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pdfAPPENDIX A
FIFTH-GRADE
CHILD QUESTIONNAIRE SPECIFICATIONS
Early Childhood Longitudinal Study, Kindergarten Class of 2010-11
(ECLS-K:2011)
Spring Fifth-Grade National Data Collection
OMB Clearance Package
#1850-0750 v.18
This appendix includes the programmer specifications for the audio-CASI child questionnaire, which indicate
the exact instructions to be provided to the child and the items that will be administered.
Spring 2016 Child Assessment: ECLS-K:2011
Section
CLQ
[Child Questionnaire ACASI]
Sequence: 2
CLQGLB005
RAPID RESPONSE
IF A CHILD SELECTS A COMMAND BUTTON (NEXT, BACK) OR A RESPONSE BEFORE ACASI HAS READ THE
ENTIRE CONTENTS OF THE SCREEN, PROGRAM SHOULD ACCEPT THE CHILD'S SELECTION BY FOLLOWING
THE COMMAND OR ACCEPTING THE ANSWER.
CLQGLB010
INACTIVITY SETTINGS
FOR SCREEN CLQ605:
AFTER 10 SECONDS OF IDLE TIME [FROM WHEN THE LAST WORD HAS BEEN READ], THE FOLLOWING
MESSAGE SHOULD BE READ ON AUDIO.
If you are ready to start, please touch the "NEXT" button to move to the next screen.
FOR SCREENS CLQ620-CLQ855:
AFTER 10 SECONDS OF IDLE TIME ON ONE SCREEN [FROM WHEN THE LAST RESPONSE CATEGORY HAS BEEN
READ], THE FOLLOWING MESSAGE SHOULD BE READ ON AUDIO.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
THE PHRASE "Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to
skip this question" IS DISPLAYED BUT SHOULD NOT BE READ ON AUDIO FOR ITEMS CLQ620-CLQ855 (EXCEPT
AFTER A PERIOD OF INACTIVITY).
FOR SCREENS CLQ605-CLQ855:
AFTER THE INACTIVITY MESSAGE HAS BEEN READ THREE TIMES, REPEAT THE SCREEN TEXT.
FOR SCREEN CLQ860:
ACASI SHOULD REPEAT THE SCREEN TEXT EVERY 15 SECONDS.
Spring 2016 Child Assessment: ECLS-K:2011 :: CLQ
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CLQGLB015
CONFIRMATION SCREEN
IF THE CHILD TOUCHES THE NEXT BUTTON BEFORE TOUCHING AN ANSWER TO A QUESTION, THEN
PROGRAM SHOULD MOVE TO THE CONFIRMATION SCREEN.
DISPLAY PREVIOUS ITEM TEXT AND CONFIRMATION QUESTION AT THE TOP OF THE SCREEN. DISPLAY
RESPONSE OPTIONS IN THE MIDDLE OF THE SCREEN BELOW THE QUESTION.
PROGRAM READS CONFIRMATION QUESTION (THAT IS TEXT IN THE SPECS BETWEEN AND
): Do you want to skip this question?
PROGRAM READS RESPONSE OPTIONS:
Yes. (1)
No. (2)
IF THE CHILD CHOOSES 1, THEN PROGRAM MOVES TO THE NEXT SCREEN WITHOUT NEEDING TO PRESS ANY
OTHER BUTTONS. 1 = REFUSED (code 8)
IF THE CHILD CHOOSES 2, THEN PROGRAM MOVES TO THE PREVIOUS SCREEN WITHOUT NEEDING TO PRESS
ANY OTHER BUTTONS.
CLQGLB020
CHANGE RESPONSE PROCEDURE
THE CHILD'S ANSWER SELECTION SHOULD ALWAYS BE VISUALLY EMPHASIZED.
IF THE CHILD WANTS TO CHANGE AN ANSWER, HE OR SHE CAN TOUCH THE "ERASE" BUTTON AND THEN
TOUCH HIS/HER NEW ANSWER. ACASI SHOULD DO THE FOLLOWING:
REMOVE THE VISUAL EMPHASIS FROM THE OLD ANSWER BUTTON
VISUALLY EMPHASIZE THE NEW ANSWER BUTTON
THE CHILD CAN CHANGE AN ANSWER MULTIPLE TIMES. ACASI SHOULD ACCEPT THE LAST ANSWER.
