Iowa Deafblind Services Project Iowa Deafblind Online Registry Form

Child's Name*

First Last

Address*

Street Address City 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*

Child's Date of Birth*

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 State ZIP Code

Phone*

Email*

Referred by

First Last

Employer

Address

Street Address City 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 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

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

Auditory Neuropathy

Cochlear Implant

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

Indicate

Define the imapirment

Other Impairments or Conditions - Cognitive

Inidcate

Other Impairments or Conditions - Behavioral

Inidcate

Other Impairments or Conditions - Complex Health Care Needs

Inidcate

Other Impairments or Conditions - Communication (Speech/Language)

Inidcate

Other Impairments or Conditions

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*

Please Specify

Pre-Natal/Congenital Complications*

Other

Post-Natal/Non-Congenital Complications*

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.)

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)

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

Other

Corrective Lenses - Does child/student wear glasses or contact lenses?

Assistive Listening Devices - Does the child/student wear hearing aids or use an FM system or other assistive listening device?

Additional Assistive Technology - Does the child/student use any additional assistive technology (other than corrective lenses or assistive listening devices)?

Intervener Services: Please indicate whether the child/student in ECSE or school-aged special education receives Intervener Service.

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.

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

Phone

This field is for validation purposes and should be left unchanged.

Event

Event

Iowa Deafblind Online Registry Form

Deafblind Registry

End of Registry