STatewide Autism Resources and Training (START)
Pre-Training Questionnaire ~ 12-12
Site name: _________________________________
Date: ______________________
Name: _____________________________________________________________________________
School Site/Agency Affiliation: _________________________________________________________
Mailing Address: ____________________________________________________________________
Position Title: _______________________________________________________________________
Email Address: ______________________________________________________________________
Phone number:
School: _________________
OR
Home: _____________________
Educational Attainment: Degree(s), Certification, Endorsement(s). List: _______________________
____________________________________________________________________________________
Status:
Certified Sp.Ed
Current Field:
__ Autism Consultant
__ School Administrator
__ Special Ed. Teacher
__ General Ed. Teacher
Autism Endorsed
Licensed
__ Social Worker
__ Speech/Language Spec.
__ Occupational Therapist
__ Parapro/ Aide
Other: ____________________
__ Psychologist/Counselor
__ Parent
__ Other: __________________
Number of years in current position: _____________
Number of years in education:
<1 yr.
1-5 yrs.
6-10 yrs.
11-15 yrs.
16+ yrs.
Number of years working with students with Autism Spectrum Disorder (ASD):
<1 yr.
1-5 yrs.
6-10 yrs.
11-15 yrs.
16+ yrs.
Approximate number of students with ASD that you have worked with: ___________
Number of students with ASD you are working with this school year: ______________
If you are a teacher, what kind of classroom are you teaching in (check one):
____ECSE
_____ASD only preschool
_____Typical
Is your program (check one): _____half day
_____Other ___________________
_____full day
1
How many structured classes (e.g., college courses) have you taken specifically about ASD?
None
1
2-3
4-5
6+
Approximately how many workshops/conferences have you attended specifically about ASD?
None
1
1-5
5 - 10
10+
How often do you read professional journals or books about ASD?
Weekly
Monthly
Biannually
Annually
Never
How often do you visited Internet sites specifically about ASD?
Weekly
Monthly
Biannually
Annually
Never
Are there specific ASD “experts” or professionals that you tend to follow or read more than
others?
Yes
No
If Yes, list:
_________________________________________________________________________________
_________________________________________________________________________________
Do you follow a specific program model (e.g., ABA, TEACCH, Greenspan)?
Yes
No
If Yes, list:
_________________________________________________________________________________
_________________________________________________________________________________
What do you hope to get out of this training?
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
2
We are interested in learning more about your level of skill in several areas relative to providing
educational services to children with Autism Spectrum Disorder (ASD). Your responses to this survey
will be kept confidential. All data will be compiled as group data.
Please rate your level of skill in the following areas:
1
Not very skilled
3
Somewhat skilled
5
Very skilled
How skilled are you at ….
Creating a highly structured classroom environment?
1
2
3
4
5
Ensuring that students are engaged and actively learning
most of the time?
1
2
3
4
5
Developing individual schedules for students?
1
2
3
4
5
Teaching developmentally appropriate routines and behaviors?
1
2
3
4
5
Creating and supporting typical social opportunities?
1
2
3
4
5
Teaching object-focused play?
1
2
3
4
5
Teaching social interactive play?
1
2
3
4
5
Using social stories or social scripts?
1
2
3
4
5
Developing and teaching functional communication systems?
1
2
3
4
5
Using high and low tech communication supports?
1
2
3
4
5
Making and using visual supports?
1
2
3
4
5
Teaching students to initiate communication?
1
2
3
4
5
Conducting a functional assessment of behavior?
1
2
3
4
5
Developing positive behavior support plans?
1
2
3
4
5
Proactively addressing challenging behaviors?
1
2
3
4
5
Ensuring consistent responding to children across all staff?
1
2
3
4
5
Using applied behavior analysis?
1
2
3
4
5
Using discrete trial training?
1
2
3
4
5
Using incidental teaching?
1
2
3
4
5
Task analyzing a skill?
1
2
3
4
5
3
Identifying and using reinforcement effectively?
1
2
3
4
5
Using correct prompting procedures?
1
2
3
4
5
Utilizing appropriate curriculum for young children with ASD?
1
2
3
4
5
Differentiating activities for various student needs?
1
2
3
4
5
Teaching self-help skills (e.g. toileting, eating, dressing)?
1
2
3
4
5
Keeping data to show academic and behavioral progress?
1
2
3
4
5
Providing training in awareness of ASD to children/peers?
1
2
3
4
5
Educating adults about ASD?
1
2
3
4
5
Planning for transitions to elementary school?
1
2
3
4
5
Communicating with families about their child?
1
2
3
4
5
Providing parent training?
1
2
3
4
5
Developing a home activity program to support learning?
1
2
3
4
5
Conducting productive team meetings?
1
2
3
4
5
Utilizing problem solving strategies skillfully?
1
2
3
4
5
To help us better understand your program, please rate the following:
Weak
1 2
Moderate
3
4
Strong
5 6
Very Strong
7
8
Excellent
9 10
Rate the effectiveness of your school program in supporting young children with ASD.
1 2
3 4
5 6
7 8
9 10
Rate the effectiveness of your school program in supporting families of young children with ASD.
1 2
3 4
5 6
7 8
9 10
Rate the effectiveness of your school program in working with other agencies and organizations to
support young children with ASD.
1 2
3 4
5 6
7 8
9 10
4
List 4 changes that could lead to a dramatic improvement in programming for young children with ASD
in your school system.
1.
___________________________________________________________________________________
___________________________________________________________________________________
2.
___________________________________________________________________________________
___________________________________________________________________________________
3.
___________________________________________________________________________________
___________________________________________________________________________________
4.
___________________________________________________________________________________
___________________________________________________________________________________
Thank you for filling out this questionnaire.
5