APPENDIX A 

CHILD QUESTIONNAIRE

Early Childhood Longitudinal Study, Kindergarten Class of 2010-11 

(ECLS-K:2011) 

Spring Third-Grade National Data Collection, Fourth-Grade 

Recruitment, and Fifth-Grade Tracking 

OMB Clearance Package 

# 1850-0750 v.15 

This appendix includes the programmer specifications for the audio-CASI child questionnaire, 

which indicate the exact instructions to be provided to the child and the items that will be

administered. 

Note: A decision on the exact laptop that will be used to administer the child questionnaire is 

still pending. Therefore, some of the instructions provided to the child about how to use the 

computer to take the survey, for example the instructions about how to adjust the volume in 

item CLQ006, may need to be revised to be appropriate for the laptops that are selected. 
Social Distress 

The child questionnaire to be fielded in the spring third-grade data collection will include three 

items (CLQ205, CLQ220, and CLQ235) used to evaluate children’s social anxiety, specifically 

their fear of negative evaluation by their peers. The exact wording of these items is not 

included here because they are copyright protected. 

Source: Social anxiety scale for children-revised: Factor structure and concurrent validity. © 1993 A.M. La 

Greca and W.L. Stone. Used with permission. 
Section CLQ [Child Questionnaire ACASI]

Child Questionnaire

Sequence: 0

CLQGLB005

RAPID RESPONSE

IF A CHILD SELECTS A COMMAND BUTTON (NEXT, BACK) OR A RESPONSE BEFORE ACASI HAS READ THE 

ENTIRE CONTENTS OF THE SCREEN, PROGRAM SHOULD ACCEPT THE CHILD'S SELECTION BY FOLLOWING 

THE COMMAND OR ACCEPTING THE ANSWER.

CLQGLB010

INACTIVITY SETTINGS

AFTER 15 SECONDS OF IDLE TIME ON ONE SCREEN [FROM WHEN THE LAST RESPONSE CATEGORY HAS BEEN 

READ], THE FOLLOWING MESSAGE SHOULD APPEAR AT THE BOTTOM CENTER OF THE SCREEN AND BE 

READ ON AUDIO.

"Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this 

question."

CLQGLB015

CONFIRMATION SCREEN

IF THE CHILD TOUCHES THE NEXT BUTTON BEFORE TOUCHING AN ANSWER TO A QUESTION, THEN 

PROGRAM SHOULD MOVE TO THE CONFIRMATION SCREEN. 

DISPLAY PREVIOUS ITEM TEXT AND CONFIRMATION QUESTION AT THE TOP CENTER OF THE SCREEN. 

DISPLAY RESPONSE OPTIONS IN THE MIDDLE OF THE SCREEN BELOW THE QUESTION.

PROGRAM READS CONFIRMATION QUESTION: Do you want to skip this question? 

PROGRAM READS RESPONSE OPTIONS:

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Child Questionnaire :: CLQ
Yes. (1)

No. (2)

IF THE CHILD CHOOSES 1, THEN PROGRAM MOVES TO THE NEXT SCREEN WITHOUT NEEDING TO PRESS ANY 

OTHER BUTTONS.

IF THE CHILD CHOOSES 2, THEN PROGRAM MOVES TO THE PREVIOUS SCREEN WITHOUT NEEDING TO PRESS 

ANY OTHER BUTTONS.

CLQGLB020

CHANGE RESPONSE PROCEDURE

THE CHILD'S ANSWER SELECTION SHOULD ALWAYS BE READ ON AUDIO, AND THE SELECTED BUTTON 

SHOULD BE VISUALLY EMPHASIZED.

IF THE CHILD WANTS TO CHANGE AN ANSWER, HE OR SHE CAN TOUCH THE "Erase" BUTTON AND THEN 

TOUCH HIS/HER NEW ANSWER. ACASI SHOULD DO THE FOLLOWING:

REMOVE THE VISUAL EMPHASIS FROM THE OLD ANSWER BUTTON

VISUALLY EMPHASIZE THE NEW RESPONSE BUTTON

READ THE NEW RESPONSE

THE CHILD CAN CHANGE AN ANSWER MULTIPLE TIMES. ACASI SHOULD ACCEPT THE LAST ANSWER.

CLQGLB025

DISPLAY INSTRUCTIONS

WHEN TOUCHED, THE CHILD'S ANSWER SELECTION SHOULD BE READ ON AUDIO AND VISUALLY 

EMPHASIZED.

