Appendix F3
C
Form Approved
OMB NO. __________
Exp. Date __________
Many children participate in classroom based preschool programs:
A1. Has [CHILD] attended classroom programs in the past?
YES 1 NO 2 RF 8 DK 9
A2. When did he/she begin attending a classroom program? (MM/YYYY)
__ __ /__ __ __ __
A3. Does [CHILD] currently attend a classroom program?
YES 1 NO 2 RF 8 DK 9
A4. When did he/she stop attending the classroom program? (MM/YYYY)
__ __/ __ __ __ __
A5. How many children are in [CHILD’S] class?
A6. Does [CHILD] have a 1:1 aide or a shadow full time or part-time?
Full time 1 Part time 2 RF 8 DK 9
A7. How many days per week does your child attend this school program?
____ days
A8. How many hours per day does your child attend this school program?
____ hours
A9. Is this a special program that is related to your child’s disability?
YES 1 NO 2 RF 8 DK 9
Public Reporting Burden Statement
Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)
A10. Now, I'd like to know if your child has ever used any of the following services to meet his/her developmental needs?
Note to interviewer – services can be received anytime, either in/outside of school.
Behavior modification 1 2 8 9
Occupational therapy 1 2 8 9
Physical therapy 1 2 8 9
Respite care 1 2 8 9
Sensory Integration therapy 1 2 8 9
Social Skills training 1 2 8 9
Speech therapy 1 2 8 9
Vision services 1 2 8 9
Other (specify and rate) 1 2 8 9
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Note to interviewer – skip A11 if YES is not marked at least once in A10.
A11. How many service hours does your child currently receive per week?
____ Hours per week
A12. Now, I'd like to know if your child has ever seen any of the following service providers for his/her developmental needs?
Note to interviewer – providers can be either in/outside of school.
Service Providers YES NO RF DK
Audiologist 1 2 8 9
Developmental Pediatrician 1 2 8 9
Case manager 1 2 8 9
Chiropractor 1 2 8 9
Neurologist 1 2 8 9
Nutritionist 1 2 8 9
Nurse (home/long-term care) 1 2 8 9
Paraprofessional (_______________________________________indicate type)
1 2 8 9
Psychiatrist 1 2 8 9
Psychologist 1 2 8 9
Social worker 1 2 8 9
Other (specify and rate) 1 2 8 9
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Note to interviewer – skip A13 if YES is not marked at least once in A12.
A13. How many hours per week does your child currently work with these service providers?
____ Hours per week
B1. Please describe what special diets, vitamins, food supplements, alternative treatments [including over-the-counter medications, prescriptions, or special injections to treat your child’s developmental problems], or interventions your child has ever received that were not previously reported.
Interviewer Note - refer respondent to List 11f-g (Alternative treatments and Herbal medications) in the prep guide. Write down ALL parent responses verbatim :
Med/TX 1:
Med/TX 2:
Med/TX 3:
Med/TX 4:
Med/TX 5:
Med/TX 6:
Med/TX 7:
Med/TX 8:
Med/TX 9:
Med/TX 10:
B2. What special diets, vitamins, food supplements, alternative treatments [including over-the-counter medications, prescriptions, or special injections to treat your child’s developmental problems], or interventions is your child currently receiving that were not previously reported?
Interviewer Note - refer respondent to List 11f-g (Alternative treatments and Herbal medications) in the prep guide. Write down ALL parent responses verbatim :
CAM, Therapy, Intervention Currently Receiving: YES NO RF DK
________________________ 1 2 8 9
________________________ 1 2 8 9
________________________ 1 2 8 9
________________________ 1 2 8 9
________________________ 1 2 8 9
________________________ 1 2 8 9
________________________ 1 2 8 9
________________________ 1 2 8 9
________________________ 1 2 8 9
________________________ 1 2 8 9
________________________ 1 2 8 9
________________________ 1 2 8 9
________________________ 1 2 8 9
________________________ 1 2 8 9
________________________ 1 2 8 9
________________________ 1 2 8 9
________________________ 1 2 8 9
| File Type | application/msword |
| File Title | Early Development Questionnaire |
| Author | User |
| Last Modified By | pax1 |
| File Modified | 2006-12-29 |
| File Created | 2006-12-29 |