CAPTAIN Surver

First Name:

Last Name:

Agency you are representing (Who nominated you for CAPTAIN?) conduct surveys?

SELPA/School District

Regional Center

FRC/FEC

UCEDD

CDE

DDS

County in which you provide the most services/support.

Your position or role in supporting individuals with ASD:

If "Other" position or role supporting individuals with ASD applies, briefly describe:

Highest degree held:

List additional licenses, credentials or certifications held:

Number of years in your field:

Number of years in your current position: