Brain-CODE demographic form |
What is the subject’s date of birth? |
DD/MMM/YYYY |
Brain-CODE demographic form |
What is the sex of the subject? |
Female
Male
Unknown
Unspecified
|
Brain-CODE demographic form |
What is the ethnicity of the subject? |
Aboriginal
Arab
Black
Chinese
East Asian
Filipino
Japanese
Jewish
Korean
Latin American/Hispanic
South Asian
Southeast Asian
West Asian
White
Other ethnic group
Do not know
Prefer not to answer
|
Brain-CODE demographic form |
What is the subject’s primary caregiver’s highest grade or level of school completed or the highest degree obtained? |
Associate degree: academic program
Bachelor’s degree (e.g.; BA; AB; BS; BBA)
Master’s degree (e.g.; MA; MS; MEng; MEd; MBA)
Professional school degree (e.g.; MD; DDS; DVM; JD)
Doctoral degree (e.g.; PhD; EdD)
Unknown
|
Brain-CODE demographic form |
What is the subject’s approximate total household income (from all sources) before taxes last year? |
Less than $10,000
$10,000–$24,999
$25,000–$49,999
$50,000–$74,999
$75,000–$99,999
$100,000–$149,999
$150,000–$199,999
$200,000 or more
Do not know
Prefer not to answer
|
Child’s sleep habits questionnaire (CSHQ) |
45 questions pertaining to sleep habits and possible difficulties with sleep |
Usually (5 or more times/week)
Sometimes (2–4 times/week)
Rarely (never or 1 time/week)
|
KINDL-R |
24 questions pertaining to child’s well-being and health-related quality of life |
Never
Seldom
Sometimes
Often
All the time
|
Revised children’s anxiety and depression scale (RCADS) |
47 questions pertaining to internalizing symptoms (anxiety and depression) of the child |
Never
Sometimes
Often
Always
|