16.4 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Modified Checklist for Autism in Toddlers (M-CHAT) SAQ, Phase 2g

OMB Specification

Modified Checklist for Autism in Toddlers (M-CHAT) SAQ

Event Category:	Time-Based
Event:	18M, 24M
Administration:	N/A
Instrument Target:	Child
Instrument Respondent:	Primary Caregiver
Domain:	Neuro-Psychosocial
Document Category:	Scored Assessment
Method:	Self-Administered
Mode (for this instrument*):	In-Person, PAPI
OMB Approved Modes:	In-Person, PAPI; Phone, PAPI; Web, CAI
Estimated Administration Time:	5 minutes
Multiple Child/Sibling Consideration:	Per Child
Special Considerations:	N/A
Version:	2.0
MDES Release:	4.0

*This instrument is OMB-approved for multi-mode administration but this version of the instrument is designed for administration in this/these mode(s) only.

© 1999 Diana Robins, Deborah Fein, & Marianne Barton

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Modified Checklist for Autism in Toddlers (M-CHAT) SAQ

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

M-CHAT SAQ 3

FOR OFFICE USE ONLY 9

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Modified Checklist for Autism in Toddlers (M-CHAT) SAQ

GENERAL PROGRAMMER INSTRUCTIONS:

WHEN PROGRAMMING INSTRUMENTS, VALIDATE FIELD LENGTHS AND TYPES AGAINST THE MDES TO ENSURE DATA COLLECTION RESPONSES DO NOT EXCEED THOSE OF THE MDES. SOME GENERAL ITEM LIMITS USED ARE AS FOLLOWS:

DATA ELEMENT FIELDS	MAXIMUM CHARACTERS PERMITTED	DATA TYPE	PROGRAMMER INSTRUCTIONS
ADDRESS AND EMAIL FIELDS	100	CHARACTER
UNIT AND PHONE FIELDS	10	CHARACTER
_OTH AND COMMENT FIELDS	255	CHARACTER	Limit text to 255 characters
FIRST NAME AND LAST NAME	30	CHARACTER	Limit text to 30 characters
ALL ID FIELDS	36	CHARACTER
ZIP CODE	5	NUMERIC
ZIP CODE LAST FOUR	4	NUMERIC
CITY	50	CHARACTER
DOB AND ALL OTHER DATE FIELDS (E.G., DT, DATE, ETC.)	10	NUMERIC CHARACTER	DISPLAY AS MM/DD/YYYY STORE AS YYYY-MM-DD HARD EDITS: MM MUST EQUAL 01 TO 12 DD MUST EQUAL 01 TO 31 YYYY MUST BE BETWEEN 1900 AND CURRENT YEAR.
TIME VARIABLES	TWO-DIGIT HOUR AND TWO-DIGIT MINUTE, AM/PM DESIGNATION	NUMERIC	HARD EDITS: HOURS MUST BE BETWEEN 00 AND 12; MINUTES MUST BE BETWEEN 00 AND 59

Instrument Guidelines for Participant and Respondent IDs:

PRENATALLY, THE P_ID IN THE MDES HEADER IS THAT OF THE PARTICIPANT (E.G. THE NON-PREGNANT WOMAN, PREGNANT WOMAN, OR THE FATHER).

POSTNATALLY, A RESPONDENT ID WILL BE USED IN ADDITION TO THE PARTICIPANT ID BECAUSE SOMEBODY OTHER THAN THE PARTICIPANT MAY BE COMPLETING THE INTERVIEW. FOR EXAMPLE, THE PARTICIPANT MAY BE THE CHILD AND THE RESPONDENT MAY BE THE MOTHER, FATHER, OR ANOTHER CAREGIVER. THEREFORE, MDES VERSION 2.2 AND ALL FUTURE VERSIONS CONTAIN A R_P_ID (RESPONDENT PARTICIPANT ID) HEADER FIELD FOR EACH POST-BIRTH INSTRUMENT. THIS WILL ALLOW ROCs TO INDICATE WHETHER THE RESPONDENT IS SOMEBODY OTHER THAN THE PARTICIPANT ABOUT WHOM THE QUESTIONS ARE BEING ASKED.

A REMINDER:

ALL RESPONDENTS MUST BE CONSENTED AND HAVE RECORDS IN THE PERSON, PARTICIPANT, PARTICIPANT_CONSENT AND LINK_PERSON_PARTICIPANT TABLES, WHICH CAN BE PRELOADED INTO EACH INSTRUMENT. ADDITIONALLY, IN POST-BIRTH QUESTIONNAIRES WHERE THERE IS THE ABILITY TO LOOP THROUGH A SET OF QUESTIONS FOR MULTIPLE CHILDREN, IT IS IMPORTANT TO CAPTURE AND STORE THE CORRECT CHILD P_ID ALONG WITH THE LOOP INFORMATION. IN THE MDES VARIABLE LABEL/DEFINITION COLUMN, THIS IS INDICATED AS FOLLOWS: EXTERNAL IDENTIFIER: PARTICIPANT ID FOR CHILD DETAIL.

