Request for ADOS-2 Administration

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Email *

School District *

Name, Age and Grade of Student being evaluated. *

Have you notified parents and received consent for an Autism evaluation? If so, please provide the date you received consent. *

Please select all forms of data that have been collected. *

Observations in multiple settings

Parent Input/Interview

Teacher Input/Interview

Developmental History

Rating Scales (BASC-3, ASRS, SRS-2, GARS, Sensory Profile etc).

Adaptive Behavior Assessment

Language Evaluation

Cognitive Assessment

Other

Required

If answered "Other" to previous question, please provide more information.

Has existing data been reviewed by MDT members? *

Yes

Do all team members feel an ADOS-2 is necessary to make eligibility decisions? *

Yes

Child's Verbal Ability? *

Please select the one that BEST describes the child's verbal abilities.

Preverbal/Single Words (no speech to simple phrases)

Phrase Speech (regular production of non-echoed phrases made up of 3 independent units - sometimes containing an action verb i.e. "Baby no eat")

Fluent Speech (at least a 4-year-old level in functional expressive language or higher)

Provide a date for when the ADOS-2 needs to be completed by. *

YYYY

Is this an initial evaluation for Autism? *

Yes

Has this child been administered an ADOS-2 before? *

Yes

Unknown

Does your administrator give approval for an ADOS-2 to be administered by ESU #11 staff? *

Yes

The results of the ADOS-2 will be used as a piece of information along with multiple sources of data to make decisions regarding the verification of Autism according to NDE Rule 51.

I agree

I disagree

Clear selection

A copy of your responses will be emailed to the address you provided.

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