CLQGLB025
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DISPLAY INSTRUCTIONS
WHEN TOUCHED, THE CHILD'S ANSWER SELECTION SHOULD BE VISUALLY EMPHASIZED.
CLQGLB030
AUDIO INSTRUCTIONS
WORDS IN ALL CAPS SHOULD BE EMPHASIZED WHEN READ OVER AUDIO.
ALL RESPONSE SETS ARE READ FOR ALL QUESTIONS.
CLQGBL035
ADMINISTRATION TIMING
FOR ENTIRE CQ ADMINISTRATION TIMINGS, BEGIN TIMING WHEN THE OPENING SCREEN FOR THE
ASSESSOR APPEARS (CLQ600) AND END TIMING WHEN THE ASSESSOR PRESSES THE NEXT BUTTON TO
LEAVE THE CLOSING SCREEN (CLQ865).
CLQGLB040
ANSWER BUTTON DISPLAY CHARACTERISTICS
Vertical spacing: 15 pixels
Button height: 50 pixels
Button width: 200 pixels
BUTTON DISPLAY
PLACE A "NEXT" BUTTON AT THE BOTTOM RIGHT OF EACH SCREEN.
PLACE A "BACK" BUTTON AT THE BOTTOM LEFT OF EACH SCREEN. FOR SCREENS CLQ600, CLQ605 AND
CLQ865, SHOW THE BUTTON BUT DISABLE IT SO IT CANNOT BE USED.
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PLACE AN "ERASE" BUTTON AT THE BOTTOM CENTER OF EACH SCREEN. FOR SCREENS CLQ600, CLQ605,
CLQ860, AND CLQ865, SHOW THE BUTTON BUT DISABLE IT SO IT CANNOT BE USED.
CLQGLB045
BREAKOFF
ADD F8 AS A KEY COMBINATION TO BREAKOFF THE INTERVIEW.
THE FIELD AT WHICH THE BREAKOFF OCCURS IS STORED IN THE WBA AUDIT TRAIL.
CLQ600
QUESTION TEXT:
TURN LAPTOP AROUND AND ROTATE LAPTOP SCREEN TO FACE THE CHILD. PLUG HEADPHONES INTO THE
COMPUTER. POSITION LAPTOP IN FRONT OF THE CHILD.
SAY: Now, you are going to use the computer to tell us about yourself. The computer will read some
sentences while you listen on the headphones. [HOLD UP HEADPHONES.]
SAY: Then you will pick the answer that best describes you by touching your answer on the computer screen.
[TOUCH THE MIDDLE OF THE COMPUTER SCREEN WITH ONE FINGER.]
SAY: If the volume is too loud or too soft, you can change it with these buttons. [POINT TO VOLUME
BUTTONS ABOVE STICKER.]
SAY: Okay, go ahead and put these headphones on and adjust them so they fit. Then, you will get started.
ENTER TEXT
PROGRAMMER INSTRUCTIONS:
TURN OFF CONFIRMATION SCREEN.
THE TEXT ON THIS SCREEN SHOULD NOT BE READ ALOUD.
CLQ605
DISPLAY INSTRUCTIONS:
The text "According to the Paperwork Reduction Act….in the statistical reports" should appear at the very
Spring 2016 Child Assessment: ECLS-K:2011 :: CLQ
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bottom of the screen and in smaller font.
QUESTION TEXT:
Hello. In a minute, sentences will be read to you, along with a list of answers. For these questions, there are
no right or wrong answers, and your parents, teachers, and principal will not told the answers that you pick.
To choose your answer, just touch it on the computer screen. You don't have to wait for the computer to
finish reading all the answers before you choose your answer.
If you want to change your answer, touch the "ERASE" button and then touch the new answer you want to
pick.
To go back and change an answer, touch the "BACK" button to move to earlier screens.
If there is a question you do not want to answer, touch the “NEXT” button to skip it.
If you are ready to start, please touch the "NEXT" button to move to the next screen.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this voluntary
survey is 1850-0750. Approval expires XX/XX/XXXX. The time required to complete this survey is estimated to
average 10 minutes per response, including the time to review instructions, and complete and review the
survey. If you have any comments concerning the accuracy of the time estimate or suggestions for improving
this survey, or any comments or concerns regarding the status of your individual submission of this survey,
please write to: Early Childhood Longitudinal Study, National Center for Education Statistics, 1990 K Street,
N.W., Washington, D.C. 20006-5574.
