Online Survey | Built with Qualtrics Experience Management™

Thank you for your interest in this study. The goal of this research study is to develop a virtual reality program that helps typically developing adults better understand the experiences of individuals with ASD. Our approach to achieving this goal will include analyzing recorded audio from a focus group comprised of individuals with ASD.

We will use this data to construct a virtual reality application that aims to give typically developing young adults a better understanding of how differences in sensory and language are experienced. With some individuals with autism spectrum disorder, these may affect interaction. We will test this application’s effectiveness through follow-up questionnaires designed for this purpose.

We are inviting you to fill out this screening form because you have a diagnosis of autism spectrum disorder (ASD). In order to determine if you are eligible to participate in this study as a focus group member we will ask you several questions listed below. Your answers to some of these questions may mean you will be unable to participate in this study.

Whether or not you are able to participate in the rest of the study, all responses will be kept confidential and will only be identified with a number that is not connected to your name. You may decide to not fill out this questionnaire or leave questions blank. That is perfectly fine but may preclude your entrance into this study. If you have any questions about the information asked on this screening form please speak contact the Principle Investigator, Elizabeth Redcay (Redcay@umd.edu); 301-405- 2884.

Name:

Email:

We are planning on hosting focus groups soon. Please let us know if you would prefer a particular time listed below:

Sunday, January 21, 2-4 PM
Sunday, January 28, 2-4 PM
Sunday, February 4, 2-4 PM

What is your age? (Years and months):

Years

Months

What is your date of birth?

What gender do you identify with?

Which ethnicity do you identify with?

Hispanic or Latino
Non-Hispanic/Latino

Which racial category do you identify with?

Telephone: (xxx) xxx - xxxx

Current employment or educational setting:

1. Do you have a diagnosis of autism spectrum disorder? (e.g., Autism, Asperger’s, PDD-NOS)

Yes
No

Please describe and provide rough age of diagnosis as well as source of diagnosis (e.g., neurologist, psychologist, etc)

2. Do you have a medical diagnosis in addition to ASD (e.g., ADHD, Anxiety, OCD, depression?)

Yes
No

If yes, please describe:

3. Are you currently on any medication?

Yes
No

If yes, please describe:

4. Have you ever taken any neuropsychiatric medications?

Yes
No

If yes, please describe:

5. Do you use any recreational drugs?

Yes
No

If yes, please describe and note the last time you used such drugs:

6. Are you currently seeing a:

6. Are you currently seeing a:
	Yes	No
Neurologist	Yes	No
Psychologist	Yes	No
Psychiatrist	Yes	No

If yes, please describe:

7. Do you have any difficulties in hearing or sound processing?

Yes
No

If yes, please describe:

8. Have you ever had/do you have cataracs, glaucoma, or macular degeneration?

Yes
No

If yes, please describe: