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Minimally Verbal - Common Demographic Intake Form

mv_demo_intake

01

The Common Demographic Intake Form as defined by the Minimally Verbal Workgroup

Download Definition as
Download Submission Template as
Element NameData TypeSizeRequiredDescriptionValue RangeNotes
subjectkeyGUIDRequiredThe NDAR Global Unique Identifier (GUID) for research subjectNDAR*
src_subject_idString20RequiredSubject ID how it's defined in lab/project
genderString20RequiredSex of the subjectM;FM = Male; F = Female
gradeString50RecommendedCurrent Grade
interview_dateDateRequiredDate on which the interview/genetic test/sampling/imaging was completed. MM/DD/YYYYRequired field
hispanicIntegerRecommendedIs subject of Hispanic, Latino, or Spanish origin?0; 10 = No; 1 = Yes
raceString30RecommendedRace of study subjectAmerican Indian/Alaska Native; Asian; Hawaiian or Pacific Islander; Black or African American; White; More than one race; Unknown or not reported
race_otherString100RecommendedRace of Respondent Specify
part_educationString100RecommendedParticipant's Current Education LevelDay care;Nursery;Preschool;Kindergarten;Elementary School;Secondary School;Other
mv_household_incomeString100RecommendedTotal Household Income Last YearLess 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_genderString10RecommendedCaregiver/Parent 1's GenderMale;Female
cg1_relation_statusString100RecommendedCaregiver/Parent 1's Relationship Status
Married;Never married;Widowed;Divorced and remarried;Separated;Divorced;Widowed and remarried;Other; Living with Partner
cg1_relation_status_specifyString100RecommendedCaregiver/Parent 1's Relationship Status Other Specify
cg1_relationshipString100RecommendedCaregiver/Parent 1's Relationship to ParticipantParent;Step-parent;Foster parent;Grandparent;Other family member;Other; Biological Mother; Biological Father; Biological Parent; Adoptive Parent; Adoptive/Foster Parent; I do not wish to disclose
cg1_relationship_specifyString100RecommendedCaregiver/Parent 1's Relationship to Participant Other Specify
cg1_guardianString10RecommendedCaregiver/Parent 1. Is this the Participant's Custodian/Legal Guardian?
Yes;No
cg1_cohabitateString10RecommendedCaregiver/Parent 1. Does the participant live with this custodian?
Yes;No
cg1_raceString100RecommendedRace of the Caregiver/Parent 1American Indian/Alaska Native; Asian; Hawaiian or Pacific Islander; Black or African American; White; More than one race; Unknown or not reported
cg1_race_specifyString100RecommendedRace of the Caregiver/Parent 1 Other Specify
cg1_educationString100RecommendedCaregiver/Prent 1's Highest Level of EducationSome primary school;Some high school;High school diploma;GED;Some college or technical school;Associate degree;Baccalaureate degree;Graduate or professional degree
cg1_occupationString100RecommendedCaregiver/Parent 1's Occupation
num_in_house_adultsIntegerRecommendedNumber of Individuals in Household Adults
num_in_house_kidsIntegerRecommendedNumber of Individuals in Household Children
nih_mom_hispanicString10RecommendedBiological Parents Not in Household - Is the Mother of Hispanic or Latino Origin?
Yes;No
nih_mom_raceString100RecommendedBiological Parents Not in Household - Mother's RaceAmerican Indian or Alaskan Native;Asian;Pacific Islander;Black or African American;White;Other
nih_mom_race_specifyString100RecommendedBiological Parents Not in Household - Mother's Race Other Specify
nih_dad_hispanicString10RecommendedBiological Parents Not in Household - Is the Father of Hispanic or Latino Origin?
Yes;No
nih_dad_raceString100RecommendedBiological Parents Not in Household - Father's RaceAmerican Indian or Alaskan Native;Asian;Pacific Islander;Black or African American;White;Other
nih_dad_race_specifyString100RecommendedBiological Parents Not in Household - Father's Race Other Specify
cg2_relationshipString100RecommendedCaregiver/Parent 2's Relationship to ParticipantParent;Step-parent;Foster parent;Grandparent;Other family member;Other; Biological Mother; Biological Father; Biological Parent; Adoptive Parent; Adoptive/Foster Parent; I do not wish to disclose
cg2_relationship_specifyString100RecommendedCaregiver/Parent 2's Relationship to Participant Other Specify
cg2_guardianString10RecommendedCaregiver/Parent 2. Is this the Participant's Custodian/Legal Guardian?
Yes;No
cg2_hispanicString10RecommendedIs Caregiver/Parent 2 of Hispanic or Latino Origin?
