1.

Name: optional
2. On what city do you live?
3. Gender of your child
a. Male
b. Female
c. Others: please specify
4. How old is your child?
5. Are you aware of what is autism? Rate how knowledgeable you are about the spectrum disorder
With one being the lowest and 10 being the highest
6. How did you know that your child/relative has an autism?
a. Clinically diagnosed by a professional
b. By observation
c. It is obvious
7. Gender of your child
d. Male
e. Female
f. Others: please specify
8. How severe is your child/relative’s autistic tendency?
a. High severity
b. Low severity
c. Atypical
9. What are you most afraid of, as a parent, having a child with special needs?
a. My child being bullied by others
b. The thought that he won’t be independent when she/he grows up
c. Others calling names to my child (labels such as monggoloid and such)
d. I’m afraid that we have no means of supporting him deliberately
e. Others: please specify
10. Please select everything that you have noticed your youngster performing thus far.
a. Prefers to be alone
b. Has communication skills
c. Does not directly look at the eye
d. Repetitive actions, or utterance of words (ex: pacing back and forth,
e. Not sharing thoughts, stories, or interests to you
f. Requires special attention
g. Sensitivity to light
h. Sensitivity to sound
i. Sensitivity to touch
j. Sensitivity to taste/has a taste preference
k. Organizes things neatly (Ex: lining up toys in a specified manner)
l. Flaps hand repetitively
m. Habit to turn heads repetitively, or head rocking
n. Paces or walks back and forth, sometimes looks like lost
o. Excels on a particular activity or has a High IQ (Example: excellent in solving math problems,
playing instruments, writing, and such)
 p. Unconsciously saying hurtful words
q. Antisocial, locks in the room
r. Lack of facial expression
s. Slow in responding when called
t. Aggressive/physically hurts others
u. Difficulty sleeping
v. Unusual tone of voice/robotic voice
w. Exercises self-harm (example: head banging into the wall) and others
x. Has an own world
y. Others:
11. Have you yet seen an expert to assist your child?
A. Yes
B. No
C. I am planning to in the future
12. If your answer in number 6. Is yes and you are intending to. Do you have the means: funds,
transportation vehicle, access to the city proper’s resources?
a. Yes
b. No
c. We will seek ways
13. If there is an Autism Spectrum Disorder Learning and Learning and Therapy Center in your
location or in the country, are you willing to sign up your child there?
a. Yes, of course!
b. No, I don’t really think it would change a thing.
c. I am not sure. It depends.
d. I am already sending my child to one of those in the present time
14. What help or therapy are you willing to sign up your child into?
A. Behavioral therapy
B. Specialized education
C. Speech therapy
D. All of the above
E. Others: please specify
15. Do you as a guardian or parent, willing to be with your child as the therapy undergoes?
a. Of course!
b. Maybe, depending on my schedule
c. No, I’ll trust the experts on the field
16. Lastly, may particular ba na preferences yung relative o anak mo sa mga kwarto o space sa
bahay niyo? (halimbawa: ayaw sa masisikip, ayaw sa matitingkad na kulay ng pader, etc) please
feel free to express your thoughts on the space provided
17. Please upload a picture of you and the child experiencing autism spectrum disorder (Just in case
that my professor requires some proof). I promise that I will not disclose any information,
without your permission. Thank you.