August, 1999
|
SPECIAL EDUCATION ELEMENTARY LONGITUDINAL STUDY (SEELS) | |
ALMOST FINAL SURVEY OF SCHOOL PROGRAMS |
SRI Project 3421 | |
THE SPECIAL EDUCATION ELEMENTARY LONGITUDINAL STUDY (SEELS)
Students School Program Survey
Label with students name
PLEASE TURN THE PAGE TO BEGIN THE SURVEY Ô Ô Ô Ô Ô Ô
Todays Date: ______/_____/_____
MM DD YY
Are you able to describe the school program for the student named on the front cover?
No |
STOP: Do not complete this survey. Please pass the survey on to the school professional who is best able to describe the students school program.
|
Yes |
Please PROCEED to Section A. |
SECTION A. ABOUT THIS STUDENTS SCHOOL PROGRAM
A1. What is the current grade level placement of this student?
Please circle ONE number.
0 |
Ungraded |
4 |
4th grade |
8 |
8th grade |
1 |
1st grade |
5 |
5th grade |
9 |
9th grade |
2 |
2nd grade |
6 |
6th grade |
10 |
10th grade |
3 |
3rd grade |
7 |
7th grade |
11 |
11th grade |
12 |
12th grade |
A2. Does this student participate in any of the following?
PLEASE CIRCLE ALL THAT APPLY.
1 |
Program for gifted and talented students |
2 |
Chapter 1 |
3 |
Bilingual education or instruction for English language learners |
4 |
Summer school during the previous summer |
5 |
Free/reduced-price lunch program |
6 |
None of these |
7 |
Not sure |
A3. Please indicate ALL the settings in which this student currently receives instruction this school year for each subject listed below. (Please note: Some students may receive instruction in a subject area in multiple settings, such as a resource room and a general education classroom.) PLEASE CIRCLE ALL THAT APPLY FOR EACH LINE.
Subject Area |
CIRCLE ALL Setting(s) of Instruction |
|||||
General education classroom |
|
Special education classroom |
|
|
||
a. |
Language arts |
1 |
2 |
3 |
4 |
5 |
b. |
Mathematics |
1 |
2 |
3 |
4 |
5 |
c. |
Science |
1 |
2 |
3 |
4 |
5 |
d. |
Social studies |
1 |
2 |
3 |
4 |
5 |
e. |
Art, music |
1 |
2 |
3 |
4 |
5 |
f. |
Physical education |
1 |
2 |
3 |
4 |
5 |
g. |
Life skills |
1 |
2 |
3 |
4 |
5 |
h. |
Study skills |
1 |
2 |
3 |
4 |
5 |
i. |
Vocational/prevocational training, industrial arts |
1 |
2 |
3 |
4 |
5 |
j. |
Social skills instruction |
1 |
2 |
3 |
4 |
5 |
k. |
Other (please specify): _______________________ |
1 |
2 |
3 |
4 |
5 |
NOTE: QUESTIONS SS6 THROUGH SS8 WILL BE INCLUDED ONLY IN THE VERSION OF THE QUESTIONNAIRE USED FOR STUDENTS AGES 14 OR OLDER. OTHER RESPONDENTS GO FROM HERE TO A4a, NEXT PAGE.
SS6. Please indicate which of the following services this student received from or through the school system during this school year. PLEASE CIRCLE ALL THAT APPLY.
1 |
A formal assessment of career skills or interests |
2 |
Career counseling |
3 |
Job readiness or prevocational training |
4 |
Work exploration |
5 |
Work experience |
6 |
Specific job skills training |
7 |
Referrals to potential employers |
8 |
Instruction in looking for jobs |
9 |
School staff worked with employer to modify jobs for this student |
10 |
School staff contacted student or employer to monitor performance on the job |
11 |
None of these |
SS7. What percentage of this students school day is currently being spent in the two activities below (do not include after-school employment)?
PLEASE CIRCLE ONE NUMBER ON EACH LINE.
None |
1-24% |
25-49% |
50-74% |
75-99% |
100% |
Dont know |
||
a. |
School-based work experience |
0 |
1 |
2 |
3 |
4 |
5 |
8 |
b. |
Community-based work experience |
0 |
1 |
2 |
3 |
4 |
5 |
8 |
SS8. Which of the following best describes the primary goal of this students current educational program for the period immediately following high school?
Please circle ONE number.
