| Short Name: | mv_demo_intake |
|---|---|
| Version: |
Minimally Verbal - Common Demographic Intake Form
The Common Demographic Intake Form as defined by the Minimally Verbal Workgroup
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| ElementName | DataType | Size | Required | ElementDescription | ValueRange | Notes |
|---|---|---|---|---|---|---|
| subjectkey | GUID | Required | The NDAR Global Unique Identifier (GUID) for subjects which identifies a subject in NDAR | NDAR* | ||
| src_subject_id | String | 20 | Required | The site or study's subject identification | ||
| gender | String | 50 | Required | Gender | M; F | |
| grade | String | 50 | Recommended | Current Grade | ||
| interview_date | Date | Required | Date on which the interview/genetic test/sampling/imaging was completed | Required field | ||
| hispanic | Integer | Recommended | Is the child of Hispanic, Latino, or Spanish origin? | 0; 1 | No=0; Yes =1 | |
| race | String | 30 | Recommended | Race of participant | American Indian/Alaska Native; Asian; Hawaiian or Pacific Islander; Black or African American; White; More than one race; Unknown or not reported | |
| race_other | String | 100 | Recommended | Race of Participant Specify | ||
| part_education | String | 100 | Recommended | Participant's Current Education Level | Day care; Nursery; Preschool; Kindergarten; Elementary School; Secondary School; Other | |
| mv_household_income | String | 100 | Recommended | Total Household Income Last Year | "Less than $9,999; Between $10,000 and $19,999; Between $20,000 and $29,999; Between $30,000 and $39,999; Between $40,000 and $49,999; Between $50,000 and $59,999; Between $60,000 and $69,999; Between $70,000 and $79,999; Between $80,000 and $89,999; Between $90,000 and $99,999; Over $100,000" | |
| cg1_gender | String | 10 | Recommended | Caregiver 1's Gender | Male; Female | |
| cg1_relation_status | String | 100 | Recommended | Caregiver 1's Relationship Status | Married; Never married; Widowed; Divorced and remarried; Separated; Divorced; Widowed and remarried; Other | |
| cg1_relation_status_specify | String | 100 | Recommended | Caregiver 1's Relationship Status Other Specify | ||
| cg1_relationship | String | 100 | Recommended | Caregiver 1's Relationship to Participant | Parent; Step-parent; Foster parent; Grandparent; Other family member; Other | |
| cg1_relationship_specify | String | 100 | Recommended | Caregiver 1's Relationship to Participant Other Specify | ||
| cg1_guardian | String | 10 | Recommended | Caregiver 1. Is this the Participant's Custodian/Legal Guardian? | Yes; No | |
| cg1_cohabitate | String | 10 | Recommended | Caregiver 1. Does the participant live with this custodian? | Yes; No | |
| cg1_race | String | 100 | Recommended | Race of the Caregiver 1 | American Indian/Alaska Native; Asian; Hawaiian or Pacific Islander; Black or African American; White; More than one race; Unknown or not reported | |
| cg1_race_specify | String | 100 | Recommended | Race of the Caregiver 1 Other Specify | ||
| cg1_education | String | 100 | Recommended | Caregiver 1's Highest Level of Education | Some primary school; Some high school; High school diploma; GED; Some college or technical school; Associate degree; Baccalaureate degree; Graduate or professional degree | |
| cg1_occupation | String | 100 | Recommended | Caregiver 1's Occupation | ||
| num_in_house_adults | Integer | Recommended | Number of Individuals in Household Adults | |||
| num_in_house_kids | Integer | Recommended | Number of Individuals in Household Children | |||
| nih_mom_hispanic | String | 10 | Recommended | Biological Parents Not in Household - Is the Mother of Hispanic or Latino Origin? | Yes; No | |
| nih_mom_race | String | 100 | Recommended | Biological Parents Not in Household - Mother's Race | American Indian or Alaskan Native; Asian; Pacific Islander; Black or African American; White; Other | |
| nih_mom_race_specify | String | 100 | Recommended | Biological Parents Not in Household - Mother's Race Other Specify | ||
| nih_dad_hispanic | String | 10 | Recommended | Biological Parents Not in Household - Is the Father of Hispanic or Latino Origin? | Yes; No | |
| nih_dad_race | String | 100 | Recommended | Biological Parents Not in Household - Father's Race | American Indian or Alaskan Native; Asian; Pacific Islander; Black or African American; White; Other | |
| nih_dad_race_specify | String | 100 | Recommended | Biological Parents Not in Household - Father's Race Other Specify | ||
| cg2_relationship | String | 100 | Recommended | Caregiver 2's Relationship to Participant | Parent; Step-parent; Foster parent; Grandparent; Other family member; Other | |
| cg2_relationship_specify | String | 100 | Recommended | Caregiver 2's Relationship to Participant Other Specify | ||
| cg2_guardian | String | 10 | Recommended | Caregiver 2. Is this the Participant's Custodian/Legal Guardian? | Yes; No | |
| cg2_hispanic | String | 10 | Recommended | Is Caregiver 2 of Hispanic or Latino Origin? | Yes; No | |
| cg2_race | String | 100 | Recommended | Race of the Caregiver 2 | American Indian/Alaska Native; Asian; Hawaiian or Pacific Islander; Black or African American; White; More than one race; Unknown or not reported | |
| cg1_cg2_relationship | String | 100 | Recommended | Relationship of Caregiver 2 to Caregiver 1 | "Spouse; In a relationship, unmarried; Other" | |
| cg1_cg2_relationship_specify | String | 100 | Recommended | Relationship of Caregiver 2 to Caregiver 1 Other Specify | ||
| cg2_relation_status | String | 100 | Recommended | Caregiver 2's Relationship Status | Married; Never married; Widowed; Divorced and remarried; Separated; Divorced; Widowed and remarried; Other | |
| cg2_relation_status_specify | String | 100 | Recommended | Caregiver 2's Relationship Status Other Specify | ||
| cg2_education | String | 100 | Recommended | Caregiver 2's Highest Level of Education | Some primary school; Some high school; High school diploma; GED; Some college or technical school; Associate degree; Baccalaureate degree; Graduate or professional degree | |
| cg2_occupation | String | 100 | Recommended | Caregiver 2's Occupation | ||
| child1_age | String | 100 | Recommended | Other Child in Household 1 Age | 0-4 years;5-8 years;9-12 years;13-17 years;18+ years | |
| child1_gender | String | 10 | Recommended | Other Child in Household 1 Gender | Male; Female | |
| child1_education | String | 100 | Recommended | Other Child in Household 1 School Level | Pre-school; Elementary; Jr high/middle; High school; Post-HS | |
| child1_handedness | String | 100 | Recommended | Other Child in Household 1 Handedness | Left-handed; Right-handed | |
| child1_proband_relationship | String | 100 | Recommended | Other Child in Household 1 Relationship to Participant | Sibling; Half-sibiling; Other relative; Not related | |
| child2_age | String | 100 | Recommended | Other Child in Household 2 Age | 0-4 years;5-8 years;9-12 years;13-17 years;18+ years | |
