MarkVCID Neuropsychological Testing

Battery Worksheets
Version 2.0, Nov 2018
MarkVCID Consortium

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 MarkVCID
MoCA & Neuropsychological Testing Battery Worksheets

Table of Contents

MoCA Worksheets ............................................................................................................................................................... 2

Verbal Fluency – F-Word Worksheet ................................................................................................................................ 3
Craft Story 21 Recall (Immediate) Worksheets ............................................................................................................... 5
Number Span Test (Forward & Backward) Instructions & Worksheets ....................................................................... 8
Category Fluency Worksheets ......................................................................................................................................... 10
Trail Making A & B Worksheets ....................................................................................................................................... 12
Multilingual Naming Test (MINT) Worksheets ............................................................................................................... 18
Craft Story 21 Recall (Delayed) Worksheets ................................................................................................................. 52
Word List Learning with Immediate/Delay/Recognition Worksheets ......................................................................... 55
Clinical Dementia Rating Instructions & Worksheets ................................................................................................... 56
CDR (CLINICAL DEMENTIA RATING) .......................................................................................................................... 56
Section 1: Standard CDR .............................................................................................................................................. 56
Section 2: Supplemental CDR...................................................................................................................................... 57
Geriatric Depression Scale (GDS) Worksheet............................................................................................................... 58

Based in substantial part on the Uniform Data Set 3.0 Neuropsychological Battery of the National Alzheimer’s Coordinating Center. Reproduced with
Permission. Copyright 2006, 2008, 2015, 2017 University of Washington. Created and published by the ADC Clinical Task Force Copyright© 2006,
2008, 2015 University of Washington. Created and published by the ADC Clinical Task Force (John C. Morris, MD, Chair) and the National Alzheimer’s
Coordinating Center (U01 AG 016976 - Walter A. Kukull, PhD, Director).

The MarkVCID Consortium is funded by the National Institutes of Health through the National Institute of Neurological Disorders and Stroke and National
Institute on Aging (Cooperative Agreement U24NS100591)

Before using these worksheets, please read the

MarkVCID Evaluator’s Instructions Manual for the Neuropsychological Testing Battery.

Page 1 of 58
MoCA Worksheets
Corresponds with NACC Form C2 Neuropsychological Battery Scores (UDS 3)
Subject ID Date / / Examiner’s initials

Alzheimer’s Coordinating Center Uniform Data Set, copyright 2013 University of Washington.

Insert the score for each item in the MarkVCID e-Case Report Form MoCA (Montreal Cognitive Assessment)

Page 2 of 58
Verbal Fluency – F-Word Worksheet
Corresponds with NACC Form C2 Neuropsychological Battery Scores (UDS 3)

This is the response form to record all responses or F-word fluency on the MoCA. Instructions for verbal
fluency administration are included in the MoCA section of the MarkVCID Evaluator’s Instructions Manual.

Say: “Tell me as many words as you can think of that begin with a certain letter of the alphabet that
I will tell you in a moment. You can say any kind of word you want, except for proper nouns (like
Bob or Boston), numbers, or words that begin with the same sound but have a different suffix, for
example, love, lover, loving. I will tell you to stop after one minute. Are you ready? [Pause] Now, tell
me as many words as you can think of that begin with the letter F. [Time for 60 sec]. Stop.”
PROMPTS:
If the subject pauses for 15 seconds:
Say “Keep going.” – or – “What other words beginning with “F” can you think of?”
If the subject gives three consecutive words that do not start with the designated letter (provide this
prompt only once):
Say “We are now using the letter F.”

Complete the worksheet below and enter the scores here.

Record F responses:

1. 11. 21. 31.

2. 12. 22. 32.

3. 13. 23. 33.

4. 14. 24. 34.

5. 15. 25. 35.

6. 16. 26. 36.

7. 17. 27. 37.

8. 18. 28. 38.

9. 19. 29. 39.

10. 20. 30. 40.

SCORING Number of correct F-words generated in 1 minute (0–40)

Number of F-words repeated in 1 minute (0–15)

Number of non-F-words and rule violation errors in 1 minute (0–15)

If number of correct F-words in 1 minutes is greater than or equal to 11, enter 1 on MarKVCID e-Case Report Form MoCA #12, otherwise enter 0.
Insert the three additional scores in the MarkVCID e-Case Report Form NP Testing Battery #6b-d.

