Caller Name:Student Name:
EQUIP FOR EQUALITY’S SPECIAL EDUCATION HELPLINE QUESTIONNAIRE
PARENT VERSION
Student’s Information1. Name
2.Date of birth & age
If student is 14-21, please complete Transition questions at the end of the Questionnaire
3. Student’s racial background / ethnicity
4. Mailing address
5. County
6. Telephone number(s)
7. E-mail address
8. Where does your child live? Ex. With mom and dad? With Grandma? In a residential facility? In a CILA?, etc.
Caller Information
1. Name
2. Mailing Address
3. County
4. Telephone number(s)
5. E-mail Address
6. Is caller a registered voter?
If no, would you like our office to send you a voter registration packet?
7. How did you hear about EFE?
8. Would you like to receive our e-newsletter?
9. Is anyone in the student’s family currently serving on active duty in the U.S. military?
10. What do you think is the highest unmet legal need for people with disabilities in Illinois? (Please choose one from the list on the right.) / Special Education Rights for Children
Freedom from Abuse & Neglect
Quality of Services
Equal Employment Opportunities
Equal Housing Opportunities
Access to Public Services
Access to Private Businesses
Access to Transportation
Getting out of Institutions
Rights to Make own Life Decisions
Other (please specify):
Caller’s Authority
1. If the student is a minor, are the mother and father married? If yes, go to next section.
2. If no, does the parent calling have sole educational decision-making authority?
What written proof of this do you have?
3. If there is shared educational decision-making authority, what is the other parent’s viewpoint?
4. If there are no parents, what is name/contact information for the decision-making authority?
(i.e. guardian)
Conflict Questions
1. Are you involved in any litigation?
2. If yes, what type?
3. Who is it against?
4. Do you know who is representing you and the other side?
Student’s Disability/Needs
1.Disability
(If autism, please complete autism questions at end of Questionnaire.)
2. What education level is the student with a disability? (usually the grade would be based on age)
3. Does the student’s disability substantially affect any of the following areas?
a. Learning
b. Mobility
c. Self-direction
(age appropriate judgment skills)
d. Receptive & Expressive Language
Looking into the future with services as they currently are, does your child have the…
e. Capacity (ability) for Independent Living
Looking into the future with services as they currently are, does your child have the ability for …
f. Economic Self-sufficiency (work)
Adverse Party
1. Name of school & district the student currently attends
2. Is this a Charter School?
(If yes, please complete charter school questions at end of Questionnaire.)
3. Name of school & district student would attend if not disabled
Prior History
1. Did student with a disability receive special education services at the last education level? (Early Intervention, Preschool, Elementary School, Middle School, High School)
2a. Does the student currently have an IEP or 504 plan? (If yes, which one?)
3. Date of last IEP/504 meeting
4. Date of next scheduled IEP/504 meeting
5. Does the student have a Behavior Intervention Plan (BIP)?
If yes, please complete discipline questions at the end of the Questionnaire.
6. Has your child ever been restrained at school? Restrained: held against will (eg: held down on ground, against a wall, tied to chair, or held in someone’s lap) If yes, please ask Restraint/Seclusion questions at the end of the Questionnaire.
7. Has your child ever been secluded at school?
Secluded – placed in room alone with a door that is/could be closed
If yes, please complete the Restraint/Seclusion questions at the end of the Questionnaire.
5. Have you filed a request for a due process hearing? If yes, when?
A due process hearing is an administrative hearing, similar to a trial.
6. If yes, have you received the name of a hearing officer? Who? When?
Additional Intake Information
1. Does the student receive free or reduced lunch? Which one?
2. What is the student’s family’s gross annual income?
3. What is the source of income?
4. What is the number of people in the household?
Reason for Calling the Helpline
Provide a detailed explanation of the current problem that caused you to call EFE, include what you are asking of EFE and your specific goal.
Please make your goal as specific as possible.
If the student with a disability is a teenager, would the student agree with your goal? Can we talk to the teenager?
AUTISM SURVEY QUESTIONS
Please complete these additional questions only for students with autism or who are on the autism spectrum.
“The University of Illinois at Chicago, through its Institute on Disability and Human Development, is conducting a survey and research on the effectiveness of our work. The survey will be conducted by someone from the University and will be kept confidential and anonymous. Your answer will not affect any future work with Equip for Equality. Do I have your permission to give your first name and telephone number to the University?”
If yes, what is the best number(s) to contact you and the best time(s) of day or night to reach you?
1. How much do you agree with the following statement?
“I am satisfied with the services that my child receives?”
1. Completely Disagree
2. Slightly Disagree
3. Neither Agree nor Disagree
4. Slightly Agree
5. Completely Agree
2. How much do you agree with the following statement?
“I have a strong understanding of the legal rights of myself and my family member.”
1. Completely Disagree
2. Slightly Disagree
3. Neither Agree nor Disagree
4. Slightly Agree
5. Completely Agree
3. How much do you agree with the following statement?
“I am self-confident that I can deal with problems with the school.”
