27.3 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Infant/Toddler Sensory Profile™ SAQ, Phase 2g

OMB Specification

Infant/Toddler Sensory Profile™ SAQ

Event Category:	Time-Based
Event:	30M
Administration:	N/A
Instrument Target:	Child
Instrument Respondent:	Primary Caregiver
Domain:	Neuro-Psychosocial
Document Category:	Scored Assessment
Method:	Self-Administered
Mode (for this instrument*):	In-Person, PAPI
OMB Approved Modes:	In-Person, PAPI; Phone, PAPI
Estimated Administration Time:	15 minutes
Multiple Child/Sibling Consideration:	Per Child
Special Considerations:	N/A
Version:	2.0
MDES Release:	4.0

Copyright © 2002 NCS Pearson, Inc.  All rights reserved.  *This instrument is OMB-approved for multi-mode administration but this version of the instrument is designed for administration in this/these mode(s) only.

Copyright © 2002 NCS Pearson, Inc.  All rights reserved. 

This page intentionally left blank.

Infant/Toddler Sensory Profile™ SAQ

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

INFANT/TODDLER SENSORY PROFILE 3

FOR OFFICE USE ONLY: 17

This page intentionally left blank.

Infant/Toddler Sensory Profile™ SAQ

GENERAL PROGRAMMER INSTRUCTIONS:

WHEN PROGRAMMING INSTRUMENTS, VALIDATE FIELD LENGTHS AND TYPES AGAINST THE MDES TO ENSURE DATA COLLECTION RESPONSES DO NOT EXCEED THOSE OF THE MDES. SOME GENERAL ITEM LIMITS USED ARE AS FOLLOWS:

DATA ELEMENT FIELDS	MAXIMUM CHARACTERS PERMITTED	DATA TYPE	PROGRAMMER INSTRUCTIONS
ADDRESS AND EMAIL FIELDS	100	CHARACTER
UNIT AND PHONE FIELDS	10	CHARACTER
_OTH AND COMMENT FIELDS	255	CHARACTER	Limit text to 255 characters
FIRST NAME AND LAST NAME	30	CHARACTER	Limit text to 30 characters
ALL ID FIELDS	36	CHARACTER
ZIP CODE	5	NUMERIC
ZIP CODE LAST FOUR	4	NUMERIC
CITY	50	CHARACTER
DOB AND ALL OTHER DATE FIELDS (E.G., DT, DATE, ETC.)	10	NUMERIC CHARACTER	DISPLAY AS MM/DD/YYYY STORE AS YYYY-MM-DD HARD EDITS: MM MUST EQUAL 01 TO 12 DD MUST EQUAL 01 TO 31 YYYY MUST BE BETWEEN 1900 AND CURRENT YEAR.
TIME VARIABLES	TWO-DIGIT HOUR AND TWO-DIGIT MINUTE, AM/PM DESIGNATION	NUMERIC	HARD EDITS: HOURS MUST BE BETWEEN 00 AND 12; MINUTES MUST BE BETWEEN 00 AND 59

Instrument Guidelines for Participant and Respondent IDs:

PRENATALLY, THE P_ID IN THE MDES HEADER IS THAT OF THE PARTICIPANT (E.G. THE NON-PREGNANT WOMAN, PREGNANT WOMAN, OR THE FATHER).

POSTNATALLY, A RESPONDENT ID WILL BE USED IN ADDITION TO THE PARTICIPANT ID BECAUSE SOMEBODY OTHER THAN THE PARTICIPANT MAY BE COMPLETING THE INTERVIEW. FOR EXAMPLE, THE PARTICIPANT MAY BE THE CHILD AND THE RESPONDENT MAY BE THE MOTHER, FATHER, OR ANOTHER CAREGIVER. THEREFORE, MDES VERSION 2.2 AND ALL FUTURE VERSIONS CONTAIN A R_P_ID (RESPONDENT PARTICIPANT ID) HEADER FIELD FOR EACH POST-BIRTH INSTRUMENT. THIS WILL ALLOW ROCs TO INDICATE WHETHER THE RESPONDENT IS SOMEBODY OTHER THAN THE PARTICIPANT ABOUT WHOM THE QUESTIONS ARE BEING ASKED.

A REMINDER:

ALL RESPONDENTS MUST BE CONSENTED AND HAVE RECORDS IN THE PERSON, PARTICIPANT, PARTICIPANT_CONSENT AND LINK_PERSON_PARTICIPANT TABLES, WHICH CAN BE PRELOADED INTO EACH INSTRUMENT. ADDITIONALLY, IN POST-BIRTH QUESTIONNAIRES WHERE THERE IS THE ABILITY TO LOOP THROUGH A SET OF QUESTIONS FOR MULTIPLE CHILDREN, IT IS IMPORTANT TO CAPTURE AND STORE THE CORRECT CHILD P_ID ALONG WITH THE LOOP INFORMATION. IN THE MDES VARIABLE LABEL/DEFINITION COLUMN, THIS IS INDICATED AS FOLLOWS: EXTERNAL IDENTIFIER: PARTICIPANT ID FOR CHILD DETAIL.

INFANT/TODDLER SENSORY PROFILE

ISP01000. INSTRUCTIONS: Please check the box that best describes the frequency with which your child does the following behaviors. Please answer all of the statements. If you are unable to comment because you have not observed the behavior or believe that it does not apply to your child, please select "Does Not Apply" for that item. Write any comments at the end of the questionnaire.

 

Use the following key to mark your responses:

• ALMOST ALWAYS - When presented with the opportunity, your child almost always responds in this manner, 90% or more of the time.

• FREQUENTLY - When presented with the opportunity, your child frequently responds in this manner, about 75% of the time. 

