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To assist AOWA in evaluating the effectiveness of this program, the below is a data gathering tool to collect valuable information before your child commences the program and is repeated at one week prior to the end of term. As the parent/guardian of your child registered in this program, we would appreciate your valued contribution through the completion of this form.

Below are a list of things that might be a problem for you. Please tell us how much of a problem each one has been for you during the PAST MONTH by selecting the most suitable answer from the drop-down menu:

0 if it is never a problem
1 if it is almost never a problem
2 if it is sometimes a problem
3 if it is always a problem
4 if it is almost always a problem There are no right or wrong answers.
If you do not understand a question, please ask for help.

When you have completed the form and answered all questions, please click the SUBMIT button.

Peds QL for Hydro

Child's Name:(Required)

About My Health and Activities (problems with ....)

About My Feelings (problems with....)

How I Get On with Others (problems with....)

About School (problems with....)


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