LOI2-QUEX-5 Exemplar Telephone Screener

TELEPHONE SCREENER OMB #: 0925-XXXX

LOI2-QUEX-5 Expiration Date: XX/XX/XXXX

Bayley Short Form Telephone Screener

Thank you for your interest in The Bayley Child Development Study. It is because of the interest of parents like you that makes it possible for us to conduct this kind of research.

1. First, I’d like to obtain some basic information to see whether your child is eligible for the study.

Your name: ________________________________________

2. Are you the child’s parent or legally authorized representative?

Yes

No  IF NO, THEN: We need the permission of the parent/legal guardian. Can you

please provide that person’s name and phone number so that we can call: ____________________________________________________________

________________________________________________________________

3. Parent/Guardian’s Address: ___________________________________________________________

_________________________________________________________

4. Parent/Guardian/s Phone Number: __________________________________________

Alternate Phone Number: __________________________________________

5. Child’s name: ___________________________________________

6. Child’s gender: Male or Female (circle one)

7. Child’s Date of Birth: _____________________________________ Age: __________

8. What is the primary language used in your home? (circle one):

English Spanish Chinese Other (specify):____________________

9. Do you consider your child to be Hispanic or Latino/a?

NO, NOT OF HISPANIC,
LATINO/A, OR SPANISH

ORIGIN………………………………………. [1]

YES, MEXICAN, MEXICAN AMERICAN,
CHICANO/A………………………………… [2]

YES, PUERTO RICAN……………………. [3]

YES, CUBAN………………………………… [4]

YES, ANOTHER HISPANIC,
LATINO/A, OR SPANISH ORIGIN [5]

10. Do you consider your child to be (READ LIST). You may select one or more:

WHITE [1]

BLACK OR AFRICAN AMERICAN [2]

AMERICAN INDIAN OR
ALASKA NATIVE [3]

ASIAN INDIAN [4]

CHINESE [5]

FILIPINO [6]

JAPANESE [7]

KOREAN [8]

VIETNAMESE [9]

OTHER ASIAN [10]

NATIVE HAWAIIAN [11]

GUAMANIAN OR CHAMORRO [12]

SAMOAN [13]

OTHER PACIFIC ISLANDER [14]

OTHER [SPECIFY] [15]

INTERVIEWER INSTRUCTION.

• CODE “OTHER” ONLY IF VOLUNTEERED

11. Does your child have any medical conditions? (circle one) Yes No

If yes, please explain: ___________________________________________________________________

12. What is the highest level of education that you completed? (circle one)

LESS THAN A HIGH SCHOOL
DIPLOMA OR GED [1]

HIGH SCHOOL DIPLOMA OR GED [2]

SOME COLLEGE BUT NO DEGREE [3]

ASSOCIATE DEGREE [4]

BACHELOR’S DEGREE (e.g., BA, BS) [5]

POST GRADUATE DEGREE
(e.g., Masters or Doctoral) [6]

REFUSED [-1]

DON’T KNOW [-2]

13. Of these income groups, which category best represents your combined family income during the last calendar year?

Less than $4,999 [1]

$5,000-$9,999 [2]

$10,000-$19,999 [3]

$20,000-$29,999 [4]

$30,000-$39,999 [5]

$40,000-$49,999 [6]

$50,000-$74,999 [7]

$75,000-$99,999 [8]

$100,000-$199,000 [9]

$200,000 or more [10]

REFUSED [-1]

DON’T KNOW [-2]

Thank you.

[OPTION ONE:] I will forward this information to our study staff. They will contact you at the number you provided if your child is eligible to participate.

[OPTION TWO:] Your child is eligible to participate in this study. I will forward this information to our study coordinator who will call you to set up a time to come in that is convenient for you. What are the best times of day to reach you? ______________________________________

[OPTION THREE:]I’m sorry, but your child is not eligible to participate in this study. However, if you are interested, I will keep your name and contact you if this changes or if we have any other studies that you may be interested in.

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-XXXX). Do not return the completed form to this address.