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 Rules for single-item scoring and index score calculations for the MoCA*

INDEX SCORES
Points
Attention/
ITEMS towards total Memory*** Executive Language Visuospatial Orientation
concentration
score

Trails 1 – 1 – – –

Cube 1 – – – – 1 –

Clock Circle 1 – 1 – – 1 –

Clock Hands 1 – 1 – – 1 –

Clock Time 1 – 1 – – 1 –

Language Naming 3 – – – 3 3 –

Memory: Registration (2
Immediate recall, 2
learning trials, total 0, not scored – – – – –
trials total, max=10
possible = 10)

Attention: Digits 2 – 2 2 – – –

Attention: Letter A 1 – 1 1 – – –

Attention: Serial 7s 3 – 3 3 – – –

Language: Repetition 2 – – 2 2 – –

Language: Fluency 1 – 1 – 1 – –

Abstraction 2 – 2 – – – –

=3x number words recalled

Delayed Recall with no cue 5 – – – – –
freely (max=15)

=2x number of words

Delayed Recall with
0** retrieved with category cue – – – – –
category cue
(max=10)

=1x number of words

Delayed Recall, recognition 0** – – – – –
recognized (max=5)

Orientation: date 1 – – – – – 1

Orientation: month 1 – – – – – 1

Orientation: year 1 – – – – – 1

Orientation: day 1 – – – – – 1

Orientation: place (name) 1 – – – – – 1

Orientation: city 1 – – – – – 1

Totals 30 15 13 18 6 7 6

*©Ziad Nasreddine MD 2004. MoCA® is a registered trademark property of Neurosearch Développements Inc. and is used under license. Form created as
part of the National Alzheimer’s Coordinating Center Uniform Data Set, copyright 2013 University of Washington.

**The standard administration of the MoCA does not score category and recognition responses, even if administered.

***If all five words are freely recalled, then cued and category recall are not administered and the total score would be 15 (3 points for each word recalled).
After free recall, category cues are given only for items not recalled. Each word correct with category cue is awarded 2 points. After category cues, only words
not correct are then tested with recognition. Award 1 point for each word correct on recognition (max=5).
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Craft Story 21 Recall (Immediate) Worksheets
Corresponds with NACC Form C2 Neuropsychological Battery Scores (UDS 3)

Subject ID Date / / Examiner’s initials

INSTRUCTIONS: Making sure you have the participant’s attention and read the following instructions aloud. Then read
the story slowly, articulating clearly and with normal inflection.
SAY: “I am going to read you a story. Listen carefully, and when I am through, I want you to tell me everything you can
remember. Try to use the same words I use but you may also use your own words. The story is …”

Maria’s / child / Ricky / played / soccer / every / Monday /

at 3:30. / He / liked / going / to the field / behind / their / house /

and joining / the game. / One / day, / he / kicked / the ball / so / hard /

that it / went / over / the neighbor’s / fence / where three / large /

dogs / lived. / the dogs’ / owner / heard / loud / barking, / came /

out, / and helped / them / retrieve / the ball.

Record time administration ended:

Total story units recalled (VERBATIM SCORING): / 44
Total story units recalled (PARAPHRASE SCORING): / 25

Insert the score in the MarkVCID e-Case Report Form NP Testing Battery #1b,c Craft Story 21 recall (immediate)

As soon as the story is over, give the recall instruction:

SAY: “Now tell me the story I just told you. Try to remember as much as you can.”
Record the participant’s recall, writing between the lines of the story above. For rapid and accurate transcribing of the
story, use abbreviations as needed, omit filler words and irrelevant verbiage, and if absolutely necessary, say “A little
slower, please,” rather than miss story elements. Make sure your transcription of the story is legible before
proceeding.
After transcribing the story, you must give the delayed recall cue.
SAY: “Later on, I will ask you to tell me this story again, so try not to forget it.” Note the time so that later you can
calculate the time that has elapsed between Craft Story 21 Recall (Immediate) test and the Craft Story 21 Recall
(delayed) test.
Reproduced by permission of the author, Suzanne Craft, PhD; do not copy or distribute without author’s permission. Form created as part of the
Uniform Data Set of the National Alzheimer’s Coordinating Center, copyright ©2013 University of Washington.

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Craft Story 21 RECALL (Immediate): Verbatim SCORING

PERFECT VERBATIM RESPONSE (1.0 POINT): Give the subject 1 point for every part for which
content words are recalled exactly and completely. Allowances can be made for variations of verbs (e.g.,
“likes” for “liked,” “join” for “joining”) and minor omissions (e.g., “neighbor” for “neighbor’s”) or changes in
number (e.g., “games” for “game”). The content words do not need to be recalled by the subject in the same
order they were read to receive credit. The words can appear anywhere in the recall.