CLQGLB030

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Child Questionnaire :: CLQ
AUDIO INSTRUCTIONS

WORDS IN ALL CAPS SHOULD BE EMPHASIZED WHEN READ OVER AUDIO.

THE PHRASE "Please pick an answer and then touch the "Next" button or just touch the "Next" button to 

skip this question" IS DISPLAYED BUT SHOULD NOT BE READ ON AUDIO FOR ITEMS CLQ030CLQ275.

CLQGBL035

ADMINISTRATION TIMING

FOR CQ ENTIRE ADMINISTRATION TIMINGS, BEGIN TIMING WHEN THE OPENING SCREEN FOR THE 

ASSESSOR APPEARS (CLQ005) AND END TIMING WHEN THE ASSESSOR PRESSES 1 & ENTER TO LEAVE THE 

CLOSING SCREEN (CLQ285).

CLQGLB040

RESPONSE BUTTON DISPLAY CHARACTERISTICS

Vertical spacing: 15 pixels

Button height: 50 pixels

Button width: 200 pixels

BUTTON DISPLAY

PLACE A "Next" BUTTON AT THE BOTTOM RIGHT OF THE FOLLOWING SCREENS (CLQ012CLQ275).

PLACE A "Back" BUTTON AT THE BOTTOM LEFT OF THE FOLLOWING SCREENS (CLQ015CLQ280).

PLACE AN "Erase" BUTTON AT THE BOTTOM CENTER OF THE FOLLOWING SCREENS (CLQ015, CLQ025, 

CLQ030CLQ275).

CLQ005

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Child Questionnaire :: CLQ
QUESTION TEXT:

PLUG HEADPHONES INTO THE COMPUTER. POSITION LAPTOP IN FRONT OF THE CHILD.

SAY: Now you are going to use the computer to tell us a little more about yourself. The computer will read 

some sentences and questions to you while you listen on the headphones [HOLD UP HEADPHONES].

SAY: Then you will pick the answer that best describes you by touching your answer on the computer screen 

[TOUCH THE MIDDLE OF THE COMPUTER SCREEN WITH ONE FINGER]. If you don’t want to pick an answer, 

you don’t have to.

PRESS 1 AND ENTER TO CONTINUE.

CLQ006

QUESTION TEXT:

POINT TO THE VOLUME CONTROL BUTTONS ON THE BOTTOM RIGHT CORNER OF THE COMPUTER SCREEN.

SAY: To make the sound louder, [POINT TO THE RIGHT BUTTON] press the right button. To make the sound 

softer, [POINT TO THE MIDDLE BUTTON] press the middle button. If you want to turn the sound off, just turn 

the volume all the way down.

SHOW THE CHILD HOW TO ADJUST THE SIZE OF THE HEADPHONES.

SAY: Once you put the headphones on, you will hear directions about what to do. Do you have any questions? 

[PAUSE 2-3 SECONDS AND ANSWER ANY QUESTIONS.]

SAY: Ok, go ahead and put these headphones on now. [HAND THE CHILD THE HEADPHONES.] Do the 

headphones fit OK? [ADJUST HEADPHONES IF NECESSARY.]

PRESS 1 AND ENTER TO CONTINUE.

CLQ012

QUESTION TEXT:

Hello. Before we begin, let’s make sure the volume on the headphones is right for you. This is how loud it will 

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Child Questionnaire :: CLQ
PROGRAMMER INSTRUCTIONS:

ENTER TEXT

be when the sentences are read to you. If it is too loud or too soft please change the volume now or ask for 

help.

In a minute, sentences will appear on the screen, and they will be read to you along with a list of answers. 

Think about each sentence and decide how well it describes you. Once you've decided, touch your answer on 

the computer screen. You can touch your answer even if the computer is still reading to you.

For these questions, there are no right or wrong answers, and all your answers are private. No one will be 

told the answers that you pick. And remember, be sure your answers tell me about YOU.

Please touch the "Next" button and move to the next screen.

TURN OFF CONFIRMATION SCREEN.

CLQ015

DISPLAY INSTRUCTIONS:

QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Not at all true

2 A little bit true

3 Mostly true

4 Very true

MARIA'S ANSWER SELECTION "A LITTLE BIT TRUE" SHOULD BE HIGHLIGHTED.

