Research Survey

More Information

Autism has been growing at alarming rates across the world; the cause is

still unknown.

Developmental Delays and Autism Research Survey

We are conducting research based on a hypothesis of the cause(s) and as

a blind study survey, we can not at this time provide further information on what our study is,

but, after we receive a sufficient number surveys, we will examine the data and post our

findings for you to view, and hopefully move to the next step of our research...

First Name

*

Last Name

*

Email

*

If you would like results sent to you.

Service Date

*

Please specify today's date.

Survey Question: Survey

Survey Question: Do you have Children on the Autism Spectrum or with

Developmental delays?

Yes

No

If you answered "No" to this question, Please stop here.

Survey Question: How many children do you have?

None

1

2

3

4

5

6

If you answered "None", then please stop here.

Survey Question:How many of your children are autistic or have

developmental delays?

None

1

2

3

If you answered "None", then please stop here.

Survey Question:How many are under the age of 5 and are on the autism

spectrum or have developmental delays?

None

1

23

If you answered "None", then please list age in the text box above and

continue with the form.

Survey Question:Have you had a cell phone in the past 5 years?

Yes

No

Survey Question:If yes, how many cell phones registered for use in your

home?

None

1-2

3-4

5 or more

Survey Question:What is the average daily usage of your cell phones?

None

Less than 1 hour a day

1 to 5 hours a day

More than 5 hours a day

This includes texting and surfing on smart phones.

Survey Question: Do you have cable or satellite TV?

None

Cable

Satellite

Survey Question:How many satellite dishes do you have?

None

1

2

3

Survey Question:How many satellite receivers do you have?

None

1

2

3

4

5 or More

Survey Question:What is the combined daily usage of satellite viewing?

None

1 hour

2 to 6 hours

6 hours and more

If more than 6 hours, please list hours in the txt box above.

Survey Question:How many satellite remotes do you use in your home?

None

1

2

3

4

5

6 or more

If more than 6, please list in txt box above..

Survey Question:How many cable boxes do you use?

None

1

23

4 or more

If more than 4, please list in txt box above.

Survey Question:How many cable remotes do you use?

None

1

2

3

4

5

6 or more

If more than 6, please list in txt box above.

Survey Question:How many combined hours is cable TV viewed in your home?

None

1 hour

2 - 6 hours

6 hours and more

If more than 6 hours, please list hours in the txt box above.

Survey Question:Do you use wireless internet?

Yes

No

If you answered "None", then please stop here.

Survey Question:How many computers do you have that are using wireless

internet?

None

One

Two

Three

Four

Five or more

If more than five, please specify in txt box above.

Survey Question:How many computers do you have that are using wireless

internet?

None

1 hour

2 to 3 hours

3 to 4 hours

5 to 6 hours

7 to 8 hours

9 to 10 hours

11 to 12 hours

More than 12 hours a day

If more than 12 hours combined usage a day, please specify in txt box above.

Survey Question:Do you own a microwave?

Yes

No

Survey Question:What is the combined usage of the microwave per day?

None

1 hour

2 hours

3 hours

4 hours

5 hours6 hours

More than 6 hours a day

Please specify how many hours a day in txt box above, if more than 6 hours.

Survey Question:Do you live near power lines?

Yes

No

If yes, please provide how many lines are near your home and the

distance in feet in the txt box above.

Survey Question:Do you live near a radio tower?

Yes

No

If so, please state what one and how close (in Miles) in txt box above.

Survey Question:If you have or use or live by any other wireless

apparatuses, please state them in txt box below and please state the

proximity they are to you or the amount of usage per day.

Submit your survey

Only click this button once you have finished all questions and reviewed

your answers. Thank you for your time.

Contact

Mustard Seeds Therapy - Autism Therapy in Texas
Located at 212 North Oak Street, Roanoke, TX 76262
Phone: (817) 541-7770
Website:
Enroll Now!(817) 541-7770
Serving Roanoke,TX

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