GNI Collabration GNA Data Entry AdministrationHealthStory Memory 1Story Memory 2Perceptual ComparisonDigit SpanStory Memory DelayAnimal NamingCategory SwitchingSpatial SpanPHQ-4Summary0% Complete1 of 12 Administration Instructions plus 3 minus3 Introduce yourself and say: I am helping a nonprofit organization develop tests of memory and other mental abilities. We need to test many people, and I would like you to participate. If you agree, it will take 15 to 20 minutes, but you may stop at any time. This will not help you, but it could help other people. Some people feel embarrassed by giving wrong answers. We do not want to embarrass you. We will take steps to keep all information about you private and not disclose any personal information about you to anyone outside our organization. Ask examinee: Do you agree to participate (or let your child/family member participate) in this project? Consent Consent: Yes No Consent signed? Not askedGiven by selfGiven by parentGiven by otherRevokedRefused Examiner Examiner name: Examinee number: Examinee number optional, as per examiner. Study Examinee is a: Healthy controlClinic patientResearch patientUnknown Location: Select StudyHopkins Baltimore Study Need to create a new study or group? Country Afghanistan Albania American Samoa Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belgium Benin Bermuda Bolivia Bosnia and Herzegovina Brazil Brunei Bulgaria Burkina Faso Burundi Guam Puerto Rico United Arab Emirates United States State/Province Date & Sex Preferred hand: MaleFemaleOther Preferred hand: Preferred hand: RightLeftMixed Age Test Date: Year of birth: year Month of birth: month 123456789101112 unknown Age: Years years Age: Months months Age Confidence Known Estimated Race Race (🗹 all that apply): White/European Black/African Asian Native/Aboriginal Other/Unknown Ethnicity Ethnicity: Hispanic Non-Hispanic Where examinee mainly lived before age 16: Urban Rural area Administration # Years of school completed: School Confidence Known Estimated GNA Form: 1 2 3 4 5 Language of Testing How many languages does examinee speak fluently? [SPSS 22] Language AfrikaansAlbanianAmharicArabicArmenianAzerbaijaniBasqueBelarusianBengaliBosnianBulgarianCatalanCebuanoChichewaChinese (Simplified)Chinese (Traditional)CorsicanCroatianCzechDanishDutchEnglishEsperantoEstonianFilipinoFinnishFrenchFrisianGalicianGeorgianGermanGreekGujaratiHaitianHausaHawaiianHebrewHindiHmongHungarianIcelandicIgboIndonesianIrishItalianJapaneseJavaneseKannadaKazakhKhmerKoreanKurdishKyrgyzLaoLatinLatvianLithuanianLuxembourgishMacedonianMalagasyMalayalamMalayMalteseMaoriMarathiMongolianMyanmar (Burmese)NepaliNorwegianPashtoPersianPolishPortuguesePunjabiRomanianRussianSerbianShonaSesothoSindhiSinhalaSlovakSlovenianSamoanScots GaelicSomaliSpanishSundaneseSwahiliSwedishTajikTamilTeluguThaiTurkishUkrainianUrduUzbekVietnameseWelshXhosaYiddishYorubaZuluOther Language How proficient is examinee in this language? Fully Proficient Partially Proficient [SPSS 21] Is this the examinee’s preferred language? Yes No If you are human, leave this field blank. Save and Next
