Parent/Guardian Survey

PARENT/GUARDIAN SURVEY

Functional Vocational Assessment

Student Name /

Grade

Parent Name / Phone No.
1. What year do you expect your child to graduate?
2. List two or three jobs your child has held: (include volunteer work). / 3. What type of job do you see your child doing in the future?
4. In order for your child to get and keep a job, how much help
will he/she need? Check (ü) appropriate response. / 5.  Does your child’s career choice require any further education beyond high school? Check (ü) appropriate response.
¨ None needed / ¨ Some help as needed / ¨ None
¨ Some help at beginning / ¨ Continued help throughout career / ¨ Technical/trade school
¨ Community college/university
6. As an adult, where will he/she live? Check (ü) appropriate response. / 7. As an adult, in order to be involved in recreation and leisure activities and participate in the community, how much help will your child need? Check (ü) appropriate response.
¨ On his/her own with no help
¨ On his/her own with a little help at the beginning
¨ On his/her own with help as needed
¨ Group home
¨ With family
¨ None needed
¨ Family support
¨ Will always need help throughout life
8.  Following high school graduation, what transportation do you see your child using to get to work or activities? Check (ü)
¨  His/her own car/truck/vehicle ¨ Use Public Transportation (taxi, bus, etc.) ¨ Walk
¨  Family/relatives ¨ Bicycle ¨ Depending on others

9. Following high school graduation, do you feel there will need to be physical and/or mental health needs/options. Check (ü)

¨ Required medical support ¨ Required hearing support ¨ Required physical therapy

¨ Required vision support ¨ Required occupational therapy ¨ Required speech/language therapy

¨ Other ______

10. Below are agencies that help adults with disabilities. Visit websites for more agency information to plan your child’s future.

·  Health and Human Services Commission - www.cms.hhs.gov/

·  Medicaid, CHIP, Services Eligibility Determination

·  Department of Aging and Disability Services, www.dads.state.tx.us/

·  Mental Retardation Services-State Schools-Community Services/Care Services, Medically Dependent Children’s Program

·  Department of State Health Services - www.dshs.state.tx.us/

·  Health Services, Mental Health Services -State Hospitals-Community Services

·  Department of Family and Protective Services - www.dfps.tx.us/

·  Child Protective Services

·  Department of Assistive and Rehabilitative Services www.dars..state.tx.us/

·  Rehabilitation Services, Blind and Visually Impaired Services, Deaf and Hard of Hearing Services

·  Mental Health/Mental Retardation Authority (MH/MRA) of Harris County – www.mhmraofharriscounty.org

·  Texas Workforce Commission –

·  www.twc.state.tx.us/

Please indicate the name of an agency if you want them invited to your child’s ARD meeting. ______

11.  Do you feel your child will continue to need your help in making his/her decisions regarding finances or health issues once your child

graduates? Check (ü) ¨ YES ¨ NO

Are you aware: Transfer of Parental Rights at Age of Majority means “unless the student’s parents or other individual has been granted guardianship of the student under the Probate Code, Chapter XIII, Guardianship, all rights granted to the parent under the Individuals with Disabilities Education Act (IDEA), Part B, other than the right to receive any notice required under IDEA, Part B, will transfer to the student upon reaching age 18”. § 89.1048.(a)

Parent(s) Signature ______Date ______

CNR-32(MS-ENG) Copy to: Audit ,Vocational Fold Medicaid #: ______

Update 8/11