The collection of information in this survey is authorized by 20 U.S. Code, Section 9543. Participation is
voluntary. You may skip questions you do not wish to answer; however, we hope that you will answer as
many questions as you can. Your responses are protected from disclosure by federal statute (20 U.S. Code,
Section 9573). All responses that relate to or describe identifiable characteristics of individuals may be used
only for statistical purposes and may not be disclosed, or used, in identifiable form for any other purpose
except as required by law. Data will be combined to produce statistical reports. No individual data that links
your name, address, telephone number, or identification number with your responses will be included in the
statistical reports.
ENTER TEXT
PROGRAMMER INSTRUCTIONS:
TURN OFF CONFIRMATION SCREEN.
THE TEXT "ACCORDING TO THE PAPERWORK REDUCTION ACT…IN THE STATISTICAL REPORT" SHOULD NOT
BE READ ALOUD.
CLQ620
QUESTION TEXT:
Think about yourself and your experiences this school year. How often do the following things happen?
I try hard to do well in school.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
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2
Rarely
3
Sometimes
4
Often
5
Very often
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ625
QUESTION TEXT:
In class, I work as hard as I can.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Rarely
3
Sometimes
4
Often
5
Very often
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ630
QUESTION TEXT:
When I'm in class, I participate in class discussions.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Rarely
3
Sometimes
4
Often
5
Very often
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
Spring 2016 Child Assessment: ECLS-K:2011 :: CLQ
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CLQ635
QUESTION TEXT:
I pay attention in class.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Rarely
3
Sometimes
4
Often
5
Very often
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ640
QUESTION TEXT:
When I'm in class, I listen very carefully.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Rarely
3
Sometimes
4
Often
5
Very often
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ645
QUESTION TEXT:
This school year, how often did you…
Feel like you fit in at your school?
Spring 2016 Child Assessment: ECLS-K:2011 :: CLQ
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Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Sometimes
3
Often
4
Always
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ650
QUESTION TEXT:
[This school year, how often did you…]
Feel close to classmates at your school?
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Sometimes
3
Often
4
Always
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ655
QUESTION TEXT:
[This school year, how often did you…]
Feel close to teachers in your school?
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Sometimes
3
Often
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4
Always
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ660
QUESTION TEXT:
[This school year, how often did you…]
Enjoy being at your school?
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Sometimes
3
Often
4
Always
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ665
QUESTION TEXT:
[This school year, how often did you…]
Feel safe at your school?
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Sometimes
3
Often
4
Always
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ670
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QUESTION TEXT:
How much does each of the following statements describe a person like you?
I finish whatever I begin.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Not at all like me
2
A little bit like me
3
Somewhat like me
4
Quite a bit like me
5
Very much like me
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ675
QUESTION TEXT:
[How much does each of the following statements describe a person like you?]
I try very hard even after making mistakes.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Not at all like me
2
A little bit like me
3
Somewhat like me
4
Quite a bit like me
5
Very much like me
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ680
QUESTION TEXT:
[How much does each of the following statements describe a person like you?]
Spring 2016 Child Assessment: ECLS-K:2011 :: CLQ
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I continue to work towards my goals, even when they take a long time to complete.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Not at all like me
2
A little bit like me
3
Somewhat like me
4
Quite a bit like me
5
Very much like me
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ685
QUESTION TEXT:
[How much does each of the following statements describe a person like you?]
I keep working hard even when I feel like quitting.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Not at all like me
2
A little bit like me
3
Somewhat like me
4
Quite a bit like me
5
Very much like me
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ690
QUESTION TEXT:
[How much does each of the following statements describe a person like you?]
I continue working on what I set out to do, even when it takes a long time to complete.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
Spring 2016 Child Assessment: ECLS-K:2011 :: CLQ
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CODES
1
Not at all like me
2
A little bit like me
3
Somewhat like me
4
Quite a bit like me
5
Very much like me
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ695
QUESTION TEXT:
[How much does each of the following statements describe a person like you?]
