Pediatric Clinical Research Center (PCRC)

Study Title:

Study Code (if known):

Principle Investigator:

Protocol Version Date:

Addendum for

Pediatric Clinical Research Center (PCRC)

Psychometry Services

Prior to submitting IRB Application, please complete PCRC Psychometry Services Application and email it to PCRC at . Upon receipt, the Lead Psychometrist will contact you to review your protocol, assist with budgeting for Psychometry Services and ensure that required resources can be accommodated.

Protocols involving the Bayley or Mullen Scales: Psychometry visits involving the Bayley Scales or Mullen Scales are strongly recommended to be videotaped for more accurate and quality scoring results. However, research participants have the option to decline recording the Psychometry session. The Lead Psychometrist will provide the appropriate consent verbiage needed for the IRB Application.

First expected visit date: / Last expected visit date:
Total number of Psychometry visits:
Total number of subjects requiring testing:
Age range of subjects:
Test administration schedule (e.g. Baseline, Month 12):
Data submission timeline is two weeks; please describe any alternate timeline request below.
Feedback letters required? ☐ No ☐ Yes If yes, provided to: ☐ Family ☐ PI ☐ Other:
Does study provide feedback letter template?
David Breiger, PhD provides oversight for PCRC Psychometry Services. Please list the name and title of the Consulting Psychologist if the study has made other arrangements for oversight:
Note: The PCRC requires the licensed Psychologist providing oversight to be readily available during Psychometry session.
Visit location: ☐ PCRC ☐ Other location:
Supplies needed: (only for studies utilizing PCRC Psychometry Services)
Note: The PCRC owns some tests (marked by asterisk on next page). Studies utilizing PCRC Psychometry Services have access to PCRC Psychometry supplies and scoring software. Studies may need to provide test materials, record forms and scoring software.
Additional PCRC Psychometry Services needs: ☐ No ☐ Yes
If yes, describe below and provide estimated time requirements for budgeting purposes.
Note: Study-specific time for trainings, certifications, meetings, conferences, pilot visits and development of feedback templates are charged at the current Psychometry Services rate.
Psychometry services needed for administration of the following measures. Note: If only selected subtests of a test will be administered, please list each subtest below:
☐ *Bayley Scales of Infant Development 3rd Edition (III)
☐ *Beery Developmental Test of Visual-Motor Integration (Beery VMI): ☐ 5th Edition or ☐ 6th Edition
☐ *Benton Facial Recognition Test
☐ *Benton Judgment of Line Orientation Test (JOLO)
☐ California Verbal Learning Test: ☐ *(CVLT-C) – Children’s Version or ☐ CVLT-II (ages 16+)
☐ *Connor’s Continuous Performance Test: ☐ Kiddie Version or ☐ CPT-II
☐ *Differential Ability Scales-II (DAS-II)
☐ *Delis-Kaplan Executive Function System (D-KEFS)
☐ *Eyes Test
☐ *Grooved Pegboard
☐ Hopkins Verbal Learning Test
☐ *Mullen Scales of Early Learning
☐ *NEPSY-II
☐ *Peabody Picture Vocabulary Test – 4th Edition (PPVT-4)
☐ *Vineland Adaptive Behavior Scales-II: ☐ Parent Report or ☐ Survey Interview
☐ *Wechsler Abbreviated Scale of Intelligence: ☐ (WASI) or ☐ WASI-II (Second Edition)
☐ *Wechsler Individual Achievement Test: ☐ Abbreviated (WIAT-IIA) or ☐ Full WIAT-II
☐ *Wechsler Intelligence Scale for Children: ☐ 4th Edition (WISC-IV) or ☐ 5th Edition (WISC-V)
☐ *Wechsler Adult Intelligence Scale – 4th Edition (WAIS-IV)
☐ *Wechsler Preschool & Primary Scale of Intelligence: ☐ 3rd Edition (WPPSI-III) or ☐ 4th Edition (WPPSI-IV)
☐ *Wide Range Achievement Test -4th Edition (WRAT-4)
☐ *Wide Range Assessment of Memory and Learning-2 (WRAML-2)
☐ *Wisconsin Card Sorting Test (WCST64)
☐ Woodcock-Johnson-III
* Indicates tests that the PCRC owns
Other measures not listed or other comments:

Version 10 Rev. 09.21.2015

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