UF NBD Lab Initial Intake

Initial Intake

You may be eligible to participate in a current research study at the Neurocognitive and Behavioral Development (NBD) Lab at the University of Florida. This form helps us determine if you or your ward are eligible.

You must be at least 18 years old to complete this form. If you are completing it for someone under 18 or who is unable to complete it themselves, you must be that individual's legal guardian.

Your responses are kept confidential and are only accessed by current members of the research team. Questions? Contact the NBD Lab at (352) 294-5309 or nbd-lab@ufl.edu.

Type your full legal name (e.g., Adam Jones)

By typing your full legal name you are electronically signing this form and confirming that you have read the information above.

Best phone number (include area code)

Whose number is this?

Self Parent Other with legal guardianship

Is it ok to leave a voicemail message on this phone?

Yes No

Other phone number (optional)

Whose number is the other phone? (optional)

Self Parent Other with legal guardianship

Is it ok to leave a voicemail on the other phone? (optional)

Yes No

Best email address

Preferred method of contact (check all that apply)

Email Phone

What is your relationship to the potential participant?

Self Parent with legal guardianship Other with legal guardianship

Please describe your relationship to the potential participant

Participant's Legal Name (first and last)

Participant's Date of Birth

Format: Month/Day/Year (e.g., 01/15/2005)

Participant's Biological Sex

Male Female Intersex

Participant's Gender

Male Female Other I prefer not to answer this question

How would you describe your / the potential participant's role in this study?

Person with a previous diagnosis of ASD OR has been suspected of having ASD (includes Autism Spectrum Disorder, Asperger's syndrome, or Pervasive Developmental Disorder not otherwise specified (PDD-NOS)) Person without an Autism Spectrum Disorder (control)

How old was the participant when they were diagnosed? (in years)

Who diagnosed them?

Self-diagnosed School Psychologist Physician Other

Please specify who diagnosed them

Do you typically seek out conversations with others?

Yes No

Please explain

Do you typically avoid making eye contact with others?

Yes No

Please explain

Do you have difficulty engaging in social interactions with others (i.e. at work)?

Yes No

Please explain

Do you have difficulty reading the facial expressions of others?

Yes No

Please explain

Do you have any topics of interest that you think about a lot?

Yes No

Please explain

Do you tend to do things in a certain way or order, with difficulty changing from your routine?

Yes No

Please explain

Does the potential participant ever use the same phrase over and over again?

Yes No I don't know

Please describe

How is the potential participant's eye contact? Can you catch their eye from across a room? Do they look at you when talking to you?

Please check each of the following gestures the potential participant uses spontaneously (without prompting):

Point Nod head Wave Beckon None of these above

Is the potential participant interested in peers (that they do not know)?

Yes No I don't know

If a peer comes towards the potential participant, how do they typically respond?

Does the potential participant have any unusual interests (e.g. fascination with swizzle sticks, fans, elevators) or intense topics of interest (e.g. trains, schedules, computers)?

Yes No I don't know

Please describe

Does the potential participant seem to have to do anything in a particular way or order?

Yes No I don't know

Please describe

Does the potential participant have any difficulty with transitions?

Yes No I don't know

Please describe

Does the potential participant have any peculiar ways of moving their hands, fingers, or body?

Yes No I don't know

Please describe

What is your ability to understand English?

Beginner (May or may not be able to understand single words, cannot understand sentences) Intermediate (Can understand 1-2 step instructions) Advanced (Can understand more than 2 step instructions)

What is the potential participant's ability to understand English?

Beginner (May or may not be able to understand single words, cannot understand sentences) Intermediate (Can understand 1-2 step instructions) Advanced (Can understand more than 2 step instructions)

How did you find out about this study?

Student's Name

Specify Other

What study did you hear/read about?

"Aging Well with ASD" Study "Brain and Blood Markers of Dementia in ASD" Study "Pain Sensitivity and Responsivity in ASD" Study

Do you have other wards who may be eligible for this study?

Yes No I don't know

Would you like to enroll your other ward(s) in this study?

Yes No I prefer to wait until after my first ward has participated in the study I don't know

City and State

If you do not meet the criteria for this study, would you like us to contact you if another study comes up that you may qualify for?

Yes No

What types of studies would you be interested in?

List comma separated keywords