002_CAAI_Research

Grantee Name____________________________

Attachment E

Research Network Questionnaire

OMB Number: XXXX-NEW

Expiration Date

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is XXXX-XXXX.  Public reporting burden for this collection of information is estimated to average ____ minutes per respondent annually, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14-33, Rockville, Maryland, 20857.

Combating Autism Act Initiative (CAAI)

Autism Intervention Research Networks

Data Collection Form

1. Conduct Research Leading To Evidence-Based Interventions for Children and Adolescents with ASD/DD

In Table 1, please document your Network’s progress in developing and funding studies.

Table 1: Activity	TOTAL NUMBER
Research Proposals Developed and Funded
Number of research proposals developed and/or funding sought
Number of studies funded (note: can be currently in process)
Studies Completed
Number of studies completed
Sustainability of Projects
Number of studies with mixed CAAI funding and other funding
Dollar amount of outside funding obtained as a consequence of the CAAI funds

1. Please list the studies funded by CAAI funds.

In Table 2, please document your Network’s progress toward publishing findings.

NOTE: If a study addresses more than one subject, please count it whenever appropriate in each of the boxes (the individual columns will not always add up to the total number).

Table 2: Publications		Subject of Publication
	TOTAL NUMBER	Reducing Barriers	Inter-vention	Network Activities and Functions	Measures/Tools	Guidelines	Other
Number of manuscripts in preparation
Number of manuscripts submitted
Number of manuscripts in press/accepted
Number of manuscripts published
Number of scientific conference presentations

II and III. Test and Validate Tools and Develop Evidence-Based Guidelines for Implementation of Interventions

In Table 3 below, please document your Network’s progress in developing measures, tools, and guidelines.

Table 3: Measures, Tools, and Guidelines	TOTAL NUMBER	Developed, Tested, or Validated	Piloted Within the Network	Adopted Beyond the Network	Published
Measures and Tools
Number of tools and measures
Guidelines for Interventions
Number of guidelines

1. Please provide a list of the measures, tools, and guidelines developed.

IV. Disseminate Information of Research, Guidelines, and Validated Tools for ASD/DD Interventions

Please summarize your Network’s activities directed to disseminating information in Table 4 below.

Table 4: Materials, Training Sessions, Outreach Sessions, Grand Rounds, Presentations, and Conferences	TOTAL NUMBER	Target: Health Professionals	Target: Families of Children With ASD and the Public
Materials Developed
Number of materials (e.g., studies/briefs, articles, or informational materials) developed
Number of “hits” on Network Web sites
Training Sessions/Symposiums Conducted
Number of training sessions
Number of individuals reached through training sessions
Outreach Sessions Conducted
Number of outreach sessions
Number of individuals reached through outreach sessions
Grand Rounds, Presentations, Conferences
Total number of Grand Rounds (health professionals only)			N/A
Individuals Engaged in Research
Number of health professionals engaged in research
Number of families participating in research

Provide information below on the 8-10 most significant technical assistance/collaborative activities in the past year in Table 5 below.

COLLABORATION - mutual problem solving and collaboration on a range of issues, which may include program development, clinical services, collaboration, program evaluation, needs assessment, and policy & guidelines formulation. Collaborative partners might include State or local health agencies, and education or social-service agencies. The effort may be a one-time or ongoing activity of brief or extended frequency.

Table 5: List of Collaborations
Collaborator Name		Intensity	Primary Target Audience	Nature of Collaboration
		1. One-Time Brief (single contact) 2. One-Time Extended (multi-day contact provided one time) 3. Ongoing Infrequent (3 or less contacts per year) 4. Ongoing Frequent (more than 3 contacts per year)	1. Providers 2. Families 3. Individuals With Autism a. Regional b. National
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V. Reducing Barriers to ASD/DD Interventions

Please detail your efforts to serve minority and underserved populations and to engage in family-centered activities in Table 6.

Table 6: Reducing Barriers for Families and Underserved Populations	Number of Studies
Minority and Underserved Populations
Number of studies that are responsive to the cultural and linguistic needs of special populations
Number of studies that support a broad representation of culturally distinct and underrepresented groups
Engage in Family-Centered Activities
Number of studies that are family-centered

1. What is your Network’s Web site address?

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