| child2_gender | String | 10 | Recommended | Other Child in Household 2 Gender | Male; Female | |
| child2_education | String | 100 | Recommended | Other Child in Household 2 School Level | Pre-school; Elementary; Jr high/middle; High school; Post-HS | |
| child2_handedness | String | 100 | Recommended | Other Child in Household 2 Handedness | Left-handed; Right-handed | |
| child2_proband_relationship | String | 100 | Recommended | Other Child in Household 2 Relationship to Participant | Sibling; Half-sibiling; Other relative; Not related | |
| child3_age | String | 100 | Recommended | Other Child in Household 3 Age | 0-4 years;5-8 years;9-12 years;13-17 years;18+ years | |
| child3_gender | String | 10 | Recommended | Other Child in Household 3 Gender | Male; Female | |
| child3_education | String | 100 | Recommended | Other Child in Household 3 School Level | Pre-school; Elementary; Jr high/middle; High school; Post-HS | |
| child3_handedness | String | 100 | Recommended | Other Child in Household 3 Handedness | Left-handed; Right-handed | |
| child3_proband_relationship | String | 100 | Recommended | Other Child in Household 3 Relationship to Participant | Sibling; Half-sibiling; Other relative; Not related | |
| child4_age | String | 100 | Recommended | Other Child in Household 4 Age | 0-4 years;5-8 years;9-12 years;13-17 years;18+ years | |
| child4_gender | String | 10 | Recommended | Other Child in Household 4 Gender | Male; Female | |
| child4_education | String | 100 | Recommended | Other Child in Household 4 School Level | Pre-school; Elementary; Jr high/middle; High school; Post-HS | |
| child4_handedness | String | 100 | Recommended | Other Child in Household 4 Handedness | Left-handed; Right-handed | |
| child4_proband_relationship | String | 100 | Recommended | Other Child in Household 4 Relationship to Participant | Sibling; Half-sibiling; Other relative; Not related | |
| child5_age | String | 100 | Recommended | Other Child in Household 5 Age | 0-4 years;5-8 years;9-12 years;13-17 years;18+ years | |
| child5_gender | String | 10 | Recommended | Other Child in Household 5 Gender | Male; Female | |
| child5_education | String | 100 | Recommended | Other Child in Household 5 School Level | Pre-school; Elementary; Jr high/middle; High school; Post-HS | |
| child5_handedness | String | 100 | Recommended | Other Child in Household 5 Handedness | Left-handed; Right-handed | |
| child5_proband_relationship | String | 100 | Recommended | Other Child in Household 5 Relationship to Participant | Sibling; Half-sibiling; Other relative; Not related | |
| child6_age | String | 100 | Recommended | Other Child in Household 6 Age | 0-4 years;5-8 years;9-12 years;13-17 years;18+ years | |
| child6_gender | String | 10 | Recommended | Other Child in Household 6 Gender | Male; Female | |
| child6_education | String | 100 | Recommended | Other Child in Household 6 School Level | Pre-school; Elementary; Jr high/middle; High school; Post-HS | |
| child6_handedness | String | 100 | Recommended | Other Child in Household 6 Handedness | Left-handed; Right-handed | |
| child6_proband_relationship | String | 100 | Recommended | Other Child in Household 6 Relationship to Participant | Sibling; Half-sibiling; Other relative; Not related | |
| child7_age | String | 100 | Recommended | Other Child in Household 7 Age | 0-4 years;5-8 years;9-12 years;13-17 years;18+ years | |
| child7_gender | String | 10 | Recommended | Other Child in Household 7 Gender | Male; Female | |
| child7_education | String | 100 | Recommended | Other Child in Household 7 School Level | Pre-school; Elementary; Jr high/middle; High school; Post-HS | |
| child7_handedness | String | 100 | Recommended | Other Child in Household 7 Handedness | Left-handed; Right-handed | |
| child7_proband_relationship | String | 100 | Recommended | Other Child in Household 7 Relationship to Participant | Sibling; Half-sibiling; Other relative; Not related | |
| function_use_head | String | 100 | Recommended | Does participant have functional use of head | Normal use; Some Use/Functional Use; No Functional Use | |
| function_use_hands | String | 100 | Recommended | Does participant have functional use of hands | Normal use; Some Use/Functional Use; No Functional Use | |
| function_use_arms | String | 100 | Recommended | Does participant have functional use of arms | Normal use; Some Use/Functional Use; No Functional Use | |
| function_use_torso | String | 100 | Recommended | Does participant have functional use of torso | Normal use; Some Use/Functional Use; No Functional Use | |
| function_use_legs | String | 100 | Recommended | Does participant have functional use of legs | Normal use; Some Use/Functional Use; No Functional Use | |
| function_use_feet | String | 100 | Recommended | Does participant have functional use of feet | Normal use; Some Use/Functional Use; No Functional Use | |
| function_use_vision | String | 100 | Recommended | Does participant have functional use of vision | Normal use; Some Use/Functional Use; No Functional Use | |
| function_use_hearing | String | 100 | Recommended | Does participant have functional use of hearing | Normal use; Some Use/Functional Use; No Functional Use | |
| premature_weeks | Integer | Recommended | Weeks premature | 0 is full term | ||
| birth_weight_lbs | Float | Recommended | Birth weight pounds | |||
| birth_weight_oz | Float | Recommended | Birth weight ounces | |||
| birth_injury | String | 10 | Recommended | Was there any evidence of injury at birth? | Yes; No | |
| birth_injury_specify | String | 200 | Recommended | If evidence of injury at birth, describe | ||
| ear_infection_num | Integer | Recommended | How many ear infections has the participant had? | |||
| rev_earpetube | String | 50 | Recommended | PE Tubes | Yes; No; NK | |
| rev_earpetube_month | Integer | Recommended | If participant has received ear tubes, what month? | MM month as two digits | ||
| rev_earpetube_year | Integer | Recommended | If participant has received ear tubes, what year? | YY year as two digits | ||
| injury1 | String | 500 | Recommended | List any significant injuries the participant has had? First occurrence | ||
| injury1_age_years | Integer | Recommended | If participant has had a significant injury, at what age in years? First occurrence | Age in years using two digit format | ||
| injury1_age_months | Integer | Recommended | If participant has had a significant injury, at what age in months? First occurrence | Age in months using two digit format | ||
| injury2 | String | 500 | Recommended | List any significant injuries the participant has had? Second occurrence | ||
| injury2_age_years | Integer | Recommended | If participant has had a significant injury, at what age in years? Second occurrence | Age in years using two digit format | ||
| injury2_age_months | Integer | Recommended | If participant has had a significant injury, at what age in months? Second occurrence | Age in months using two digit format | ||
| injury3 | String | 500 | Recommended | List any significant injuries the participant has had? Third occurrence | ||
