1



# Appendix **C .**  **Provider Questionnaire**  **and TA Recipient Supplement** 2

**If identified from the district/principal :**  **You are receiving this survey because you have been identified by your school principal or district special education administrator as someone who**  **works with**  **students with deafblindness (also known as Dual Sensory Impairment) on at least a weekly basis**  **. On the next screen, we will ask you to confirm that you d**  **o work with one or more students with**  **deafblindness during the current**  **school year. First, here is some brief information about this study. If identified through the State Deaf**  **- Blind Project** **: You are**  **receiving this survey because you have been identified by your state project, [Project name], as someone who received child**  **- specific support from**  **that project related to serving one of more students with deafblindness. On the next screen, we will ask you**  **to confirm that you have worked with one or more students with deafblindness. First, here is some brief information about this study.**  **Please note :**  **If you have already received and completed this survey, you do not need to complete it again.**  **Click here .**  [w ill open a contact information form to complete] **What is this survey about?** This survey is about the experiences of people who provide services to children with deafblindness in school and related settings. The questions will ask about your background, your experiences working with students generally, and about your experiences with the [Project name] . You will not be asked to share any personally identifiable or confidential information about your students. **Who is asking these q uestions?**  The survey is funded and directed by the U.S. Department of Education. The organization contracted to conduct the survey is called Westat. Westat is an organization that designs and conducts social science research studies for the U.S. government and other agencies. Westat has no connection to any of the State Deaf
- Blind Projects; it is an independent research agency. **What is the benefit or value of completing this survey?** To show our appreciation for your time and effort, you will receive a $20 gift code to Amazon immediately after completing the survey. This gift code will be sent to the email address you provide at the end of the survey. Your responses will help the Department of Education understand the areas where support or guidance may be needed, and the role of the State Deaf
- Blind Projects in helping providers serve students with deafblindness . There is no direct benefit to your school, or any student you work with, but the findings will inform decisions that have to do with children and the schools where they are served. **What will happen with the information I provide? Will it have a negative effect on my school or on me?** We will ask you for your name and contact information, but can assure you all information collected in this survey i s strictly confidential. That means that your name and school name will not be linked in any way with your responses. Nothing you say can have a negative effect on you personally or your school, because this information will not be available to anyone outs ide the survey team, and will not be disclosed or released to others for any purpose.3

**How long will it take to complete?** Depending on your responses, t he survey contains between 20 and 31 questions, and we estimate that it will take you between 15 and 2 0 minutes to complete. You may start and stop the survey at any time. **Notice of Confidentiality** Information collected from the surveys comes under the confidentiality and data protection requirements of the Institute of Education Sciences ( Public Law 107
- 2 79, Section 183). Information that could identify an individual or institution will be separated from the survey responses submitted, kept in secured locations, and be destroyed as soon as they are no longer required. Surv ey responses will be used only for research purposes. The reports prepared for the study will summarize survey findings across service providers, by characteristics of service providers, and by state. No individual respondent or school will be identifi ed at any stage of reporting. The info rmation collected for this study will be used only for statistical purposes and may not be disclosed or used, in identifiable form, for any other purpose except as required by law
. **Paperwork Reduction Act of 1995** According to the Paperwork Reduction Act of 1995, no persons are required to respond to this voluntary collection of informat ion unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is **18 50** **- New**  . The time required to complete this information collection is estimated to average 1 **5 -** **2 0**  **minutes** per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review th e informatio n collection. **If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:**  U.S. Department of Education, Washington, D.C. 20202
-4537. **If you have comments or concerns regarding the sta** **tus of your individual submission of this form, write directly to:** Jonathan Jacobson, U.S. Department of Education, Institute of Education Sciences, 555 New Jersey Avenue, NW, Suite 500J, Washington, D.C. 20208, or email jonathan.jacobson@ed.gov. If you h ave any questions, contact: Tamara Daley, 1
-888
-xxx-xxxx E
- mail: TADEval@westat.com4

**For the purpose of verification, do**  **you currently provide services to**  **any students with deafblindness or**  **Dual Sensory Impairment on at least a weekly basis ?** 