For each sentence, decide how well it describes you. Is the sentence "Not at all true; A little bit true; Mostly 

true; or Very true" for you? 

A student, Maria, has already given an answer for one sentence to show you how to do it. The sentence read 

to Maria was

I am neat and tidy.

Maria touched the button on the screen with the answer "A little bit true" because she is not very neat, but 

she is not very messy either. 

Please touch the "Next" button and move to the next screen.

TURN OFF CONFIRMATION SCREEN.

CLQ025

QUESTION TEXT:

If you want to change an answer, touch the "Erase" button and then touch the new answer you want to pick. 

If you want to go back and change any of the answers you already gave, touch the "Back" button and move 

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Child Questionnaire :: CLQ
PROGRAMMER INSTRUCTIONS:

CODES

1 Not at all true

2 A little bit true

3 Mostly true

4 Very true

REFUSED

DON'T KNOW

to the past screen. Once there, touch the "Erase" button and then touch the new answer you want to pick. 

Now, let's practice. Listen to the following statement. Choose the answer that best describes you. After you 

choose, remember to touch the "Next" button.

I like to watch TV.

DISPLAY EXAMPLE ITEM AND RESPONSE OPTIONS.

CLQ028

QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

ENTER TEXT

Great, thank you for practicing with me.

One last thing before we begin: If there is a question that you do not want to answer, just touch the “Next” 

button to skip over it. When you touch the “Next” button without answering, the computer will ask if you 

want to skip the question, just to make sure you didn’t skip the question by accident.

Please touch the "Next" button and move to the next screen.

TURN OFF CONFIRMATION SCREEN.

CLQ030

QUESTION TEXT:

CODES

1 Not at all true

2 A little bit true

3 Mostly true

4 Very true

Let's begin.

I have lots of friends.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

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Child Questionnaire :: CLQ
PROGRAMMER INSTRUCTIONS:

REFUSED

DON'T KNOW

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ035

QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Not at all true

2 A little bit true

3 Mostly true

4 Very true

REFUSED

DON'T KNOW

I am good at SCIENCE.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ050

QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Not at all true

2 A little bit true

3 Mostly true

4 Very true

REFUSED

DON'T KNOW

I enjoy doing work in SCIENCE.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ055

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Child Questionnaire :: CLQ
QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Not at all true

2 A little bit true

3 Mostly true

4 Very true

REFUSED

DON'T KNOW

I like READING.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ060

QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Not at all true

2 A little bit true

3 Mostly true

4 Very true

REFUSED

DON'T KNOW

I make friends easily.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ065

QUESTION TEXT:

CODES

1 Not at all true

2 A little bit true

3 Mostly true

4 Very true

I cannot wait to do MATH each day.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

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Child Questionnaire :: CLQ
PROGRAMMER INSTRUCTIONS:

REFUSED

DON'T KNOW

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ075

QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Not at all true

2 A little bit true

3 Mostly true

4 Very true

REFUSED

DON'T KNOW

I like SCIENCE.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ085

QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Not at all true

2 A little bit true

3 Mostly true

4 Very true

REFUSED

DON'T KNOW

I am interested in READING.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ090

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Child Questionnaire :: CLQ
QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Not at all true

2 A little bit true

3 Mostly true

4 Very true

REFUSED

DON'T KNOW

I get along with kids easily.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ095

QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Not at all true

2 A little bit true

3 Mostly true

4 Very true

REFUSED

DON'T KNOW

I cannot wait to READ each day.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ100

QUESTION TEXT:

CODES

1 Not at all true

2 A little bit true

3 Mostly true

4 Very true

I am interested in MATH.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

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Child Questionnaire :: CLQ
PROGRAMMER INSTRUCTIONS:

REFUSED

DON'T KNOW

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ105

QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Not at all true

2 A little bit true

3 Mostly true

4 Very true

REFUSED

DON'T KNOW

I am easy to like.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ120

QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Not at all true

2 A little bit true

3 Mostly true

4 Very true

REFUSED

DON'T KNOW

Other kids want me to be their friend.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ130

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Child Questionnaire :: CLQ
QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Not at all true

2 A little bit true

3 Mostly true

4 Very true

REFUSED

DON'T KNOW

I like MATH.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ135

QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Not at all true

2 A little bit true

3 Mostly true

4 Very true

REFUSED

DON'T KNOW

I have more friends than most other kids.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ140

QUESTION TEXT:

CODES

1 Not at all true

2 A little bit true

3 Mostly true

4 Very true

I am good at READING.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

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Child Questionnaire :: CLQ
PROGRAMMER INSTRUCTIONS:

REFUSED

DON'T KNOW

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ145

QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Not at all true

2 A little bit true

3 Mostly true

4 Very true

REFUSED

DON'T KNOW

I am interested in SCIENCE.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ155

QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Not at all true

2 A little bit true

3 Mostly true

4 Very true

REFUSED

DON'T KNOW

I enjoy doing work in MATH.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ160

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Child Questionnaire :: CLQ
QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Not at all true

2 A little bit true

3 Mostly true

4 Very true

REFUSED

DON'T KNOW

I cannot wait to do SCIENCE.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ165

QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Not at all true

2 A little bit true

3 Mostly true

4 Very true

REFUSED

DON'T KNOW

I enjoy doing work in READING.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ170

QUESTION TEXT:

CODES

1 Not at all true

2 A little bit true

3 Mostly true

4 Very true

I am good at MATH.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

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Child Questionnaire :: CLQ
PROGRAMMER INSTRUCTIONS:

REFUSED

DON'T KNOW

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ180

QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Never

2 Rarely

3 Sometimes

4 Often

5 Very often

REFUSED

DON'T KNOW

The next set of questions and sentences are about how often things happen to you. Think about the question 

or sentence and decide if these things happen "Never; Rarely; Sometimes; Often; or Very often."

During this school year, how often have other students teased you, made fun of you, or called you names?

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ185

QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Never

2 Rarely

3 Sometimes

4 Often

5 Very often

REFUSED

DON'T KNOW

During this school year, how often have other students told lies or untrue stories about you?

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

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Child Questionnaire :: CLQ
CLQ190

QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Never

2 Rarely

3 Sometimes

4 Often

5 Very often

REFUSED

DON'T KNOW

During this school year, how often have other students pushed, shoved, slapped, hit, or kicked you?

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ200

QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Never

2 Rarely

3 Sometimes

4 Often

5 Very often

REFUSED

DON'T KNOW

During this school year, how often have other students left you out from playing with them on purpose?

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ215

QUESTION TEXT:

I try to cheer up other classmates who are upset or sad about something.

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Child Questionnaire :: CLQ
PROGRAMMER INSTRUCTIONS:

CODES

1 Never

2 Rarely

3 Sometimes

4 Often

5 Very often

REFUSED

DON'T KNOW

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ230

QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Never

2 Rarely

3 Sometimes

4 Often

5 Very often

REFUSED

DON'T KNOW

I help out other kids when they need it.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ245

QUESTION TEXT:

CODES

1 Never

2 Rarely

3 Sometimes

4 Often

I say or do nice things for other classmates.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

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Child Questionnaire :: CLQ
PROGRAMMER INSTRUCTIONS:

5 Very often

REFUSED

DON'T KNOW

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ250

QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Not at all

2 A little bit

3 Somewhat

4 Quite a bit

5 Very much

REFUSED

DON'T KNOW

The next set of sentences are about how you feel about your life. Think about the sentence and decide how 

well it describes you. Does the sentence describe you "Not at all; A little bit; Somewhat; Quite a bit; or Very 

much"?

I am happy with my hobbies and free time activities.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ255

QUESTION TEXT:

CODES

1 Not at all

2 A little bit

3 Somewhat

4 Quite a bit

5 Very much

REFUSED

DON'T KNOW

I am happy with the clothes, games, toys, and other things I have.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

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Child Questionnaire :: CLQ
PROGRAMMER INSTRUCTIONS:

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ260

QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Not at all

2 A little bit

3 Somewhat

4 Quite a bit

5 Very much

REFUSED

DON'T KNOW

I am happy with how much attention I get from my parents.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ265

QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Not at all

2 A little bit

3 Somewhat

4 Quite a bit

5 Very much

REFUSED

DON'T KNOW

I am happy with the friends I have.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ270

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Child Questionnaire :: CLQ
QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Not at all

2 A little bit

3 Somewhat

4 Quite a bit

5 Very much

REFUSED

DON'T KNOW

I am happy with my skills and talents.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ275

QUESTION TEXT:

PROGRAMMER INSTRUCTIONS:

CODES

1 Not at all

2 A little bit

3 Somewhat

4 Quite a bit

5 Very much

REFUSED

DON'T KNOW

I am happy with the neighborhood and community in which I live.

