15.2 Survey

Continuation of National Children's Study Vanguard (Pilot) Study Data Collection: Study Visits through 60-Months

MCHATSAQ

18-Month Interview

OMB: 0925-0593

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OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Modified Checklist for Autism in Toddlers (M-CHAT) SAQ, Phase 2g

OMB Specification


Modified Checklist for Autism in Toddlers (M-CHAT) SAQ


Event Category:

Time-Based

Event:

18M, 24M

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;
Web, CAI

Estimated Administration Time:

5 minutes

Multiple Child/Sibling Consideration:

Per Child

Special Considerations:

N/A

Version:

2.0

MDES Release:

4.0


*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.


© 1999 Diana Robins, Deborah Fein, & Marianne Barton


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Modified Checklist for Autism in Toddlers (M-CHAT) SAQ



TABLE OF CONTENTS





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Modified Checklist for Autism in Toddlers (M-CHAT) 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.





M-CHAT SAQ


MS00100/(RESP_NAME). Your name: _________________________________________


SOURCE

New


MS00200/(RESP_REL_CHILD). Your relationship to the child: ________________________________


SOURCE

New


MS00300/(MCHAT_DATE). Date completed: _________________________


SOURCE

New


MS01000. Please fill out the following about your child’s usual behavior, and try to answer every question. If the behavior is rare (you’ve only seen it once or twice), please answer as if your child does not do it.


SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton


MS02000/(MCHAT_SWUNG). Does your child enjoy being swung, bounced on your knee, etc.?


Label

Code

Go To

Yes

1


No

2



SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton


MS03000/(MCHAT_CHILDREN). Does your child take an interest in other children?


Label

Code

Go To

Yes

1


No

2



SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton


MS04000/(MCHAT_CLIMB). Does your child like climbing on things, such as up stairs?


Label

Code

Go To

Yes

1


No

2



SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton


MS05000/(MCHAT_HIDE). Does your child enjoy playing peek-a-boo/hide-and-seek? 


Label

Code

Go To

Yes

1


No

2



SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton


MS06000/(MCHAT_PRETEND). Does your child ever pretend, for example, to talk on the phone or take care of a doll or pretend other things?


Label

Code

Go To

Yes

1


No

2



SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton


MS07000/(MCHAT_ASK). Does your child ever use his/her index finger to point, to ask for something?


Label

Code

Go To

Yes

1


No

2



SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton


MS08000/(MCHAT_INTEREST). Does your child ever use his/her index finger to point, to indicate interest in something?


Label

Code

Go To

Yes

1


No

2



SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton


MS09000/(MCHAT_TOYS). Can your child play properly with small toys (e.g. cars or blocks) without just mouthing, fiddling, or dropping them?


Label

Code

Go To

Yes

1


No

2



SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton


MS10000/(MCHAT_OBJECTS). Does your child ever bring objects over to you (parent) to show you something?


Label

Code

Go To

Yes

1


No

2



SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton


MS11000/(MCHAT_EYE). Does your child look you in the eye for more than a second or two?


Label

Code

Go To

Yes

1


No

2



SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton


MS12000/(MCHAT_NOISE). Does your child ever seem oversensitive to noise? (e.g., plugging ears)


Label

Code

Go To

Yes

1


No

2



SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton


MS13000/(MCHAT_SMILE). Does your child smile in response to your face or your smile?


Label

Code

Go To

Yes

1


No

2



SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton


MS14000/(MCHAT_IMITATE). Does your child imitate you? (e.g., you make a face-will your child imitate it?)


Label

Code

Go To

Yes

1


No

2



SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton


MS15000/(MCHAT_NAME). Does your child respond to his/her name when you call?


Label

Code

Go To

Yes

1


No

2



SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton


MS16000/(MCHAT_POINT). If you point at a toy across the room, does your child look at it?


Label

Code

Go To

Yes

1


No

2



SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton


MS17000/(MCHAT_WALK). Does your child walk?


Label

Code

Go To

Yes

1


No

2



SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton


MS18000/(MCHAT_LOOK). Does your child look at things you are looking at?


Label

Code

Go To

Yes

1


No

2



SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton


MS19000/(MCHAT_FINGER). Does your child make unusual finger movements near his/her face?


Label

Code

Go To

Yes

1


No

2



SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton


MS20000/(MCHAT_ATTENTION). Does your child try to attract your attention to his/her own activity?


Label

Code

Go To

Yes

1


No

2



SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton


MS21000/(MCHAT_DEAF). Have you ever wondered if your child is deaf?


Label

Code

Go To

Yes

1


No

2



SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton


MS22000/(MCHAT_UNDERSTAND). Does your child understand what people say?


Label

Code

Go To

Yes

1


No

2



SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton


MS23000/(MCHAT_STARE). Does your child sometimes stare at nothing or wander with no purpose?


Label

Code

Go To

Yes

1


No

2



SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton


MS24000/(MCHAT_REACTION). Does your child look at your face to check your reaction when faced with something unfamiliar?


Label

Code

Go To

Yes

1


No

2



SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton



FOR OFFICE USE ONLY


FOU01000. Child Participant Name:_______________


FOU03000/(P_ID). Child Participant ID:_______________


FOU04000. Parent/Caregiver Name:_______________


FOU06000/(R_P_ID). Parent/Caregiver ID:_______________


FOU07000. Relationship to Child:_______________________________________


FOU09000/(MCHAT_DATE_COMP). Date of completion: ___ /___ / _____


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 (0925-0593). Do not return the completed form to this address.

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