked on, or excluded by other children
or teenagers?
☐ Never in the past 12 months
☐ 1-2 times in the past 12 months
☐ 1-2 times per month
☐ 1-2 times per week
☐ Almost every day
☐ Don’t know
☐ Prefer not to answer
b.
During the past 12 months, have you ever been electronically bullied? Count being bullied through
texting, Instagram, Snapchat, Facebook, or other social media.
☐ Yes
☐ No
☐ Don’t know
☐ Prefer not to answer
A.13 [ASK IF CHILD AGE 12+ YEARS] In your day-to-day life, how often have any of the following things
happened to you?
[Source: Everyday Discrimination Scale, Short Form, Johns Hopkins question]
5
a.
b.
c.
You are treated with less courtesy or
respect than other people your age
You receive poorer service than other
people your age at restaurants or
stores
People act as if they think you are not
smart
Don’t
know
A few times
a month
Less
than
once a
year
Never
A few
times a
year
Prefer
not to
answer
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Almost
every day
At least
once a
week
☐
d.
People act as if they are afraid of you
☐
☐
☐
☐
☐
☐
☐
☐
e.
You are threatened or harassed
☐
☐
☐
☐
☐
☐
☐
☐
A.14 [ASK IF CHILD 12+ & ANSWERED “A FEW TIMES A YEAR” OR MORE FREQUENTLY TO AT
LEAST ONE OF THE ABOVE] What do you think is the main reason for these experiences? (Interviewer
instruction: Check more than one if volunteered. This question is asked only once and not for each type of
discrimination reported in A.13)
[Source: Everyday Discrimination Scale, Short Form; Johns Hopkins question]
☐ Your ancestry or national origins
☐ Your gendersex
☐ Your race
☐ Your age
☐ Your religion
☐ Your height
☐ Your weight
☐ Some other aspect of your physical appearance
☐ Your sexual orientation
☐ The amount of money your family has
☐ Other (Specify): ______________________________
☐ Don’t know
☐ Prefer not to answer
6
Module B. Child-Reported Health, Diet, and Nutrition (Age
10-17 Years)
Now we would like to talk about your health, diet, and physical activity.
B.0 [ASK IF CHILD AGE 10+ YEARS OLD] During the school year, about how many times a week do you
usually get breakfast at school?
[Source: CDC National Health and Nutrition Examination Survey, 2017-2020 (NHANES), Johns Hopkins
question]
☐ [ENTER NUMBER OF TIMES] _____
☐ None
☐ Don’t know
☐ Prefer not to answer
B.1 [ASK IF CHILD AGE 10+ YEARS OLD] During the school year, about how many times a week do you
usually get lunch at school?
[Source: CDC National Health and Nutrition Examination Survey, 2017-2020 (NHANES), Johns Hopkins
question]
☐ [ENTER NUMBER OF TIMES] _____
☐ None
☐ Don’t know
☐ Prefer not to answer
7
B.2 [ASK IF CHILD AGE 10+ YEARS OLD] In the past month please indicate your response for each beverage type you drink.
-Indicate how often you drank the following beverages, for example, if you drank 5 glasses of water per week, respond with 4-6 times per week for
"HOW OFTEN"
-Indicate the approximate amount of beverage you drank each time, for example, if you 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.
[Source: Beverage Intake Questionnaire (BEVQ), Johns Hopkins question]
Type of Beverage
How often?
Never
or less
than 1
time per
week
1 time
per
week
2-3
times
per
week
4-5
times
per
week
How much?
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.)
1½
cups (12
fl. oz.)
2 cups
(16 fl.
oz.)
2½
cups (20
fl. oz.)
Don’t
know
Prefer
not to
answer
a.
Water
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
b.
100% Fruit Juice
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
c.
Whole Milk
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
d.
Reduced Fat Milk
(2%)
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
e.
Low Fat/Fat Free
Milk (Skim, 1%,
Buttermilk, Soymilk)
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Soft drinks
(Interviewer
instruction if needed:
Coca-Cola or Pepsi)
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
f.
8
g.
h.
i.
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.
9
B.3 [ASK IF CHILD AGE 10+ YEARS OLD] Next, I'm going to ask you about meals. By meal, I mean
breakfast, lunch, and dinner. During the past 7 days, how many meals did you 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 (NHANES), Johns
Hopkins question]
☐ [ENTER NUMBER OF MEALS 1-21]
☐ None
☐ More than 21 meals per week
☐ Don’t know
☐ Prefer not to answer
B.4 [ASK IF CHILD AGE 10+ YEARS OLD; SKIP IF B.4 IS NOT “None”, “Prefer not to answer”, or
“Don’t Know”, ASK] How many of those meals did you get from a fast-food or pizza place?
[Source: CDC National Health and Nutrition Examination Survey, 2017-2020 (NHANES), Johns
Hopkins question]
☐ [ENTER NUMBER OF MEALS 1-21]
☐ None
☐ More than 21 meals per week
☐ Don’t know
☐ Prefer not to answer
B.5 [ASK IF CHILD AGE 10+ YEARS OLD] During the past 7 days, on how many days were you
physically active for a total of at least 60 minutes per day? (Add up all the time you spent in any kind of
physical activity that increased your heart rate and made you breathe hard some of the time.)
