ASQ3InPersonMailInstructions

OMB #: 0925-0593

OMB Expiration Date: 08/31/2014

Neuro-Psychosocial Ages and Stages-3 (ASQ-3™) Instructions: In-Person and Mail, Phase 2g

The National Children’s Study

Ages and Stages-3 (ASQ-3™) Instructions

Questionnaire

Thank you for agreeing to participate in the National Children’s Study (NCS) and completing the Ages and Stages Questionnaires, Third Edition (ASQ-3™). This questionnaire will take about 13 minutes to complete. It includes questions about activities that children may do. Your child may have done some of these activities already, and there may be some activities the child has not started doing yet. 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 your name, your relationship to the child, and the date you complete the questionnaire where indicated on the form.

• The ASQ-3™ consists of questions about children’s behaviors. Some of the questions have pictures that show you what the behavior looks like.

• Review the items and look for the behaviors and skills described; then think about whether the child always performs the skill, sometimes does it, or does not do it yet.

• Note that there is no need to try out each item with your child. Rather, you should answer on the basis of the child’s typical, everyday behavior.

• There are no right or wrong answers.

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

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

• Before returning the questionnaire to the Regional Operations Center (ROC), please make sure you have answered all the questions and that there is only one answer for each question.

• Please follow the instructions on the next page for returning this questionnaire to the 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 ASQ-3™ Instructions: In-Person and Mail, MDES 4.0, V2.0 1