Parent-report child competence questionnaire

TOPIC CATEGORY	QUESTION	RESPONSE CATEGORIES	T1	T2
	THERE WILL BE A SEPARATE FAMILY INFORMATION FORM where we will collect PII (for follow-up and to send the family the $25). This will have a document ID (different from MPR ID but linked in a spreadsheet at Mathematica).
Child Name	First Name of Child		X
Parent Name	First and Last Name of parent completing SAQ		X
Parent Phone	Home Phone and Cell Phone of Parent		X
Parent Address	Complete Parent Address (Street, City, State, Zip Code)		X
MPR ID	MATHEMATICA WILL FILL THIS FIELD		X	X
Classroom and Setting	WE WILL ALSO PUT NAME OF SETTING AND SOMETHING TO SIGNIFY CLASSROOM ON THE TOP OF THE SAQ		X	X
Instructions	Include instructions to parent - voluntary, don’t need to answer all Qs, answer for child between 0 and 3 years old who attends setting and classroom marked on the top of the form.		X	X
Date	Today's date	MM/DD/YY	X	X
Child Care	When did your child first start attending this child care setting (name on top of form)?	RESPONSE CATEGORIES FOR MONTH AND YEAR	X
Child Care	How many days each week does your child go to this child care setting (name on top of form)?	RESPOND WITH DAYS A WEEK WE PROVIDE CHECK BOXES 1, 2, 3, 4, 5, 6, 7, no longer at setting	X	X
Child Care	How many hours each day does your child go to this child care setting?	RESPOND WITH HOURS A DAY WE PROVIDE CHECK BOXES less than 3, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, more than 12, no longer at setting	X	X
Exit Date	Is your child still enrolled in the same classroom as on September 2012 (name at top of form)?	Yes/No		X
Exit Date	If no, when did your child stop going to that classroom (name at top of form)?	MM/YY		X
Child Care	When did your child first start attending his/her current classroom (name on top of form)?	RESPONSE CATEGORIES FOR MONTH AND YEAR	X
Child Care	Which of the following types of child care do you use for your child on a weekly basis for more than 8 hours a week when (he/she) is not in this child care setting (name on top of form)?	MARK ALL THAT APPLY 1. Early Head Start 2. A State Child Care program 3. A child care center, preschool or nursery school (other than Early Head Start or a State Child Care program) 4. Someone cares for your child in a home that you and the caregiver share 5. Someone cares for your child in their home 6. Someone cares for your child in your home THESE CHOICES SHOULD ALL BE IF MARKED, HOW MANY DAYS A WEEK? HOW MANY HOURS A DAY?	X	X
Child DOB	What is your child’s birth date?	TWO DIGIT MONTH/TWO DIGIT DAY/TWO DIGIT YEAR	X
Child Sex	Is your child male or female?	Male/Female	X
Child County of Origin	In what country was your child born?	a. United States b. Other (Specify)	X
Child Ethnicity	Is your child of Spanish, Hispanic or Latino origin?	Yes/No	X
Household Language	What languages are spoken in your home?	MARK ALL THAT APPLY 1. English 2. Spanish 3. Other (SPECIFY)	X
Household Language	Overall, what language is spoken most often to child at home?	MARK ALL THAT APPLY 1. English 2. Spanish 3. Other (SPECIFY)	X
Child Language	Please tell me all of the languages your child can speak even if it is only a few words.	MARK ALL THAT APPLY 1. English 2. Spanish 3. Other (SPECIFY)	X	X
Child Race	What is your child's race? You may choose more than one if you like.	MARK ALL THAT APPLY 1. White 2. Black or African American 3. American Indian or Alaska Native 4. Asian 5. Native Hawaiian or other Pacific Islander 6. Other Pacific (please specify)	X
Child's Health	The next questions are about health and health related issues. Overall, would you say your child’s health is . . .	1. excellent 2. very good 3. good 4. fair, or 5. poor?	X	X
Special Needs	Does your child have... a. behavioral trouble or a higher than normal activity level? b. difficulty hearing? c. difficulty seeing objects in the distance? d. any physical development issues such as problems with the way (he/she) uses (his/her) arms or legs ? e. a below normal activity level? f. difficulty with communicating? g. trouble sleeping because of a breathing problem or sleep apnea? h. a developmental disability or delay?	ALL ARE YES/NO		X