1 |
Attend a 2- or 4-year college |
2 |
Attend a postsecondary vocational training program |
3 |
Get competitive employment (includes military) |
4 |
Get into sheltered employment (where most other workers are also disabled) |
5 |
Get supported employment (similar to competitive employment, but where supervision/training is provided by an agency/individual other than the employer) |
6 |
Employment or postsecondary education is not a goal for this student. The educational program goal is to help this student become as self-sufficient as possible. |
7 |
Other (please describe): ________________________________________________ _____________________________________________________________________ |
8 |
No goal as yet for this student beyond high school |
A4a. At the beginning of this school year, did this student make any of the following transitions within the past 9 months?
Please circle ONE number.
1 |
Elementary to middle school |
PLEASE CONTINUE WITH QUESTION A4b. |
2 |
Middle school to high school |
|
3 |
No transitions this past year |
PLEASE GO TO QUESTION A6. |
4 |
No, the student did not change |
A4b. Which of the following were provided to support this students transition?
PLEASE CIRCLE ALL THAT APPLY.
1 |
Staff or students from your school visited the sending school to meet with groups of students who were preparing for the transition. |
2 |
Groups of transitioning students visited your school before school started. |
3 |
Information was provided to your school staff by the sending school about this student (e.g., student performance information, disability awareness). |
4 |
Your school staff met with staff of the sending school specifically about this student. |
5 |
Parent and/or student met with staff of this school before starting school here. |
6 |
Preparatory strategies were developed specifically for this student (e.g., behavior plans, school scheduling modifications, etc.). |
7 |
The sending school sent the students file before the student started school here. |
8 |
Other: _____________________________________________________________ |
9 |
None of these |
10 |
Dont know |
A4c. How would you rate the amount of planning and support that were provided this student during this transition? Please circle ONE number.
1 |
It was more than he/she needed. |
2 |
It was appropriate to the needs of this student. |
3 |
This student could have benefited from more transition support. |
9 |
Dont know |
A5a. Will this student be involved in any of the following transitions at the end of this school year?
1 |
Elementary to middle school |
PLEASE CONTINUE WITH QUESTION A5b. |
2 |
Middle school to high school |
|
3 |
No transitions this past year |
PLEASE GO TO QUESTION A7. |
4 |
No, the student did not change |
A5b. Which of the following will be provided to support this students transition?
PLEASE CIRCLE ALL THAT APPLY.
1 |
Groups of transitioning students will visit their next school before school starts. |
2 |
Information will be provided to the receiving school about this student (e.g., student performance information, disability awareness). |
3 |
Your school staff will meet with receiving school staff specifically about this student. |
4 |
Parent and/or student will meet with staff of the receiving school individually before starting school there. |
5 |
Preparatory strategies will be developed specifically for this student (e.g., behavior plans, school scheduling modifications, etc.). |
6 |
Other: _____________________________________________________________ |
7 |
None of these |
8 |
Dont know |
A6. To the best of your knowledge, what school do you expect this student to be attending next year?
1 |
Same school as this year |
|
2 |
Different school next year: |
Name of school: ________________________________ School address: ________________________________ _________________________________ |
A7. Does this student currently have either an Individualized Education Plan (IEP) or a "504 plan" for students with disabilities?
PLEASE CIRCLE ONE NUMBER
1 |
Yes, this student has an IEP Ô
Ô
|
PLEASE GO TO SECTION B, QUESTION B2, PAGE 7. |
2 |
Yes, this student has a 504 plan. Ô Ô |
PLEASE GO TO SECTION B, QUESTION B1a, PAGE 7 |
3 |
No Ô Ô Ô Ô Ô Ô Ô Ô |
PLEASE GO TO SECTION C, QUESTION C1a. |
Section B. About this students Special Education
and 504 plan services
PLEASE COMPLETE THIS SECTION ONLY FOR STUDENTS WITH AN IEP FOR SPECIAL EDUCATION SERVICES OR A 504 PLAN. FOR OTHER STUDENTS, PLEASE GO TO SECTION C, PAGE 13.
IF THIS STUDENT CURRENTLY HAS AN INDIVIDUALIZED EDUCATION PLAN OR A 504 PLAN, BEGIN WITH QUESTION B2a.
IF THIS STUDENT CURRENTLY HAS A 504 PLAN, BUT NOT AN INDIVIDUALIZED EDUCATION PLAN, BEGIN WITH QUESTION B1a.
B1a. If this student does not currently have an Individualized Education Plan (IEP), has this student ever had an Individualized Education Plan (IEP) for special education or related services?
