53 School Performance and Activities

Attachment 53
School Performance and Activities

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

School Performance and Activities
Estimated time burden: 6 minutes
Proxy Report for Children 3-17
[00 IADLs Peds]

On the next screens, you will see questions about some of your child’s behaviors
including his/her performance in school. Read each question carefully and answer
as best you can. Please consider each question by itself and choose an answer that
honestly shows how you see your child's behaviors. 1
After you make your choice, the computer will automatically 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.

[01_IADLs_Peds]

Is your child attending or enrolled in school or preschool?
Yes
No

[02_IADLs_Peds]

During the past 12 months, about how many days did your child miss
school/preschool?

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
[03_IADLs_Peds]

The next questions are about your child's performance at school.
Would you describe his/her work at school as...
Excellent
Above average
Average
Below average
Failing
Prefer not to answer
Don't know

[04_IADLs_Peds]

Now we would like to ask you about your child's grades during this school year.
Overall, across all subjects he/she takes at school does he/she get...
Mostly A's
Mostly B's
Mostly C's
Mostly D's
Mostly F's
The child's school does not give these grades
Prefer not to answer
Don't know

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[05_IADLs_Peds ]

Thinking about your child's performance in academic subjects at school, how does
he/she do in…
Reading, Language Arts, or English?
Much above average
Above average
Average
Below average
Failing
Child has not yet started kindergarten

[06_IADLs_Peds ]

Thinking about your child's performance in academic subjects at school, how does
he/she do in…
Math or Arithmetic?
Much above average
Above average
Average
Below average
Failing
Child has not yet started kindergarten

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[07_IADLs_Peds ]

Thinking about your child's performance in academic subjects at school, how does
he/she do in…
Social Studies or History?
Much above average
Above average
Average
Below average
Failing
Child has not yet started kindergarten

[08_IADLs_Peds ]

Thinking about your child's performance in academic subjects at school, how does
he/she do in...
Science?
Much above average
Above average
Average
Below average
Failing
Child has not yet started kindergarten

[09_IADLs_Peds ]

Since starting kindergarten, has your child ever failed a subject in school?
No
Yes
Child has not yet started kindergarten

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[10_IADLs_Peds ]

If Yes (child failed a subject in school), how many times has your child failed a
subject in school?

[11_IADLs_Peds ]

Since starting kindergarten, has your child repeated any grades?
Yes
No

[12_IADLs_Peds ]

If yes (child repeated any grade), how many times did your child repeat a grade since
starting kindergarten?

[13_IADLs_Peds ]

Has your child ever had an in- or out-of-school suspension? NOTE: Do not count
detentions.
Yes
No

[14_IADLs_Peds]

If yes (child has had an in- or out-of-school suspension), how many times was he/she
suspended?

[15_IADLs_Peds ]

Has your child ever been expelled?
Yes
No

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[16_IADLs_Peds ]

If yes (your child has been expelled), how many times was he/she expelled?

[17_IADLs_Peds ]

For the next set of questions, please base your answer on how the child compares to
other children of the same age.
Your child is independent and takes care of himself/herself...
Better than other children his/her age
As well as other children
Slightly less well than other children
Much less well than other children
Prefer not to answer
Don't know

[18_IADLs_Peds ]

Does your child pay attention...
Better than other children his/her age
As well as other children
Slightly less well than other children
Much less well than other children
Prefer not to answer
Don't know

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[19_IADLs_Peds ]

Does your child learn, think, and solve problems...
Better than other children his/her age
As well as other children
Slightly less well than other children
Much less well than other children
Prefer not to answer
Don't know

[20_IADLs_Peds ]

Thinking about your child's overall activity level, would you say he/she is…
Less active than other children his/her age
About as active
Slightly more active
A lot more active than other children his/her age
Prefer not to answer
Don't know

[21_IADLs_Peds ]

Does your child pronounce words, communicate with and understand others…
Better than other children his/her age
As well as other children
Slightly less well than other children
Much less well than other children
Prefer not to answer
Don't know

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[22_IADLs_Peds ]

Does your child show good coordination in moving his/her arms and legs…
Better than other children his/her age
As well as other children
Slightly less well than other children
Much less well than other children
Prefer not to answer
Don't know

[23_IADLs_Peds ]

Would you say your child behaves and relates to other children and adults…
Better than other children his/her age
As well as other children
Slightly less well than other children
Much less well than other children
Prefer not to answer
Don't know

[24_IADLs_Peds ]

Do you have any concerns about your child's overall emotional health, such as your
child being depressed or overly anxious?
Yes
No

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[25_IADLs_Peds ]

When a child with a disability or developmental delay receives special education
and/or related services sponsored through your local education agency -- that is, the
school system -- these services are initiated after a diagnosis of a condition, or
professional evaluation of the child, and development of an IEP (Individualized
Education Program) or an IFSP (Individualized Family Service Plan), which is
discussed with and signed by the parent.
Is your child receiving special education services related to either an IEP or an IFSP?
No
Yes
Prefer not to answer
Don't know

[37_IADLs_Peds]

Please mark all that apply. Has your child or family received any of the following
services to help with your child's special needs?
Speech or language therapy
Occupational therapy
Physical therapy
Vision services
Hearing services (this does not include a temporary loss of hearing due to a cold or
congestion)
Prefer not to answer
Don't know

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[37a_IADLs Peds]