Special Needs	If yes, does your child receive services for any of these special needs?	Yes/No		X
Special Needs	Does your child have an Individual Family Service Plan (IFSP)?	Yes/No		X
Relationship of respondent	Now we have some questions about you and your family. What is your relationship to the child?	1. Mother/Female Guardian 2. Father/Male Guardian 3. Grandmother 4. Grandfather 5. Other Relative 6. Other Non-Relative	X	X
Marital status	Are you…	1. Married, 2. Divorced, 3. Separated, or 4. never married?	X
Household composition	How many children age 17 and younger live in your household?	TWO DIGIT NUMBER	X	X
Parent Age	In what year were you born?	FOUR DIGITS	X
Parent Country of Origin	In what country were you born?	1. United States 2. Other (Specify)	X
Maternal Education	What is the highest grade or year of school that your child's mother completed?	MARK ONLY ONE 1. 1st up to 8th grade 2. 9th to 11th grade 3. 12th grade but no diploma 4. High school diploma or GED 5. Associate's degree 6. Bachelor's degree 7. Master's degree 8. Doctorate 9. Other (Please specify)	X
Parent Ethnicity	Are you of Spanish, Hispanic, or Latino origin?	Yes/ No	X
Parent Language	What is your first language?	1. English 2. Spanish 3. Other (Specify)	X
Parent Race	What is your race?	MARK ALL THAT APPLY 1. White 2. Black or African American 3. American Indian or Alaska Native 4. Asian 5. Native Hawaiian or other Pacific Islander 6. Other Pacific (please specify)	X
Household income	In the last 12 months, what was the total income of all members of your household from all sources before taxes and other deductions? Please include your own income and the income of everyone living with you. Was it . . .	1. Less than $15,000 2. $15,000 to $24,999 3. $25,000 to $49,999 4. $50,000 to $74,999 5. $75,000 to 150,000 6. $150,000 or more	X
Household income assistance	In the past 12 months, did you or anyone in your household receive... a. support from [State Welfare name from Box U1] or welfare? b. support from unemployment insurance? c. food stamps (also known as SNAP: Supplemental Nutrition Assistance Program)? d. WIC - Special Supplemental Food Program for Women, Infants, and Children? e. child support? f. SSI or Social Security Retirement, Disability, or Survivor’s benefits? g. payments for providing foster care? h. energy assistance?	ALL ARE YES/NO	X
Major Changes in Household Circumstances	During the last 12 months, have any of the following events occurred in your immediate family?	MARK ALL THAT APPLY 1. Divorce 2. Marital reconciliation 3. Marriage 4. Separation 5. Pregnancy 6. Other relative moved into household 7. Income increased substantially (20% or more) 8. Went deeply into debt 9. Moved to a new location 10. Promotion at work 11. Income decreased substantially 12. Alcohol or Drug Problem 13. Death of close family friend 14. Began new job 15. Entered new school 16. Trouble with superiors at work 17. Trouble with teachers at school 18. Legal problems 19. Death of immediate family member		X
STANDARDIZED MEASURES
Name of Instrument	Citation	Domain Measured	Age of Administration
Ages & Stages Questionnaires (ASQ)	Squires, Jane, Diane Bricker, Elizabeth Twombly, Robert Nickel, Jantina Clifford, Kimberly Murphy, Robert Hoselton, LaWanda Potter, Linda Mounts, and Jane Farrell. Ages & Stages Questionnaires, Third Edition (ASQ-3): A Parent-Completed, Child-Monitoring System. Baltimore: Paul H. Brookes Publishing Co., 2009.	Comprehensive Development	6 to 36 months
MacArthur-Bates Communicative Development Inventories— Short Forms	Fenson, L., S. Pethick, C. Renda, J. L. Cox, P.S. Dale, and J. S. Reznick. “Short-Form Versions of the MacArthur Communicative Development Inventories.” Applied Psycholinguistics, vol. 21, 2000, pp. 95–115.	Language Development	8 to 36 months
Brief Infant Toddler Social Emotional Assessment (BITSEA)	Carter, A.S., and M. Briggs-Gowan. ITSEA BITSEA: The Infant-Toddler and Brief Infant Toddler Social Emotional Assessment. San Antonio, TX: PsychCorp, 2005.	Social-Emotional Development	12 to 36 months