IIACC DISI Award Nomination

Do you want to recognize an outstanding organization that:

Engages the community and promote innovative ideas in the field of Autism Spectrum Disorder?
Embodies the IIACC’s mission, facilitate sharing of information on autism‐related activities?
Drives the implementation of services aligned with the goals in the Indiana Comprehensive State Plan?

Then complete the survey below to nominate them for the DISI Award!

1. Please provide your contact information so we may follow up should we have further questions. *This question is required.

Name
Email address
Phone number
Organization
Role
Relationship to nominee

2. What is the name of the organization you are nominating? *This question is required.

3. List the organization's website address if available:

4. Where is this organization located (city and state)? *This question is required.

5. Please provide a brief description of the organization's mission and vision *This question is required.

6. Please provide a brief description of the organization's activities. If you can provide any additional sources of information (e.g., feedback from the organization's patrons, satisfaction ratings, materials shared, etc.), they will help with the selection process. *This question is required.

7. *This question is required.

Does this organization engage community partners to discuss and realize innovative ideas in the field of autism?

Please describe/provide examples.

8. *This question is required.

Does this organization exemplify the characteristics of the IIACC's mission to facilitate the efficient and effective exchange of information on autism-related activities?

Please describe/provide examples.

9. Does this organization drive the implementation of services and programming that align with the goals outlined in the Indiana Comprehensive State Plan for Individuals with ASD?

Please select all appropriate options.

Yes, Family and Professional Partnerships Goal
Yes, Early and Continuous Developmental and Medical Screening for ASD Responses Goal
Yes, Access to all needed ASD Health, Mental, Education, and Social Services Goal
Yes, Successful Youth Transition to Adult Services, Work, and Independence Goal
Yes, Adequate Public/Private Insurance for All Affected by ASD Goal
Yes, Justice System & Public Safety Goal
No

Please describe/Provide examples.

10. Please provide any other information you feel would be relevant to this nomination.