 By deafblindness, we mean students who had a combinat ion of vision and hearing loss, also called a dual
-sensory impairment.  Few children who are considered deafblind have total vision and hearing lo sses. Children may have losses in varying degrees of severity. For example, one student may have low vision and mild to moderate hearing loss, and another student may be both legally blind and have severe or profound deafness. For the purpose of this survey, both students are considered deafblind.  Students do not need to have been eligible for services under the IDEA category of deafblindness to answer “yes” to this question. **Select the best answer:** O Yes, I work with one or more students with deafblindnes s on at least a weekly basis
.  Will continue to survey O No, I do not work with any students with deafblindness on a weekly basis
.  Will not receive the survey O I am unsure if I work with a student with deafblindness
.  Will receive follow up5



## Follow up page for **“ No** **” and**  **“ Unsure** **” providers**  You are seeing this screen because you indicated that you either do not work with any students with deafblindness or you are unsure whether you worked with any students with deafblindness. Please enter contact information below so we may clarify our records. First Name: Last Name: Email Address: Name of school or primary work setting: Phone Number (xxx
-xxx-xxxx): Best day and time to reach you by phone, if needed ? To submit this information, please click here
. If you wish to return to the survey, please click here
.6 

## A. **Information about you and your experiences 1.**  **Which of the following**  **best describes your**  **district -** **wide professional role**  **during the current**  **school year** **? If you played more than one role, select the one that describes you best.**  O Administrator O Regular education classroom teacher O Special education teacher O Teacher of the Hearing Impaired O Teacher of the Visually Impaired O Teacher of the Deafblind/Dual Sensory Impaired O Early childhood educator/specialist O Paraprofessional or Assistant Teacher O Intervener O Audiologist O Behavior Specialist O Independent Living Skills Instructor O Occupational Therapist O Orientation & Mobility Specialist O Physical Therapist O Psychologist O Rehabilitation Counselor O School counselor O Sign Language Interpreter O Social worker O Speech Pathologist O Transition Specialist O Consultant O Other:
**2. What is the total**  **number of schools and districts**  **in which you work**  **during the current**  **school year ,**  **across your entire caseload of students ?**  [a] schools located in [b] district(s)
**3. T** **hinking across your entire caseload, in**  **what type of setting do you**  **provide services most**  **of the time?**  **If none of these apply, use “Other” to explain.**  O General education classroom O S elf
- contained special education classroom O Special education resource room or therapy room (including service
- provider location) O Classroom in a s eparate school for students with disabilities O Reside ntial school for students with disabilities O Other:7

**4. Is**  **your primary work**  **setting any of the following? Select one.** O School for the Deaf or Hard of Hearing O School for the Blind O School for the Deafblind O None of the above **5. T** **hinking only about your students with deafblindness,**  **in what type of setting do**  **you provide services**  **most of the time?**  **If none of these apply, use “Other” to explain.** O General education classroom O S elf
- contained special education classroom O Special education resource room or therapy room (including service
- provider location) O Classroom in a s eparate school for students with disabilities O Residential school for students with disabilities O Other: **6. Do**  **you work exclusively with students**  **with deafblindness?** O No O Yes **7. How many**  **students with**  **deafblind ness do**  **you work with in total**  **during the school day**  **this year ?**  [a] children or youth located in [b] different schools **8. Please estimate the number of**  **different children or youth**  **with deafblind**  **ness with**  **whom you have worked in your entire career**  **in any capacity or setting**  **.**

children or youth **9. How long have you worked in the field of special education**  **or with people with disabilities**  **?** [a] Years [b] Months **10. Do you consider yourself**  **primarily to be**  **a service**  **provider for children and youth**  **with deafblindness?**  O No O Yes **11. What is your educational background? Check all that apply.**   High school degree or GED  Associate’s degree (AA, A.Sc)  Bachelor’s degree ( e.g., BA, BS, B.Sc., BFA)  Master’s degree ( e.g., M.Ed., MA, MS, M.Sc.)  Doctoral degree ( e.g., Ph.D, Ed.D)  Other:8

**12. How knowledgeable do you**  **consider yourself to be overall**  **in working with**  **children and youth with**  **deafblindness? On a scale of 1**  **- 5, rate yourself from “Not at all knowledgeable” to “Very**  **knowledgeable”. 1**  **Not at all knowledgeable**  **2 3**  **4 5**  **Very knowledgeable**  

###     
**In responding to question s 13**  **- 14**  **below, please**  **think about the student**  **( s**  **) with deafblindness with** 

