UNIVERSITY OF WASHINGTON
DO-IT (Disabilities, Opportunities, Internetworking & Technology)
AccessSTEM/AccessComputing/DO-IT Longitudinal Transition Study (ALTS)
DEMOGRAPHICS
3. Sex
[ ] Male
[ ] Female
4. Birth date
4a. Is the participant a veteran?
[ ]Yes
[ ] No
4aa. If Yes, (Please specify Period of Service:___-____)
5. Ethnicity: (indicate all that apply)
[ ] African American or Black
[ ] American Indian or Alaska Native
[ ] Asian American
[ ] Pacific Islander
[ ] Caucasian or White
[ ] Hispanic or Latino
[ ] Other
5a. Other (please specify): ______
6. Primary disability
[ ] Amputee – Mobility without Personal Care Attendant
[ ] Cerebral Palsy – Mobility without Personal Care Attendant
[ ] Hemiparesis – Mobility without Personal Care Attendant
[ ] Motor Neuron Disease – Mobility without Personal Care Attendant
[ ] Multiple Sclerosis – Mobility without Personal Care Attendant
[ ] Muscular Degenerative Disease – Mobility without Personal Care Attendant
[ ] Orthopedic Conditions (bone or connective tissue) – Mobility without Personal Care Attendant
[ ] Spina Bifida – Mobility without Personal Care Attendant
[ ] Spinal cord injury – Mobility without Personal Care Attendant
[ ] Traumatic Brain Injury – Mobility without Personal Care Attendant
[ ] Amputee – Mobility with Personal Care Attendant
[ ] Cerebral Palsy – Mobility with Personal Care Attendant
[ ] Hemiparesis – Mobility with Personal Care Attendant
[ ] Motor Neuron Disease – Mobility with Personal Care Attendant
[ ] Multiple Sclerosis – Mobility with Personal Care Attendant
[ ] Muscular Degenerative Disease – Mobility with Personal Care Attendant
[ ] Orthopedic Conditions (bone or connective tissue) – Mobility with Personal Care Attendant
[ ] Spina Bifida – Mobility with Personal Care Attendant
[ ] Spinal cord injury – Mobility with Personal Care Attendant
[ ] Traumatic Brain Injury – Mobility with Personal Care Attendant
[ ] Deaf – Hearing
[ ] Hard of Hearing – Hearing
[ ] Profound Deafness – Hearing
[ ] Blind – Vision
[ ] Legal Blind – Vision
[ ] Low Vision – Vision
[ ] Cardiovascular/Pulmonary – Chronic/Acute Health
[ ] Cancer – Chronic/Acute Health
[ ] Diabetes – Chronic/Acute Health
[ ] Epilepsy/Seizures – Chronic/Acute Health
[ ] Organ, Blood, Gastrointestinal, Immune Disorders – Chronic/Acute Health
[ ] Dysgraphia (writing ) – Learning
[ ] Dyscalculia (math) – Learning
[ ] Dyspraxia (speech) – Learning
[ ] Dyslexia (reading) – Learning
[ ] Non-verbal Learning Disorder – Learning
[ ] ADD – Psycho-social
[ ] ADHD – Psycho-social
[ ] Aspergers – Psycho-social
[ ] Autism – Psycho-social
[ ] Brain Injury – Stroke, TBI – Psycho-social
[ ] Developmental Disability – Mental Retardation – Psycho-social
[ ] Pervasive Developmental Disorder – Psycho-social
[ ] Psychiatric – Mental Illness – Psycho-social
[ ] Tourette Syndrome – Psycho-social
[ ] Speech/Language – Communication Disorder
[ ] Other
6a. Other (please specify): ______
7. Secondary disability