Maria’s hard

child it

Ricky went

played over

soccer neighbor’s

every fence

Monday three

three thirty large

he dogs

liked lived

going dogs’

field owner

behind heard

their loud

house barking

joining came

game out

one helped

day them

retrieve
he
ball
kicked

ball
Total
so

SCORING

Number of items recalled for verbatim scoring: Immediate Recall Score: /44 maximum

Insert the score in the MarkVCID e-Case Report Form NP Testing Battery #1b Craft Story 21 recall (immediate)

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GUIDELINES FOR PARAPHRASE SCORING, Craft Story 21

Item General rule Alternative 1-point responses 0-point responses Points

“Maria” or a variant of the
Maria’s Mary, Marie Martha, Anna
name
“child” or a phrase denoting it
child son, kid, boy, teenager, young man guy, children, daughter
was a young person
“Ricky” or a variant of the Rick, Rich, Richie, Richard,
Ricky Randy, Rusty, Robert
name Ricardo

played “played” is required to play, plays did (soccer)

baseball, volleyball, other

soccer “soccer” is required futbol
sport
“Monday” or an indication that it every day, another day of the
every Monday —
occurred on a weekday week
an indication that the activity took after dinner, at night, in
at 3:30 after school, every afternoon
place in the afternoon the morning
He liked going to an indication that he went to an went outside, went to the yard, going to
went to the school, gym
the field outdoor area the backyard
behind their house “house” or word denoting a house
home, residence, where they lived any other building

an indication that he played w/ other kids, became part of watching, played in the park
and joining
participated in a game the team, playing w/ the team

the game. “game” in any context — —

One day “One day” is required — —

indication that he performed the threw, hit (with no mention of

he kicked booted, punted
activity with his foot the foot)

the ball “Ball” is required football, soccer ball baseball, volleyball

an indication that force was used so much force, so strongly, (kicked it)
so hard —
so far

that it went over “Over” is required — —

an indication that the person lived

the neighbor’s nearby resident friend’s
in the same area
“fence” or a word denoting a
fence garden wall, wall property line, street
fence of some kind

where three “Three” is required three (boys) —

an indication that there were dogs puppies, cats, kittens, other

large dogs lived. hounds, doggies
present animals
an indication that the person was neighbor (if owner implied and
the dogs’ owner a bystander, the police
responsible for the dogs “neighbor” mentioned twice)
heard loud an indication that the dogs were yelping, baying, yapping, heard the dogs saw the dogs running around
barking making noise
a word or phrase indicating that his mother came out, the
came out (owner) saw the ball
the owner was present dogs came out
a word or phrase indicating that
and helped them assisted, aided, had to help —
help was provided
an indication that they got the gave him the ball, return the ball,
retrieve the ball.
ball back (helped him) get the ball —

Number of items recalled for paraphrase scoring: Immediate Recall Score: /25 maximum

Insert the score in the MarkVCID e-Case Report Form NP Testing Battery #1c Craft Story 21 recall (immediate)

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Number Span Test (Forward & Backward) Instructions & Worksheets
Corresponds with NACC Form C2 Neuropsychological Battery Scores (UDS 3)

Subject ID Date / / Examiner’s initials

Number Span Test: Forward

SAY: “I am going to ask you to repeat some numbers for me. Wait until I finish saying the
numbers and then repeat them in the same order. For example, if I say 1 – 8 – 7, you would say
1– 8 – 7. If I say 2 – 9 – 8, what would you say?” If the subject gives the wrong answer, say,
“Actually, you would say 2 – 9 – 8.”
SAY: “Repeat only the numbers I say each time.” Then start with the test items. Read each item at a
pace of 1 number per second.

Before each item, say, “Ready?”

Stop testing after two consecutive failures of the same span length.
Response code
Span incorrect = 0
length Response correct = 1
1- 8 - 4
3 2 -7- 9

4 -1- 6 - 2
4 8 - 1- 9 - 5

6-4-9-2-8
5 7-3-8-6-1

3-9-2-4-7-5
6 6-2-8-3-1-9

9-6-4-7-1-5-3
7 7-4-9-2-6-8-1

4-7-2-5-8-1-3-9
8 2-9-5-7-3-6-1-8

6 - 8 - 4 - 1- 9 - 3 - 5 - 2 - 7
9 1 - 3 - 9 - 2 - 7- 5 - 8 - 6 - 4

Total correct:

Length of longest correct series:

Reproduced by permission of the author, Joel Kramer, PsyD; do not copy or distribute without author’s permission. Form created as part of the Uniform Data
Set of the National Alzheimer’s Coordinating Center, copyright ©2013 University of Washington.

