Child Survey: Ages 3-5 Years - OhioGuidestone Research Portal

Electronic Agreement *

By checking this box, I agree to use electronic records and electronic signatures.

Access Code *

Date *

Person Completing Form *

Mom
Dad
Other

If other, please explain *

Form Number *

If other, please explain *

Questionnaire for Children 3-5 Years Old

Please read each statement carefully and answer for your child that is participating in the Joyful Play study. If you have more than one child participating, please complete one for each child. There are no right or wrong answers!

Select the answer that best fits: Never, Rarely, Occasionally, Frequently or Very Frequently

During the past 4 weeks, how often did your child:

Act in a way that made adults smile or show interest in him/her? *

Listen to or respect others? *

Control his/her anger? *

Seem sad or unemotional at a happy occasion? *

Show confidence in his/her abilities (for instance, say "I can do it")? *

Have a temper tantrum? *

Keep trying when unsuccessful (show persistence)? *

Seem uninterested in other children or adults? *

Use obscene gestures or offensive language? *

Try different ways to solve a problem? *

Seem happy or excited to see his/her parents or guardian? *

Destroy or damage property? *

Try or ask to try new things or activities? *

Show affection for familiar adults? *

Start or organize play with other children? *

Show patience? *

Ask adults to play with or read to him/her? *

Have a short attention span (difficulty concentrating)? *

Share with other children? *

Handle frustration well? *

Fight with other children? *

Become upset or cry easily? *

Show an interest in learning new things? *

Trust familiar adults and believe what they say? *

Accept another choice when his/her first choice was not available? *

Seek help from children/adults when necessary? *

Hurt others with actions or words? *

Cooperate with others? *

Calm himself/herself down? *

Get easily distracted? *

Make decisions for himself/herself? *

Appear happy when playing with others? *

Choose to do a task that was hard for him/her? *

Look forward to activities at home or school (for instance, birthdays or trips)? *

Touch children or adults in a way you thought was inappropriate? *

Show preference for a certain adult, teacher or parent? *

Play well with others? *

Remember important information? *

How was this form completed? *

In-Person
By Phone
Online
Mail-In