Please pick an answer and then touch the "Next" button or just touch the "Next" button to skip this question.

DISPLAY ITEM AND RESPONSE OPTIONS.

CLQ280

QUESTION TEXT:

ENTER TEXT

Thank you for working with me. You are done answering questions on the computer. Please take off the 

headphones now.

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Child Questionnaire :: CLQ
CLQ285

TAKE THE HEADPHONES FROM THE CHILD. TAKE THE LAPTOP FROM THE CHILD AND PLACE THE LAPTOP 

DIRECTLY IN FRONT OF YOU.

SAY: Thank you. Now we are going to do something else.

PRESS 1 AND ENTER TO CONTINUE.

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Child Questionnaire :: CLQ
APPENDIX B 

CHILD QUESTIONS FOR HEARING 

EVALUATIONS

Early Childhood Longitudinal Study, Kindergarten Class of 2010-11 

(ECLS-K:2011) 

Spring Third-Grade National Data Collection, Fourth-Grade 

Recruitment, and Fifth-Grade Tracking 

OMB Clearance Package 

# 1850-0750 v.15 
Section PTQ [Pre-Test Questionnaire]

Child Hearing Evaluation Questionnaire 3rd Grade: 

ECLS-K:2011

Sequence: 0

PTQ001

DISPLAY INSTRUCTIONS:

QUESTION TEXT:

CODES

1 YES PTQ003

2 NO PTQ002

REFUSED PTQ002

DON'T KNOW PTQ002

AT THE TOP OF THE SCREEN, DISPLAY:

"{NAME OF CHILD}, {CASE ID}"

FOR "NAME OF CHILD", DISPLAY THE FIRST AND LAST NAME OF THE CHILD. FOR "CASE ID", DISPLAY THE 

CASE ID OF THE CHILD.

Do you have a cold or a runny nose today?

HELP:

A COLD REFERS TO A DISORDER IN THE @UUPPER@U RESPIRATORY TRACT. IF THE CHILD IS NOT SURE IF 

HE HAS/HAD A COLD, PROBE FOR SYMPTOMS FROM THE @UNECK UP@U, SUCH AS:

•STUFFY NOSE OR HEAD

•SORE THROAT

•COUGH

•ALLERGIES SHOULD BE CODED AS A @UYES@U RESPONSE IF THEY INCLUDE ANY OF THESE SYMPTOMS.

PTQ002

DISPLAY INSTRUCTIONS:

QUESTION TEXT:

AT THE TOP OF THE SCREEN, DISPLAY:

"{NAME OF CHILD}, {CASE ID}"

FOR "NAME OF CHILD", DISPLAY THE FIRST AND LAST NAME OF THE CHILD. FOR "CASE ID", DISPLAY THE 

CASE ID OF THE CHILD.

Did you have a cold or a runny nose yesterday?

HELP:

A COLD REFERS TO A DISORDER IN THE @UUPPER@U RESPIRATORY TRACT. IF THE CHILD IS NOT SURE IF 

HE HAS/HAD A COLD, PROBE FOR SYMPTOMS FROM THE @UNECK UP@U, SUCH AS:

•STUFFY NOSE OR HEAD

•SORE THROAT

•COUGH

•ALLERGIES SHOULD BE CODED AS A @UYES@U RESPONSE IF THEY INCLUDE ANY OF THESE SYMPTOMS.

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Child Hearing Evaluation Questionnaire 3rd Grade: ECLS-K:2011 :: PTQ
CODES

1 YES

2 NO

REFUSED

DON'T KNOW

PTQ003

DISPLAY INSTRUCTIONS:

QUESTION TEXT:

HELP AVAILABLE

CODES

1 YES PTQ005

2 NO PTQ004

REFUSED PTQ004

DON'T KNOW PTQ004

AT THE TOP OF THE SCREEN, DISPLAY:

"{NAME OF CHILD}, {CASE ID}"

FOR "NAME OF CHILD", DISPLAY THE FIRST AND LAST NAME OF THE CHILD. FOR "CASE ID", DISPLAY THE 

CASE ID OF THE CHILD.

Have you had an earache today?

HELP TEXT:

Earache refers to any pain WITHIN the ear. It does not include pain on the external ear (e.g., recently pierced 

ears, cuts or sores on the external ear).