Insert the score in the MarkVCID e-Case Report Form NP Testing Battery #3 Number Span test – Forward.

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Subject ID Date / / Examiner’s initials

Number Span Test: Backward

SAY: “I am now going to ask you to repeat some numbers for me but to reverse them from the
way I say them. Wait until I finish saying the numbers and then repeat them in reverse order, or
backward. For example, if I say 3-7-4, you would say 4-7-3. If I say 7-3-6, what would you say?” If
the subject gives the wrong answer, say, “Actually, you would say 6-3-7.”
SAY: “Repeat only the numbers I say each time, backward, in reverse order.” Then start with the
test items. Read each item at a pace of 1 number per second. Before each item, say, “Ready?”
Stop testing after two consecutive failures of the same span length

Response code
Span incorrect = 0
length Response correct = 1

2-5
2 4-7

2-9-6
3 3-7-4

7-1-8-6
4 5-1-6-3

5-2-4-9-1
5 9-1-7-3-6

6-8-5-7-9-2
6 8-1-6-3-5-9

1-5-2-9-7-3-8
7 7-3-1-6-8-5-2

3-6-4-9-5-2-7-1
8 6-3-5-7-1-8-2-9

Total correct:

Length of longest correct series:

Reproduced by permission of the author, Joel Kramer, PsyD; do not copy or distribute without author’s permission. Form created as part of the Uniform Data Set of the
National Alzheimer’s Coordinating Center, copyright ©2013 University of Washington.

Insert the score in the MarkVCID e-Case Report Form NP Testing Battery #4 Number Span test – Backward.

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Category Fluency Worksheets
Corresponds with NACC Form C2 Neuropsychological Battery Scores (UDS 3)

Subject ID Date / / Examiner’s initials

Category Fluency
INSTRUCTIONS SAY: “I am going to give you a category and I want you to name, as fast as you
can, all of the things that belong in that category. For example, if I say ‘articles of clothing,’ you
could say ‘shirt,’ ‘tie,’ or ‘hat.’ Can you think of other articles of clothing?”
Allow up to 20 seconds for the subject to produce two responses. Circle the number
corresponding to the subject’s responses, and read the associated instruction.

Response code Instruction

0 (No response) “You could have said ‘shoes’ or ‘coat’ since they are articles of clothing.”
(One or more incorrect responses, no “No, is (are) not an article(s) of clothing. You could have said ‘shoes’ or
1
correct response) ‘coat’ since they are articles of clothing.”
(One or more correct response, no
2 “That’s right. You also could have said ‘shoes’ or ‘coat’.”
incorrect responses)
(One or more correct responses, one “ is (are) correct, but is (are) not an article of clothing. You also
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or more incorrect responses) could have said ‘shoes’ or ‘coat’.”
4 (Two or more correct responses) “That’s right.”

Next, read the instructions for the Animals category (worksheet follows this instruction page):
SAY: “Now I want you to name things that belong to another category: Animals.
You will have one minute. I want you to tell me all the animals you can think of in
one minute. Ready? Begin.”

Start timer as you say “Begin.” Write actual responses as legibly as possible on the
Worksheet for Category Fluency — Animals. Stop the procedure at 60 seconds. One
prompt (“tell me all the animals you can think of”) is permitted if the participant makes
no response for 15 seconds or expresses incapacity (e.g., “I can’t think of any more”). It is
also permissible to repeat the instruction or category if the subject specifically requests it.

Insert the score in the MarkVCID e-Case Report Form NP Testing Battery #5 Category Fluency – Animals.

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Worksheet for Category Fluency — Animals

1. 27. 53.

2. 28. 54.

3. 29. 55.

4. 30. 56.

5. 31. 57.

6. 32. 58.

7. 33. 59.

8. 34. 60.

9. 35. 61.

10. 36. 62.

11. 37. 63.

12. 38. 64.

13. 39. 65.

14. 40. 66.

15. 41. 67.

16. 42. 68.

17. 43. 69.

18. 44. 70.

19. 45. 71.

20. 46. 72.

