Distance learning modules
*Response Required
*Program Type (Check all that apply):
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UCEDD
LEND
LEAH
PPC
DBP
SDHG
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*Fiscal Year:2016
*Title______
*Author(s)/Organizations(s)______
(Last Name, First Name)
*Author(s) Type (Check all that apply, required for MCH Programs only):
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Faculty Member
Trainee
Staff
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*Date the module was developed______
*Include(d) into DGIS/EHB export for______
Type current FY for new product; type FY in the past if you are recreating the product for dissemination purposes.
*Type(select one)
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Blogs
Podcasts
Web-based video clips
RSS feeds
News aggregators
Social networking sites
CD-Roms
DVDs
Audiotapes
Videotapes
Other – please specify: ______
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*Target Audience (Check All the Apply)
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Consumers/Families
Professionals
Policymakers
Students
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Product Dissemination Check this box if you are planning to report this product as dissemination product to AIDD for the current Fiscal year
Quantity of the disseminated product ______
*To obtain copies (URL or email)______
APA Citation
______
______
Keyword 1______
Keyword 2______
Keyword 3______
Keyword 4______
Keyword 5______
Brief Description for AUCD NIRS Public Search (up to 1000 characters)
______
______
______
______
Alternative Formats (Check all that apply for alternative format(s) in which the product was actually disseminated)
Captioned
Braille
Audio (cassette, audio file, etc.)
Visual Format or Large Print
Electronic (e.g. disc, CD, Section 508 Compliant web posting)
Language other than English
Ordering Information
Cost$______(Price/Unit; May use the format 99.99 but no commas are allowed)
Product Contact
Name______
Address______
Phone (999-999-9999)______E-mail______
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