48 Pediatric Perceived Cognitive Proxy

Attachment 48

Pediatric Perceived Cognitive Function (PCF) - Proxy

On the next screens, we will ask you questions about organization, memory,
speed, concentration, and other abilities that are used in everyday life. Read each
question carefully and answer as well as you can. Please consider each question
by itself and choose an answer that really shows any problems your child may
have.
After you make your choice, the computer will automatically go on to the next
question. If you want to change your answer, click on the GO BACK button to
return to the question, then choose a different answer.
Click on the CONTINUE button when you are ready to begin.

Context

Stem

Responses

NQCOG
ped02A
2

ID

In the past 4 weeks,

Your child has a hard time keeping
track of his/her homework

1= None of the time
2= A little of the time
3= Some of the time
4= Most of the time
5= All of the time
9= Not applicable (My child has not been
in school at all in the last 4 weeks)

NQCOG
ped04A
2

In the past 4 weeks,

Your child forgets to bring things to
and from school that he/she needs
for homework

1= None of the time
2= A little of the time
3= Some of the time
4= Most of the time
5= All of the time
9= Not applicable (My child has not been
in school at all in the last 4 weeks)

NQCOG
ped05A
2

In the past 4 weeks,

Your child forgets what he/she is
going to say

1= None of the time
2= A little of the time
3= Some of the time
4= Most of the time
5= All of the time

NQCOG
ped07A
2

In the past 4 weeks,

Your child has to read things
several times to understand them

1= None of the time
2= A little of the time
3= Some of the time
4= Most of the time
5= All of the time

NQCOG
ped08A
2

In the past 4 weeks,

Your child reacts slower than most
people his/her age when he/she
plays games

1= None of the time
2= A little of the time
3= Some of the time
4= Most of the time
5= All of the time

NQCOG
ped10A
2

In the past 4 weeks,

It is hard for your child to find the
right words to say what he/she
means

1= None of the time
2= A little of the time
3= Some of the time
4= Most of the time
5= All of the time

NQCOG
ped14A
2

In the past 4 weeks,

It takes your child longer than other
people to get his/her school work
done

1= None of the time
2= A little of the time
3= Some of the time
4= Most of the time
5= All of the time
9= Not applicable (My child has not been
in school at all in the last 4 weeks)

NQCOG
ped15A
2

In the past 4 weeks,

Your child forgets things easily

1= None of the time
2= A little of the time
3= Some of the time
4= Most of the time
5= All of the time

NQCOG
ped16A
2

In the past 4 weeks,

Your child has to use written lists
more often than other people
his/her age so he/she will not forget
things

1= None of the time
2= A little of the time
3= Some of the time
4= Most of the time
5= All of the time

NQCOG
ped17A
2

In the past 4 weeks,

Your child has trouble remembering
to do things like school projects or
chores

1= None of the time
2= A little of the time
3= Some of the time
4= Most of the time
5= All of the time

NQCOG
ped18A
2

In the past 4 weeks,

It is hard for your child to
concentrate in school

1= None of the time
2= A little of the time
3= Some of the time
4= Most of the time
5= All of the time

NQCOG
ped19A
2

In the past 4 weeks,

Your child has trouble paying
attention to the teacher

9= Not applicable (My child has not been
in school at all in the last 4 weeks)
1= None of the time
2= A little of the time
3= Some of the time
4= Most of the time
5= All of the time
9= Not applicable (My child has not been
in school at all in the last 4 weeks)

NQCOG
ped20_2
A2

In the past 4 weeks,

Your child has to work really hard to
pay attention or he/she makes
mistakes

1= None of the time
2= A little of the time
3= Some of the time
4= Most of the time
5= All of the time