30M_BSIMailInstructions

OMB #: 0925-0593

OMB Expiration Date: 08/31/2014

Neuro-Psychosocial Brief Symptom Inventory (BSI®) Instructions: Mail, Phase 2g

The National Children’s Study

Brief Symptom Inventory (BSI®) Instructions

Questionnaire

Thank you for agreeing to participate in the National Children’s Study and completing the Brief Symptom Inventory (BSI®). This questionnaire will take about 10 minutes to complete. It includes questions about problems or difficulties that people may sometimes have. 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 BSI® includes questions about problems or difficulties people sometimes have.

• Read each item carefully before you begin and select the response that best describes how much that problem or difficulty has distressed or bothered you during the PAST 7 DAYS, INCLUDING TODAY.

• Please try not to skip any questions and please mark only one response for each problem.

• 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.

• Follow instructions on the next page for information about returning this questionnaire to the Regional Operations Center.

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 Brief Symptom Inventory (BSI®) Instructions: Mail, MDES 4.0, V1.1 1