changed information circled Date information is unchanged Mid-Project Update

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1 SECTION - ABOUT YOUR CHILD S HEALTH AND WELL BEING USE THE CHECKLIST BELOW TO TRACK CHANGES. REVIEW INFORMATION IN THIS SECTION WITH RESPONDENT EACH AND CHECK BOX INDICATING IF DATA IS THE SAME OR HAS CHANGED. Data Collection Point Mid-Project Data Collection Point Data Collection Point Data Collection Point NOW I AM GOING TO ASK YOU QUESTIONS ABOUT [CHILD] S BIRTH HISTORY AND HEALTH.. How much did [CHILD] weigh at birth? NOTE: IF PARENT ANSWERS IN KILOGRAMS, CONVERT TO GRAMS. KILOGRAM =,000 GRAMS. Was [CHILD] born or more weeks before he/she was due? NOTE: WEEKS OF PREGNANCY OR LESS lbs. (0-0) oz. (0-) grams (00-) DON T KNOW REFUSED YES NO DON T KNOW REFUSED If no, don t know or refused, go to question. Section - About Your Child s Health and Well-Being- Family Interview- Demographics Page of NECTC, 00 NECTC Training Manual-Appendix A

2 . a) If child was premature, how many weeks early was he/she? a) WEEKS (-0) DON T KNOW REFUSED b) [CHILD] WAS BORN AT b) WEEKS (0-) MONTHS (-) DON T KNOW REFUSED. NOTE: IF CHILD WAS BORN 0+ WEEKS EARLY, PLEASE VERIFY. So, [CHILD] was born at _ weeks?. Was [CHILD] a twin, triplet, or other children born as part of a multiple birth?. Were there any complications in [CHILD] s birth or delivery?. As a newborn baby, did the child stay in the hospital after he/she was born because of medical problems? YES NO DON T KNOW REFUSED YES NO DON T KNOW REFUSED YES NO DON T KNOW REFUSED YES NO DON T KNOW REFUSED If no, don t know or refuses go to question 0. Section - About Your Child s Health and Well-Being- Family Interview- Demographics Page of NECTC, 00 NECTC Training Manual-Appendix A

3 . How many nights did [CHILD] stay in the hospital when he/she was born?. Was he/she in intensive care during that time? NIGHTS (-0 NIGHTS) DON T KNOW REFUSED YES NO DON T KNOW REFUSED 0. Since [CHILD] came home from the hospital after he/she was born, how many nights has he/she stayed overnight in a hospital? NOTE: AFTER, ASK: Since the last time we spoke, how many nights has [CHILD] stayed overnight in the hospital? Number (0-0) days Number weeks Number months Number years. Does [CHILD] have a diagnosed developmental delay, disability, or medical disease/condition? NOTE: AFTER ASK: Has child s diagnosis, developmental delay, disability, or medical/disease condition changed or have additional diagnoses been added? YES NO DON T KNOW REFUSED If no, don t know, or refuses go to question. Section - About Your Child s Health and Well-Being- Family Interview- Demographics Page of NECTC, 00 NECTC Training Manual-Appendix A

