Form 36.1 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

54M Questionnaire – Child, Phase 2g

OMB Specification

54M Questionnaire - Child

Event Category:	Time-Based
Event:	54M
Administration:	N/A
Instrument Target:	Child
Instrument Respondent:	Primary Caregiver
Domain:	Questionnaire
Document Category:	Questionnaire
Method:	Data Collector Administered
Mode (for this instrument*):	In-Person, CAI; Phone, CAI
OMB Approved Modes:	In-Person, CAI; Phone, CAI; Web-Based, CAI
Estimated Administration Time:	8 minutes
Multiple Child/Sibling Consideration:	Per Child
Special Considerations:	N/A
Version:	1.0
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.

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54M Questionnaire - Child

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

HEALTH BEHAVIORS (INJURY BEHAVIOR CHECKLIST) 3

PSYCHOSOCIAL (AUTISM QUOTIENT TEST) 16

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54M Questionnaire - Child

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.

HEALTH BEHAVIORS (INJURY BEHAVIOR CHECKLIST)

(TIME_STAMP_HB_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

• PRELOAD PARTICIPANT ID (P_ID) FOR CHILD AND RESPONDENT ID (R_P_ID) FOR ADULT CAREGIVER.

• PRELOAD C_FNAME AND CHILD_SEX FROM INSTRUMENT_ID = XX (PARTICIPANT VERIFICATION, SCHEDULING & TRACING QUESTIONNAIRE).

• IF C_FNAME ≠ -1 OR -2, DISPLAY THE CHILD'S NAME IN C_FNAME AS APPROPRIATE THROUGHOUT INSTRUMENT.

• OTHERWISE, IF C_FNAME = -1 OR -2, DISPLAY "the child" IN APPROPRIATE FIELDS THROUGHOUT THE INSTRUMENT.

• IF CHILD_SEX = 1, DISLAY "he," "his," AND "him" IN APPROPRIATE FIELDS THROUGHOUT INSTRUMENT.

• IF CHILD_SEX = 2, DISLAY "she" and "her" IN APPROPRIATE FIELDS THROUGHOUT INSTRUMENT.

HB01000. These next questions ask how often {C_FNAME/the child} has shown different behaviors during the past 6 months.  

HB03000/(JUMP_SURFACES). Jumps off furniture or other structures such as playground equipment

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NOT AT ALL	1
VERY SELDOM (ONCE OR TWICE)	2
SOMETIMES (ONCE A MONTH)	3
PRETTY OFTEN (ONCE A WEEK)	4
VERY OFTEN (MORE THAN ONCE A WEEK)	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Injury Behavior Checklist (Speltz, M.L., Gonzales, N., Sulzbacher, S., & Quan, L. (1990).  Assessment of injury risk in young children: A preliminary study of the Injury Behavior Checklist.  Journal of Pediatric Psychology, 15:373-383.) (modified)

HB04000/(JUMP_STAIRS). Jumps down stairs

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NOT AT ALL	1
VERY SELDOM (ONCE OR TWICE)	2
SOMETIMES (ONCE A MONTH)	3
PRETTY OFTEN (ONCE A WEEK)	4
VERY OFTEN (MORE THAN ONCE A WEEK)	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Injury Behavior Checklist (Speltz, M.L., Gonzales, N., Sulzbacher, S., & Quan, L. (1990).  Assessment of injury risk in young children: A preliminary study of the Injury Behavior Checklist.  Journal of Pediatric Psychology, 15:373-383.)

HB05000/(RIDE_UNSAFE_AREA). Rides something with wheels such as a big wheel, kiddie car, or skateboard in unsafe areas such as a busy street, a hill, or down stairs

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NOT AT ALL	1
VERY SELDOM (ONCE OR TWICE)	2
SOMETIMES (ONCE A MONTH)	3
PRETTY OFTEN (ONCE A WEEK)	4
VERY OFTEN (MORE THAN ONCE A WEEK)	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Injury Behavior Checklist (Speltz, M.L., Gonzales, N., Sulzbacher, S., & Quan, L. (1990).  Assessment of injury risk in young children: A preliminary study of the Injury Behavior Checklist.  Journal of Pediatric Psychology, 15:373-383.) (modified)

HB06000/(BUMP_INTO). Runs or bumps into things such as furniture, walls, or poles

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NOT AT ALL	1
VERY SELDOM (ONCE OR TWICE)	2
SOMETIMES (ONCE A MONTH)	3
PRETTY OFTEN (ONCE A WEEK)	4
VERY OFTEN (MORE THAN ONCE A WEEK)	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Injury Behavior Checklist (Speltz, M.L., Gonzales, N., Sulzbacher, S., & Quan, L. (1990).  Assessment of injury risk in young children: A preliminary study of the Injury Behavior Checklist.  Journal of Pediatric Psychology, 15:373-383.) (modified)

