UD BrainyAct Intervention Study - Participant Screening Form

Date of Form Entry

Child's Name

Child's Age in Years and Months (e.g., 6, 3)

Child's Biological Sex

Parent 1 - First & Last Name

Contact Phone #1

Parent Email #1

Parent 2 - First & Last Name (if applicable)

Contact Phone #2 (if applicable)

Parent Email #2 (if applicable)

Sibling 1 - Name and Age (e.g. John, 9):

Sibling 2 - Name and Age:

Sibling 3 - Name and Age:

Please list any additional siblings (if applicable):

Do you have a family history of Autism?

Does your child have a diagnosis of Autism Spectrum Disorder?

List your child's other developmental diagnoses (e.g., ADHD, OCD, ODD, etc.):

Could you provide us a copy of any record confirming your child's ASD diagnosis before the first lab visit?

If you cannot provide documentation of an ASD diagnosis, this screener will end here and your child will NOT be eligible for participation in this study. Are you sure you want to end the screening form now?

What type of record can you provide us? Check one or more options.

Does your child have an intellectual disability?

Does your child have hearing or vision problems?

In the last two months, did your child undergo any surgery or experience any physical injury or trauma that would affect their ability to engage in physical or movement activity?

If you responded yes to the previous question, please briefly describe the surgery, injury, or trauma.

Does your child have any medical (heart or breathing-related), behavioral, or neurological problems that may affect their ability to engage in physical or movement activity with some supervision?

If you responded yes to the previous question, please briefly describe their medical/behavioral/neurological problems.

Does your child get seizures?

If you responded yes to the previous question, please briefly describe their history of seizures.

How much support/help does your child need (minimal to none, moderate, or significant) to complete daily activities (e.g., tying shoelaces, zipping, dressing, organizing desk, bed, clothes, eating/cleaning up, managing his schedule, self-care, and assisting you around the house, etc.)?

If there is a need for moderate to significant support, please list some activities that need your support.

Is your child non-verbal (uses no words), low-verbal (can use one to two-word phrases) or high-verbal (can use greater than two-word phrases) in their communication abilities?

Does your child understand what you and others are saying, for example, will your child follow 1-step commands, such as "move like this"?

Does your child have difficulty with gross motor skills such as playing on the playground or sport-related activities - ball throwing, catching, etc. or moving his/her body through space (jump, hop, etc.)?

If you responded yes to the previous question, please briefly describe your child's gross motor difficulties.

Does your child have difficulty with fine motor skills such as playing with blocks/legos (fitting pieces together), drawing/coloring, or hand writing or daily living skills like zipping or tying shoe laces?

If you responded yes to the previous question, please briefly describe your child's fine motor difficulties.

Is English your child's first language?

If your child's first language is not English, please specify the language spoken to your child at home.

Would you be able to come to our lab for the testing sessions?

Would you be able to visit the DFit community center at 2150 New Castle Ave, New Castle, DE for the videogaming training 2-3 times per week?

If you are ineligible for this study, do we have your permission to keep your contact information to re-contact you about future studies?