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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 National Child Count of Children and Youth who are Deafblind provides extensive information on the population of children identified with deafblindness in the U.S, aged birth through 21. Data includes state and national information on:
Population demographics (age, race/ethnicity/gender)
Type and severity of vision and hearing loss
Causes of deafblindness
Presence of additional disabilities
Educational setting
Living setting
1.First Name of Child(Required.)
2.Last Name of Child(Required.)
3.Middle Initial(Required.)
4.Gender(Required.)
5.Child’s Date of Birth(Required.)
6.Child’s County of Residence(Required.)
7.Parent/Guardian Name(Required.)
8.Street Address of parent(s)(Required.)
9.City/Town(Required.)
10.Zip Code(Required.)
11.Phone
12.Email
13.Etiology(Required.)
14.Ethnicity(Required.)
15.Race(Required.)
16.Primary language spoken in the home(Required.)
17.Current living setting(Required.)
18.Documented Vision Loss: Select ONE that best describes the individual’s vision loss(Required.)
19.Documented Hearing Loss: Select ONE that best describes the individual’s hearing loss(Required.)
20.Auditory Neuropathy(Required.)
21.Central Auditory Processing Disorder (CAPD)(Required.)
22.Cochlear Implant(Required.)
23.Corrective Lenses(Required.)
24.Assistive Listening Devices (i.e. hearing aids or FM system)(Required.)
25.Physical Impairments(Required.)
26.Cognitive Impairments(Required.)
27.Behavior Disorder(Required.)
28.Complex Health Care Needs(Required.)
29.Communication/Speech and Language(Required.)
30.Cortical Vision Impairment(Required.)
31.Additional Assistive Technology (other than corrective lenses or assistive listening devices). Please list.(Required.)
32.Reporting Category(Required.)
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.(Required.)
34.If Part C (0-2 years of age) Indicate where the child receives services.(Required.)
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.(Required.)
36.3-5 years of age only: Educational setting: Please choose the one which best describes which type of program the child attends.(Required.)
37.6-21 years of age only: Please choose the one which best describes which type of program the child attends.(Required.)
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.(Required.)
39.Participation in Statewide Assessments: Please indicate what assessment system the child participates.(Required.)
40.Agency/School Name(Required.)
41.Street Address(Required.)
42.City(Required.)
43.State(Required.)
44.Zip Code(Required.)
45.Telephone Number(Required.)
46.Primary contact name(Required.)
47.Primary contact email(Required.)
48.Name of individual completing reporting form(Required.)
49.Title/Relationship(Required.)
50.Email(Required.)
51.Phone(Required.)
52.By checking this box, you agree that all answers in this reporting form are accurate to the best of your knowledge.(Required.)