**whom you are working during the current**  **school year. 13.**  **What a re ages of the children or youth with**  **deafblindness with whom you**  **currently work** **? Check all that apply.**   Birth
- 2 years  3
- 5 years  6
- 11 years  12
- 17 years  18
- 21 years  Over 21 **14. What**  **are the primary educatio**  **nal placement of these student** **s ?**  **Check all that apply .**   In the general education class 80% or more of day  In the general education class 40% to 79% of the day  In the general education class less than 40% of the day  Separate school  Residential facility  Homebound / Hospital  Correctional facilities  Parentally placed in private school **15. Wh**  **ich of the following best describes the approx** **imate communication level of those student** **s? Check all that apply** **.**  **Pre -** **symbolic communication** (use d primarily behaviors, signals to request, reject, or comment), limited ability to initiate participation in routines witho ut support  **Emerging symbolic communication** (use d behaviors, signals, gestures, pictures, object symbols along with very limited signs or speech to request, reject, or comment ), partial ly participated in routine s and instructional activities  **Symbolic communication in familiar routines**  ( used more formal signals, gestures, some sign language, tactile symbols, pictures; emerg ing print or Braille), initiated interactions with others  **Symbolic communication** (used primarily speech, signs, fingerspelling, pict ures, print, or Braille), engaged in instructional activities at or near grade
- level9 

## B. **Topic Areas Needed for Support**  **16. Currently** **, what a**  **re t he topic areas for which you have**  **a need for information or support in your work with students with deafblind**  **ness? Check yes or no for each topic. You can see more**  **information by holding your cursor over each topic.** [will be functional in web version only] No, I did not need support on this topic Yes, I needed

support on this topic Adaptive living / Self

- care skills O O Assessment O O Assistive technology O O Behavioral issues & behavioral management O O Cochlear Implants O O Collaboration O O Communication O O Community and independent living O O Curriculum (What to teach) O O Deafblindness overview O O Etiology O O IEP/IFSP development and implementation O O Inclusion O O Intervener roles and competencies O O Instructional strategies (How to Teach) O O Orientation and Mobility (O&M) O O Parent/family support O O Socialization, leisure & recreation O O State and local policies O O Teachers roles and competencies O O Transition (early childhood) O O Transition (secondary) O O Visual and tactile accommodations to sign language O O10

**17. Do**  **you need information or support**  **in any other**  **topic areas in order to provide service** **s to**  **a student**  **who is deafblind ?** 



## C. Knowledge and Receipt of **Support 18.**  **Where do you usually**  **turn for information**  **or support on how to work with students with**  **deafblindness? Check all that apply.**  Colleagues at my school  Colleagues at other schools  School administrators  My district Special Education director or staff in the district special education office  Schools for the deaf, blind or deafblind  Parents and family members of my student  The Internet  National organizations or projects serving children with deafness, blindness, or deafblindness  State organizations or projects serving children with deafness, blindness, or deafblindness  Local organizations or projects serving children with deafness, blindness, or deafblindness  Other: **19. Do you have any familiarity with the [Name of state deafblind project?] Check all that apply.**   I have not heard of this center/project before.  I have heard about this center/project but have never had any interaction with it.  I interacted with this center/project in some way in the past but not last year or this year.  I had interaction with this center/project during the 2013

- 14 school year  I have interacted with this center/project during the current school year. **20. During the pas** **t two school**  **years (2013 -**  **14 school year and the current school year), did you receive child**  **- specific support from anyone affiliated with [Name of state deafblind project?]**  By child
specific support, we mean assistance that was centered on a particular chil d and took place either in
person or through the use of distance technology. If the support you received was exclusively by email or phone, check “no.” O No  Survey is complete and respondent will automatically go to Contact Information
. O Yes  Respondent continues to item 21
.11 