HB07000/(FALL_DOWN). Falls down

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NOT AT ALL	1
VERY SELDOM (ONCE OR TWICE)	2
SOMETIMES (ONCE A MONTH)	3
PRETTY OFTEN (ONCE A WEEK)	4
VERY OFTEN (MORE THAN ONCE A WEEK)	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Injury Behavior Checklist (Speltz, M.L., Gonzales, N., Sulzbacher, S., & Quan, L. (1990).  Assessment of injury risk in young children: A preliminary study of the Injury Behavior Checklist.  Journal of Pediatric Psychology, 15:373-383.)

HB08000/(PLAY_FIRE). Plays with fire, things such as matches, candles, or lighters

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NOT AT ALL	1
VERY SELDOM (ONCE OR TWICE)	2
SOMETIMES (ONCE A MONTH)	3
PRETTY OFTEN (ONCE A WEEK)	4
VERY OFTEN (MORE THAN ONCE A WEEK)	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Injury Behavior Checklist (Speltz, M.L., Gonzales, N., Sulzbacher, S., & Quan, L. (1990).  Assessment of injury risk in young children: A preliminary study of the Injury Behavior Checklist.  Journal of Pediatric Psychology, 15:373-383.) (modified)

HB09000/(SOCKETS). Puts fingers or objects in electrical wall sockets or appliances such as a toaster

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NOT AT ALL	1
VERY SELDOM (ONCE OR TWICE)	2
SOMETIMES (ONCE A MONTH)	3
PRETTY OFTEN (ONCE A WEEK)	4
VERY OFTEN (MORE THAN ONCE A WEEK)	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Injury Behavior Checklist (Speltz, M.L., Gonzales, N., Sulzbacher, S., & Quan, L. (1990).  Assessment of injury risk in young children: A preliminary study of the Injury Behavior Checklist.  Journal of Pediatric Psychology, 15:373-383.) (modified)

HB10000/(LEAVE_NO_PERM). Leaves the house without permission

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NOT AT ALL	1
VERY SELDOM (ONCE OR TWICE)	2
SOMETIMES (ONCE A MONTH)	3
PRETTY OFTEN (ONCE A WEEK)	4
VERY OFTEN (MORE THAN ONCE A WEEK)	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Injury Behavior Checklist (Speltz, M.L., Gonzales, N., Sulzbacher, S., & Quan, L. (1990).  Assessment of injury risk in young children: A preliminary study of the Injury Behavior Checklist.  Journal of Pediatric Psychology, 15:373-383.)

HB11000/(REF_SEATBELT). Refuses to use a seat belt or stay seated in the car

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NOT AT ALL	1
VERY SELDOM (ONCE OR TWICE)	2
SOMETIMES (ONCE A MONTH)	3
PRETTY OFTEN (ONCE A WEEK)	4
VERY OFTEN (MORE THAN ONCE A WEEK)	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Injury Behavior Checklist (Speltz, M.L., Gonzales, N., Sulzbacher, S., & Quan, L. (1990).  Assessment of injury risk in young children: A preliminary study of the Injury Behavior Checklist.  Journal of Pediatric Psychology, 15:373-383.) (modified)

HB12000/(SHARP_OBJECTS). Plays with sharp objects such as tools or knives

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NOT AT ALL	1
VERY SELDOM (ONCE OR TWICE)	2
SOMETIMES (ONCE A MONTH)	3
PRETTY OFTEN (ONCE A WEEK)	4
VERY OFTEN (MORE THAN ONCE A WEEK)	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Injury Behavior Checklist (Speltz, M.L., Gonzales, N., Sulzbacher, S., & Quan, L. (1990).  Assessment of injury risk in young children: A preliminary study of the Injury Behavior Checklist.  Journal of Pediatric Psychology, 15:373-383.) (modified)

HB13000/(PUSH_HEAVY). Pulls or pushes furniture or heavy objects over

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NOT AT ALL	1
VERY SELDOM (ONCE OR TWICE)	2
SOMETIMES (ONCE A MONTH)	3
PRETTY OFTEN (ONCE A WEEK)	4
VERY OFTEN (MORE THAN ONCE A WEEK)	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Injury Behavior Checklist (Speltz, M.L., Gonzales, N., Sulzbacher, S., & Quan, L. (1990).  Assessment of injury risk in young children: A preliminary study of the Injury Behavior Checklist.  Journal of Pediatric Psychology, 15:373-383.) (modified)

HB14000/(FALL_WINDOWS). Falls out of windows or down stairways

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NOT AT ALL	1
VERY SELDOM (ONCE OR TWICE)	2
SOMETIMES (ONCE A MONTH)	3
PRETTY OFTEN (ONCE A WEEK)	4
VERY OFTEN (MORE THAN ONCE A WEEK)	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Injury Behavior Checklist (Speltz, M.L., Gonzales, N., Sulzbacher, S., & Quan, L. (1990).  Assessment of injury risk in young children: A preliminary study of the Injury Behavior Checklist.  Journal of Pediatric Psychology, 15:373-383.)

