40 Initial Child/Proxy Questionaire

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX

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Attachment 40 Initial Questionnaire – PROXY and CHILD

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX

Initial Questionnaire - Proxy
Thank you for participating in the NIH Toolbox Project. Prior to your child’s appointment,
please take a few minutes to complete this survey. Yours and your child’s participation is
voluntary. You may choose not to answer any questions and you may stop the survey at
any time. There are no known risks or benefits to completing this survey. The survey is
estimated to take 12 minutes to complete.
Please bring this completed survey with you to your child’s testing appointment. If you
have any questions about the study, please call the study's toll-free number, 1-xxx-xxxxxxx.
Thank you!
(Note: Throughout the survey, instructions are printed in italics.)
Instructions: Please mark only one response per question unless otherwise noted.
[SDNormP01]

1) Today's Date:
_____/_____/_____
dd mm yyyy
[SDNormP02]

2) What is your child’s date of birth?
_____/_____/_____
dd mm yyyy
[SDNormP03]

3) What is your child’s gender?

Male
Female

[SDNormP04]

4) Is your child Spanish/Hispanic/Latino?

Yes (complete question 4a below)
No
[SDNormP04a]

4a) Is your child...?

Mexican, Mexican-American, Chicano
Puerto Rican
Cuban, Cuban-American
Other Spanish/Hispanic/Latino

Public reporting burden for this collection of information is estimated to average 2 1/2 hours per response for the entire project and 12
minutes for this questionnaire, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: NIH, Project
Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx*) EXP: (xx/xxxx). Do not return the
completed form to this address.

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[SDNormP05]

5) What is your child’s race? Mark one or more.

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

[SDNormP06]

6) In what country was your child born?

United States
Other Country
[SDNormP06a]

6a) If Other Country, which?
_____________________________________
[SDNormP06b]

6b) If Other Country, in what year did your child come to the United States to stay?
______
yyyy
[SDNormP07]

7) What was the family's total household income in 2010 before taxes? Please include income
from all sources including child support, alimony, disability, SSI, unemployment. (Remember
your answers are confidential.)

Less than $5,000
$5,000 to $9,999
$10,000 to $19,999
$20,000 to $39,999
$40,000 to $74,999
$75,000 to $99,999
$100,000 or more
Don’t know

[SDNormP08]

8) How many children under 18 and adults in the child’s household depend on this income?
________________
Number of children under 18
[SDNormP08a]

________________
Number of adults

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Expiration Date: XX/XX/XXXX

Instructions: The following questions ask about your child’s current health and health
history. Please mark only one response per question unless otherwise noted.
[SDNormP09]

1) In general, would you say your child’s health is…?

Excellent
Very good
Good
Fair
Poor

[SDMC_Proxy_01]

2) Has a health professional told you that your child has any of the following?
Please mark one or more.

A specific learning disability
Mental retardation
A speech or language impairment (please specify): ___________________________
A serious emotional disturbance
Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD)
Autism
Asperger’s syndrome
Pervasive Developmental Disorder (PDD)
Other autism spectrum disorder
Developmental delay
None of the above

[SDMC_Proxy_01a]

2a) If you marked any of the conditions above, please answer the following question. Otherwise
go to question 3.
Does your child’s condition affect his/her ability to learn?

Yes
No

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[SDMC_Proxy_01f]

3) Does your child have or has your child had any of the following?
Please mark one or more.

Deafness (profound hearing loss)
Other hearing impairment (please specify): __________________________________
Total blindness (no light perception)
Other visual impairment not corrected with glasses (please specify):
____________________________________________________________________
An orthopedic impairment (please specify): __________________________________
Joint replacement
Dizziness or Vertigo
None of the above

[SDMC_Proxy_02]

4) Does your child have a history of any of the following medical conditions?
Please mark one or more.

Hypertension/high blood pressure
Peripheral vascular disease (problems with circulation, blocked arteries to the legs)
Diabetes
Cerebral palsy
Bipolar Disorder or Schizophrenia
Depression/anxiety/emotional problem
Epilepsy, seizures
Traumatic Brain Injury (TBI)
Multiple sclerosis (MS)
Muscular Dystrophy (MD)
Thyroid problems, Graves’ disease
HIV/AIDS
Alcohol abuse
Drug abuse
None of the above

[SDMC_Proxy_02b]

5) Does your child have, or has a health professional told you that your child has, any of the
following?
Please mark one or more.

Heart problem (heart attack, angina, other)
Stroke problem or TIA (transient ischemic attack)
Lung/breathing problem (such as asthma, emphysema, COPD)
Problems with his/her hip, knee or ankle joints
Cervical spine instability

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None of the above

[SDMC_Proxy_09]

6) Does your child use any of the following?
Please mark one or more.

Hearing aid(s)
Cochlear implant
Eyeglasses or contact lenses
Hand or wrist splints
Cane
Walker
Leg or ankle braces
Manual wheelchair
Motorized wheelchair
Scooter
Special telephone
Prosthetic limb (Please specify) __________________________________________________
Other (Please specify) ___________________________________________________________
None of the above

[SDMC_Proxy_11]

7) Can your child stand independently, without an assistive device, for at least 3 minutes?

