Family Demographics Questionnaire
Date: Name of person completing form: Relationship to child:
Where did your child participate in research today? □ On campus in the ADDL
□ A researcher came to my home □ Online study only
□ At an ADDL sponsored event (please specify) □ Other (please specify)
Identification Information
Family Name:
Name of child in study: Date of birth:
Address: Gender of child: Male
Female
Please list both and check which form of contact is most preferred
Telephone: Email:
Background Information
Gender of your child Male Female
Please select handedness of your child: Left Right Does he/she wear glasses? Yes No
Is he/she colour blind? Yes No
Primary language spoken at home: Other language(s) spoken:
What is your child’s cultural or ethnic background? (E.g., Italian, Métis, Cantonese, English, Canadian):
Child’s parents are: (circle one) Married, Common Law, Divorced, Separated, Other With whom does the child live? (please list ALL members of the household)
Name Age Date of Birth Relationship (e.g., mother, brother, aunt)
If the child lives in more than one household at times, please describe the arrangement and the people involved:
Are there other family members who do not live in the home but who provide regular childcare assistance?: (please describe)
What is the primary employment status of the child’s parents? (please circle ONE answer for each parent)
Mother 1. Unemployed 2. Retired
3. Employed part time 4. Employed full time 5. Homemaker 6. Student 7. Other Father 1. Unemployed 2. Retired
3. Employed part time 4. Employed full time 5. Homemaker 6. Student 7. Other Occupation of Parents:
Mother: Father:
Approximate gross family income:
Less than $20,000 $20-49,999 $50-79,999
80-109,000 $110- 140,000 Greater than $140,000 What is the highest level of education of the child’s parents? (please circle ONE answer for each parent) Mother 1. Elementary School 2. High School 3. Professional Diploma 4. University Degree 5. Graduate Degree 6. Other Father 1. Elementary School 2. High School 3. Professional Diploma 4. University Degree 5. Graduate Degree 6. Other
Educational Information of Parents:
Mother: Father:
Diagnostic Information
Please check one or more of the following: Autism
Asperger’s Syndrome
PDD-NOS (Pervasive Developmental Disorder- Not Otherwise Specified) Other (Please state all)
No Diagnosis
Where was your child diagnosed? Professional who diagnosed him/her?
When was your child diagnosed (year and age)?
Do you receive funding from the Ministry of Children and Family Development? Yes No
Has your child been given any other diagnosis (E.g. ADHD, anxiety disorder, depression, learning difficulties, sleeping disorder)?
Yes No What?
Who diagnosed him/her? When was he/she diagnosed?
Does your child have any other medical conditions? (E.g. seizures, Tourette’s syndrome, etc.)
Yes No (if Yes, what are they?)
Does your child take any prescription medications regularly? Yes No (if Yes, please list)
Does your child participate in any type of therapy or tutoring program? (Please describe)
Do any family members other than the child participating experience significant medical problems, emotional problems, learning problems, mental health issues, or have a developmental disability?
Yes No (if Yes, please describe below)
Educational Information
Does your child attend school outside of the home? Yes No Current Grade: If no, please explain academic situation:
Please indicate whether this child has had any of the following school experiences: Has changed schools for reasons other than normal academic progression (E.g. elementary to high school) Yes No
If yes, when and why?
Is currently placed in a special education class Yes No If yes, what type of class?
Hours per day?
Receives extra help in school Yes No If yes, please describe
Social Information
Who does your child typically spend most of their free time with at school? (E.g., during lunch, breaks)
(Please circle one)
Alone Teacher(s) Peer(s) Close Friend(s) Don’t Know
*Please Note: If your child is homeschooled please answer the following question instead:
Who does your child typically spend free time with within their home-school program? Alone Parent(s) or Teacher(s) Peer(s) Close Friend(s) Don’t Know
Is your child part of a consistent social group at school? (E.g., hangs out with the same kids on a regular basis)
Yes No Don’t Know
*Please Note: If your child is homeschooled please answer the following question instead:
Is your child part of a consistent social within their home-school program? (E.g., hangs out with the same kids on a regular basis)
Yes No Don’t Know
How well do the following statements describe your child?
Please circle only one answer based on what is true most of the time for your child *Please Note: If your child is homeschooled please answer these questions based on your child in a home-school or extracurricular setting or other structured peer-based setting
Is liked by peers at school
Never Rarely Sometimes Often Almost Always Don’t Know Is considered “odd” or “weird” by peers at school
Never Rarely Sometimes Often Almost Always
Don’t Know
Gets along with his/her classmates
Never Rarely Sometimes Often Almost Always
Don’t Know Is teased or bullied at
school
Never Rarely Sometimes Often Almost Always
Don’t Know Is ignored by peers at
school
Never Rarely Sometimes Often Almost Always Don’t Know Is invited to parties/social events (outside of school) by kids his/her age
Never Rarely Sometimes Often Almost Always
Don’t Know
Attends parties/other social events with other kids
Never Rarely Sometimes Often Almost Always
Don’t Know
Friendships
How many acquaintances does your child have? (kids who he/she interacts with regularly at school/ extracurricular activity/church etc.)
0 1 2 3 4 5+
How many close friends does your child have? (kids who he/she knows well and spends time with outside of school/extracurricular activities)
0 1 2 3 4 5+
How often does your child spend time with a friend (in person) outside of school/ extracurricular activities?
(If it occurs at least once per week on a regular basis, indicate the number of days/week. If it occurs less often, indicate approximately how many times per month OR per year it occurs on average.)
Times per Week OR Times per Month OR Times
per Year
Does your child identify someone as their best friend?
Yes No Don’t Know
Does your child have a best friend? (someone who is approximately the same age that they see outside of school/extracurricular activities, and is a friendship in which both of them seek each other’s company and share similar interests/activities)?
Yes No Don’t Know
If you are unsure, please explain:
How often does your child spend time with a best friend (in person) outside of school/ extracurricular activities?
(If it occurs at least once per week on a regular basis, indicate the number of days/week. If it occurs less often, indicate approximately how many times per month OR per year it occurs on average.)
Times per Week OR Times per Month OR Times
per Year