Yes;No
cg2_raceString100RecommendedRace of the Caregiver/Parent 2American Indian/Alaska Native; Asian; Hawaiian or Pacific Islander; Black or African American; White; More than one race; Unknown or not reported
cg1_cg2_relationshipString100RecommendedRelationship of Caregiver/Parent 2 to Caregiver/Parent 1Spouse;In a relationship, unmarried;Other
cg1_cg2_relationship_specifyString100RecommendedRelationship of Caregiver/Parent 2 to Caregiver/Parent 1 Other Specify
cg2_relation_statusString100RecommendedCaregiver/Parent 2's Relationship StatusMarried;Never married;Widowed;Divorced and remarried;Separated;Divorced;Widowed and remarried;Other; Living with Partner
cg2_relation_status_specifyString100RecommendedCaregiver/Parent 2's Relationship Status Other Specify
cg2_educationString100RecommendedCaregiver/Parent 2's Highest Level of EducationSome primary school;Some high school;High school diploma;GED;Some college or technical school;Associate degree;Baccalaureate degree;Graduate or professional degree
cg2_occupationString100RecommendedCaregiver/Parent 2's Occupation
child1_ageString100RecommendedOther Child in Household 1 Age0-4 years; 5-8 years; 9-12 years; 13-17 years; 18+ years
child1_genderString10RecommendedOther Child in Household 1 GenderMale;Female
child1_educationString100RecommendedOther Child in Household 1 School LevelPre-school;Elementary;Jr high/middle;High school;Post-HS
child1_handednessString100RecommendedOther Child in Household 1 HandednessLeft-handed;Right-handed
child1_proband_relationshipString100RecommendedOther Child in Household 1 Relationship to ParticipantSibling;Half-sibling;Other relative;Not related
child2_ageString100RecommendedOther Child in Household 2 Age0-4 years; 5-8 years; 9-12 years; 13-17 years; 18+ years
child2_genderString10RecommendedOther Child in Household 2 GenderMale;Female
child2_educationString100RecommendedOther Child in Household 2 School LevelPre-school;Elementary;Jr high/middle;High school;Post-HS
child2_handednessString100RecommendedOther Child in Household 2 HandednessLeft-handed;Right-handed
child2_proband_relationshipString100RecommendedOther Child in Household 2 Relationship to ParticipantSibling;Half-sibling;Other relative;Not related
child3_ageString100RecommendedOther Child in Household 3 Age0-4 years; 5-8 years; 9-12 years; 13-17 years; 18+ years
child3_genderString10RecommendedOther Child in Household 3 GenderMale;Female
child3_educationString100RecommendedOther Child in Household 3 School LevelPre-school;Elementary;Jr high/middle;High school;Post-HS
child3_handednessString100RecommendedOther Child in Household 3 HandednessLeft-handed;Right-handed
child3_proband_relationshipString100RecommendedOther Child in Household 3 Relationship to ParticipantSibling;Half-sibling;Other relative;Not related
child4_ageString100RecommendedOther Child in Household 4 Age0-4 years; 5-8 years; 9-12 years; 13-17 years; 18+ years
child4_genderString10RecommendedOther Child in Household 4 GenderMale;Female
child4_educationString100RecommendedOther Child in Household 4 School LevelPre-school;Elementary;Jr high/middle;High school;Post-HS
child4_handednessString100RecommendedOther Child in Household 4 HandednessLeft-handed;Right-handed
child4_proband_relationshipString100RecommendedOther Child in Household 4 Relationship to ParticipantSibling;Half-sibling;Other relative;Not related
child5_ageString100RecommendedOther Child in Household 5 Age0-4 years; 5-8 years; 9-12 years; 13-17 years; 18+ years
child5_genderString10RecommendedOther Child in Household 5 GenderMale;Female
child5_educationString100RecommendedOther Child in Household 5 School LevelPre-school;Elementary;Jr high/middle;High school;Post-HS
child5_handednessString100RecommendedOther Child in Household 5 HandednessLeft-handed;Right-handed
child5_proband_relationshipString100RecommendedOther Child in Household 5 Relationship to ParticipantSibling;Half-sibling;Other relative;Not related
child6_ageString100RecommendedOther Child in Household 6 Age0-4 years; 5-8 years; 9-12 years; 13-17 years; 18+ years
child6_genderString10RecommendedOther Child in Household 6 GenderMale;Female
child6_educationString100RecommendedOther Child in Household 6 School LevelPre-school;Elementary;Jr high/middle;High school;Post-HS
child6_handednessString100RecommendedOther Child in Household 6 HandednessLeft-handed;Right-handed
child6_proband_relationshipString100RecommendedOther Child in Household 6 Relationship to ParticipantSibling;Half-sibling;Other relative;Not related
child7_ageString100RecommendedOther Child in Household 7 Age0-4 years; 5-8 years; 9-12 years; 13-17 years; 18+ years
child7_genderString10RecommendedOther Child in Household 7 GenderMale;Female
child7_educationString100RecommendedOther Child in Household 7 School LevelPre-school;Elementary;Jr high/middle;High school;Post-HS
child7_handednessString100RecommendedOther Child in Household 7 HandednessLeft-handed;Right-handed
child7_proband_relationshipString100RecommendedOther Child in Household 7 Relationship to ParticipantSibling;Half-sibling;Other relative;Not related
function_use_headString100RecommendedDoes participant have functional use of headNormal use;Some Use/Functional Use;No Functional Use
function_use_handsString100RecommendedDoes participant have functional use of handsNormal use;Some Use/Functional Use;No Functional Use
function_use_armsString100RecommendedDoes participant have functional use of armsNormal use;Some Use/Functional Use;No Functional Use
function_use_torsoString100RecommendedDoes participant have functional use of torsoNormal use;Some Use/Functional Use;No Functional Use
function_use_legsString100RecommendedDoes participant have functional use of legsNormal use;Some Use/Functional Use;No Functional Use
function_use_feetString100RecommendedDoes participant have functional use of feetNormal use;Some Use/Functional Use;No Functional Use
function_use_visionString100RecommendedDoes participant have functional use of visionNormal use;Some Use/Functional Use;No Functional Use
function_use_hearingString100RecommendedDoes participant have functional use of hearingNormal use;Some Use/Functional Use;No Functional Use
premature_weeksIntegerRecommendedWeeks premature0 = Full term
birth_weight_lbsFloatRecommendedBirth weight pounds
birth_weight_ozFloatRecommendedBirth weight ounces
birth_injuryString10RecommendedWas there any evidence of injury at birth?
