DELAWARE AUTISM SURVEILLANCE AND REGISTRATION
AUTISM REGISTRY REPORTING FORM

Any case of an autism spectrum disorder (ASD) is reportable to the Delaware Autism Registry
within one month of diagnosis.
Follow-up reporting is due each year.


PATIENT INFORMATION

Child’s Name: __________________________________________________________________
		Last               	    First                            MI
Date of Birth: 		/	/	
             	MM	  DD	   YYYY	
Hospital of Birth: _____________________________________________________________
Place of Birth: ________________________________________________________________					

Child’s Address: _______________________________________________________
City: _____________________ State: _____Zip: __________ 		
Sex:   _____M  _____ F                  Phone: (_____)_____________________


Race – check all that apply:
_ White
_ Black or African American
_ American Indian or Alaska Native
_ Asian Indian
_ Chinese
_ Filipino
_ Japanese
_ Korean
_ Vietnamese
_ Other Asian: _____________
_ Native Hawaiian
_ Guamanian or Chamorro
_ Samoan
_ Other Pacific Islander: ___________
_ Other: ________________________
Ethnicity – Hispanic:  _ Yes      _ No

If Yes, please specify:
   _ Mexican, Mexican American, Chicano
   _ Puerto Rican
   _ Cuban
   _ Other:  ________________________



Parent/Legal Guardian (name):______________________________________________________ 
				Last              First			MI
Address (if different than child): ________________________________________________
City: __________________ State: ________  Zip: ________	
Age symptoms first noted: _____________________ 
County and State of Residence at time of Diagnosis: _______________________________
Current Medication(s) (please specify): 												
															
Diagnosis
_____ Autistic Disorder                     _____ Asperger’s Disorder      
_____ Pervasive Developmental Disorder      _____ Rett’s Disorder
_____ Childhood Disintegrative Disorder     _____ Other (please specify): 								
Date of Diagnosis: ____________________ Co-morbidities: ___________________________						

DIAGNOSTICIAN INFORMATION

Name: ___________________________________________________________________
	Last       	 First                MI		  Title                
Address: ________________________________________________________________
City: ______________________ State: ________Zip: _________		
Phone Number: (____)______________________ Fax: (____)___________________  
Licensure Type: _________________________________________________________				
Highest degree attained: ________________________________________________ 
Year attained: __________					
Specialty: ______________________________________________________________  
Subspecialty: ___________________________________________________________
				
Facility where diagnosis was made:
	_____Private Practice (name): 								
        _____Specialty Clinic (name): 								
        _____Practice (name): 									
	_____Hospital (name): 									
        _____Other (name of facility): 								

Diagnostician Signature: ____________________________________________________________ 
Reporting Date: __________________			



				Doc No. 35-05-20/05/09/14



Instructions for Completing the Delaware Autism Surveillance System Reporting Form
Please submit within one month of diagnosis and annually.


PATIENT INFORMATION
Child’s name:  last name, first name, middle initial
Date of Birth:  child’s date of birth, month/day/year
Hospital of Birth:  name of hospital where child was born
Place of Birth:  city, state where child was born
Child’s address:  street address, city, state, and zip code
Sex:  check male or female
Phone number:  area code and phone number
Race:  check all that apply; fill in “other” if needed
Ethnicity:  check Hispanic Yes, or No;  If Hispanic Yes, check the origin listed,  
or fill in  “other” if needed
Parent or legal guardian:  last name, first name
Parent or legal guardian address:  (if different than child’s)
Age symptoms first noted:  the age when the symptoms of an Autism Spectrum Disorder 
(ASD) were first noted by parent, caregiver or physician
County and State of Residence at time of Diagnosis:  county and state where patient 
lived at time of diagnosis
Current Medication(s):  list all medications that the patient is taking at the time 
of diagnosis
Diagnosis:  Check confirmed diagnosis
Date of diagnosis:  date on which the diagnosis of an ASD was made
Co-morbidities:  list any other condition(s) that co-exists with the ASD

DIAGNOSTICIAN INFORMATION
Name:  name of diagnostician: last name, first name, middle initial, title
Address:  street address, city, state, and zip code
Phone number:  area code and phone number
Fax number:  area code and phone number
Licensure Type:  type of licensure, if any, attained by diagnostician
Highest Degree and Year Attained:  highest degree and year attained by diagnostician
Specialty:  diagnostician area of specialty 
Subspecialty:  diagnostician area of subspecialty, if any
Facility where diagnosis was made:  check type of facility and fill in name of facility 
where diagnosis was made
Diagnostician Signature:  signature of the person/diagnostician who made the diagnosis
Reporting Date:  date the diagnostician reporting form was filled out