HB15000/(PUT_IN_MOUTH). Puts objects or non-food items in mouth

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NOT AT ALL	1
VERY SELDOM (ONCE OR TWICE)	2
SOMETIMES (ONCE A MONTH)	3
PRETTY OFTEN (ONCE A WEEK)	4
VERY OFTEN (MORE THAN ONCE A WEEK)	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Injury Behavior Checklist (Speltz, M.L., Gonzales, N., Sulzbacher, S., & Quan, L. (1990).  Assessment of injury risk in young children: A preliminary study of the Injury Behavior Checklist.  Journal of Pediatric Psychology, 15:373-383.)

HB16000/(SCRATCH_SCRAPE). Gets scratches, scrapes, or bruises during outdoor play 

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NOT AT ALL	1
VERY SELDOM (ONCE OR TWICE)	2
SOMETIMES (ONCE A MONTH)	3
PRETTY OFTEN (ONCE A WEEK)	4
VERY OFTEN (MORE THAN ONCE A WEEK)	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Injury Behavior Checklist (Speltz, M.L., Gonzales, N., Sulzbacher, S., & Quan, L. (1990).  Assessment of injury risk in young children: A preliminary study of the Injury Behavior Checklist.  Journal of Pediatric Psychology, 15:373-383.)

HB17000/(CHANCES_PLAYGROUND). “Takes chances” on playground equipment

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NOT AT ALL	1
VERY SELDOM (ONCE OR TWICE)	2
SOMETIMES (ONCE A MONTH)	3
PRETTY OFTEN (ONCE A WEEK)	4
VERY OFTEN (MORE THAN ONCE A WEEK)	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Injury Behavior Checklist (Speltz, M.L., Gonzales, N., Sulzbacher, S., & Quan, L. (1990).  Assessment of injury risk in young children: A preliminary study of the Injury Behavior Checklist.  Journal of Pediatric Psychology, 15:373-383.)

HB18000/(CLIMB_SURFACES). Tries to climb on top of furniture such as cabinets

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NOT AT ALL	1
VERY SELDOM (ONCE OR TWICE)	2
SOMETIMES (ONCE A MONTH)	3
PRETTY OFTEN (ONCE A WEEK)	4
VERY OFTEN (MORE THAN ONCE A WEEK)	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Injury Behavior Checklist (Speltz, M.L., Gonzales, N., Sulzbacher, S., & Quan, L. (1990).  Assessment of injury risk in young children: A preliminary study of the Injury Behavior Checklist.  Journal of Pediatric Psychology, 15:373-383.) (modified)

HB19000/(STAND_CHAIRS). Stands on chairs

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NOT AT ALL	1
VERY SELDOM (ONCE OR TWICE)	2
SOMETIMES (ONCE A MONTH)	3
PRETTY OFTEN (ONCE A WEEK)	4
VERY OFTEN (MORE THAN ONCE A WEEK)	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Injury Behavior Checklist (Speltz, M.L., Gonzales, N., Sulzbacher, S., & Quan, L. (1990).  Assessment of injury risk in young children: A preliminary study of the Injury Behavior Checklist.  Journal of Pediatric Psychology, 15:373-383.)

HB20000/(EXPLORE_UNSAFE). Explores places that are off limits, like a medicine cabinet or a storage shed

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NOT AT ALL	1
VERY SELDOM (ONCE OR TWICE)	2
SOMETIMES (ONCE A MONTH)	3
PRETTY OFTEN (ONCE A WEEK)	4
VERY OFTEN (MORE THAN ONCE A WEEK)	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Injury Behavior Checklist (Speltz, M.L., Gonzales, N., Sulzbacher, S., & Quan, L. (1990).  Assessment of injury risk in young children: A preliminary study of the Injury Behavior Checklist.  Journal of Pediatric Psychology, 15:373-383.) (modified)

HB21000/(DANGER_SUBSTANCES). Gets into dangerous substances like medicine, gasoline, or cleaning supplies

