Georgia Sensory Assistance Project

Registration of NEW Students with Vision and Hearing Loss

 

 

STUDENT'S NAME: _______________________________ 

RACE: _______________________________ 

DATE OF BIRTH:   _________/_______/______

                                                                ^{Month                         Day                YEAR}

Age    _______________________________         

SEX: (Circle one)             Male                Female

 

 

SCHOOL SYSTEM (COUNTY): _______________________________ 

NAME OF SCHOOL:  _______________________________________

SCHOOL ADDRESS: _________________________________________________________________

CITY, STATE, ZIP:     _________________________________________________________________

CITy                                                                                       stATE                                                                                   zIP

SCHOOL PHONE: (_____________)  __________---- _____________

                                                                           ^{aREA CODE}

 

STUDENT'S CURRENT TEACHER: _____________________________________________________

TEACHER’S E-MAIL ADDRESS: ________________________________________________________

 

 

PARENT/GUARDIAN: ________________________________________________________________

PARENT ADDRESS: __________________________________________________________________

City, State Zip Code:  _______________________________________________________________

City                                                                                       State                                                            Zip Code

           

                                               

HOME PHONE: (_____________) __________----_____________

                                      ^{aREA CODE}

BUSINESS PHONE: (_____________) __________---- _____________

                                                                           ^{aREA CODE}

PARENT’S EMAIL ADDRESS: _________________________________________________________

 

 

 

1.  Major Causes of Deafblindness: (Please check appropriate category and   specify exact etiology)

 

____   Hereditary/Chromosomal Syndromes and Disorders.  Please Specify type______________

____   Pre-Natal/Congenital Complications. Specify type ___________________

____   Post-Natal/Non-Congenital Complications. Specify type______________________  

____   Related to Prematurity

____   Other.  Specify type ____________________________

____   Undiagnosed

2.         Race/Ethnicity: (Please check one)

 

____   American Indian or Alaska Native

____   Asian or Pacific Islander

____   Black or African American (not Hispanic)

____   Hispanic or Latino

____   White (not Hispanic)

 

           

3.   Vision Loss:

 

       A.  Month and Year of last Ophthalmological/Optometrical Exam:   _____   /_____

     mONTH         YEAR

       B.  Month and Year of last Functional Vision Assessment: _____/______ 

                                                                                                                         mONTH     YEAR

 

 

 C.  Please circle the one code that best describes the individual’s visual   impairment in the better eye with correction:

 

____1.  Low Vision (visual acuity of 20/70 to 20/200 in better eye with correction)

____2.  Legally Blind (visual acuity of 20/200 or less or field restriction of 20       degrees or less in the better eye with correction)

____3.  Light Perception Only

____4.  Totally Blind

____5.  Cortical Visual Impairment

____6.  Diagnosed Progressive Loss

____7.  Further Testing Needed

____8.  Tested-Results Nonconclusive

 

 

4.  Hearing Loss:

 

      A.  Please indicate month and year of last audiological exam:   _____/ ______

                                                                                                                                                                      mONTH     YEAR

B.  Please INDICATE month and year of last functional hearing assessment: ___/___

                                                                                                                                                                                                                       MONTH   YEAR

C.  Please circle the one code that best describes the individuals hearing    impairment with the better ear aided where appropriate:

 

____1.  Mild (26-40dB loss)

____2.  Moderate (41-55 dB loss)

____3.  Moderately Severe (56-70 dB loss)

____4.  Severe (71-90 dB loss)

____5.  Profound (91+ loss)

____6.  Central Auditory Processing Disorder

____7.  Diagnosed Progressive Loss

____8.  Further Testing Needed

____9. Tested- Results Nonconclusive

 

D. Does the individual have a central processing disorder?  (Please check below)            ____ Yes        ____No

 

 

 

 

5.  Additional Disabilities:     (Please circle)

 

Physical Impairments                      No       Yes

Cognitive Impairments                    No       Yes

Behavior Disorder                         No       Yes

Complex Health Care Needs       No       Yes

Other (please specify) ____________________________________________________________

                                                   

 

6.      How THE STUDENT IS REPORTED ON the December 1 FTE count.   CHECK ONLY ONE TO indicate the STUDENT’S PRIMARY Disability as reported to the state?

 

____0.    Individual under 3 years old

____1.    Autistic                      

____2.    Hearing Impaired (includes deafness)

____3.    Deaf-Blind

____4.    Mental Retardation

____5.    Multi-disabled

____6.    Other Health Impairments

____7.    Orthopedic Impairment

____8.    Emotionally Disturbed

____9.    Specific Learning Disability

____10.  Speech or Language Impairment

____11.  Traumatic Brain Injury

____12.  Visually Impaired (including blindness)

____13.  Developmentally Delayed (for age 3 through 9 only)

____14.  Non-categorical

      ____888.Not reported under Part B of IDEA

 

 

 7.  Setting of Services:  (Identify the students current age.  Then check only one that best describes the individual’s current educational setting)

 

Birth through Age 2:

 

____101.   Early Intervention Center/Classroom

____102.   Home Based Early Intervention

____103.   Combination of Center Based and Home Based

____104.   Clinical Outpatient Services

____105.   Day care/Child care

____106.   Homebound/Hospital Environment

____107.   Not Receiving Early Intervention Services

____155.   Other (Specify) ____________________________________________________________

 

Ages 3-5:

 

____201.  Early Childhood Setting

____202.  Early Childhood Special Education Setting

____203.  Combination of 1 & 2

____204.  Home school Program

____205.  Residential School

____206.  Specialized School

____207.  Itinerant Service Outside the Home

____208.  Reverse Mainstream Setting

____209.  Charter School     _{(cONTINUE AGES 3-5 ON NEXT PAGE)}

 

____210.  Homebound/Hospital Environment

____211.  Not Receiving Early Childhood Special Education Services

____255.  Other (Specify) ____________________________________________________________

 

Ages 6-21:

 

____301.  General Education class

____302.   Resource room

____303.   Specialized class

____304.  Public specialized school

____305.  Private specialized school

____306.  Public residential school