MCHATInPersonMailInstructions

OMB #: 0925-0593

OMB Expiration Date: 08/31/2014

Neuro-Psychosocial M-CHAT™ Instructions: In-Person, Phase 2g

The National Children’s Study

M-CHAT™ Instructions

Questionnaire: (18M, 24M Events)

Thank you for agreeing to participate in the National Children’s Study (NCS) and completing the Modified Checklist for Autism in Toddlers (M-CHAT™). This questionnaire will take about 5 minutes to complete. It includes questions about children’s behavior. If you have more than one child in the NCS, please fill out a separate questionnaire for each child. You may use a pencil or pen to record your answers.

Your answers are important to us. We will keep everything that you tell us confidential.

Listed below are several points that you may find helpful in completing the questionnaire:

• Please write your name, your relationship to the child, and the date you completed the questionnaire where indicated on the form.

• The M-CHAT™ consists of a list of behaviors that children sometimes engage in.

• Answer the questions based on how your child usually is. If the behavior is rare (e.g., you’ve seen it only once or twice), please answer as if the child does not do it.

• Read each item carefully before you begin and circle the response (Yes or No) that best describes the child’s behavior.

• Please try not to skip any items and please circle only one answer for each item.

• If you change your mind about an answer, strike through your original answer and then select your new answer.

• Return the M-CHAT™ questionnaire according to the instructions printed on the next page.

If you have any questions, please call the local contact number located on the last page.

Thank you for taking the time to complete this questionnaire!

For Office Use Only:

Instructions for returning the questionnaire to the Regional Operations Center (ROC):

{Local instructions inserted by ROC. Provide the parent/caregiver with ROC-specific instructions for returning the questionnaire to the ROC here, such as instructions about the data collector retrieving the questionnaire at the in-person visit.

Insert ROC contact information label here.

NEU M-CHAT™ Instructions: In-Person, MDES 4.0, V2.0 1