1 |
Yes, this student has had an IEP for special education services Ô Ô PLEASE CONTINUE WITH B1b. |
2 |
No PLEASE GO TO QUESTION B2a. |
3 |
Dont know |
B1b. In what school year was this student discontinued from special education?
PLEASE RECORD SCHOOL YEAR OR CIRCLE CODE.
____________ |
School year discontinued special education services |
99 Dont know
B2a. Approximately how many TOTAL hours per week does this student attend school?
(If this student does not attend school, indicate approximately how many total hours of instruction he/she receives in a typical week.)
__________ |
Number of TOTAL hours per week student attends school |
B2b. Approximately how much time per week does this student currently spend in the following instructional settings?
Number of minutes/week |
or |
Number of hours/week |
|
__________ |
__________ |
General education classroom |
|
__________ |
__________ |
Special education self contained classroom |
|
__________ |
__________ |
Special education resource classroom |
|
__________ |
__________ |
Homebound instruction |
B3. In column A, please circle ALL of this students disabilities.
PLEASE CIRCLE ALL THAT APPLY in column a.
In column B, please circle the students primary disability.
PLEASE CIRCLE ONE NUMBER IN COLUMN B.
A All disability categories |
B Primary disability category |
|
1 |
1 |
Autism |
2 |
2 |
Deaf-blindness |
3 |
3 |
Developmental delay |
4 |
4 |
Emotional or behavioral impairment |
5 |
5 |
Hearing impairment/deafness |
6 |
6 |
Learning disability |
7 |
7 |
Mental retardation |
8 |
8 |
Orthopedic impairment |
9 |
9 |
Other health impairment |
10 |
10 |
Speech or language impairment |
11 |
11 |
Traumatic brain injury |
12 |
12 |
Visual impairment/blindness |
13 |
13 |
Other: _____________________________ |
B4. For this school year, what are the primary goals for this student?
PLEASE CIRCLE ALL THAT APPLY.
1 |
Improve overall academic performance |
2 |
Improve academic performance in a specific area: _________________________ |
3 |
Build social skills |
4 |
Improve appropriateness of general behavior |
5 |
Increase functional skills |
6 |
Improve speech and communication skills |
7 |
Vocational preparation |
8 |
Postsecondary education preparation |
9 |
Other (please specify): ________________________________________________ |
10 |
Dont know |
B5. Which of the following are provided to this student as part of his/her IEP or 504 plan? Please circle All that apply.
Accommodations/modifications |
|
1 |
More time in taking tests |
2 |
Test read to student |
3 |
Modified tests |
4 |
Modified grading standards |
5 |
Slower-paced instruction |
6 |
Additional time to complete assignments |
7 |
Shorter assignments |
8 |
Physical adaptations (e.g., preferential seating, special desk) |
Learning aids |
|
9 |
Books on tape |
10 |
Communication aids (e.g., Touch Talker, manual printing board) |
11 |
Use of spell checker |
12 |
Computer software designed for students with disabilities |
13 |
Computer hardware adapted for students unique needs (e.g. alternative keyboards, switch interface) |
14 |
Other: ___________________________________________________________ |
15 |
None of these were provided |
B6a. Does the student use any medical devices that require school staff attention during any part of the school day? (Medical devices could include suctioning equipment, oxygen, catheters, etc. Do not include nonmedical devices such as communication devices, electronic equipment, etc.)
1 |
Yes |
2 |
No |
B6b. Is there an emergency medical plan for this student?
1 |
Yes |
2 |
No |
B7. For each service listed below, please indicate the approximate number of minutes per week the service was provided to the student through the school system during the current school year (include services the school contracted from other agencies).
Services provided during the current school year |
Approximate minutes per week service provided |
|
a. |
Adaptive physical education |
|
b. |
Audiology |
|
c. |
Communication services (e.g., instruction in sign language or lip reading, Braille, augmentative communication) |
|
d. |
Training, counseling, and other supports/services provided to students family |
|
e. |
Health services (e.g., administering of medication, oxygen, tracheostomy care, tube feeding, catheterization) |
|
f. |
Mental health services, personal/group counseling, therapy, or psychiatric care provided to student |
|
g. |
Occupational therapy |
|
h. |
One-to-one paraeducator/assistant (e.g., full-inclusion assistant, behavioral assistant, nurses aide) |
|
i. |
Physical therapy |
|
j. |
Social work services |
|
k. |
Speech or language therapy |
|
l. |
Vision services |
|
m. |
Reader or interpreter |
|
n. |
Additional academic tutoring/remediation by a special education teacher |
|
o. |
Behavioral interventionist/specialist |
|
p. |
Learning strategies/study skills assistance by a special educator |
|
q. |
Other (specify): _________________________________ |
B8. Did this student receive any of the following services from or through the school system during the current school year, including services contracted from other agencies? PLEASE CIRCLE ONE NUMBER ON EACH LINE.
