10 Neuro

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FORM CODE: NEE VERSION: A 7/31/07

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OMB#: 0925-XXXX

Exp. XX/XXXX

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CHS/SOL Neurocognitive Assessment

ID NUMBER:

FORM CODE: NEE VERSION: A 7/31/07

Contact Occasion

SEQ #

Acrostic:

Administrative Information

0a. Completion Date: // 0b. Staff ID:

Month Day Year

Instructions: Read and follow instructions given for each section.

Part A. Six-Item Screener

In this part of the exam I will ask you some questions and give you a couple of short tasks that will require memory and concentration. First, I will ask you some questions that ask you to use your memory. I am going to say three words. Please wait until I have said all three words, then repeat them. Remember what they are, because I am going to ask you to name them again in a few minutes. Please repeat these words for me: BLUE - PEAR - SOFA.

Interviewer may repeat the words up to 3 times if necessary.

1. Number of presentations necessary for the participant to repeat the words:

1 2 3 Incorrect

Not Attempted/Disability

Not Attempted/Refusal

Not attempted/ Not attempted/

Correct Incorrect Disability Refusal

2. What year is this?

3. What month is this?

4. What is the day of the week?

Now, what were those three words I asked you to remember?

Not attempted/ Not attempted/

Correct Incorrect Disability Refusal

5. Blue

6. Pear

7. Sofa

Part B. SEVLT

8. (Trial 1) Next, I am going to read a list of words. I want you to listen carefully and try to remember the words as I read them. When I stop, I would like you to recall as many of the words as you can. You may know some of the words by a different name, but I want you to try to remember the exact words I say. You will not be able to remember all of the words so just do the best you can. You do not have to recall the words in the same order that I read them. The words are…

After reading the list say:

Now tell me all of the words you can remember.

After the participant's response, provide one prompt for additional words before going to the next trial.

Check off all words recalled.

Words	8. (Trial 1)	9. (Trial 2)	10. (Trial 3)	Distracter	Words	11. (Trial 5)
Cabbage				Eggs	Cabbage
Ladle				Pot	Ladle
Coffee				Milk	Coffee
Beets				Cherries	Beets
Dictionary				Bowl	Dictionary
Cocoa				Cheese	Cocoa
Beans				Lettuce	Beans
Strainer				Spoon	Strainer
Oranges				Water	Oranges
Corn				Fish	Corn
Newspaper				Pen	Newspaper
Juice				Peach	Juice
Asparagus				Cookies	Asparagus
Pan				Notebook	Pan
Tea				Onions	Tea

9. (Trial 2) I am going to read the same list of words to you again. I want you to try to remember as many of the words as you can, including those you have recalled before. When I stop I want you to tell me as many of the words as you can remember.

After reading the list say:

Now tell me all of the words you can remember.

After the participant's response, provide one prompt for additional words before going to the next trial.

10. (Trial 3) I will read the same words once more. Listen carefully and when I finish tell me as many of the words as you can remember.

After reading the list say:

Now tell me all of the words you can remember.

After the participant's response, provide one prompt for additional words before going to the next trial.

Distracter

I am going to read you a different list of words. This time, I want you to repeat each word out loud after I read it.

11. (Trial 5) Immediately after the participant repeats the last word from the distracter list say:

Now, I want you to tell me as many of the words from the first list that I read to you as you can remember.

Do not repeat the first list.

After the participant's response, provide one prompt for additional words.

Part C. Word Fluency: Letters F and A

On this next task, I will say a letter. Then I want you to tell me as many different words as you can think of, as fast as you can, that begin with that letter. You may tell me words in English or Spanish so long as they are different words. Leave out names of people, names of places, and numbers. So, if I were to say "T," you would not say words like 'Thomas,' 'Texas,' or the number 'Ten.' But you could say words like 'table,' 'take,' or 'turtle.'

Also, do not use the same word again with a different ending. For example, if you said 'take,' then you could not say 'takes,' or 'taking.' These would all be considered the same word.

Are you ready? Pause

Allow one minute for each letter (F and A).

If the participant discontinues before the end of the minute, encourage him/her to try to think of more words.

If there is a silence of 15 seconds, repeat the basic instructions and the letter.

Inadmissible words include proper nouns, variations, plurals, and repetitions

12. Tell me as many words as you can that start with the letter F. I will tell you when to stop. Ready, go.

(Begin timing)

Letter
F
1		11		21
2		12		22
3		13		23
4		14		24
5		15		25
6		16		26
7		17		27
8		18		28
9		19		29
10		20		30

13. That was great. Now, tell me as many words as you can that start with the letter A. I will tell you when to stop. Ready, go. (Begin timing)

Letter
A
1		11		21
2		12		22
3		13		23
4		14		24
5		15		25
6		16		26
7		17		27
8		18		28
9		19		29
10		20		30

Part D. Digit-Symbol Substitution (DSS)

This last task is the digit-symbol task. Look at these boxes. Notice that each box has a number in the upper part and a special mark in the lower part. Each number has its own mark.

