N New York State Technical Assistance Project

Office Use Only: Name Code:______Code Number:______State Code: NY

N New York State Technical Assistance Project

Serving Children and Youth who are Deafblind

TeachersCollegeColumbiaUniversity

Box 223

525 West 120th Street

New York, NY10027

Student First Name: Student Middle Initial: Gender

Student Last Name: DOB:

Parent First Name: Parent Last Name:

Address:

City: State: Zip Code:

Telephone: Race/Ethnicity: check one only

American Indian or Alaska NativeAsian or Pacific Islander Hispanic or Latino

Black or African American (not Hispanic) White (not Hispanic)

Etiology Select ONE from the list below

Hereditary/Chromosomal Syndromes and Disorders

Pre-Natal/CongenitalComplications

Aicardi syndrome

Alport syndrome

Alstrom syndrome

Apert Syndrome (Acrocephalosyndactyly Type 1)

Bardet-Biedl syndrome (Laurence Moon-Biedl)

Batten disease

CHARGE association

Chromosome 18, Ring 18

Cockayne syndrome

Cogan syndrome

Cornelia de Lange

Cri du chat syndrome (Chromosome 5p-syndrome)

Crigler-Najjar syndrome

Crouzon syndrome (Cranipfacia Dysolosis)

Dandy Walker syndrome

Down syndrome (Trisomy 21 syndorme)

Goldenhar syndrome

Hand-Schuller-Christian (Histiocytosis X0

Hallgren syndrome

Herpes-Zoster (or Hunt)

Hunter syndrome (MPS II)

Hurler syndrome (MPS I-H)

Kearns-Sayre syndrome

Kippel-Feil sequence

Kippel-Trenaunay-Weber syndrome

Kniest Dysplasia

Leber congenital amaurosis

Leigh Disease

Marfan syndrome

Visual Impairment

Date of Last Ophthamalogical/Optometrical: Date of Last Functional Vision Assessment:

Month Year Month Year

Primary Classification of Visual Impairment:

Low Vision (Visual acuity of 20/70 to 20/200 in

better eye with corrections)

2. Legally Blind (Visual acuity of 20/200 or less or field restriction

of 20 degrees or less in better eye with correction)

3. Light Perception Only

4. Totally Blind

Hearing Impairment:

Date of Last Audiological Exam: Date of Last Functional Hearing Assessment:

Month Year MonthYear

Primary Classification of Hearing Impairment:

1. Mild (26-40 dB loss)

2. Moderate (41-55 dB loss)

3. Moderately Severe (55-70 dB loss)

4. Severe (71-90 dB loss)

Does the Individual have a central auditory processing disorder?

Other Impairments: Indicate impairments, in addition to the individual's hearing and visual impairments, that have a

significant impact on the individual's developmental or educational progress

Physical Impairment: Complex Health Care Needs:

Cognitive Impairments: Other Impairments:

Specify:

Behavioral Disorder:

IDEA Funding/Code:

Funding Category:

IDEA Part B (3-21)

Part B Category Code:

Not Applicable - Individual is under 3 yrs old

Autism

Hearing Impaired (includes deafness)

Deafblind

Mental Retardation

Multi-disabled

Other Health Impairments

* Optional category for age 3 through 9

Living Setting:

Home: Birth/Adoptive Parents

Home: Extended Family

Home: Foster parents

State Residential Facility

Private Residential Facility

Educational Placement:

Age: Birth through 2:

Early Intervention Center/Classroom

Home Based Early Intervention

Combination of Center Based and Home Based E.I.

Clinical Outpatient Services

Age 3-5:

Early Childhood Setting

Early Childhood Special Education Setting

Combinaton of Previous 2 choices

HomeSchool Program

Residential School

SeparateSchool

Age: 6 - 21:

General Education Class

Resource Room

Specialized Class

Public Specialized School

Private Specialized School

Public Residential School

PrivateResidentailSchool

Age: 22 - 28:

Individual is age 22-28

Special Education Status:

In special Education Program

No Longer Receives Special Education

Graduated with Diploma

Graduated with Certificate

Reached Maximum Age for Part B Services

Person Completing Form:

(First Name, Last Name) Date Completed:

Relationship/Title: Telephone:

Return Form To

Agency/Program::

Address:

City: State: Zipcode: