Iowa Deafblind Services Project
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Home
About
For Families
Resources
For Professionals
Transition Planning
Learning Opportunities
Communication Resources
Interveners
Technical Assistance Team
Technical Assistance
Services
Deafblind Registry
Contact
Iowa Deafblind Online Registry Form
Join us on Twitter
Follow us on Facebook
Deafblind Registry Referral (pdf)
Event
Lorem ipsum
Iowa Deafblind Online Registry Form
Deafblind Registry
Online Submittable Registry for the Iowa Deafblind Project
Child's Name
*
First
Last
Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Is there an IFSP or IEP in place for this child?
*
Yes
No, In this case, written consent from parents is required PRIOR TO adding their child’s name to this registry.
Although written parental consent is not necessary for adding this child’s name to the registry, parent notification is required. Please indicate: Date parents were notified
Method parents were notified (Tel, email, etc)
Who notified parents
Child's Gender
*
Male
Female
Child's Date of Birth
*
MM slash DD slash YYYY
Area Education Agency (AEA): Indicate the AEA in which this child/youth resides: (Keystone AEA, AEA 267, Prairie Lakes AEA, Northwest AEA, Mississippi Bend AEA, Grant Wood AEA, Heartland AEA, Des Moines Public Schools, Green Hills AEA, or Great Prairie AEA.
Parent/Guardian Name(s)
First
Last
Address (if different from the child's above)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
*
Email
*
Referred by
First
Last
Employer
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
Phone
*
Check here if this child does not attend school
Attending School Building
Attending School District
Building Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Building Telephone
Best Professional Contact
First
Last
Service/Role
Email
Phone
Race/Ethnicity: Select the one race/ethnicity code that best describes the individual.
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic/Latino
White
Native Hawaiian or Other Pacific Islander
Two or moe races
Documented Vision Loss
*
Indicate the code(s) that best describes the individual
1. Low Vision (visual acuity of 20/70 to 20/200)
2. Legally Blind (visual acuity of 20/200 or less or a field restriction of 20 degrees
3. Light Perception Only
4. Totally Blind
6. Diagnosed Progressive Loss
7. Further Testing Needed
9. Documented Functional Vision Loss
10. N/A
Cortical Vision Impairment
No
Yes
Unknown
Documented Hearing Loss
*
Indicate the code that best describes the individual’s Documented degree of hearing loss, or Indicates that “further testing is needed” (This testing must be completed within one year to remain on the registry.)
1. Mild (26-40 dB loss)
2. Moderate (41-55 dB loss)
3. Moderately Severe (56-70 dB loss)
4. Severe (71-90 dB loss)
5. Profound (91+ dB loss)
6. Diagnosed Progressive Loss
7. Further Testing Needed (1 year only)
9. Documented Functional Hearing Loss
10. N/A
Central Auditory Processing Disorder
No
Yes
Unknown
Auditory Neuropathy
No
Yes
Unknown
Cochlear Implant
No
Yes
Unknown
Other Impairments or Conditions;
indicate any additional impairment or condition which has a significant impact on the individual’s developmental or educational progress.
Other Impairments or Conditions-Orthopedic/Physical
No
Yes
Indicate
Define the imapirment
Other Impairments or Conditions - Cognitive
No
Yes
Inidcate
Other Impairments or Conditions - Behavioral
No
Yes
Inidcate
Other Impairments or Conditions - Complex Health Care Needs
No
Yes
Inidcate
Other Impairments or Conditions - Communication (Speech/Language)
No
Yes
Inidcate
Other Impairments or Conditions
No
Yes
Please Specify
Primary Identified Etiology
: Select the one etiology code from the list that best describes the primary etiology of the individual’s primary disability. If “Other” is selected, please specify.
Primary Identified Etiology
*
Hereditary/Chromosomal Syndromes and Disorders
Pre-Natal/Congenital Complications
Post-Natal/Non-Congenital Complications
Pick one for more specific options.