| injury3_age_years | Integer | Recommended | If participant has had a significant injury, at what age in years? Third occurrence | Age in years using two digit format | ||
| injury3_age_months | Integer | Recommended | If participant has had a significant injury, at what age in months? Third occurrence | Age in months using two digit format | ||
| operation1 | String | 500 | Recommended | List any operations the participant has had? First occurrence | ||
| operation1_age_years | Integer | Recommended | If participant has had an operation, at what age in years? First occurrence | Age in years using two digit format | ||
| operation1_age_months | Integer | Recommended | If participant has had an operation, at what age in months? First occurrence | Age in months using two digit format | ||
| operation2 | String | 500 | Recommended | List any operations the participant has had? Second occurrence | ||
| operation2_age_years | Integer | Recommended | If participant has had an operation, at what age in years? Second occurrence | Age in years using two digit format | ||
| operation2_age_months | Integer | Recommended | If participant has had an operation, at what age in months? Second occurrence | Age in months using two digit format | ||
| operation3 | String | 500 | Recommended | List any operations the participant has had? Third occurrence | ||
| operation3_age_years | Integer | Recommended | If participant has had an operation, at what age in years? Third occurrence | Age in years using two digit format | ||
| operation3_age_months | Integer | Recommended | If participant has had an operation, at what age in months? Third occurrence | Age in months using two digit format | ||
| measles_age_years | Integer | Recommended | If the participant has had measles, provide the age in months when they had measles | Age in years using two digit format | ||
| measles_age_months | Integer | Recommended | If the participant has had measles, provide the age in years when they had measles | Age in months using two digit format | ||
| germanmeasles_age_years | Integer | Recommended | If the participant has had German measles, provide the age in months when they had German measles | Age in years using two digit format | ||
| germanmeasles_age_months | Integer | Recommended | If the participant has had German measles, provide the age in years when they had German measles | Age in months using two digit format | ||
| mumps_age_years | Integer | Recommended | If the participant has had mumps, provide the age in months when they had mumps | Age in years using two digit format | ||
| mumps_age_months | Integer | Recommended | If the participant has had mumps, provide the age in years when they had mumps | Age in months using two digit format | ||
| brokenbone_age_years | Integer | Recommended | If the participant has had broken bones, provide the age in months when they had broken bones | Age in years using two digit format | ||
| brokenbone_age_months | Integer | Recommended | If the participant has had broken bones, provide the age in years when they had broken bones | Age in months using two digit format | ||
| headachemigraine_age_years | Integer | Recommended | If the participant has had headaches/migraines, provide the age in months when they had headaches/migraines | Age in years using two digit format | ||
| headachemigraine_age_months | Integer | Recommended | If the participant has had headaches/migraines, provide the age in years when they had headaches/migraines | Age in months using two digit format | ||
| hearingtest_age_years | Integer | Recommended | If the participant has had hearing test, provide the age in months when they had hearing test | Age in years using two digit format | ||
| hearingtest_age_months | Integer | Recommended | If the participant has had hearing test, provide the age in years when they had hearing test | Age in months using two digit format | ||
| whoopingcough_age_years | Integer | Recommended | If the participant has had whooping cough, provide the age in months when they had whooping cough | Age in years using two digit format | ||
| whoopingcough_age_months | Integer | Recommended | If the participant has had whooping cough, provide the age in years when they had whooping cough | Age in months using two digit format | ||
| chickenpox_age_years | Integer | Recommended | If the participant has had chicken pox, provide the age in months when they had chicken pox | Age in years using two digit format | ||
| chickenpox_age_months | Integer | Recommended | If the participant has had chicken pox, provide the age in years when they had chicken pox | Age in months using two digit format | ||
| eeg_age_months | Integer | Recommended | If the participant has had EEG, provide the age in months when they had EEG | Age in years using two digit format | ||
| eeg_age_years | Integer | Recommended | If the participant has had EEG, provide the age in years when they had EEG | Age in months using two digit format | ||
| diagnosis_autism | String | 10 | Recommended | Has the participant been diagnosed with Autism? | Yes; No | |
| diagnosis_autism_madeby | String | 100 | Recommended | If the participant has been diagnosed with autism, who gave this diagnosis? | ||
| diagnosis_seizures | String | 10 | Recommended | Has the participant been diagnosed with seizures? | Yes; No | |
| diagnosis_other_specify | String | 500 | Recommended | What other diagnoses has the participant had? | ||
| atypical_dev_signs | String | 500 | Recommended | Prior to a diagnosis, were there any signes that led you to believe that the participant was developing atypically? | ||
| earlydev_fsymc | String | 1024 | Recommended | First symptoms to arouse parental concern (specify) | ||
| feed_swallow_problem | String | 10 | Recommended | Has the participant demonstrated any feeding or swallowing problems? | Yes; No | |
| feed_swallow_problem_specify | String | 500 | Recommended | If they have demonstrated feeding or swallowing problems, describe them | ||
| medication1_name | String | 100 | Recommended | Name first medication that the participant has taken | ||
| medication1_current | String | 10 | Recommended | First medication currently taking? | Yes; No | |
| medication1_past | String | 10 | Recommended | First medication took in the past? | Yes; No | |
| medication2_name | String | 100 | Recommended | Name second medication that the participant has taken | ||
| medication2_current | String | 10 | Recommended | second medication currently taking? | Yes; No | |
| medication2_past | String | 10 | Recommended | second medication took in the past? | Yes; No | |
| medication3_name | String | 100 | Recommended | Name third medication that the participant has taken | ||
| medication3_current | String | 10 | Recommended | third medication currently taking? | Yes; No | |
| medication3_past | String | 10 | Recommended | third medication took in the past? | Yes; No | |
