PAIRSAQInstructions

OMB #: 0925-0593

OMB Expiration Date: 08/31/2014

Neuro-Psychosocial Personal Assessment of Intimacy in Relationships (PAIR) Instructions, Phase 2g

The National Children’s Study

Personal Assessment of Intimacy in Relationships Instructions

Questionnaire

Thank you for agreeing to participate in the National Children’s Study and completing the Personal Assessment of Intimacy in Relationships (PAIR) questionnaire. This questionnaire will take less than 14 minutes to complete. It includes 26 questions about aspects of relationships. You are asked to answer each item twice, once for how your relationship is at present, and once for how you would like your relationship to be. You may use a pencil or pen to record your answers.

Your answers are important to us. We will keep everything that you tell us confidential.

Listed below are several points that you may find helpful in completing the questionnaire:

• The PAIR includes statements about relationships with your spouse/partner.

• The answers range from 0 (“Not at all true”) to 4 (“Completely true”).

• Please read each statement carefully and first select the rating that best describes your relationship with your spouse/partner as it is presently. Next select the rating that best describes what you would like your relationship with your spouse/partner to be.

• Please do not skip any statements and please mark two answers for each statement, one for how your relationship is at present and one for how you would want your relationship to be.

• If you change your mind about an answer, please strike out your original answer and then select your new answer.

• Before returning this questionnaire to the Regional Operations Center (ROC), please make sure you have answered all the items and that there is only one answer for each item.

• To keep your answers confidential, please seal the PAIR questionnaire in the prepaid envelope.

• Follow instructions on the next page for information about returning this questionnaire to the ROC.

If you have any questions, please call the local contact number located on the last page.

Thank you for taking the time to complete this questionnaire!

For Office Use Only:

Instructions for returning the questionnaire to the Regional Operations Center (ROC):

{Local instructions inserted by ROC: Provide the parent/caregiver with ROC-specific instructions for returning the questionnaire to the ROC here.}

Insert ROC contact information label here.

NEU Personal Assessment of Intimacy in Relationships (PAIR) Instructions: Mail, MDES 4.0, V1.0 1