PTQ004

DISPLAY INSTRUCTIONS:

QUESTION TEXT:

HELP AVAILABLE

CODES

1 YES PTQ005

AT THE TOP OF THE SCREEN, DISPLAY:

"{NAME OF CHILD}, {CASE ID}"

FOR "NAME OF CHILD", DISPLAY THE FIRST AND LAST NAME OF THE CHILD. FOR "CASE ID", DISPLAY THE 

CASE ID OF THE CHILD.

Did you have an earache yesterday?

HELP TEXT:

Earache refers to any pain WITHIN the ear. It does not include pain on the external ear (e.g., recently pierced 

ears, cuts or sores on the external ear).

Page 2 of 7 2013-06-24 10:37

Child Hearing Evaluation Questionnaire 3rd Grade: ECLS-K:2011 :: PTQ
2 NO PTQ006

REFUSED PTQ006

DON'T KNOW PTQ006

PTQ005

DISPLAY INSTRUCTIONS:

QUESTION TEXT:

CODES

1 LEFT

2 RIGHT

3 BOTH

REFUSED

DON'T KNOW

AT THE TOP OF THE SCREEN, DISPLAY:

"{NAME OF CHILD}, {CASE ID}"

FOR "NAME OF CHILD", DISPLAY THE FIRST AND LAST NAME OF THE CHILD. FOR "CASE ID", DISPLAY THE 

CASE ID OF THE CHILD.

DISPLAY "LEFT" IN BOLD AND BLUE TEXT. DISPLAY "RIGHT" IN BOLD AND RED TEXT.

Which ear(s) hurt?

PTQ006

DISPLAY INSTRUCTIONS:

QUESTION TEXT:

HELP AVAILABLE

AT THE TOP OF THE SCREEN, DISPLAY:

"{NAME OF CHILD}, {CASE ID}"

FOR "NAME OF CHILD", DISPLAY THE FIRST AND LAST NAME OF THE CHILD. FOR "CASE ID", DISPLAY THE 

CASE ID OF THE CHILD.

Have you listened to sounds today that were so loud you would have to shout so someone close by could 

hear you?

HELP TEXT:

Sounds are considered “very loud” if either 

1) The child would have had to raise his voice to speak to someone an arm’s length away, or

2) The child’s ears were ringing or felt “funny” afterwards.

3) Examples of sounds that do NOT count: parents/teachers/children yelling, dogs barking, recess, school 

bells, sounds that last less than five minutes EXCEPT for firecrackers, gunfire, or other "impulse" type noises.

4) Examples of sounds that DO count: loud TV or radio, loud music, sporting events, motorbikes, 

lawnmowers, firecrackers, gunfire, or any "impulse" type noise.

Page 3 of 7 2013-06-24 10:37

Child Hearing Evaluation Questionnaire 3rd Grade: ECLS-K:2011 :: PTQ
CODES

1 YES PTQ008

2 NO PTQ007

REFUSED PTQ007

DON'T KNOW PTQ007

PTQ007

DISPLAY INSTRUCTIONS:

QUESTION TEXT:

HELP AVAILABLE

CODES

1 YES

2 NO

REFUSED

DON'T KNOW

AT THE TOP OF THE SCREEN, DISPLAY:

"{NAME OF CHILD}, {CASE ID}"

FOR "NAME OF CHILD", DISPLAY THE FIRST AND LAST NAME OF THE CHILD. FOR "CASE ID", DISPLAY THE 

CASE ID OF THE CHILD.

Did you listen to any sounds that were that loud yesterday? [Did you listen to any sounds yesterday that were 

so loud you would have to shout so someone close by could hear you?]

HELP TEXT:

Sounds are considered “very loud” if either 

1) The child would have had to raise his voice to speak to someone an arm’s length away, or

2) The child’s ears were ringing or felt “funny” afterwards.

3) Examples of sounds that do NOT count: parents/teachers/children yelling, dogs barking, recess, school 

bells, sounds that last less than five minutes EXCEPT for firecrackers, gunfire, or other "impulse" type noises.

4) Examples of sounds that DO count: loud TV or radio, loud music, sporting events, motorbikes, 

lawnmowers, firecrackers, gunfire, or any "impulse" type noise.

