* 1. This form will help us determine whether your child can participate in the Deaf Autism Research Project. Please answer all questions as accurately as possible. A member of the research team will contact you to discuss your child’s participation. The information you enter will only be used for the purposes of this research and will be kept confidential. Your answers will NOT be shared with others.

Please enter your first and last name.

* 2. What is your email address?

* 3. What is your state of residence?

* 4. What is your child's date of birth?


* 5. What is your child's gender?

* 6. What is your child's hearing status?

* 7. What is your hearing status?

* 8. What is your spouse or partner's hearing status?

* 9. What forms of communication do you MOSTLY use at home?

* 10. Does your child have any of the following diagnoses?

* 11. If you answered yes to the previous question, at what age did your child receive this diagnosis? Please answer to the best of your knowledge.

* 12. Where was your child diagnosed, and by whom? Please answer to the best of your memory and knowledge.

* 13. Does your child wear hearing aids?

* 14. Does your child have a cochlear implant (CI)?

* 15. Does your child carry any other diagnoses?

* 16. Is there anything else you would like us to know about your child?

The following questions pertain to your child's use of language and communication. Please answer each question carefully. Answer each question YES or NO depending on if your child has shown the behavior described IN THE LAST THREE MONTHS. A few of the questions refer to different kinds of related behaviors; in these cases, mark YES if he/she has produced any of these behaviors during this timeframe. If you are not sure if your child has produced the behavior described or not, please answer YES or NO according to your best guess.

* 17. Is your child able to speak or sign using short phrases or sentences? If no, skip to question 22.

* 18. Do you have a to and fro “conversation” with her/him that involves taking turns or building on what you have said?

* 19. Does she/he ever use odd phrases or speak/sign the same thing over and over in almost exactly the same way (either phrases that she/he sees or hears other people use or ones that she/he makes up?

* 20. Does she/he ever use socially inappropriate questions or statements? For example, does she/he ever regularly ask personal questions or make personal comments at awkward times?

* 21. Does she/he ever get her/his pronouns mixed up (e.g., saying or signing YOU or SHE/HE for ME)? Does she/he ever sign "backwards", with her/his hand turned around the opposite way?

* 22. Does she/he ever use words or signs that she/he seems to have invented or made up him/herself; put things in odd, indirect ways; or use metaphorical ways of saying/signing things (e.g. saying or signing ‘silver bird’ instead of ‘airplane’)?

* 23. Does she/he ever say or sign the same thing over and over in exactly the same way or insist that you say or sign the same thing over and over again?

* 24. Does she/he ever have things that she/he seems to have to in a very particular order or rituals that she/he insists that you go through?

* 25. Does her/his facial expression usually seem appropriate for the particular situation, as far as you can tell?

* 26. Does she/he ever use your hand like a tool or as if it were part of her/his own body (e.g., pointing with your finger or putting your hand on a doorknob to get you to open the door)?

* 27. Does she/he ever have any interests that preoccupy her/him and might seem odd to other people (e.g., traffic lights, drainpipes, or timetables)?

* 28. Does she/he ever seem to be more interested in parts of a toy or an object (e.g., spinning the wheels of a car), rather than using the object as it was intended?

* 29. Does she/he ever have any special interests that are unusual in their intensity but otherwise appropriate for her/his age (e.g., trains or dinosaurs)?

* 30. Does she/he ever seem to be unusually interested in the sight, sound, feel, taste, or smell of things or people?

* 31. Does she/he ever have any mannerisms or odd ways of moving her/his hands or fingers, such as flapping or moving her/his fingers in front of her/his eyes?

* 32. Does she/he ever have any complicated movements of her/his whole body, such as spinning or repeatedly bouncing up and down?

* 33. Does she/he ever injure her/himself deliberately, such as by biting her/his arms or banging her/his head?

* 34. Does she/he ever have any objects (other than a soft toy or comfort blanket) that she/he has to carry around?

* 35. Does she/he ever have any particular friends or a best friend?

* 36. Does she/he ever talk or sign with you just to be friendly (rather than to get something)?

* 37. Does she/he ever spontaneously copy you (or other people) or what you are doing (such as vacuuming, gardening, or mending things)?

* 38. Does she/he ever spontaneously point at things around her/him just to show you things (not because she/he wants them)?

* 39. Does she/he nod her/his head to indicate yes?

* 40. Does she/he shake her/his head to indicate no?

* 41. Does she/he usually look at you directly in the face when doing things with you or talking/signing with you?

* 42. Does she/he smile back if someone smiles at her/him?

* 43. Does she/he ever show you things that interest her/him to engage your attention?

* 44. Does she/he ever offer to share things other than food with you?

* 45. Does she/he ever seem to want you to join in her/his enjoyment of something?

* 46. Does she/he ever try to comfort you if you are sad or hurt?

* 47. If she/he wants something or wants help, does she/he look at you and use gestures, signs, sounds or words to get your attention?

* 48. Does she/he show a normal range of facial expressions?

* 49. Does she/he ever spontaneously join in and try to copy the actions in social games, such as The Mulberry Bush or London Bridge is Falling Down?

* 50. Does she/he play any pretend or make-believe games?

* 51. Does she/he seem interested in other children of approximately the same age whom she/he does not know?

* 52. Does she/he respond positively when another child approaches her/him?

* 53. Does she/he ever play imaginative games with another child in such a way that you can tell that each child understands what the other is pretending?

* 54. Does she/he play cooperatively in games that need some form of joining in with a group of other children, such as hide-and-seek or ball games?

* 55. You have reached the end of the screening. If there is anything else you would like to share with us, please do so in the comment box below. Don't forget to click "Done" to submit your form!

Thank you again for your collaboration! You will be hearing from us shortly.


Aaron Shield, Ph.D.
Deaf Autism Research Project at Boston University