NSCH "Healthy and Ready to Learn" Questions 2020 (Self-administered/English)

Attachment 1: Questions to be cognitively tested

Form Approved

OMB No. 0920-0222

Exp. Date: 08/31/2021

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The following questions are about your child’s health, learning, and development:

1. Is this child able to do the following: Understand 'in' 'on' and 'under?’

   1. Yes

   2. No

2. How often can this child recognize the beginning sound of a word? For example, the word “ball” starts with the “buh” sound?

   1. None of the time

   2. Some of the time

   3. Half of the time

   4. Most of the time

   5. All of the time

3. When you say a word, how often can this child come up with another word that starts with the same sound?

   1. None of the time

   2. Some of the time

   3. Half of the time

   4. Most of the time

   5. All of the time

4. Does this child repeat or sing rhymes?

   1. Yes

   2. No

5. If you say the word “cat”, how often can this child tell you a word that rhymes with “cat”?

   1. None of the time

   2. Some of the time

   3. Half of the time

   4. Most of the time

   5. All of the time

6. How often can this child explain things they have seen or done so that you understand?

   1. None of the time

   2. Some of the time

   3. Half of the time

   4. Most of the time

   5. All of the time

7. Is this child able to do the following: Ask questions that start with, who what where when?

   1. Yes

   2. No

8. Is this child able to do the following: Ask questions that start with why and how?

   1. Yes

   2. No

9. Can this child sort objects by: color?

   1. Yes

   2. No

10. Can this child sort objects by: shape?

    1. Yes

    2. No

11. Can this child sort objects by: size?

    1. Yes

    2. No

12. Can this child sort objects by: length?

    1. Yes

    2. No

13. How high can this child count correctly?

    1. Child cannot count

    2. Up to 5

    3. Up to 10

    4. Up to 15

    5. Up to 20

    6. Up to 30

14. If asked to count objects, how high could this child count correctly?

    1. Child cannot count

    2. Up to 5

    3. Up to 10

    4. Up to 15

    5. Up to 20

    6. Up to 30

15. If you had four objects, could this child divide them in half so you have two and they have two?

    1. Yes

    2. No

16. Can this child show you with their fingers how old they are?

    1. Yes

    2. No

17. Can this child read one-digit numbers like 4 or 7?

    1. Yes

    2. No

18. How often can this child correctly add two numbers, like 2 plus 3?

    1. None of the time

    2. Some of the time

    3. Half of the time

    4. Most of the time

    5. All of the time

19. How often can this child correctly subtract two numbers, like 5 take away 2?

    1. None of the time

    2. Some of the time

    3. Half of the time

    4. Most of the time

    5. All of the time

20. Can this child identify: a square?

    1. Yes

    2. No

21. Can this child identify: a circle?

    1. Yes

    2. No

22. Can this child identify: a triangle?

    1. Yes

    2. No

23. If shown two balls, could this point to the larger ball?

    1. Yes

    2. No

24. Can this child consistently write his or her first name, even if some of the letters aren’t quite right or are backwards?

