New Jersey Department of Health

NEW JERSEY AUTISM REGISTRY

PO Box 364, Trenton, NJ 08625-0364

Fax: 609-292-8235	AUTISM REGISTRATION
Child’s information
Name of Child (as appears on birth certificate)
Last Name	Suffix

First Name	None Given

Middle Name

Also Known As
Last Name	Suffix

First Name	None Given

Middle Name

Child’s Current Residence Address
Street Address

Unit Description

Unit

P.O. Box

City

State

Zip Code

County

Country

Hospital / Place of Birth
Medical Facility Name or Description of Location

Unknown	City

State

Country

Primary Care Provider
Practice Name -OR- Provider Name (Last Name, First Name)

Undecided

Unknown	Telephone Number	Extension

( )
Birth Information
Date of Birth

Sex

Female

Male

Indeterminate	Birthweight

_____ Grams

-OR-

Lbs., Ozs.

-OR-

Unknown	Plurality

Single

Twin

Other Multiple: ___

Unknown	If Multiple, Birth Order:

Weeks of Pregnancy

Preterm (<37 Wks.)

Term (37-41 Wks.)

Post term (>42 Wks.)

Unknown
Ethnicity Information
Hispanic/Latino

Yes No Unknown	Primary Language Spoken in Home
English Spanish Other, Specify:
Race (Check ALL that apply)
White	Black/African American

Chinese	American Indian/Native Alaskan

Japanese	Native Hawaiian

Korean	Filipino

Vietnamese	Guamanian or Chamorro

Asian Indian	Samoan	Other Asian, Specify:
Other Pacific Islander, Specify:
Other, Specify:
Not Classifiable / Unknown
Birth Mother’s Residence at Time of Birth

(If mother was institutionalized at time of birth, enter residence address before she was institutionalized.)
Unknown	Same as child’s current residence address
Street Address

Unit Description

Unit

P.O. Box

City

State

Zip Code

County

Country

Case Tracking information	Insurance information
Medical Record Number

Birth Certificate/VIP Number

Insurance Type

None Private Medicaid Unknown
INFORMATION ON PERSON SUBMITTING REPORT
Submitted by

Diagnostician(s) or their Staff/Facility Case Manager (SCHS/EI) Primary Care Provider Other Health Care Provider/Facility
Title

Dr. Mr. Ms.	Name (Last, First)

Practice/Facility Name

Telephone Number

( )	No Phone
Street Address

Unit Description

Unit

P.O. Box

City

State

Zip Code

Country (if not USA)

PARENT A information
Parent A Vital Status

Alive Dead Unknown	Sex

Male Female	Biological

Yes No Unknown
Parent A Name
Last Name	Suffix

First Name

Middle Name

Maiden Name

Parent A Mailing Address
Same as child’s current residence address
Street Address

Unit Description

Unit

P.O. Box

City

State

Zip Code

County

Country

Parent A Legal Guardian Status

Yes No Unknown	Date of Birth

Telephone Number

( )	No Phone
PARENT B information
Parent B Vital Status

Alive Dead Unknown	Sex

Male Female	Biological

Yes No Unknown
Parent B Name
Last Name	Suffix

First Name

Middle Name

Parent B Mailing Address
Same as child’s current residence address
Street Address

Unit Description

Unit

P.O. Box

City

State

Zip Code

County

Country

Parent B Legal Guardian Status

Yes No Unknown	Date of Birth

Telephone Number

( )	No Phone
GUARDIAN INFORMATION IS TO BE COMPLETED ONLY IF NEITHER PARENT IS THE LEGAL GUARDIAN!

guardian information
Legal Guardian Status

Yes No Unknown	Guardian Type

Relative Individual (Non-Relative) Government Agency (DCP&P, etc.) Private Agency
Guardian Name
Last Name	Suffix

First Name

Middle Name

Contact Information
Telephone Number

( )	No Phone
Mailing Address
Same as child’s current residence address
Street Address

Unit Description

Unit

P.O. Box

City

State

Zip Code

County

Country

IF AGENCY IS THE LEGAL Guardian, THEN COMPLETE GUARDIAN AGENCY INFORMATION
Guardian Agency Information
Agency Name

Division/Program

Street Address

Unit Description

Unit

P.O. Box

City

State

Zip Code

County

Country

Guardian Agency Contact Information
Contact Name (Last Name, First Name)

Telephone Number

( )	No Phone
REGISTRATION
Registering this Child for:

First Registration Updated Registration Audit	YES, Parent/Guardian Requests Non‑Identifiable Autism Registration
DIAGNOSTICIAN INFORMATION
Name (Last, First)

