ATLAS Interest Form ATLAS Interest Form A brief questionnaire for those who may be interested in participating in the ATLAS project. Step 1 of 3 33% Consent*Before completing this survey, we need your consent to gather preliminary information about you and your child. This information will be used to determine eligibility to participate in ATLAS. The purpose of this study is to explore if a novel video game can help young adults and adolescents with autism with their auditory attention abilities. Auditory attention is the ability to pay attention to sounds that are important or to pay less attention to sounds that are less important. Participation is completely voluntary. Any information you provide will be kept confidential. Do you consent to continue with this form? Yes, I consent No, I do not consent Who is filling out this form?* Potential participant Parent/caregiver/guardian of a potential participant If the participant is eligible, who should we contact throughout the study?*We would contact this person regarding the participant's eligibility, for scheduling visits, and for friendly reminders to play the video game. At minimum, please enter the contact information for this person. Potential participant Parent/caregiver/guardian of a potential participant Participant's first name* Participant's last name* Your first name* Your last name* Participant's phone number Participant's email Parent/caregiver/guardian's phone number Parent/caregiver/guardian's email What's the best way to contact you?* Phone Email How do you prefer to be contacted via phone?* Call Text Either call or text Your primary address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Does the interested individual have an ASD diagnosis?*If the individual is in the process of being diagnosed, or has only an unofficial diagnosis, please select Other and elaborate as much as you like. Yes No Does the interested individual have additional diagnoses?*If the individual is in the process of being diagnosed, or has only an unofficial diagnosis, please select Other and elaborate as much as you like. Yes No What other diagnoses does the interested individual have?*Please elaborate as much as you would like. What is the language ability of the interested individual?* Verbal Minimally Verbal Please describe the interested individual's language ability further.*Should the participant be eligible for our study, this helps us know how to modify our assessments to meet the participant's needs. Little to no speech (i.e., does not usually use single words or phrases) Phrased speech (i.e., usually uses single words or phrases over sentences) Verbally fluent (i.e., usually uses full sentences over single words or phrases) HiddenADOS MOD 3 HiddenADOS MOD 4 HiddenADOS MOD 1A HiddenADOS MOD 2A What is the individual's date of birth?* Month Day Year How old is the individual?*What is the gender of the individual?* Male Female Can the individual play a video game or use an iPad/tablet/smartphone/computer?*Because ATLAS will require participants to play a video game, eligible participants will have enough manual dexterity to do so comfortably and a mental age that will allow them to understand the video game. Yes No How often does the individual hear or speak English at home?*Some of the behavioral assessments we will be using are only available in English, so we want to be sure that the participant would comfortably understand them. More than 75% 50% to 75% 25% to 49% Less than 25% Does the individual have a history of traumatic brain injury?*Because we will be using EEG (a NONINVASIVE brain imaging technique) to examine auditory processing, it is helpful for us to know about brain injuries. Yes No Does the individual have a history of hearing loss?*Because we will be studying auditory processing, it is helpful for us to know about hearing abilities. Yes No Does the individual have access to reliable internet (for at least 3 times a week for 20 minutes)?*The video game requires internet access, so it is important that the individual be able use the internet for at least 3 times a week for 30 minutes each time. Yes No Please fill out at least one form of contact information.Without your contact information, we cannot notify you of the participant's potential eligibility. Once you fill out at least one form of contact information, you can proceed to the next page. Thanks! Thank you!Without your consent, we cannot gather information about you or your child's eligibility. Thank you very much for taking the time to visit CARE's site and for your interest in ATLAS.Auditory Processing InformationBecause ATLAS is about learning how to help individuals with ASD process sounds, it is helpful for us to learn a little bit about how the potential participant processes sounds. For this section, you will be asked about behaviors the potential participant may experience in relation to sounds. Please indicate how often they display these behaviors. ALWAYS = 100% of the time; FREQUENTLY = about 75% of the time; OCCASIONALLY = about 50% of the time; SELDOM = about 25% of the time; NEVER = 0% of the timeIs distracted or has trouble functioning if there is a lot of noise around.* Always Frequently Occasionally Seldom Never Appears to not hear what others say (for example, does not "tune-in" to what others say, appears to ignore them).* Always Frequently Occasionally Seldom Never Can't work with background noise (for example, fan or refrigerator).* Always Frequently Occasionally Seldom Never Has trouble completing tasks when the radio is on.* Always Frequently Occasionally Seldom Never Doesn't respond when their name is called but hearing is OK.* Always Frequently Occasionally Seldom Never Has difficulty paying attention.* Always Frequently Occasionally Seldom Never Thanks so much, we will contact you shortly.Thanks so much for filling out the interest form, you can expect to hear from us when we begin recruitment. If you have any additional information you'd like to share, or questions you'd like to ask us, please do so here.