1. Completely Disagree
2. Slightly Disagree
3. Neither Agree nor Disagree
4. Slightly Agree
5. Completely Agree
4. How much do you agree with the following statement?
“The school considers my input with respect to decision-making.”
1. Completely Disagree
2. Slightly Disagree
3. Neither Agree nor Disagree
4. Slightly Agree
5. Completely Agree
5. In the last month, how much academic progress did your child make?
1. A lot of regression
2. Some regression
3. No progress
4. Some progress
5. A lot of progress
6. In the last month, how much behavioral progress did your child make?
1. A lot of regression
2. Some regression
3. No progress
4. Some progress
5. A lot of progress
7. In the last month, how much progress in communication skills did your child make?
1. A lot of regression
2. Some regression
3. No progress
4. Some progress
5. A lot of progress
8. In the last month, how much progress in social interactions with peers did your child make?
1. A lot of regression
2. Some regression
3. No progress
4. Some progress
5. A lot of progress
CHARTER SCHOOLS
Please complete these additional charter school questions only if the student attends a charter school.
Which charter school does your child attend?
What school and district would your child attend if they did not attend a charter school?
Have you ever been told that:
1. Your child should go to a different school?
2. The charter school cannot serve your child?
If yes, what reason did the charter school give? Is this in writing?
What is the name of the charter network?
If the child attends a school in the Noble network, please ask the parent:
1. Has your child earned any detentions?
2. How much money have you paid for detentions since your child started at Noble High School?
3. How much money do you currently owe in detentions?
DISCIPLINE
Please complete these discipline questions only if there is a discipline issue.
Does your child have a BIP (Behavior Intervention Plan)?
Has a functional behavioral analysis (FBA) been completed?
Has your child been suspended? If so, approximately how many times?
Has your child ever been expelled from school?
Does your child see a psychiatrist or a therapist?
If yes, has that person provided anything in writing about your child’s disability or needs?
If it would help us advise you, would you and the child sign a release for EFE to speak with the child’s doctors and/or therapists?
Is the school trying to expel your child?
If yes, was a Manifestation Determination Review (MDR) meeting already held?
MDR=A meeting to decide if the child’s behavior was caused by or directly related to his/her disability.
If an MDR was held, what was the result?
What was the date of the MDR?
Did you agree with the result of the MDR?
If the MDR has not been held, has one been scheduled? If yes, when?
Did you receive a certified letter in the mail regarding the expulsion?
RESTRAINT/SECLUSION QUESTIONS
Please complete these questions only if the child has been restrained or secluded. Seclusion means being placed in a room alone with a door that shuts. Restraint means being held against one’s will.
Provide as many details as you can concerning the following:
a. When was your child restrained or secluded?
How many times? Dates?
b. What types of restraint(s) were used?
c. For how long was your child restrained or secluded?
d. Were you told/notified in writing about the restraint or seclusion?
e. What was your response to the restraint or seclusion?
f. Did you put anything in writing to the school about the restraint or seclusion? (If yes, what happened as a result?)
g. Does your student have a Behavior Intervention Plan (BIP)?
If yes, is restraint part of the BIP or IEP?
TRANSITION QUESTIONS
Please complete these questions for students between the ages of 14 and 21.
Does the student have a transition plan in his or her IEP?
A transition plan is supposed to prepare the student for adulthood.
Is the transition plan designed to prepare the student for independent living, employment, and/or further education?
Would you like more information or help with the student’s transition plan?
Has the student applied for Department of Rehabilitation Services (“DRS”) services?
If yes, do you know your child’s DRS case number?
(List name number here)
If yes, is the student receiving DRS services?
If not, why not?
If Yes, student has already applied for DRS services….
Equip for Equality has recently partnered with Department of Rehabilitation Services (DRS) in order to ensure that current DRS customers are receiving appropriate transition services from their schools. As part of that partnership, DRS would like to know which of its current customers are working with Equip for Equality. Do I have your permission to forward your child’s name and case number to DRS?
If no, Equip for Equality has partnered with the Department of Rehabilitation Services (DRS) to connect students over 14 1/2and their families to transition services from DRS, such as job training, payment for community and four year college, and help with employment. Is that something you believe your child would be interested in?
1. Do you think your child would like help getting or keeping a job or help living independently in the future or both?
2. Does your child have the most difficulty with seeing, hearing, talking, using his or her hands, getting around, interacting with others, learning or thinking, or with other activities?
As part of our partnership, Equip for Equality would like to forward your child’s name, date of birth, social security number and contact information to DRS. They will follow up with you, with no obligation on your part. DRS and EFE will keep this information confidential and will not be sharing it with anyone else without your permission. Do I have your permission to give your child’s name, contact information, social security number and answers to the two questions you just answered to DRS?
If yes, after providing EFE with this Helpline form, please call Katie at (312) 895-7320 with your child’s Social Security number (“SSN”). Please DO NOT email your child’s SSN.
DRS Referral Number
Email this form to or fax Attn: Katie L to (312) 541-8543. A helpline specialist will respond to you within one week. If you have any questions please let Katie know, .
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