| medication4_name | String | 100 | Recommended | Name fourth medication that the participant has taken | ||
| medication4_current | String | 10 | Recommended | fourth medication currently taking? | Yes; No | |
| medication4_past | String | 10 | Recommended | fourth medication took in the past? | Yes; No | |
| medication5_name | String | 100 | Recommended | Name fifth medication that the participant has taken | ||
| medication5_current | String | 10 | Recommended | fifth medication currently taking? | Yes; No | |
| medication5_past | String | 10 | Recommended | fifth medication took in the past? | Yes; No | |
| medication6_name | String | 100 | Recommended | Name sixth medication that the participant has taken | ||
| medication6_current | String | 10 | Recommended | sixth medication currently taking? | Yes; No | |
| medication6_past | String | 10 | Recommended | sixth medication took in the past? | Yes; No | |
| medication7_name | String | 100 | Recommended | Name seventh medication that the participant has taken | ||
| medication7_current | String | 10 | Recommended | seventh medication currently taking? | Yes; No | |
| medication7_past | String | 10 | Recommended | seventh medication took in the past? | Yes; No | |
| medication8_name | String | 100 | Recommended | Name eighth medication that the participant has taken | ||
| medication8_current | String | 10 | Recommended | eighth medication currently taking? | Yes; No | |
| medication8_past | String | 10 | Recommended | eighth medication took in the past? | Yes; No | |
| medication9_name | String | 100 | Recommended | Name ninth medication that the participant has taken | ||
| medication9_current | String | 10 | Recommended | ninth medication currently taking? | Yes; No | |
| medication9_past | String | 10 | Recommended | ninth medication took in the past? | Yes; No | |
| medication10_name | String | 100 | Recommended | Name tenth medication that the participant has taken | ||
| medication10_current | String | 10 | Recommended | tenth medication currently taking? | Yes; No | |
| medication10_past | String | 10 | Recommended | tenth medication took in the past? | Yes; No | |
| play_opps_other_kids | String | 10 | Recommended | Does the participant have opportunities to play with other children? | Yes; No | |
| likes_play_other_kids | String | 10 | Recommended | Does the participant like to play with other children? | Yes; No | |
| assist_dressing | String | 10 | Recommended | Is the participant able to assist with dressing himself/herself? | Yes; No | |
| special_behavior_problems | String | 10 | Recommended | Does the participant present any special behavior problems? | Yes; No | |
| special_behavior_probs_specify | String | 200 | Recommended | If the participant does present special behavior problems, please describe | ||
| milestone_age_mo_smile | Integer | Recommended | Age in which the participant accomplished the following milestone in months: smiled | |||
| milestone_age_yr_smile | Integer | Recommended | Age in which the participant accomplished the following milestone in years: smiled | |||
| milestone_age_mo_satup | Integer | Recommended | Age in which the participant accomplished the following milestone in months: sat up without support | |||
| milestone_age_yr_satup | Integer | Recommended | Age in which the participant accomplished the following milestone in years: sat up without support | |||
| milestone_age_mo_crawl | Integer | Recommended | Age in which the participant accomplished the following milestone in months: crawled | |||
| milestone_age_yr_crawl | Integer | Recommended | Age in which the participant accomplished the following milestone in years: crawled | |||
| milestone_age_mo_solidfood | Integer | Recommended | Age in which the participant accomplished the following milestone in months: started solid foods | |||
| milestone_age_yr_solidfood | Integer | Recommended | Age in which the participant accomplished the following milestone in years: started solid foods | |||
| milestone_age_mo_words | Integer | Recommended | Age in which the participant accomplished the following milestone in months: used words | |||
| milestone_age_yr_words | Integer | Recommended | Age in which the participant accomplished the following milestone in years: used words | |||
| milestone_age_mo_stopbottle | Integer | Recommended | Age in which the participant accomplished the following milestone in months: gave up bottle | |||
| milestone_age_yr_stopbottle | Integer | Recommended | Age in which the participant accomplished the following milestone in years: gave up bottle | |||
| milestone_age_mo_toilettrain | Integer | Recommended | Age in which the participant accomplished the following milestone in months: was toilet trained | |||
| milestone_age_yr_toilettrain | Integer | Recommended | Age in which the participant accomplished the following milestone in years: was toilet trained | |||
| milestone_age_mo_walkalone | Integer | Recommended | Age in which the participant accomplished the following milestone in months: walked alone | |||
| milestone_age_yr_walkalone | Integer | Recommended | Age in which the participant accomplished the following milestone in years: walked alone | |||
| milestone_age_mo_fedselfspoon | Integer | Recommended | Age in which the participant accomplished the following milestone in months: fed self with a spoon | |||
| milestone_age_yr_fedselfspoon | Integer | Recommended | Age in which the participant accomplished the following milestone in years: fed self with a spoon | |||
| milestone_age_mo_drankcup | Integer | Recommended | Age in which the participant accomplished the following milestone in months: drank with a cup | |||
| milestone_age_yr_drankcup | Integer | Recommended | Age in which the participant accomplished the following milestone in years: drank with a cup | |||
| respond_to_sounds | String | 10 | Recommended | Does the participant respond consistently to sounds in the home (doorbell, phone, etc)? | Yes; No | |
| understand_what_others_say | String | 10 | Recommended | Does the participant understand what you say to him/her? | Yes; No | |
| suspect_hearing_loss | String | 10 | Recommended | Do you suspect a hearing loss? | Yes; No | |
| babble | String | 10 | Recommended | Does the participant babble (e.g., baba, didi, yada)? | Yes; No | |
| babble_short_phrases | String | 10 | Recommended | Does the participant babble using short phrases (e.g., mama up, ball please, bye-bye dada)? | Yes; No | |
| cg_understand_speech | String | 10 | Recommended | Do the caregivers understand the participant's speech? | Yes; No | |
| strangers_understand_speech | String | 10 | Recommended | Do strangers understand the participant's speech? | Yes; No | |
| otherkids_understand_speech | String | 10 | Recommended | Do other children understand the participant's speech? | Yes; No | |
| imitate_soundswords | String | 10 | Recommended | Does the participant imitate sounds and/or words after you say them first? | Yes; No | |
