Example:

SURVEY ON COMPUTERS AND KIDS WITH ASD

Dear Participant,

Thank you for agreeing to participate in this survey on the use of computers by children with Autistic Spectrum Disorders (ASD). This study is part of a larger research project whose focus is the design of language intervention software for children with ASD. The answers to the questions below should help us understand which features of software are important and engaging to this population and whether those features differ from the features that are engaging to children who are not developmentally delayed. I realize that the questionnaire turned out to be longer than any of us expected -- I hope your patience will be rewarded by knowing that the information you provide will directly affect our software design process in order to serve this population more effectively.

If you have more than one child who qualifies for this survey, please send the information for each child on a separate piece of paper or as a separate e-mail message. If you know of other parents, teachers, or therapists who might be willing to complete the survey, please feel free to make copies and pass them along.

To ensure anonymity in the analysis and presentation or publication of the results of this survey, each child will be assigned a unique identifier. The correspondence between the child and the identifier will be known only to myself, and all data will be identified by ID only. On-line data identified by ID will be password-protected with access only to project members. (You received this questionnaire as a blind carbon copy so that no other participants would see your email address).

All participants will receive a summary of results in either hard-copy or web-accessible form. If you have questions or comments, please contact:

Dr. Mary Banks
School of Computer Science
Survey University
Pittsburgh, PA 15213
107-665-1234
survey@cs.cmu.edu

>>> PLEASE RETURN QUESTIONNAIRES BY MAY 17, 1997. <<<

Once again, THANK YOU for your time, effort and information!

Adapted from http://www-2.cs.cmu.edu/~jef/surveys.html March 6, 2005