21. 47. 73.

22. 48. 74.

23. 49. 75.

24. 50. 76.

25. 51. 77.

26. 52.

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Trail Making A & B Worksheets
Corresponds with NACC Form C2 Neuropsychological Battery Scores (UDS 3)

Subject ID Date / / Examiner’s initials

Trail Making Test

Part A
Place the form for SAMPLE A in front of the subject. Read aloud the instructions:
SAY: “There are numbers in circles on this page. Please take the pencil and draw
a line from one number to the next, in order. Start at 1 [point to the number], then
go to 2 [point to the number], then go to 3 [point to the number] and so on.
Please try not to lift the pencil as you move from one number to the next. Work
as quickly as you can. Begin here [point to “Begin” number] and end here [point to
“End” number].”

If the subject makes an error, mark through the line and go back to the point at which
the error was made and say, for example, “You were at number 2. What is the next
number?” Wait for the subject’s response. If the subject indicates 3, say “Please start
here [point to the 2] and continue.” If the subject indicates any other number, say
“the next number would be 3.” Then point to 2 and say “Please start here and
continue.” If the subject cannot complete the sample and clearly does not
comprehend the task, do not administer Test.

A. In that event, on the recording form enter the appropriate code (996 = cognitive/ behavioral
problem).

If the subject completes the sample, go to TEST A.

SAY: “On this page there are more numbers in circles. Please take the pencil and
draw a line from one circle to the next, in order. Start at 1 [point to “Begin” number]
and end here [point to “End” number]. Please try not to lift the pencil as you move
from one circle to the next. Work as quickly as you can.” Start timing as soon as the
instruction is given to begin.

NOTE: In giving the instructions for the test form (as opposed to the sample), the
examiner tells the subject to move from one circle to the next and does not use the
word “number.”

If the subject makes an error, mark through the line and say “that one was not
correct.” Point to the last correct number and say “Please start here and
continue.” This is done for each error. The examiner should attempt to provide
corrections as quickly as possible. Stop timing when the Trail is completed, or stop
subject when the maximum time is reached. Allow a maximum of 150 seconds for
the test.

Part B
Place the form for SAMPLE B in front of the subject. Present the sample for Part B even if
the subject failed the sample for Part A. Read aloud the instructions:

SAY: “there are numbers and letters in circles on this page. Please take the
pencil and draw a line, alternating in order between the numbers and letters.
12
 Start at number 1 [point to the number], then go to the first letter, A [point to the
letter], then go to the next number, 2 [point to the number], and then the next letter,
B [point to the letter], and so on. Please try not to lift the pencil as you move from
one number or letter to the next. Work as quickly as you can.”

If the subject makes an error, mark through the line and go back to the point at which
the error was made and say, for example, “You were at number 2. What is the next
letter?” Wait for the subject’s response. If it is correct, say “Please start here [point to
the 2] and continue.” If the subject picks the wrong item, say “the next letter would
be B [point to the B].” Then point to the 2 and say “Please start here and continue.”
If the subject cannot complete the sample and clearly does not comprehend the task,
do not administer the test. Enter the appropriate code (996 = cognitive/behavioral
problem).

If the subject completes the sample correctly, go to TEST B.

SAY: “On this page, there are more numbers and letters in circles. Please take
the pencil and draw a line from one circle to the next, alternating in order
between the numbers and letters. Start at 1 [point to the “Begin” number] and end
here [point to the “End” number]. Please try not to lift the pencil as you move
from one circle to the next. Work as quickly as you can.” Start timing as soon as
the instruction is given to begin.

NOTE: In giving the instructions for the test form (as opposed to the sample), the
examiner tells the subject to move from one circle to the next and does not use the
words “number” or “letter.”

If the subject makes an error, mark through the line and say, “that one was not
correct.” Point to the last correct item and say, “Please start here and continue.”
This is done for each error. Do not indicate whether the next item should be a number
or a letter. The examiner should attempt to provide corrections as quickly as possible.
Stop timing when the Trail is completed, or stop subject when the maximum time is
reached. Allow a maximum of 300 seconds for the test.

Insert the score in the MarkVCID e-Case Report Form NP Testing Battery Trail Making Test A (#7) and B (#8).

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Multilingual Naming Test (MINT) Worksheets
Corresponds with NACC Form C2 Neuropsychological Battery Scores (UDS 3)

Subject ID Date / / Examiner’s initials

MINT (Multilingual Naming Test)

Instructions and Cueing

SAY: “I am going to show you some pictures of objects, one at a time. Please tell me the
name of each object, that is, tell me what it is called. If you cannot think of the name try to
make your best guess. If you don’t know what the object is, I will try to help you. Do you
have any questions?”

