# 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 Fif

th -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 i s 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, spec ifically their fear of negative evaluation by their peers. The exact wording of these items is not included here because they are copyright protecte d. 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 CL Q [Child Questionnaire ACASI]



## Child Questionnaire Sequence: 0 

## CLQG LB005

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

INAC TIVITY 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

CONF IRMATION 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: Page 1 of 21 2013-07-05 14:56 Child Questionnaire :: CLQYes. (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

CHAN GE 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

DISP LAY INSTRUCTIONS WHEN TOUCHED, THE CHILD'S ANSWER SELECTION SHOULD BE READ ON AUDIO AND VISUALLY EMPHASIZED. 

## CLQGLB030
Page 2 of 21 2013-07-05 14:56 Child Questionnaire :: CLQAUDIO I NSTRUCTIONS 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

ADMIN ISTRATION 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

RESPO NSE 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

Page 3 of 21 2013-07-05 14:56 Child Questionnaire :: CLQQUEST ION 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: POIN T 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: Hell o. Before we begin, let’s make sure the volume on the headphones is right for you. This is how loud it will Page 4 of 21 2013-07-05 14:56 Child Questionnaire :: CLQPROGRA MMER INSTRUCTIONS:

ENTER TEXT be w hen 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 y ou 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 Page 5 of 21 2013-07-05 14:56 Child Questionnaire :: CLQPROGRA MMER 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.

Page 6 of 21 2013-07-05 14:56 Child Questionnaire :: CLQPROGRA MMER 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 en joy 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

Page 7 of 21 2013-07-05 14:56 Child Questionnaire :: CLQQUEST ION 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 li ke 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 mak e 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 can not 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.

Page 8 of 21 2013-07-05 14:56 Child Questionnaire :: CLQPROGRA MMER 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 li ke 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

Page 9 of 21 2013-07-05 14:56 Child Questionnaire :: CLQQUEST ION 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 ge t 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 can not 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.

Page 10 of 21 2013-07-05 14:56 Child Questionnaire :: CLQPROGRA MMER 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 Othe r 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

Page 1 1 of 21 2013-07-05 14:56 Child Questionnaire :: CLQQUEST ION 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 li ke 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 hav e 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.

Page 12 of 21 2013-07-05 14:56 Child Questionnaire :: CLQPROGRA MMER 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 en joy 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

Page 1 3 of 21 2013-07-05 14:56 Child Questionnaire :: CLQQUEST ION 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 can not 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 en joy 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.

Page 14 of 21 2013-07-05 14:56 Child Questionnaire :: CLQPROGRA MMER INSTRUCTIONS: REFUSED DON'T KNOW DISPLAY ITEM AND RESPONSE OPTIONS. 

## CLQ180
QUESTION TEXT:

PROGRAMMER INSTRUCTIONS: CODES 1 Never 2 Ra rely 3 Sometimes 4 Often 5 Very often

REFUSED DON'T KNOW The n ext 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 Ra rely 3 Sometimes 4 Often 5 Very often

REFUSED DON'T KNOW Durin g 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. Page 1 5 of 21 2013-07-05 14:56 Child Questionnaire :: CLQ

## CLQ1 90

QUESTION TEXT:

PROGRAMMER INSTRUCTIONS: CODES 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very often

REFUSED DON'T KNOW Durin g 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 Ra rely 3 Sometimes 4 Often 5 Very often

REFUSED DON'T KNOW Durin g 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 tr y to cheer up other classmates who are upset or sad about something. Page 16 of 21 2013-07-05 14:56 Child Questionnaire :: CLQPROGRA MMER INSTRUCTIONS:

CODES 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very often

REFUSED DON'T KNOW Plea se 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 Ra rely 3 Sometimes 4 Often 5 Very often

REFUSED DON'T KNOW I he lp 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 Ra rely 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.

Page 17 of 21 2013-07-05 14:56 Child Questionnaire :: CLQPROGRA MMER 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 n ext 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.

Page 18 of 21 2013-07-05 14:56 Child Questionnaire :: CLQPROGRA MMER 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

Page 1 9 of 21 2013-07-05 14:56 Child Questionnaire :: CLQQUEST ION 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 Than k you for working with me. You are done answering questions on the computer. Please take off the headphones now.

Page 2 0 of 21 2013-07-05 14:56 Child Questionnaire :: CLQ

## CLQ28 5

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.

Page 21 of 21 2013-07-05 14:56 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 Fif

th -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. Page 1 of 7 2013-06-24 10:37 Child Hearing Evaluation Questionnaire 3rd Grade: ECLS-K:2011 :: PTQCODES

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 :: PTQ2 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 :: PTQCODES

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 :: PTQCODES

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)?

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## 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 :: PTQQUESTION 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.

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