Table 6.
UNIVERSITY OF VERMONT PARENT SURVEY (To be completed by the parent/guardian who is most involved in the student's care/daily life)
| Relation to student: (Circle one) | Father | Mother | Legal Guardian | Other (specify): |
| Number of hours child spends a day on Internet total: (Circle one) | < 1 | 1–2 | 3–4 | >4 |
| Number of hours a day child spends on computer games: (Circle one) | < 1 | 1–2 | 3–4 | >4 |
| Number hours a day child spends on console games (Playstation, Nintendo, etc.): (Circle one) | < 1 | 1–2 | 3–4 | >4 |
| Number hours a day child spends watching television: (Circle one) | < 1 | 1–2 | 3–4 | >4 |
| Has your son/daughter ever been diagnosed with: (Circle one) | Depression | Anxiety Disorder | ADD/ADHD | Other (specify): |
| If so, for how many years? | ||||
| Does your son/daughter have any other medical illnesses (diabetes, epilepsy, etc.)? | Yes | No | If so, please specify: | |
| Is your son/daughter currently on any prescription medications? | Yes | No | ||
| If so, please list medications: | ||||
| Is your son/daughter: | NOT TRUE AT ALL (NEVER, SELDOM) | JUST A LITTLE TRUE (SOMETIMES) | PRETTY MUCH TRUE (OFTEN) | VERY MUCH TRUE (VERY OFTEN) |
| 1 Inattentive, easily distracted | ||||
| 2 Angry and resentful | ||||
| 3 Difficulty doing or completing homework | ||||
| 4 Always "on the go" | ||||
| 5 Short attention span | ||||
| 6 Argues with adults | ||||
| 7 Fidgets with hands/feet, squirm in seat | ||||
| 8 Fails to complete assignments on time | ||||
| 9 Hard to control in malls or grocery shopping | ||||
| 10 Messy or disorganized at home or school | ||||
| 11 Loses temper | ||||
| 12 Needs close supervision to get through assignments | ||||
| 13 Only attends if it is something he/she is very interested in | ||||
| 14 Runs or climbs excessively in situations where it is inappropriate | ||||
| 15 Distractibility or attention span a problem | ||||
| 16 Irritable | ||||
| 17 Avoids, expresses reluctance about, or has difficulty engaging in tasks that require sustained mental effort (such as school work or homework) | ||||
| 18 Restless in the "squirmy" sense | ||||
| 19 Gets distracted when given instruction to do something | ||||
| 20 Actively defies or refuses to comply with adults' requests | ||||
| 21 Has trouble concentrating in class | ||||
| 22 has difficulty waiting in lines or awaiting turn in games or group situations | ||||
| 23 Leaves seat in classroom or other situation in which remaining seated is expected | ||||
| 24 Deliberately does things that annoy other people | ||||
| 25 Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace | ||||
| 26 has difficulty playing or engaging in leisure activities quietly | ||||
| 27 Easily frustrated in efforts | ||||
Thank you for taking part in our survey. All results are confidential. Please contact Philip Chan (research coordinator) at Philip.Chan@uvm.edu anytime with questions.
PLEASE PLACE FINISHED SURVEY IN A SEALED ENVELOPE