BITSEAInPersonMailInstructions

OMB #: 0925-0593

OMB Expiration Date: 08/31/2014

Neuro-Psychosocial BITSEA™ Instructions: In-Person and Mail, Phase 2g

The National Children’s Study

BITSEA™ Instructions

Questionnaire

Thank you for agreeing to participate in the National Children’s Study (NCS) and completing the Brief Infant-Toddler Social and Emotional Assessment (BITSEA™). This questionnaire will take about 10 minutes to complete. It includes questions about children’s social and emotional behavior. If you have more than one child in the NCS, please fill out a separate questionnaire for each child. You may use a pencil or pen to record your answers.

Your answers are important to us. We will keep everything that you tell us confidential.

Listed below are several points that you may find helpful in completing the questionnaire:

• Please write today’s date, your child’s name, your name, and your relationship to child where indicated on the first page of the questionnaire.

• The BITSEA™ includes items that describe children’s social and emotional behaviors.

• Read each item carefully and then mark the response that best describes your child’s behavior over the past MONTH.

• There are no right or wrong answers.

• Please try not to skip any items and please mark only one number for each item.

• If you change your mind about an answer, strike out your original answer and then select your new answer.

• Before returning the questionnaire to the Regional Operations Center, please make sure you have answered all the items and that there is only one answer for each item.

• Please follow the directions printed on the last page of the questionnaire for returning the BITSEA to the Regional Operations Center (ROC).

If you have any questions, please call the local contact number located on the last page.

Thank you for taking the time to complete this questionnaire!

For Office Use Only:

Instructions for returning the questionnaire to the Regional Operations Center (ROC):

{Local instructions inserted by ROC. Provide the parent/caregiver with ROC-specific instructions for returning the questionnaire to the ROC here, such as instructions about the data collector retrieving the questionnaire at the in-person visit.

Insert ROC contact information label here.

NEU BITSEA™ Instructions: In-Person and Mail, MDES 4.0, V2.0 1