    1. Yes

    2. No

25. How often does this child demonstrate an interest in books by choosing a children’s book and turning pages?

    1. None of the time

    2. Some of the time

    3. Half of the time

    4. Most of the time

    5. All of the time

26. How many letters of the alphabet can this child recognize?

    1. None of the time

    2. Some of the time

    3. Half of the time

    4. Most of the time

    5. All of the time

27. Can this child draw a: circle?

    1. Yes

    2. No

28. Can this child draw a: triangle?

    1. Yes

    2. No

29. Can this child draw a: square?

    1. Yes

    2. No

30. Can this child feed him/herself with a spoon with little spilling?

    1. Yes

    2. No

31. Can this child make a tower of three or more blocks?

    1. Yes

    2. No

32. Can this child open doors by turning a doorknob or handle?

    1. Yes

    2. No

33. Can this child draw a face with eyes and mouth?

    1. Yes

    2. No

34. Can this child draw a person with arms and legs?

    1. Yes

    2. No

35. When using a pencil, can he or she use fingers to hold it?

    1. Yes

    2. No

36. Can this child climb stairs with one foot on each stair?

    1. Yes

    2. No

37. Can this child jump forward at least six inches?

    1. Yes

    2. No

38. Can this child throw a ball overhand?

    1. Yes

    2. No

39. Can this child catch a large ball with both hands?

    1. Yes

    2. No

40. Can this child stand on one foot for at least 5 seconds?

    1. Yes

    2. No

41. Can this child kick a ball?

    1. Yes

    2. No

42. Can this child bounce a ball for several seconds?

    1. Yes

    2. No

43. In general, how would you describe this child’s health?

    1. Poor

    2. Fair

    3. Good

    4. Very good

    5. Excellent

44. To what extent do this child’s health conditions or problems affect his or her ability to do things?

    1. Daily activities consistently affected

    2. Often a great deal

    3. Daily activities moderately affected some of the time

    4. Does not have any conditions/Daily activities never affected

45. During the past 12 months, how often have this child's health conditions or problems affected his or her ability to do things other children his or her age do?

    1. Daily activities consistently affected

    2. Often a great deal

    3. Daily activities moderately affected some of the time

    4. Does not have any conditions/Daily activities never affected

46. How would you describe the condition of this child’s teeth?

    1. Poor

    2. Fair

    3. Good

    4. Very good

    5. Excellent

47. How often does this child show concern when they see others are hurt or unhappy?

    1. None of the time

    2. Some of the time

    3. Half of the time

    4. Most of the time

    5. All of the time

48. How much difficulty does this child have making or keeping friends?

    1. A lot of difficulty

    2. A little difficulty

    3. No difficulty

49. How often does this child play well with others?

    1. None of the time

    2. Some of the time

    3. Half of the time

    4. Most of the time

    5. All of the time

50. How often does this child physically fight with other children?

    1. None of the time

    2. Some of the time

    3. Half of the time

    4. Most of the time

    5. All of the time

51. How often does this child hit, kick, or bite other children?

    1. None of the time

    2. Some of the time

    3. Half of the time

    4. Most of the time

    5. All of the time

52. How often does this child lose their temper?

    1. None of the time

    2. Some of the time

    3. Half of the time

    4. Most of the time

    5. All of the time

53. Can this child recognize and name emotions in themselves?

    1. Yes

    2. No

54. How often does this child get distracted?

    1. None of the time

    2. Some of the time

    3. Half of the time

    4. Most of the time

    5. All of the time

55. When necessary, how often does this child listen to adults?

    1. None of the time

    2. Some of the time

    3. Half of the time

    4. Most of the time

    5. All of the time

56. How often does this child have trouble waiting for a turn?

    1. None of the time

    2. Some of the time

    3. Half of the time

    4. Most of the time

    5. All of the time

57. How often does this child take turns during games or fun activities?

    1. None of the time

    2. Some of the time

    3. Half of the time

    4. Most of the time

    5. All of the time

58. How often does this child keep working at a task after setbacks?

    1. None of the time

    2. Some of the time

    3. Half of the time

    4. Most of the time

    5. All of the time

59. How often does this child keep working at a task when things don’t work out?

    1. None of the time

    2. Some of the time

    3. Half of the time

    4. Most of the time

    5. All of the time

60. How often does this child have trouble calming down?

    1. None of the time

    2. Some of the time

    3. Half of the time

    4. Most of the time

    5. All of the time

61. Child bounces back easily when things do not go his/her way.

    1. None of the time

    2. Some of the time

    3. Half of the time

    4. Most of the time

    5. All of the time

62. How often does this child have difficulty when moving between one activity and a new one?

    1. None of the time

    2. Some of the time

    3. Half of the time

    4. Most of the time

    5. All of the time

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