[ ] Amputee – Mobility without Personal Care Attendant
[ ] Cerebral Palsy – Mobility without Personal Care Attendant
[ ] Hemiparesis – Mobility without Personal Care Attendant
[ ] Motor Neuron Disease – Mobility without Personal Care Attendant
[ ] Multiple Sclerosis – Mobility without Personal Care Attendant
[ ] Muscular Degenerative Disease – Mobility without Personal Care Attendant
[ ] Orthopedic Conditions (bone or connective tissue) – Mobility without Personal Care Attendant
[ ] Spina Bifida – Mobility without Personal Care Attendant
[ ] Spinal cord injury – Mobility without Personal Care Attendant
[ ] Traumatic Brain Injury – Mobility without Personal Care Attendant
[ ] Amputee – Mobility with Personal Care Attendant
[ ] Cerebral Palsy – Mobility with Personal Care Attendant
[ ] Hemiparesis – Mobility with Personal Care Attendant
[ ] Motor Neuron Disease – Mobility with Personal Care Attendant
[ ] Multiple Sclerosis – Mobility with Personal Care Attendant
[ ] Muscular Degenerative Disease – Mobility with Personal Care Attendant
[ ] Orthopedic Conditions (bone or connective tissue) – Mobility with Personal Care Attendant
[ ] Spina Bifida – Mobility with Personal Care Attendant
[ ] Spinal cord injury – Mobility with Personal Care Attendant
[ ] Traumatic Brain Injury – Mobility with Personal Care Attendant
[ ] Deaf – Hearing
[ ] Hard of Hearing – Hearing
[ ] Profound Deafness – Hearing
[ ] Blind – Vision
[ ] Legal Blind – Vision
[ ] Low Vision – Vision
[ ] Cardiovascular/Pulmonary – Chronic/Acute Health
[ ] Cancer – Chronic/Acute Health
[ ] Diabetes – Chronic/Acute Health
[ ] Epilepsy/Seizures – Chronic/Acute Health
[ ] Organ, Blood, Gastrointestinal, Immune Disorders – Chronic/Acute Health
[ ] Dysgraphia (writing ) – Learning
[ ] Dyscalculia (math) – Learning
[ ] Dyspraxia (speech) – Learning
[ ] Dyslexia (reading) – Learning
[ ] Non-verbal Learning Disorder – Learning
[ ] ADD – Psycho-social
[ ] ADHD – Psycho-social
[ ] Aspergers – Psycho-social
[ ] Autism – Psycho-social
[ ] Brain Injury – Stroke, TBI – Psycho-social
[ ] Developmental Disability – Mental Retardation – Psycho-social
[ ] Pervasive Developmental Disorder – Psycho-social
[ ] Psychiatric – Mental Illness – Psycho-social
[ ] Tourette Syndrome – Psycho-social
[ ] Speech/Language – Communication Disorder
[ ] Other
7a. Other (please specify): ______
8. Third disability
[ ] Amputee – Mobility without Personal Care Attendant
[ ] Cerebral Palsy – Mobility without Personal Care Attendant
[ ] Hemiparesis – Mobility without Personal Care Attendant
[ ] Motor Neuron Disease – Mobility without Personal Care Attendant
[ ] Multiple Sclerosis – Mobility without Personal Care Attendant
[ ] Muscular Degenerative Disease – Mobility without Personal Care Attendant
[ ] Orthopedic Conditions (bone or connective tissue) – Mobility without Personal Care Attendant
[ ] Spina Bifida – Mobility without Personal Care Attendant