PTQ008

DISPLAY INSTRUCTIONS:

QUESTION TEXT:

AT THE TOP OF THE SCREEN, DISPLAY:

"{NAME OF CHILD}, {CASE ID}"

FOR "NAME OF CHILD", DISPLAY THE FIRST AND LAST NAME OF THE CHILD. FOR "CASE ID", DISPLAY THE 

CASE ID OF THE CHILD.

Do you have tubes in your ears now that a doctor put there [to keep you from getting earaches]?

Page 4 of 7 2013-06-24 10:37

Child Hearing Evaluation Questionnaire 3rd Grade: ECLS-K:2011 :: PTQ
CODES

1 YES PTQ010

2 NO PTQ012

REFUSED PTQ009

DON'T KNOW PTQ009

PTQ009

DISPLAY INSTRUCTIONS:

QUESTION TEXT:

CODES

1 YES PTQ011

2 NO PTQ012

REFUSED PTQ012

DON'T KNOW PTQ012

AT THE TOP OF THE SCREEN, DISPLAY:

"{NAME OF CHILD}, {CASE ID}"

FOR "NAME OF CHILD", DISPLAY THE FIRST AND LAST NAME OF THE CHILD. FOR "CASE ID", DISPLAY THE 

CASE ID OF THE CHILD.

Do you have to wear earplugs when you swim or take a bath or shower?

PTQ010

DISPLAY INSTRUCTIONS:

QUESTION TEXT:

CODES

1 LEFT PTQ012

2 RIGHT PTQ012

3 BOTH PTQ012

REFUSED PTQ012

DON'T KNOW PTQ012

AT THE TOP OF THE SCREEN, DISPLAY:

"{NAME OF CHILD}, {CASE ID}"

FOR "NAME OF CHILD", DISPLAY THE FIRST AND LAST NAME OF THE CHILD. FOR "CASE ID", DISPLAY THE 

CASE ID OF THE CHILD.

DISPLAY "LEFT" IN BOLD AND BLUE TEXT. DISPLAY "RIGHT" IN BOLD AND RED TEXT.

In which ear do you have the tube(s)?

Page 5 of 7 2013-06-24 10:37

Child Hearing Evaluation Questionnaire 3rd Grade: ECLS-K:2011 :: PTQ
PTQ011

DISPLAY INSTRUCTIONS:

QUESTION TEXT:

CODES

1 LEFT

2 RIGHT

3 BOTH

REFUSED

DON'T KNOW

AT THE TOP OF THE SCREEN, DISPLAY:

"{NAME OF CHILD}, {CASE ID}"

FOR "NAME OF CHILD", DISPLAY THE FIRST AND LAST NAME OF THE CHILD. FOR "CASE ID", DISPLAY THE 

CASE ID OF THE CHILD.

DISPLAY "LEFT" IN BOLD AND BLUE TEXT. DISPLAY "RIGHT" IN BOLD AND RED TEXT.

In which ear do you wear the earplug(s)?

PTQ012

DISPLAY INSTRUCTIONS:

QUESTION TEXT:

CODES

1 YES

2 NO BOX1

REFUSED BOX1

DON'T KNOW BOX1

AT THE TOP OF THE SCREEN, DISPLAY:

"{NAME OF CHILD}, {CASE ID}"

FOR "NAME OF CHILD", DISPLAY THE FIRST AND LAST NAME OF THE CHILD. FOR "CASE ID", DISPLAY THE 

CASE ID OF THE CHILD.

Is it easier for you to hear out of one ear than the other?

PTQ013

DISPLAY INSTRUCTIONS:

Page 6 of 7 2013-06-24 10:37

Child Hearing Evaluation Questionnaire 3rd Grade: ECLS-K:2011 :: PTQ
QUESTION TEXT:

CODES

1 LEFT

2 RIGHT

REFUSED

DON'T KNOW

AT THE TOP OF THE SCREEN, DISPLAY:

"{NAME OF CHILD}, {CASE ID}"

FOR "NAME OF CHILD", DISPLAY THE FIRST AND LAST NAME OF THE CHILD. FOR "CASE ID", DISPLAY THE 

CASE ID OF THE CHILD.

DISPLAY "LEFT" IN BOLD AND BLUE TEXT. DISPLAY "RIGHT" IN BOLD AND RED TEXT.

Which ear is easier to hear with?

BOX1

GO TO OTOSCOPE EXAM RESULTS SECTION.

Page 7 of 7 2013-06-24 10:37

Child Hearing Evaluation Questionnaire 3rd Grade: ECLS-K:2011 :: PTQ