EPICure@16participantQv3Feb2012
Office use only Study ID No
EPICure@16
Population based studies of survival and later health
status after extremely premature birth
CONFIDENTIAL
Participant questionnaire
In this questionnaire we would like to ask you questions about yourself, your family, your school and how
you feel about things in general.
Please answer ALL the questions in each section as honestly and accurately as possible.
All the information will be treated in the strictest confidence and will not be seen by
anyone outside the study. The questionnaire will also be destroyed when we have
finished with it.
If you have any queries about completing this questionnaire or would like any help, please do not hesitate
to contact Laura McCormack in theEPICure Office on 0203 108 2045 or by email on [email protected].
Thank you very much for your help
EPICure@16participantQv3Feb2012
Office use only Study ID No
How to complete this questionnaire
Please write in Black or Blueinkand place a tick or a crossinthe boxesas they appear in the
questionnaire.Where there is a continuous line under the questions, please write in CAPITALS.
To help you find your way through the questionnaire, some YES/NO questions are followed by an arrow
and the number of the question you need to answer next. The example below illustrates this.
EXAMPLE
Q3. Did you have breakfast this morning?
YES
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 Q4
NO
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 Q10
In this example, if you answer NO to question 3 (Q3) you would go straight to question 10 (Q10). If you answer yes
you would continue with question 4 (Q4).
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EPICure@16participantQv3Feb2012
A
Office use only Study ID No
Please tell us about yourself
In this section we ask a few questions about you, your current school and any exams you may have
taken. Please remember that the questionnaire is confidential and the answers you give will be seen
only by the EPICure Study Team.
A1. Your First Name
A2. Your date of Birth
Your Surname
DD
MM
YYYY
A3.What do you prefer to be called ?(if different from above)
A4.Are you still in school?
Yes
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A5. If not, when did you leave school?
No
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A6
MM
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A5
YYYY
A6. What is the name of your current/previous school?
A7. Have you sat any exams in the last 2 years?
Yes
No
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A8. What exams did you sit (e.g GCSE etc)?
A9. Please tell us the subjects you have taken and the grades you obtained
Exam type
Subject
3
Grade
EPICure@16participantQv3Feb2012
Office use only Study ID No
B
You and your family
In this section we ask you questions about your family, your relationship with your parents and your
brothers and sisters if you have any.
B1.In the past 7 days how many times have you eaten an evening meal together with the rest of your family
who live with you?
None
1-2 times
3-5 times
6-7 times
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B2.Do you feel supported by your family, that is the people who live with you?
I feel supported by my
family in most of all the
things I do
I feel supported by my
family in some of the
things I do
I do not feel supported
by my family in the
things I do
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B3.Suppose you felt upset or worried about something and you wanted to talk about it. Who would you turn
to first within your family? Please tick one box only.
Another
Mum or
Dad or
A brother or
Another
relative not
No-one
stepmum
stepdad
sister (or step- relative living living with
within my
brother/sister) with you
you
family
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B4.In the past month, how many times have you stayed out after 9.00pm at night without your parents knowing
where you were?
Never
1-2 times
3-9 times
10 or more times
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B5.Do you have any brothers or sisters living with you at home?
Yes
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B6
No
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B8
B6.How often do any of your brothers or sisters do any of the following to you at home?
Never
Not much(1-3 times
in last 6 months)
Quite a lot(more
than 4 times in the
last 6 months)
A lot (a few times
every week)
Hit, kick or push you
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Take your belongings
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Call you nasty names
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Make fun of you
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EPICure@16participantQv3Feb2012
B
Office use only Study ID No
You and your family (continued)
B7.How often do you do any of the following to your brothers or sisters at home?
Never
Not much (1-3 times
in last 6 months)
Quite a lot (more
than 4 times in the
last 6 months)
A lot(a few times
every week)
Hit, kick or push them
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Take their belongings
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Call them nasty names
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Make fun of them
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Please answer the following questions even if either of your parents live in a different house to you.
B8.Most children have occasional quarrels with their parents. How often do you quarrel with your mother?
Most days
More than once
a week
Less than once
a week
Hardly ever
Don’t have a
mother
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B9.How often do you quarrel with your father?
Most days
More than once
a week
Less than once
a week
Hardly ever
Don’t have a
father
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B10.How often do you talk to your mother, about things that matter to you?
Most days
More than once
a week
Less than once
a week
Hardly ever
Don’t have a
mother
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B11.How often do you talk to your father, about things that matter to you?
Most days
More than once
a week
Less than once
a week
Hardly ever
Don’t have a
father
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EPICure@16participantQv3Feb2012
Office use only Study ID No
C
Your feelings
In this section we ask how you feel about your life in general. The faces express various types of feelings. Below
each face is a number where ‘1’ is completely happy and ‘7’ is not at all happy. Please tick the box which comes
closest to expressing how you feel about each of the following things....
C1.Your school work?
1
2
3
4
5
6
7
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1
2
3
4
5
6
7
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1
2
3
4
5
6
7
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1
2
3
4
5
6
7
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1
2
3
4
5
6
7
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C2.Your appearance?
C3.Your family?
C4.Your friends?
C5. The school you go to?
C6. How do you feel about your life as a whole?