4 . What is [CHILD] s diagnosed condition/developmental problem or delay? ON NEXT PAGE, CIRCLE ALL NUMBERS THAT APPLY FOR EACH DATA COLLECTION POINT, THEN PLACE A * NEXT TO PRIMARY DIAGNOSED CONDITION, DEVELOPMENTAL PROBLEM OR DELAY. HAS NO PROBLEM/ DISABILITY/NOT GETTING SPECIAL SERVICES AMPUTATION OF A LIMB DIABETES DOWN S SYNDROME LANGUAGE LEARNING DISABILITY/LEARNING HANDICAP (LD) APHASIA 0 DYSLEXIA LEUKEMIA ARTHRITIS DYSPHAGIA ASPERGER S SYNDROME ASTHMA ATTENTION DEFICIT DISORDER (ADD) EDUCATIONAL HANDICAP (EH) EDUCATIONAL DISABILITY (ED) EMOTIONAL DISTURBANCE (ED, HAVING EMOTIONAL PROBLEMS, SED, SEM) MENTAL RETARDATION (EMR, TMR, SMR, MR) MULTIPLE SCLEROSIS (MS) 0 MUSCULAR DYSTROPHY NEUROLOGICAL AUTISM EMPHYSEMA NEUROSIS 0 BEHAVIOR DISORDER (BD) BLINDNESS/COMPLETE BLINDNESS ENCEPHALITIS ORGANIC BRAIN INJURY 0 EPILEPSY CEREBRAL PALSY (CP) FINE MOTOR SKILLS COMMUNICATION / DELAY/ DISABILITY CYSTIC FIBROSIS (CF) 0 DEAFNESS DEAFNESS AND BLINDNESS GROSS MOTOR SKILLS HEALTH (SPECIFY DISEASE) HEARING / HARD OF HEARING PARAPLEGIA OR PARTIAL PARALYSIS PHYSICAL OR ORTHOPEDIC SLOW / JUST SLOW DIFFICULTY WITH SOCIAL SKILLS SPEECH / DELAY/DISABILITY SPINA BIFIDA STROKE POLIO PSYCHOSIS QUADRAPLEGIA OR COMPLETE PARALYSIS HEART DISEASE READING DIFFICULTY TRAUMATIC BRAIN INJURY (TBI) TROUBLE WITH SCHOOL SUBJECT (E.G., MATH OR READING) VISUAL / PARTIAL SIGHT SENSORY INTEGRATION DISORDER FETAL ALCOHOL SYNDROME PRENATAL DRUG AND ALCOHOL EXPOSURE FAILURE TO THRIVE REACTIVE ATTACHMENT DISORDER OTHER (SPECIFY): OTHER (SPECIFY): DEPRESSION HEMOPHILIA 0 SCHIZOPHRENIA DON T KNOW HYPERACTIVE/ DEVELOPMENTAL ATTENTION DEFICIT DIFFICULTY WITH SELF DISABILITY OR DELAY REFUSED HYPERACTIVITY HELP SKILLS (DD) DISORDER (ADHD) Section - About Your Child s Health and Well-Being- Family Interview- Demographics Page of NECTC, 00 NECTC Training Manual-Appendix A

5 Section - About Your Child s Health and Well-Being- Family Interview- Demographics Page of NECTC, 00 NECTC Training Manual-Appendix A

6 . How many months old was [CHILD] when the concern(s) was (were) first identified? IF THERE ARE MULTIPLE CONCERNS RAISED AT DIFFERENT TIMES, WE WANT THE EARLIEST AGE AT WHICH ANY OF THE CONCERNS WERE RAISED. PROBE FOR A WHOLE NUMBER OF MONTHS.. At that time did you discuss the concern with the child s doctor or another professional?. How helpful was the professional (e.g. physician, nurse, speech therapist) that you discussed the concern with at that time?. Did [CHILD] ever have frequent or repeated ear infections?. Has [CHILD] s vision or hearing been evaluated by a professional? BEFORE BIRTH AT BIRTH LESS THAN MONTH MONTHS: (-0) DON T KNOW REFUSED If don t know or refuses go to Section. YES NO DON T KNOW REFUSED If no, don t know, or refuses go to Section. VERY HELPFUL SOMEWHAT HELPFUL NOT AT ALL HELPFUL MIXED; SOME HELPFUL, SOME NOT DON T KNOW REFUSED YES NO DON T KNOW REFUSED YES NO DON T KNOW REFUSED Section - About Your Child s Health and Well-Being- Family Interview- Demographics Page of NECTC, 00 NECTC Training Manual-Appendix A

7 . Does [CHILD] wear a hearing aid?. Does the [CHILD] wear glasses? 0. Compared with other children about the same age, would you say [his/her] general health is... YES NO DON T KNOW REFUSED YES NO DON T KNOW REFUSED EXCELLENT VERY GOOD GOOD FAIR POOR DON T KNOW REFUSED Section - About Your Child s Health and Well-Being- Family Interview- Demographics Page of NECTC, 00 NECTC Training Manual-Appendix A