4 Ages and Stages Social Emotional Questionnaire

Attach. 11 Ages and Stages Social Emotional Questionnaire OMB #: 0925-0661

Executive Function Expiration Date: 06/30/2015

Name of test: Ages and Stages Social Emotional Questionnaire (ASQ:SE)

Estimated time burden: 10 minutes

Estimated number of items: 30 items

Summary:

The Ages and Stages Social Emotional Questionnaire (ASQ:SE) is a parent-completed questionnaire that aims to identify young children at risk for social or emotional difficulties. There are questionnaires appropriate at 30, 36, 48, and 60 months of age: all ages that are included in the proposed study. ASQ:SE has been investigated with more than 3,000 children across the age intervals and their families. Its reliability was found to be 94%, while the validity was between 75% and 89%.

This is a questionnaire published and copyrighted by Brookes Publishing; as such, we do not have permission to share items or other published information with third parties. For more information about this test, please visit the test publisher’s website:

http://www.brookespublishing.com/resource-center/screening-and assessment/asq/asq-se/

Public reporting burden for this collection of information is estimated to average 10 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. 1