Please mark all that apply. Has your child or family received any of the following
services to help with your child's special needs?
Social work services
Psychological services
Home visits
Parent support or training
Prefer not to answer
Don't know

[37b_IADLs_Peds]

Please mark all that apply. Has your child or family received any of the following
services to help with your child's special needs?
Special classes with other children, some or all of whom also had special needs
Private tutoring or schooling for learning problems
No services received
Prefer not to answer
Don't know

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

School Performance and Activities
Estimated time burden: 6 minutes
Self Report for Children 13-17
[00-IADLs-Peds-self]

On the next screens, you will see questions about some of your behaviors, including
your performance at school. Read each question carefully and answer as best you
can. Please consider each question by itself and choose an answer that honestly
shows how you see your behavior.
After you make your choice, the computer will automatically 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.
[01-IADLs-Peds-Self]

Are you currently attending or enrolled in school?
Yes
No

[02-IADLs-Peds-self]

During the past 12 months, about how many days did you miss school?

[03-IADLs-Peds-self]

Would you describe your school work as... 2
Excellent
Above average

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
Average
Below average
Failing
Prefer not to answer
Don't know

[04-IADLs-Peds-self]

During this school year, overall across all subjects, do you get...
Mostly A's
Mostly B's
Mostly C's
Mostly D's
Mostly F's
My school does not give these grades
Prefer not to answer
Don't know

[05-IADLs-Peds-self]

How do you do in these subjects--Reading, Language Arts, or English?
Much above average
Above average
Average
Below average
Failing
Prefer not to answer

[06-IADLs-Peds-self]

How do you do in these subjects--Math or Arithmetic?
Much above average

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Above average
Average
Below average
Failing
Prefer not to answer

[07-IADLs-Peds-self]

How do you do in these subjects--Social Studies or History?
Much above average
Above average
Average
Below average
Failing
Prefer not to answer

[08-IADLs-Peds-self]

How do you do in Science?
Much above average
Above average
Average
Below average
Failing
Prefer not to answer

[09-IADLs-Peds-self]

Since kindergarten, have you ever failed a subject in school?
Yes
No

[10-IADLs-Peds-self]

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
If yes, how many times did you fail a subject in school?

[11-IADLs-Peds-self]

Since kindergarten, have you repeated a grade?
Yes
No

[12-IADLs-Peds-self]

If yes, how many times did you repeat a grade since kindergarten?

[13-IADLs-Peds-self]

Have you ever had an in- or -out-of-school suspension (not detention)?
Yes
No

[14-IADLs-Peds-self]

If yes, how many times were you suspended?

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[15-IADLs-Peds-self]

Have you ever been expelled?
Yes
No

[16-IADLs-Peds-self]

If yes, how many times have you been expelled?

[17-IADLs-Peds-self]

Compared to other children your age, how independent are you and how well do you
take care of yourself?
Better than other children my age
As well as other children
Slightly less well than other children
Much less well than other children
Prefer not to answer
Don't know

[18-IADLs-Peds-self]

Compared to other children your age, how well do you pay attention?
Better than other children my age
As well as other children
Slightly less well than other children
Much less well than other children
Prefer not to answer
Don't know

[19-IADLs-Peds-self]

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

Compared to other children your age, how do you learn, think, and solve problems?
Better than other children your age
As well as other children
Slightly less well than other children
Much less well than other children
Prefer not to answer
Don't know

[20-IADLs-Peds-self]

Compared to other children your age, your activity level is...
Less active than other children your age
About as active as other children
Slightly more active than other children
A lot more active than other children
Prefer not to answer
Don't know

[21-IADLs-Peds-self]

Compared to other children your age, do you pronounce words, communicate
with and understand others...
Better than other children your age
As well as other children
Slightly less well than other children
Much less well than other children
Prefer not to answer
Don't know

[22-IADLs-Peds-self]

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Compared to other children your age, your coordination in moving your arms and
legs is...
Better than other children your age
As well as other children
Slightly less well than other children
Much less well than other children
Prefer not to answer
Don't know

[23-IADLs-Peds-self]

Compared to other children your age, your behavior and relationships to other
children and adults are...
Better than other children your age
As well as other children
Slightly less well than other children
Much less well than other children
Prefer not to answer
Don't know

[24-IADLs-Peds-self]

Do you have concerns about your overall emotional health, such as being depressed
or overly anxious?
Yes
No

[25-IADLs-Peds-self]

When a child with a disability or developmental delays receives special education
and/or related services through the school system, these services are initiated after a

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
diagnosis of a condition, or professional evaluation of the child, and development of
an IEP (Individualized Education Program) or an IFSP (Individualized Family Service
Plan) which is discussed with and signed by the parent.
Have you ever received special education services related to either an IEP or an
IFSP?
No
Yes
Prefer not to answer
Don't know

[26a-IADLs-Peds-self]

Please mark all that apply.
Have you or your family received any of the following services?
Speech or language therapy
Occupational therapy
Vision services
Hearing services (not including temporary loss of hearing due to a cold or congestion)
Social work services
No services received
Prefer not to answer
Don't know

[26-IADLs-Peds-self]

Please mark all that apply.
Have you or your family received any of the following services?

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Psychological services
Home visits
Parent support or training
Special classes with other children, some or all of whom also had special needs
Private tutoring or schooling for learning problems
No services received
Prefer not to answer
Don't know