Self Administered Forms (Mother)

Study to Explore Early Development

Attachment 8.l.

Green Folder – Materials to Fill Out and Return

Entire Packet Total Time: <95 or 110> Minutes

This packet can be completed by you at your home or we can ask you the questions over the phone or during a visit to our clinic office.

• <at select sites> Consent Form 5 Minutes

• Child Behavior Checklist 20 Minutes

Asks questions about any behavior problems your child may have. Also asks about his/her social skills.

• Social Responsiveness Scale 20 Minutes

Asks questions about how your child behaves in social settings.

• Child Health History 30 Minutes

Asks questions about medical diagnoses that a physician may have given your child. It also includes questions about gastrointestinal symptoms, sleep characteristics, and health insurance and health care.

• Maternal and Child Residential History 5 Minutes

Asks questions about where you lived during the year before the child was born and where the child has lived from birth to the current time.

• Maternal Medical History 10 Minutes

Asks questions about medical diagnoses that a physician or health care provider may have given you.

• Paternal Medical and Occupational History 10 Minutes

Asks questions about medical diagnoses that a physician or health care provider may have given your child’s biological father. Also asks occupational history questions about your child’s biological father.

• <at select sites> Services and Treatments 10 Minutes

Asks questions about different types of services or therapies your child may have received.

Time Sensitive. Please Complete and Return In the Envelopes Provided.

THANK YOU!

Version 9-2015 ASD Page 1 of 1