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1.
Which best describes you:
Choose from list
Person w/ ASD
Relative-Person w/ ASD
Relative-Parent
Relative-Sibling
Relative-Grandparent
Relative-Extended family member
Relative-Friend
Relative-Other
Professional-Psychiatrist
Professional-Pediatrician
Professional-General Practitioner
Professional-Occupational Therapist
Professional-Speech & Language Pathologist
Professional-Audiologist
Professional-Optomologist
Professional-Student
Professional-Other
Educator-Teacher
Educator-Teachers' Aid
Educator-Principal
Educator-Special Needs Facilitator
Educator-Administrator
Educator-Other
Gender:
Age:
First
Name
Last
Name
Address
City
State/Province
Choose from
list
Outside US / Canada
Alabama
Alaska
Alberta
American Samoa
Arizona
Arkansas
British Columbia
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland
North Carolina
North Dakota
Northern Mariana Is
Northwest Territories
Nova Scotia
Ohio
Oklahoma
Ontario
Oregon
Palau
Pennsylvania
Prince Edward Island
Province du Quebec
Puerto Rico
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon Territory
Country
Choose from
list
United States of America
Canada
Germany
France
United Kingdom
India
---------------------
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegowina
Botswana
Bouvet Island
Brazil
British Indian Ocean
Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocoa (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote Divoire
Croatia (local name:Hrvatska)
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France, Metropolitan
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Ghana
Gibraltar
Greece
Greenland
Grenada
>Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and Mc Donald
Islands
Honduras
Hong Kong
Hungary
Iceland
Indonesia
Iran (Islamic Republic
of)
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic
Peoples Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao Peoples Democratic
Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia, The Former
Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated
States of
Moldova, Republic
of
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and
the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia (Slovak Republic)
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and
the South Sandwich Islands
Spain
Sri Lanka
St. Helena
St. Pierre and Miquelon
Sudan
Suriname
Svalbard and Jan Mayen
Islands
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic
of
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor
Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City State
(Holy See)
Venezuela
Viet Nam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallisw and Futuna
Islands
Western Sahara
Yeman
Yugoslavia
Zaire
Zambia
Zimbabwe
Not Listed
Zip/Postal
Code
Email
Address
Phone:
Fax:
2.
What are your Top 5 areas of interest?
#1 -
Choose from
list
What is Autism/Diagnostic
Behavior Management
Social Skills &
Communication
Sensory Integration,
Visual, OT
Education, Inclusion,
& Collaboration
Biomedical, Nutrition
& Medications
Positive Enrichment
Music, Art & Poetry
Adolescence
Relationships
Personal Accounts
Novels/Stories
Children
#2 -
Choose from
list
What is Autism/Diagnostic
Behavior Management
Social Skills &
Communication
Sensory Integration,
Visual, OT
Education, Inclusion,
& Collaboration
Biomedical, Nutrition
& Medications
Positive Enrichment
Music, Art & Poetry
Adolescence
Relationships
Personal Accounts
Novels/Stories
Children
#3 -
Choose from
list
What is Autism/Diagnostic
Behavior Management
Social Skills &
Communication
Sensory Integration,
Visual, OT
Education, Inclusion,
& Collaboration
Biomedical, Nutrition
& Medications
Positive Enrichment
Music, Art & Poetry
Adolescence
Relationships
Personal Accounts
Novels/Stories
Children
#4 -
Choose from
list
What is Autism/Diagnostic
Behavior Management
Social Skills &
Communication
Sensory Integration,
Visual, OT
Education, Inclusion,
& Collaboration
Biomedical, Nutrition
& Medications
Positive Enrichment
Music, Art & Poetry
Adolescence
Relationships
Personal Accounts
Novels/Stories
Children
#5 -
Choose from
list
What is Autism/Diagnostic
Behavior Management
Social Skills &
Communication
Sensory Integration,
Visual, OT
Education, Inclusion,
& Collaboration
Biomedical, Nutrition
& Medications
Positive Enrichment
Music, Art & Poetry
Adolescence
Relationships
Personal Accounts
Novels/Stories
Children
3.
How do you (or would you) like to receive
your educational information on ASD?
Choose from
list
Books
Online Courses
Audio Files
TeleClass
On Location Conferences
e-Books
Webcast
4. How
much time in advance do you need before
purchasing ASD products?
Choose from
list
None
1-3 Months
3-6 Months
6-12 Months
5.
Where would you like to go for a Major Autism
Conference?
Choose from
list
Outside US / Canada
Alabama
Alaska
Alberta
American Samoa
Arizona
Arkansas
British Columbia
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland
North Carolina
North Dakota
Northern Mariana Is
Northwest Territories
Nova Scotia
Ohio
Oklahoma
Ontario
Oregon
Palau
Pennsylvania
Prince Edward Island
Province du Quebec
Puerto Rico
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon Territory
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