[Source: CDC Youth Risk Behavior Survey (YRBS) - 2023, validated national survey question, Johns
Hopkins question]
☐ [ENTER NUMBER OF DAYS] _____
☐ None
☐ Don’t know
☐ Prefer not to answer
B.6 [ASK IF CHILD AGE 10+ YEARS OLD] During the past 12 months, on how many sports teams did
you play? (Count any teams run by your 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
10
☐ 3 or more teams
☐ Don’t know
☐ Prefer not to answer
Now I am going to ask a few questions about how you feel about your body. Please remember that we will
not share this information with your parents or anyone else. You can choose not to answer any question.
B.7 [ASK IF CHILD IS 12+] Please tell me on a scale of 1 to 10, where 1 is “Extremely Unsatisfied” and
10 is “Extremely Satisfied” how you rate the following questions.
[Source: Neumark-Sztainer et al. (2006), Johns Hopkins question]
Question
Satisfaction
1
2
3
4
5
6
7
8
9
Extremely
Unsatisfied
10
DK
Extremely
Satisfied
a. How satisfied are
you with your weight?
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
b. How satisfied are
you with your body
shape?
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Prefer not
to answer
B.8 [ASK IF CHILD AGE 12+ YEARS OLD] How often have you gone on a diet in the past year?
[Source: Neumark-Sztainer et al. (2006), Johns Hopkins question]
☐ Never
☐ One to four times
☐ Five to ten times
☐ More than ten times
☐ I am always dieting
☐ Don’t know
☐ Prefer not to answer
B.9 [ASK IF CHILD AGE 12+ YEARS OLD] Have you done any of the following things in order to lose
weight or keep from gaining weight during the past year including fasting, ate very little food, took diet
pills, made yourself vomit, used laxatives, used diuretics (water pills), used food substitute (powder or
special drinks), skipped meals, or smoked more cigarettes?
[Source: EAT Gen2 Adolescent Study, Johns Hopkins question]
☐ Yes
☐ No
☐ Don’t know
☐ Prefer not to answer
11
B.10 [ASK IF CHILD AGE 12+ YEARS OLD] In the past year, have you ever eaten so much food in
a short period of time that you would be embarrassed if others saw you (binge-eating)?
[Source: EAT Gen2 Preadolescent Survey; Johns Hopkins question]
☐ Yes
☐ No
☐ Don’t know
☐ Prefer not to answer
B.11 [IF YES TO B.10 AND CHILD AGE 12+ YEARS OLD] During the times when you ate this
way, did you feel like you couldn’t stop eating or control what or how much you were eating?
☐ Yes
☐ No
☐ Don’t know
☐ Prefer not to answer
[IF CHILD AGE 12+ YEARS OLD] [INTERVIEWER INSTRUCTIONS: Hand the child the tablet to
complete questions B.13 through B.17]
B.12 The following questions are about how you feel. Over the last 2 weeks, how often have you been
bothered by the following problems:
[Source: Patient Health Questionnaire-2; questions B12a and B12b are summed into a composite
score; Johns Hopkins questions]
More than
Nearly
Not at all Several days half of days every day
Don’t
Know
Prefer not
to answer
a.
Little interest or pleasure in doing things
☐
☐
☐
☐
☐
☐
b.
Feeling down, depressed, or hopeless
☐
☐
☐
☐
☐
☐
Now we are going to ask a question about smoking. I want to remind you that we will not tell your
parent/guardian your answers to any questions.
B.13 [ASK IF CHILD AGE 12+ YEARS OLD] Have you ever tried cigarette smoking, vaping, or
other tobacco products (such as e-cigarettes, cigars, cigarillos, little cigars, or chewing tobacco)? Ecigarettes are battery powered devices that usually contain a nicotine-based liquid that is vaporized and
inhaled. You may also know them as e-cigs, vape-pens, e-hookahs, or mods.
[Source: EAT Gen2 Adolescent Survey, Johns Hopkins question]
☐ Yes
☐ No
☐ Don’t know
12
☐ Prefer not to answer
B.14 [ASK IF CHILD AGE 12+ YEARS OLD AND B.13=YES] During the past 30 days, on how
many days did you smoke cigarettes, vape, or use other tobacco products?
[Source: EAT Gen2 Adolescent Survey; Johns Hopkins question]
☐ 0 days
☐ 1 or 2 days
☐ 3 to 5 days
☐ 6 to 9 days
☐ 10 to 19 days
☐ 20 to 29 days
☐ All 30 days
☐ Don’t know
☐ Prefer not to answer
Lastly, we are going to ask questions about how you describe yourself.
B.15
[ASK IF CHILD AGE 12+ YEARS OLD] Are you (select all that apply):
[Source: National Center for Health Statistics, Johns Hopkins question]
☐ Male
☐ Female
☐ Transgender, non-binary, or another gender
☐ Don’t know
☐ Prefer not to answer
B.16
[ASK IF CHILD IS AGE 12+ YEARS OLD] Which of the following best describes you?
[Source: CDC Youth Risk Behavior Survey (YRBS) – 2023, Johns Hopkins question]
☐ Heterosexual (straight)
☐ Gay or lesbian
☐ Bisexual
☐ I describe my sexual identity some other way
☐ I am not sure about my sexual identity (questioning)
☐ I do not know what this question is asking
☐ Prefer not to answer
That is all the questions we have at this time. Thank you very much for taking the time to talk with us
today.
13
| File Type | application/pdf |
| File Title | Microsoft Word - Redline.Attachment I.1_The Child Assessment_Direct Child Assessment_Baseline.docx |
| Author | H03483 |
| File Modified | 2025-05-19 |
| File Created | 2025-05-19 |