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Appendix C.

Provider Questionnaire and 

TA Recipient Supplement
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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 do 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. [will 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 questions?

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 is 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 outside the survey team, and will not be 

disclosed or released to others for any purpose.
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How long will it take to complete?

Depending on your responses, the survey contains between 20 and 31 questions, and we estimate that it 

will take you between 15 and 20 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 107-279, 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. Survey 

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 identified at any 

stage of reporting. The information 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 information 

unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 

1850-New. The time required to complete this information collection is estimated to average 15-20 minutes per response, 

including the time to review instructions, search existing data resources, gather the data needed, and complete and review the 

information 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 status 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 have any questions, contact:

Tamara Daley, 1-888-xxx-xxxx

E-mail: TADEval@westat.com
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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 combination of vision and hearing loss, also called 

a dual-sensory impairment.

 Few children who are considered deafblind have total vision and hearing losses. 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 deafblindness 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 up
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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.
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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. Thinking 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 Self-contained special education classroom

O Special education resource room or therapy room (including service-provider location)

O Classroom in a separate school for students with disabilities

O Residential school for students with disabilities

O Other:
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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. Thinking 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 Self-contained special education classroom

O Special education resource room or therapy room (including service-provider location)

O Classroom in a separate 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 deafblindness 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 deafblindness 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:
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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 questions 13-14 below, please think about the student(s) with deafblindness with 

whom you are working during the current school year.

13. What are 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 educational placement of these students? 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. Which of the following best describes the approximate communication level of those students? 

Check all that apply.

 Pre-symbolic communication (used primarily behaviors, signals to request, reject, or comment), 

limited ability to initiate participation in routines without support 

 Emerging symbolic communication (used behaviors, signals, gestures, pictures, object symbols 

along with very limited signs or speech to request, reject, or comment), partially participated in 

routines and instructional activities

 Symbolic communication in familiar routines (used more formal signals, gestures, some sign 

language, tactile symbols, pictures; emerging print or Braille), initiated interactions with others 

 Symbolic communication (used primarily speech, signs, fingerspelling, pictures, print, or Braille), 

engaged in instructional activities at or near grade-level 
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B. Topic Areas Needed for Support

16. Currently, what are the topic areas for which you have a need for information or support in your 

work with students with deafblindness? 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 O
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17. Do you need information or support in any other topic areas in order to provide services 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 past 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 childspecific support, we mean assistance that was centered on a particular child and took place either inperson 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.
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TA Recipient Supplement

[These questions are received only by providers who indicate “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 an 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.

 In a student’s home

 In a school setting 

 In a student’s home using distance technology

 In 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 

name]? 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 staff earlier in the 2014-15 school year.

O I have most recently been in contact with project staff during the 2013-14 school year.
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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. Please indicate whether the support you received covered each of the topic areas shown 

below. You can see more information 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 O
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D. Satisfaction with Support from Project

27. Please rate how much you agree with each of the following statements about the child-specific 

support you have received from [Project name], considering any support you received during the 

current (2014-15) and the previous (2013-14) school years.

Strongly 

disagree

Somewhat 

disagree

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 O
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30. What recommendations 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?
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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, computer 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 behavioral 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; developing 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; prematurity; 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 cues or auditory cues; hand-under-hand; 

physical assistance with children/students who have multiple 
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Topic Areas of TA May Include...

disabilities; Documenting child/student progress and 

modifying instruction accordingly; Literacy mode 

determination (use of braille, large print, etc.); Organizing 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;

travel and navigation independence 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

Transition (early childhood) Transition from early intervention to preschool; from 

preschool program to kindergarten program

Transition (secondary) Transition from school to adult services, including college, 

work, rehabilitation, group homes, vocational 

training/employment

Visual and tactile accommodations to 

sign language

Assessing the students’ need for accommodations; training 

staff in specific strategies (tactile, signing, coactive signing)