I keep trying to improve myself, even when it takes a long time to get there.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Not at all like me
2
A little bit like me
3
Somewhat like me
4
Quite a bit like me
5
Very much like me
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ700
QUESTION TEXT:
How true is each of these things about you?
I worry about taking tests.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Not at all true
2
A little bit true
3
Mostly true
4
Very true
Spring 2016 Child Assessment: ECLS-K:2011 :: CLQ
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2015-08-11 10:04
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ705
QUESTION TEXT:
[How true is each of these things about you?]
It's hard for me to finish my school work.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Not at all true
2
A little bit true
3
Mostly true
4
Very true
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ710
QUESTION TEXT:
[How true is each of these things about you?]
I feel ashamed when I make mistakes at school.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Not at all true
2
A little bit true
3
Mostly true
4
Very true
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ715
Spring 2016 Child Assessment: ECLS-K:2011 :: CLQ
Page 13 of 27
2015-08-11 10:04
QUESTION TEXT:
[How true is each of these things about you?]
I worry about doing well in school.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Not at all true
2
A little bit true
3
Mostly true
4
Very true
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ720
QUESTION TEXT:
[How true is each of these things about you?]
I worry about finishing my work.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Not at all true
2
A little bit true
3
Mostly true
4
Very true
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ725
QUESTION TEXT:
Think about yourself and your experiences this school year. How often do the following things
happen?
Kids in my class make me feel better if I'm having a bad day.
Spring 2016 Child Assessment: ECLS-K:2011 :: CLQ
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Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Rarely
3
Sometimes
4
Often
5
Very often
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ730
QUESTION TEXT:
I worry about what other kids think of me.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Rarely
3
Sometimes
4
Often
5
Very often
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
Source: Adapted from the Social Anxiety Scale for
Children-Revised. ©1993 Annette M. La Greca,
University of Miami. Used with permission.
CLQ735
QUESTION TEXT:
I feel lonely at school.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Rarely
3
Sometimes
4
Often
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5
Very often
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ740
QUESTION TEXT:
Kids in my class let me play with them.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Rarely
3
Sometimes
4
Often
5
Very often
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ745
QUESTION TEXT:
I worry that other kids don't like me.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Rarely
3
Sometimes
4
Often
5
Very often
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
Source: Adapted from the Social Anxiety Scale for
Children-Revised. ©1993 Annette M. La Greca,
University of Miami. Used with permission.
CLQ750
Spring 2016 Child Assessment: ECLS-K:2011 :: CLQ
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QUESTION TEXT:
I feel left out at school.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Rarely
3
Sometimes
4
Often
5
Very often
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ755
QUESTION TEXT:
Kids in my class make me feel happy.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Rarely
3
Sometimes
4
Often
5
Very often
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ760
QUESTION TEXT:
Kids in my class would help me if I hurt myself at school.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
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CODES
1
Never
2
Rarely
3
Sometimes
4
Often
5
Very often
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ765
QUESTION TEXT:
I'm afraid other kids will not like me.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Rarely
3
Sometimes
4
Often
5
Very often
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
Source: Adapted from the Social Anxiety Scale for
Children-Revised. ©1993 Annette M. La Greca,
University of Miami. Used with permission.
CLQ770
QUESTION TEXT:
Kids in my class tell me that I'm their friend.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Rarely
3
Sometimes
4
Often
5
Very often
REFUSED
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PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ775
QUESTION TEXT:
I feel alone at school.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Rarely
3
Sometimes
4
Often
5
Very often
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ780
QUESTION TEXT:
Kids in my class would help me if other kids were being mean to me.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Rarely
3
Sometimes
4
Often
5
Very often
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ785
QUESTION TEXT:
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Next, please think about experiences that you have had with other students.
During this school year, how often have other students teased you, made fun of you, or called you
names?
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Rarely
3
Sometimes
4
Often
5
Very often
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ790
QUESTION TEXT:
During this school year, how often have other students told lies or untrue stories about
you?
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Rarely
3
Sometimes
4
Often
5
Very often
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ795
QUESTION TEXT:
During this school year, how often have other students pushed, shoved, slapped, hit, or kicked
you?
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
Spring 2016 Child Assessment: ECLS-K:2011 :: CLQ
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2015-08-11 10:04
CODES
1
Never
2
Rarely
3
Sometimes
4
Often
5
Very often
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ800
QUESTION TEXT:
During this school year, how often have other students left you out from playing with them on
purpose?