| diagnosis_apraxia_motorsensdis | String | 10 | Recommended | Has the participant been diagnosed with apraxia or a motor/sensory disorder? | Yes; No | |
| sounds_used_number | String | 10 | Recommended | How many different sounds does the participant use? | ||
| sounds_used_specify | String | 50 | Recommended | Give examples of sounds he/she says (e.g., b, p, m, n, ) | ||
| vocabulary_size | String | 50 | Recommended | Estimate the participants current vocabulary size | No words yet; 1-2 words; 3-5 words; 6-10 words; 11-20 words; 21-30 words; 31-50 words; 50 or more | |
| vocabulary_specify | String | 200 | Recommended | Give examples of words or phrases | ||
| augcomm_taught_pecs | String | 10 | Recommended | Has the participant ever been taught to use any of these augmentative communication devices or systems: Picture Exchange Communication System | Yes; No | |
| augcomm_taught_pointpics | String | 10 | Recommended | Has the participant ever been taught to use any of these augmentative communication devices or systems: Pointing to pictures | Yes; No | |
| augcomm_taught_speechdevice | String | 10 | Recommended | Has the participant ever been taught to use any of these augmentative communication devices or systems: Speech generating device (e.g., DynaVox, SpeakEasy, etc) | Yes; No | |
| augcomm_taught_signlanguage | String | 10 | Recommended | Has the participant ever been taught to use any of these augmentative communication devices or systems: Sign language | Yes; No | |
| earlyint1_start_date | Date | Recommended | Early Intervention Program Occurrence 1: If participant participated in the following intervention, what date did the intervention begin? | |||
| earlyint1_end_date | Date | Recommended | Early Intervention Program Occurrence 1: If participant participated in the following intervention, what date did the intervention end | |||
| earlyint1_week_hrs | Integer | Recommended | Early Intervention Program Occurrence 1:For the following intervention, how many hours per week were provided? | |||
| earlyint1_group_ind | String | 50 | Recommended | Early Intervention Program Occurrence 1: For the following intervention, how was it provided? | Individual; Group; Both | |
| earlyint1_setting | String | 75 | Recommended | Early Intervention Program Occurrence 1:For the following intervention, where was it delivered? | Home; School; Clinic; Home and School; Home and Clinic; School and Clinic; All | |
| earlyint1_funding | String | 50 | Recommended | Early Intervention Program Occurrence 1:Was the following intervention funded by the school district? | SD; PP; SD and PP; SD and Other; PP and Other; SD and PP and Other; Other | SD= school district;PP=private pay |
| earlyint1_funding_specify | String | 200 | Recommended | Early Intervention Program Occurrence 1: If the intervention was funded by a source other than the school district or private pay, provide details on source of funding? | ||
| earlyint2_start_date | Date | Recommended | Early Intervention Program Occurrence 2: If participant participated in the following intervention, what date did the intervention begin? | |||
| earlyint2_end_date | Date | Recommended | Early Intervention Program Occurrence 2: If participant participated in the following intervention, what date did the intervention end | |||
| earlyint2_week_hrs | Integer | Recommended | Early Intervention Program Occurrence 2:For the following intervention, how many hours per week were provided? | |||
| earlyint2_group_ind | String | 50 | Recommended | Early Intervention Program Occurrence 2: For the following intervention, how was it provided? | Individual; Group; Both | |
| earlyint2_setting | String | 75 | Recommended | Early Intervention Program Occurrence 2:For the following intervention, where was it delivered? | Home; School; Clinic; Home and School; Home and Clinic; School and Clinic; All | |
| earlyint2_funding | String | 50 | Recommended | Early Intervention Program Occurrence 2:Was the following intervention funded by the school district? | SD; PP; SD and PP; SD and Other; PP and Other; SD and PP and Other; Other | SD= school district;PP=private pay |
| earlyint2_funding_specify | String | 200 | Recommended | Early Intervention Program Occurrence 2: If the intervention was funded by a source other than the school district or private pay, provide details on source of funding? | ||
| earlyint3_start_date | Date | Recommended | Early Intervention Program Occurrence 3: If participant participated in the following intervention, what date did the intervention begin? | |||
| earlyint3_end_date | Date | Recommended | Early Intervention Program Occurrence 3: If participant participated in the following intervention, what date did the intervention end | |||
| earlyint3_week_hrs | Integer | Recommended | Early Intervention Program Occurrence 3:For the following intervention, how many hours per week were provided? | |||
| earlyint3_group_ind | String | 50 | Recommended | Early Intervention Program Occurrence 3: For the following intervention, how was it provided? | Individual; Group; Both | |
| earlyint3_setting | String | 75 | Recommended | Early Intervention Program Occurrence 3:For the following intervention, where was it delivered? | Home; School; Clinic; Home and School; Home and Clinic; School and Clinic; All | |
| earlyint3_funding | String | 50 | Recommended | Early Intervention Program Occurrence 3:Was the following intervention funded by the school district? | SD; PP; SD and PP; SD and Other; PP and Other; SD and PP and Other; Other | SD= school district;PP=private pay |
| earlyint3_funding_specify | String | 200 | Recommended | Early Intervention Program Occurrence 3: If the intervention was funded by a source other than the school district or private pay, provide details on source of funding? | ||
| behavioral1_start_date | Date | Recommended | Behavioral Therapy Occurrence 1: If participant participated in the following intervention, what date did the intervention begin? | |||
| behavioral1_end_date | Date | Recommended | Behavioral Therapy Occurrence 1: If participant participated in the following intervention, what date did the intervention end | |||
| behavioral1_week_hrs | Integer | Recommended | Behavioral Therapy Occurrence 1:For the following intervention, how many hours per week were provided? | |||
| behavioral1_group_ind | String | 50 | Recommended | Behavioral Therapy Occurrence 1: For the following intervention, how was it provided? | Individual; Group; Both | |
| behavioral1_setting | String | 75 | Recommended | Behavioral Therapy Occurrence 1:For the following intervention, where was it delivered? | Home; School; Clinic; Home and School; Home and Clinic; School and Clinic; All | |
| behavioral1_funding | String | 50 | Recommended | Behavioral Therapy Occurrence 1:Was the following intervention funded by the school district? | SD; PP; SD and PP; SD and Other; PP and Other; SD and PP and Other; Other | SD= school district;PP=private pay |
