Texas Deafblind Census !! " !!

#
Complete one for each student *************** ************** New !ast Name <irst Name ********************************** Update Parents Name ********************************** No Changes Address **************** **** ******** Delete Cit& %tate Dip Code RACE/ETHNICITY

%chool District Name +egion P'I3% or %% Num(er

Male

Fe$ale
Da%e &f 'i(%) **** 9 *****9 **********
3onth Da& 7ear (0 Digit

American Indian or Alaska Native Asian or Pacific Islander

Black or African American (not Hispanic Hispanic or !atino

"hite (not Hispanic #ther$ %pecif&

INSTRUCTIONAL STATUS INFORMATION

Continues in %pecial 'ducation (& No !onger on Census No !onger +eceives %pecial 'ducation ,raduated (& Completing all +egular 'ducation +e-uirements (./

%pecif& reason) ***********************************

%pecif& reason) ***********************************

,raduated (& Completing I'P +e-uirements$ Including Credit +e-uirements (.0 $ (.1 $ (.2 ,raduated (& Completing I'P +e-uirements and (& +eaching 3a4imum Age for Part B %ervices (.5 +eached 3a4imum Age for Part B %ervices "ithout 3eeting I'P #(6ectives 3oved$ in %tate to ******************* 3oved$ #ut of %tate to ****************** Deceased Dropped #ut %elect one if applica(le: (If student is no longer in school$ please complete this section and return forms:

PARENTAL CONSENT

No

7es

Parent Phone Num(er ********************

8he district has o(tained specific consent from the parents9guardians of the student for the 8e4as 'ducation Agenc& and its contractors responsi(le for the 8e4as Deaf(lind Census to release personall& identifia(le education and statistical data from the annual census to specific agencies: 8his Consent must (e documented in the district on the 3arch ;..; 8'A <orm) Consent for the +elease of Confidential Information = %tudent with Deaf(lindness:

He(edia%(*/C)(&$&s&$al S*nd(&$es and Dis&(de(s /;5 !e(ers congenital amaurosis

/./ Aicardi s&ndrome /.; Alport s&ndrome /.> Alstrom s&drome /.0 Apert s&ndrome (Acrocephalos&ndact&l&$ 8&pe / /.1 Bardet?Biedl s&ndrome /.2 Batten disease /.5 CHA+,' association /.@ Chromosome /@$ +ing /@ /.A Cocka&ne s&ndrome //. Cogan s&drome /// Cornelia de !ange //; Cri du chat s&ndrome (Chromosome 1p? s&ndrome //>Crigler?Na66ar s&ndrome //0 CrouBon s&ndrome = (Craniofacia D&sotosis //1 Dand& "alker s&ndrome //2 Down s&ndrome (8risom& ;/ s&ndrome //5 ,oldenhar s&ndrome //@ Hand?%chuller?Christian (Histioc&tosis C //A Hallgren s&ndrome /;.Herpes Doster (or Hunt /;/ Hunter s&ndrome (3P% II /;; Hurler s&ndrome (3P% I?H /;> Eearns?%a&re s&ndrome /;0 Elippel?<eil s&ndrome /;1 Elippel?8renauna&?"e(er s&ndrome /;2 Eniest D&splasia /;@!eigh disease /;A 3arfan s&ndrome

PRIMARY IDENTIFIED ETIOLOGY

'tiolog& (write one numeric code in this (o4

/>. 3arshall s&ndrome />/ 3aroteau4?!am& s&ndrome (3P% FI />; 3oe(ius s&ndrome />> 3onosom& /.p />0 3or-uio s&ndrome (3P% IF?B />1 N</ = Neurofi(romatosis = (von +ecklinghausen disease />2 N<; = Bilateral Acoustic Neurofi(romatosis />5 Norrie disease />@ #ptico?Cochleo?Dentate Degeneration />A Pfieffer s&ndrome /0. Prader?"illi /0/ Pierre?+o(in s&ndrome /0; +efsum s&ndrome /0> %cheie s&ndrome (3P% I?% /00 %mith?!emli?#pitB (%!# s&ndrome /01 %tickler s&ndrome /02 %turge?"e(er s&ndrome /05 8reacher Collins s&ndrome /0@ 8risom& /> (8risom&/>?/1$ Patau s&ndrome /0A 8risom& /@ ('dwards s&ndrome /1. 8urner s&ndrome /1/ Usher I s&ndrome /1; Usher II s&ndrome /1> Usher III s&ndrome /10 Fogt?Eo&anagi?Harada s&ndrome /11 "aarden(urg s&ndrome /12 "ildervanck s&ndrome

