SEED - Clinic Visit- Case Parent

The Study to Explore Early Development (SEED)

Appendix_F.3 Study Start Services and Treatment Questionnaire 2007

SEED - Clinic Visit- Case Parent

OMB: 0920-0741

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F orm Approved

OMB NO. 0920-0741

Exp. Date 6/30/2010

Study to Explore Early Development

Services and Treatments Questionnaire

Study ID #: ______________

Date of Completion:________

SECTION A: Classroom programs

Many children participate in classroom-based preschool programs.

A1. Has your child ever attended a classroom program?

YES	NO	DON’T KNOW
□	□	□
Go to question A2	Go to Section B	Go to question A3

A2. When did he or she begin attending a classroom program?

__ __ /__ __ __ __ (MM/YYYY)

A3. Does your child currently attend a classroom program?

YES	NO	DON’T KNOW
□	□	□
Go to question A5	Go to question A4	Go to Section B

A4. When did he or she stop attending the classroom program?

If your child is not currently attending a program, skip to Section B

__ __/ __ __ __ __ (MM/YYYY)

A5. How many children are in your child’s current class?

____ children

A6. Does your child have a 1:1 aide or a shadow or an aide full-time or part-time?

NO	YES – FULL-TIME	YES – PART-TIME	DON’T KNOW
□	□	□	□

Public Reporting Burden Statement

Public reporting burden of this collection of information is estimated to average 10 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 (0920-0741)

A7. How many days per week does your child attend this classroom program?

____ days

A8. How many hours per day does your child attend this classroom program?

____ hours

A9. Is this a special program that is related to your child’s disability?

YES	NO	DON’T KNOW
□	□	□

SECTION B: Professional Individual and Group Services

B1. Has your child ever used any of the following services to meet his or her developmental needs?

Note: services can be received anytime, either in or outside of school.

Services	YES	NO	DON’T KNOW
Behavior modification	□	□	□
Occupational therapy	□	□	□
Physical therapy	□	□	□
Respite care	□	□	□
Sensory integration therapy	□	□	□
Social skills training	□	□	□
Speech therapy	□	□	□
Vision services	□	□	□
Other (specify and rate)	□	□	□
____________________________	□	□	□
____________________________	□	□	□
	If YES to any of the above, go to question B2	If NO or DON’T KNOW for all the above services, go to question B3.

B2. How many service hours does your child currently receive per week?

____ Hours per week

B3. Has your child ever seen any of the following service providers for his or her developmental needs?

Note: Providers can be either in school or outside of school.

Service Providers	YES	NO	DON’T KNOW
Audiologist	□	□	□
Developmental pediatrician	□	□	□
Case manager	□	□	□
Chiropractor	□	□	□
Neurologist	□	□	□
Nutritionist	□	□	□
Nurse (home/long-term care)	□	□	□
Paraprofessional Indicate type:_________________	□	□	□
Psychiatrist	□	□	□
Psychologist	□	□	□
Social worker	□	□	□
Other (specify and rate)	□	□	□
____________________________	□	□	□
____________________________	□	□	□
	If YES to any of the above, go to question B4	If NO or DON’T KNOW for all the above service providers, go to Section C

B4. How many hours per week does your child currently work with these service providers?

____ Hours per week

SECTION C: Complementary and Alternative Medicines (CAM), Therapies, Interventions

C1. 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 has your child ever received that were not previously reported?

See lists on pages 5-6 for examples of CAM, therapies, and interventions and lists on page 6 for over-the-counter medications.

Medicine/Treatment 1: __________________________________________________________

Medicine/Treatment 2: __________________________________________________________

Medicine/Treatment 3: __________________________________________________________

Medicine/Treatment 4: __________________________________________________________

Medicine/Treatment 5: __________________________________________________________

Medicine/Treatment 6: __________________________________________________________

Medicine/Treatment 7: __________________________________________________________

Medicine/Treatment 8: __________________________________________________________

Medicine/Treatment 9: __________________________________________________________

Medicine/Treatment 10: _________________________________________________________

C2. 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?

See lists on pages 4-5 for examples of CAM, therapies, and interventions and lists on page 5 for over-the-counter medications..