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NOT AT ALL	1
VERY SELDOM (ONCE OR TWICE)	2
SOMETIMES (ONCE A MONTH)	3
PRETTY OFTEN (ONCE A WEEK)	4
VERY OFTEN (MORE THAN ONCE A WEEK)	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Injury Behavior Checklist (Speltz, M.L., Gonzales, N., Sulzbacher, S., & Quan, L. (1990).  Assessment of injury risk in young children: A preliminary study of the Injury Behavior Checklist.  Journal of Pediatric Psychology, 15:373-383.) (modified)

HB22000/(PLAY_RECKLESS). Plays carelessly or recklessly

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NOT AT ALL	1
VERY SELDOM (ONCE OR TWICE)	2
SOMETIMES (ONCE A MONTH)	3
PRETTY OFTEN (ONCE A WEEK)	4
VERY OFTEN (MORE THAN ONCE A WEEK)	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Injury Behavior Checklist (Speltz, M.L., Gonzales, N., Sulzbacher, S., & Quan, L. (1990).  Assessment of injury risk in young children: A preliminary study of the Injury Behavior Checklist.  Journal of Pediatric Psychology, 15:373-383.)

HB23000/(BURNS_SELF). Burns him or herself with hot objects such as a stove or iron

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NOT AT ALL	1
VERY SELDOM (ONCE OR TWICE)	2
SOMETIMES (ONCE A MONTH)	3
PRETTY OFTEN (ONCE A WEEK)	4
VERY OFTEN (MORE THAN ONCE A WEEK)	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Injury Behavior Checklist (Speltz, M.L., Gonzales, N., Sulzbacher, S., & Quan, L. (1990).  Assessment of injury risk in young children: A preliminary study of the Injury Behavior Checklist.  Journal of Pediatric Psychology, 15:373-383.) (modified)

HB24000/(WATER_HAZARDS). Behaves carelessly in or around water hazards like a pool or a bathtub

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NOT AT ALL	1
VERY SELDOM (ONCE OR TWICE)	2
SOMETIMES (ONCE A MONTH)	3
PRETTY OFTEN (ONCE A WEEK)	4
VERY OFTEN (MORE THAN ONCE A WEEK)	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Injury Behavior Checklist (Speltz, M.L., Gonzales, N., Sulzbacher, S., & Quan, L. (1990).  Assessment of injury risk in young children: A preliminary study of the Injury Behavior Checklist.  Journal of Pediatric Psychology, 15:373-383.) (modified)

HB25000/(TEASE_ANIMALS). Teases animals, such as unfamiliar dogs

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
NOT AT ALL	1
VERY SELDOM (ONCE OR TWICE)	2
SOMETIMES (ONCE A MONTH)	3
PRETTY OFTEN (ONCE A WEEK)	4
VERY OFTEN (MORE THAN ONCE A WEEK)	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Injury Behavior Checklist (Speltz, M.L., Gonzales, N., Sulzbacher, S., & Quan, L. (1990).  Assessment of injury risk in young children: A preliminary study of the Injury Behavior Checklist.  Journal of Pediatric Psychology, 15:373-383.)

(TIME_STAMP_HB_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

PSYCHOSOCIAL (AUTISM QUOTIENT TEST)

(TIME_STAMP_PC_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

PC01000. These next questions are about {C_FNAME/the child}.   ​ For each item please tell us if you definitely agree, slightly agree, slightly disagree, or definitely disagree. 

PC02000/(DO_THINGS_SELF). {She/He} prefers to do things with others rather than on {his/her} own.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC03000/(DO_THINGS_SAME). {She/He} prefers to do things the same way over and over again.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+)

PC04000/(EASY_IMAGINE). If {she/he} tries to imagine something, {she/he} finds it very easy to create a picture in {his/her} mind.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC05000/(DISTRACTED). {She/He} frequently gets so strongly absorbed in one thing that {she/he} loses sight of other things.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC06000/(NOTICE_SMALL). {She/He} often notices small sounds when others do not.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC07000/(NOTICE_STRINGS). {She/He} usually notices house numbers or similar strings of information.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC08000/(KNOW_BEHAV_RULES). {She/He} has difficulty understanding rules for polite behavior.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) (modified)

PC09000/(IMAGINE_CHAR). When {she/he} is read a story, {she/he} can easily imagine what the characters might look like.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC10000/(INTEREST_DATES). {She/He} is fascinated by dates.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC11000/(FOLLOW_CONVERS). In a social group, {she/he} can easily keep track of several different people’s conversations.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC12000/(SOCIAL_EASY). {She/He} finds social situations easy.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+)

