43 Cognition Information Form

Attachment 43
Cognition Information Form

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

Cognition Information Form
Estimated time burden: 2 minutes
Self Report (age 18 and up)1
Introduction: On the following screens, we will ask you questions about your birthplace as well as
school history and location. Some of the questions have many answer choices. Read each question
carefully and answer as well as you can. After you make your choice, click the NEXT button to go
on to the next question. If you want to change your answer, click on the GO BACK button to return
to the previous question and then choose a different answer. Click on the CONTINUE button when
you are ready to begin.
1. If you are Spanish/Hispanic/Latino and born outside of the U.S., please select your birthplace from
the list below: (convert to drop down list)
Argentina
068 Bolivia
076 Brazil
170 Colombia
188 Costa Rica
222 El Salvador
Guatemala
Honduras
320
340
484 Mexico
591 Panama
600Paraguay
604 Peru
858 Uruguay
862 Venezuela
630 Puerto Rico
084 Belize
214 Dominican Republic
997 Other (Specify) _______________
999 N/A (born in U.S.)
032

152 Chile
218 Ecuador
558Nicaragua

Spain
192 Cuba
724

2. If you were born in the United States, in what city and state were you born?
City __ (freeform field) _______________ State: (make drop down list)
Alaska
1 Alabama
6 California
8 Colorado
11 District of Columbia
12 Florida
Idaho
Illinois
16
17
Kansas
20
21 Kentucky
24 Maryland
25 Massachusetts
28 Mississippi
29Missouri
32 Nevada
33 New Hampshire
36 New York
37 North Carolina
2

Arizona
9 Connecticut
13 Georgia
18 Indiana
22 Louisiana
26 Michigan
30 Montana
34 New Jersey
38 North Dakota
4

Arkansas
10 Delaware
15 Hawaii
19 Iowa
23 Maine
27 Minnesota
31 Nebraska
35 New Mexico
39 Ohio
5

Public reporting burden for this collection of information is estimated to average 2 1/2 hours per response, 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.

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Oklahoma
South
Carolina
45
49 Utah
54 West Virginia
40

Oregon
46 South Dakota
50 Vermont
55 Wisconsin
41

Pennsylvania
47 Tennessee
51 Virginia
56 Wyoming
42

Rhode Island
48 Texas
53Washington
44

3. Where did you attend primary/elementary school? (Check all that apply)
U.S.

U.S. Territory

Other Country

If you selected more than one, please indicate the number of grades in each:
U.S. _____

U.S. Territory _____ Other Country _____

4. If you attended primary/elementary school in the U.S., please indicate city, state and ZIP code (if
known) for the school attended longest:
City ______ (freeform field)______ State: (make drop down list) ZIP Code _________
Alaska
1 Alabama
6 California
8 Colorado
11 District of Columbia
12 Florida
Idaho
Illinois
16
17
Kansas
20
21 Kentucky
24 Maryland
25 Massachusetts
28 Mississippi
29Missouri
32 Nevada
33 New Hampshire
36 New York
37 North Carolina
40 Oklahoma
41 Oregon
45 South Carolina
46 South Dakota
49 Utah
50 Vermont
54 West Virginia
55 Wisconsin
2

Arizona
9 Connecticut
13 Georgia
18 Indiana
22 Louisiana
26 Michigan
30 Montana
34 New Jersey
38 North Dakota
42 Pennsylvania
47 Tennessee
51 Virginia
56 Wyoming
4

Arkansas
10 Delaware
15 Hawaii
19 Iowa
23 Maine
27 Minnesota
31 Nebraska
35 New Mexico
39 Ohio
44 Rhode Island
48 Texas
53Washington
5

5. If you attended primary/elementary school in a U.S. Territory or another country, please select the
location from the list and provide the city name below (if known) for the school attended longest:
Argentina
068 Bolivia
076 Brazil
170 Colombia
188 Costa Rica
222 El Salvador
320 Guatemala
340 Honduras
484 Mexico
591 Panama
600Paraguay
604 Peru
858 Uruguay
862 Venezuela
630 Puerto Rico
084 Belize
214 Dominican Republic
997 Other (Specify) _______________
999 N/A (born in U.S.)
032

City (freeform field) ____________

152 Chile
218 Ecuador
558Nicaragua

Spain
192 Cuba
724

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

6. Was your primary/elementary school…
01 Public
02 Private
03 Did not attend primary/elementary school
7. Did you attend a vocational high school?
01 Yes
02 No
03 Did not attend high school
8. Was your secondary/high school…
01 Public
02 Private
03 Did not attend high school
9. How well would you say you did in school?
01 Above average
02 Average
03 Below average
10. Have you ever failed a subject in school?
Yes
02 No
01