Yes;No
birth_injury_specifyString200RecommendedIf evidence of injury at birth, describe
ear_infection_numIntegerRecommendedHow many ear infections has the participant had?
rev_earpetubeString50RecommendedPE Tubes
Yes;No;NK
NK = Not known
rev_earpetube_monthIntegerRecommendedIf participant has received ear tubes, what month?MM month as two digits
rev_earpetube_yearIntegerRecommendedIf participant has received ear tubes, what year?YY year as two digits
injury1String500RecommendedList any significant injuries the participant has had? First occurrence
injury1_age_yearsIntegerRecommendedIf participant has had a significant injury, at what age in years? First occurrenceAge in years using two digit format
injury1_age_monthsIntegerRecommendedIf participant has had a significant injury, at what age in months? First occurrenceAge in months using two digit format
injury2String500RecommendedList any significant injuries the participant has had? Second occurrence
injury2_age_yearsIntegerRecommendedIf participant has had a significant injury, at what age in years? Second occurrenceAge in years using two digit format
injury2_age_monthsIntegerRecommendedIf participant has had a significant injury, at what age in months? Second occurrenceAge in months using two digit format
injury3String500RecommendedList any significant injuries the participant has had? Third occurrence
injury3_age_yearsIntegerRecommendedIf participant has had a significant injury, at what age in years? Third occurrenceAge in years using two digit format
injury3_age_monthsIntegerRecommendedIf participant has had a significant injury, at what age in months? Third occurrenceAge in months using two digit format
operation1String500RecommendedList any operations the participant has had? First occurrence
operation1_age_yearsIntegerRecommendedIf participant has had an operation, at what age in years? First occurrenceAge in years using two digit format
operation1_age_monthsIntegerRecommendedIf participant has had an operation, at what age in months? First occurrenceAge in months using two digit format
operation2String500RecommendedList any operations the participant has had? Second occurrence
operation2_age_yearsIntegerRecommendedIf participant has had an operation, at what age in years? Second occurrenceAge in years using two digit format
operation2_age_monthsIntegerRecommendedIf participant has had an operation, at what age in months? Second occurrenceAge in months using two digit format
operation3String500RecommendedList any operations the participant has had? Third occurrence
operation3_age_yearsIntegerRecommendedIf participant has had an operation, at what age in years? Third occurrenceAge in years using two digit format
operation3_age_monthsIntegerRecommendedIf participant has had an operation, at what age in months? Third occurrenceAge in months using two digit format
measles_age_yearsIntegerRecommendedIf the participant has had measles, provide the age in months when they had measlesAge in years using two digit format
measles_age_monthsIntegerRecommendedIf the participant has had measles, provide the age in years when they had measlesAge in months using two digit format
germanmeasles_age_yearsIntegerRecommendedIf the participant has had German measles, provide the age in months when they had German measlesAge in years using two digit format
germanmeasles_age_monthsIntegerRecommendedIf the participant has had German measles, provide the age in years when they had German measlesAge in months using two digit format
mumps_age_yearsIntegerRecommendedIf the participant has had mumps, provide the age in months when they had mumpsAge in years using two digit format
mumps_age_monthsIntegerRecommendedIf the participant has had mumps, provide the age in years when they had mumpsAge in months using two digit format
brokenbone_age_yearsIntegerRecommendedIf the participant has had broken bones, provide the age in months when they had broken bonesAge in years using two digit format
brokenbone_age_monthsIntegerRecommendedIf the participant has had broken bones, provide the age in years when they had broken bonesAge in months using two digit format
headachemigraine_age_yearsIntegerRecommendedIf the participant has had headaches/migraines, provide the age in months when they had headaches/migrainesAge in years using two digit format
headachemigraine_age_monthsIntegerRecommendedIf the participant has had headaches/migraines, provide the age in years when they had headaches/migrainesAge in months using two digit format
hearingtest_age_yearsIntegerRecommendedIf the participant has had hearing test, provide the age in months when they had hearing testAge in years using two digit format
hearingtest_age_monthsIntegerRecommendedIf the participant has had hearing test, provide the age in years when they had hearing testAge in months using two digit format
whoopingcough_age_yearsIntegerRecommendedIf the participant has had whooping cough, provide the age in months when they had whooping coughAge in years using two digit format
whoopingcough_age_monthsIntegerRecommendedIf the participant has had whooping cough, provide the age in years when they had whooping coughAge in months using two digit format
chickenpox_age_yearsIntegerRecommendedIf the participant has had chicken pox, provide the age in months when they had chicken poxAge in years using two digit format
chickenpox_age_monthsIntegerRecommendedIf the participant has had chicken pox, provide the age in years when they had chicken poxAge in months using two digit format
eeg_age_monthsIntegerRecommendedIf the participant has had EEG, provide the age in months when they had EEGAge in years using two digit format
eeg_age_yearsIntegerRecommendedIf the participant has had EEG, provide the age in years when they had EEGAge in months using two digit format
diagnosis_autismString10RequiredHas the participant been diagnosed with Autism?