Stop testing after six consecutive failures.

Uncued Semantic cue Phonemic cue

Item # English Semantic cue Spontaneous response(s) correct correct incorrect correct incorrect
1 Butterfly an insect

2 Glove an article of clothing

3 Lightbulb used to see better and

is turned on
electrically
4 Watch used to tell the time

5 Candle is used in the dark to

make light
6 Clown found in a circus

7 Kite a toy that uses the

wind to make it fly
8 rainbow it's colorful and is
found in the sky after it
rains
9 Witch a woman with
magical powers
10 Seesaw found on a playground

11 Flashlight used to see better and

is battery- operated

a bird
12 Peacock

an animal
13 Snail

an ocean animal
14 Whale

15 Cage an enclosure for

animals
16 nest it's where birds lay
their eggs

From A multilingual Naming Test, Tamar H. Gollan, PhD; reproduced by permission. Do not copy or distribute without author’s permission. Form created as part of
the Uniform Data Set of the National Alzheimer’s Coordinating Center, copyright ©2013 University of Washington

18
 Uncued Semantic cue Phonemic cue
Item # English Semantic cue Spontaneous Response(s) correct correct incorrect correct incorrect
17 Plug found on electronic
devices

18 Wig it's worn on the head

19 Screw it's like a nail but it

grooves into wood or a
wall
20 Scarf clothing worn on the
neck

21 Well used to obtain water

22 Dustpan used to remove dust

and trash
23 Pa rachute used to jump from
airplane
24 Blind used to block out
light

25 Hinge part of a door

26 Funnel used for pouring

liquid from one
container to another
27 Gauge used to measure air
pressure

28 Porthole found on a ship

used for shaping

29 Anvil
metal

30 Mortar used to grind different

substances
31 Pestle used to grind different
substances
32 Axle a supporting shaft on
which wheels revolve

SCORING:

1.0 point for each correct answer under Uncued or Semantic columns, 0.0 points for correct answer under
Phonemic column

a. Total correct without a cue (“Uncued” column):

b. Total correct with a semantic cue given (“Semantic” column):

c. Total correct (sum of a + b, maximum of 32):

Insert the score in the MarkVCID e-Case Report Form NP Testing Battery #9 Multilingual Naming Test

19
 MiNT
Multilingual Naming Test
For speakers of English, Spanish, Mandarin, Hebrew, or any
combination of these languages
Address for correspondence: [email protected]
Ivanova, I., Salmon, D.P., & Gollan, T.H. The Multilingual Naming Test in Alzheimer’s disease: Clues to the origin of naming
impairments. The Journal of the International Neuropsychological Society, 2013; 19:272-283.

Gollan, T.H., Weissberger, G., Runnqvist, E., Montoya, R.I., & Cera, C.M. (2012) Self- ratings of spoken language
dominance: A multi-lingual naming test (MINT) and preliminary norms for young and aging Spanish-English bilinguals.
Bilingualism: Language and Cognition, 15, 594-615.

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Craft Story 21 Recall (Delayed) Worksheets
Corresponds with NACC Form C2 Neuropsychological Battery Scores (UDS 3)

Subject ID Date / / Examiner’s initials

Craft Story 21 Recall (Delayed)

Instructions: Administer this test approximately 20 minutes after Craft Story 21 Recall
(Immediate), making note of the time administration of Craft Story 21 Recall (Delayed) began. NOTE:
If 20 minutes have not elapsed, do not add other tests to fill the interval. You may obtain other data, such
as blood pressure, weight, etc. Administer Craft Story 21 Recall (Delayed) and record the actual
time elapsed.

SAY: “I read you a story a few minutes ago. Can you tell me what you remember about that story now?
If the subject does not recall the story or having been told a story, make a note as indicated below
and SAY: “It was a story about a boy. Can you tell it to me now?”

Maria’s / child / Ricky / played / soccer / every / Monday /

at 3:30. / He / liked / going / to the field / behind / their / house /

and joining / the game. / One / day, / he / kicked / the ball / so / hard /

that it / went / over / the neighbor’s / fence / where three / large /

dogs / lived. / the dogs’ / owner / heard / loud / barking, / came /

out, / and helped / them / retrieve / the ball.