| behavioral1_funding_specify | String | 200 | Recommended | Behavioral Therapy Occurrence 1: If the intervention was funded by a source other than the school district or private pay, provide details on source of funding? | ||
| behavioral2_start_date | Date | Recommended | Behavioral Therapy Occurrence 2: If participant participated in the following intervention, what date did the intervention begin? | |||
| behavioral2_end_date | Date | Recommended | Behavioral Therapy Occurrence 2: If participant participated in the following intervention, what date did the intervention end | |||
| behavioral2_week_hrs | Integer | Recommended | Behavioral Therapy Occurrence 2:For the following intervention, how many hours per week were provided? | |||
| behavioral2_group_ind | String | 50 | Recommended | Behavioral Therapy Occurrence 2: For the following intervention, how was it provided? | Individual; Group; Both | |
| behavioral2_setting | String | 75 | Recommended | Behavioral Therapy Occurrence 2:For the following intervention, where was it delivered? | Home; School; Clinic; Home and School; Home and Clinic; School and Clinic; All | |
| behavioral2_funding | String | 50 | Recommended | Behavioral Therapy Occurrence 2:Was the following intervention funded by the school district? | SD; PP; SD and PP; SD and Other; PP and Other; SD and PP and Other; Other | SD= school district;PP=private pay |
| behavioral2_funding_specify | String | 200 | Recommended | Behavioral Therapy Occurrence 2: If the intervention was funded by a source other than the school district or private pay, provide details on source of funding? | ||
| behavioral3_start_date | Date | Recommended | Behavioral Therapy Occurrence 3: If participant participated in the following intervention, what date did the intervention begin? | |||
| behavioral3_end_date | Date | Recommended | Behavioral Therapy Occurrence 3: If participant participated in the following intervention, what date did the intervention end | |||
| behavioral3_week_hrs | Integer | Recommended | Behavioral Therapy Occurrence 3:For the following intervention, how many hours per week were provided? | |||
| behavioral3_group_ind | String | 50 | Recommended | Behavioral Therapy Occurrence 3: For the following intervention, how was it provided? | Individual; Group; Both | |
| behavioral3_setting | String | 75 | Recommended | Behavioral Therapy Occurrence 3:For the following intervention, where was it delivered? | Home; School; Clinic; Home and School; Home and Clinic; School and Clinic; All | |
| behavioral3_funding | String | 50 | Recommended | Behavioral Therapy Occurrence 3:Was the following intervention funded by the school district? | SD; PP; SD and PP; SD and Other; PP and Other; SD and PP and Other; Other | SD= school district;PP=private pay |
| behavioral3_funding_specify | String | 200 | Recommended | Behavioral Therapy Occurrence 3: If the intervention was funded by a source other than the school district or private pay, provide details on source of funding? | ||
| ot1_start_date | Date | Recommended | Occupational Therapy Occurrence 1: If participant participated in the following intervention, what date did the intervention begin? | |||
| ot1_end_date | Date | Recommended | Occupational Therapy Occurrence 1: If participant participated in the following intervention, what date did the intervention end | |||
| ot1_week_hrs | Integer | Recommended | Occupational Therapy Occurrence 1:For the following intervention, how many hours per week were provided? | |||
| ot1_group_ind | String | 50 | Recommended | Occupational Therapy Occurrence 1: For the following intervention, how was it provided? | Individual; Group; Both | |
| ot1_setting | String | 75 | Recommended | Occupational Therapy Occurrence 1:For the following intervention, where was it delivered? | Home; School; Clinic; Home and School; Home and Clinic; School and Clinic; All | |
| ot1_funding | String | 50 | Recommended | Occupational Therapy Occurrence 1:Was the following intervention funded by the school district? | SD; PP; SD and PP; SD and Other; PP and Other; SD and PP and Other; Other | SD= school district;PP=private pay |
| ot1_funding_specify | String | 200 | Recommended | Occupational Therapy Occurrence 1: If the intervention was funded by a source other than the school district or private pay, provide details on source of funding? | ||
| ot2_start_date | Date | Recommended | Occupational Therapy Occurrence 2: If participant participated in the following intervention, what date did the intervention begin? | |||
| ot2_end_date | Date | Recommended | Occupational Therapy Occurrence 2: If participant participated in the following intervention, what date did the intervention end | |||
| ot2_week_hrs | Integer | Recommended | Occupational Therapy Occurrence 2:For the following intervention, how many hours per week were provided? | |||
| ot2_group_ind | String | 50 | Recommended | Occupational Therapy Occurrence 2: For the following intervention, how was it provided? | Individual; Group; Both | |
| ot2_setting | String | 75 | Recommended | Occupational Therapy Occurrence 2:For the following intervention, where was it delivered? | Home; School; Clinic; Home and School; Home and Clinic; School and Clinic; All | |
| ot2_funding | String | 50 | Recommended | Occupational Therapy Occurrence 2:Was the following intervention funded by the school district? | SD; PP; SD and PP; SD and Other; PP and Other; SD and PP and Other; Other | SD= school district;PP=private pay |
| ot2_funding_specify | String | 200 | Recommended | Occupational Therapy Occurrence 2: If the intervention was funded by a source other than the school district or private pay, provide details on source of funding? | ||
| ot3_start_date | Date | Recommended | Occupational Therapy Occurrence 3: If participant participated in the following intervention, what date did the intervention begin? | |||
| ot3_end_date | Date | Recommended | Occupational Therapy Occurrence 3: If participant participated in the following intervention, what date did the intervention end | |||
| ot3_week_hrs | Integer | Recommended | Occupational Therapy Occurrence 3:For the following intervention, how many hours per week were provided? | |||
| ot3_group_ind | String | 50 | Recommended | Occupational Therapy Occurrence 3: For the following intervention, how was it provided? | Individual; Group; Both | |
| ot3_setting | String | 75 | Recommended | Occupational Therapy Occurrence 3:For the following intervention, where was it delivered? | Home; School; Clinic; Home and School; Home and Clinic; School and Clinic; All | |
| ot3_funding | String | 50 | Recommended | Occupational Therapy Occurrence 3:Was the following intervention funded by the school district? | SD; PP; SD and PP; SD and Other; PP and Other; SD and PP and Other; Other | SD= school district;PP=private pay |
| ot3_funding_specify | String | 200 | Recommended | Occupational Therapy Occurrence 3: If the intervention was funded by a source other than the school district or private pay, provide details on source of funding? | ||