Hereditary/Chromosomal Syndromes and Disorders
*
101 Aicardi syndrome
102 Alport syndrome
103 Alstrom syndrome
104 Apert syndrome(Acrocephalosyndactyly,T1)
105 Bardet-Biedl syndrome(LaurenceMoon-Biedl)
106 Batten disease
107 CHARGE association
108 Chromosome18,Ring18
109 Cockayne syndrome
110 Cogan Syndrome
111 Corneliade Lange
112 Criduchatsyndrome(Chromosome5p-syndrome)
113 Crigler-Najjarsyndrome
114 Crouzon syndrome(CraniofacialDysotosis)
115 Dandy Walker syndrome
116 Down syndrome(Trisomy21syndrome)
117 Goldenhar syndrome
118 Hand-Schuller-Christian(HistiocytosisX)
119 Hallgren syndrome
120 Herpes-Zoster(orHunt)
121 Hunter Syndrome(MPSII)
122 Hurler syndrome(MPSI-H)
123 Kearns-Sayresyndrome
124 Klippel-Feilsequence
125 Klippel-Trenaunay-Webersyndrome
126 KniestDysplasia
127 Lebercongenitalamaurosis
128 LeighDisease
129 Marfansyndrome
130 Marshallsyndrome
131 Maroteaux-Lamysyndrome(MPSVI)
132 Moebiussyndrome
133 Monosomy10p
134 Morquio syndrome(MPSIV-B)
135 NF1-Neurofibromatosis(vonRecklinghausendisease)
136 NF2-Bilateral Acoustic Neurofibromatosis
137 Norrie disease
138 Optico-Cochleo-DentateDegeneration
139 Pfieffer syndrome
140 Prader-Willi
141 Pierre-Robin syndrome
142 Refsum syndrome
143 Scheie syndrome(MPSI-S)
144 Smith-Lemli-Opitz(SLO) syndrome
145 Stickler syndrome
146 Sturge-Weber syndrome
147 Treacher Collins syndrome
148 Trisomy13(Trisomy13-15,Patausyndrome)
149 Trisomy18(Edwardssyndrome)
150 Turner syndrome
151 Usher I syndrome
152 Usher II syndrome
153 Usher III syndrome
154 Vogt-Koyanagi-Haradasyndrome
155 Waardenburg syndrome
156 Wildervanck syndrome
157 Wolf-Hirschhorn syndrome(Trisomy4p)
Other
Please Specify
Pre-Natal/Congenital Complications
*
201 Congenital Rubella
202 Congenital Syphilis
203 Congenital Toxoplasmosis
204 Cytomegalovirus(CMV)
205 Fetal Alcoholsyndrome
206 Hydrocephaly
207 Maternal Drug Use
208 Microcephaly
209 Neonatal Herpes Simplex(HSV)
401 Complications of Prematurity
299 Other (please specify)
Other
Post-Natal/Non-Congenital Complications
*
301 Asphyxia
302 Direct Trauma tot he eye and/or ear 303 Encephalitis
304 Infections
305 Meningitis
306 Severe Head Injury
307 Stroke
308 Tumors
309 Chemically Induced
501 No Determination of Etiology (Undiagnosed)
399 Other (please specify)
Other
Column 22 - Funding Category
IDEA Part B (3-21)
IDEA Part C (birth-2 years / IFSP)
Not reported under Part B or Part C
Part C Category Code
Select “888 Not Reported Under Part C” for any child who does NOT have an IFSP. (For example, if a child has an IEP, s/he is reported under Part B, and you will select “888 Not Reported Under Part C” in this section.)
At-risk (InIowa,this is HP-High Probability)
Developmentally Delayed (In Iowa, this is TD – Part C 25% Delay)
888. Not Reported Under Part C
Part B Category Code
What is the primary (first) disability code listed on the bottom of Page A of this child’s current IEP? Typically, in Iowa, this will be “EI – Eligible Individual”, which you will code “14 Non-Categorical” below. Select “888 Not Reported Under Part B” for any child who does NOT have an IEP. (For example, if a child has an IFSP, s/he is reported under Part C, and you will select “888 Not Reported Under Part B” in this section.)
