37.2 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

SWAN Rating Scale for ADHD SAQ, Phase 2g

OMB Specification

SWAN Rating Scale for ADHD SAQ

Event Category:	Time-Based
Event:	36M, 60M
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
Estimated Administration Time:	3 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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SWAN Rating Scale for ADHD SAQ

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

SWAN 3

FOR OFFICE USE ONLY 9

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SWAN Rating Scale for ADHD 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.

SWAN

SWA01000. Instructions:

 

For each item listed below, how does this child compare to other children of the same age? Please select the best rating based on your observations over the past month. 

 

Compared to other children, how does this child do the following:

SWA02000/(ATTENTION_DETAIL). Give close attention to detail and avoid careless mistakes

Label	Code	Go To
Far Below	1
Below	2
Slightly Below	3
Average	4
Slightly Above	5
Above	6
Far Above	7

SOURCE

Strengths and Weaknesses of Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior Scale (SWAN)

SWA03000/(ATTENTION_TASKS). Sustain attention on tasks or play activities

Label	Code	Go To
Far Below	1
Below	2
Slightly Below	3
Average	4
Slightly Above	5
Above	6
Far Above	7

SOURCE

Strengths and Weaknesses of Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior Scale (SWAN)

SWA04000/(LISTEN_SPOKEN_TO). Listen when spoken to directly

Label	Code	Go To
Far Below	1
Below	2
Slightly Below	3
Average	4
Slightly Above	5
Above	6
Far Above	7

SOURCE

Strengths and Weaknesses of Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior Scale (SWAN)

SWA05000/(FOLLOW_THROUGH). Follow through on instructions and finish school work/chores

Label	Code	Go To
Far Below	1
Below	2
Slightly Below	3
Average	4
Slightly Above	5
Above	6
Far Above	7

SOURCE

Strengths and Weaknesses of Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior Scale (SWAN)

SWA06000/(ORGANIZE_TASKS). Organize tasks and activities

Label	Code	Go To
Far Below	1
Below	2
Slightly Below	3
Average	4
Slightly Above	5
Above	6
Far Above	7

SOURCE

Strengths and Weaknesses of Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior Scale (SWAN)

SWA06100/(TASKS_MENTAL_EFFORT). Engage in tasks that require sustained mental effort

Label	Code	Go To
Far Below	1
Below	2
Slightly Below	3
Average	4
Slightly Above	5
Above	6
Far Above	7

SOURCE

Strengths and Weaknesses of Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior Scale (SWAN)

SWA06200/(KEEP_TRACK_THINGS). Keep track of things necessary for activities

Label	Code	Go To
Far Below	1
Below	2
Slightly Below	3
Average	4
Slightly Above	5
Above	6
Far Above	7

SOURCE

Strengths and Weaknesses of Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior Scale (SWAN)

SWA07000/(IGNORE_STIMULI). Ignore extraneous stimuli

Label	Code	Go To
Far Below	1
Below	2
Slightly Below	3
Average	4
Slightly Above	5
Above	6
Far Above	7

SOURCE

Strengths and Weaknesses of Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior Scale (SWAN)

SWA08000/(REMEMBER_ACTIVITIES). Remember daily activities

Label	Code	Go To
Far Below	1
Below	2
Slightly Below	3
Average	4
Slightly Above	5
Above	6
Far Above	7

SOURCE

Strengths and Weaknesses of Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior Scale (SWAN)

SWA09000/(SIT_STILL). Sit still (control movement of hands/feet or control squirming)

Label	Code	Go To
Far Below	1
Below	2
Slightly Below	3
Average	4
Slightly Above	5
Above	6
Far Above	7

SOURCE

Strengths and Weaknesses of Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior Scale (SWAN)

SWA10000/(STAY_SEATED). Stay seated (when required by class rules/social conventions)

Label	Code	Go To
Far Below	1
Below	2
Slightly Below	3
Average	4
Slightly Above	5
Above	6
Far Above	7

SOURCE

Strengths and Weaknesses of Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior Scale (SWAN)

SWA11000/(MODULATE_MOTOR_ACTIVITY). Modulate motor activity (inhibit inappropriate running/climbing)

Label	Code	Go To
Far Below	1
Below	2
Slightly Below	3
Average	4
Slightly Above	5
Above	6
Far Above	7

SOURCE

Strengths and Weaknesses of Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior Scale (SWAN)

SWA12000/(PLAY_QUIETLY). Play quietly (keep noise level reasonable)

Label	Code	Go To
Far Below	1
Below	2
Slightly Below	3
Average	4
Slightly Above	5
Above	6
Far Above	7

SOURCE

Strengths and Weaknesses of Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior Scale (SWAN)

SWA13000/(SETTLE_DOWN). Settle down and rest (control constant activity)

Label	Code	Go To
Far Below	1
Below	2
Slightly Below	3
Average	4
Slightly Above	5
Above	6
Far Above	7

SOURCE

Strengths and Weaknesses of Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior Scale (SWAN)

SWA14000/(MODULATE_VERBAL_ACTIVITY). Modulate verbal activity (control excess talking)

Label	Code	Go To
Far Below	1
Below	2
Slightly Below	3
Average	4
Slightly Above	5
Above	6
Far Above	7

SOURCE

Strengths and Weaknesses of Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior Scale (SWAN)

SWA15000/(REFLECT_QUESTIONS). Reflect on questions (control blurting out answers)

Label	Code	Go To
Far Below	1
Below	2
Slightly Below	3
Average	4
Slightly Above	5
Above	6
Far Above	7

SOURCE

Strengths and Weaknesses of Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior Scale (SWAN)

SWA16000/(AWAIT_TURN). Await turn (stand in line and take turns)

Label	Code	Go To
Far Below	1
Below	2
Slightly Below	3
Average	4
Slightly Above	5
Above	6
Far Above	7

SOURCE

Strengths and Weaknesses of Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior Scale (SWAN)

SWA17000/(ENTER_CONVERSATION_GAMES). Enter into conversations and games (control interrupting/intruding)

Label	Code	Go To
Far Below	1
Below	2
Slightly Below	3
Average	4
Slightly Above	5
Above	6
Far Above	7

SOURCE

Strengths and Weaknesses of Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior Scale (SWAN)

SWA18000. Thank you for participating in the National Children’s Study and for taking the time to complete this survey.

FOR OFFICE USE ONLY

FOU01000/(P_ID). PARTICIPANT ID:________________________________________

FOU02000/(R_P_ID). RESPONDENT ID:____________________________________________

Public reporting burden for this collection of information is estimated to average 3 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.