PC13000/(NOTICE_DETAILS). {She/He} tends to notice details that others do not.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC14000/(LIBRARY_PARTY). {She/He} would rather go to a library than a birthday party.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+)

PC15000/(STORYTELL_EASY). {She/He} finds making up stories easy.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC16000/(PREFER_PPL_THINGS). {She/He} is drawn more strongly to people than to things.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC17000/(UPSET_INTERESTS). {She/He} tends to have very strong interests, which {she/he} gets upset about if {she/he} can’t pursue.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC18000/(LIKE_CHITCHAT). {She/He} enjoys social chit-chat.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+)

PC19000/(EASY_INTERRUPT). When {she/he} talks, it isn’t always easy for others to get a word in edgeways.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+)

PC20000/(INTEREST_NUMBERS). {She/He} is fascinated by numbers.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC21000/(HARD_CHAR_MOTIV). When {she/he} is read a story, {she/he} finds it difficult to work out the characters’ intentions or feelings.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+)

PC22000/(LIKE_FICTION). {She/He} doesn’t particularly enjoy fictional stories.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC23000/(HARD_FRIENDS). {She/He} finds it hard to make new friends.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC24000/(NOTICE_PATTERNS). {She/He} notices patterns in things all the time.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+)

PC25000/(CINEMA_MUSEUM). {She/He} would rather go to the cinema than a museum.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+)

PC26000/(INTERRUPT_ROUTINE). It does not upset {him/her} if {his/her} daily routine is disturbed.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+)

PC27000/(DIFF_CONVERSAT). {She/He} doesn’t know how to keep a conversation going with {his/her} peers.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC28000/(EASY_INFER). {She/He} finds it easy to “read between the lines” when someone is talking to {him/her}.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC29000/(BIG_PIC_DETAILS). {She/He} usually concentrates more on the whole picture, rather than the small details.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC30000/(REMEMBER_NUMBER). {She/He} is not very good at remembering phone numbers.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC31000/(NOTICE_SM_CHANGES). {She/He} doesn’t usually notice small changes in a situation or a person’s appearance.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC32000/(NOTICE_OTH_BORED). {She/He} knows how to tell if someone listening to {him/her} 

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC33000/(SWITCH_ACTIVITIES). {She/He} finds it easy to go back and forth between different activities.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC34000/(PHONE_TURNS). When {she/he} talks on the phone, {she/he} is not sure when it’s {his/her} turn to speak.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+)

PC35000/(LIKE_SPONTAN). {She/He} enjoys doing things spontaneously.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+)

PC36000/(UNDERSTAND_JOKE). {She/He} is often the last to understand the point of a joke.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC37000/(READ_FACE). {She/He} finds it easy to work out what someone is thinking or feeling just by looking at their face.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+)

PC38000/(RETURN_INTERRUPT). If there is an interruption, {she/he} can switch back to what {she/he} was doing very quickly.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+)

PC39000/(GOOD_CHITCHAT). {She/He} is good at social chit-chat

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC40000/(TALK_SAME_THING). People often tell {her/him} that {she/he} keeps going on and on about the same thing.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC41000/(LIKE_PRETEND_GAMES). When {she/he} was in preschool, {she/he} used to enjoy playing games involving pretending with other children.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+)

PC42000/(LIKE_CATEGORIES). {She/He} likes to collect information about categories of things (e.g. types of car, types of bird, types of train, types of plant, etc.).

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC43000/(IMAGINE_OTHERS). {She/He} finds it difficult to imagine what it would be like to be someone else.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC44000/(PLAN_ACTIV_CAREFUL). {She/He} likes to plan any activities {she/he} participates in carefully.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+)

PC45000/(ENJOY_SOCIAL). {She/He} enjoys social occasions

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+)

PC46000/(DIFF_READ_MOTIV). {She/He} finds it difficult to work out people’s intentions.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC47000/(NEW_SIT_ANX). New situations make {him/her} anxious.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC48000/(LIKE_MEETING_PPL). {She/He} enjoys meeting new people.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+)

PC49000/(NO_HURT_PPL). {She/He} is good at taking care not to hurt other people’s feelings.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

PC50000/(NO_REMEM_DOB). {She/He} is not very good at remembering people’s date of birth.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+)

PC51000/(EASY_PRETEND). {She/He} finds it very easy to play games with children that involve pretending.

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
DEFINITELY AGREE	1
SLIGHTLY AGREE	2
SLIGHTLY DISAGREE	3
DEFINITELY DISAGREE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

Cambridge University Behaviour and Personality Questionnaire For Children (Autism Quotient Test – validated for ages 4+) 

(TIME_STAMP_PC_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 8 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.