Form 17 Short Strengths and Difficulties Questionnaire

Attachment F: Short Strengths and Difficulties Questionnaire

OMB #xxxxxxxxx; Expiration Date: xx/xx/xx

Notice - Public reporting burden for this collection of information is estimated to average 1 minute per parent or guardian participating in the survey. 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 burden to: CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0222).

Assurances of Confidentiality – All information which would permit identification of an individual, a practice, or an establishment will be held confidential, will be used only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

I am going to read a list of items that describe children. For each item, please tell me if it ha s been NOT TRUE, SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: SC name]

DURING THE PAST SIX MONTHS. [fill2: He/She...]

CMB.020_01 …is generally well behaved, usually does what adults request.

1 Not true

2 Somewhat true

3 Certainly true

7 Refused

9 Don't know

CMB.020_02 has many worries, or often seems worried.

1 Not true

2 Somewhat true

3 Certainly true

7 Refused

9 Don't know

CMB.020_03...is often unhappy, depressed, or tearful.

1 Not true

2 Somewhat true

3 Certainly true

7 Refused

9Don't know

CMB.020_04…gets along better with adults than with other [fill3: children/youth].

1 Not true

2 Somewhat true

3 Certainly true

7 Refused

9Don't know

CMB.020_05 …has good attention span, sees chores or homework through to the end.

1 Not true

2 Somewhat true

3 Certainly true

7 Refused

9 Don't know