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Rarely
3
Sometimes
4
Often
5
Very often
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ805
QUESTION TEXT:
How often do you send texts, messages, or emails using an app, cell phone, computer, iPad or
tablet, or other electronic device?
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Less than once a week
3
A few times a week
4
About once a day
5
Many times a day
Spring 2016 Child Assessment: ECLS-K:2011 :: CLQ
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2015-08-11 10:04
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ810
QUESTION TEXT:
How often do you play an online game against another online player using an app, cell phone,
computer, iPad or tablet, or other electronic device?
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Less than once a week
3
A few times a week
4
About once a day
5
Many times a day
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ815
QUESTION TEXT:
How often do you use a social networking site like Facebook, Twitter, Instagram, or Vine using an
app, cell phone, computer, iPad or tablet, or other electronic device?
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Less than once a week
3
A few times a week
4
About once a day
5
Many times a day
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ820
Spring 2016 Child Assessment: ECLS-K:2011 :: CLQ
Page 22 of 27
2015-08-11 10:04
QUESTION TEXT:
Does your family have rules about who you can send texts, messages, or emails to?
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
YES
2
NO
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
DISPLAY "who" in UNDERLINED TEXT.
THE UNDERLINED WORD "who" SHOULD BE EMPHASIZED.
CLQ825
QUESTION TEXT:
Does your family have rules about when you can send texts, messages, or emails?
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
YES
2
NO
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
DISPLAY "when" in UNDERLINED TEXT.
CLQ830
QUESTION TEXT:
How often do your parents/guardians...
Know what you do during your free time?
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
Spring 2016 Child Assessment: ECLS-K:2011 :: CLQ
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2015-08-11 10:04
CODES
1
Never
2
Rarely
3
Sometimes
4
Often
5
Very often
6
Always
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ835
QUESTION TEXT:
[How often do your parents/guardians…]
Know how much homework you have ?
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Rarely
3
Sometimes
4
Often
5
Very often
6
Always
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ840
QUESTION TEXT:
[How often do your parents/guardians…]
Know what your school grades are?
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Never
2
Rarely
Spring 2016 Child Assessment: ECLS-K:2011 :: CLQ
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2015-08-11 10:04
3
Sometimes
4
Often
5
Very often
6
Always
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ845
QUESTION TEXT:
The next set of sentences are about how you feel about your life. Think about the sentence and decide how
well it describes you. Does the sentence describe you "Not at all; A little bit; Somewhat; Quite a bit; or Very
much"?
I am happy with the clothes, games, toys, and other things I have.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Not at all
2
A little bit
3
Somewhat
4
Quite a bit
5
Very much
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ850
QUESTION TEXT:
I am happy with how much attention I get from my parents.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Not at all
2
A little bit
3
Somewhat
4
Quite a bit
5
Very much
Spring 2016 Child Assessment: ECLS-K:2011 :: CLQ
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2015-08-11 10:04
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ855
QUESTION TEXT:
I am happy with the neighborhood and community in which I live.
Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" button to skip this
question.
CODES
1
Not at all
2
A little bit
3
Somewhat
4
Quite a bit
5
Very much
REFUSED
PROGRAMMER INSTRUCTIONS:
DISPLAY ITEM AND RESPONSE OPTIONS.
CLQ860
QUESTION TEXT:
Thank you for working with me.
You are done answering questions on the computer. Please take off the headphones now.
ENTER TEXT
PROGRAMMER INSTRUCTIONS:
TURN OFF CONFIRMATION SCREEN.
CLQ865
QUESTION TEXT:
TAKE THE HEADPHONES FROM THE CHILD. UNPLUG HEADPHONES FROM COMPUTER.
TAKE THE LAPTOP FROM THE CHILD AND PLACE THE LAPTOP DIRECTLY IN FRONT OF YOU.
SAY: Thank you. Now we are going to do something else.
Spring 2016 Child Assessment: ECLS-K:2011 :: CLQ
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2015-08-11 10:04
TOUCH THE "NEXT" BUTTON TO CONTINUE.
ENTER TEXT
PROGRAMMER INSTRUCTIONS:
THE TEXT ON THIS SCREEN SHOULD NOT BE READ ALOUD.
Box 8
QUESTION TEXT:
ROUTE TO R5001.
