AUTISM SPECTRUM DISORDER REPORT NORTH DAKOTA DEPARTMENT OF HEALTH (NDDoH) OFFICE OF THE STATE EPIDEMIOLOGIST SFN 60804 (4-2018) Office of the State Epidemiologist 600 E. Boulevard Ave., Dept. 301 Bismarck, ND 58505-0200 701.328.4832 or 1.800.755.2714 Fax: 701.328.2785 Website: www.ndhealth.gov/cshs/autism.htm Instructions: A mandatory reporter or the reporter’s designee must report newly diagnosed individuals to the NDDoH within 30 days of diagnosis. Previously diagnosed individuals must be reported to the NDDoH within 30 days of the individual’s first patient or client encounter with the reporter. The form must be completed in its entirety as required by NDCC 23-01-41. INFORMATION ON PERSON SUBMITTING REPORT FORM Name of the Reporter (Last, First, MI) Telephone Number Name of the Reporter's Practice/Facility City State ZIP Code Today's Date REGISTRATION INFORMATION Registration Type New Update to previously reported information Has the individual or the Parent/Guardian been informed of reporting requirements? Yes No INFORMATION OF INDIVIDUAL DIAGNOSED WITH ASD Name (Last, First, MI) Date of Birth Sex Male Female Indeterminate Address City State ZIP Code County Telephone Number Home Cell Race (Check all that apply) White Black/African American Native Hawaiian/Pacific Islander Asian American Indian/Native Alaskan Other (specify): Hispanic/Latino Yes No Refused Unknown PARENT/GUARDIAN INFORMATION IF INDIVIDUAL IS UNDER THE AGE OF 18 Name of Parent A (Last, First, MI Telephone Number Cell Home Address (Street) Same as the reported individual’s address City State ZIP Code Name of Parent B (Last, First, MI Telephone Number Cell Home Address (Street) Same as the reported individual’s address City State ZIP Code INSURANCE INFORMATION None Private Medicaid Medicare Tricare Other (specify): Asperger’s Disorder Unknown DIAGNOSTIC INFORMATION Diagnosed with Autism Spectrum Disorders (ASD) If previously diagnosed, specify type: Autistic Disorder Pervasive Developmental Disorder NOS Update to Diagnostic Information Deceased, Date of Death: Never met ASD criteria Date of Diagnosis (M/D/Y) Age at Diagnosis Yrs. < 12 months Unknown Screening/Diagnostic Tools Used (check all that apply) Adaptive Behavior Assessments (e.g., Vineland Adaptive Behavior Scales (VABS)) Autism Behavior Checklist (ABC) Autism Diagnostic Interview-Revised (ADI-R) Autism Diagnostic Observation Schedules (ADOS) Autism Spectrum Rating Scale (ASRS) Childhood Autism Rating Scale (CARS) Childhood Autism Spectrum Test (CAST) Clinical Impressions Intellectual/ Cognitive Testing (e.g., Stanford-Binet Intelligence Scale (SBIS)) Gilliam Autism Rating Scale (GAR) Modified Checklist for Autism in Toddlers (M-CHAT) Social Responsiveness Scale Other (specify): Unknown
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AUTISM SPECTRUM DISORDER REPORT NORTH DAKOTA DEPARTMENT OF HEALTH (NDDoH) OFFICE OF THE STATE EPIDEMIOLOGIST SFN 60804 (4-2018)
Office of the State Epidemiologist 600 E. Boulevard Ave., Dept. 301 Bismarck, ND 58505-0200 701.328.4832 or 1.800.755.2714 Fax: 701.328.2785 Website: www.ndhealth.gov/cshs/autism.htm
Instructions: A mandatory reporter or the reporter’s designee must report newly diagnosed individuals to the NDDoH within 30 days of diagnosis. Previously diagnosed individuals must be reported to the NDDoH within 30 days of the individual’s first patient or client encounter with the reporter. The form must be completed in its entirety as required by NDCC 23-01-41.
