Autism Needs Assessment 2011-Adult Survey

Thank you for agreeing to complete this survey. Since most respondents will be parents/guardians, we refer to the person with autism as “your child.” The term autism is used to refer to all Autism Spectrum Disorders (ASD). You may receive more than one copy of this survey if you have more than one child with autism. You may fill out both surveys if you whis. If you fill out only one survey, please complete the survey for your oldest child with autism. Mark only one answer choice per question unless otherwise specified.

Please note that you must be at least 18 years of age to complete this survey

1. Please identify yourself:

Please identify yourself: Mother Father	Foster parent Legal guardian
Other (please specify)

2. Which of the following best describes your current marital status?

Which of the following best describes your current marital status? Married to/Living with child’s other parent Never been married Married to/Living with person other than child’s parent	Separated/Divorced Widowed
Other (please specify)

3. What is your race/ethnicity? (Check all that apply)

What is your race/ethnicity? (Check all that apply) African American Latino, Hispanic, or Chicano Asian/Pacific Islander	Native American Caucasian/European American
Other (please specify)

4. What is the race/ethnicity of your spouse or significant other? (Check all that apply)

What is the race/ethnicity of your spouse or significant other? (Check all that apply) African American Latino, Hispanic, or Chicano Asian/Pacific Islander	Native American Caucasian/European American N/A
Other (please specify)

*
5. What is your zip code (e.g. 19104)?

What is your zip code (e.g. 19104)? ZIP:

6. Which of the following is closest to your annual household income?

Which of the following is closest to your annual household income? Under $20,000

$60,000-$79,999

$20,000-$39,999

$80,000-$99,999

$40,000-$59,999

$100,000 or above

7. What is your highest level of completed education?

What is your highest level of completed education? No high school

Some high school

High school graduate/GED

Vocational/Technical school

Some college/ College degree

College degree

Some graduate studies

Graduate degree

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