SNMCS Individuals

APPENDIX o

Student Height and Weight Measurement Form

This page has been left blank for double-sided copying.

OMB Clearance Number: 0584-XXXX

Expiration Date: XX/XX/XXXX

Weight and Standing Height Measurement Form	ID Label							Interviewer MPR ID #: | | | | | | | | | | | | / | | | / 2015 Month Day
1. ASK STUDENTS TO REMOVE SHOES, HATS, EXTRA CLOTHES
2. Weight
2a. 1st measurement					.		P IF DIFFERENCE BETWEEN 1ST & 2ND MEASUREMENT IS GREATER THAN 1 POUND, TAKE 3RD MEASUREMENT. ounds
2b. 2nd measurement					.		Pounds
2c. 3rd measurement					.		Pounds

3. Concerns about weight measurement:

MARK ALL THAT APPLY

	0	£	No concerns						5	£		Difficulty obtaining measurement
	1	£	Wearing heavy clothing, brace, or cast						6	£		Child or parent report [Describe reason in Comments]
	2	£	Wearing shoes						7	£		Refusal (no measurement or report)
	3	£	Weight exceeded scale limit						8	£		Other (Specify) _______________________________
	4	£	Pregnant
4. Standing Height
4a. 1st measurement						.					I IF DIFFERENCE BETWEEN 1ST & 2ND MEASUREMENT IS GREATER THAN 1 INCH, TAKE 3RD MEASUREMENT. nches
4b. 2nd measurement						.					Inches
4c. 3rd measurement						.					Inches

5. Concerns about height measurement:

MARK ALL THAT APPLY

	0	£	No concerns	3	£	Difficulty obtaining measurement
	1	£	Wearing shoes or boots	4	£	Child or parent report [Describe reason in Comments]
	2	£	Hair, hair piece, or hat interfered	5	£	Refusal (no measurement or report)
				6	£	Other (Specify) ______________________________
Comments:________________________________________________________________________________________

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-XXXX. The time required to complete this information collection is estimated to average 3 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.