Highest Degree

MD/DO Doctorate Masters Unknown
Specialty

Family Practice	Pediatrics–General	Pediatrics–Neurology	Social Work

Neurology	Pediatrics-Developmental/	Pediatrics–Psychiatry	Other (specify): ________________

Neuropsychology	Neurodevelopmental	Psychology	Unknown
Name of Practice/Facility where Diagnosis Made

AUTISM DIAGNOSIS INFORMATION
Autism Spectrum Disorders (ASD)

IF PREVIOUSLY DIAGNOSED, SPECIFY TYPE

(Choose One):

Autistic Disorder

Pervasive Developmental Disorder NOS

Asperger’s Disorder

No Longer Meets Criteria

NEVER Met Criteria	Date of Diagnosis (Month/Day/Year)
Is this the FIRST TIME this child

has been diagnosed with an ASD?	Yes No

If NO, then at what age was

this child diagnosed with an ASD?	Years Months
Age Symptoms First Noted by Anyone?

Years Months Unknown
Instruments/References Used (check all that apply):

ABC	Autism Behavior Checklist

ADI-R	Autism Diagnostic Interview - Revised

ADOS	Autism Diagnostic Observation Schedules

CARS	Childhood Autism Rating Scale

DSM-5	Diagnostic and Statistical Manual, 5th Ed.

DSM-IV-TR	Diagnostic and Statistical Manual, 4th Ed.-TR

GARS-3	Giliam Autism Rating Scale

Other (specify): __________________________	If Diagnosed using the DSM-5, indicate the levels of support needed for:

Restricted, Repetitive Behavior Severity Levels:

Level 3: Requiring VERY substantial support

Level 2: Requiring substantial support

Level 1: Requiring support

Social and Communication Severity Levels:

Level 3: Requiring VERY substantial support

Level 2: Requiring substantial support

Level 1: Requiring support

Unknown/Not Assessed
Additional Diagnoses (Check all that apply) NOTE: All Congenital Diagnoses should be listed below.

ADHD/ADD	Schizophrenia	Tic Disorder/Tourette’s	Obesity

Depression	Anxiety, including OCD	Seizure Disorder/Epilepsy	Eczema

Mood/Bipolar	Oppositional Defiant Disorder	Asthma	Intellectual Disability
OTHER DIAGNOSIS INFORMATION
Other Diagnosis Descriptions (Be Specific and include all congenital diagnoses):
1.
4.
2.
5.
3.
6.
SYMPTOMS/BEHAVIORS INFORMATION
Verbal Ability at the Time of Registration

Nonverbal (no language at all)

Limited verbal skills (specify all that apply below, if known):

Stereotyped and repetitive use of language (echolalia)

Problems taking steps to start a conversation/lacking pragmatic language

Uses mostly sign language/assistive devices to get needs met

Difficulty understanding others when spoken to

Verbal skills appropriate for developmental age

Unknown	Symptoms/Behaviors at the Time of Registration (Check all that apply):

Aggressiveness towards others

Constipation/gastro-intestinal issues

Coordination issues/motor skills difficulties

Excessive tantrums not due to developmental age

Feeding disorder/difficulties

Hyperlexia

Self-injurious behavior

Sensory integration issues

Sleep disruptions/disturbances

Wandering/elopement

Unknown
Intellectual Disability/Cognitive Impairment

Not measured/assessed or unknown	IQ is 71 to 85

IQ score is 70 or below	IQ is above 85
MEDICATION INFORMATION
Medication(s) Used at the Time of Registration (Check all that apply):

Alpha Agonist (guanfacine, clonidine)

Anticonvulsants (barbiturates, aldehyde, Depakote, Lamictal)

Antidepressants-SSRI (Prozac, Zoloft, Lexapro)

Antidepressants-Trycyclic, SSNRI, etc. (Cymbalta, Wellbutrin, Elavil)

Anxiolytics (Buspar, Ativan)

CAMS (Complementary/Alternative) (massage therapy, yoga, acupuncture)

Neuroleptics (Risperdal, Abilify, Seroquel)

Non-stimulants (Strattera)

Nutritional Supplements (vitamins, minerals, herbs)

Sleep Aid (Ambien, Lunesta, Rozerem, or melatonin)

Stimulants (Ritalin, Adderall)

Other (specify): ________________

Unknown
Does the child have a sibling(s) diagnosed with an ASD? Yes – How many? ______ No Unknown

AUTISM REGISTRATION (Continued)

SCH-1

NOV 16	Page 2 of 3 Pages.

NOV 16	Page 1 of 3 Pages.

SCH-1, Autism Supplemental Information

SCH-1, autism, supplemental information, special child health, registration, sch-0

ewhite

2016-11-09

NJDOH