2012 CA Autism Survey

Tell Us About Your Family

10% of survey complete.

This survey was compiled by the Autism Society of California with the collaboration of many agencies throughout the state. It is being distributed to gather information about families in California living with an Autism Spectrum Disorder (ASD). Information will be kept confidential. We may use part of your answers to help us highlight the problems we face, however, your identity will be kept confidential.

The survey does take in account that there may be more than 1 family member (two children, parent and child) living with ASD. If you have only 1 family member with autism, please complete the information under Person 1 and ignore the other columns.

You may skip any question you do not wish to answer. Comments are optional. Thank you for your assistance.

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* 1. What county do you live in?

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* 2. How many total people in your household (parents, brothers, sisters)?

7 or more

2011 California Income for Families
1 person in household - $40,906
2 people in household - $53,493
3 people in household - $66,079
4 people in household - $78,666
5 people in household - $91.253
6 people in household - $103,839

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* 3. The median income is listed above for families in California. Please indicate if your family makes more or less than the median income.

More than the median income

Less than the median income

Do not wish to state

Comments:

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* 4. How many people in the household have been diagnosed with an autism spectrum disorder?

5 or more

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* 5. How many people in the household (not the person or people with ASD) have been diagnosed with another type of disorder (epilepsy, cerebral palsy, learning disorder, mental health disorder, etc)?

5 or more

Other (please specify)

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* 6. Now we are just going to focus on family members with Autism Spectrum Disorders or ASD. Please indicate which form or classification you or other family members have been diagnosed with. Skip the columns if they don't apply.

	Person 1	Person 2	Person 3
Autism	Autism Person 1	Autism Person 2	Autism Person 3
Asperger Syndrome	Asperger Syndrome Person 1	Asperger Syndrome Person 2	Asperger Syndrome Person 3
Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS)	Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS) Person 1	Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS) Person 2	Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS) Person 3
Fragile X	Fragile X Person 1	Fragile X Person 2	Fragile X Person 3
No formal diagnosis	No formal diagnosis Person 1	No formal diagnosis Person 2	No formal diagnosis Person 3

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* 7. For the people with an autism spectrum disorder, what other co-morbid disorders exist? Check all that apply.

	Person 1	Person 2	Person 3
ADD or ADHD	ADD or ADHD Person 1	ADD or ADHD Person 2	ADD or ADHD Person 3
Allergies (i.e. food or pollen)	Allergies (i.e. food or pollen) Person 1	Allergies (i.e. food or pollen) Person 2	Allergies (i.e. food or pollen) Person 3
Anxiety	Anxiety Person 1	Anxiety Person 2	Anxiety Person 3
Bipolar	Bipolar Person 1	Bipolar Person 2	Bipolar Person 3
Cerebral Palsy	Cerebral Palsy Person 1	Cerebral Palsy Person 2	Cerebral Palsy Person 3
Depression	Depression Person 1	Depression Person 2	Depression Person 3
Down Syndrome	Down Syndrome Person 1	Down Syndrome Person 2	Down Syndrome Person 3
Executive Functioning	Executive Functioning Person 1	Executive Functioning Person 2	Executive Functioning Person 3
Feeding Issues/Picky Eater	Feeding Issues/Picky Eater Person 1	Feeding Issues/Picky Eater Person 2	Feeding Issues/Picky Eater Person 3
GI Issues	GI Issues Person 1	GI Issues Person 2	GI Issues Person 3
Intellectual Disability (used to be called mental retardation)	Intellectual Disability (used to be called mental retardation) Person 1	Intellectual Disability (used to be called mental retardation) Person 2	Intellectual Disability (used to be called mental retardation) Person 3
Non verbal learning disorder	Non verbal learning disorder Person 1	Non verbal learning disorder Person 2	Non verbal learning disorder Person 3
Obsessive Compulsive Disorder (OCD)	Obsessive Compulsive Disorder (OCD) Person 1	Obsessive Compulsive Disorder (OCD) Person 2	Obsessive Compulsive Disorder (OCD) Person 3
Seizures or Epilepsy	Seizures or Epilepsy Person 1	Seizures or Epilepsy Person 2	Seizures or Epilepsy Person 3
Sensory Processing Disorder	Sensory Processing Disorder Person 1	Sensory Processing Disorder Person 2	Sensory Processing Disorder Person 3
Sleep disorder	Sleep disorder Person 1	Sleep disorder Person 2	Sleep disorder Person 3
Tourette's	Tourette's Person 1	Tourette's Person 2	Tourette's Person 3
Tubular Sclerosis	Tubular Sclerosis Person 1	Tubular Sclerosis Person 2	Tubular Sclerosis Person 3

Other (please specify)

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* 8. How old is the person with ASD now?

Person 1

Person 2

Person 3

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* 9. Ethnicity of the person or people with ASD?

	Person 1	Person 2	Person 3
White	White Person 1	White Person 2	White Person 3
Black or African-American	Black or African-American Person 1	Black or African-American Person 2	Black or African-American Person 3
Latino	Latino Person 1	Latino Person 2	Latino Person 3
American Indian or Alaskan Native	American Indian or Alaskan Native Person 1	American Indian or Alaskan Native Person 2	American Indian or Alaskan Native Person 3
Asian	Asian Person 1	Asian Person 2	Asian Person 3
Middle Eastern	Middle Eastern Person 1	Middle Eastern Person 2	Middle Eastern Person 3
Native Hawaiian or other Pacific Islander	Native Hawaiian or other Pacific Islander Person 1	Native Hawaiian or other Pacific Islander Person 2	Native Hawaiian or other Pacific Islander Person 3
Do Not Wish to State	Do Not Wish to State Person 1	Do Not Wish to State Person 2	Do Not Wish to State Person 3

Some other race (please specify)

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* 10. Male or female?

	Person 1	Person 2	Person 3
Male	Male Person 1	Male Person 2	Male Person 3
Female	Female Person 1	Female Person 2	Female Person 3