Point to 1 and its mark, then to 2 and its mark.

Now, look down here to where the boxes have numbers in the top part, but the squares at the bottom are empty. Point to the sample items.

I want you to put in each of the empty squares the mark that should go there, like this.

Point to the first sample item, then to the mark below the 2 in the key.

Here is a 2; the 2 has this mark. So I put it in this square, like this. Write in the symbol.

Here is a 1; the 1 has this mark. Point to the second sample item, then to the mark below the 1 in the key.

So I put it in this square. Write in the symbol.

This number is 3; the 3 has this mark. Point to the third sample item, then to the mark below the 3 in the key]

So I put it in this square. Write in the symbol.

Now, you fill in the squares up to this heavy line.

If the subject makes an error on a sample item, correct the error immediately and review the use of the key. Continue to help (if necessary) until the seven sample items have been filled in correctly. Do not proceed with the test until the participant clearly understands the task.

Look to see if a left-handed participant blocks the key when filling in the marks. If so, fold a separate template in half, exposing only the key, for the participant to use.

When the sample exercise has been completed successfully say:

Yes, now you know how to do them.

To begin the formal test say: When I tell you to start, you do the rest of them. Point to the first test item. Begin here and fill in as many squares as you can, one after the other, without skipping any. Keep working until I tell you to stop. Work as quickly as you can without making mistakes.

Sweep finger across the first row. When you finish this line, go on to this one.

[Point to the first item in row 2. Ready? Go ahead. Begin timing

If the participant omits an item or starts to do only one type (e.g., only the 1’s), say, Do them in order. Don’t skip any. Point to the first item omitted and say, Do this one next. Give no further assistance except (if necessary) to remind the participant to continue until instructed to stop.

At the end of 90 seconds, say: Stop. That's good, thank you. That completes this set of tasks.

DIGIT-SYMBOL

		1		2		3		4		5		6		7		8		9
		−		⊥		⊐		∟		⊔		○		∧		×		=

SAMPLES
2	1	3	7	2	4	8	2	1	3	2	1	4	2	3	5	2	3	1	4	5	6	3	1	4

1	5	4	2	7	6	3	5	7	2	8	5	4	6	3	7	2	8	1	9	5	8	4	7	3

6	2	5	1	9	2	8	3	7	4	6	5	9	4	8	3	7	2	6	1	5	4	6	3	7

9	2	8	1	7	9	4	6	8	5	9	7	1	8	5	2	9	4	8	6	3	7	9	8	6

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CHS/SOL Neurocognitive Scoring Summary

ID NUMBER:

FORM CODE: NEE VERSION: A 7/31/07

Contact Occasion

SEQ #

Acrostic:

Administrative Information

0a. Completion Date: // 0b. Staff ID:

Instructions: If summary scores are permanently missing because part of the battery was skipped or not applicable, enter "=" in those fields."

PART A: SIX ITEM SCREENER

For Questions 1 – 7, see Page 1, Section A of Neurocognitive Assessment Booklet. ENTER results as they appear on the form.

PART B: SEVLT

Record the number of correct words recalled for each trial on Part B, page 2 below.

Words Recalled from Part B:

8. (Trial 1)

9. (Trial 2)

10. (Trial 3)

11. (Trial 5)

PART C: WORD FLUENCY

Record the number of acceptable words produced for each letter (F and A) on Part C, pages 4 – 5 below.

Words Produced on Part C:

12. Letter F

13. Letter A

PART D: DIGIT SYMBOL SUBSTITUTION

Apply the DSST scoring template to the responses on Part D, pages 7 – 8 and enter the number of correct symbols below.

14. Total Correct Symbols on Part D:

15. What language were tests administered in?

English 1

Spanish 2

16a. Were any of the cognitive function tests discontinued (from Parts B, C, or D)?

Yes 1

No 0

16b. Which test(s) was discontinued?

YES NO

16b.1. SEVLT 1 0

16b.2. Word Fluency 1 0

16b.3. Digit Symbol Substitution 1 0

16c. If yes, test(s) discontinued due to (record the appropriate letter for each test that was

discontinued)

Refusal 1

Task difficulty 2

Impairment (Visual, Hearing, Limb or Motor Problem) 3

16c1. Reason for discontinued SEVLT

16c2. Reason for discontinued Word Fluency

16c3. Reason for discontinued Digit Symbol Substitution

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