11. Have you ever repeated a grade in school?
Yes
02 No
01

12. Did you ever receive special classes or tutoring for performance difficulties in school?
Yes
02 No
01

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Proxy Report (age 3 to 17)2
1. If the child is Spanish/Hispanic/Latino and was born outside of the U.S., please select his/her birth
country from the list below: (convert to drop down list)
Argentina
068 Bolivia
076 Brazil
170 Colombia
188 Costa Rica
222 El Salvador
320 Guatemala
340 Honduras
484 Mexico
591 Panama
600Paraguay
604 Peru
858 Uruguay
862 Venezuela
630 Puerto Rico
084 Belize
214 Dominican Republic
997 Other (Specify) _______________
840 N/A (born in U.S.)
032

152 Chile
218 Ecuador
558Nicaragua

Spain
192 Cuba
724

2. If the child was born in the United States, in what city and state was he/she born?
City (freeform field) ______________ State: (make drop down list)
Alaska
1 Alabama
6 California
8 Colorado
11 District of Columbia
12 Florida
16 Idaho
17 Illinois
Kansas
20
21 Kentucky
24 Maryland
25 Massachusetts
28 Mississippi
29Missouri
32 Nevada
33 New Hampshire
36 New York
37 North Carolina
40 Oklahoma
41 Oregon
45 South Carolina
46 South Dakota
49 Utah
50 Vermont
54 West Virginia
55 Wisconsin
2

Arizona
9 Connecticut
13 Georgia
18 Indiana
22 Louisiana
26 Michigan
30 Montana
34 New Jersey
38 North Dakota
42 Pennsylvania
47 Tennessee
51 Virginia
56 Wyoming
4

Arkansas
10 Delaware
15 Hawaii
19 Iowa
23 Maine
27 Minnesota
31 Nebraska
35 New Mexico
39 Ohio
44 Rhode Island
48 Texas
53Washington
5

3. Where did the child attend primary/elementary school? (check all that apply)
U.S.
U.S. Territory
Other Country
Has not attended primary/elementary school
If you selected more than one please indicate the number of grades in each:
U.S. _____ U.S. Territory ______ Other Country _____
Public reporting burden for this collection of information is estimated to average 2 1/2 hours per response, 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.

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
4. If the child attended primary/elementary school in the U.S., please indicate city, state and ZIP code (if
known) for the school attended longest:
City ______ (freeform field)_______ State: (make drop down list) ZIP code _________
Alaska
1 Alabama
California
6
8 Colorado
11 District of Columbia
12 Florida
16 Idaho
17 Illinois
20 Kansas
21 Kentucky
24 Maryland
25 Massachusetts
28 Mississippi
29Missouri
32 Nevada
33 New Hampshire
36 New York
37 North Carolina
40 Oklahoma
41 Oregon
45 South Carolina
46 South Dakota
49 Utah
50 Vermont
West
Virginia
54
55 Wisconsin
2

Arizona
9 Connecticut
13 Georgia
18 Indiana
22 Louisiana
26 Michigan
30 Montana
34 New Jersey
38 North Dakota
42 Pennsylvania
47 Tennessee
51 Virginia
56 Wyoming
4

Arkansas
10 Delaware
15 Hawaii
19 Iowa
23 Maine
27 Minnesota
31 Nebraska
35 New Mexico
39 Ohio
44 Rhode Island
48 Texas
53Washington
5

5. If the child attended primary/elementary school in a U.S. Territory or another country, please select
the location from the list and provide the city name below (if known) for the school attended longest:
Argentina
068 Bolivia
076 Brazil
170 Colombia
188 Costa Rica
222 El Salvador
320 Guatemala
340 Honduras
484 Mexico
591 Panama
600Paraguay
604 Peru
858 Uruguay
862 Venezuela
630 Puerto Rico
084 Belize
214 Dominican Republic
997 Other (Specify) _______________
840 N/A (born in U.S.)
032

City (freeform field) ____________
6. Is the child’s primary/elementary school…
01 Public
02 Private
03 Has not attended primary/elementary school
7. Is the child attending a vocational high school?
01 Yes
02 No
03 Has not attended vocational high school

152 Chile
218 Ecuador
558Nicaragua

Spain
192 Cuba
724

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

8. Is the child’s secondary/high school…
01 Public
02 Private
03 Has not attended secondary/high school