“Considering Culture in Autism” Screening Kit Feedback Survey

We hope you found the Massachusetts Act Early “Considering Culture in Autism” screening kit to be a helpful addition to your practice. We would like to hear your impressions of this new tool.

Please complete this survey after you have reviewed the materials in the screening kit (available for download at www.MAActEarly.org).

1.Please tell us how helpful the screening kit components were for each of the following:(Required.)

2.Do you currently conduct autism screening in your practice
as recommended by the American Academy of Pediatrics (AAP)?

Yes

No

3.Will you use the enclosed autism screening kit?

Yes

No

4.Will you integrate any of these approaches into your practice?

Yes

No

5.Will you download and print these materials from our web site?

Yes

No

6.What do you like most about the screening kit?

7.Do you have any suggestions for improving this tool?

8.Please share any further comments about the MA Act Early culturally competent autism screening kit.

9.If you would like to provide us with your contact information, please let us know your preferences:

Receiving information and updates from MA Act Early

Joining the state team

10.Your name:

11.Your organization:

12.Your address:

13.Your email address:

14.Your phone #:

Thank you for your feedback! Please visit our web site at: www.MAActEarly.org.