ENTER TEXT
Spring 2016 Child Assessment: ECLS-K:2011 :: CLQ
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2015-08-11 10:04
APPENDIX B
FIFTH-GRADE
CHILD QUESTIONS FOR THE HEARING EVALUATIONS
SPECIFICATIONS
Early Childhood Longitudinal Study, Kindergarten Class of 2010-11
(ECLS-K:2011)
Spring Fifth-Grade National Data Collection
OMB Clearance Package
#1850-0750 v.17
This appendix includes the programmer specifications for the questions to be asked of the child during the
hearing evaluations, which indicate the exact instructions to be provided to the child and the items that will be
administered.
Child Hearing Evaluation Questionnaire 5th Grade:
ECLS-K:2011
Section
PTQ
[Pre-Test Questionnaire]
Sequence: 0
PTQ001
DISPLAY INSTRUCTIONS:
AT THE TOP OF THE SCREEN, DISPLAY:
"{NAME OF CHILD}, {CASE ID}"
FOR "NAME OF CHILD", DISPLAY THE FIRST AND LAST NAME OF THE CHILD. FOR "CASE ID", DISPLAY THE
CASE ID OF THE CHILD.
QUESTION TEXT:
Do you have a cold or a runny nose today?
HELP:
A COLD REFERS TO A DISORDER IN THE @UUPPER@U RESPIRATORY TRACT. IF THE CHILD IS NOT SURE IF
HE OR SHE HAS/HAD A COLD, PROBE FOR SYMPTOMS FROM THE @UNECK UP@U, SUCH AS:
•STUFFY NOSE OR HEAD
•SORE THROAT
•COUGH
•ALLERGIES SHOULD BE CODED AS A @UYES@U RESPONSE IF THEY INCLUDE ANY OF THESE SYMPTOMS.
CODES
1
YES
PTQ003
2
NO
PTQ002
REFUSED
PTQ002
DON'T KNOW
PTQ002
PTQ002
DISPLAY INSTRUCTIONS:
AT THE TOP OF THE SCREEN, DISPLAY:
"{NAME OF CHILD}, {CASE ID}"
FOR "NAME OF CHILD", DISPLAY THE FIRST AND LAST NAME OF THE CHILD. FOR "CASE ID", DISPLAY THE
CASE ID OF THE CHILD.
QUESTION TEXT:
Did you have a cold or a runny nose yesterday?
HELP:
A COLD REFERS TO A DISORDER IN THE @UUPPER@U RESPIRATORY TRACT. IF THE CHILD IS NOT SURE IF
HE OR SHE HAS/HAD A COLD, PROBE FOR SYMPTOMS FROM THE @UNECK UP@U, SUCH AS:
•STUFFY NOSE OR HEAD
•SORE THROAT
•COUGH
Child Hearing Evaluation Questionnaire 5th Grade: ECLS-K:2011 ::
Page 1 of 7
PTQ 2015-06-25 15:13
•ALLERGIES SHOULD BE CODED AS A @UYES@U RESPONSE IF THEY INCLUDE ANY OF THESE SYMPTOMS.
CODES
1
YES
2
NO
REFUSED
DON'T KNOW
HELP AVAILABLE
PTQ003
DISPLAY INSTRUCTIONS:
AT THE TOP OF THE SCREEN, DISPLAY:
"{NAME OF CHILD}, {CASE ID}"
FOR "NAME OF CHILD", DISPLAY THE FIRST AND LAST NAME OF THE CHILD. FOR "CASE ID", DISPLAY THE
CASE ID OF THE CHILD.
QUESTION TEXT:
Have you had an earache today?
HELP TEXT:
Earache refers to any pain WITHIN the ear. It does not include pain on the external ear (e.g., recently pierced
ears, cuts or sores on the external ear).
CODES
1
YES
PTQ005
2
NO
PTQ004
REFUSED
PTQ004
DON'T KNOW
PTQ004
PTQ004
HELP AVAILABLE
DISPLAY INSTRUCTIONS:
AT THE TOP OF THE SCREEN, DISPLAY:
"{NAME OF CHILD}, {CASE ID}"
FOR "NAME OF CHILD", DISPLAY THE FIRST AND LAST NAME OF THE CHILD. FOR "CASE ID", DISPLAY THE
CASE ID OF THE CHILD.
QUESTION TEXT:
Did you have an earache yesterday?
HELP TEXT:
Earache refers to any pain WITHIN the ear. It does not include pain on the external ear (e.g., recently pierced
ears, cuts or sores on the external ear).
Child Hearing Evaluation Questionnaire 5th Grade: ECLS-K:2011 ::
Page 2 of 7
PTQ 2015-06-25 15:13
CODES
1
YES
PTQ005
2
NO
PTQ006
REFUSED
PTQ006
DON'T KNOW
PTQ006
PTQ005
DISPLAY INSTRUCTIONS:
AT THE TOP OF THE SCREEN, DISPLAY:
"{NAME OF CHILD}, {CASE ID}"
FOR "NAME OF CHILD", DISPLAY THE FIRST AND LAST NAME OF THE CHILD. FOR "CASE ID", DISPLAY THE
CASE ID OF THE CHILD.
DISPLAY "LEFT" IN BOLD AND BLUE TEXT. DISPLAY "RIGHT" IN BOLD AND RED TEXT.
QUESTION TEXT:
Which ear(s) hurt?
CODES
1
LEFT
2
RIGHT
3
BOTH
REFUSED
DON'T KNOW
PTQ006
HELP AVAILABLE
DISPLAY INSTRUCTIONS:
AT THE TOP OF THE SCREEN, DISPLAY:
"{NAME OF CHILD}, {CASE ID}"
FOR "NAME OF CHILD", DISPLAY THE FIRST AND LAST NAME OF THE CHILD. FOR "CASE ID", DISPLAY THE
CASE ID OF THE CHILD.
QUESTION TEXT:
Have you listened to sounds today that were so loud you would have to shout so someone close by could
hear you?
HELP TEXT:
Sounds are considered “very loud” if either
1) The child would have had to raise his voice to speak to someone an arm’s length away, or
2) The child’s ears were ringing or felt “funny” afterwards.
Examples of sounds that do NOT count: parents/teachers/children yelling, dogs barking, recess, school bells,
sounds that last less than five minutes EXCEPT for firecrackers, gunfire, or other "impulse" type noises.
Child Hearing Evaluation Questionnaire 5th Grade: ECLS-K:2011 ::
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PTQ 2015-06-25 15:13
Examples of sounds that DO count: loud TV or radio, loud music, sporting events, motorbikes, lawnmowers,
firecrackers, gunfire, or any "impulse" type noise.
CODES
1
YES
PTQ008
2
NO
PTQ007
REFUSED
PTQ007
DON'T KNOW
PTQ007
HELP AVAILABLE
PTQ007
DISPLAY INSTRUCTIONS:
AT THE TOP OF THE SCREEN, DISPLAY:
"{NAME OF CHILD}, {CASE ID}"
FOR "NAME OF CHILD", DISPLAY THE FIRST AND LAST NAME OF THE CHILD. FOR "CASE ID", DISPLAY THE
CASE ID OF THE CHILD.
QUESTION TEXT:
Did you listen to any sounds that were that loud yesterday? [Did you listen to any sounds yesterday that were
so loud you would have to shout so someone close by could hear you?]
HELP TEXT:
Sounds are considered “very loud” if either
1) The child would have had to raise his voice to speak to someone an arm’s length away, or
2) The child’s ears were ringing or felt “funny” afterwards.
Examples of sounds that do NOT count: parents/teachers/children yelling, dogs barking, recess, school bells,
sounds that last less than five minutes EXCEPT for firecrackers, gunfire, or other "impulse" type noises.
Examples of sounds that DO count: loud TV or radio, loud music, sporting events, motorbikes, lawnmowers,
firecrackers, gunfire, or any "impulse" type noise.
CODES
1
YES
2
NO
REFUSED
DON'T KNOW
PTQ008
DISPLAY INSTRUCTIONS:
AT THE TOP OF THE SCREEN, DISPLAY:
"{NAME OF CHILD}, {CASE ID}"
FOR "NAME OF CHILD", DISPLAY THE FIRST AND LAST NAME OF THE CHILD. FOR "CASE ID", DISPLAY THE
CASE ID OF THE CHILD.