[ ] Spinal cord injury – Mobility without Personal Care Attendant
[ ] Traumatic Brain Injury – Mobility without Personal Care Attendant
[ ] Amputee – Mobility with Personal Care Attendant
[ ] Cerebral Palsy – Mobility with Personal Care Attendant
[ ] Hemiparesis – Mobility with Personal Care Attendant
[ ] Motor Neuron Disease – Mobility with Personal Care Attendant
[ ] Multiple Sclerosis – Mobility with Personal Care Attendant
[ ] Muscular Degenerative Disease – Mobility with Personal Care Attendant
[ ] Orthopedic Conditions (bone or connective tissue) – Mobility with Personal Care Attendant
[ ] Spina Bifida – Mobility with Personal Care Attendant
[ ] Spinal cord injury – Mobility with Personal Care Attendant
[ ] Traumatic Brain Injury – Mobility with Personal Care Attendant
[ ] Deaf – Hearing
[ ] Hard of Hearing – Hearing
[ ] Profound Deafness – Hearing
[ ] Blind – Vision
[ ] Legal Blind – Vision
[ ] Low Vision – Vision
[ ] Cardiovascular/Pulmonary – Chronic/Acute Health
[ ] Cancer – Chronic/Acute Health
[ ] Diabetes – Chronic/Acute Health
[ ] Epilepsy/Seizures – Chronic/Acute Health
[ ] Organ, Blood, Gastrointestinal, Immune Disorders – Chronic/Acute Health
[ ] Dysgraphia (writing ) – Learning
[ ] Dyscalculia (math) – Learning
[ ] Dyspraxia (speech) – Learning
[ ] Dyslexia (reading) – Learning
[ ] Non-verbal Learning Disorder – Learning
[ ] ADD – Psycho-social
[ ] ADHD – Psycho-social
[ ] Aspergers – Psycho-social
[ ] Autism – Psycho-social
[ ] Brain Injury – Stroke, TBI – Psycho-social
[ ] Developmental Disability – Mental Retardation – Psycho-social
[ ] Pervasive Developmental Disorder – Psycho-social
[ ] Psychiatric – Mental Illness – Psycho-social
[ ] Tourette Syndrome – Psycho-social
[ ] Speech/Language – Communication Disorder
[ ] Other
8a. Other (please specify): ______
9. Fourth disability
[ ] Amputee – Mobility without Personal Care Attendant
[ ] Cerebral Palsy – Mobility without Personal Care Attendant
[ ] Hemiparesis – Mobility without Personal Care Attendant
[ ] Motor Neuron Disease – Mobility without Personal Care Attendant
[ ] Multiple Sclerosis – Mobility without Personal Care Attendant
[ ] Muscular Degenerative Disease – Mobility without Personal Care Attendant
[ ] Orthopedic Conditions (bone or connective tissue) – Mobility without Personal Care Attendant
[ ] Spina Bifida – Mobility without Personal Care Attendant
[ ] Spinal cord injury – Mobility without Personal Care Attendant
[ ] Traumatic Brain Injury – Mobility without Personal Care Attendant
[ ] Amputee – Mobility with Personal Care Attendant
[ ] Cerebral Palsy – Mobility with Personal Care Attendant
[ ] Hemiparesis – Mobility with Personal Care Attendant
[ ] Motor Neuron Disease – Mobility with Personal Care Attendant
[ ] Multiple Sclerosis – Mobility with Personal Care Attendant
[ ] Muscular Degenerative Disease – Mobility with Personal Care Attendant
[ ] Orthopedic Conditions (bone or connective tissue) – Mobility with Personal Care Attendant