Yes;No;999
diagnosis_autism_madebyString100RecommendedIf the participant has been diagnosed with autism, who gave this diagnosis?
diagnosis_seizuresString10RequiredHas the participant been diagnosed with seizures?
Yes;No;-7;-8;-9
CPEA STAART: -7 = Don't know; -8 = Refused to answer; -9 = Does not apply
diagnosis_other_specifyString500RecommendedWhat other diagnoses has the participant had?
atypical_dev_signsString500RecommendedPrior to a diagnosis, were there any signes that led you to believe that the participant was developing atypically?
earlydev_fsymcString1,024RecommendedFirst symptoms to arouse parental concern (specify)
feed_swallow_problemString10RecommendedHas the participant demonstrated any feeding or swallowing problems?
Yes;No; NK
feed_swallow_problem_specifyString500RecommendedIf they have demonstrated feeding or swallowing problems, describe them
medication1_nameString100RecommendedName first medication that the participant has taken999= Legitimately skipped;
medication1_currentString10RequiredFirst medication currently taking?
Yes;No;999
medication1_pastString10RecommendedFirst medication took in the past?
Yes;No
medication2_nameString100RecommendedName second medication that the participant has taken999= Legitimately skipped;
medication2_currentString10Recommendedsecond medication currently taking?
Yes;No
medication2_pastString10Recommendedsecond medication took in the past?
Yes;No
medication3_nameString150RecommendedName third medication that the participant has taken999= Legitimately skipped;
medication3_currentString10Recommendedthird medication currently taking?
Yes;No
medication3_pastString10Recommendedthird medication took in the past?
Yes;No
medication4_nameString100RecommendedName fourth medication that the participant has taken999= Legitimately skipped;
medication4_currentString10Recommendedfourth medication currently taking?
Yes;No
medication4_pastString10Recommendedfourth medication took in the past?
Yes;No
medication5_nameString100RecommendedName fifth medication that the participant has taken
medication5_currentString10Recommendedfifth medication currently taking?
Yes;No
medication5_pastString10Recommendedfifth medication took in the past?
Yes;No
medication6_nameString100RecommendedName sixth medication that the participant has taken
medication6_currentString10Recommendedsixth medication currently taking?
Yes;No
medication6_pastString10Recommendedsixth medication took in the past?
Yes;No
medication7_nameString100RecommendedName seventh medication that the participant has taken
medication7_currentString10Recommendedseventh medication currently taking?
Yes;No
medication7_pastString10Recommendedseventh medication took in the past?
Yes;No
medication8_nameString100RecommendedName eighth medication that the participant has taken
medication8_currentString10Recommendedeighth medication currently taking?
Yes;No
medication8_pastString10Recommendedeighth medication took in the past?
Yes;No
medication9_nameString100RecommendedName ninth medication that the participant has taken
medication9_currentString10Recommendedninth medication currently taking?
Yes;No
medication9_pastString10Recommendedninth medication took in the past?
Yes;No
medication10_nameString100RecommendedName tenth medication that the participant has taken
medication10_currentString10Recommendedtenth medication currently taking?
Yes;No
medication10_pastString10Recommendedtenth medication took in the past?
Yes;No
play_opps_other_kidsString10RecommendedDoes the participant have opportunities to play with other children?
Yes;No
likes_play_other_kidsString10RecommendedDoes the participant like to play with other children?
Yes;No
assist_dressingString10RecommendedIs the participant able to assist with dressing himself/herself?
Yes;No
special_behavior_problemsString10RecommendedDoes the participant present any special behavior problems?