Yes
No

[SDMC_Proxy_13]

8) Has your child experienced a neck injury in the last 12 months?

Yes
No

[SDMC_Proxy_19]

9) How many times has your child fallen in the last 6 months?

No falls (if no falls, please go to question 10)
One time
More than one time

[SDMC_Proxy_19a]

9a) If your child fell one or more times, please specify the reason(s) for your child’s fall(s).
_________________________________________________________________________________________
_________________________________________________________________________________________

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10) Has a doctor or other medical professional ever told you that your child has an allergy or
sensitivity to quinine? Quinine is sometimes used in treating malaria.

Yes
No
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[SDMC_Proxy_16]

11) If your child is female, is she currently pregnant?

Yes, 3 months or greater
Yes, less than 3 months
No

12) Does your child have a history of any of the following?
Please mark one or more.

He/she has been hospitalized for emotional problems
He/she has had hand surgery in the last 3 months
He/she has had brain surgery
None of the above

[SDMC_Proxy_6]

13) Is your child limited in any way in any activities because of a physical problem?

Yes (if yes, complete questions 13a and 13b below)
No

[SDMC_Proxy_06a]

13a)
What physical problem(s) limits your child’s activities? Please specify.
_______________________________________________________________________________________
_______________________________________________________________________________________
[SDMC1_Self_06b]

13b) In what ways is your child limited by this (these) physical problem(s)? Please describe.
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
[SDMC_Proxy_03]

14) How tall is your child without shoes?
_____ feet _____ inches

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[SDMC_Proxy_04]

15) How much does your child weigh without shoes?
__________ pounds
[SDMC_Proxy_08]

16) Do you consider your child to be a person with a disability?

Yes
No

[SDMC_Proxy_08a]

16a) Have you or someone else ever applied for disability benefits on behalf of your child?

Yes, disability benefits were applied for on behalf of my child and were
denied
Yes, disability benefits were applied for on behalf of my child and were
received
No, I or someone else have never applied for disability benefits on behalf of my child

[SDMC_Proxy_02c]

17) Does your child regularly exercise?

Yes (answer question 17a)
No

[SDMC_Proxy_02e]

17a) If yes, what type and how often?
_______________________________________________________________________________________
[SDMC_Proxy_02d]

18) Does your child regularly have problems climbing stairs?

Yes
No

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OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[PTLS_01a]

Instructions: The next few questions are about the language or languages that you
and your child speak. Please mark only one response per question.
[PTLS_01a]

1) What was the first language your child learned?

English
Spanish
Some other language

[PTLS_02a]

2) What language do you usually speak with your child?

Only Spanish
Mostly Spanish
Spanish and English equally
Mostly English
Only English
Some other language

[PTLS_03]

3) How frequently does your child speak English in his/her day-to-day life?

Never
Rarely
Often
Every day

[PTLS_04]

4) How frequently does your child speak Spanish in his/her day-to-day life?

Never
Rarely
Often
Every day

[PTLS_5a]

5) Does your child go to school in the U.S.?

Yes (answer question 5a)
No

[PTLS_05b]

5a) If yes (child goes to school in the U.S.), what is your child’s current level or grade?
_________________________________

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6) Was your child born outside of the U.S.?

Yes (answer question 6a)
No

[PTLS_6a]

6a) If yes (born outside of U.S.), did your child go to school in his/her country of origin?

Yes (answer question 6b)
No

[PTLS_06b]

6b) If yes (went to school in his/her country of origin), what was the highest level or grade your
child completed?
__________________________________

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OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX

Initial Questionnaire - Child
If your child is age 8 years or older, please ask him/her to complete the rest of the
survey. It will take him/her approximately 2 minutes.
[CTLS_01a]

Instructions: The next few questions are about the language or languages that you
speak. Please mark only one response per question.
[CTLS_01]

1) What was the first language you learned?

English
Spanish
Some other language
Don’t know

[CTLS_02a]

2) What language do you usually speak with your friends?

Only Spanish
Mostly Spanish
Spanish and English equally
Mostly English
Only English
Some other language
Don’t know

[CTLS_03]

3) How frequently do you speak English in your day-to-day life?

Never
Rarely
Often
Every day
Don’t know

Public reporting burden for this collection of information is estimated to average 2 1/2 hours per response for the entire
project and 2 minutes for this questionnaire, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency
may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to: NIH, Project Clearance Branch, 6705
Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx*) EXP: (xx/xxxx). Do not return the
completed form to this address.

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OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[CTLS_04]

4) How frequently do you speak Spanish in your day-to-day life?

Never
Rarely
Often
Every day
Don’t know

[CTLS_5a]

5) Do you go to school in the U.S.?

Yes (answer question 5a)
No

[CTLS_05b]

5a) If yes (go to school in the U.S.), what is your current grade or level?
_________________________________

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