1
2
3
4
5
6
7
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EPICure@16participantQv3Feb2012
D
Office use only Study ID No
Your school and future choices
In this section we would like to know more detail about your school and what you want to do in the future.
D1.How important do you think it is for you to do well in your GCSE exams or Standard Grades (if you live in
Scotland)?
Very Important
Important
Not very important
Not important at all
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D2.At the moment, young people can leave school at 16. What would you most like to do when you are 16?
Get a full time
job
Study full time
Get a job and
study
Do something
else
Don’t know
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Q4
Q3
Q3
Q3
Q3
D3. Would you like to go on to do further full-time education at a college or University after you finish school?
Yes
No
Don’t know
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D4.Are yourparents interested in how you do at school?
Always or nearly
always
Sometimes
Hardly ever
Never
Not sure
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D5. Do your parents come to school parent evenings?
Always or nearly
always
Sometimes
Hardly ever
Never
Not sure
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D6. In the last 12 months, have you ever played truant, that is missed school without permission, even if it was
only for a half day or single lesson?
Yes
No
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D7. How often do other pupils at your school misbehave or cause trouble in your classes?
In most of our
classes
Less often but in In about half
more than half of your classes
our classes
Now and then
This is not a
problem at all
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EPICure@16participantQv3Feb2012
D
Office use only Study ID No
Your school and future choices
(continued)
D8. And how often would you say you misbehave or cause trouble in your class?
In most of my
classes
Less often but in In about half my
more than half of classes
my classes
Now and then
Never
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Now we ask some questions about bullying at school
D9.How often do you get physically bullied at school, for example getting pushed around, hit or threatened, or
having belongings stolen?
Never
Not much (1-3 times
in last 6 months)
Quite a lot (more
than 4 times in last 6
months)
A lot (a few times
every week)
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D10.How often do you get bullied in other ways at school such as getting called names, getting left out of games,
or having nasty stories spread about you on purpose?
Never
Not much (1-3 times
in last 6 months)
Quite a lot (more
than 4 times in last 6
months)
A lot (a few times
every week)
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D11.Do you physically bully other children at school by hitting or pushing them around, threatening them or
stealing their things?
Never
Not much (1-3 times
in last 6 months)
Quite a lot (more
than 4 times in last 6
months)
A lot (a few times
every week)
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D12.Do youbully other children in other ways at school such as calling them names, leaving them out of games or
spreading nasty stories about them on purpose?
Never
Not much (1-3 times
in last 6 months)
Quite a lot (more
than 4 times in last 6
months)
A lot (a few times
every week)
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EPICure@16participantQv3Feb2012
E
Office use only Study ID No
Your strengths and difficulties
For each item, please mark the box for NOT TRUE, SOMEWHAT TRUE or CERTAINLY TRUE. It would help
us if you answered all items as best as you can even if you are not absolutely certain or the item seems
strange! Please give your answers on the basis of how things have been for you over the last six months.
E1
I try to be nice to other people. I care about their feelings
I am restless, I cannot stay still for long
I get a lot of headaches, stomach-aches or sickness
I usually share with others (food, games, pens etc.)
I get very angry and often lose my temper
I am usually on my own. I generally play alone or keep to myself
I usually do as I am told
I worry a lot
I am helpful if someone is hurt, upset or feeling ill
I am constantly fidgeting or squirming
I have one good friend or more
I fight a lot. I can make other people do what I want
I am often unhappy, down-hearted or tearful
Other people my age generally like me
I am easily distracted, I find it difficult to concentrate
I am nervous in new situations. I easily lose confidence
I am kind to younger children
I am often accused of lying or cheating
Other children or young people pick on me or bully me
I often volunteer to help others (parents, teachers, children)
I think before I do things
I take things that are not mine from home, school or elsewhere
I get on better with adults than with people my own age
I have many fears, I am easily scared
I finish the work I'm doing. My attention is good
Not
True
Somewhat
True
Certainly
True
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Do you have any other comments or concerns about things covered in these questions?
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EPICure@16participantQv3Feb2012
E
Office use only Study ID No
Your strengths and difficulties (continued)
E2. Overall, do you think that you have difficulties in one or more of the following areas:
emotions, concentration, behaviour or being able to get on with other people?
Yes
Yes
Minor
Definite
No
Difficulties
Difficulties
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Yes
Severe
difficulties
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If you have answered "Yes", please answer the following questions about these difficulties:
If you have answered “No” please fill in the date of completion box at the end of the questionnaire
E3. How long have these difficulties been present?
Less than 1
month
1-5 months
6-12 months
Over a year
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Not at all
Only a little
Quite a lot
A great deal
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E4. Do the difficulties upset or distress you?
E5. Do the difficulties interfere with your everyday life in the following areas?
Not at all
Only a little
Quite a lot
A great deal
HOME LIFE
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FRIENDSHIPS
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CLASSROOM LEARNING
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LEISURE ACTIVITIES
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E6. Do the difficulties make it harder for those around you (family, friends, teachers, etc.)?
Not at all
Only a little
Quite a lot
A great deal
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Date of completion
PLEASE RETURN THE QUESTIONNAIRE IN THE ENVELOPE PROVIDED. THANK YOU
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