| slp1_start_date | Date | Recommended | Speech and Language Therapy Occurrence 1: If participant participated in the following intervention, what date did the intervention begin? | |||
| slp1_end_date | Date | Recommended | Speech and Language Therapy Occurrence 1: If participant participated in the following intervention, what date did the intervention end | |||
| slp1_week_hrs | Integer | Recommended | Speech and Language Therapy Occurrence 1:For the following intervention, how many hours per week were provided? | |||
| slp1_group_ind | String | 50 | Recommended | Speech and Language Therapy Occurrence 1: For the following intervention, how was it provided? | Individual; Group; Both | |
| slp1_setting | String | 75 | Recommended | Speech and Language Therapy Occurrence 1:For the following intervention, where was it delivered? | Home; School; Clinic; Home and School; Home and Clinic; School and Clinic; All | |
| slp1_funding | String | 50 | Recommended | Speech and Language Therapy Occurrence 1:Was the following intervention funded by the school district? | SD; PP; SD and PP; SD and Other; PP and Other; SD and PP and Other; Other | SD= school district;PP=private pay |
| slp1_funding_specify | String | 200 | Recommended | Speech and Language Therapy Occurrence 1: If the intervention was funded by a source other than the school district or private pay, provide details on source of funding? | ||
| slp2_start_date | Date | Recommended | Speech and Language Therapy Occurrence 2: If participant participated in the following intervention, what date did the intervention begin? | |||
| slp2_end_date | Date | Recommended | Speech and Language Therapy Occurrence 2: If participant participated in the following intervention, what date did the intervention end | |||
| slp2_week_hrs | Integer | Recommended | Speech and Language Therapy Occurrence 2:For the following intervention, how many hours per week were provided? | |||
| slp2_group_ind | String | 50 | Recommended | Speech and Language Therapy Occurrence 2: For the following intervention, how was it provided? | Individual; Group; Both | |
| slp2_setting | String | 75 | Recommended | Speech and Language Therapy Occurrence 2:For the following intervention, where was it delivered? | Home; School; Clinic; Home and School; Home and Clinic; School and Clinic; All | |
| slp2_funding | String | 50 | Recommended | Speech and Language Therapy Occurrence 2:Was the following intervention funded by the school district? | SD; PP; SD and PP; SD and Other; PP and Other; SD and PP and Other; Other | SD= school district;PP=private pay |
| slp2_funding_specify | String | 200 | Recommended | Speech and Language Therapy Occurrence 2: If the intervention was funded by a source other than the school district or private pay, provide details on source of funding? | ||
| slp3_start_date | Date | Recommended | Speech and Language Therapy Occurrence 3: If participant participated in the following intervention, what date did the intervention begin? | |||
| slp3_end_date | Date | Recommended | Speech and Language Therapy Occurrence 3: If participant participated in the following intervention, what date did the intervention end | |||
| slp3_week_hrs | Integer | Recommended | Speech and Language Therapy Occurrence 3:For the following intervention, how many hours per week were provided? | |||
| slp3_group_ind | String | 50 | Recommended | Speech and Language Therapy Occurrence 3: For the following intervention, how was it provided? | Individual; Group; Both | |
| slp3_setting | String | 75 | Recommended | Speech and Language Therapy Occurrence 3:For the following intervention, where was it delivered? | Home; School; Clinic; Home and School; Home and Clinic; School and Clinic; All | |
| slp3_funding | String | 50 | Recommended | Speech and Language Therapy Occurrence 3:Was the following intervention funded by the school district? | SD; PP; SD and PP; SD and Other; PP and Other; SD and PP and Other; Other | SD= school district;PP=private pay |
| slp3_funding_specify | String | 200 | Recommended | Speech and Language Therapy Occurrence 3: If the intervention was funded by a source other than the school district or private pay, provide details on source of funding? | ||
| floortime1_start_date | Date | Recommended | Floortime Therapy Occurrence 1: If participant participated in the following intervention, what date did the intervention begin? | |||
| floortime1_end_date | Date | Recommended | Floortime Therapy Occurrence 1: If participant participated in the following intervention, what date did the intervention end | |||
| floortime1_week_hrs | Integer | Recommended | Floortime Therapy Occurrence 1:For the following intervention, how many hours per week were provided? | |||
| floortime1_group_ind | String | 50 | Recommended | Floortime Therapy Occurrence 1: For the following intervention, how was it provided? | Individual; Group; Both | |
| floortime1_setting | String | 75 | Recommended | Floortime Therapy Occurrence 1:For the following intervention, where was it delivered? | Home; School; Clinic; Home and School; Home and Clinic; School and Clinic; All | |
| floortime1_funding | String | 50 | Recommended | Floortime Therapy Occurrence 1:Was the following intervention funded by the school district? | SD; PP; SD and PP; SD and Other; PP and Other; SD and PP and Other; Other | SD= school district;PP=private pay |
| floortime1_funding_specify | String | 200 | Recommended | Floortime Therapy Occurrence 1: If the intervention was funded by a source other than the school district or private pay, provide details on source of funding? | ||
| floortime2_start_date | Date | Recommended | Floortime Therapy Occurrence 2: If participant participated in the following intervention, what date did the intervention begin? | |||
| floortime2_end_date | Date | Recommended | Floortime Therapy Occurrence 2: If participant participated in the following intervention, what date did the intervention end | |||
| floortime2_week_hrs | Integer | Recommended | Floortime Therapy Occurrence 2:For the following intervention, how many hours per week were provided? | |||
| floortime2_group_ind | String | 50 | Recommended | Floortime Therapy Occurrence 2: For the following intervention, how was it provided? | Individual; Group; Both | |
| floortime2_setting | String | 75 | Recommended | Floortime Therapy Occurrence 2:For the following intervention, where was it delivered? | Home; School; Clinic; Home and School; Home and Clinic; School and Clinic; All | |
| floortime2_funding | String | 50 | Recommended | Floortime Therapy Occurrence 2:Was the following intervention funded by the school district? | SD; PP; SD and PP; SD and Other; PP and Other; SD and PP and Other; Other | SD= school district;PP=private pay |
| floortime2_funding_specify | String | 200 | Recommended | Floortime Therapy Occurrence 2: If the intervention was funded by a source other than the school district or private pay, provide details on source of funding? | ||
