ACORN Screener Form ACORN Screener To help us determine your eligibility for the remote ACORN study. Step 1 of 3 33% Consent*We need your consent to gather information about you and your child. This information will be used to determine whether you are eligible to participate in this study. You don't have to answer any questions you don't want to and you can stop filling out this form at any point. All information provided by you will be kept confidential. Only our project staff will have access to the information for research purposes. Do you consent to answering these questions so we can know more about you and your child? Yes, I consent No, I do not consent Check box if form is completed by researcher Yes, I am research staff Today's Date* MM slash DD slash YYYY Your name* First Last Your child's name* First Last Your child's gender* Male Female Other or prefer not to answer Your child's date of birth* MM slash DD slash YYYY Your child's age*(years, months) How may we contact you?*Select all that apply Phone call Text message Email Please select your preferred method of contact* Phone call Text message Email Preferred phone number:*Preferred email address:* Additional Contact Name First Last Alternative phone number:Alternative email address: How did you hear about us?* SPARK or Simon's Foundation Facebook Family/Friend Referral Printed Recruitment Materials (Brochures, Flyers, etc.) Other Please specify how you heard about us* May we refer you to future studies at our Center?* Yes No Is English the language primarily spoken to your child?* Yes No Please specify which language is mostly spoken to your child* Does your child's primary caregiver speak and read English fluently?* Yes No Please specify which languages your child's primary caregiver speaks and reads fluently* Is your child exposed to any other languages?* Yes No Please specify what other languages your child is exposed to* Do you and your child live within the USA?* Yes No In what country do you and your child live?* Please select your timezone*Please select your timezoneAlaska (UTC-09:00)American Samoa (UTC-11:00)Atlantic (UTC-04:00)Central (UTC-06:00)Chamorro (UTC+12:00)Eastern (UTC-05:00)Hawaii Aleutian (UTC-10:00)Mountain (UTC-07:00)Pacific (UTC-08:00)OtherIn what timezone do you and your child live?* Does your child have an official diagnosis of ASD (including PDD-NOS, Autism, or Asperger's, or Social Communication Disorder)?* Yes No Are you comfortable being recorded during the interview?* Yes No For data analysis purposes, we will need to record the interviews and activities. Please note, when we analyze and save data, your name will always be kept separate from your data. How does your child most often communicate?* Speech sounds and gestures AAC (Augmentative/Communication Device) or PECS (Picture Exchange Communication System) Single word approximations and gestures Single words 2-3 word phrase speech Full sentences Select all that applyDoes your child regularly speak in phrases with 2 or 3 words (e.g. "I want go", "More cookie", "My turn")* Yes No Does your child ever speak in sentences with 3+ words? (e.g. "I want to go outside.", "I need help opening it.")* Yes No Does your child regularly speak in sentences with 3+ words?* Yes No Does your child ever speak using longer, complex sentences (e.g. using "and" or "because")* Yes No Thank you!Thanks so much for filling out the interest form! You can expect to hear from us shortly. Is there anything else we should know that will help us understand how to work with your child? Do you have any other questions for us? Thank you!Without your consent, we cannot gather information about you. Thank you very much for taking the time to visit CARE's site and for your interest in our study. ACORN Screener To help us determine your eligibility for the remote ACORN study. Step 1 of 3 33% Consent*We need your consent to gather information about you and your child. This information will be used to determine whether you are eligible to participate in this study. You don’t have to answer any questions you don’t want to and you can stop filling out this form at any point. All information provided by you will be kept confidential. Only our project staff will have access to the information for research purposes. Do you consent to answering these questions so we can know more about you and your child? Yes, I consent No, I do not consent Check box if form is completed by researcher Yes, I am research staff Today's Date* MM slash DD slash YYYY Your name* First Last Your child's name* First Last Your child's gender* Male Female Other or prefer not to answer Your child's date of birth* MM slash DD slash YYYY Your child's age*(years, months) How may we contact you?*Select all that apply Phone call Text message Email Please select your preferred method of contact* Phone call Text message Email Preferred phone number:*Preferred email address:* Additional Contact Name First Last Alternative phone number:Alternative email address: How did you hear about us?* SPARK or Simon’s Foundation Facebook Family/Friend Referral Printed Recruitment Materials (Brochures, Flyers, etc.) Other Please specify how you heard about us* May we refer you to future studies at our Center?* Yes No Is English the language primarily spoken to your child?* Yes No Please specify which language is mostly spoken to your child* Does your child's primary caregiver speak and read English fluently?* Yes No Please specify which languages your child's primary caregiver speaks and reads fluently* Is your child exposed to any other languages?* Yes No Please specify what other languages your child is exposed to* Do you and your child live within the USA?* Yes No In what country do you and your child live?* Please select your timezone*Please select your timezoneAlaska (UTC-09:00)American Samoa (UTC-11:00)Atlantic (UTC-04:00)Central (UTC-06:00)Chamorro (UTC+12:00)Eastern (UTC-05:00)Hawaii Aleutian (UTC-10:00)Mountain (UTC-07:00)Pacific (UTC-08:00)OtherIn what timezone do you and your child live?* Does your child have an official diagnosis of ASD (including PDD-NOS, Autism, or Asperger's, or Social Communication Disorder)?* Yes No Are you comfortable being recorded during the interview?* Yes No For data analysis purposes, we will need to record the interviews and activities. Please note, when we analyze and save data, your name will always be kept separate from your data. How does your child most often communicate?* Speech sounds and gestures AAC (Augmentative/Communication Device) or PECS (Picture Exchange Communication System) Single word approximations and gestures Single words 2-3 word phrase speech Full sentences Select all that applyDoes your child regularly speak in phrases with 2 or 3 words (e.g. "I want go", "More cookie", "My turn")* Yes No Does your child ever speak in sentences with 3+ words? (e.g. "I want to go outside.", "I need help opening it.")* Yes No Does your child regularly speak in sentences with 3+ words?* Yes No Does your child ever speak using longer, complex sentences (e.g. using "and" or "because")* Yes No Thank you!Thanks so much for filling out the interest form! You can expect to hear from us shortly. Is there anything else we should know that will help us understand how to work with your child? Do you have any other questions for us? Thank you!Without your consent, we cannot gather information about you. Thank you very much for taking the time to visit CARE’s site and for your interest in our study.