2022 WDBTAP Deafblind Child Count

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This form is used to update a child's information on the 2022 Statewide Deafblind Count which is conducted yearly by the Wisconsin Deafblind Technical Assistance Project (WDBTAP). Children being included on this count should already be registered with WDBTAP, be between the ages of birth and 21 years, have combined hearing and vision loss, and not yet graduated from a high school program. The Deafblind Census is conducted for the Wisconsin Department of Public Instruction (DPI) and is required annually by the Office of Special Education Programing (OSEP) in order to maintain grant funding for deafblind student programming at school and at home.
Please answer these questions as completely and accurately as possible, not every questions needs a response, just the ones that apply to your child or student. Please complete the form by April 1, 2023. If you have any questions, please contact Jenny at 608-356-2023 or jennifer.hudson-stanek@wesp-dhh.wi.gov

Thank you!

Email *

Today's date *

YYYY

Child's first name *

Child's last name *

Child's gender *

0 Male

1 Female

2 Other

Child's date of birth *

YYYY

Ethnicity *

0 Not Hispanic / Latino

1 Yes, Hispanic / Latino

Race *

1 American Indian or Alaskan Native

2 Asian

3 Black or African American

5 White

6 Native Hawaiian or other Pacific Islander

7 Two or more races

999 Unknown

Best e-mail address for family

Deafblind project status *

0 Eligible to receive services from the deafblind project (Has combined hearing & vision loss and if over 18 enrolled in a high school program).

1 No longer eligible to receive services from DB Project.

Agency/school child attends, please include mailing address: *

Child's primary contact at school: (primary teacher ages 3-21 or service coordinator birth to 2) *

Primary teacher/service coordinator e-mail address

Name of person completing census and relationship to child. *

Living setting

1 Home: parents

2 Home: extended family

3 Home: foster parents

4 State residential facility

5 Private residential facility

9 Pediatric nursing home

10 Community residence (includes group home or supported apartment)

555 Other

Clear selection

Primary language in the home.

1 English

2 Spanish

3ASL

9 Other

999 Unknown / missing

Clear selection

Is braille being learned or used by the child?

Yes

Unknown

Clear selection

Etiology

Please indicate the one etiology from the lists below that best describes the primary etiology of the child/student's primary disability. Please indicate other if none of the listed etiologies are the primary disability.

Chromosomal syndromes and disorders

101 Aicardi syndrome

102 Alport syndrome

103 Alstrome syndrome

104 Apert syndrome (Acrocephalosyndactly)

105 Bardet-Biedl syndrome (Laurence Moon-Biedl)

106 Batten diesease

107 CHARGE syndrome

108 Chromosome 18 (Ring 18)

109 Cockayne syndrome

110 Cogan dyndrome

111 Cornelia de Lange

112 Cri du chat syndrome (Chromosome 5p)

113 Crigler-Najjar syndrome

114 Crouzon syndrome (Craniofacial Dysotosis)

115 Dandy Walker syndrome

116 Down syndrome (Trisomy 21)

117 Goldenhar syndrome

118 Hand-Schuller-Christian (Histiocytosis X)

119 Hallgren syndrome

120 Herpes-Zoster (Hunt)

121 Hunter syndrome (MPSII)

122 Hurler syndrome (MPS I-H)

123 Kearns-Sayre syndrome

124 Klippel-Feil sequence

125 Klippel-Trenaunay-Weber syndrome

126 Kniest Dysplasia

127 Leber congenital amaurosis

128 Leigh disease

129 Marfan syndrome

130 Marshall syndrome

131 Maroteaux-Lamy syndrome (MPSVI)

132 Moebius syndrome

133 Monosomy Tenp

134 Morquio syndrome (MPS IV-B)

135 NF 1--Neurofibromatosis

136 NF 2--Bilateral Acoustic Neurofibromatosis

137 Norrie disease

138 Optico-Cochleo-Dentate degeneration

139 Pfieffer syndrome

140 Prader-Willi

141 Pierre-Robin syndrome

142 Refsum syndrome

143 Scheie syndrome (MPS I-S)

144 Smith-Lemli-Optiz (SLO syndrome)

145 Stickler syndrome

146 Sturge-Weber syndrome

147 Treacher Collins syndrome

148 Trisomy 13 (Patau syndrome)

149 Trisomy 18 (Edwards syndrome)

150 Turner syndrome

151 Usher I syndrome

152 Usher II syndrome

153 Usher III syndrome

154 Vogt-Koyanagi-Harada syndrome

155 Waardenburg syndrome

156 Wildervanck syndrome

157 Wolf-Hirschhorn syndrome (Trisomy 4p)

Other:

Clear selection

Prenatal / congenital complications

201 Congenital Rubella Syndrome

202 Congenital Syphilis

203 Congenital Toxoplasmosis

204 Cytomegalovirus (CMV)

205 Fetal Alcohol Syndrome

206 Hydrocephaly

207 Maternal drug use

208 Microcephaly

209 Neonatal Herpes Simplex (HSV)

Other:

Clear selection

Postnatal / Non-congenital Complications

301 Asphyxia 1

302 Direct trauma to the eye and/or ear

303 Encephalitis

304 Infections

305 Meningitis

306 Severe head injury

307 Stroke

308 Tumors

309 Chemically induced

401 Complications of prematurity

501 No determination of etiology

Other:

Clear selection

Documented vision loss *

1 Low vision (visual acuity of 20/70 to 20/200 or greater)

2 Legally blind (visual acuity of 20/70 to 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.

Cortical vision impairment

0 No

1 Yes

2 Unknown

Clear selection

Corrective lenses

0 No

1 Yes

2 Unknown

Clear selection

Documented hearing loss *

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

9 Documented functional hearing loss

Central auditory processing disorder

0 No

1 Yes

2 Unknown

Clear selection

Auditory neuropathy

0 No

1 Yes

2 Unknown

Clear selection

Cochlear implants

0 No

1 Yes

2 Unknown

Clear selection

Assistive listening devices (hearing aides, FM system or other assisted listening device).

0 No

1 Yes

2 Unknown

Clear selection

Physical or orthopedic impairments

0 No

1 Yes

2 Unknown

Clear selection

Intellectual / cognitive disabilities

0 No

1 Yes

2 Unknown

Clear selection

Emotional / behavioral disorders

0 No

1 Yes

2Unknown

Clear selection

Complex health care needs

0 No

1 Yes

2 Unknown

Clear selection

Communication, speech or language impairments

0 No

1 Yes

2 Unknown

Clear selection

Other impairments

0 No

1 Yes

2 Unknown

Clear selection

Additional assistive technology

0 No

1 Yes

2 Unknown

Clear selection

Intervener services
(Provided by a person who has completed or is currently enrolled in a nationally credentialed intervener program.)

0 No

1 Yes

2 Unknown

Clear selection

IDEA services (Individuals with Disabilities Education Act)

1 IDEA part C (for babies and toddlers up to age 3)

2 IDEA part B (for school age children, age 3 and over)

3 Not reported under part B or C

4 504 plan

Clear selection

Part C category for children age birth to age 3 only

If your child is 3 or older you can skip this section and continue to part b.

1 At risk for developmental delays.

2 Developmentally delayed

888 Not reported under Part C of IDEA

Clear selection

Part C early intervention setting

1 Home

2 Community based setting

3 Other settings

888 N/A Not served under Part C of IDEA

Clear selection

Part C exiting status (children from birth through age 3)

0 Not exited 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.

888 N/A Not served under Part C

Clear selection

Part B disability code, children ages 3 - 21

Please indicate the primary category code under which the child was reported on the state department of education Part B IDEA Child Count-. All children over the age of 3 should have a code, SELECT ONLY ONE. If your child is under 3 you can skip this section.

1 Intellectual disabilities

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 Deafblindness

10 Multiple disabilities

11 Autism

12 Traumatic brain injury

13 Developmentally delayed age 3 through 9

14 Non-categorical

Not reported under Part B IDEA

Clear selection

Part B Educational settings (children ages 3 - 21)

Ages 3 - 5: early childhood special education

301 Attending a regular early childhood program (10+ hours)

302 Other location regular early childhood program (10+ hours)

303 Services in regular early childhood program (less than 10 hours)

304 Other location regular early childhood program (less than 10 hours)

305 Attending a separate class.

306 Attending a separate school

307 Attending a residential facility

309 Home, at public expense

310 Home, not at public expense

888 N/A Not served under part b

Other:

Clear selection

Ages 6 - 21: school aged students:

610 Inside the regular class 80% or more of the day.

611 Inside the regular class 40% to 79% of day.

612 Inside the regular class less than 40% of the day.

613 Separate school

614 Residential facility

615 Homebound / hospital

616 Correctional facilities

617 Parentally placed in private schools

620 Home school / remote learning at public expense.

621 Home school / remote learning not at public expense.

888 Not served under Part B

Clear selection

Participation in statewide assessments

1 Regular grade-level state assessment.

2 Regular grade-level state assessment with accommodations.

3 Alternate assessment

6 Not required at age or grade level.

7 Parent opt out

Clear selection

Part B exiting status

0 In special education program.

1 Transferred to regular education

2 Graduated with regular high school diploma

22 Graduated with alternate diploma.

3 Received a certificate.

4 Reached maximum age

5 Died

6 Moved, known to be continuing

8 Dropped out

Clear selection

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