Attach. 10 Children’s Behavior Questionnaire Very Short Form,
with EF extension (CBQ-VSF+EF) OMB #: 0925-0661
Executive Function Expiration Date: 06/30/2015
Name of test: Children's Behavior Questionnaire Very Short Form, with EF extension (CBQ-VSF+EF)
Estimated time burden: 10 minutes
Estimated number of items: 36 items
Description:
Version l
Subject No. _____________ Date of Child's Birth:
Today's Date ____________ ______ ______ ______
Month Day Year
Sex of Child ____________
Age of Child ______ ______
Years months
Instructions: Please read carefully before starting:
On the next pages you will see a set of statements that describe children's reactions to a number of situations. We would like you to tell us what your child's reaction is likely to be in those situations. There are of course no "correct" ways of reacting; children differ widely in their reactions, and it is these differences we are trying to learn about. Please read each statement and decide whether it is a "true" or "untrue" description of your child's reaction within the past six months. Use the following scale to indicate how well a statement describes your child:
Circle # If the statement is:
l extremely untrue of your child
2 quite untrue of your child
3 slightly untrue of your child
4 neither true nor false of your child
5 slightly true of your child
6 quite true of your child
7 extremely true of your child
If you cannot answer one of the items because you have never seen the child in that situation, for example, if the statement is about the child's reaction to your singing and you have never sung to your child, then circle NA (not applicable).
Please be sure to circle a number or NA for every item.
1. Seems always in a big hurry to get from one place to another.
l 2 3 4 5 6 7 NA
2. Gets quite frustrated when prevented from doing something s/he wants to do.
l 2 3 4 5 6 7 NA
3. When drawing or coloring in a book, shows strong concentration.
l 2 3 4 5 6 7 NA
4. Likes going down high slides or other adventurous activities.
l 2 3 4 5 6 7 NA
5. Is quite upset by a little cut or bruise.
l 2 3 4 5 6 7 NA
6. Prepares for trips and outings by planning things s/he will need.
l 2 3 4 5 6 7 NA
7. Often rushes into new situations.
l 2 3 4 5 6 7 NA
8. Tends to become sad if the family's plans don't work out.
l 2 3 4 5 6 7 NA
9. Likes being sung to.
l 2 3 4 5 6 7 NA
10. Seems to be at ease with almost any person.
l 2 3 4 5 6 7 NA
11. Is afraid of burglars or the "boogie man."
l 2 3 4 5 6 7 NA
12. Notices it when parents are wearing new clothing.
l 2 3 4 5 6 7 NA
13. Prefers quiet activities to active games.
l 2 3 4 5 6 7 NA
14. When angry about something, s/he tends to stay upset for ten minutes or longer.
l 2 3 4 5 6 7 NA
15. When building or putting something together, becomes very involved in what s/he is doing, and works for long periods.
l 2 3 4 5 6 7 NA
16. Likes to go high and fast when pushed on a swing.
l 2 3 4 5 6 7 NA
17. Seems to feel depressed when unable to accomplish some task.
l 2 3 4 5 6 7 NA
18. Is good at following instructions.
l 2 3 4 5 6 7 NA
19. Takes a long time in approaching new situations.
l 2 3 4 5 6 7 NA
20. Hardly ever complains when ill with a cold.
l 2 3 4 5 6 7 NA
21. Likes the sound of words, such as nursery rhymes.
l 2 3 4 5 6 7 NA
22. Is sometimes shy even around people s/he has known a long time.
l 2 3 4 5 6 7 NA
23. Is very difficult to soothe when s/he has become upset.
l 2 3 4 5 6 7 NA
24. Is quickly aware of some new item in the living room.
l 2 3 4 5 6 7 NA
25. Is full of energy, even in the evening.
l 2 3 4 5 6 7 NA
26. Is not afraid of the dark.
l 2 3 4 5 6 7 NA
27. Sometimes becomes absorbed in a picture book and looks at it for a long time.
l 2 3 4 5 6 7 NA
28. Likes rough and rowdy games.
l 2 3 4 5 6 7 NA
29. Is not very upset at minor cuts or bruises.
l 2 3 4 5 6 7 NA
30. Approaches places s/he has been told are dangerous slowly and cautiously.
l 2 3 4 5 6 7 NA
31. Is slow and unhurried in deciding what to do next.
l 2 3 4 5 6 7 NA
32. Gets angry when s/he can't find something s/he wants to play with.
l 2 3 4 5 6 7 NA
33. Enjoys gentle rhythmic activities such as rocking or swaying.
l 2 3 4 5 6 7 NA
34. Sometimes turns away shyly from new acquaintances.
l 2 3 4 5 6 7 NA
35. Becomes upset when loved relatives or friends are getting ready to leave following a visit.
l 2 3 4 5 6 7 NA
36. Comments when a parent has changed his/her appearance.
l 2 3 4 5 6 7 NA
Please check back to make sure you have completed all items by marking a number or "NA".
Thank you very much for your help!
Public
reporting burden for this collection of information is estimated to
average 10 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 (0925-0661). Do not return
the completed form to this address.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Abby Sivan |
| File Modified | 0000-00-00 |
| File Created | 2021-01-26 |