Assessment of children's health and social needs for community

[Guest guest]

Assessment of children's health and social needs for community

programming

Introduction

This survey is part of a project for the Division of

Occupational Science at the University of North Carolina. The goal

is

to gain a better understanding of the needs of typically functioning

children and children with physical disabilities between the ages of

7

and 11 for community activity programs. The data collected will

contribute to the planning of a community program for children with

and without disabilities. Anonymity and confidentiality of

respondents will be maintained. If possible, please return the

survey

by February 18th. Thank you for your time.

Demographics

City and state of residence ________________________ Child's

age_____

Social Skills and Adjustment

1. Indicate (with X's) if your child has experienced any of the

following problems at school or in other social situations:

___Social isolation

___Physical bullying (pushing, hitting, etc.)

___Rejection/exclusion from peer groups

___Verbal bullying (threats, angry words, etc.)

___Teasing

___Not applicable

2. To your knowledge, has your child ever engaged in behavior that

resulted in the social isolation, rejection/exclusion, bullying, or

teasing of others?

___Yes ___No

3. Please indicate (with X's) if you have ever noticed your child

struggling with any of the following when interacting with other

children:

___Following social cues (knowing when the game is over, engaging in

pretend play, moving from one game/activity to another)

___Joining/leaving group play activities

___Working together with other children toward a common goal

___Compromising

___Engaging in positive peer interactions (laughing, joking, etc.)

___Taking turns with others, waiting for his or her turn

___Respecting others' property, space, and ideas

___Not applicable

4. Indicate if your child has ever experienced or expressed any of

the following either at school or in social situations:

___Low self-esteem ___Chronic sadness

___Negative self-image ___Anxiety

___Hopelessness ___Not applicable

5. Indicate if your child has ever been professionally diagnosed

with

any of the following:

___Anxiety disorder: separation anxiety disorder, generalized anxiety

disorder, social phobia/social anxiety disorder, or panic

attacks/panic disorder

___Depression: depressive or major depressive disorder

___Other psychiatric disorder

___Not applicable

Physical Activity

6. Indicate approximately how many hours per day your child engages

in physical activity.

___more than 1 hour ___less than 30 minutes

___30 minutes to 1 hour ___my child rarely plays outside

7. Do you feel that your child would benefit from increased physical

activity?

___Yes ___No

Community Programming

8. Select and rank the top 10 skills and issues you feel should be

emphasized in children's programs and activities outside of school.

1=most important, 10=least important

___Conflict resolution ___Confidence

___Teamwork ___Coping

___Sportsmanship ___Imagination

___Caring ___Problem solving

___Making friends ___Literacy

___Empathy ___Arts and crafts

___Acceptance ___Community service

___Tolerance ___Mental health

___Loyalty to friends ___Safety skills

___Understanding of emotions ___Motor skills

___Respect ___Sports skills

___Emotional regulation/control ___Physical health and physical

___Active listening activity

___Diversity ___Outdoor exploration and discovery

___Self-expression

___Other_________________________

9. Based on your experiences with your child, do you feel that

programs in community settings (outside of school and the home)

sufficiently address the skills and issues you selected above?

___Yes ___No

10. Do you feel that it is important for these skills and issues to

be addressed in settings outside of school and the home?

___Yes ___No

Diagnosis and Functioning

11. What is your child's diagnosis? Please describe the features

and

presentation of your child's condition (mobility impairments,

cognitive involvement, communication problems, etc.).

12. Indicate the types of equipment or other assistance your child

requires for daily functioning:

___Wheelchair ___Enteral feeding device

___ ___Intravenous drug therapy

___Communication device ___Transfer device

___Hearing aide ___Ventilator or other respiratory

equipment

___Other:_____________________

Activity Participation

13. Has your child ever been unable or unwilling to participate in

an

activity of interest because of his or her disability?

___Yes ___No

If so, describe why your child did not or could not participate.

Exposure to Typically Functioning Individuals

14. Indicate which of the following descriptions is most accurate

regarding your child's exposure to typically functioning individuals

in regular school or extracurricular situations:

My child has

___a great deal of exposure to typically functioning individuals

___some exposure to typically functioning individuals

___little exposure to typically functioning individuals

___no exposure to typically functioning individuals

15. Briefly describe an interaction your child has had with a

typically functioning individual or group of individuals. Was the

interaction a positive or negative experience for your child? How

did

the experience impact your child?

16. List some of the potential positive and negative results of

increased social interactions between your child and typically

functioning children.

Positive Results Negative Results

Thank you for your time. If you have any questions, you can email

them to cferry@... or call at 919-986-7861.