Record time administration began:

Total story units recalled (VERBATIM SCORING): / 44
Total story units recalled (PARAPHRASE SCORING): / 25

Time elapsed since Craft Story 21 Recall (Delayed): __________ minutes

Cue (“boy”) needed: ___ No ___ Yes

Reproduced by permission of the author, Suzanne Craft, PhD; do not copy or distribute without author’s permission. Form created as part of the
Uniform Data Set of the National Alzheimer’s Coordinating Center, copyright ©2013 University of Washington

Insert the score in the MarkVCID e-Case Report Form NP Testing Battery #2b-e Craft Story 21 recall (delayed)

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 CRAFT STORY 21 RECALL (DELAYED): VERBATIM SCORING

Maria’s so

child hard

Ricky it

played went
soccer over
every neighbor’s
Monday fence
three thirty three
he large

liked dogs

going lived

field dogs’

behind owner

their heard

house loud

joining barking

game came

one out

day helped

he them

kicked retrieve
ball
ball
TOTAL

Number of items recalled for verbatim scoring: Delayed Recall Score ________/44 maximum

Insert the score in the MarkVCID e-Case Report Form NP Testing Battery #2b Craft Story 21 recall (delayed)

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GUIDELINES FOR PARAPHRASE SCORING, CRAFT STORY 21

Item General rule Alternative 1-point responses 0-point responses Points

“Maria” or a variant of the
Maria’s Mary, Marie Martha, Anna
name
“child” or a phrase denoting it was
child son, kid, boy, teenager, young man guy, children, daughter
a young person
“Ricky” or a variant of the Rick, Rich, Richie, Richard,
Ricky Randy, Rusty, Robert
name Ricardo

played “played” is required to play, plays did (soccer)

baseball, volleyball, other sport

soccer “soccer” is required futbol

“Monday” or an indication that it every day, another day of the

every Monday —
occurred on a weekday week
an indication that the activity took after dinner, at night, in the
at 3:30 after school, every afternoon
place in the afternoon morning
He liked going to an indication that he went to an went outside, went to the yard, going to
went to the school, gym
the field outdoor area the backyard
behind their house “house” or word denoting a house
home, residence, where they lived any other building

an indication that he played w/ other kids, became part of the watching, played in the park
and joining
participated in a game team, playing w/ the team

the game. “game” in any context — —

One day “One day” is required — —

indication that he performed the threw, hit (with no mention of

he kicked booted, punted
activity with his foot the foot)

the ball “Ball” is required football, soccer ball baseball, volleyball

an indication that force was used so much force, so strongly, (kicked it) so
so hard —
far

that it went over “Over” is required — —

an indication that the person lived

the neighbor’s nearby resident friend’s
in the same area
“fence” or a word denoting a fence
fence garden wall, wall property line, street
of some kind

where three “Three” is required three (boys) —

an indication that there were dogs puppies, cats, kittens, other

large dogs lived. hounds, doggies
present animals
an indication that the person was neighbor (if owner implied and “neighbor”
The dogs’ owner a bystander, the police
responsible for the dogs mentioned twice)
heard loud an indication that the dogs were yelping, baying, yapping, heard the dogs saw the dogs running around
barking making noise
a word or phrase indicating that the his mother came out, the
came out (owner) saw the ball
owner was present dogs came out
a word or phrase indicating that
and helped them assisted, aided, had to help —
help was provided
an indication that they got the ball gave him the ball, return the ball,
retrieve the ball.
back (helped him) get the ball —

Number of items recalled for paraphrase scoring: Delayed Recall Score: ____/25 maximum

Insert the score in the MarkVCID e-Case Report Form NP Testing Battery #2c (craft story 21 recall, delayed)

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Word List Learning with Immediate/Delay/Recognition Worksheets
(Corresponds with CVLT, CVLT-SF, HVLT, SEVLT (SPANISH)

This manual does NOT contain administration and scoring instructions for the
CVLT, CVLT-SF, HVLT, or SEVLT.
Please contact your site neuropsychologist or psychometrician for additional instructions specific to
your site’s practices.

Insert each score in the MarkVCID e-Case Report Form NP Testing Battery, item #10 (word list learning with immediate/delay/recognition).

55
 Clinical Dementia Rating Instructions & Worksheets
Corresponds with NACC Form B4 (UDS 3)
This form is to be completed by the clinician or other trained health professional, based on co -participant report and behavioral
and neurological exam of the subject. In the extremely rare instances when no co-participant is available, the clinician or other
trained health professional must complete this form using all other available information and his/her best clinical judgment. Score
only as decline from previous level due to cognitive loss, not impairment due to other factors, such as physical disability.