| floortime3_start_date | Date | Recommended | Floortime Therapy Occurrence 3: If participant participated in the following intervention, what date did the intervention begin? | |||
| floortime3_end_date | Date | Recommended | Floortime Therapy Occurrence 3: If participant participated in the following intervention, what date did the intervention end | |||
| floortime3_week_hrs | Integer | Recommended | Floortime Therapy Occurrence 3:For the following intervention, how many hours per week were provided? | |||
| floortime3_group_ind | String | 50 | Recommended | Floortime Therapy Occurrence 3: For the following intervention, how was it provided? | Individual; Group; Both | |
| floortime3_setting | String | 75 | Recommended | Floortime Therapy Occurrence 3:For the following intervention, where was it delivered? | Home; School; Clinic; Home and School; Home and Clinic; School and Clinic; All | |
| floortime3_funding | String | 50 | Recommended | Floortime Therapy Occurrence 3:Was the following intervention funded by the school district? | SD; PP; SD and PP; SD and Other; PP and Other; SD and PP and Other; Other | SD= school district;PP=private pay |
| floortime3_funding_specify | String | 200 | Recommended | Floortime Therapy Occurrence 3: If the intervention was funded by a source other than the school district or private pay, provide details on source of funding? | ||
| othertherapy1_name | String | 200 | Recommended | Other Therapy1: If a therapy other than one listed was provided to participant, provide the name and description of the therapy | ||
| othertherapy1_start_date | Date | Recommended | Other Therapy Occurrence 1: If participant participated in the following intervention, what date did the intervention begin? | |||
| othertherapy1_end_date | Date | Recommended | Other Therapy Occurrence 1: If participant participated in the following intervention, what date did the intervention end | |||
| othertherapy1_week_hrs | Integer | Recommended | Other Therapy Occurrence 1:For the following intervention, how many hours per week were provided? | |||
| othertherapy1_group_ind | String | 50 | Recommended | Other Therapy Occurrence 1: For the following intervention, how was it provided? | Individual; Group; Both | |
| othertherapy1_setting | String | 75 | Recommended | Other Therapy Occurrence 1:For the following intervention, where was it delivered? | Home; School; Clinic; Home and School; Home and Clinic; School and Clinic; All | |
| othertherapy1_funding | String | 50 | Recommended | Other Therapy Occurrence 1:Was the following intervention funded by the school district? | SD; PP; SD and PP; SD and Other; PP and Other; SD and PP and Other; Other | SD= school district;PP=private pay |
| othertherapy1_funding_specify | String | 200 | Recommended | Other Therapy Occurrence 1: If the intervention was funded by a source other than the school district or private pay, provide details on source of funding? | ||
| othertherapy2_name | String | 200 | Recommended | Other Therapy2: If a therapy other than one listed was provided to participant, provide the name and description of the therapy | ||
| othertherapy2_start_date | Date | Recommended | Other Therapy Occurrence 2: If participant participated in the following intervention, what date did the intervention begin? | |||
| othertherapy2_end_date | Date | Recommended | Other Therapy Occurrence 2: If participant participated in the following intervention, what date did the intervention end | |||
| othertherapy2_week_hrs | Integer | Recommended | Other Therapy Occurrence 2:For the following intervention, how many hours per week were provided? | |||
| othertherapy2_group_ind | String | 50 | Recommended | Other Therapy Occurrence 2: For the following intervention, how was it provided? | Individual; Group; Both | |
| othertherapy2_setting | String | 75 | Recommended | Other Therapy Occurrence 2:For the following intervention, where was it delivered? | Home; School; Clinic; Home and School; Home and Clinic; School and Clinic; All | |
| othertherapy2_funding | String | 50 | Recommended | Other Therapy Occurrence 2:Was the following intervention funded by the school district? | SD; PP; SD and PP; SD and Other; PP and Other; SD and PP and Other; Other | SD= school district;PP=private pay |
| othertherapy2_funding_specify | String | 200 | Recommended | Other Therapy Occurrence 2: If the intervention was funded by a source other than the school district or private pay, provide details on source of funding? | ||
| othertherapy3_name | String | 200 | Recommended | Other Therapy3: If a therapy other than one listed was provided to participant, provide the name and description of the therapy | ||
| othertherapy3_start_date | Date | Recommended | Other Therapy Occurrence 3: If participant participated in the following intervention, what date did the intervention begin? | |||
| othertherapy3_end_date | Date | Recommended | Other Therapy Occurrence 3: If participant participated in the following intervention, what date did the intervention end | |||
| othertherapy3_week_hrs | Integer | Recommended | Other Therapy Occurrence 3:For the following intervention, how many hours per week were provided? | |||
| othertherapy3_group_ind | String | 50 | Recommended | Other Therapy Occurrence 3: For the following intervention, how was it provided? | Individual; Group; Both | |
| othertherapy3_setting | String | 75 | Recommended | Other Therapy Occurrence 3:For the following intervention, where was it delivered? | Home; School; Clinic; Home and School; Home and Clinic; School and Clinic; All | |
| othertherapy3_funding | String | 50 | Recommended | Other Therapy Occurrence 3:Was the following intervention funded by the school district? | SD; PP; SD and PP; SD and Other; PP and Other; SD and PP and Other; Other | SD= school district;PP=private pay |
| othertherapy3_funding_specify | String | 200 | Recommended | Other Therapy Occurrence 3: If the intervention was funded by a source other than the school district or private pay, provide details on source of funding? | ||
| barriers_services | String | 500 | Recommended | What were the barriers that you encountered in obtaining or receiving services? | ||
| barriers_implement_strategies | String | 500 | Recommended | What were the barriers you encountered in implementing the strategies from these service provders? | ||
| strategy_implement_competency | String | 500 | Recommended | How competent do you feel in your ability to use the strategies from these services? | ||
| goals_important | String | 500 | Recommended | What are you most important goals for the participant? | ||
| goals_future | String | 500 | Recommended | What do you foresee as important future goals for the participant? | ||
| training_parent_behavior | String | 500 | Recommended | Please list any parent training or behavior management training in which you've participated. | ||
| training_prompted_changes | String | 500 | Recommended | What are you doing differently as a result of these training programs and What did you gain from this service? |
