Service Dogs for Autism Survey

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This survey has five sections, and may take up to 15 minutes to complete.   Throughout the survey, your family member with autism is referred to as “Family Member” or “Family Member with Autism.”  The service dog is referred to as “Service Dog.”
Section One: About the Family Member with Autism Before The Service Dog This section asks you to remember the symptoms of autism that your Family Member experienced before working with a trained Service Dog.  This section also asks you to consider the impact that autism had on you family before the Service Dog joined your household.
1	What is the gender of the Family Member with Autism?	Male Female
2	How old was the Family Member with Autism when the Service Dog arrived?
3	Each of the following items represents a common symptom of autism, and has a brief description of example.  For each item, choose the best description of how your Family Member's life was impacted by that symptom of autism before working with the service dog.
	Mild or very little impact Moderate impact Severely Impacted
		Communication: What was the impact of Autism on your Family Member's ability to get their wants and needs met?  A mild impact might be a child who uses sentences on a regular basis to get their wants and needs met, while someone who is non-verbal may be considered severe.
		Self-Stimulatory Behaviors: How frequntely and severely did repetitive behaviors (such as hand flapping or repetitive vocalizations) impact your Family Member's ability to pay attention, participate, and learn?
		Rituals and Obsessions: How frequently did rituals (such as routines) or obsessions (such as special interests) interrupt your Family Member's ability to pay attention and participate, or cause your family to have to change routines to avoid problem behaviors?
		Other Behavior Problems: How severely was your Family Member's life impacted by other behavior problems, such as tantrumming, self-injury, running away, etc.?
		Social Skills: How much did deficits in social skills (such as making friends, making eye contact, or avoiding other people) impact your Family Member's ability to participate with his or her peers?
4	The following questions ask you to rate the impact of your Family Member's autism on his or her day to day life, as well as the impact on the family.  Remember to answer these questions in terms of your Family Member before working with a Service Dog. 1 2 3 4 5 Never Ocassionally Sometimes Often Always
	1 2 3 4 5	My family member was able to participate with his/her typical peers at school or work with minimal or no assistance
	1 2 3 4 5	My Family Member was making good progress at school or work, including being successful at their work, learning new things, and pleasing their teachers / boss.
	1 2 3 4 5	My Family Member was able to go most places in the community with the same level of independence as his/her peers
	1 2 3 4 5	My Family Member enjoyed rich and full relationships with other people in our family.
	1 2 3 4 5	My Family Member took care of himself (brushing teeth, dressing, etc.) in the same way most of his/her peers could.
5	Has your Family Member with Autism participated in any of the following services during the time they have worked with the Service Dog (whether or not the Service Dog attended the therapy with them) Yes No   ABA-based in-home or center-based therapy more than 10 hours per week (count Verbal Behavior and Pivotal Response Training as ABA-based therapies) Floor Time, Greenspan or Relationship Development Intervention Specialized day pogram, classroom, or non-public school for people with Autism Speech Therapy Occupational Therapy Music Therapy Other Animal Therapies
Section Two: About the Service Dog This section asks you to consider the Service Dog who works with your Family Member, includig the ways in which they help your family and Family Member, and what the training process for the dog was like.
6	How old was the Service Dog when he/she came to live with your family?
7	What breed of dog is the Service Dog?
8	Different families choose many different avenues towards bringing a Service Dog into their family.  In the following items you will rate your family's experience with each of several common steps in getting a Service Dog.  Your choices range from "intensive and exhaustive" to "none at all." These ratings shouldn't be based on how good or bad, adequate or inadequate you felt the training was (that will come later).  For this question, answer only in regards to how intensive or how much time was spent for each of the common steps.
	Intensive, Thorough Moderate, Average Minimal or None at all   Assessment and Application: Rate the process that you went through to apply for a service dog.  Consider your interactions with the provider of the service dog, their efforts to fully understand your Family Member's needs, and requirements placed on your family to qualify for a Service Dog with the provider Time with Trainer: Rate the amount of time and training that your Service Dog recieved from the provider.  Consider if the dog recieved one or more years of rearing and training, or if you brought the dog home as a puppy.  This question applies only to time the Service Dog lived with a trainer, provider, or host family -- not time that a trainer came to visit with your family in your home / environment to train the Service Dog. Preparation for Family Member with Autism: Rate the amount of preparation that was given to the Family Member with Autism before the dog came.  Some families use social stories, rehearsals, visits, or even desensitization training for individuals who may be afraid of dogs.  For other families, less preparation may be done. Training with Family: Consider the amount of and intensity of the instruction your family and the Service Dog recieved from the trainer.  This might include 2+ weeks dedicated to family training with parents or primary caregivers, or a trainer coming to you to work with your family in the home or community.
9	Was the training your family and the Service Dog recieved adequate to enable the Service Dog to meet the needs of your Family Member with Autism?  Were you satisfied with the training that your Service Dog and your Family recieved?
