August, 1999

 

  SPECIAL EDUCATION ELEMENTARY LONGITUDINAL STUDY (SEELS)
   
  ALMOST FINAL SURVEY OF SCHOOL PROGRAMS
   
   
   
   
   
  SRI Project 3421
   
   
   


THE SPECIAL EDUCATION ELEMENTARY LONGITUDINAL STUDY (SEELS)

Student’s School Program Survey

 

 

 

 

Label with student’s name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLEASE TURN THE PAGE TO BEGIN THE SURVEY Ô Ô Ô Ô Ô Ô


 

 

Today’s 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 student’s school program.

 

Yes

Please PROCEED to Section A.

 

 

SECTION A. ABOUT THIS STUDENT’S 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


Resource room

Special education classroom


Homebound instruction


Not applicable

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 student’s 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%

Don’t 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 student’s 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
schools for these transitions

 

 

A4b. Which of the following were provided to support this student’s 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 student’s file before the student started school here.

8

Other: _____________________________________________________________

9

None of these

10

Don’t 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

Don’t 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
schools for these transitions

 

A5b. Which of the following will be provided to support this student’s 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

Don’t 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
for special education services.

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 student’s 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

Don’t 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 Don’t 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 student’s disabilities.
PLEASE CIRCLE ALL THAT APPLY in column a.

In column B, please circle the student’s 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

Don’t 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 student’s 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 student’s 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, nurse’s 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

Don’t know

 

SS10b. Is the student’s 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 STUDENT’S 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
for special education services Ô Ô PLEASE CONTINUE WITH C1b.

2

No PLEASE GO TO QUESTION C2.

3

Don’t 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 Don’t know

C2. During the month of February of this year, how many days was this student absent, excluding days suspended? If days aren’t 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
days

 

__________

   

Suspensions (may include in-school suspensions)

__________

OR

_________

Disciplinary actions (e.g., referral to the office, detentions, etc.), excluding suspensions or expulsions

999

 

999

Don’t 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 student’s 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

Don’t know

 

C6. Approximately how often have you communicated with this student’s 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 student’s parent/guardian(s)?
Please circle ONE number.

1

A language other than English

Please specify language: ________________________________

2

English

3

Don’t 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 student’s 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)

SEELS DESIGN DOCUMENTS