Yes;No
special_behavior_probs_specifyString200RecommendedIf the participant does present special behavior problems, please describe
milestone_age_mo_smileIntegerRecommendedAge in which the participant accomplished the following milestone in months: smiled
milestone_age_yr_smileIntegerRecommendedAge in which the participant accomplished the following milestone in years: smiled
milestone_age_mo_satupIntegerRecommendedAge in which the participant accomplished the following milestone in months: sat up without support
milestone_age_yr_satupIntegerRecommendedAge in which the participant accomplished the following milestone in years: sat up without support
milestone_age_mo_crawlIntegerRecommendedAge in which the participant accomplished the following milestone in months: crawled
milestone_age_yr_crawlIntegerRecommendedAge in which the participant accomplished the following milestone in years: crawled
milestone_age_mo_solidfoodFloatRecommendedAge in which the participant accomplished the following milestone in months: started solid foods
milestone_age_yr_solidfoodIntegerRecommendedAge in which the participant accomplished the following milestone in years: started solid foods
milestone_age_mo_wordsIntegerRecommendedAge in which the participant accomplished the following milestone in months: used words
milestone_age_yr_wordsIntegerRecommendedAge in which the participant accomplished the following milestone in years: used words
milestone_age_mo_stopbottleIntegerRecommendedAge in which the participant accomplished the following milestone in months: gave up bottle
milestone_age_yr_stopbottleIntegerRecommendedAge in which the participant accomplished the following milestone in years: gave up bottle
milestone_age_mo_toilettrainIntegerRecommendedAge in which the participant accomplished the following milestone in months: was toilet trained
milestone_age_yr_toilettrainIntegerRecommendedAge in which the participant accomplished the following milestone in years: was toilet trained
milestone_age_mo_walkaloneIntegerRecommendedAge in which the participant accomplished the following milestone in months: walked alone
milestone_age_yr_walkaloneIntegerRecommendedAge in which the participant accomplished the following milestone in years: walked alone
milestone_age_mo_fedselfspoonIntegerRecommendedAge in which the participant accomplished the following milestone in months: fed self with a spoon
milestone_age_yr_fedselfspoonIntegerRecommendedAge in which the participant accomplished the following milestone in years: fed self with a spoon
milestone_age_mo_drankcupIntegerRecommendedAge in which the participant accomplished the following milestone in months: drank with a cup
milestone_age_yr_drankcupIntegerRecommendedAge in which the participant accomplished the following milestone in years: drank with a cup
respond_to_soundsString10RecommendedDoes the participant respond consistently to sounds in the home (doorbell, phone, etc)?
Yes;No
understand_what_others_sayString10RecommendedDoes the participant understand what you say to him/her?
Yes;No
suspect_hearing_lossString10RequiredDo you suspect a hearing loss?
Yes;No;999
babbleString10RecommendedDoes the participant babble (e.g., baba, didi, yada)?
Yes;No
babble_short_phrasesString10RecommendedDoes the participant babble using short phrases (e.g., mama up, ball please, bye-bye dada)?
Yes;No
cg_understand_speechString10RecommendedDo the caregivers understand the participant's speech?
Yes;No
strangers_understand_speechString10RecommendedDo strangers understand the participant's speech?
Yes;No
otherkids_understand_speechString10RecommendedDo other children understand the participant's speech?
Yes;No
imitate_soundswordsString10RecommendedDoes the participant imitate sounds and/or words after you say them first?
Yes;No
diagnosis_apraxia_motorsensdisString10RecommendedHas the participant been diagnosed with apraxia or a motor/sensory disorder?
Yes;No
sounds_used_numberString10RecommendedHow many different sounds does the participant use?
sounds_used_specifyString50RecommendedGive examples of sounds he/she says (e.g., b, p, m, n, )
vocabulary_sizeString50RecommendedEstimate the participants current vocabulary sizeNo words yet;1-2 words;3-5 words;6-10 words;11-20 words;21-30 words;31-50 words;50 or more
vocabulary_specifyString200RecommendedGive examples of words or phrases
augcomm_taught_pecsString10RecommendedHas the participant ever been taught to use any of these augmentative communication devices or systems: Picture Exchange Communication System
Yes;No
augcomm_taught_pointpicsString10RecommendedHas the participant ever been taught to use any of these augmentative communication devices or systems: Pointing to pictures
Yes;No
augcomm_taught_speechdeviceString10RecommendedHas 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_signlanguageString10RecommendedHas the participant ever been taught to use any of these augmentative communication devices or systems: Sign language
Yes;No
earlyint1_start_dateDateRecommendedEarly Intervention Program Occurrence 1: If participant participated in the following intervention, what date did the intervention begin?
earlyint1_end_dateDateRecommendedEarly Intervention Program Occurrence 1: If participant participated in the following intervention, what date did the intervention end
earlyint1_week_hrsFloatRecommendedEarly Intervention Program Occurrence 1:For the following intervention, how many hours per week were provided?
earlyint1_group_indString50RecommendedEarly Intervention Program Occurrence 1: For the following intervention, how was it provided?Individual;Group;Both
earlyint1_settingString75RecommendedEarly 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_fundingString50RecommendedEarly 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;OtherSD = School district; PP = Private pay
earlyint1_funding_specifyString200RecommendedEarly 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_dateDateRecommendedEarly Intervention Program Occurrence 2: If participant participated in the following intervention, what date did the intervention begin?