SECTION 1: Standard CDR

CDR (CLINICAL DEMENTIA RATING)

Was the CDR administered? No Yes

If No, please provide the primary reason: Physical problem Verbal refusal
Cognitive/behavior problem Other problem (specify): _________________________________________________________

Date of Evaluation: ___ ___ / ___ ___ / ___ ___ ___ ___ (MM/DD/YYYY)

Section 1: Standard CDR

IMPAIRMENT
Please enter
Questionable –
score below: None – 0 Mild – 1 Moderate – 2 Severe – 3
0.5
1. Memory No memory loss, or Consistent slight Moderate memory loss, more Severe memory loss; Severe memory loss;
slight inconsistent forgetfulness; marked for recent events; only highly learned only fragments
forgetfulness partial recollection defect interferes with material retained; new remain
of events; everyday activities material rapidly lost
___ . ___ “benign”
forgetfulness

2. Orientation Fully oriented Fully oriented Moderate difficulty with time Severe difficulty with Oriented to person
except for slight relationships; oriented for time relationships; only
difficulty with time place at examination; may usually disoriented to
relationships have geographic time, often to place
___ . ___ disorientation elsewhere

3. Judgment and Solves everyday Slight impairment Moderate difficulty in Severely impaired in Unable to make
problem problems, handles in solving handling problems, handling problems, judgments or solve
solving business and financial problems, similarities, and differences; similarities, and problems
affairs well; judgment similarities, and social judgment usually differences; social
good in relation to differences maintained judgment usually
___ . ___ past performance impaired

4. Community Independent function Slight impairment Unable to function No pretense of No pretense of

affairs at usual level in job, in these activities independently at these independent function independent function
shopping, volunteer activities, although may still outside the home; outside the home;
and social groups be engaged in some; appears well enough appears too ill to be
appears normal to casual to be taken to taken to functions
___ . ___ inspection functions outside the outside the family
family home home

5. Home and Life at home, hobbies, Life at home, Mild but definite impairment Only simple chores No significant function
hobbies and intellectual hobbies, and of function at home; more preserved; very in the home
interests well intellectual difficult chores abandoned; restricted interests,
maintained interests slightly more complicated hobbies poorly maintained
___ . ___ impaired and interests abandoned

6. Personal care Fully capable of self-care (= 0). Needs prompting Requires assistance in Requires much help
dressing, hygiene, with personal care;
keeping of personal frequent incontinence
___ . 0 effects

7. Auto-calculated Standard CDR Sum of Boxes

8. ___. ___ STANDARD GLOBAL CDR

use calculator: https://www.alz.washington.edu/cdrnacc.html
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CDR SECTION 2:

Section 2: Supplemental CDR

IMPAIRMENT
Please enter score
below:
None – 0 Questionable – 0.5 Mild – 1 Moderate – 2 Severe – 3

Socially appropriate Questionable Mild but definite Moderate Severe

behavior changes in changes in behavior behavioral behavioral
9. Behavior, comportment, changes, changes, making
comportment, and empathy, affecting interpersonal
personality appropriateness of interpersonal interactions all
actions relationships and unidirectional
___ . ___ interactions in a
significant
manner

No language Consistent mild Moderate word- Moderate to Severe

difficulty, or word-finding finding difficulty in severe comprehension
occasional mild tip- difficulties; speech; cannot name impairments in deficits; no
10. Language of-the tongue simplification of objects in either speech or intelligible
word choice; environment; reduced comprehension; speech
circumlocution; phrase length and/or has difficulty
decreased phrase agrammatical speech communicating
___ . ___ length; and/or mild and/or reduced thoughts; writing
comprehension comprehension in may be slightly
difficulties conversation and more effective
reading

Insert each score in the MarkVCID e-Case Report Form CDR section.
To calculate the Standard Global CDR, please use the following calculator: https://www.alz.washington.edu/cdrnacc.html
Enter the Calculated Global CDR in the space provided.

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Geriatric Depression Scale (GDS) Worksheet
Corresponds with NACC Form B6 (UDS 3)
Subject ID Date / / Examiner’s initials

Input the patient’s response in the MarkVCID e-Case Report Form GDS section. Items will auto-calculate to generate a total score.
Any missing responses will NOT ALLOW a total score to be calculated.

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