Social Responsiveness Scale Instructions

Attachment 6.d.1 – Social Responsiveness Scale Instructions

Social Responsiveness Scale (SRS) Instructions

Please complete this questionnaire about [FILL IN CHILD’S NAME] development.

The questionnaire should be completed in dark blue or black pen.

For each question, please circle the number that best describes this child’s behavior DURING THE PAST 6 MONTHS:

1 = Not True 2 = Somewhat True 3 = Often True 4 = Almost Always True

Please circle only one number.

If you make a mistake, please cross out the wrong answer with an X, and circle the correct answer. Please do not use scribble marks to make a correction.

Participation in this questionnaire is voluntary. There are no penalties for refusing to answer questions. However, your cooperation is very important to ensure complete and accurate results. Your participation is appreciated.

All answers that you give will be kept private. Because sensitive health information is collected in this study, <site> received a ‘Certificate of Confidentiality.’ This means that any information that <site> has that identifies you or your child will be used only for this project. It cannot be given to anyone else unless you give your written consent.

This Statement is provided pursuant to the Privacy Act of 1974 (5 U.S.C. § 552a): 

The information you are being asked to provide is authorized to be collected under the System of Records Notices 09-20-0136, Epidemiologic Studies and Surveillance of Disease Problems.  Providing this information is voluntary.  The principal purpose(s) for which CDC will use the information that you provide for SEED Teen are to (1) understand the health and development of a group of U.S. adolescents with and without autism or other developmental disabilities, including adolescents from diverse population groups; (2) provide information that local, state, and federal organizations could use to allocate resources that help U.S. adolescents and adults with autism or other developmental disabilities; and (3) provide information that could be useful to clinicians who treat U.S. adolescents and adults with autism or other developmental disabilities.  The information that you provide for SEED Teen will only be used to conduct the project. The information you provide will be included in a Privacy Act system of records, and will be used and may be disclosed for the purposes and routine uses described and published in the following System of Records Notice (SORN): 09-20-0136: Epidemiologic Studies and Surveillance of Disease Problems, [Federal Register: December 31, 1992 (Volume 57, Number 252)] [Notices] [Page 62812-62813].

If you have questions about the questionnaire you can call <site PI or project coordinator> at <phone number>. Please also call this number if you decide you would rather complete the questionnaire over the phone with the assistance of a SEED staff member.

Ver Feb 2018