earlyint2_end_dateDateRecommendedEarly Intervention Program Occurrence 2: If participant participated in the following intervention, what date did the intervention end
earlyint2_week_hrsIntegerRecommendedEarly Intervention Program Occurrence 2:For the following intervention, how many hours per week were provided?
earlyint2_group_indString50RecommendedEarly Intervention Program Occurrence 2: For the following intervention, how was it provided?Individual;Group;Both
earlyint2_settingString75RecommendedEarly 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_fundingString50RecommendedEarly 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;OtherSD = School district; PP = Private pay
earlyint2_funding_specifyString200RecommendedEarly 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_dateDateRecommendedEarly Intervention Program Occurrence 3: If participant participated in the following intervention, what date did the intervention begin?
earlyint3_end_dateDateRecommendedEarly Intervention Program Occurrence 3: If participant participated in the following intervention, what date did the intervention end
earlyint3_week_hrsIntegerRecommendedEarly Intervention Program Occurrence 3:For the following intervention, how many hours per week were provided?
earlyint3_group_indString50RecommendedEarly Intervention Program Occurrence 3: For the following intervention, how was it provided?Individual;Group;Both
earlyint3_settingString75RecommendedEarly 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_fundingString50RecommendedEarly 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;OtherSD = School district; PP = Private pay
earlyint3_funding_specifyString200RecommendedEarly 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_dateDateRecommendedBehavioral Therapy Occurrence 1: If participant participated in the following intervention, what date did the intervention begin?
behavioral1_end_dateDateRecommendedBehavioral Therapy Occurrence 1: If participant participated in the following intervention, what date did the intervention end
behavioral1_week_hrsIntegerRecommendedBehavioral Therapy Occurrence 1:For the following intervention, how many hours per week were provided?
behavioral1_group_indString50RecommendedBehavioral Therapy Occurrence 1: For the following intervention, how was it provided?Individual;Group;Both
behavioral1_settingString75RecommendedBehavioral 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_fundingString50RecommendedBehavioral 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;OtherSD = School district; PP = Private pay
behavioral1_funding_specifyString200RecommendedBehavioral 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_dateDateRecommendedBehavioral Therapy Occurrence 2: If participant participated in the following intervention, what date did the intervention begin?
behavioral2_end_dateDateRecommendedBehavioral Therapy Occurrence 2: If participant participated in the following intervention, what date did the intervention end
behavioral2_week_hrsIntegerRecommendedBehavioral Therapy Occurrence 2:For the following intervention, how many hours per week were provided?
behavioral2_group_indString50RecommendedBehavioral Therapy Occurrence 2: For the following intervention, how was it provided?Individual;Group;Both
behavioral2_settingString75RecommendedBehavioral 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_fundingString50RecommendedBehavioral 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;OtherSD = School district; PP = Private pay
behavioral2_funding_specifyString200RecommendedBehavioral 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_dateDateRecommendedBehavioral Therapy Occurrence 3: If participant participated in the following intervention, what date did the intervention begin?
behavioral3_end_dateDateRecommendedBehavioral Therapy Occurrence 3: If participant participated in the following intervention, what date did the intervention end
behavioral3_week_hrsIntegerRecommendedBehavioral Therapy Occurrence 3:For the following intervention, how many hours per week were provided?
behavioral3_group_indString50RecommendedBehavioral Therapy Occurrence 3: For the following intervention, how was it provided?Individual;Group;Both
behavioral3_settingString75RecommendedBehavioral 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_fundingString50RecommendedBehavioral 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;OtherSD = School district; PP = Private pay
behavioral3_funding_specifyString200RecommendedBehavioral 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_dateDateRecommendedOccupational Therapy Occurrence 1: If participant participated in the following intervention, what date did the intervention begin?
ot1_end_dateDateRecommendedOccupational Therapy Occurrence 1: If participant participated in the following intervention, what date did the intervention end
ot1_week_hrsFloatRecommendedOccupational Therapy Occurrence 1:For the following intervention, how many hours per week were provided?
ot1_group_indString50RecommendedOccupational Therapy Occurrence 1: For the following intervention, how was it provided?Individual;Group;Both
ot1_settingString75RecommendedOccupational 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_fundingString50RecommendedOccupational 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;OtherSD = School district; PP = Private pay
ot1_funding_specifyString200RecommendedOccupational 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_dateDateRecommendedOccupational Therapy Occurrence 2: If participant participated in the following intervention, what date did the intervention begin?
ot2_end_dateDateRecommendedOccupational Therapy Occurrence 2: If participant participated in the following intervention, what date did the intervention end
ot2_week_hrsIntegerRecommendedOccupational Therapy Occurrence 2:For the following intervention, how many hours per week were provided?
ot2_group_indString50RecommendedOccupational Therapy Occurrence 2: For the following intervention, how was it provided?Individual;Group;Both
ot2_settingString75RecommendedOccupational 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_fundingString50RecommendedOccupational 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;OtherSD = School district; PP = Private pay
ot2_funding_specifyString200RecommendedOccupational 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_dateDateRecommendedOccupational Therapy Occurrence 3: If participant participated in the following intervention, what date did the intervention begin?
