I. CHILD BEHAVIORS

SSQ, ECLSK, NEILS

1

2

3

I1. I am going to read you a list of statements and I want you to tell me how often CHILD acts this way. How often does CHILD.... READ EACH ITEM AND THEN ASK "Would you say Never, Sometimes, or Very Often?" CIRCLE THE APPROPRIATE CODE FOR EACH ITEM.

   

Never

Some

times

Very Often

DK

Ref

a.ssq

eclskl

*****

0

1

2

-1

-2

b. ssq

eclsk

*****

0

1

2

-1

-2

c. ssq

eclsk

*****

0

1

2

-1

-2

k ssq.

eclsk

*****

0

1

2

-1

-2

n. ssq eclsk

*****

0

1

2

-1

-2

d. ssq

*****

0

1

2

-1

-2

o. ssq eclsk

*****

0

1

2

-1

-2

e. ssq

*****

0

1

2

-1

-2

f. ssq

eclsk

*****

0

1

2

-1

-2

p. ssq eclsk

*****

0

1

2

-1

-2

q. ssq eclsk

*****

0

1

2

-1

-2

r. neils

Do things on his/her own even if it is hard

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1

2

-1

-2

i. ssq

*****

0

1

2

-1

-2

l. ssq

eclsk

*****

0

1

2

-1

-2

m. ssq eclsk

*****

0

1

2

-1

-2

g. ssq

eclsk

*****

0

1

2

-1

-2

h. ssq

*****

0

1

2

-1

-2

j. ssq

eclsk

*****

0

1

2

-1

-2

s. neils

Keep working at something until he/she is finished, even if it takes a long time

0

1

2

-1

-2

 

***** Note: These items are under copyright to American Guidance Service and cannot be publicly released. The SEELS implementation contract will purchase the use of the items from AGS.

 

1

2

3

I2. Children have a variety of strengths and interests. Would you say CHILD is particularly strong in any of the following areas: READ EACH ITEM, CIRCLE CORRECT RESPONSE FOR EACH ITEM

   

Yes

No

DK

Ref

a.

Athletic ability

1

2

-1

-2

b.

Performing arts ability, like music, theater or dance

1

2

-1

-2

c.

Mechanical ability, like building or fixing things

1

2

-1

-2

d.

Artistic ability, like drawing or sculpting,

1

2

-1

-2

e.

Creative writing, like writing poetry

1

2

-1

-2

f.

Leadership ability

1

2

-1

-2

g.

Computer use

1

2

-1

-2

h.

Being well organized

1

2

-1

-2

i.

Being sensitive to other peopleís feelings

1

2

-1

-2

j.

Having a sense of humor

1

2

-1

-2

CHECKPOINT: IF B1a= LEARNING DISABILITY (01), HEARING IMPAIRMENT (06), SPEECH IMPAIRMENT (04) OR EMOTIONAL DISTURBANCE (05) ONLY OR B1c=3 (PARENT SAYS NO DISABILITY) GO TO I4. ELSE ASK I3

 

NLTS

1

2

3

I3. How well does CHILD do each of the following things on his/her own, without help? READ STATEMENTS. CODE ONE RESPONSE FOR EACH. Would you say (he/she) does it very well, pretty well, not very well, not at all well
   

Very Well

Pretty Well

Not Very Well

Not At All Well

DK

Ref

a.

Dress himself/herself completely.

4

3

2

1

-1

-2

b.

Feed himself/herself completely

4

3

2

1

-1

-2

 

 

NLTS

1

2

3

I4. How well does CHILD do each of the following things on his her own, without help? READ STATEMENTS. CODE ONE RESPONSE FOR EACH. Would you say (he/she) does it very well, pretty well, not very well, not at all well?
   

Very Well

Pretty Well

Not Very Well

Not At All Well

Child not allowed

DK

Ref

a.

Tell time on a clock with hands

4

3

2

1

5

-1

-2

b.

Read and understand common signs, like STOP, MEN, WOMEN or DANGER.

4

3

2

1

5

-1

-2

c.

Count change

4

3

2

1

5

-1

-2

d.

Look up telephone numbers in the phone book and use the phone.

4

3

2

1

5

-1

-2

e.

Get places outside the home, like to school, to a nearby store or park, or to a neighborís house.

4

3

2

1

5

-1

-2

 

NLTS

1

2

3

I5. When the following chores need doing, about how often, on his/her own, does CHILD Ö READ STATEMENTS. CODE ONE RESPONSE FOR EACH. Would you always, usually, sometimes, or never?
   

Always

Usually

Sometimes

Never

DK

Ref

a.

Fix his/her own breakfast or lunch

4

3

2

1

-1

-2

b.

Do laundry

4

3

2

1

-1

-2

c.

Straighten up his her own room or living area

4

3

2

1

-1

-2

d.

Buy a few things at the store he/she needs

4

3

2

1

-1

-2

NLTS

1

2

3

I6. WAVE 1 AND CHILD IS 12 YEARS OR OLDER OR IF WAVE 2 OR 3 AND CHILD IS 12 YEARS OR OLDER AND HAS NOT BEEN ASKED IN PREVIOUS WAVE, ASK: Has (CHILD) ever been arrested? (CIRCLE ONE CODE)
WAVES 2 AND 3 AND CHILD IS 12 YEARS OR OLDER AND HAS BEEN ASKED IN PREVIOUS WAVE, ASK: Has CHILD been arrested in the past 2 years?

   

YES

1
   

NO

2
   

DONíT KNOW

-1
   

REFUSED

-2

 
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