INFORMATION ON PERSON SUBMITTING REPORT FORM Name of the Reporter (Last, First, MI) Telephone Number
Name of the Reporter's Practice/Facility City State ZIP Code
Today's DateREGISTRATION INFORMATION
Registration TypeNew Update to previously reported information
Has the individual or the Parent/Guardian been informed of reporting requirements? Yes No
INFORMATION OF INDIVIDUAL DIAGNOSED WITH ASDName (Last, First, MI) Date of Birth Sex
Male Female Indeterminate
Address City State ZIP Code
County Telephone Number HomeCell
Race (Check all that apply)White Black/African American Native Hawaiian/Pacific IslanderAsian American Indian/Native Alaskan Other (specify):
Hispanic/LatinoYes NoRefused Unknown
PARENT/GUARDIAN INFORMATION IF INDIVIDUAL IS UNDER THE AGE OF 18Name of Parent A (Last, First, MI Telephone Number
CellHome
Address (Street) Same as the reported individual’s address City State ZIP Code
Name of Parent B (Last, First, MI Telephone NumberCellHome
Address (Street) Same as the reported individual’s address City State ZIP Code
INSURANCE INFORMATIONNone Private Medicaid Medicare Tricare Other (specify):
Asperger’s Disorder
Unknown
DIAGNOSTIC INFORMATIONDiagnosed with Autism Spectrum Disorders (ASD)If previously diagnosed, specify type:
Autistic DisorderPervasive Developmental Disorder NOS
Update to Diagnostic Information
Deceased, Date of Death:Never met ASD criteria
Date of Diagnosis (M/D/Y)
Age at Diagnosis
Yrs. < 12 monthsUnknown
Screening/Diagnostic Tools Used (check all that apply)Adaptive Behavior Assessments (e.g., Vineland Adaptive Behavior Scales (VABS))Autism Behavior Checklist (ABC) Autism Diagnostic Interview-Revised (ADI-R) Autism Diagnostic Observation Schedules (ADOS)Autism Spectrum Rating Scale (ASRS) Childhood Autism Rating Scale (CARS) Childhood Autism Spectrum Test (CAST) Clinical Impressions
Intellectual/ Cognitive Testing (e.g., Stanford-Binet Intelligence Scale (SBIS))Gilliam Autism Rating Scale (GAR) Modified Checklist for Autism in Toddlers (M-CHAT) Social Responsiveness Scale Other (specify): Unknown
www.ndhealth.gov/cshs/autism.htm
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SFN 60804 (4-2018)Page 2 of 2
ASD Diagnosis was Made: Independently by a single provider Interdisciplinary/multidisciplinary team approach Other (specify): Unknown
Were the following evaluations done by a licensed independent practitioner as part of the diagnostic process for ASD?
Physical Evaluation Completed Hearing Test Done Have Excluded Organic Causes
Yes No UnknownYes No UnknownYes No Unknown
Co-morbidities (check all that apply)ADHD/ADDAnxietyBipolar DisorderDepressionDown SyndromeFeeding/Eating Disorders
Fragile X Syndrome Gastorintestinal Symptoms (e.g., GERD)Immune DisordersIntellectual disabilityMicrocephaly/MacrocephalyObesity
Obsessive Compulsive DisorderOppositional Defiant DisorderSchizophreniaSeizures/EpilepsySensory Processing DisordersSleep Disorders
Tourette Syndrome/Tic DisordersTuberous SclerosisOther (specify):NoneUnknown
DIAGNOSTICIAN INFORMATIONName of the Diagnostician (Last, First, MI) Unknown Degree of Diagnostician (Select One)
M.D. D.O. Psy.D. Ph.D. Masters
Specialty of DiagnosticianSocial Work (e.g., LICSW)
Other (specify):
Psychology
Psychiatry
Pediatrics
Nursing (e.g., NP, CNS)
Neurology
Internal Medicine
Family PracticeCounseling (e.g., LPCC, LMFT)
Clinical Genetics
Name of Diagnostician’s Practice/Facility City State
BIRTH INFORMATIONBirth Weight
Lbs., Oz. UnknownPlurality
Single Twin Other Multiple UnknownHospital/Place of Birth
City State ZIP Code Mother’s Age at Time of Delivery Father’s Age at Time of Delivery
Weeks of PregnancyEarly Term (between 37 weeks 0 days and 38 weeks 6 days)Late Term (between 41 weeks 0 days and 41 weeks 6 days)Full Term (between 39 weeks 0 days and 40 weeks 6 days)
Post Term (between 42 weeks 0 days and beyond) Other (specify):Unknown