ot3_end_dateDateRecommendedOccupational Therapy Occurrence 3: If participant participated in the following intervention, what date did the intervention end
ot3_week_hrsIntegerRecommendedOccupational Therapy Occurrence 3:For the following intervention, how many hours per week were provided?
ot3_group_indString50RecommendedOccupational Therapy Occurrence 3: For the following intervention, how was it provided?Individual;Group;Both
ot3_settingString75RecommendedOccupational 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_fundingString50RecommendedOccupational 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;OtherSD = School district; PP = Private pay
ot3_funding_specifyString200RecommendedOccupational 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_dateDateRecommendedSpeech and Language Therapy Occurrence 1: If participant participated in the following intervention, what date did the intervention begin?
slp1_end_dateDateRecommendedSpeech and Language Therapy Occurrence 1: If participant participated in the following intervention, what date did the intervention end
slp1_week_hrsIntegerRecommendedSpeech and Language Therapy Occurrence 1:For the following intervention, how many hours per week were provided?
slp1_group_indString50RecommendedSpeech and Language Therapy Occurrence 1: For the following intervention, how was it provided?Individual;Group;Both
slp1_settingString75RecommendedSpeech 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_fundingString50RecommendedSpeech 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;OtherSD = School district; PP = Private pay
slp1_funding_specifyString200RecommendedSpeech 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_dateDateRecommendedSpeech and Language Therapy Occurrence 2: If participant participated in the following intervention, what date did the intervention begin?
slp2_end_dateDateRecommendedSpeech and Language Therapy Occurrence 2: If participant participated in the following intervention, what date did the intervention end
slp2_week_hrsIntegerRecommendedSpeech and Language Therapy Occurrence 2:For the following intervention, how many hours per week were provided?
slp2_group_indString50RecommendedSpeech and Language Therapy Occurrence 2: For the following intervention, how was it provided?Individual;Group;Both
slp2_settingString75RecommendedSpeech 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_fundingString50RecommendedSpeech 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;OtherSD = School district; PP = Private pay
slp2_funding_specifyString200RecommendedSpeech 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_dateDateRecommendedSpeech and Language Therapy Occurrence 3: If participant participated in the following intervention, what date did the intervention begin?
slp3_end_dateDateRecommendedSpeech and Language Therapy Occurrence 3: If participant participated in the following intervention, what date did the intervention end
slp3_week_hrsIntegerRecommendedSpeech and Language Therapy Occurrence 3:For the following intervention, how many hours per week were provided?
slp3_group_indString50RecommendedSpeech and Language Therapy Occurrence 3: For the following intervention, how was it provided?Individual;Group;Both
slp3_settingString75RecommendedSpeech 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_fundingString50RecommendedSpeech 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;OtherSD = School district; PP = Private pay
slp3_funding_specifyString200RecommendedSpeech 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_dateDateRecommendedFloortime Therapy Occurrence 1: If participant participated in the following intervention, what date did the intervention begin?
floortime1_end_dateDateRecommendedFloortime Therapy Occurrence 1: If participant participated in the following intervention, what date did the intervention end
floortime1_week_hrsFloatRecommendedFloortime Therapy Occurrence 1:For the following intervention, how many hours per week were provided?
floortime1_group_indString50RecommendedFloortime Therapy Occurrence 1: For the following intervention, how was it provided?Individual;Group;Both
floortime1_settingString75RecommendedFloortime 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_fundingString50RecommendedFloortime 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;OtherSD = School district; PP = Private pay
floortime1_funding_specifyString200RecommendedFloortime 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_dateDateRecommendedFloortime Therapy Occurrence 2: If participant participated in the following intervention, what date did the intervention begin?
floortime2_end_dateDateRecommendedFloortime Therapy Occurrence 2: If participant participated in the following intervention, what date did the intervention end
floortime2_week_hrsIntegerRecommendedFloortime Therapy Occurrence 2:For the following intervention, how many hours per week were provided?
floortime2_group_indString50RecommendedFloortime Therapy Occurrence 2: For the following intervention, how was it provided?Individual;Group;Both
floortime2_settingString75RecommendedFloortime 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_fundingString50RecommendedFloortime 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;OtherSD = School district; PP = Private pay
floortime2_funding_specifyString200RecommendedFloortime 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_dateDateRecommendedFloortime Therapy Occurrence 3: If participant participated in the following intervention, what date did the intervention begin?
floortime3_end_dateDateRecommendedFloortime Therapy Occurrence 3: If participant participated in the following intervention, what date did the intervention end
floortime3_week_hrsIntegerRecommendedFloortime Therapy Occurrence 3:For the following intervention, how many hours per week were provided?
