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Project Viva (CQ12-F)
05/10/2012
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EARLY TEEN QUESTIONNAIRE
Thank you for continuing to help us learn how kids and teenagers grow up! This year’s survey is a little
bit longer than last year’s, but has a lot of the same questions you have seen before. Just like last year,
please read each question, mark your answers, and return the survey to us. Remember, you don’t
have to answer any question that you don’t want to.
SECTION A. QUESTIONS ABOUT YOUR EATING HABITS A.1. How many days per week (including weekdays and weekends) do you eat breakfast?
1 Less than 1 day per week 4 5 or 6 days per week
2 1 or 2 days per week 5 Every day
3 3 or 4 days per week
A.2. Where do you get your lunch on a school day? (Please check all that apply.)
A Bring from home D Get from a store or food truck
B Get from school cafeteria E Get from a vending machine
C Get from a fast food restaurant F I don’t eat lunch on school days
A.3. How many days per week do you eat supper or dinner together with family members (“family
dinner”)?
1 Less than 1 day per week 4 5 or 6 days per week
2 1 or 2 days per week 5 Every day
3 3 or 4 days per week
V. 1 SA 2 IA
Project Viva (CQ12-F)
05/10/2012
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A.4. How often do you eat supper or dinner while watching TV?
A.5. How often do you eat a snack while watching TV?
1 Less than 1 day per week 4 5 or 6 days per week
2 1 or 2 days per week 5 Every day
3 3 or 4 days per week
A.6. How often do you eat something from a fast food restaurant (like Burger King, McDonald’s,
Dunkin’ Donuts, Taco Bell, or a pizza place)?
1 Less than 1 day per week 4 5 or 6 days per week
2 1 or 2 days per week 5 Every day
3 3 or 4 days per week
A.7. How often do you eat something from any other restaurant?
1 Less than 1 day per week 4 5 or 6 days per week
2 1 or 2 days per week 5 Every day
3 3 or 4 days per week
A.8. In the past 12 months, have you ever eaten so much food in a short period of time that you would
be embarrassed if others saw you?
1 Yes (Go to A.8.a)
2 No (Go to A.9.)
1 Less than 1 day per week 4 5 or 6 days per week
2 1 or 2 days per week 5 Every day
3 3 or 4 days per week
a) During the times when you ate this way, did
you feel out of control, like you couldn’t stop
eating even if you wanted to stop?
1 Yes
2 No
Project Viva (CQ12-F)
05/10/2012
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A.9. Imagine you are eating a meal or snack at home or at a restaurant. Imagine that you have
eaten enough so you are no longer hungry. How often would you keep eating?
1 Never 2 Rarely 3 Sometimes 4 Often 5 Always
A.10. Imagine you ate a meal or snack a little while ago and are not hungry anymore. How often
would you start eating again?
SECTION B. QUESTIONS ABOUT WHAT YOU DRINK AND EAT
B.1. In the past month, how often did you
drink a can, bottle, or glass of …
Less than
once per
week
Once
per
week
2-4 times
per week
Nearly
daily or
daily
Twice or
more per
day
a. Soda, such as Coke, Pepsi or Sprite? 1 2 3 4 5
b. Diet soda, such as Diet Coke, Diet
Pepsi or Sprite Zero? 1 2 3 4 5
c. Sports drink, such as Gatorade or
PowerAde? 1 2 3 4 5
d. Low-calorie sports drink, such as
Propel or G2? 1 2 3 4 5
e. Energy drink, such as Red Bull or Jolt? 1 2 3 4 5
f. 100% fruit juice, such as orange juice,
apple juice, or grape juice? 1 2 3 4 5
g. Fruit drinks, lemonade, Snapple, Sunny
Delight, sweetened tea or coffee
drinks? 1 2 3 4 5
h. White milk? 1 2 3 4 5
i. Chocolate or other flavored milk? 1 2 3 4 5
j. Plain water? (Tap and bottled) 1 2 3 4 5
1 Never 2 Rarely 3 Sometimes 4 Often 5 Always
Project Viva (CQ12-F)
05/10/2012
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For each question below, mark how often you have eaten the food or foods during the past month.
Remember to include things you eat at home and at school. Not all of the foods you eat are listed in the
questions below.
