Electronic Products
*Response Required
*Program Type (Check all that apply):
FY16 NIRS Product Paper Form, Page 1 of 1
UCEDD
LEND
LEAH
PPC
DBP
SDHG
FY16 NIRS Product Paper Form, Page 1 of 1
*Fiscal Year:2016
*Title______
*Author(s)/Organizations(s)______
(Last Name, First Name)
*Author(s) Type (Check all that apply, required for MCH Programs only):
FY16 NIRS Product Paper Form, Page 1 of 1
Faculty Member
Trainee
Staff
FY16 NIRS Product Paper Form, Page 1 of 1
*Date the product was presented______
*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)
FY16 NIRS Product Paper Form, Page 1 of 1
CD-ROMs
DVDs
Audio tapes
Video tapes
Other – please specify: ______
FY16 NIRS Product Paper Form, Page 1 of 1
*Target Audience (Check All the Apply)
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Consumers/Families
Professionals
Policymakers
Students
FY16 NIRS Product Paper Form, Page 1 of 1
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______
FY16 NIRS Product Paper Form, Page 1 of 1