27.2 Survey

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

30M_BriefSymptomInventorySAQ

30-Month Interview

OMB: 0925-0593

Document [docx]
Download: docx | pdf

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Brief Symptom Inventory (BSI®) SAQ, Phase 2g

OMB Specification


Clone of Brief Symptom Inventory (BSI®) SAQ


Event Category:

Time-Based

Event:

30M

Administration:

N/A

Instrument Target:

Primary Caregiver

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

Estimated Administration Time:

9 minutes

Multiple Child/Sibling Consideration:

Per child

Special Considerations:

N/A

Version:

1.1

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.

Copyright © 1975, 2004 Leonard R. Derogatis, PhD.  All rights reserved.  Published and distributed exclusively by NCS Pearson, Inc.


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Clone of Brief Symptom Inventory (BSI®) SAQ



TABLE OF CONTENTS


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Clone of Brief Symptom Inventory (BSI®) 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.





BRIEF SYMPTOM INVENTORY (BSI®) SAQ


BSI00100. Your Name: ___________________________________

 

Your Gender: __________________________________


BSI00200/(BSI_DATE_COMP). Date Completed: |___|___|/|___|___|/|___|___|___|___|


BSI01000. The BSI test consists of a list of problems people sometimes have. Read each one carefully and circle the number of the response that best describes HOW MUCH THAT PROBLEM HAS DISTRESSED OR BOTHERED YOU DURING THE PAST 7 DAYS INCLUDING TODAY. Circle only one number for each problem. Do not skip any items. If you change your mind, draw an X through your original answer and then circle your new answer. Read the example before you begin. If you have any questions, please ask them now.


Label

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0



SOURCE

Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI01100. HOW MUCH WERE YOU DISTRESSED BY: 


BSI02000/(BSI_NERVOUS). Nervousness or shakiness inside


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI03000/(BSI_FAINTNESS). Faintness or dizziness


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI04000/(BSI_CONTROL_THOUGHTS). The idea that someone else can control your thoughts


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI05000/(BSI_BLAME_OTHERS). Feeling others are to blame for most of your troubles


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI06000/(BSI_MEMORY_TROUBLE). Trouble remembering things


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI07000/(BSI_ANNOY_EASY). Feeling easily annoyed or irritated


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI08000/(BSI_CHEST_PAIN). Pains in heart or chest


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI09000/(BSI_AFRAID_STREETS). Feeling afraid in open spaces or on the streets


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI10000/(BSI_SUICIDE_THOUGHTS). Thoughts of ending your life


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI11000/(BSI_NO_TRUST). Feeling that most people cannot be trusted


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI12000/(BSI_NO_APPETITE). Poor appetite


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI13000/(BSI_SCARED). Suddenly scared for no reason


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI14000/(BSI_TEMPER_OUTBURST). Temper outbursts that you could not control


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI15000/(BSI_LONELY_PEOPLE). Feeling lonely even when you are with people


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI16000/(BSI_BLOCKED). Feeling blocked in getting things done


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI17000/(BSI_LONELY). Feeling lonely


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI18000/(BSI_BLUE). Feeling blue


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI19000/(BSI_NO_INTEREST). Feeling no interest in things


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI20000/(BSI_FEARFUL). Feeling fearful


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI21000/(BSI_EASILY_HURT). Your feelings being easily hurt


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI22000/(BSI_PEOPLE_UNFRIENDLY). Feeling that people are unfriendly or dislike you


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI23000/(BSI_INFERIOR). Feeling inferior to others


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI24000/(BSI_NAUSEA). Nausea or upset stomach


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI25000/(BSI_WATCHED). Feeling that you are watched or talked about by others


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI26000/(BSI_TROUBLE_SLEEP). Trouble falling asleep


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI27000/(BSI_DOUBLECHECK). Having to check and double-check what you do


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI28000/(BSI_DIFFICULT_DECISION). Difficulty making decisions


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI29000/(BSI_FEAR_TRAVEL). Feeling afraid to travel on buses, subways, or trains


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI30000/(BSI_TROUBLE_BREATHE). Trouble getting your breath


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI31000/(BSI_HOT_COLD). Hot or cold spells


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI32000/(BSI_AVOID). Having to avoid certain things, places, or activities because they frighten you


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI33000/(BSI_MIND_BLANK). Your mind going blank


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI34000/(BSI_BODY_NUMB). Numbness or tingling in parts of your body


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI35000/(BSI_PUNISH_SINS). The idea that you should be punished for your sins


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI36000/(BSI_HOPELESS_FUTURE). Feeling hopeless about the future


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI37000/(BSI_TROUBLE_ CONCENTRATE). Trouble concentrating


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI38000/(BSI_WEAK_BODY). Feeling weak in parts of your body


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI39000/(BSI_TENSE). Feeling tense or keyed up


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI40000/(BSI_DEATH_THOUGHTS). Thoughts of death or dying


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI41000/(BSI_URGE_HARM). Having urges to beat, injure, or harm someone


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI42000/(BSI_URGE_BREAK). Having urges to break or smash things


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI43000/(BSI_SELF_CONSCIOUS). Feeling very self-conscious with others


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI44000/(BSI_UNEASY_CROWDS). Feeling uneasy in crowds, such as shopping or at a movie


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI45000/(BSI_NEVER_CLOSE). Never feeling close to another person


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI46000/(BSI_TERROR_SPELLS). Spells of terror or panic


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI47000/(BSI_ARGUE). Getting into frequent arguments


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI48000/(BSI_NERVOUS_ALONE). Feeling nervous when you are left alone


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI49000/(BSI_NO_CREDIT). Others not giving you proper credit for your achievements


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI50000/(BSI_RESTLESS). Feeling so restless you couldn't sit still


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI51000/(BSI_WORTHLESS). Feelings of worthlessness


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI52000/(BSI_ADVANTAGE). Feeling that people will take advantage of you if you left them


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI53000/(BSI_GUILT). Feelings of guilt


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.


BSI54000/(BSI_MIND_WRONG). The idea that something is wrong with your mind


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Brief Symptom Inventory (BSI®), Leonard R. Derogatis, Pearson Education, Inc.



FOR OFFICE USE ONLY:


FOU01000/(P_ID). ID Number - Participant ___________________________________


FOU02000/(R_P_ID). ID Number - Respondent: ________________________________


Public reporting burden for this collection of information is estimated to average 9 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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