24.2 Survey

OMB #: 0925-0593

OMB Expiration Date: 07/31/ 2013

Neuropsychosocial M-CHAT SAQ, Phase 2e

M-CHAT SAQ

Event:	24-Month
Participant:	Child
Respondent:	Parent/Caregiver
Domain:	Neuropsychosocial
Type of Document:	Self-Administered Questionnaire
Mode:	In Person, Telephone, Mail, Web
Method:	PAPI
Recruitment Groups:	EH, PB, HI, LI, PBS
Version:	1.0
Release: Publisher: NCS Contact:	MDES 3.0 © 1999 Diana Robins, Deborah Fein, & Marianne Barton Carol Andreassen Westat, 301-251-1500

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M-CHAT SAQ

TABLE OF CONTENTS

M-CHAT. 1

M-CHAT SAQ

Please fill out the following about your child’s usual behavior, and try to answer every question. If the behavior is rare (you’ve only seen it once or twice), please answer as if your child does not do it.

1.	Does your child enjoy being swung, bounced on your knee, etc.?	Yes	No
2.	Does your child take an interest in other children?	Yes	No
3.	Does your child like climbing on things, such as up stairs?	Yes	No
4.	Does your child enjoy playing peek-a-boo/hide-and-seek?	Yes	No
5.	Does your child ever pretend, for example, to talk on the phone or take care of a doll or pretend other things?	Yes	No
6.	Does your child ever use his/her index finger to point, to ask for something?	Yes	No
7.	Does your child ever use his/her index finger to point, to indicate interest in something?	Yes	No
8.	Can your child play properly with small toys (e.g. cars or blocks) without just mouthing, fiddling, or dropping them?	Yes	No
9.	Does your child ever bring objects over to you (parent) to show you something?	Yes	No
10.	Does your child look you in the eye for more than a second or two?	Yes	No
11.	Does your child ever seem oversensitive to noise? (e.g., plugging ears)	Yes	No
12.	Does your child smile in response to your face or your smile?	Yes	No
13.	Does your child imitate you? (e.g., you make a face-will your child imitate it?)	Yes	No
14.	Does your child respond to his/her name when you call?	Yes	No
15.	If you point at a toy across the room, does your child look at it?	Yes	No
16.	Does your child walk?	Yes	No
17.	Does your child look at things you are looking at?	Yes	No
18.	Does your child make unusual finger movements near his/her face?	Yes	No
19.	Does your child try to attract your attention to his/her own activity?	Yes	No
20.	Have you ever wondered if your child is deaf?	Yes	No
21.	Does your child understand what people say?	Yes	No
22.	Does your child sometimes stare at nothing or wander with no purpose?	Yes	No
23.	Does your child look at your face to check your reaction when faced with something unfamiliar?	Yes	No

© 1999 Diana Robins, Deborah Fein, & Marianne Barton

Public reporting burden for this collection of information is estimated to average 5 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593). Do not return the completed form to this address.