YES |
NO |
|
1 |
2 |
a. Special transportation because of disability (e.g., help in travel or special equipment such as lifts, ramps) |
1 |
2 |
b. Assistive technology services/devices |
1 |
2 |
c. Service coordination/case management |
B9a. During the current school year, to what extent did this student participate in any mandated standardized test(s) administered as part of a school-, district-, or statewide testing program? Please circle ONE number.
0 |
There is no such testing at this grade level. |
||
1 |
Student did not take such tests. |
PLEASE GO TO |
|
2 |
Student participated in most or all of the testing program without accommodations or modifications. |
QUESTION B10. |
|
3 |
Student participated in most or all of the testing program with accommodations or modifications. |
Ô Ô |
PLEASE CONTINUE WITH QUESTION B9b. |
B9b. Which of the following accommodations and/or modifications, were provided to this student to participate in mandated standardized tests?
PLEASE CIRCLE ALL THAT APPLY.
1 |
Given test orally |
2 |
Reader provided |
3 |
Dictated responses |
4 |
Shortened test |
5 |
Alternative setting |
6 |
Additional time |
7 |
Alternative format for responding (e.g., pointing, typing, etc.) |
8 |
Braille/large-print version of test |
9 |
Other: ______________________________________________________________ |
B10. Who participated in the most recent IEP or 504 plan development or review for this student? PLEASE CIRCLE ALL THAT APPLY.
1 |
General education academic subject teacher(s) |
2 |
General education vocational teacher(s) |
3 |
Special education teacher(s) |
4 |
School administrator (e.g., principal, special education director, program coordinator) |
5 |
School counselor or psychologist |
6 |
Related services personnel (e.g., speech therapist/pathologist, occupational therapist, physical therapist) |
7 |
Parent/guardian(s) |
8 |
Student |
9 |
Staff of outside service agency or outside consultant |
10 |
Employer |
11 |
Representative of postsecondary institution |
12 |
Advocate |
13 |
Other (please specify): _______________________________________________ |
NOTE: QUESTION B10 WILL BE EXCLUDED AND SS10 WILL BE INCLUDED IN THE VERSION OF THE QUESTIONNAIRE USED FOR STUDENTS AGES 14 OR OLDER.
SS10a. Has there been postsecondary transition planning for this student during this school year?
1 |
Yes |
PLEASE GO ON TO QUESTION SS10b. |
2 |
No |
PLEASE GO TO SECTION C |
9 |
Dont know |
SS10b. Is the students transition plan written?
1 |
Yes |
2 |
No |
SS10c. Who has actively participated in the transition planning for this student during this school year (for example, by being involved in discussions on choosing services or goals)? PLEASE CIRCLE ALL THAT APPLY.
1 |
General education academic subject teacher(s) |
2 |
General education vocational teacher(s) |
3 |
Special education teacher(s) |
4 |
School administrator (e.g., principal, special education director, program coordinator) |
5 |
School counselor or psychologist |
6 |
Related services personnel (e.g., speech therapist/pathologist, occupational therapist, physical therapist) |
7 |
Parent/guardians |
8 |
Student |
9 |
Staff of outside service agency (please specify type of staff): _________________ |
10 |
Outside consultant (please specify type of consultant): ______________________ |
11 |
Employer |
12 |
Representative of postsecondary institution |
13 |
Advocate |
14 |
Other (please specify): _______________________________________________ |
SECTION C. ABOUT THIS STUDENTS PERFORMANCE AND FAMILY SUPPORT
IF THIS STUDENT CURRENTLY HAS AN INDIVIDUALIZED EDUCATION PLAN, BEGIN WITH QUESTION C2.
IF THIS STUDENT CURRENTLY DOES NOT HAVE AN INDIVIDUALIZED EDUCATION PLAN OR A 504 PLAN, BEGIN WITH QUESTION C1a.
C1a. If this student does not currently have an Individualized Education Plan (IEP), has this student ever had an Individualized Education Plan (IEP) for special education or related services?
1 |
Yes, this student has had an IEP |
2 |
No PLEASE GO TO QUESTION C2. |
3 |
Dont know |
C1b. In what school year was this student discontinued from special education?
