This survey will help us determine if your child is eligible for a language development research study for toddlers. Today's date Today M-D-Y
Do you have a child between 21 and 31 months old?* must provide value
Yes
No
Is your child older or younger? * must provide value
My child is younger than 21 months old
My child is older than 32 months old
My child is younger than 21 months old
My child is older than 32 months old
What is the name of this child?* must provide value
What is ______ 's date of birth?* must provide value
M-D-Y
______ 's age in months (at time of survey) View equation
______ 's age today (in months) View equation
______ 's age in days (at time of survey) View equation
______ 's age today (in days) View equation
Must be at least 914 at T30_V1
______ 's gender* must provide value
Male
Female
How often does ______ hear English at home?* must provide value
Always
Often
Sometimes
Rarely
Never
Always
Often
Sometimes
Rarely
Never
What other spoken languages are used with ______ at home?* must provide value
Arabic
Bengali
Chinese
French
German
Hindi
Japanese
Javanese
Korean
Polish
Portuguese
Russian
Spanish
Tagalog
Vietnamese
Urdu
Other (write-in)
Arabic
Bengali
Chinese
French
German
Hindi
Japanese
Javanese
Korean
Polish
Portuguese
Russian
Spanish
Tagalog
Vietnamese
Urdu
Other (write-in)
What other language do you speak at home?* must provide value
How often does ______ hear a language other than English at home? * must provide value
Rarely (less than 25% of the time)
Sometimes (25-50% of the time)
Often (more than 50% of the time)
Always (100% of the time)
Rarely (less than 25% of the time)
Sometimes (25-50% of the time)
Often (more than 50% of the time)
Always (100% of the time)
Who uses a language other than English with ______ at home?* must provide value
Biological mother
Adopted mother or non-biological mother
Stepmother
Biological father
Adopted father
Stepfather
Grandmother
Grandfather
Other (write-in)
Biological mother
Adopted mother or non-biological mother
Stepmother
Biological father
Adopted father
Stepfather
Grandmother
Grandfather
Other (write-in)
What other person?* must provide value
Does ______ have any other condition or diagnosis (other than a language delay) that might influence his or her development? * must provide value
Yes
No
What condition or diagnosis?* must provide value
Autism Spectrum Disorder (ASD)
Blindness
Cancer
Cerebral palsy
Cleft lip/palate
Down syndrome
Global developmental delay
Hearing Loss
Motor speech disorder (apraxia, dysarthria)
Seizures
Stroke
Traumatic head injury
Other diagnosis or genetic conditions (write-in)
Autism Spectrum Disorder (ASD)
Blindness
Cancer
Cerebral palsy
Cleft lip/palate
Down syndrome
Global developmental delay
Hearing Loss
Motor speech disorder (apraxia, dysarthria)
Seizures
Stroke
Traumatic head injury
Other diagnosis or genetic conditions (write-in)
What has ______ been diagnosed with?* must provide value
Do you have concerns that ______ may have autism?* must provide value
Yes
No
2-year-olds typically : Use at least 50 words Start to use 2-word phrases to talk about/ask for things 2.5-year-olds typically : Use at least 100 words Use 2- and 3-word phrases to talk about/ask for things Do you have concerns about ______ 's speech or language development? * must provide value
Yes
No
Have you discussed your concern about ______ 's language development with your pediatrician?* must provide value
Yes
No
I don't have a pediatrician
Yes
No
I don't have a pediatrician
What was your pediatricians response when you expressed this concern? * must provide value
Does anyone in your family (related to ______ ) have (or had) a language delay? * must provide value
Yes
No
Have you sought an evaluation from a professional about your concerns regarding ______ 's language or communication development?* must provide value
Yes
No
Have you ever been told by a professional (doctor, therapist, teacher) that ______ has a language delay? * must provide value
Yes
No
Currently, is ______ receiving any therapy (through Early Intervention or privately)?* must provide value
Yes
No
Which therapies is ______ receiving through Early Intervention? * must provide value
Developmental Therapy
Occupational Therapy
Physical Therapy
Speech-language Therapy
Feeding Therapy
Developmental Therapy
Occupational Therapy
Physical Therapy
Speech-language Therapy
Feeding Therapy
Why is ______ receiving physical therapy?* must provide value
Please rate ______ 's progress in speech-language therapy* must provide value
Slower than expected
As expected
Faster than expected
Slower than expected
As expected
Faster than expected
Are you interested in checking up on your child's language development? * must provide value
Yes
No
Great!______ says and understands when ______ is 29 months old. Then we will send you a summary of how their language development compares to other children their age. Is ______ 's biological mother available and willing to participate in a study?Â
* must provide value
Yes
No
Not sure
Is English the first language that ______ 's biological mother learned as a child?
* must provide value
Yes
No
How old was she when she first learned English?
* must provide value
Less than a year old 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Older than 18
Was ______ 's biological mother born in the United States?
* must provide value
Yes
No
At what age did she move to the United States?
* must provide value
Less than a year old 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Older than 18
Older than 32 months View equation
It doesn't look like ______ is eligible for the research study at this time. It looks like ______ may be eligible! The information you share with us is completely confidential and will not be given to anybody outside of the study team. Saying "yes" will allow the research teams from The Early Intervention Research Group (EIRG) at Northwestern University and KidTalk at Vanderbilt University to do two things: 1. Contact you about participation in the research study
2. Send you a 30-minute screening survey about your child's language when you child is between 29-32 months old to see if your child is a good candidate for the study.
* must provide value
Yes, I'd like to learn more about my child's language and the research study
No, I don't want to
Yes, I'd like to learn more about my child's language and the research study
No, I don't want to
Would you like us to contact you about future research opportunities for you and your child?* must provide value
Yes No
Your permission to contact you in required for us to tell you more information about the study. Please select "yes" if you wish to provide us with some information about you and your child and for someone from the research team to reach out about your eligibility. Your first and last name* must provide value
What are your pronouns? She/her
He/him
They/them
No preference
Prefer not to answer
Other (write-in)
She/her
He/him
They/them
No preference
Prefer not to answer
Other (write-in)
Please share your pronouns
Phone number* must provide value
Email address* must provide value
Street address* must provide value
City* must provide value
* must provide value
Zip code* must provide value
Is there anything else you'd like to share with us about your family?
How did you hear about the research study?* must provide value
Physician/Pediatrician
Early Intervention (EI) therapist or service coordinator
Therapist (private therapist, not E.I.)
Facebook group or advertisement
Instagram
Word of mouth (friend, colleague, family)
Web search (like Google)
Nashville Parent Magazine
Vanderbilt University Study Finder
Other (write-in)
Physician/Pediatrician
Early Intervention (EI) therapist or service coordinator
Therapist (private therapist, not E.I.)
Facebook group or advertisement
Instagram
Word of mouth (friend, colleague, family)
Web search (like Google)
Nashville Parent Magazine
Vanderbilt University Study Finder
Other (write-in)
Early Intervention coordinator/therapist's name* must provide value
Name of group* must provide value
Who told you about the study?* must provide value
Therapist's name* must provide value
Pediatrician's name* must provide value
How did you hear about us?* must provide value
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