Form 1.1 Survey

Attach 1: Exemplar Telephone Screener OMB #: 0925-0661

Bayley-3 Short Form Exp. Date: 6/30/2015

Bayley-3 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 need to obtain some basic information to see whether your child is eligible for the study.

What is your name? ________________________________________

2. Are you the child’s parent or legally authorized representative? (Circle one)

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. Is your child currently enrolled in the National Children’s Study (NCS)? (Circle one)

Yes If Yes, then say, “Thank you for your time” and discontinue the call because

the child is not eligible for the study.

No If No, then continue with remainder of screener questions.

4. Parent/Guardian’s Address: _________________________________________________________

_________________________________________________________

5. Parent/Guardian’s Phone Number: __________________________________________

6. Child’s Name: ___________________________________________

7. Child’s Gender: (Circle one) Male Female

8a. Child’s Date of Birth: _____________________________________

8b. Child’s Age: __________

9. Who lives at home with you and [insert Child’s name]? (Include adults and children)

Name of caller: _____________________________ Relationship to child: _______________

Name: ____________________________________ Relationship to child: _______________

Name: ____________________________________ Relationship to child: _______________

Name: ____________________________________ Relationship to child: _______________

10. What is the primary language used in your home to speak to your child? (Circle one)

English Spanish Chinese Other (specify): ____________________

11. Are you Hispanic, Latino/a or Spanish origin? (One or more categories may be selected)

a. _____ No, not of Hispanic, Latin/a, or Spanish origin

b. _____ Yes, Mexican, Mexican American, Chicano/a

c. _____ Yes, Puerto Rican

d. _____ Yes, Cuban

e. _____ Yes, Another Hispanic, Latino/a or Spanish origin

12. What is your race? (One or more categories may be selected)

1. ____White

2. ____Black or African American

3. ____American Indian or Alaska Native

4. ____Asian Indian

5. ____Chinese

6. ____Filipino

7. ____Japanese

8. ____Korean

9. ____Vietnamese

10. ____Other Asian

11. ____Native Hawaiian

12. ____Guamanian or Chamorro

13. ____Samoan

14. ____Other Pacific Islander

12. Are you employed outside the home: (Circle one) Yes No

If Yes, how many hours? _____________

13. Is your child in some form of child care outside the home? (Circle one) Yes No

If Yes, how many hours a week? _____________

14. Was your child born prematurely? (Circle one) Yes No

If Yes, how many weeks premature? _____________

15. Does your child have any medical problems? (Circle one) Yes No

If Yes, please explain: ___________________________________________________________________

16. What is your household income per year? __________________________

OR Circle one if caller cannot be specific

1. Less than $4,999

2. $5,00-$9,999 per year

3. $10,000-$19,999 per year

4. $20,000-$29,999 per year

5. $30,000-$39,999 per year

6. $40,000-$49,999 per year

7. $50,000-$74,999 per year

8. $75,000-$99,999 per year

9. $100,000-$199,999 per year

10. $200,000 or more

11. Refused

12. Don’t know

17. What is the highest level of education that you completed? (Circle one)

1. Less than high school diploma or GED

2. High school or GED

3. Some college

4. Bachelor’s degree (i.e. BA/BS)

5. Post graduate degree (i.e.MA/MS, Ph.D.)

6. Refused

7. Don’t know

Thank you for your time.

Option one: I will forward this information to our study staff and they will see 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 is the best time 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 (0925-0661). Do not return the completed form to this address.

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