	1  Completely Satisfied 2 Mostly Satisfied 3 Somewhat Satisfied 4 Mostly Dissatisfied 5 Very Dissatisfied
10	Once your family had decided to obtain a Service Dog for your Family Member with Autism, and/or had been approved by a provider, how long did you wait before you were able to bring a dog home? 0 to 3 months 4 to 6 months 7 to 9 months 10 to 12 months up to 18 months 2 years or more
11	In what locations does the Service Dog assist your Family Member with Autism?  Does he/she accompany your Family Member to. . . . Yes No Location School or Work Formal Community Social Events (church, theater, etc.) Every Day Community Locations (such as shops and restaurants) Outdoor community areas (such as parks) Inside the home, around the house
12	How often have you experienced resistance to the Service Dog from members of the community (such as being asked to remove the dog from a shop, asked to not bring the dog to different locations, or felt that others were uncomfortable with or disapproving of the dog's presence)? 1  Never 2 Maybe Once 3 Monthly 4 Weekly 5 Daily
13	For the next several items, identify whether or not the Family Member is the primary person to care for each of the dog’s needs.  If the family member is responsible for meeting the need, but needs help to do it, answer yes as long as the Family Member is involved in the care at least 8 out of 10 opportunities.  Answer no when a person other than the Family Member is primarily responsible. Yes No   Walks the dog Feeds the dog Grooms the dog Provides affection and companionship to the dog Gives commands to the dog Provides training with social and food rewards
14	There are many different 'functions' or jobs that your Service Dog may perfom for your Family Member with Autism.  Please use the drop-down lists to rank each job that your Family Member's Service Dog does.  Use each number (1-5) no more than once.  Use '0' for any jobs that is not applicable, or is not a job that your Family Member's Service Dog does. Rating Function of Dog 0 - n/a 1 - nice to have 2 3 - important 4 5 - critical Tethering to family member to keep them safe in the community 0 - n/a 1 - nice to have 2 3 - important 4 5 - critical Provide for search and rescue by orienting to Family Member and searching for if missing 0 - n/a 1 - nice to have 2 3 - important 4 5 - critical Provide comfort and companionship, decrease anxiety 0 - n/a 1 - nice to have 2 3 - important 4 5 - critical Encourage interactions with others 0 - n/a 1 - nice to have 2 3 - important 4 5 - critical Interrupt or disrupt self-stimulatory behaviors or other behavior problems 0 - n/a 1 - nice to have 2 3 - important 4 5 - critical Identify your family member to the community as a person with a disability
15	Which of the following best describes how your family relates to the Service Dog? As an adaptive tool for the Family Member with Autism to use. An adaptive tool for other family members to use to ensure the safety of the Family Member with Autism Primarily a support to the family member with autism, but also a member of the family. Primarily a member of the family
Section Three: About the Family Member with Autism after working with a Service Dog This section asks you to remember the symptoms of autism that your Family Member experienced after working with a trained Service Dog.  This section also asks you to consider the impact that autism has on your family now.
16	How long has your Service Dog been living with your Family Member with Autism? 0 to 3 months 4 to 6 months 7 to 9 months 10 to 12 months up to 18 months 2 years or more
17	Each of the following items represents a common symptom of autism, and has a brief description of example.  For each item, choose the best description of how your Family Member's life is impacted by that symptom of autism after working with the service dog.
	Mild or very little impact Moderate impact Severely Impacted
		Communication: What is the impact of Autism on your Family Member's ability to get their wants and needs met?  A mild impact might be a child who uses sentences on a regular basis to get their wants and needs met, while someone who is non-verbal may be considered severe.
		Self-Stimulatory Behaviors: How frequntely and severely do repetitive behaviors (such as hand flapping or repetitive vocalizations) impact your Family Member's ability to pay attention, participate, and learn?
		Rituals and Obsessions: How frequently do rituals (such as routines) or obsessions (such as special interests) interrupt your Family Member's ability to pay attention and participate, or cause your family to have to change routines to avoid problem behaviors?
		Other Behavior Problems: How severely is your Family Member's life impacted by other behavior problems, such as tantrumming, self-injury, running away, etc.?
		Social Skills: How much dodeficits in social skills (such as making friends, making eye contact, or avoiding other people) impact your Family Member's ability to participate with his or her peers?
18	The following questions ask you to rate the impact of your Family Member's autism on his or her day to day life, as well as the impact on the family.  Remember to answer these questions in terms of your Family Member after working with a Service Dog. 1 2 3 4 5 Never Ocassionally Sometimes Often Always
	1 2 3 4 5	My family member is able to participate with his/her typical peers at school or work with minimal or no assistance
	1 2 3 4 5	My Family Member is making good progress at school or work, including being successful at their work, learning new things, and pleasing their teachers / boss.
	1 2 3 4 5	My Family Member is able to go most places in the community with the same level of independence as his/her peers
	1 2 3 4 5	My Family Member enjoys rich and full relationships with other people in our family.
	1 2 3 4 5	My Family Member takes care of himself (brushing teeth, dressing, etc.) in the same way most of his/her peers can.
19	Individuals with Autism who are using a Service Dog are reported to go through a wide variety of changes.  If you feel like the questions in this survey have not given you an opportunity to fully describe the ways in which your Family Member has benefited from using a Service Dog, please use the space below to give us more detail:
Section Four: Concerns with Using a Service Dog This question asks you about common concerns that might occur with using a Service Dog.  Please take your time, and consider these carefully.
20	Very Concerned Concerned Somewhat Concerned Not Very Concerned Not Concerned   Initial cost of service dog Cost of caring for the dog Lifespan of dog, loss of dog Negative reaction of the community Family Member's dependence on the Service Dog Social stigma in the community Family Member with Autism is rough with the dog Other people (such as siblings) in the home are jealous of the dog The dog being a distraction at school, work, or home Decreased interactions with others
Section Five: Demographic Information To complete the survey, and submit it to our researchers, please fill out the following information regarding the person filling out this survey
21	Your relationship to the Family Member with Autism?	Mother Father Grandparent Sibling Other
22	Household Income:	Up to $30,000 Up to $50,000 Up to $75,000 Up to $100,000 More than $100,000
23	Which best describes your ethnicity?	White / Caucasian Black or African American Hispanic / Latino Asian Native American Other No Response
24	If you live in the United States, please enter the postal abbreviation for your state (i.e CA for California).  If you live outside of the United States, please enter the name of the country that you live in:
25	Where did you hear about this Survey?