B.2. Dark Green Leafy Vegetables (like spinach,
romaine lettuce, kale, turnip greens, bok
choy)
1 Less than once per week
2 Once per week
3 2-4 times per week
4 Nearly daily or daily
5 Twice or more per day
B.7. Other Fruits (like fresh apples or pears,
bananas, berries, grapes, melons)
1 Less than once per week
2 Once per week
3 2-4 times per week
4 Nearly daily or daily
5 Twice or more per day
B.3. Broccoli, Cauliflower, Cabbage, Brussel
Sprouts
1 Less than once per week
2 Once per week
3 2-4 times per week
4 Nearly daily or daily
5 Twice or more per day
B.8. Whole Milk Dairy Foods (whole milk, hard
cheese, butter, ice cream)
1 Less than once per week
2 Once per week
3 2-4 times per week
4 Nearly daily or daily
5 Twice or more per day
B.4. Carrots
1 Less than once per week
2 Once per week
3 2-4 times per week
4 Nearly daily or daily
5 Twice or more per day
B.9. Low-fat Milk Products (like low-fat/skim
milk, yogurt, cottage cheese)
1 Less than once per week
2 Once per week
3 2-4 times per week
4 Nearly daily or daily
5 Twice or more per day
B.5. Other Vegetables (like peas, corn, green
beans, tomatoes, squash)
1 Less than once per week
2 Once per week
3 2-4 times per week
4 Nearly daily or daily
5 Twice or more per day
B.10. Whole eggs
1 Less than once per week
2 Once per week
3 2-4 times per week
4 Nearly daily or daily
5 Twice or more per day
B.6. Citrus Fruits (like oranges, grapefruits, orange
juice or grapefruit juice,)
1 Less than once per week
2 Once per week
3 2-4 times per week
4 Nearly daily or daily
5 Twice or more per day
B.11. Margarine (stick-type not tub)
1 Less than once per week
2 Once per week
3 2-4 times per week
4 Nearly daily or daily
5 Twice or more per day
Project Viva (CQ12-F)
05/10/2012
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Remember to answer how often you have eaten the food or foods listed in the past month.
B.12. Whole Grain Foods (like whole grain breads,
brown rice, whole wheat pasta)
1 Less than once per week
2 Once per week
3 2-4 times per week
4 Nearly daily or daily
5 Twice or more per day
B.16. Processed Meats (sausages, salami,
bologna, hot dogs, bacon)
1 Less than once per week
2 Once per week
3 2-4 times per week
4 Nearly daily or daily
5 Twice or more per day
B.13. Pasta, Rice, Noodles
1 Less than once per week
2 Once per week
3 2-4 times per week
4 Nearly daily or daily
5 Twice or more per day
B.17. Fish/Seafood (not fried, but broiled,
baked, poached, canned)
1 Less than once per week
2 Once per week
3 2-4 times per week
4 Nearly daily or daily
5 Twice or more per day
B.14. Baked Products (donuts, cookies,
muffins, crackers, cakes, sweet rolls,
pastries)
1 Less than once per week
2 Once per week
3 2-4 times per week
4 Nearly daily or daily
5 Twice or more per day
B.18. Deep Fried Foods (deep fried chicken,
fish or seafood; French fries, onion rings)
1 Less than once per week
2 Once per week
3 2-4 times per week
4 Nearly daily or daily
5 Twice or more per day
B.15. Beef, Pork or Lamb as Main Dish
1 Less than once per week
2 Once per week
3 2-4 times per week
4 Nearly daily or daily
5 Twice or more per day
B.19. How often do you add salt to food at the
table?
1 Less than once per week
2 Once per week
3 2-4 times per week
4 Nearly daily or daily
5 Twice or more per day
B. 20 Do you currently take a multivitamin?
1 Yes (Go to B.20.a)
2 No (Go to Section C.)
a. How many days per week?
______ days per week
Project Viva (CQ12-F)
05/10/2012
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SECTION C. QUESTIONS ABOUT HOW YOU FEEL C.1. In the past year, how often do you:
a. Feel hopeful about the future
b. Notice you didn’t have as much energy as you usually do
c. Feel “down in the dumps” or depressed
d. Feel worthless
e. Have trouble concentrating
f. Have trouble enjoying activities you usually enjoy
If you are having these problems, please talk to a parent, teacher or other trusted adult.
SECTION D. QUESTIONS ABOUT YOUR PERSONALITY
For each item, mark whether it is “Not True”, “Somewhat True”, or “Certainly True” for you.
D.1. Not True Somewhat
True
Certainly
True
a. I try to be nice to other people. I care about
their feelings. 1 2 3
b. I am restless. I cannot sit still for long. 1 2 3
c. I get a lot of headaches, stomach aches
or sickness. 1 2 3
d. I usually share with others, for example, music,
games or food. 1 2 3
e. I get very angry and often lose my temper. 1 2 3
f. I would rather be alone than with people of my
own age. 1 2 3
g. I usually do as I am told. 1 2 3
1 Never 2 Rarely 3 Sometimes 4 Often 5 Always
1 Never 2 Rarely 3 Sometimes 4 Often 5 Always
1 Never 2 Rarely 3 Sometimes 4 Often 5 Always
1 Never 2 Rarely 3 Sometimes 4 Often 5 Always
1 Never 2 Rarely 3 Sometimes 4 Often 5 Always
1 Never 2 Rarely 3 Sometimes 4 Often 5 Always
Project Viva (CQ12-F)
05-10-2012
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Remember, for each item, mark whether it is “Not True”, “Somewhat True”, or “Certainly True” for you.