Child Hearing Evaluation Questionnaire 5th Grade: ECLS-K:2011 ::
Page 4 of 7
PTQ 2015-06-25 15:13
QUESTION TEXT:
Do you have tubes in your ears now that a doctor put there [to keep you from getting earaches or ear
infections]?
CODES
1
YES
PTQ010
2
NO
PTQ012
REFUSED
PTQ009
DON'T KNOW
PTQ009
PTQ009
DISPLAY INSTRUCTIONS:
AT THE TOP OF THE SCREEN, DISPLAY:
"{NAME OF CHILD}, {CASE ID}"
FOR "NAME OF CHILD", DISPLAY THE FIRST AND LAST NAME OF THE CHILD. FOR "CASE ID", DISPLAY THE
CASE ID OF THE CHILD.
QUESTION TEXT:
Do you have to wear earplugs when you swim or take a bath or shower?
CODES
1
YES
PTQ011
2
NO
PTQ012
REFUSED
PTQ012
DON'T KNOW
PTQ012
PTQ010
DISPLAY INSTRUCTIONS:
AT THE TOP OF THE SCREEN, DISPLAY:
"{NAME OF CHILD}, {CASE ID}"
FOR "NAME OF CHILD", DISPLAY THE FIRST AND LAST NAME OF THE CHILD. FOR "CASE ID", DISPLAY THE
CASE ID OF THE CHILD.
DISPLAY "LEFT" IN BOLD AND BLUE TEXT. DISPLAY "RIGHT" IN BOLD AND RED TEXT.
QUESTION TEXT:
In which ear do you have the tube(s)?
CODES
1
LEFT
PTQ012
2
RIGHT
PTQ012
3
BOTH
PTQ012
Child Hearing Evaluation Questionnaire 5th Grade: ECLS-K:2011 ::
Page 5 of 7
PTQ 2015-06-25 15:13
REFUSED
PTQ012
DON'T KNOW
PTQ012
PTQ011
DISPLAY INSTRUCTIONS:
AT THE TOP OF THE SCREEN, DISPLAY:
"{NAME OF CHILD}, {CASE ID}"
FOR "NAME OF CHILD", DISPLAY THE FIRST AND LAST NAME OF THE CHILD. FOR "CASE ID", DISPLAY THE
CASE ID OF THE CHILD.
DISPLAY "LEFT" IN BOLD AND BLUE TEXT. DISPLAY "RIGHT" IN BOLD AND RED TEXT.
QUESTION TEXT:
In which ear do you wear the earplug(s)?
CODES
1
LEFT
2
RIGHT
3
BOTH
REFUSED
DON'T KNOW
PTQ012
DISPLAY INSTRUCTIONS:
AT THE TOP OF THE SCREEN, DISPLAY:
"{NAME OF CHILD}, {CASE ID}"
FOR "NAME OF CHILD", DISPLAY THE FIRST AND LAST NAME OF THE CHILD. FOR "CASE ID", DISPLAY THE
CASE ID OF THE CHILD.
QUESTION TEXT:
Is it easier for you to hear out of one ear than the other?
CODES
1
YES
2
NO
BOX1
REFUSED
BOX1
DON'T KNOW
BOX1
PTQ013
Child Hearing Evaluation Questionnaire 5th Grade: ECLS-K:2011 ::
Page 6 of 7
PTQ 2015-06-25 15:13
DISPLAY INSTRUCTIONS:
AT THE TOP OF THE SCREEN, DISPLAY:
"{NAME OF CHILD}, {CASE ID}"
FOR "NAME OF CHILD", DISPLAY THE FIRST AND LAST NAME OF THE CHILD. FOR "CASE ID", DISPLAY THE
CASE ID OF THE CHILD.
DISPLAY "LEFT" IN BOLD AND BLUE TEXT. DISPLAY "RIGHT" IN BOLD AND RED TEXT.
QUESTION TEXT:
Which ear is easier to hear with?
CODES
1
LEFT
2
RIGHT
REFUSED
DON'T KNOW
BOX1
GO TO OTOSCOPE EXAM RESULTS SECTION.
Child Hearing Evaluation Questionnaire 5th Grade: ECLS-K:2011 ::
Page 7 of 7
PTQ 2015-06-25 15:13
| File Type | application/pdf |
| File Modified | 2015-08-11 |
| File Created | 2015-08-11 |