Guest guest Posted April 13, 2010 Report Share Posted April 13, 2010 Hi I'm interested in taking the survey but for some reason when I click the reply, the text looks really weird, can hardly read it. Could you email the survey to me instead? My email addr is kjonesgirl@... Thanks! > > Hello, > My name is . My partner, , and I are performing a research study on the effects of children with autism on parental stress at our college, California Baptist University. We are looking for parents of children with autism to fill out two short surveys, which we have at the bottom of this email. We are using random sampling so we do not need anyone of specific circumstances. Our survey asks for contact information, but if you do not feel comfortable doing so, you may fill out the survey without that information included. We do ask though that you include whether you are the father or mother in place of that information. We will be holding all your information confidential. We do need this surveys promptly if you can. > Thank you for your time and effort in helping us further are research. > > > SURVEY #1 >  > Hamilton Anxiety Scale > Below is a list of phrases that describe certain feeling that people have. Rate yourself by finding the answer which best describes the extent to which you have these conditions. Select one of the five responses for each of the eleven questions. > 0 = Not present    1 = Mild    2 = Moderate    3 = Severe    4 = Very Severe > 1.      Anxious Mood: Worries, anticipation of the worst, fearful anticipation, irritability. > 0    1    2    3    4 > 2.      Tension: Feelings of tension, fatigability, startle response, moved to tears easily, trembling, feelings of restlessness, inability to relax. > 0    1    2    3    4 > 3.      Fears: Of dark, of strangers, of being left alone, of animals, of traffic, of crowds. > 0    1    2     3    4 > 4.      Insomnia: Difficulty in falling asleep, broken sleep, unsatisfying sleep and fatigue on waking, dream, nightmares, night terrors. > 0    1    2    3    4 > 5.      Intellectual: Difficulty in concentration, poor memory. > 0    1    2    3    4 > 6.      Depressed Mood: Loss of interest, lack of pleasure in hobbies, depression, early waking, diurnal swing. > 0    1    2   3   4 > 7.      Somatic (Muscular): Pains and aches, twitching, stiffness, myoclonic jerks, grinding of teeth, unsteady voice, increased muscular tone. > 0    1    2    3    4 > 8.      Somatic (Sensory): Tinnitus, blurring of vision, hot and cold flashes, feelings of weakness, pricking sensation. > 0    1    2    3    4 > 9.      Cardiovascular Symptoms: Tachycardia, palpitations, pain in chest, throbbing of vessels, fainting feelings, missing beat. > 0    1    2    3    4 > 10.  Respiratory Symptoms: Pressure or constriction in chest, choking feelings, sighing, dyspnea. > 0    1    2    3    4 > 11.  Autonomic Symptoms: Dry mouth, flushing, pallor, tendency to sweat, giddiness, tension headache, raising of hair. > 0    1    2    3    4 >  > SURVEY #2  > Autism Survey >  > We keep your information confidential but may need your information for any possible further questions we may have. Thank you for your participation. >  > Name: ________________________________________ > E-mail:_________________________ (DOT) _________ > Phone #:______-______-________ >  >  >  >  >  >  >  >  >  >  > 1.      Gender of child with autism? > a.         male         female > 2.      What is the severity of your child’s autism? > a.                                          \                                         \                                         \                                                                                       \                                         \                                         \                                         \   > b. If needed, rate on a scale from one to ten. One being mild to ten being very severe. >           1         2         3         4         5         6         7         8         9         10 > 3.      Does your child with Autism have any additional disabilities? > a.      Yes______ No_____ > a.  If yes, what are those disabilities?    ________________________________________________________________________________\ ________________________________________________________________________________\ ____                                      \                                         \                                         \                              > 4.      How old is your child with Autism? > a._____________                                            \                                         \                                         \                                    > 5.      What are the top five strongest characteristics of your child with Autism? > a._______________________________________________                                            \                                         \                                         \                                         \  > b._______________________________________________ > c._______________________________________________ > d._______________________________________________ > e._______________________________________________ > 6.      Does your child with autism take any medication? > a.  If yes, what for? ___________________________________________________________ > 7.      Does your child with Autism attend a special education school or mainstream school? > a.  What school? _____________________________________________________________ > 8.      Is he/she offered any programs to benefit his/her studies? > a.      If yes, please explain. ________________________________________________________________________________\ ____________________________________________________________________________ > 9.      Do you spend quality time with your child with Autism each day? > a.  If so, about how much time? ____________________hrs > 10.  Are you quick to anger with your child with autism? > a.      yes___ no___ > 11.  Who spends the most time with your child with autism? > a.  Mother > b.  Father > c.  Sibling > d.  Nanny > e.  Caregiver > f.   Other > 12.  Do you have any children without autism? > a.  If yes, please list gender and age. >      i._______________________ >      ii._______________________ >      iii.______________________ >      iv.______________________ > 13.  If you have children without autism, how much quality time do you spend with each of them? > a.___________________________________________hrs > 14.  Are you quick to anger with your children without autism? > a.      Yes___ No___ > 15.  What is your stress level per day? One being lowest and ten being highest? > a.  1         2         3         4         5         6         7         8         9         10 > 16.  How often do you let out your stress in a week? > a. Never > b. 1-2 times > c. 3-4 times > d. 5 or more times > 17.  How many hours of sleep a night do you get on a regular basis? > a.      _______________hours > 18.  Does working with your child and the stress that it may cause have any effect on your marriage relationship if married? > a.       Yes___ No___ > Quote Link to comment Share on other sites More sharing options...
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