/15 "olf?Hirschhorn s&ndrome (8risom& 0p /AA #ther ************************* (Indicate the numeric code in the (o4 a(ove and specif& in this space

;AA #ther ****************** (indicate the numeric code in the (o4 a(ove and specif& in this space

P(e"Na%al/C&n+eni%al C&$,li-a%i&ns

;./ Congenital +u(ella ;.; Congenital %&philis ;.> Congenital 8o4oplasmosis ;.0 C&tomegalovirus (C3F ;.2 H&drocephal& ;.@ 3icrocephal& ;.ANeonatal Herpes %imple4 (H%F

P&s%"Na%al/N&n"C&n+eni%al C&$,li-a%i&ns
>./ Asph&4ia >.; Direct 8rauma to the e&e and9or ear >.> 'ncephalitis >.0 Infections >.1 3eningitis >.2 %evere Head In6ur& >.5 %troke

>.@ 8umors >.AChemicall& Induced >AA #ther ****************** (Indicate the num(eric code in the (o4 a(ove and specif& in this space

Rela%ed %& P(e$a%u(i%*

0./ Complications of Prematurit&

Undia+n&sed
1./ No Determination of 'tiolog&

Page /

Appendi4 E .ISUAL IMPAIRMENT Date of !ast #phthalmological9 #ptometrical '4am Date of !ast <unctional Fision Assessment "ears ,lassesG Diagnosed Cortical Fisual ImpairmentG Diagnosed Progressive !ossG Fision !oss in #ne '&e #nl&G
******9****** 3onth 7ear ******9****** 3onth 7ear

P(i$a(* Classifi-a%i&n &f .isual I$,ai($en% /Sele-% One01

Fision (etter than ;.95. with correctin !ow Fision (;.95. to ;.9;.. in (etter e&e with correction or field
loss !egall& Blind (;.9;.. or less or field restriction of ;. degrees or less !ight Perception #nl& 8otall& Blind <urther 8esting Needed 8ested Nonconclusive Not 8ested = At +isk (documented Hearing loss$ at risk for visual impairment #ther$ %pecif& **************************** P(i$a(* Classifi-a%i&n &f Hea(in+ I$,ai($en% /Sele-% One01 (Aided where appropriate

No No No No

7es 7es 7es 7es

HEARING IMPAIRMENT Diagnosed Central Auditor& Processing DisorderG Uses AmplificationG Cochlear ImplantG Diagnosed Progressive !ossG Hearing in #ne 'ar #nl&G 8ested with AmplificationG

Date of !ast Audiological '4am 3onth

******9****** 7ear

No No No No No No

7es 7es 7es 7es 7es 7es

Hearing within normal range when aided (cochlear implant Fer& 3ild (/1?;1 dB loss 3ild (;2?0. dB loss 3oderate (0/?11 dB loss 3oderatel& %evere (12?5. dB loss %evere (5/?A. dB loss Profound (A.H dB loss <urther 8esting Needed to Determine Hearing Impairment 8ested Non Conclusive Not 8ested at +isk (documented visual impairment$ at risk for hearing loss #ther$ %pecif& **********************

OTHER IMPAIRMENTS Ph&sical Impairment Cognitie Impairment Behavioral Disorder Comple4 Health Care Needs

Indicate all Documented impairments$ in addition to the individualIs hearing and visual impairments$ that have an& significant impact on the individualIs developmental or educational program:

No 7es No 7es No 7es

No 7es #ther Impairments$ %pecif& *****************************************

IDEA FUNDING/CODE <unding Categor& (as reported in the Decem(er / count )

ID'A Part B (>?;/

ID'A Part C (.?; = +eported (& 'CI

Not +eported Under Part B or Part C

Pa(% ' Ca%e+&(* C&de as (e,&(%ed in %)e De-e$be( 2 -&un% / Select Only One01

Autism Deaf(lind Developmentall& Dela&ed 'motionall& Distur(ed Hearing Impaired (includes deafness 3ental +etardation

3ulti?disa(led Non?Categoricall& <unded Not +eported #rthopedic Impairment #ther Health Impairment %pecific !earning Disa(ilit&

%peech or !anguage Disa(ilit& 8raumatic Brain In6ur& Fisuall& Impaired

Page ; Appendi4 E