Complete one for each student
New
Update
No Changes
Delete
Race/ethnicity
American Indian or Alaska Native
Asian or Pacific Islander
Black or African American (not Hispanic)
Hispanic or Latino
White (not Hispanic)
Other, Specify
Instructional Status Information
Continues in Special Education by No Longer on CensusSpecify reason: ______
No Longer Receives Special Education Specify reason: ______
Graduated by Completing all Regular Education Requirements (01)
Graduated by Completing IEP Requirements, Including Credit Requirements (04), (05), (06)
Graduated by Completing IEP Requirements and by Reaching Maximum Age for Part B Services (07)
Reached Maximum Age for Part B Services Without Meeting IEP Objectives
Moved, in State to ______
Moved, Out of State to ______
Deceased
Dropped Out
Parental Consent
No
Yes
Parent Phone Number ______
The district has obtained specific consent from the parents/guardians of the student for the Texas Education Agency and its contractors responsible for the Texas Deafblind Census to release personally identifiable education and statistical data from the annual census to specific agencies. This Consent must be documented in the district on the March 2002 TEA Form: Consent for the Release of Confidential Information – Student with Deafblindness.
Primary Identified EtiologyEtiology (write one numeric code in this box)
101 Aicardi syndrome
102 Alport syndrome
103 Alstrom sydrome
104 Apert syndrome (Acrocephalosyndactyly, Type 1)
105 Bardet-Biedl syndrome
106 Batten disease
107 CHARGE association
108 Chromosome 18, Ring 18
109 Cockayne syndrome
110 Cogan sydrome
111 Cornelia de Lange
112 Cri du chat syndrome (Chromosome 5p- syndrome)
113Crigler-Najjar syndrome
114 Crouzon syndrome – (Craniofacia Dysotosis)
115 Dandy Walker syndrome
116 Down syndrome (Trisomy 21 syndrome)
117 Goldenhar syndrome
118 Hand-Schuller-Christian (Histiocytosis X)
119 Hallgren syndrome
120Herpes Zoster (or Hunt)
121 Hunter syndrome (MPS II)
122 Hurler syndrome (MPS I-H)
123 Kearns-Sayre syndrome
124 Klippel-Feil syndrome
125 Klippel-Trenaunay-Weber syndrome
126 Kniest Dysplasia
127 Lebers congenital amaurosis
128Leigh disease
129 Marfan syndrome
130 Marshall syndrome
131 Maroteaux-Lamy syndrome (MPS VI)
132 Moebius syndrome
133 Monosomy 10p
134 Morquio syndrome (MPS IV-B)
135 NF1 – Neurofibromatosis – (von Recklinghausen disease)
136 NF2 – Bilateral Acoustic Neurofibromatosis
137 Norrie disease
138 Optico-Cochleo-Dentate Degeneration
139 Pfieffer syndrome
140 Prader-Willi
141 Pierre-Robin syndrome
142 Refsum syndrome
143 Scheie syndrome (MPS I-S)
144 Smith-Lemli-Opitz (SLO) syndrome
145 Stickler syndrome
146 Sturge-Weber syndrome
147 Treacher Collins syndrome
148 Trisomy 13 (Trisomy13-15, Patau syndrome)
149 Trisomy 18 (Edwards syndrome)
150 Turner syndrome
151 Usher I syndrome
152 Usher II syndrome
153 Usher III syndrome
154 Vogt-Koyanagi-Harada syndrome
155 Waardenburg syndrome
156 Wildervanck syndrome
157 Wolf-Hirschhorn syndrome (Trisomy 4p)
199 Other ______
Pre-Natal/Congenital Complications
201 Congenital Rubella
202 Congenital Syphilis
203 Congenital Toxoplasmosis
204 Cytomegalovirus (CMV)
206 Hydrocephaly
208 Microcephaly
209Neonatal Herpes Simplex (HSV)
299 Other ______
(indicate the numeric code in the box
above and specify in this space)
Post-Natal/Non-Congenital Complications
301 Asphyxia
302 Direct Trauma to the eye and/or ear
303 Encephalitis
304 Infections
305 Meningitis
306 Severe Head Injury
307 Stroke
308 Tumors
309Chemically Induced
399 Other ______
(Indicate the numberic code in the box
above and specify in this space)
Related to Prematurity
401 Complications of Prematurity
Undiagnosed
501 No Determination of Etiology
Page 1
Visual Impairment
Date of Last Ophthalmological/
Optometrical Exam
Date of Last Functional
Vision Assessment
Wears Glasses?
Diagnosed Cortical Visual
Impairment?
Diagnosed Progressive Loss?
Vision Loss in One Eye Only?
Primary Classification of Visual Impairment (Select One):
Vision better than 20/70 with correctin
Low Vision (20/70 to 20/200 in better eye with correction or field loss)
Legally Blind (20/200 or less or field restriction of 20 degrees or less)
Light Perception Only
Totally Blind
Further Testing Needed
Tested Nonconclusive
Not Tested – At Risk (documented Hearing loss, at risk for visual impairment)
Other, Specify ______
Hearing Impairment
Date of Last Audiological Exam
Diagnosed Central Auditory
Processing Disorder?
Uses Amplification?
Cochlear Implant?
Diagnosed Progressive Loss?
Hearing in One Ear Only?
Tested with Amplification?
Primary Classification of Hearing Impairment (Select One):
(Aided where appropriate)
Hearing within normal range when aided (cochlear implant)
Very Mild (15-25 dB loss)
Mild (26-40 dB loss)
Moderate (41-55 dB loss)
Moderately Severe (56-70 dB loss)
Severe (71-90 dB loss)
Profound (90+ dB loss)
Further Testing Needed to Determine Hearing Impairment
Tested Non Conclusive
Not Tested at Risk (documented visual impairment, at risk for hearing loss)
Other, Specify ______
Other Impairments
Physical Impairment
Cognitie Impairment
Behavioral Disorder
Complex Health Care Needs
Indicate all Documented impairments, in addition to the individual’s hearing and visual impairments, that have any significant impact on the individual’s developmental or educational program.
Other Impairments, Specify ______
IDEA Funding/Code
Funding Category (as reported in the December 1 count):
IDEA Part B (3-21)
IDEA Part C (0-2) – Reported by ECI
Not Reported Under Part B or Part C
Part B Category Code as reported in the December 1 count (Select Only One):
Autism
Deafblind
Developmentally Delayed
Emotionally Disturbed
Hearing Impaired (includes deafness)
Mental Retardation
Multi-disabled
Non-Categorically Funded
Not Reported
Orthopedic Impairment
Other Health Impairment
Specific Learning Disability
Speech or Language Disability
Traumatic Brain Injury
Visually Impaired
Page 2
Appendix K