[ ] Spina Bifida – Mobility with Personal Care Attendant
[ ] Spinal cord injury – Mobility with Personal Care Attendant
[ ] Traumatic Brain Injury – Mobility with Personal Care Attendant
[ ] Deaf – Hearing
[ ] Hard of Hearing – Hearing
[ ] Profound Deafness – Hearing
[ ] Blind – Vision
[ ] Legal Blind – Vision
[ ] Low Vision – Vision
[ ] Cardiovascular/Pulmonary – Chronic/Acute Health
[ ] Cancer – Chronic/Acute Health
[ ] Diabetes – Chronic/Acute Health
[ ] Epilepsy/Seizures – Chronic/Acute Health
[ ] Organ, Blood, Gastrointestinal, Immune Disorders – Chronic/Acute Health
[ ] Dysgraphia (writing ) – Learning
[ ] Dyscalculia (math) – Learning
[ ] Dyspraxia (speech) – Learning
[ ] Dyslexia (reading) – Learning
[ ] Non-verbal Learning Disorder – Learning
[ ] ADD – Psycho-social
[ ] ADHD – Psycho-social
[ ] Aspergers – Psycho-social
[ ] Autism – Psycho-social
[ ] Brain Injury – Stroke, TBI – Psycho-social
[ ] Developmental Disability – Mental Retardation – Psycho-social
[ ] Pervasive Developmental Disorder – Psycho-social
[ ] Psychiatric – Mental Illness – Psycho-social
[ ] Tourette Syndrome – Psycho-social
[ ] Speech/Language – Communication Disorder
[ ] Other
9a. Other (please specify): ______
10. Supports used before participation in DO-IT/AccessComputing/Summer Academy activities (Check all that apply)
[ ] Use of a computer
[ ] Internet access
[ ] Adaptive hardware or software for computer
[ ] Aide at school
[ ] Extra time on assignments or tests
[ ] Texts in alternate formats
[ ] Interpreting
[ ] Department of Vocational Rehabilitation Services
[ ] Support of an adult mentor
[ ] Peer group or other students with disabilities
[ ] Other
10a. Other (please specify): ______
11. Academic interest 1 (or favorite course) at the point of entry
12. Academic interest 2 (or favorite course) at the point of entry
13. Level of expressed interest in STEM at the point of entry
[ ] Negative interest expressed
[ ] No interest expressed
[ ] Moderate interest expressed
[ ] Strong interest expressed
14. Career goal at the point of entry
15. How did participant hear about this program (choose one)?
[ ] Parent/family member
[ ] Teachers/educators/counselors
[ ] Peers
[ ] Mentors
[ ] Other activities/projects
[ ] Publications
[ ] Advocacy groups
[ ] Vocational rehabilitation agencies
[ ] Other
15a. Other (please specify): ______
16. Most important reason for participating in DO-IT/AccessComputing/Summer Academy activities (choose one)
[ ] Part of another school activity
[ ] Access to technology
[ ] Prepare for college
[ ] Prepare for career
[ ] Social – meeting peers
[ ] Mentor support
[ ] Other
16a. Other (please specify): ______
17. Second most important reason for participating in DO-IT/AccessComputing/Summer Academy activities (choose one)
[ ] Part of another school activity
[ ] Access to technology
[ ] Prepare for college
[ ] Prepare for career
[ ] Social – meeting peers
[ ] Mentor support
[ ] Other
17a. Other (please specify): ______
Comments for Demographics:
INTERVENTIONS
18. Year 1st started participating in DO-IT/AccessComputing/Summer Academy activities: ______
19. Status when 1st involved with DO-IT/AccessComputing/Summer Academy:
[ ] Elementary school
[ ] Middle school
[ ] High school
[ ] Undergraduate
[ ] Graduate
[ ] Postgraduate
[ ] Seeking employment
[ ] Other
19a. Other (please specify): ______
20. Is participant a DO-IT Scholar?
[ ] Yes
20a. If yes, please indicate the Scholar Year: ______
[ ] No
If no, do not ask/answer question 21.
20.1. Is participant in AccessSTEM?
[ ] Yes
[ ] No
20.2. Is participant in AccessComputing?
[ ] Yes
[ ] No
20.3. Is participant in AccessSTEM2?
[ ] Yes
[ ] No
20.4. Is participant in AccessComputing2?
[ ] Yes
[ ] No
20.5. Is participant in the Summer Academy Program?
[ ] Yes
[ ] No
20.6. Is participant in AccessComputing3?
[ ] Yes
[ ] No
20.7. Is participant in [new DO-IT Project]?
[ ] Yes
- [ ] No
INTERVENTIONS - I. Program activities
21. DO-IT Scholar program participation (choose all that apply):
[ ] Phase 1: Internetworking & Mentoring
[ ] Phase 1: Summer Study I
[ ] Phase 2: Project (indicate type of project below)
[ ] Disability awareness/research
[ ] Career exploration
[ ] Computer game or website development
[ ] Other
21a. Other (please specify)______
[ ] Phase 2: Internetworking & Mentoring
[ ] Phase 2: Summer Study II
[ ] Phase 3/Ambassador: Internetworking & Mentoring
[ ] Phase 3/Ambassador: Summer Study Internship
22. Program participation (choose all that apply):
22a. Transition to college event or workshop
[ ] Yes
[ ] No
[ ] How many times______
22b. Career exploration or preparation event
[ ] Yes
[ ] No
[ ] How many times______
22c. STEM event or workshop
[ ] Yes
[ ] No
[ ] How many times______
23a. If the participant is no longer participating in the program, indicate why
[ ] Health Limitations
[ ] Change in Living Situation
[ ] Change in Personal/Educational Goals
[ ] Deceased
[ ] Other
23aa. Other (please specify): ______
23b. Indicate the year in which the participant decided to no longer or was unable to participate: ______
Comments for Program Activities:
INTERVENTIONS - II. Technology Supports
24. Has participant received training in the use of computer hardware/software?
[ ] Yes
[ ] No
24a. If yes, was some training provided by DO-IT/AccessComputing/Summer Academy?
