POLO-O Screener Page POLO Screener Step 1 of 3 33% Consent* Yes, I consent No, I do not 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? 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?* Phone call Text message Email Select all that applyPlease 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 IAN- Interactive Autism Network SPED Child & Teen Resource Fair Craigslist Facebook Boston Metro Printed Recruitment Materials (Brochures, Flyers, etc.) Autism Awareness Event Family/Friend Referral Local University Local School 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* When did your child start to walk?* (Please write in months)Has your child received any interventions?* Yes No Has your child received at least 6 months of intervention?* Yes No Does your child have an official diagnosis of ASD (including PDD-NOS, Autism, or Asperger's)?* Yes No Does your child have any immediate first-degree family members (siblings or parents - cousins or uncles/aunts are not included) diagnosed with ASD? Yes No In what order was your child born? (e.g., if born first, this would correspond to order number 1, if born second, this would correspond to order number 2, etc)* Please only consider full biological siblings in birth orderAre 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 applyAs one of our activities involves eating, does your child have any dietary restrictions?* Yes No Please specify your child's dietary restrictions* What helps your child work/attend?* What are your child's favorite activities?* Does your child have any perseverative interests that we should know about that may interfere with testing?* 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 you interest in our study.