Brief Impairment Scale

OMB No:

The Brief Impairment Scale (BIS)

The questions I am going to ask you now have to do with how _____(name of child) has been doing overall. Please answer them thinking only of the last twelve months/past year keeping in mind what one would expect of children of the same age and sex as __(name of child)_____.

Public reporting burden of this collection of information is estimated to average 4 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 Information Clearance Officer; 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (???).

1. Over the last 12 months/year, how much of a problem has he/she had getting along with his/her father/stepfather/foster father? (score about father figure with whom he/she has most contact) O No problem O Some problem O A considerable problem O A serious problem O Refused O Not Applicable (no father figure) O Don’t know 2. How much of a problem has he/she had getting along with his/her mother/stepmother/foster mother? (score about mother figure with whom he/she has most contact) O No problem O Some problem O A considerable problem O A serious problem O Refused O Not Applicable (no mother figure) O Don’t know

3. How about problems getting along with his/her brothers and sisters? O No problem O Some problem O A considerable problem O A serious problem O Refused O Not Applicable (no brothers or sisters) O Don’t know 4. How about problems getting involved in activities together with the rest of the family? O No problem O Some problem O A considerable problem O A serious problem O Refused O Don’t know

5. Over the last 12 months/year, how much of a problem has he/she had with his/her teachers at school? (If not in school and working) Or with his/her superiors at work? O No problem O Some problem O A considerable problem O A serious problem O Refused O Not Applicable (has not worked or been in school during the past year) O Don’t know 6. How much of a problem has he/she had getting along with other adults outside of the family? O No problem O Some problem O A considerable problem O A serious problem O Refused O Don’t know 7. How much of a problem has he/she had making friends? O No problem O Some problem O A considerable problem O A serious problem O Refused O Don’t know 8. How much of a problem has he/she had getting along with the friends that he/she has? O No problem O Some problem O A considerable problem O A serious problem or has no friends O Refused O Don’t know 11. In general, how much of a problem has he/she had getting his/her schoolwork/work done on time? O No problem O Some problem O A considerable problem O A serious problem O Refused O Not Applicable (not in school or working over the past year) O Don’t know 12. During the last 12 months /past year, how much of a problem has he/she had doing what he/she is expected to do at home? (Read options) O No problem O Some problem O A considerable problem O A serious problem O Refused O Don’t know 13. How much of a problem has he/she had being responsible at school/work or in jobs he/she took on outside of his home? (Read options) O No problem O Some problem O A marked problem O A serious problem O Refused O Not Applicable (not worked or in school during past year) 14. In the last 12 months/past year, how many times were you asked to come to his/her school to discuss some problem that he/she has had? O Never O Once O More than once O Refused O Not Applicable (not in school) O Don’t know 18. Compared to other kids of the same age, how neat is his/her physical appearance most of the time? Remember that we are talking about how it’s been during the last 12 months/past year. Would you say he/she is: O Like most kids his/her age O A bit sloppier than most kids his/her age O Considerably more sloppy or peculiar than most kids his/her age O Extremely sloppy or bizarre compared to other kids his/her age O Refused O Don’t know 19. Compared to others his/her age, how well does he/she take care of his/her health? He/she Takes good care of him/herself Is somewhat careless about his/her health Is quite careless about his/her health Is extremely careless about his/her health Refused Don’t know

9. During the last 12 months /past year, has he/she often missed school/work? O Never misses work/school O Occasionally (once a month or less) O Many times (2 to 4 times a month) O Quite frequently (more than 5 times per month) O Refused O Not Applicable (not in school and not working during the last 12 months) O Don’t know IF Q. 9 coded 1, 2, or 3 9A) Was this because he/she was really sick? Yes No 10. During the last 12 months /past year, how well has he/she been doing in his/her school work? O Better than average (mostly B’s or outstanding: mostly A’s, some B’s O Just average: C work O Somewhat below average (mostly C's and D's) O Markedly below average (mostly D's and F's) O Refused O Not Applicable (not in school during the last year) O Don’t know If Q. 10 scored “Not Applicable”, ask 10A. 10A. Has he/she dropped out of school during the past year? Yes No Refused Don’t know 15. To what extent does he/she get involved in sports? (Read options) O Frequently or member of a team O Some involvement, but not steady O Very rarely involved O Not involved at all O Refused O Not Applicable (no opportunities for participation in sports) O Don’t know 16. Over the past 12 months to what extent did he/she get involved in activities other than sports? (Read options) O Frequently involved in other activities O Only occasionally O Rarely got involved or dropped out easily O Never got involved in other activities O Refused O Don’t know 17. To what extent would you say he/she is a person who has many interests? Again think specifically about the last 12 months/past year. Would you say he/she (Read options): O has many and varied interests O has some interests O few things interest him/her O has no interests, is generally bored O refused O don’t know 20. How safety conscious is he/she? Very careful, attentive to safety rules Somewhat careless Quite careless Extremely careless Refused Don’t know 21. Does he/she seem to have a problem having fun and enjoying life? Again, think about how it’s been during the last 12 months. Would you say he/she has had: No problem Some problem A considerable problem A serious problem Refused Don’t know

FOR STUDY USE ONLY
Date Interviewed	Month Day Year	Interviewed by