D.3. Not True Somewhat
True
Certainly
True
a. I am kind to younger children. 1 2 3
b. I am often accused of lying or cheating. 1 2 3
c. Other children or young people pick on me or
bully me. 1 2 3
d. I often offer to help others (parents,
teachers, children). 1 2 3
e. I think before I do things. 1 2 3
f. I take things that are not mine from home, school
or elsewhere. 1 2 3
g. I get along better with adults than with people my
own age. 1 2 3
h. I have many fears; I am easily scared. 1 2 3
i. I finish the work I am doing. My attention is good. 1 2 3
D.2. Not True Somewhat
True
Certainly
True
a. I worry a lot. 1 2 3
b. I am helpful if someone is hurt, upset or feeling ill. 1 2 3
c. I am constantly fidgeting or squirming. 1 2 3
d. I have one good friend or more. 1 2 3
e. I fight a lot. I can make other people do what
I want. 1 2 3
f. I am often unhappy, depressed, or tearful. 1 2 3
g. Other people my age generally like me. 1 2 3
h. I am easily distracted; I find it difficult
to concentrate. 1 2 3
i. I am nervous in new situations. I easily
lose confidence. 1 2 3
Project Viva (CQ12-F)
05-10-2012
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SECTION E. QUESTIONS ABOUT YOUR BODY Remember, there are no right or wrong answers. We just want to know what you think.
E.1. Are you currently:
1 Not trying to do anything about your weight 3 Trying to stay the same weight
2 Trying to gain weight 4 Trying to lose weight
E.2. In the past year, how happy have you been with the way your body looks?
1 Totally 2 Pretty Much 3 A Little 4 Not at all
E.3. In the past year, have you done any of the following things to lose weight or keep from gaining
weight?
a. Exercise more 1Yes 2 No e. Go on a diet 1Yes 2 No
b. Eat more fruits or vegetables 1Yes 2 No f. Skip a meal 1Yes 2 No
c. Not eat for a day or more 1Yes 2 No g. Eat fewer sweets 1Yes 2 No
d. Eat smaller portions 1Yes 2 No h. Anything else 1Yes 2 No
h.1. If yes, please tell us what:___________________
E.4.
Girls go through normal changes as they get
older. Please LOOK at the drawings and READ
the sentences below each of them. Then
choose the drawing closest to your stage of
hair development.
Stage 1 Stage 2 Stage 3 Stage 4 Stage 5
THIS IS KINDA
EMBARRASSING!
There is no
There is no
pubic hair.
There is a little,
long, lightly
colored hair.
The hair may be
straight or a little
curly.
The hair is darker,
coarser, and
more curled.
It has spread out
and thinly covers
a larger area.
The hair is now as
dark, curly, and
coarse as that of a
grown woman.
The hair has not
spread out to the
legs.
The hair is now like
that of a grown
woman.
The hair often
forms a triangle
(▼) as it spreads
out to the legs.
Project Viva (CQ12-F)
05-10-2012
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SECTION F. QUESTIONS ABOUT FAMILY AND FRIENDS F.1. Do your parents know what you do during your free time?
F.2. Do your parents know the friends you hang out with during your free time?
My parents…
1 Know none of my friends
2 Know a couple of my friends
3 Know most of my friends
4 Know all of my friends
F.3. In the past year, how often have the following people made a comment about your weight…
Never Rarely Sometimes Often Always
a. Your teacher or coach? 1 2 3 4 5
b. Boys? 1 2 3 4 5
c. Other girls? 1 2 3 4 5
Never Rarely Sometimes Often Always
Doesn’t
apply to me
d. Your brother(s) or sister(s)? 1 2 3 4 5 9
e. Your father? 1 2 3 4 5 9
f. Your mother? 1 2 3 4 5 9
F.4. How often do other kids …
a. Pick on you?
b. Say mean things to you in person?
c. Say mean things to you online or by text message?
d. Say bad things about you to other kids in person?
e. Say bad things about you to other kids online or by text message?
f. Punch, kick or shove you?
g. Wreck your things?
If you are having these problems, please talk to a parent, teacher or other trusted adult.
