Month and year your child was born: _____________________________
Age in years of brothers or sisters: _______________________________
Would you please let us know your child’s ethnic background? (Circle as many as apply)
African American
Asian
Native American or Pacific Islander
Hispanic, Latino, or Chicano
White/non-Hispanic
Other?________________
Roughly how much time does your child spend watching TV, DVDs, and streaming video (not games)
On a typical week day?
On a typical weekend day?
What’s your child’s favorite program?
How often does (or did) your child watch each of the following programs?
Never
Very
Often
Daniel Tiger’s
Neighborhood
1……….2……….3..........4……….5
Thomas & Friends
Never
Very
Often
1……….2……….3..........4……….5
1……….2……….3..........4……….5
Doc McStuffins
Henry
Hugglemonster
Sesame Street
1……….2……….3..........4……….5
Lalaloopsy
1……….2……….3..........4……….5
Ni Hao, Kai Lan
Clifford the
Big Red Dog
1……….2……….3..........4……….5
Max & Ruby
1……….2……….3..........4……….5
1……….2……….3..........4……….5
Peppa Pig
1……….2……….3..........4……….5
Gaspard & Lisa
Jake and the
Neverland Pirates
1……….2……….3..........4……….5
Peter Rabbit
1……….2……….3..........4……….5
1……….2……….3..........4……….5
Paw Patrol
1……….2……….3..........4……….5
Henry Hugglemonster
1……….2……….3..........4……….5
Dora the Explorer
1……….2……….3..........4……….5
1……….2……….3..........4……….5
Please rate how much you agree or disagree with each statement about your child.
My child…
Strongly
Disagree
Strongly
Agree
Becomes sad when other children are sad
-4
-3
-2
-1
0
1
2
3
4
Gets upset seeing another child being punished for
being naughty
Seems to react to the moods of other people
-4
-3
-2
-1
0
1
2
3
4
-4
-3
-2
-1
0
1
2
3
4
Gets upset when another person is acting upset
-4
-3
-2
-1
0
1
2
3
4
Cries or gets upset when seeing another child cry
-4
-3
-2
-1
0
1
2
3
4
Gets sad watching sad movies or TV
-4
-3
-2
-1
0
1
2
3
4
Gets nervous when other children are nervous.
-4
-3
-2
-1
0
1
2
3
4
Acts happy when another person is acting happy.
-4
-3
-2
-1
0
1
2
3
4
Can feel okay even if people around are upset.
-4
-3
-2
-1
0
1
2
3
4
Can’t understand why other people get upset.
-4
-3
-2
-1
0
1
2
3
4
Rarely understands why other people cry.
-4
-3
-2
-1
0
1
2
3
4
Would eat the last cookie, even if someone else
wants it.
Reacts badly when people kiss and hug in public.
-4
-3
-2
-1
0
1
2
3
4
-4
-3
-2
-1
0
1
2
3
4
Doesn’t understand why people cry out of happiness -4
-3
-2
-1
0
1
2
3
4
Doesn’t seem to notice when I get sad.
-4
-3
-2
-1
0
1
2
3
4
Gets sad to see a child with no one to play with.
-4
-3
-2
-1
0
1
2
3
4
Treats cats and dogs like they have feelings.
-4
-3
-2
-1
0
1
2
3
4
Feels sorry for another child who is upset.
-4
-3
-2
-1
0
1
2
3
4
Likes to watch people open presents, even if not for
him or her.
Gets upset seeing another child get hurt.
-4
-3
-2
-1
0
1
2
3
4
-4
-3
-2
-1
0
1
2
3
4
Laughs when another child laughs.
-4
-3
-2
-1
0
1
2
3
4
Gets upset seeing an animal get hurt.
-4
-3
-2
-1
0
1
2
3
4
Feels sad for people who are physically disabled.
-4
-3
-2
-1
0
1
2
3
4
That’s it! We really appreciate it. If this was sent home from preschool with your child, we’ll send the “thank
you” money home in a sealed envelope with your child! If you’re coming to the lab, we’ll pay you there.
If you have questions, don’t hesitate to contact me at mares@wisc.edu or (608) 263-2350.
Professor Marie-Louise Mares