Home Situations Questionnaire

Child’s Name:______________________________________Date:______________
Name of person completing this form: ___________________________________

Instructions: Does your child present any problems with compliance to

instructions, commands, or rules in any of these situations? If so, please circle the
word Yes and then circle a number beside the situation that describes how severe
the problem is for you. If your child is not a problem in these situations, circle No
and go on to the next situation on the form.

Situations Yes/No If yes, how severe?

(circle one) Mild (circle one) Severe
Playing alone Yes No 1 2 3 4 5 6 7 8 9
Playing with other Yes No 1 2 3 4 5 6 7 8 9
children
Mealtimes Yes No 1 2 3 4 5 6 7 8 9
Getting Yes No 1 2 3 4 5 6 7 8 9
dressed/undressed
Washing and bathing Yes No 1 2 3 4 5 6 7 8 9
When you are on the Yes No 1 2 3 4 5 6 7 8 9
telephone
When visitors are in your Yes No 1 2 3 4 5 6 7 8 9
home
When you are visiting Yes No 1 2 3 4 5 6 7 8 9
someone’s home
In public places Yes No 1 2 3 4 5 6 7 8 9
(restaurants, stores,
churches, etc)
When father is home Yes No 1 2 3 4 5 6 7 8 9
When asked to do chores Yes No 1 2 3 4 5 6 7 8 9
When asked to do Yes No 1 2 3 4 5 6 7 8 9
homework
At bedtime Yes No 1 2 3 4 5 6 7 8 9
When in the care Yes No 1 2 3 4 5 6 7 8 9
When with a babysitter Yes No 1 2 3 4 5 6 7 8 9
 Norms for the Home Situations Questionnaire

Age groups n Number of Mean Severity

Problem settings
Boys
4-5 162 3.1 (S.D.=2.8) 1.7 (S.D.=1.4)
6-8 205 4.1 (S.D.=3.3) 2.0 (S.D.=1.4)
9-11 138 3.6 (S.D.=3.3) 1.9 (S.D.=1.5)
Girls
4-5 146 2.2 (S.D.=2.6) 1.3 (S.D.= 1.4)
6-8 202 3.4 (S.D.=3.5) 1.6 (S.D.=1.5)
9-11 142 2.7 (S.D.=3.2) 1.4 (S.D.=1.4)