1 Never 2 Rarely 3 Sometimes 4 Often 5 Always
1 Never 2 Rarely 3 Sometimes 4 Often 5 Always
1 Never 2 Rarely 3 Sometimes 4 Often 5 Always
1 Never 2 Rarely 3 Sometimes 4 Often 5 Always
1 Never 2 Rarely 3 Sometimes 4 Often 5 Always
1 Never 2 Rarely 3 Sometimes 4 Often 5 Always
1 Never 2 Rarely 3 Sometimes 4 Often 5 Always
1 Never 2 Rarely 3 Sometimes 4 Often 5 Always
Project Viva (CQ12-F)
05-10-2012
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SECTION G. QUESTIONS ABOUT SLEEPING
G.1. Imagine: School is canceled! You can get up whenever you want to. When would you get out of
bed? Between…
G.2. Is it easy for you to get up in the morning?
G.3. When do you have the most energy to do your favorite things?
G.4. When does your body start to tell you it’s time to go to bed (even if you ignore it)? Between…
G.5. Guess what? Your parents have decided to let you set your own bedtime. What time would you
pick? Between…
G.6. How often are you tired and grumpy during the day?
G.7. Are you usually alert most of the day?
1 5:00 and 6:30 am 4 9:45 and 11:00 am
2 6:30 and 7:45 am 5 After 11:00 am
3 7:45 and 9:45 am
1 No way! 3 Pretty easy
2 Sort of 4 It’s a cinch
1 Morning! I’m tired in the evening 3 Evening more than morning
2 Morning more than evening 4 Evening! I’m tired in the morning
1 8:00 and 9:00 pm 4 12:30 and 1:45 am
2 9:00 and 10:15 pm 5 1:45 and 3:00 am
3 10:15 pm and 12:30 am
1 8:00 and 9:00 pm 4 12:30 and 1:45 am
2 9:00 and 10:15 pm 5 1:45 and 3:00 am
3 10:15 pm and 12:30 am
1 Never 2 Rarely 3 Sometimes 4 Often 5 Always
1 Never 2 Rarely 3 Sometimes 4 Often 5 Always
Project Viva (CQ12-F)
05-10-2012
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G.8. How often do you…
a. Need someone to wake you up in the morning?
b. Fall back to sleep after being woken up in the morning?
c. Have trouble getting out of bed in the morning?
d. Think that you need more sleep?
e. Fall asleep or get drowsy during class periods?
f. Get sleepy or drowsy while doing your homework?
SECTION H. QUESTIONS ABOUT YOUR ACTIVITIES H.1. Have you ever tried or experimented with cigarette smoking, even a few puffs?
1 Yes (Go to H.1.a)
2 No (Go to H.2.)
H.2. Have you ever tried drinking alcohol (beer, wine or liquor), even a few sips?
1 Yes (Answer H.2.a)
2 No (Go to H.3)
1 Never 2 Rarely 3 Sometimes 4 Often 5 Always
1 Never 2 Rarely 3 Sometimes 4 Often 5 Always
1 Never 2 Rarely 3 Sometimes 4 Often 5 Always
1 Never 2 Rarely 3 Sometimes 4 Often 5 Always
1 Never 2 Rarely 3 Sometimes 4 Often 5 Always
1 Never 2 Rarely 3 Sometimes 4 Often 5 Always
a) On average, in the past year, how often did you drink beer, wine
or liquor?
1 Never in the past year 4 1-2 days per week
2 Less than once a month 5 3-5 days per week
3 Less than once a week 6 Almost every day or every day
a) On average, in the past year, how often did you smoke a
cigarette?
1 Never in the past year 4 1-2 days per week
2 Less than once a month 5 3-5 days per week
3 Less than once a week 6 Almost every day or
every day
Project Viva (CQ12-F)
05-10-2012
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H.3. What time does your school day usually start? ___ :___ ___ am
H.4. In school, how many days per week do you have gym or PE (phys ed)?
1 Less than 1 day per week 3 3 or 4 days per week
2 1 or 2 days per week 4 Every day
H.5. How many hours per day do you spend watching TV shows, not including DVDs or videos?
Include TV shows you watch on a TV, computer, or handheld device like an iPod, iPad, or iPhone.
(Check one box for school days and one for weekend days.)
a. a. On a school day?
1 None
2 Less than 1 hour a day
3 1 to less than 2 hours a day
4 2 or 3 hours a day
5 4, 5 or 6 hours a day
6 7 or more hours a day
b. On a weekend day?
1 None
2 Less than 1 hour a day
3 1 to less than 2 hours a day
4 2 or 3 hours a day
5 4, 5 or 6 hours a day
6 7 or more hours a day
Thank You!!!