NCS Scheduled Assessment Summary
SECTION 1: This section should be completed by staff familiar with developmental assessment – but DOES NOT need to be completed by the diagnosing clinician
Name of person completing this section: ___________________________________________________________
Information in this box is for site use only, and is not to be entered into data system.
Subject ID #: _____________
Child Name: ____________________________________ Child Date of Birth: _____/_____/______
Date of Assessment: _____/_____/______
Scheduled Assessment Type (answer both questions):
Research or Clinical (check one) ASD Suspicion or Other Developmental Issue (check one)
□ for a research study □ because of suspect ASD
□ done as a clinical assessment □ because of other concern (no ASD suspected a priori)
Reported Major Comorbidities: Check if any of the following comorbidities were documented in record at the time of behavioral assessment.
□ Tuberous sclerosis |
□ Constipation |
□ Down syndrome |
□ Feeding problems |
□ Rett syndrome |
□ Other GI: __________________________________ |
□ Fragile X |
|
□ Neurofibromatosis |
□ Hypotonia |
□ Angelman;s |
□ Seizure DO |
□ NF-1 |
□ Other neurologic: ____________________________ |
□ Other genetic: _____________________________ |
|
Summary results from any ASD screeners (if available):
M-CHAT Standard ____________________ Date of administration: _____/_____/______
Best of 7 ____________________
SRS Summary (raw) ______________ Date of administration: _____/_____/______
Summary (t-score) ___________
PDDST-II ____________________________ Date of administration: _____/_____/______
SCQ ____________________________ Date of administration: _____/_____/______
ASSQ ____________________________ Date of administration: _____/_____/______
ESAT ____________________________ Date of administration: _____/_____/______
FYI ____________________________ Date of administration: _____/_____/______
Tool Score Date of administration
Other ____________________________ ____________ _____/_____/______
Other ____________________________ ____________ _____/_____/______
Cognitive
Functioning: Include available results from the most recent test
that was appropriate for the child’s age, and indicate whether
the score was from a test administered during the scheduled
assessment or from a prior visit.
Prior During Scheduled
Test
administered: Visit Assessment Date
.
□ Mullen
□ □
_____/_____/______
□ Wechsler
□ □
_____/_____/______
(any
of the following: WISC, WAIS, WASI, WPPSI)
□ Stanford-Binet
(SB-IV, SB-V) □ □
_____/_____/______
□ Differential
Abilities Scale (DAS) □ □
_____/_____/______
□ Kaufman
(either KABC or KBIT) □ □
_____/_____/______
□ Leiter □ □
_____/_____/______
□ Merrill-Palmer-Revised
(2005 revision) □ □
_____/_____/______
□ Other:
_________________________ □ □
_____/_____/______
Guidelines for translating scores from tests to the following summaries will be provided.
Nonverbal score: _______
Verbal score: _______
Composite score: _______
ADOS Scores: Please ONLY report results from assessment performed at the scheduled assessment visit.
Check one:
□ ADOS not performed this visit (skip to past ADOS question)
□ ADOS performed (complete module, scoring, reliability, and past ADOS questions)
Module:
□ 1 □ 2
Complete
scoring information for at least one algorithm-
if information from both algorithms are available, complete both.
Score
- Original Algorithm
Communication
domain score: _______
□ Met for ASD □ Met for Autism □ Did
not meet for ASD/Autism
Social
domain score: _______
□
Met for ASD □ Met for Autism □ Did not meet
for ASD/Autism
Summary
score: _______
□
Met for ASD □ Met for Autism □ Did not meet
for ASD/Autism
Score
– New Algorithm
Social
Affect: _______
□
Met for ASD □ Met for Autism □ Did not meet
for ASD/Autism
Restricted,
Repetitive Behaviors: _______
□
Met for ASD □ Met for Autism □ Did not meet
for ASD/Autism
Summary
score: _______
Assessor reliability: Please indicate whether the assessor completing the ADOS was research-reliable.
□ Yes
□ No
Past ADOS: Is there any indication that the child was evaluated with an ADOS prior to this visit.
□ Yes Date: ___/ _____ (mos/yr)
□ No
ADI Scores: Please ONLY report results from assessment performed at the scheduled assessment visit.
Check one:
□ ADI not performed this visit (skip to past ADI question)
□ ADI performed (complete scoring, reliability, and past ADI questions)
Complete scoring information:
Social Interaction: __________
Communication and language: __________
Restricted and repetitive behaviors: __________
Assessor reliability: Please indicate whether the assessor completing the ADI was research-reliable.
□ Yes
□ No
Past ADOS: Is there any indication that the child was evaluated with an ADI prior to this visit.
□ Yes Date: ___/ _____ (mos/yr)
□ No
SECTION 2: This section must be completed within 24 hours of the scheduled assessment visit by a clinician who saw the child during the scheduled assessment visit and who is qualified to make ASD diagnoses.
Name of person completing this section: ___________________________________________________________
If the child was seen at the scheduled assessment because of suspect ASD (as recorded above) complete Part A below. If the child was seen at the scheduled assessment other developmental concerns with no a priori ASD suspicion complete Part B below.
PART A: Complete for subjects being evaluated for suspect ASD:
ASD DSM Diagnosis (check one):
Child meets criteria for an ASD (autistic disorder, Asperger’s disorder, PDD-NOS)
Child does not meet criteria for an ASD
Confidence Ratings: How certain are you that the above determination about an ASD diagnosis is accurate?
□ 1 (extremely certain)
□ 2
□ 3
□ 4
□ 5 (extremely uncertain)
Before completing your own assessment, but after reviewing the child’s records and preparing for the visit, how confident were you that he or she would receive this ASD diagnostic determination? Remember, this question is specific to your feelings before meeting the child, based only on the available records and visit preparation.
□ 1 (extremely certain)
□ 2
□ 3
□ 4
□ 5 (extremely uncertain)
Other DSM Diagnoses: Please list any other DSM diagnoses assigned based on this evaluation
1) _______________________________________________________________
2) _______________________________________________________________
3) _______________________________________________________________
4) _______________________________________________________________
PART B: Complete for subjects being evaluated for other developmental concerns with no a priori ASD suspicion:
DSM Diagnoses: Please list any DSM diagnoses assigned based on this evaluation
1) _______________________________________________________________
2) _______________________________________________________________
3) _______________________________________________________________
4) _______________________________________________________________
Confidence that the subject DOES NOT have ASD:
How certain are you that the subject does not have an ASD:
□ 1 (extremely certain)
□ 2
□ 3
□ 4
□ 5 (extremely uncertain)
Was this subject referred for further ASD assessment:
□ Yes
□ No
Was this subject diagnosed with an ASD (autistic disorder, Asperger’s disorder, PDD-NOS)
□ Yes
□ No
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | ADULT BLOOD DRAW INFORMATION FORM |
| Author | Children's Hospital of Philadelphia |
| File Modified | 0000-00-00 |
| File Created | 2021-01-26 |