## TA Recipient Supplement **[These questions are received only by providers who i ndicate “yes” to**  **receipt of child -** **specific support or are identified by the State Deaf -** **Blind Project as receiving**  **child -** **specific support]**
**21. Please indicate all**  **other kinds of contact you had with**  **[Project name] during 2013 -**  **14 or the current school**  **year . Check all that apply.**   Received child
-specific support (e.g., assistance that was focused on a particular child and took place either in person or through the use of distance technology)  If this is not checked, survey is complete and respondent will automatically go to Contact Information
.  Attended a n in
- person training conducted by the project/center (e.g., workshops, workgroups, seminars, symposia, institutes, forums)  Participated in web
- based training  Downloaded information or materials from the project website  Received information or materials through mail  Received information through email or telephone  Received a newsletter  Other: **22. Please indicate**  **the locations you received child**  **- specific support from [Project Name] during 2013**  **- 2014**  **or the current school year . Check all that apply.**   I n a student’s home  I n a school setting  I n a student’s home using distance technology  I n a school setting using distance technology  Other: **23. When was your first**  **contact with [Project name]? Check one.**  O This school year (2014
- 15) is my first year of contact with the project/center O Last school year ( 2013
- 14 ) was my first year of contact with the project/center O 2
- 3 years ago O 4
- 5 years ago O 6
- 10 years ago O 11
- 15 years ago O More than 15 years ago **24. Which of the following best describes the timeframe of your**  **most recent**  **contact with the [ Project**  **n ame]?**  **Check one.**  O I have most recently been in contact with project staff within the past week. O I have most recently been in contact with project staff within the past month. O I have most recently been in contact with project sta ff earlier in the 2014
- 15 school year
. O I have most recently been in contact with project staff during the 2013
- 14 school year
.12

**25. How did you**  **first come into**  **contact with**  **[Project name]? Check one.** O Someone from the project initiated contact
. O I contacted the project directly. O Another member of a student’ s team contacted the project directly
. O A student’ s family contacted the project directly. O An administrator from my school or district (or from my organization) contacted the project directly. O I am not sure how contact was established. O Other: **26. Think**  **only about the child**  **- specific**  **support you received**  **from [Project name] from 2013**  **- 14**  **onwards .**  **P lease indicate whether the support you received covered**  **each of the topic**  **areas shown below**  **. You can see more informatio**  **n by holding your cursor over the topic.** [will be functional in web version only] Did not receive support on this topic Received

support on this topic Adaptive living / Self

- care skills O O Assessment O O Assistive technology O O Behavioral issues & behavioral management O O Cochlear Implants O O Collaboration O O Communication O O Community and independent living O O Curriculum (What to teach) O O Deafblindness overview O O Etiology O O IEP/IFSP development and implementation O O Inclusion O O Intervener roles and competencies O O Instructional strategies (How to Teach) O O Orientation and Mobility (O&M) O O Parent/family support O O Socialization, leisure & recreation O O State and local policies O O Teachers roles and competencies O O Transition (early childhood) O O Transition (secondary) O O Visual and tactile accommodations to sign language O O13 

## D **. Satisfaction with Support from Project**  27. **Please rate how much you agree with each of the following statem ents about the child**  **- specific**  **support you**  **have received from [**  **Project n ame]**  **, considering any**  **support you received**  **during the current (2014** **- 15) and the previous (2013** **- 14) school years**  **. Strongly**  **dis agree**  **Somewhat**

**dis agree**  **Somewhat**

**agree Strongly** 

**agree** a. The information provided was **relevant and specific**  to the needs of my student. O O O O b. The information provided was the **right amount** for me to be able to process
. O O O O
c. I was able to **immediately apply** at least some of the information in my work with a student with deafblindness
. O O O O
d. I was able to use the information in my work with students with **other disabilities .**  O O O O
e. The consultant was **knowledgeable** in the area in which support was provided. O O O O f. The consultant was **non -** **judgmental** in his or her approach to providing support . O O O O g. The consultant was able to **explain and model** practices and procedures effectively. O O O O h. The consultant established a **collaborative partnership**  with me. O O O O i. The consultant took into account local **limitations in resources**  when providing support. O O O O
**28. Overall, how satisfied were you with the**  **support you received from [Project name]**  **, considering**  **any support you received during the current (2014** **- 15) and the previous (2013** **- 14) school years**  **.**

**1 Very dissatisfied**  **2**

**Somewhat dissatisfied**  **3 Somewhat satisfied**  **4 Very satisfied**  O O O O
**29. Following the**  **most recent child**  **- specific**  **support you received, what is your perception of the**  **progress made by the primary student with whom you worked in the 3**  **- 6 months following the**  **support ?**  Use a scale of 1 to 5 where 1 means “no progress” and 5 means “substantial progress.” **1 No progress**  **2 3**  **4 5**  **Substantial Progress**  O O O O O14