• OCCASIONALLY - When presented with the opportunity, your child occasionally responds in this manner, about 50% of the time.

• SELDOM - When presented with the opportunity, your child seldom responds in this manner, about 25% of the time.

• ALMOST NEVER - When presented with the opportunity, your child almost never? responds in this manner, 10% or less of the time.

ISP02000. Child's Name: ________________________________________

ISP03000/(SP_DATE_COMP). Date Completed: ______________________________________________

ISP04000/(SP_7_DETERIORATE). My child's behavior deteriorates when the schedule changes.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP05000/(SP_7_AVOID_PLAY). My child avoids playing with others.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP06000/(SP_7_WITHDRAWS). My child withdraws from situations.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP07000/(SP_7_LOUD_ATTN). I have to speak loudly to get my child's attention.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP08000/(SP_7_TOUCH_ATTN). I have to touch my child to gain attention.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP09000/(SP_7_SOUND_MOUTH). My child enjoys making sounds with his/her mouth.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP10000/(SP_7_LONG_RESPOND). My child takes a long time to respond, even to familiar voices.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP11000/(SP_7_STARTLE). My child startles easily at sound, compared to other children the same age.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP12000/(SP_7_DISTRACT). My child is distracted and/or has difficulty eating in noisy environments.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP13000/(SP_7_IGNORES). My child ignores me when I am talking.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP14000/(SP_7_ESCAPE_NOISE). My child tries to escape from noisy environments.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP15000/(SP_7_TOY_NOISE). My child finds ways to make noise with toys.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP16000/(SP_7_RESPOND_NAME). It takes a long time for my child to respond to his/her name when it is called.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP17000/(SP_7_LOOK_SPIN). My child enjoys looking at moving or spinning objects (for example, ceiling fans, toys with wheels, floor fans).

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP18000/(SP_7_LOOK_SHINY). My child enjoys looking at shiny objects.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP19000/(SP_7_AVOID_EYE). My child avoids eye contact with me.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP20000/(SP_7_REFUSE_BOOKS). My child refuses to look at books with me.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP21000/(SP_7_NO_RECOGNIZE). My child does not recognize self in mirror.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP22000/(SP_7_REFLECTION). My child enjoys looking at own reflection in the mirror.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP23000/(SP_7_BRIGHT_TV). My child prefers fast-paced, brightly colored TV shows.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP24000/(SP_7_RESIST_HOLD). My child resists being held.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP25000/(SP_7_AGITATE_HAIR). My child becomes agitated when having hair washed.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP26000/(SP_7_AVOID_FACE). My child avoids getting face/nose wiped.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP27000/(SP_7_DISTRESS_TRIM). My child is distressed when having nails trimmed.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP28000/(SP_7_RESIST_CUDDLE). My child resists being cuddled.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP29000/(SP_7_BATH_CHANGES). My child is upset by changes in the bath water temperature, from one bath to the next.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP30000/(SP_7_AVOID_ROUGH). My child avoids contact with rough or cold surfaces (for example, squirms, arches, cries).

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP31000/(SP_7_UPSET_MESSY). My child becomes very upset if own clothing, hands, and/or face are messy.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP32000/(SP_7_UPSET_TEMP). My child gets upset with extreme differences in room temperature (for example, hotter, colder).

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP33000/(SP_7_ANXIOUS_SURFACE). My child becomes anxious when walking or crawling on certain surfaces (for example, grass, carpet, tile).

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP34000/(SP_7_PLAY_FOOD). My child enjoys playing with food.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP35000/(SP_7_SEEK_VIBRATE). My child seeks opportunities to feel vibrations (for example, stereo speakers, washer, dryer).

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP36000/(SP_7_BUMPS). My child bumps into things, seeming to not notice objects in the way.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP37000/(SP_7_SPLASH_BATH). My child enjoys splashing during bath time.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP38000/(SP_7_HANDS_TEXTURES). My child uses hands to explore food and other textures.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP39000/(SP_7_SUPPORT_SIT). My child requires more support for sitting than other children the same age (for example, infant seat, pillows, towel roll).

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP40000/(SP_7_ENJOY_PHYS). My child enjoys physical activity (for example, bouncing, being held up high in the air).

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP41000/(SP_7_ENJOY_RHYTHM). My child enjoys rhythmical activities (for example, swinging, rocking, car rides).

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP42000/(SP_7_UPSET_DIAPER). My child becomes upset when placed on back to change diapers.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP43000/(SP_7_RESIST_TIP). My child resists having head tipped back during bathing.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP44000/(SP_7_CRIES_MOVE). My child cries or fusses whenever I try to move him/her.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP45000/(SP_7_LICK_NONFOOD). My child licks/chews on nonfood objects.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP46000/(SP_7_MOUTH_OBJECT). My child mouths objects.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP47000/(SP_7_UNAWARE_FOOD). My child is unaware of food or liquid left on lips.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP48000/(SP_7_REFUSE_FOOD). My child refuses all but a few food choices.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP49000/(SP_7_NO_TOOTHBRUSH). My child resists having teeth brushed.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP50000/(SP_7_NO_CUP). My child refuses to drink from a cup.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP51000/(SP_7_NO_NEW_FOODS). My child refuses to try new foods.

Label	Code	Go To
Almost Always	1
Frequently	2
Occasionally	3
Seldom	4
Almost Never	5
Does Not Apply	-7

SOURCE

Infant/Toddler Sensory Profile®, Winnie Dunn, Pearson Education, Inc.

ISP52000. Comments: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

FOR OFFICE USE ONLY:

FOU01000/(P_ID). Child's Participant ID:______________________________

FOU02000/(R_P_ID). PARENT/CAREGIVER ID:__________________________________

Public reporting burden for this collection of information is estimated to average 15 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.