M-CHAT SAQ

MS00100/(RESP_NAME). Your name: _________________________________________

SOURCE

New

MS00200/(RESP_REL_CHILD). Your relationship to the child: ________________________________

SOURCE

New

MS00300/(MCHAT_DATE). Date completed: _________________________

SOURCE

New

MS01000. Please fill out the following about your child’s usual behavior, and try to answer every question. If the behavior is rare (you’ve only seen it once or twice), please answer as if your child does not do it.

SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton

MS02000/(MCHAT_SWUNG). Does your child enjoy being swung, bounced on your knee, etc.?

Label	Code	Go To
Yes	1
No	2

SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton

MS03000/(MCHAT_CHILDREN). Does your child take an interest in other children?

Label	Code	Go To
Yes	1
No	2

SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton

MS04000/(MCHAT_CLIMB). Does your child like climbing on things, such as up stairs?

Label	Code	Go To
Yes	1
No	2

SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton

MS05000/(MCHAT_HIDE). Does your child enjoy playing peek-a-boo/hide-and-seek? 

Label	Code	Go To
Yes	1
No	2

SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton

MS06000/(MCHAT_PRETEND). Does your child ever pretend, for example, to talk on the phone or take care of a doll or pretend other things?

Label	Code	Go To
Yes	1
No	2

SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton

MS07000/(MCHAT_ASK). Does your child ever use his/her index finger to point, to ask for something?

Label	Code	Go To
Yes	1
No	2

SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton

MS08000/(MCHAT_INTEREST). Does your child ever use his/her index finger to point, to indicate interest in something?

Label	Code	Go To
Yes	1
No	2

SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton

MS09000/(MCHAT_TOYS). Can your child play properly with small toys (e.g. cars or blocks) without just mouthing, fiddling, or dropping them?

Label	Code	Go To
Yes	1
No	2

SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton

MS10000/(MCHAT_OBJECTS). Does your child ever bring objects over to you (parent) to show you something?

Label	Code	Go To
Yes	1
No	2

SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton

MS11000/(MCHAT_EYE). Does your child look you in the eye for more than a second or two?

Label	Code	Go To
Yes	1
No	2

SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton

MS12000/(MCHAT_NOISE). Does your child ever seem oversensitive to noise? (e.g., plugging ears)

Label	Code	Go To
Yes	1
No	2

SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton

MS13000/(MCHAT_SMILE). Does your child smile in response to your face or your smile?

Label	Code	Go To
Yes	1
No	2

SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton

MS14000/(MCHAT_IMITATE). Does your child imitate you? (e.g., you make a face-will your child imitate it?)

Label	Code	Go To
Yes	1
No	2

SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton

MS15000/(MCHAT_NAME). Does your child respond to his/her name when you call?

Label	Code	Go To
Yes	1
No	2

SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton

MS16000/(MCHAT_POINT). If you point at a toy across the room, does your child look at it?

Label	Code	Go To
Yes	1
No	2

SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton

MS17000/(MCHAT_WALK). Does your child walk?

Label	Code	Go To
Yes	1
No	2

SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton

MS18000/(MCHAT_LOOK). Does your child look at things you are looking at?

Label	Code	Go To
Yes	1
No	2

SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton

MS19000/(MCHAT_FINGER). Does your child make unusual finger movements near his/her face?

Label	Code	Go To
Yes	1
No	2

SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton

MS20000/(MCHAT_ATTENTION). Does your child try to attract your attention to his/her own activity?

Label	Code	Go To
Yes	1
No	2

SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton

MS21000/(MCHAT_DEAF). Have you ever wondered if your child is deaf?

Label	Code	Go To
Yes	1
No	2

SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton

MS22000/(MCHAT_UNDERSTAND). Does your child understand what people say?

Label	Code	Go To
Yes	1
No	2

SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton

MS23000/(MCHAT_STARE). Does your child sometimes stare at nothing or wander with no purpose?

Label	Code	Go To
Yes	1
No	2

SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton

MS24000/(MCHAT_REACTION). Does your child look at your face to check your reaction when faced with something unfamiliar?

Label	Code	Go To
Yes	1
No	2

SOURCE

Modified Checklist for Autism in Toddlers (M-CHAT™), © 1999 Diana Robins, Deborah Fein, & Marianne Barton

FOR OFFICE USE ONLY

FOU01000. Child Participant Name:_______________

FOU03000/(P_ID). Child Participant ID:_______________

FOU04000. Parent/Caregiver Name:_______________

FOU06000/(R_P_ID). Parent/Caregiver ID:_______________

FOU07000. Relationship to Child:_______________________________________

FOU09000/(MCHAT_DATE_COMP). Date of completion: ___ /___ / _____

Public reporting burden for this collection of information is estimated to average 5 minutes 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 (0925-0593). Do not return the completed form to this address.