ELSA Participant Screener | Center for Autism Research Excellence

Consent*

Before completing this survey we need your consent to gather information about you and your child. This information will be used to determine whether they are eligible to participate in this study. The purpose of this study is to explore social communication in children in a naturalistic play-based setting. Participation is completely voluntary. You will be asked to provide information about you or your child's health/developmental history, language, and behavior. You don't have to answer any questions you don't want to and you can stop filling out this form at any point. Any information you provide will be kept confidential. Do you consent to continue with this form?

Yes, I consent
No, I do not consent
No, I prefer to complete an eligibility interview over the phone

Email*

Phone*

Name of Parent/Guardian*

First Last

Name of Participant (Your Child)*

First Last

Your Relation to the Participant (Your Child)?*

Mother
Father

Your Date of Birth

Participant's (Your Child's) Date of Birth*

Age of Child (years, months)*

Sex of Participant*

Female
Male
Prefer not to respond

Participant's Ethnicity*

Hispanic
Non-Hispanic
Prefer not to respond

Participant's Race*

American Indian/ Alaska Native
Asian
Black of African American
Hispanic
Native Hawaiian or Other Pacific Islander
White
More than one race
Prefer not to respond

Participant's primary language?*

Language the participant hears or speaks the most.

Does the participant have a diagnosis of autism (ASD, PDD-NOS, Asperger's)?*

Yes
No

How does the participant communicate?*

No to some words
Phrase Speech
Full sentences

Please provide us with an example of what your child says on a typical day to you?*

Give us an example of what your child says when they want something?*

Has the participant ever been diagnosed with a traumatic brain injury or other serious head injury?*

Yes
No

Does the participant, or any of his/her siblings, have any other developmental/medical/psychiatric diagnoses?*

Yes
No

If the participant, or any of his/her siblings, have any other developmental/medical/psychiatric diagnoses, please specify here (which diagnoses):

Address

Street Address City State / Province / Region ZIP / Postal Code

Your Primary Address (Street address, City, State, Zip Code)

How did you hear about us?

Hidden

Exclude