| Question | Answers | Source | Source Link | Dates Used | |
|---|---|---|---|---|---|
| 1 | What supports or services do you and your family currently use/access to assure your child(ren)'s physical health? | Open ended response | NA | 01/11/2023-01/18/2023 | |
| 2 | What additional supports or services would be helpful in assuring your child(ren)'s physical health? | Open ended response | NA | 01/11/2023-01/18/2023 | |
| 3 | Please select all of the options that apply to any of your child(ren). | • Has asthma • Has diabetes • Is prone to getting illnesses like colds • Has low energy overall • Is considered underweight for their age • Is considered overweight for their age • Gets physical activity most days • Can participate in the physical activities appropriate for their age • Sleeps well most nights • Eats a variety of foods | NA | 01/11/2023-01/18/2023 | |
| 4 | Currently, how often do you visit each of these places in a typical month? Public parks or playgrounds | • Never • Once per month or less • A few times per month • About once per week • More than once per week | NA | 01/11/2023-01/18/2023 | |
| 5 | Currently, how often do you visit each of these places in a typical month? Public open spaces or nature preserves | • Never • Once per month or less • A few times per month • About once per week • More than once per week | NA | 01/11/2023-01/18/2023 | |
| 6 | Currently, how often do you visit each of these places in a typical month? Other outdoor recreation sites (e.g., basketball court) | • Never • Once per month or less • A few times per month • About once per week • More than once per week | NA | 01/11/2023-01/18/2023 | |
| 7 | Currently, how often do you visit each of these places in a typical month? Not Listed (please specify) | • Never • Once per month or less • A few times per month • About once per week • More than once per week | NA | 01/11/2023-01/18/2023 | |
| 8 | Does the home you currently live in include access to a safe outdoor space (e.g., a lawn, patio) for your family? | • Yes • No • Not applicable | NA | 01/11/2023-01/18/2023 | |
| 9 | My family feels welcome at our local park. | • Strongly disagree • Disagree • Neutral • Agree • Strongly agree | NA | 01/11/2023-01/18/2023 | |
| 10 | Is it safe for your child(ren) to walk or bike alone in your area? | • Yes • No • Not applicable | NA | 01/11/2023-01/18/2023 |