[ ] Yes
[ ] No
25. Has participant received technical support in the use of computer hardware/software?
[ ] Yes
[ ] No
25a. If yes, was some technical support provided by DO-IT/AccessComputing/Summer Academy?
[ ] Yes
[ ] No
26. Was computer equipment provided by DO-IT/AccessComputing/Summer Academy?
[ ] Yes
[ ] No
27. Does the participant use scanning/reading software with his/her computer?
[ ] Yes
[ ] No
27a. If yes, was the software provided by DO-IT/AccessComputing/Summer Academy?
[ ] Yes
[ ] No
28. Does the participant use word prediction software with his/her computer?
[ ] Yes
[ ] No
28a. If yes, was the software provided by DO-IT/AccessComputing/Summer Academy?
[ ] Yes
[ ] No
29. Does the participant use mind mapping/outlining software with his/her computer?
[ ] Yes
[ ] No
29a. If yes, was the software provided by DO-IT/AccessComputing/Summer Academy?
[ ] Yes
[ ] No
30. Does the participant use speech recognition software with his/her computer?
[ ] Yes
[ ] No
30a. If yes, was the software provided by DO-IT/AccessComputing/Summer Academy?
[ ] Yes
[ ] No
31. Does the participant use screen magnification software with his/her computer?
[ ] Yes
[ ] No
31a. If yes, was the software provided by DO-IT/AccessComputing/Summer Academy?
[ ] Yes
[ ] No
32. Does the participant use an alternative keyboard (mini, expanded, on-screen-keyboard, etc.)?
[ ] Yes
[ ] No
32a. If yes, was it provided by DO-IT/AccessComputing/Summer Academy?
[ ] Yes
[ ] No
33. Does the participant use a mouse alternative (trackball, joystick, etc.)?
[ ] Yes
[ ] No
33a. If yes, was it provided by DO-IT/AccessComputing/Summer Academy?
[ ] Yes
[ ] No
34. Does the participant use a Braille embosser?
[ ] Yes
[ ] No
34a. If yes, was it provided by DO-IT/AccessComputing/Summer Academy?
[ ] Yes
[ ] No
35. Does the participant use a portable digital assistant?
Yes
No
35a. If yes, was it provided by DO-IT/AccessComputing/Summer Academy?
[ ] Yes
[ ] No
36. Does the participant use an augmentative communication device?
[ ] Yes
[ ] No
36a. If yes, was it provided by DO-IT/AccessComputing/Summer Academy?
[ ] Yes
[ ] No
37. Does the participant use other hardware?
[ ] Yes, please specify: ______
[ ] No
37a. If yes, was it provided by DO-IT/AccessComputing/Summer Academy?
[ ] Yes
[ ] No
38. Does the participant use other software?
[ ] Yes, please specify: ______
[ ] No
38a. If yes, was it provided by DO-IT/AccessComputing/Summer Academy?
[ ] Yes
[ ] No
39. Does the participant have regular access to the Internet?
[ ] Yes
[ ] No
39a. Was Internet access provided by DO-IT/AccessComputing/Summer Academy?
[ ] Yes
[ ] No
39.1. Does the student use parental or family supports:
39.1a.For job or school related tasks (typing, reading, etc.)
[ ] Low
[ ] Medium
[ ] High
[ ] Not applicable
39.1b.For personal care or hygiene
[ ] Low
[ ] Medium
[ ] High
[ ] Not applicable
39.1c.Other (please specify): ______
[ ] Low
[ ] Medium
[ ] High
39.2. Level of parental support for participant going to college.
[ ] Parents very supportive of participant going to college.
[ ] Parents supportive of participant going to college
[ ] Parents neutral about participant going to college.
[ ] Parents unsupportive of participant going to college.
[ ] Parents very unsupportive of participant going to college.
Comments for Technology Supports:
INTERVENTIONS - III. Mentoring
40. Did the participant have access to mentors, including DO-IT/AccessComputing/Summer Academy staff mentors, through the DO-IT program? If no, please skip to item 42.