Have Any Siblings Been Diagnosed with ASD?Yes, how many: No Unknown
EACH SIBLING WITH AN ASD DIAGNOSIS SHOULD BE REGISTERED ON A SEPARATE FORM
SERVICE UTILIZATIONAge Symptoms First Noted by Anyone
Yrs -OR- Less than 12 months-OR- Unknown Yrs -OR-
Age When Services First StartedUnknownLess than 12 months-OR-
What Services Have Been Utilized (mark all that apply)ASD Medicaid WaiverASD Services Voucher Program
Early Intervention Program (e.g., Right Track Infant Development) Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) (e.g., Health Tracks)
Home and Community Based Services (HCBS)/Developmental Disabilities (DD) Waiver
Special Education Services (e.g., IEP)
Therapy (specify):
Other (specify): 504 Plan
UnknownNone
If None, Why Not
Other (specify):Unknown
Currently being referredOn waiting list
Didn’t need servicesDidn’t qualify for services
Didn’t know about available services Aged out before services could be utilized
BEHAVIOR/RISK ASSESSMENT At the time of submission has the individual had any of the following behaviors
Aggressiveness towards others
Self-injurious behavior (e.g., head banging, punching or hitting oneself, hand/arm biting, picking at skin or sores, swallowing dangerous substances or objects, and excessive rubbing or scratching)
Wandering/elopement No Unknown
At the time of submission has the individual ever been admitted to any of the following because of the previously listed behaviors?Psychiatric Residential Treatment Facility Residential Care Facility Emergency Department/Emergency Room No Unknown
AUTISM SPECTRUM DISORDER REPORTNORTH DAKOTA DEPARTMENT OF HEALTH (NDDoH)
OFFICE OF THE STATE EPIDEMIOLOGISTSFN 60804 (4-2018)
U:\GRAPHICS\Seal.tif
Office of the State Epidemiologist600 E. Boulevard Ave., Dept. 301
Bismarck, ND 58505-0200701.328.4832 or 1.800.755.2714Fax: 701.328.2785Website: www.ndhealth.gov/cshs/autism.htm
SFN 60804 (4-2018)
Page of
Instructions: A mandatory reporter or the reporter’s designee must report newly diagnosed individuals to the NDDoH within 30 days of diagnosis. Previously diagnosed individuals must be reported to the NDDoH within 30 days of the individual’s first patient or client encounter with the reporter. The form must be completed in its entirety as required by NDCC 23-01-41.
INFORMATION ON PERSON SUBMITTING REPORT FORM
REGISTRATION INFORMATION
Registration Type
Has the individual or the Parent/Guardian been informed of reporting requirements?
INFORMATION OF INDIVIDUAL DIAGNOSED WITH ASD
Sex
Telephone Number
Race (Check all that apply)
Hispanic/Latino
PARENT/GUARDIAN INFORMATION IF INDIVIDUAL IS UNDER THE AGE OF 18
Telephone Number
Address (Street)
Telephone Number
Address (Street)
INSURANCE INFORMATION
DIAGNOSTIC INFORMATION
If previously diagnosed, specify type:
Update to Diagnostic Information
Age at Diagnosis
Yrs.
Screening/Diagnostic Tools Used (check all that apply)
ASD Diagnosis was Made:
Were the following evaluations done by a licensed independent practitioner as part of the diagnostic process for ASD?
Physical Evaluation Completed Hearing Test Done Have Excluded Organic Causes
Co-morbidities (check all that apply)
DIAGNOSTICIAN INFORMATION
Name of the Diagnostician (Last, First, MI)
Degree of Diagnostician (Select One)
Specialty of Diagnostician
BIRTH INFORMATION
Birth Weight
Lbs.,
Oz.
Plurality
Weeks of Pregnancy
Have Any Siblings Been Diagnosed with ASD?
EACH SIBLING WITH AN ASD DIAGNOSIS SHOULD BE REGISTERED ON A SEPARATE FORM
SERVICE UTILIZATION
Age Symptoms First Noted by Anyone
Yrs -OR-
Yrs -OR-
Age When Services First Started
What Services Have Been Utilized (mark all that apply)
If None, Why Not
BEHAVIOR/RISK ASSESSMENT
At the time of submission has the individual had any of the following behaviors
At the time of submission has the individual ever been admitted to any of the following because of the previously listed behaviors?
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