floortime3_group_indString50RecommendedFloortime Therapy Occurrence 3: For the following intervention, how was it provided?Individual;Group;Both
floortime3_settingString75RecommendedFloortime 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_fundingString50RecommendedFloortime 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;OtherSD = School district; PP = Private pay
floortime3_funding_specifyString200RecommendedFloortime 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_nameString200RecommendedOther Therapy1: If a therapy other than one listed was provided to participant, provide the name and description of the therapy
othertherapy1_start_dateDateRecommendedOther Therapy Occurrence 1: If participant participated in the following intervention, what date did the intervention begin?
othertherapy1_end_dateDateRecommendedOther Therapy Occurrence 1: If participant participated in the following intervention, what date did the intervention end
othertherapy1_week_hrsFloatRecommendedOther Therapy Occurrence 1:For the following intervention, how many hours per week were provided?
othertherapy1_group_indString50RecommendedOther Therapy Occurrence 1: For the following intervention, how was it provided?Individual;Group;Both
othertherapy1_settingString75RecommendedOther 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_fundingString50RecommendedOther 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;OtherSD = School district; PP = Private pay
othertherapy1_funding_specifyString200RecommendedOther 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_nameString200RecommendedOther Therapy2: If a therapy other than one listed was provided to participant, provide the name and description of the therapy
othertherapy2_start_dateDateRecommendedOther Therapy Occurrence 2: If participant participated in the following intervention, what date did the intervention begin?
othertherapy2_end_dateDateRecommendedOther Therapy Occurrence 2: If participant participated in the following intervention, what date did the intervention end
othertherapy2_week_hrsIntegerRecommendedOther Therapy Occurrence 2:For the following intervention, how many hours per week were provided?
othertherapy2_group_indString50RecommendedOther Therapy Occurrence 2: For the following intervention, how was it provided?Individual;Group;Both
othertherapy2_settingString75RecommendedOther 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_fundingString50RecommendedOther 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;OtherSD = School district; PP = Private pay
othertherapy2_funding_specifyString200RecommendedOther 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_nameString200RecommendedOther Therapy3: If a therapy other than one listed was provided to participant, provide the name and description of the therapy
othertherapy3_start_dateDateRecommendedOther Therapy Occurrence 3: If participant participated in the following intervention, what date did the intervention begin?
othertherapy3_end_dateDateRecommendedOther Therapy Occurrence 3: If participant participated in the following intervention, what date did the intervention end
othertherapy3_week_hrsIntegerRecommendedOther Therapy Occurrence 3:For the following intervention, how many hours per week were provided?
othertherapy3_group_indString50RecommendedOther Therapy Occurrence 3: For the following intervention, how was it provided?Individual;Group;Both
othertherapy3_settingString75RecommendedOther 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_fundingString50RecommendedOther 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;OtherSD = School district; PP = Private pay
othertherapy3_funding_specifyString200RecommendedOther 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_servicesString500RecommendedWhat were the barriers that you encountered in obtaining or receiving services?
barriers_implement_strategiesString500RecommendedWhat were the barriers you encountered in implementing the strategies from these service provders?
strategy_implement_competencyString500RecommendedHow competent do you feel in your ability to use the strategies from these services?
goals_importantString500RecommendedWhat are you most important goals for the participant?
goals_futureString500RecommendedWhat do you foresee as important future goals for the participant?
training_parent_behaviorString500RecommendedPlease list any parent training or behavior management training in which you've participated.
training_prompted_changesString500RecommendedWhat are you doing differently as a result of these training programs and What did you gain from this service?
Data Structure

This page displays the data structure defined for the measure identified in the title and structure short name. The table below displays a list of data elements in this structure (also called variables) and the following information:

  • Element Name: This is the standard element name
  • Data Type: Which type of data this element is, e.g. String, Float, File location.
  • Size: If applicable, the character limit of this element
  • Required: This column displays whether the element is Required for valid submissions, Recommended for valid submissions, Conditional on other elements, or Optional
  • Description: A basic description
  • Value Range: Which values can appear validly in this element (case sensitive for strings)
  • Notes: Expanded description or notes on coding of values
  • Aliases: A list of currently supported Aliases (alternate element names)
  • For valid elements with shared data, on the far left is a Filter button you can use to view a summary of shared data for that element and apply a query filter to your Cart based on selected value ranges

At the top of this page you can also:

  • Use the search bar to filter the elements displayed. This will not filter on the Size of Required columns
  • Download a copy of this definition in CSV format
  • Download a blank CSV submission template prepopulated with the correct structure header rows ready to fill with subject records and upload

Please email the The NDA Help Desk with any questions.

Distribution for DataStructure: mv_demo_intake01 and Element:
Chart Help

Filters enable researchers to view the data shared in NDA before applying for access or for selecting specific data for download or NDA Study assignment. For those with access to NDA shared data, you may select specific values to be included by selecting an individual bar chart item or by selecting a range of values (e.g. interview_age) using the "Add Range" button. Note that not all elements have appropriately distinct values like comments and subjectkey and are not available for filtering. Additionally, item level detail is not always provided by the research community as indicated by the number of null values given.

Filters for multiple data elements within a structure are supported. Selections across multiple data structures will be supported in a future version of NDA.