[ ] Yes
[ ] No
41. Level of communication with DO-IT mentors and DO-IT/AccessComputing/Summer Academy staff?
[ ] Low
[ ] Medium
[ ] High
42. Level of communication with DO-IT Scholars, Pals, and/or other AccessComputing/Summer Academyparticipants?
[ ] Low
[ ] Medium
[ ] High
43. Did the participant participate in any extracurricular STEM professional organizations, service groups, or clubs?
[ ] Yes
[ ] No
43a. Yes (please specify): ______
Comments for Mentoring:
INTERVENTIONS - IV. Internships
For each internship, record items #44-54
44. Was (is) the internship developed through DO-IT/AccessComputing/Summer Academy contact?
[ ] Yes
[ ] No
45. Job title
46. Job responsibilities
47. Total hours
48. Year in which it was (is) completed/taking place
49. Were (are) accommodations used?
[ ] Yes
[ ] No
50. If yes, what accommodations were (are) used
51. How were you mentored?
[ ] By a co-worker
[ ] A supervisor
[ ] Was not mentored
[ ] Other
51a. Other (Please specify): ______
52. Paid?
[ ] Yes
[ ] No
53a. If paid, hourly wage ______
53b. If paid, salary ______
53.1. Was salary paid by DO-IT grant or by employer?
[ ] DO-IT grant
[ ] Employer
54. Were you asked to return to do another internship?
[ ] Yes
[ ] No
Comments for Internship:
INTERVENTIONS - V. Other work-based opportunities
55. Has the participant assisted with a DO-IT/AccessComputing/Summer Academy conference exhibit or information booth?
[ ] Yes
[ ] No
56. If yes, how many times?
57. Has the participant served as a DO-IT/AccessComputing/Summer Academy workshop or lab assistant?
[ ] Yes
[ ] No
58. If yes, how many times?
59. Has the participant served as a DO-IT/AccessComputing/Summer Academy panelist, co-presenter or presenter?
[ ] Yes
[ ] No
60. If yes, how many times?
61. Has the participant participated in mock interviews, resume-writing, or other job preparation workshops?
[ ] Yes
[ ] No
62. If yes, how many times?
63. Has the participant participated in company tours or visits?
[ ] Yes
[ ] No
64. If yes, how many times?
65. If yes, what companies?
66. Has the participant participated in any information interviews?
[ ] Yes
[ ] No
67. If yes, how many times?
68. If yes, what industries?
69. Has the participant participated in any job shadows?
[ ] Yes
[ ] No
70. If yes, how many times?
71. If yes, what careers?
72. Has the participant participated in any other STEM related work experiences?
[ ] Yes
[ ] No
72a. Yes (please specify): ______
72.1. Did the student have jobs or internships during college that were related to his/her major area of study?
[ ] Yes
[ ] No
72.1a. If yes what jobs?
72.2. Did the student have jobs or internships in college in non-major areas?
[ ] Yes
[ ] No
72.2a. If yes what jobs?
Comments for Work-based Opportunities:
EDUCATIONAL OUTCOMES
73. List any awards and/or honors related to academic success or extra-curricular activities the participant received.
74. Year graduated from high school
75. Year first attended college
76. Last year attended college
77. Did (does) the participant attend a community/junior/technical college?
[ ] Yes
[ ] No
78. Major 1
79. Major 2
80. Minor
81. Did the participant graduate from community/junior/technical college?
[ ] Graduated
[ ] Still enrolled
[ ] Not enrolled currently
[ ] Transferred
[ ] Other
81a. Transferred (please specify the change) ______
81b. Other (please specify) ______
82. If graduated, what degrees or certificates were earned?
82a. Degree 1 or certificate 1
[ ] A.A. – Associate of Arts
[ ] A.S. – Associate of Science
[ ] A.A.S. – Associate of Applied Science
Professional Technical Programs:
[ ] Accounting
[ ] Aeronautical Technology
[ ] Apparel Design & Services
[ ] Applications Support
[ ] Arts Management
[ ] Auto Body Collision repair
[ ] Automotive Technology
[ ] Aviation (airplane) maintenance
[ ] Biotechnology
[ ] Business Administration (Transfer)
[ ] Business Information Technology