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Minimally Verbal - Common Demographic Intake Form

0 Shared Subjects

The Common Demographic Intake Form as defined by the Minimally Verbal Workgroup
Clinical Assessments
Demographics
09/27/2011
mv_demo_intake01
09/28/2011
View Change History
01
Definition
Submission Template
Query Element Name Data Type Size Required Description Value Range Notes Aliases
subjectkey GUID Required The NDAR Global Unique Identifier (GUID) for research subject NDAR*
src_subject_id String 20 Required Subject ID how it's defined in lab/project
sex String 20 Required Sex of subject at birth M;F; O; NR M = Male; F = Female; O=Other; NR = Not reported gender
grade String 50 Recommended Current Grade
interview_date Date Required Date on which the interview/genetic test/sampling/imaging/biospecimen was completed. MM/DD/YYYY
Query hispanic Integer Recommended Is subject of Hispanic, Latino, or Spanish origin? 0; 1; 999 0 = No; 1 = Yes; 999= missing
race String 30 Recommended Race of study subject American Indian/Alaska Native; Asian; Hawaiian or Pacific Islander; Black or African American; White; More than one race; Unknown or not reported; Other Non-White; Other
race_other String 100 Recommended Race of Respondent 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/Parent 1's Gender Male;Female
cg1_relation_status String 100 Recommended Caregiver/Parent 1's Relationship Status
Married;Never married;Widowed;Divorced and remarried;Separated;Divorced;Widowed and remarried;Other; Living with Partner
cg1_relation_status_specify String 100 Recommended Caregiver/Parent 1's Relationship Status Other Specify
cg1_relationship String 100 Recommended Caregiver/Parent 1's Relationship to Participant Parent;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; Step-father; Step-mother
cg1_relationship_specify String 100 Recommended Caregiver/Parent 1's Relationship to Participant Other Specify
cg1_guardian String 10 Recommended Caregiver/Parent 1. Is this the Participant's Custodian/Legal Guardian?
Yes;No
cg1_cohabitate String 10 Recommended Caregiver/Parent 1. Does the participant live with this custodian?
Yes;No
cg1_race String 100 Recommended Race of the Caregiver/Parent 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/Parent 1 Other Specify
cg1_education String 100 Recommended Caregiver/Prent 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; did not graduate from high school; college graduate; Middle School
cg1_occupation String 100 Recommended Caregiver/Parent 1's Occupation
Query num_in_house_adults Integer Recommended Number of Individuals in Household Adults
Query 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/Parent 2's Relationship to Participant Parent;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; Step-father; Step-mother
cg2_relationship_specify String 100 Recommended Caregiver/Parent 2's Relationship to Participant Other Specify
cg2_guardian String 10 Recommended Caregiver/Parent 2. Is this the Participant's Custodian/Legal Guardian?
Yes;No
cg2_hispanic String 10 Recommended Is Caregiver/Parent 2 of Hispanic or Latino Origin?
Yes;No
cg2_race String 100 Recommended Race of the Caregiver/Parent 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/Parent 2 to Caregiver/Parent 1 Spouse;In a relationship, unmarried;Other
cg1_cg2_relationship_specify String 100 Recommended Relationship of Caregiver/Parent 2 to Caregiver/Parent 1 Other Specify
cg2_relation_status String 100 Recommended Caregiver/Parent 2's Relationship Status Married;Never married;Widowed;Divorced and remarried;Separated;Divorced;Widowed and remarried;Other; Living with Partner
cg2_relation_status_specify String 100 Recommended Caregiver/Parent 2's Relationship Status Other Specify
cg2_education String 100 Recommended Caregiver/Parent 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; did not graduate from high school; college graduate; Middle School
cg2_occupation String 100 Recommended Caregiver/Parent 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;Other
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-sibling;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;Other
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-sibling;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;Other
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-sibling;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;Other
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-sibling;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;Other
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-sibling;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;Other
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-sibling;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-sibling;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
Query premature_weeks Integer Recommended Weeks premature 0 = Full term
Query birth_weight_lbs Float Recommended Birth weight pounds
Query 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
Query ear_infection_num Integer Recommended How many ear infections has the participant had?
rev_earpetube String 50 Recommended PE Tubes
Yes;No;NK
NK = Not known
Query rev_earpetube_month Integer Recommended If participant has received ear tubes, what month? MM month as two digits
Query 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query 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 Required Has the participant been diagnosed with Autism?
Yes;No;999
999=NA/missing
diagnosis_autism_madeby String 100 Recommended If the participant has been diagnosed with autism, who gave this diagnosis?
diagnosis_seizures String 10 Required Has 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_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 1,020 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; NK
feed_swallow_problem_specify String 500 Recommended If they have demonstrated feeding or swallowing problems, describe them
medication1_name String 500 Recommended Name first medication that the participant has taken 0 = No medication; 999= Legitimately skipped
medication1_current String 10 Required First medication currently taking?
Yes;No;999
999=NA/missing
medication1_past String 10 Recommended First medication took in the past?
Yes;No
medication2_name String 500 Recommended Name second medication that the participant has taken 0 = No medication; 999= Legitimately skipped
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 500 Recommended Name third medication that the participant has taken 0 = No medication; 999= Legitimately skipped
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 500 Recommended Name fourth medication that the participant has taken 0 = No medication; 999= Legitimately skipped
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 500 Recommended Name fifth medication that the participant has taken 0 = No medication; 999= Legitimately skipped
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 500 Recommended Name sixth medication that the participant has taken 0 = No medication; 999= Legitimately skipped
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 500 Recommended Name seventh medication that the participant has taken 0 = No medication; 999= Legitimately skipped
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 500 Recommended Name eighth medication that the participant has taken 0 = No medication; 999= Legitimately skipped
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 500 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
Query milestone_age_mo_smile Integer Recommended Age in which the participant accomplished the following milestone in months: smiled
Query milestone_age_yr_smile Integer Recommended Age in which the participant accomplished the following milestone in years: smiled
Query milestone_age_mo_satup Integer Recommended Age in which the participant accomplished the following milestone in months: sat up without support
Query milestone_age_yr_satup Integer Recommended Age in which the participant accomplished the following milestone in years: sat up without support
Query milestone_age_mo_crawl Integer Recommended Age in which the participant accomplished the following milestone in months: crawled
Query milestone_age_yr_crawl Integer Recommended Age in which the participant accomplished the following milestone in years: crawled
Query milestone_age_mo_solidfood Float Recommended Age in which the participant accomplished the following milestone in months: started solid foods
Query milestone_age_yr_solidfood Integer Recommended Age in which the participant accomplished the following milestone in years: started solid foods
Query milestone_age_mo_words Integer Recommended Age in which the participant accomplished the following milestone in months: used words
Query milestone_age_yr_words Integer Recommended Age in which the participant accomplished the following milestone in years: used words
Query milestone_age_mo_stopbottle Integer Recommended Age in which the participant accomplished the following milestone in months: gave up bottle
Query milestone_age_yr_stopbottle Integer Recommended Age in which the participant accomplished the following milestone in years: gave up bottle
Query milestone_age_mo_toilettrain Integer Recommended Age in which the participant accomplished the following milestone in months: was toilet trained
Query milestone_age_yr_toilettrain Integer Recommended Age in which the participant accomplished the following milestone in years: was toilet trained
Query milestone_age_mo_walkalone Integer Recommended Age in which the participant accomplished the following milestone in months: walked alone
Query milestone_age_yr_walkalone Integer Recommended Age in which the participant accomplished the following milestone in years: walked alone
Query milestone_age_mo_fedselfspoon Integer Recommended Age in which the participant accomplished the following milestone in months: fed self with a spoon
Query milestone_age_yr_fedselfspoon Integer Recommended Age in which the participant accomplished the following milestone in years: fed self with a spoon
Query milestone_age_mo_drankcup Integer Recommended Age in which the participant accomplished the following milestone in months: drank with a cup
Query 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 Required Do you suspect a hearing loss?
Yes;No;999
999=NA/missing
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
Query earlyint1_week_hrs Float 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query ot1_week_hrs Float 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
Query 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
Query 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
Query 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
Query 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
Query 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
Query floortime1_week_hrs Float 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
Query 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
Query 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
Query othertherapy1_week_hrs Float 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
Query 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
Query 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?
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
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