Missouri DeafBlind Census Reporting Form

As authorized under the Individuals with Disabilities Education Act (IDEA), the Office of Special Education Programs (OSEP) funds State and Multi-State Technical Assistance Projects such as the Missouri DeafBlind Project to improve services and results for children who are DeafBlind CFDA 84.326T.

The annual National DeafBlind Child Count is the world’s first and longest-running count of children who are deafblind through the Offices of Special Education Programs. Launched in 1986 on behalf of the U.S. Department of Education, it represents a collaborative effort between the National Center on Deafblindness (NCDB) and state deafblind projects throughout the country.

The annual DeafBlind Census helps identify state and national technical assistance needs for children who are deafblind, their families, and the systems and providers who serve them.

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* 1. First Name of Child

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* 2. Last Name of Child

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* 3. Middle Initial

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* 4. Gender

Female

Male

Other

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* 5. Child’s Date of Birth

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* 6. Child’s County of Residence

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* 7. Parent/Guardian Name

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* 8. Address

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* 9. City/Town

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* 10. Zip Code

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* 11. Phone

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* 12. Email

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* 13. Choose Etiology

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* 14. Ethnicity

Not Hispanic

Hispanic

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* 15. Race

American Indian or Alaskan Native

Asian

White

Black/African American

Native Hawaiian/ Pacific Islander

Two or more races

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* 16. Primary language spoken in the home

English

Spanish

Chinese

American Sign Language (ASL)

Other (please specify)

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* 17. Current living setting

Home: Parents

Home: Extended Family

Home: Foster Parents

State Residential Facility

Private Residential Facility

Pediatric Rehabilitation Center

Community Residence (includes group home/supported apartment)

Other (please specify)

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* 18. Documented Vision Loss: Select ONE that best describes the individual’s vision loss

Low Vision

Legally Blind

Light Perception Only

Totally Blind

Diagnosed Progressive Loss

Further Testing Needed/In Process

Documented Functional Vision Loss/Cortical Vision Impairment

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* 19. Documented Hearing Loss: Select ONE that best describes the individual’s hearing loss

Mild (26-40 dB loss)

Moderate (41-55 dB loss)

Moderately Severe (56-70 dB loss)

Severe (71-90 dB loss)

Profound (91+ dB loss)

Diagnosed Progressive Loss

Further Testing Needed

Documented Functional Hearing Loss

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* 20. Auditory Neuropathy

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* 21. Central Auditory Processing Disorder (CAPD)

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* 22. Cochlear Implant

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* 23. Corrective Lenses

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* 24. Assistive Listening Devices (i.e. hearing aids or FM system)

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* 25. Physical Impairments

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* 26. Cognitive Impairments

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* 27. Behavior Disorder

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* 28. Complex Health Care Needs

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* 29. Communication/Speech and Language

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* 30. Cortical Vision Impairment

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* 31. Additional Assistive Technology (other than corrective lenses or assistive listening devices). Please list.

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* 32. Reporting Category

IDEA Part C

IDEA Part B

504 Plan

Not reported under Part C or Part B

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* 33. Part C Reporting Category: If the child is 0-2 years of age, please enter the category under which the child was reported within the Early Intervention program.

At-risk for developmental delay

Developmentally delayed

Not reported under Part C

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* 34. If Part C (0-2 years of age) Indicate where the child receives services.

Home

Community-Based Setting

Not applicable (3 years of age or older)

Other (please specify)

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* 35. Part B Reporting Category: If the child is 3-21 years of age, indicate the primary category code under which the individual was reported on Part B, IDEA Child Count.

Intellectual Disability

Hearing Impairment (includes deafness)

Speech and/or Language Impairment

Visual Impairment (includes blindness)

Emotional Disturbance

Orthopedic Impairment

Other Health Impairment

Specific Learning Disability

DeafBlind

Multiple Disabilities

Autism

Traumatic Brain Injury

Young Child with Developmental Delay

Not Reported under Part B of IDEA

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* 36. 3-5 years of age only: Educational setting: Please choose the one which best describes which type of program the child attends.

Not applicable (6 years of age or older OR currently in Part C)

Services in regular early childhood program (10+ hours)

Other location regular early childhood program (10+ hours)

Services in regular early childhood program (<10 hours)

Other location regular early childhood program (<10 hours)

Attending a separate class

Attending a separate school

Attending a residential facility

Home, at public expense

Home, NOT at public expense

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* 37. 6-21 years of age only: Please choose the one which best describes which type of program the child attends.

Not applicable (5 years of age or younger)

Inside the regular class 80% or more of the day

Inside the regular class 40% to 79% of the day

Inside the regular class less than 40% of the day

Separate school

Residential Facility

Homebound/Hospital

Correctional Facility

Parentally placed in private school

Homeschool/Remote, at public expense

Homeschool/Remote, NOT at public expense

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* 38. Is this individual receiving services from an Intervener? Or a one-to-one paraprofessional trained in dual sensory losses?
An intervener is a specially trained individual in the area of deafblindness, usually a paraprofessional.

Missouri DeafBlind Census Reporting Form

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* 1. First Name of Child

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* 2. Last Name of Child

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* 3. Middle Initial

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* 4. Gender

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* 5. Child’s Date of Birth

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* 6. Child’s County of Residence

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* 7. Parent/Guardian Name

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* 8. Address

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* 9. City/Town

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* 10. Zip Code

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* 11. Phone

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* 12. Email

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* 13. Choose Etiology

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* 14. Ethnicity

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* 15. Race

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* 16. Primary language spoken in the home

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* 17. Current living setting

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* 18. Documented Vision Loss: Select ONE that best describes the individual’s vision loss

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* 19. Documented Hearing Loss: Select ONE that best describes the individual’s hearing loss

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* 20. Auditory Neuropathy

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* 21. Central Auditory Processing Disorder (CAPD)

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* 22. Cochlear Implant

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* 23. Corrective Lenses

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* 24. Assistive Listening Devices (i.e. hearing aids or FM system)

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* 25. Physical Impairments

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* 26. Cognitive Impairments

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* 27. Behavior Disorder

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* 28. Complex Health Care Needs

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* 29. Communication/Speech and Language

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* 30. Cortical Vision Impairment

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* 31. Additional Assistive Technology (other than corrective lenses or assistive listening devices). Please list.

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* 32. Reporting Category

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* 33. Part C Reporting Category: If the child is 0-2 years of age, please enter the category under which the child was reported within the Early Intervention program.

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* 34. If Part C (0-2 years of age) Indicate where the child receives services.

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* 35. Part B Reporting Category: If the child is 3-21 years of age, indicate the primary category code under which the individual was reported on Part B, IDEA Child Count.

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* 36. 3-5 years of age only: Educational setting: Please choose the one which best describes which type of program the child attends.

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* 37. 6-21 years of age only: Please choose the one which best describes which type of program the child attends.

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* 38. Is this individual receiving services from an Intervener*? Or a one-to-one paraprofessional trained in dual sensory losses?* An intervener is a specially trained individual in the area of deafblindness, usually a paraprofessional.

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* 39. Participation in Statewide Assessments: Please indicate what assessment system the child participates.

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* 38. Is this individual receiving services from an Intervener? Or a one-to-one paraprofessional trained in dual sensory losses?
An intervener is a specially trained individual in the area of deafblindness, usually a paraprofessional.