PLEASE RECORD SCHOOL YEAR OR CIRCLE CODE.
____________ |
School year discontinued special education services |
999 Dont know
C2. During the month of February of this year, how many days was this student absent, excluding days suspended? If days arent available, please indicate the number of classes from which the student was absent.
PLEASE ENTER EITHER NUMBER OF DAYS OR NUMBER OF CLASSES ON EACH LINE.
Number of days |
or |
Number of classes |
|
__________ |
__________ |
Excused absences |
|
__________ |
__________ |
Unexcused absences |
C3. During this school year, how many times has this student experienced the following disciplinary actions?
PLEASE ENTER ONE NUMBER ON EACH LINE OR CIRCLE "999." ENTER "0" FOR NONE.
Number of incidents |
Number of |
||
__________ |
Suspensions (may include in-school suspensions) |
||
__________ |
OR |
_________ |
Disciplinary actions (e.g., referral to the office, detentions, etc.), excluding suspensions or expulsions |
999 |
999 |
Dont know |
C4a. What grade level in reading and mathematics has this student achieved as of the most recent assessment(s)?
PLEASE Circle one number for reading and one number for math.
Grade level in: |
||
Reading |
Mathematics |
|
999 |
999 |
No grade level determined |
0 |
0 |
Preschool/Kindergarten |
1 |
1 |
Grade 1 |
2 |
2 |
Grade 2 |
3 |
3 |
Grade 3 |
4 |
4 |
Grade 4 |
5 |
5 |
Grade 5 |
6 |
6 |
Grade 6 |
7 |
7 |
Grade 7 |
8 |
8 |
Grade 8 |
9 |
9 |
Grade 9 |
10 |
10 |
Grade 10 |
11 |
11 |
Grade 11 |
12 |
12 |
Grade 12 or above |
C4b. Most recent year of reading assessment: __________________ (year)
C4c. Most recent year of math assessment: ___________________ (year)
REMINDER: IF YOU HAVE ALREADY COMPLETED THE TEACHER SURVEY, YOU DO NOT NEED TO COMPLETE THE REST OF THIS SURVEY. PLEASE GO TO THE NOTE AT THE END OF THE SURVEY, PAGE 17.
C5. During this school year, has this students parent/guardian(s) attended parent-teacher conferences or "back-to-school night?"
Please circle ONE number.
1 |
Yes |
2 |
No |
3 |
We do not have parent conferences or "back-to-school night. " |
4 |
Dont know |
C6. Approximately how often have you communicated with this students parent/guardian(s) during this school year about his/her progress (by phone, in person, or in writing), excluding routine progress reports or report cards?
Please circle ONE number.
0 |
Never |
1 |
Once |
2 |
A few times over the school year |
3 |
Once every other month |
4 |
Once a month |
5 |
Once a week or several times a month |
6 |
Every day or several times a week |
C7a. What is the primary language used by this students parent/guardian(s)?
Please circle ONE number.
1 |
A language other than English Please specify language: ________________________________ |
2 |
English |
3 |
Dont know |
SECTION D. ABOUT YOU
D1. What is your main role in this school?
Please circle All That apply.
1 |
General education classroom teacher |
2 |
Special education classroom teacher |
3 |
Resource room teacher |
4 |
Related services provider (e.g., speech therapist) |
5 |
Program specialist (e.g., full inclusion specialist) |
6 |
Case manager |
7 |
School psychologist |
8 |
School counselor |
9 |
Other: ___________________________________ |
D2. In what capacity (or capacities) are you involved with this student?
PLEASE CIRCLE ALL THAT APPLY.
1 |
Provide instruction directly to this student |
2 |
Provide related services directly to this student |
3 |
Provide consultation services to students teacher(s) |
4 |
Provide case management (e.g., program monitoring) for this student |
5 |
Program administrator/supervisor |
6 |
Supervise instructional assistant or paraeducator assigned to work with this student |
7 |
Other: _____________________________________________________________ |
D3. Approximately how often do you currently provide direct services to this student? Please circle ONE number.
1 |
Daily |
2 |
Two to three times per week |
3 |
Once a week |
4 |
Several times per month |
5 |
Once per month |
6 |
Once every two to six months |
7 |
Very rarely |
THANK YOU FOR COMPLETING THIS QUESTIONNAIRE!
Please return it in the postage-paid envelope to:
The Special Education Elementary Longitudinal Study (SEELS)
(contractor address)