1. Mental Retardation
2. Hearing Impairment (includes deafness)
3. Speech or Language Impairment
4. Visual Impairment (includes blindness)
5. Emotional Disturbance
6. Orthopedic Impairment
7. Other Health Impairment
8. Specific Learning Disability
9. Deaf-blindness
10. Multiple Disabilities
11. Autism
12. Traumatic Brain Injury
13. Developmentally Delayed-age 3 through 9
14. Non-Categorical (In Iowa, this is “EI”)
888. Not Reported under Part B of IDEA
Early Intervention Setting (Birth through 2 only)
1. Home
2. Community-based settings
3. Other settings
Educational Setting Age 3 - 5
1. Attending a regular early childhood program at
least 80% of the time
2. Attending a regular early childhood program 40% to 79% of the time
3. Attending a regular early childhood program less than 40 % of the time
4. Attending a separate class
5. Attending a separate school
6. Attending a residential facility
7. Service provider location
8. Home
Educational Setting 6 - 21
9. Inside the regular class 80% or more of day
10. Inside the regular class 40% to 79% of day
11. Inside the regular class less than 40% of day
12. Separate school
13. Residential facility
14. Homebound/Hospital
15. Correctional facilities
16. Parentally placed in private schools
Participation in Statewide Assessments
Select the option which best describes the student’s participation in their last statewide assessment activities.
1. Regulargrade-levelstateassessment
2. Regular grade-level state assessment with accommodations
3. Alternateassessmentsalignedwithgrade-level achievement standards (Not an available option in Iowa.)
4. Alternate assessments based on alternate achievement standards (Iowa Alternate Assessment)
5. Modified achievement standards
6. Not yet required
Part C Exiting Status (Birth through 2)
0. In a Part C early intervention program
1. Completion of IFSP prior to reaching maximum age for Part C
2. Eligible for IDEA, Part B
3. Not eligible for Part B, exit with referrals to other programs
4. Not eligible for Part B, exit with no referrals
5. Part B eligibility not determined
6. Deceased
7. Moved out of state
8. Withdrawal by parent (or guardian)
9. Attempts to contact the parent and/or child were unsuccessful
Part B Exiting Status
1. Transferred to regular education
2. Graduated with regular diploma
3. Received a certificate
4. Reached maximum age
5. Died
6. Moved, known to be continuing
7. (intentionally not used)
8. Dropped out
Deaf-Blind Project Exiting Status
0. Receiving services from the deaf-blind project
1. No longer receiving services from the state deaf-blind project
Living Setting - Select the living setting in which the individual resides the majority of the year
1. Home: With parents
2. Home: Extended family
3. Home: Foster parents
4. State residential facility
5. Private residential facility
6. Group home (less than 6 residents)
7. Group home (6 or more residents)
8. Apartment (with non-family person(s))
9. Pediatric nursing home
0. Other (Specify)
Other
Corrective Lenses - Does child/student wear glasses or contact lenses?
No
Yes
Unknown
Assistive Listening Devices - Does the child/student wear hearing aids or use an FM system or other assistive listening device?
No
Yes
Unknown
Additional Assistive Technology - Does the child/student use any additional assistive technology (other than corrective lenses or assistive listening devices)?
No
Yes
Unknown
Intervener Services: Please indicate whether the child/student in ECSE or school-aged special education receives Intervener Service.
No
Yes
Unknown
Note: A “yes” answer indicates an individual with the title and the function of an intervener OR from an individual with the function of an intervener working under a different title.
May we assist you in any way?
Helen Keller National Center National Deafblind Registry: The purpose of the HKNC National Registry of Persons Who Are Deaf-Blind is to provide basic information about people with combined vision and hearing loss in the United States. This information is to be used as a census of persons who are deaf-blind, as a planning tool and for research purposes. Do parents/guardians give permission to the Iowa Deafblind Project to share child’s name and contact information with HKNC? If yes, you will be contacted by a HKNC representative to complete additional paperwork.
No
Yes
End of Registry
Questions? Please Contact
Katy Ring Deafblind Project Coordinator/Consultant Iowa Educational Services for the Blind and Visually Impaired 3501 Harry Langdon Boulevard Council Bluffs, IA 51503 Mobile: (712) 310-4623 katy.ring@iaedb.org
Email
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