“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).

Question Title

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

	Not helpful	Somewhat helpful	Neutral	Helpful	Very helpful
Clinician Tips: Considering Culture in Autism Screening	Clinician Tips: Considering Culture in Autism Screening Not helpful	Clinician Tips: Considering Culture in Autism Screening Somewhat helpful	Clinician Tips: Considering Culture in Autism Screening Neutral	Clinician Tips: Considering Culture in Autism Screening Helpful	Clinician Tips: Considering Culture in Autism Screening Very helpful
Referral Information at a Glance	Referral Information at a Glance Not helpful	Referral Information at a Glance Somewhat helpful	Referral Information at a Glance Neutral	Referral Information at a Glance Helpful	Referral Information at a Glance Very helpful
Resources sheet	Resources sheet Not helpful	Resources sheet Somewhat helpful	Resources sheet Neutral	Resources sheet Helpful	Resources sheet Very helpful
Pediatric Developmental Screening Flow Chart	Pediatric Developmental Screening Flow Chart Not helpful	Pediatric Developmental Screening Flow Chart Somewhat helpful	Pediatric Developmental Screening Flow Chart Neutral	Pediatric Developmental Screening Flow Chart Helpful	Pediatric Developmental Screening Flow Chart Very helpful
Fact sheets from the CDC	Fact sheets from the CDC Not helpful	Fact sheets from the CDC Somewhat helpful	Fact sheets from the CDC Neutral	Fact sheets from the CDC Helpful	Fact sheets from the CDC Very helpful
Tracking Milestones brochure(s) in English & Spanish	Tracking Milestones brochure(s) in English & Spanish Not helpful	Tracking Milestones brochure(s) in English & Spanish Somewhat helpful	Tracking Milestones brochure(s) in English & Spanish Neutral	Tracking Milestones brochure(s) in English & Spanish Helpful	Tracking Milestones brochure(s) in English & Spanish Very helpful
M-CHAT Instructions	M-CHAT Instructions Not helpful	M-CHAT Instructions Somewhat helpful	M-CHAT Instructions Neutral	M-CHAT Instructions Helpful	M-CHAT Instructions Very helpful
M-CHAT in English	M-CHAT in English Not helpful	M-CHAT in English Somewhat helpful	M-CHAT in English Neutral	M-CHAT in English Helpful	M-CHAT in English Very helpful
M-CHAT in Chinese	M-CHAT in Chinese Not helpful	M-CHAT in Chinese Somewhat helpful	M-CHAT in Chinese Neutral	M-CHAT in Chinese Helpful	M-CHAT in Chinese Very helpful
M-CHAT in Haitian-Creole	M-CHAT in Haitian-Creole Not helpful	M-CHAT in Haitian-Creole Somewhat helpful	M-CHAT in Haitian-Creole Neutral	M-CHAT in Haitian-Creole Helpful	M-CHAT in Haitian-Creole Very helpful
M-CHAT in Spanish	M-CHAT in Spanish Not helpful	M-CHAT in Spanish Somewhat helpful	M-CHAT in Spanish Neutral	M-CHAT in Spanish Helpful	M-CHAT in Spanish Very helpful
M-CHAT in Vietnamese	M-CHAT in Vietnamese Not helpful	M-CHAT in Vietnamese Somewhat helpful	M-CHAT in Vietnamese Neutral	M-CHAT in Vietnamese Helpful	M-CHAT in Vietnamese Very helpful
M-CHAT Follow-Up Interview	M-CHAT Follow-Up Interview Not helpful	M-CHAT Follow-Up Interview Somewhat helpful	M-CHAT Follow-Up Interview Neutral	M-CHAT Follow-Up Interview Helpful	M-CHAT Follow-Up Interview Very helpful

Question Title

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

Yes

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* 3. Will you use the enclosed autism screening kit?

Yes

Question Title

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

Yes

Question Title

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

Yes

“Considering Culture in Autism” Screening Kit Feedback Survey

Question Title

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

Question Title

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

Question Title

* 3. Will you use the enclosed autism screening kit?

Question Title

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

Question Title

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

Question Title

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

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

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

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

Question Title

* 10. Your name:

Question Title

* 11. Your organization:

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* 12. Your address:

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* 13. Your email address:

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* 14. Your phone #:

Question Title

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

Question Title

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

Question Title

* 3. Will you use the enclosed autism screening kit?

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 10. Your name:

Question Title

* 11. Your organization:

Question Title

* 12. Your address:

Question Title

* 13. Your email address:

Question Title

* 14. Your phone #:

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