**30. What recommendatio**  **ns or suggestions made by the consultant did you find most helpful?** 

**31. What additional assistance or training, if any, would you**  **like to receive?**



## E **. Contact Information** Thank you for taking the time to respond to these questions. Your input is extremely important and will be used to improve opportunities to receive support for those who work with children and students with deafblindness. While your responses are confidential, we do need your contact information to follow up if necessary and for tracking purposes. Please ensure that the information below is accurate. When you are done, hit ‘SUBMIT’ and your survey will be sent. When you hit submit, you will immediately receive confirmation at the email address below, along with a gift code number for $20 at Amazon.com, so please ensure that the email you enter is correct. If you have any questions, please feel free to contact us at TADEval@westat.com or toll
-free at 1
-800
-xxxxxxx. Thank you again for your time and effort in completing this survey! First Name: Last Name: Sex: O Male O Female Email Address: Name of school or primary work setting: Phone Number (xxx
-xxx-xxxx): Best day and time to reach you , if needed ?15 

# TA Topics [The information in the second column will be visible when a respondent scrolls over the topic area] **Topic Areas of TA May Include...**  Adaptive living / Self

- care skills Personal care and self
- help skills such as toileting, dressing, eating, and cooking Assessment Using assessment strategies for program planning for a student; vision, auditory/hearing, cognitive, communication, functional, educational, developmental or other assessment Assistive technology Technology to maximize sensory input; learning how to use devices; Switches for toys and daily living, compute r access; Assistive listening devices (hearing aids, FM systems), low vision devices Behavioral issues & behavioral management Behavioral issues, behavior management; help in identifying why the child/student engages in problem behaviors; functional behav ioral analysis and positive behavior support Cochlear implants Eligibility questions related to cochlear implants; adapting Auditory Verbal Therapy; maintenance and use of the device Collaboration Teaming skills and transdisciplinary teams; Collaborative teaming, transdisciplinary teams; Conveying effective strategies to new teachers/new settings Communication Communication system development (e.g., object use, tactile symbols, Braille, gesture) ; building relationships with the student; developi ng and extending conversations Community and independent living Strategies to improve community and independent living skills ; self
- determination Curriculum (What to teach) What to teach and target; ideas for teaching meaningful skills for the student’s age; teaching skills in the natural environment/setting Deafblindness overview Overview of deaf
- blindness, vision and hearing loss, gaining more information about a child’s diagnosed condition Etiology Usher Syndrome; CHARGE Syndrome ; prematuri ty; impact of etiology on learning and interacting IEP/IFSP development and implementation Developing an appropriate IEP/IFSP for a student with combined vision and hearing loss; person
- centered planning; Inclusion Appropriate adaptations for inclusive education; accessing general education curriculum; targeting appropriate skills for inclusive education; effective strategies for teaching in inclusive settings Intervener roles and competencies (Interveners are people who have specialized training in deafblindness to work consistently and one
-to -one with a child who is deafblind). Topics could include the role of the intervener; Council for Exceptional Children competencies for interveners Instructional strategies (How to Teach) How to use visual cue s or auditory cues; hand
- under
- hand; physical assistance with children/students who have multiple16

**Topic Areas of TA May Include...**  disabilities; Documenting child/student progress and modifying instruction accordingly; Literacy mode determination (use of braille, large print, etc.); Organ izing a daily routine (Sequence of activities, transition from one activity to another) Orientation and Mobility (O&M) Instruction on helping a student locating himself in his environment and using environmental information; t ravel and nav igation indepe ndence for any age Parent/family support Connecting parents to other parents; increasing collaboration between family and school personnel; parent advocacy and leadership; sibling issues; wills, trusts and benefits; respite care Socialization, leisure & recreation Recreation and leisure skills, social
- emotional concerns (relationships with others); friendship facilitation State and local policies Alternate assessment; Common Core standards Teachers roles and competencies Developing credentialing plans ; defining the role of the teacher of deafblind; keeping teachers up to date; Council for Exceptional Children competencies for teachers of deafblind; professional activities for continuing ed; collaboration with team members T ransition (early childhood) Transition from early intervention to preschool; from preschool program to kindergarten program T ransition (secondary) Transition from school to adult services, including college, work, rehabilitation, group homes, vocational training/employment Visual a nd tactile accommodations to sign language Assessing the students’ need for accommodations; training staff in specific strategies (tactile, signing, coactive signing)