APPENDIX E

FOURTH-GRADE

SPECIAL EDUCATION TEACHER QUESTIONNAIRES

Early Childhood Longitudinal Study, Kindergarten Class of 2010-11 

(ECLS-K:2011)

Spring Fourth-Grade National Data Collection

and Fifth-Grade Recruitment

OMB Clearance Package

#1850-0750 v.16
1

Spring 2015

Special Education Teacher

Questionnaire A

RETURN THIS COMPLETED QUESTIONNAIRE IN THE SEALED

TYVEK® ENVELOPE DIRECTLY TO YOUR SCHOOL COORDINATOR

OR AN ECLS‐K:2011 STAFF MEMBER. DO NOT MAIL THIS

QUESTIONNAIRE UNLESS YOU ARE ASKED TO DO SO BY STUDY

STAFF AND ARE PROVIDED WITH AN ENVELOPE FOR MAILING.

Use a black or blue ball point pen to complete this questionnaire.

National Center for Education Statistics by:

Prepared for the U.S. Department of Education

Westat

Rockville, Maryland

S_ID T_ID T

According to the Paperwork Reduction Act of 1995, no persons are required 

to respond to a collection of information unless it displays a valid OMB 

control number. The valid OMB control number for this voluntary survey is 

1850‐XXXX. Approval expires XX/XX/XXXX. The time required to complete this 

survey is estimated to average 30 minutes per response, including the time to 

review instructions, search existing data resources, gather the data needed, 

and complete and review the survey. If you have any comments concerning 

the accuracy of the time estimate or suggestions for improving this survey, or 

any comments or concerns regarding the status of your individual submission 

of this survey, please write to: Early Childhood Longitudinal Study, National 

Center for Education Statistics, 1990 K Street, N.W., Washington, D.C. 20006‐

5574.

The collection of information in this survey is authorized by 20 U.S. 

Code, Section 9543. Participation is voluntary. You may skip questions 

you do not wish to answer; however, we hope that you will answer as 

many questions as you can. Your responses are protected from 

disclosure by federal statute ﴾20 U.S. Code, Section 9573﴿. All 

responses that relate to or describe identifiable characteristics of 

individuals may 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. Data will be combined to produce statistical reports. 

No individual data that links your name, address, telephone number, 

or identification number with your responses will be included in the 

statistical reports. 

15

Draft
2

Draft
3

Dear Special Education Teacher/Related Services Provider,

This questionnaire is an important part of a major longitudinal study of children's early

educational experiences beginning with kindergarten and continuing through grade 5. The

Early Childhood Longitudinal Study, Kindergarten Class of 2010‐11 ﴾ECLS‐K:2011﴿ is

collecting information from the special education teachers/related service providers of

sampled children who have Individualized Education Programs ﴾IEPs﴿ to investigate the

relationship between the children's academic progress and various school, classroom,

teacher, and home characteristics. This questionnaire collects information about your

background and your work in this school with children with disabilities.

Taking part in the study is voluntary. You may stop at any time or choose not to answer a

question you do not want to answer. However, only you can provide this information.

Although we realize you are very busy, we urge you to complete this questionnaire as

completely and accurately as possible. The information you provide is being collected for

research purposes only and will be protected from disclosure to the fullest extent allowable

by law ﴾Education Sciences Reform Act of 2002, 20 U.S.C. § 9573﴿. Information from multiple

individuals will be combined to produce statistical reports; no information that identifies you

will be included in any reports or provided to students, their parents, or other school staff.

THANK YOU VERY MUCH FOR YOUR HELP.

Draft
4

Draft
5

1. What is your gender? MARK ONE RESPONSE.

2. In what year were you born? WRITE IN YEAR BELOW.

3. Are you Hispanic or Latino? MARK ONE RESPONSE.

Male

Female

Yes

No

4. Which best describes your race? MARK ONE OR MORE RESPONSES TO INDICATE WHAT YOU 

CONSIDER YOURSELF TO BE.

5. What is the highest level of education you have completed? MARK ONE RESPONSE.

Did not complete high school

High school diploma or equivalent/GED

Some college or technical or vocational school

Associate’s degree

Bachelor's degree

Master's degree

An advanced professional degree beyond a master’s degree ﴾for example, Ph.D., MD﴿

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

YEAR

1 9

/

Draft
6

8. Counting this school year, how many total years have you been working with children in any

school, including years in which you worked part time? This would include other assignments

such as teaching in a regular classroom or otherwise providing services to children. WRITE THE

NUMBER OF YEARS TO THE NEAREST FULL SCHOOL YEAR. IF THIS IS YOUR FIRST YEAR, WRITE "1."

Year﴾s﴿

7. Counting this school year, how many total years have you been working with children receiving

special education or related services in any school, including years in which you worked part

time? WRITE THE NUMBER OF YEARS TO THE NEAREST FULL SCHOOL YEAR. IF THIS IS YOUR FIRST

YEAR, WRITE "1."

Year﴾s﴿

6. Is this school year the first year you have worked with children in this school? MARK ONE

RESPONSE.

Yes

No

Draft
7

9. Which of the following credentials, licenses, or certificates do you have for working with children

with disabilities? DO NOT INCLUDE ACADEMIC DEGREES, SUCH AS A BACHELOR'S DEGREE, MASTER'S

DEGREE, OR PH.D. MARK YES OR NO ON EACH ROW.

a. Emergency credential

b. Provisional or temporary credential

c. Disability‐specific credential or endorsement

d. Special education credential or endorsement

 ﴾for more than one disability category﴿

e. General education credential

f. Speech/language therapy state license or certification

g. Physical therapy state license or certification

h. Occupational therapy state license or certification

i. Social work license or certification

m. Other professional license, credential, or endorsement

 ﴾PLEASE SPECIFY﴿

l. Certificate of Clinical Competence

k. Clinical psychology license or certification

j. School psychology license or certification

Yes No

10. Have you taken the exam for National Board for Professional Teaching Standards certification? 

MARK ONE RESPONSE.

Not taken

Taken and passed

Taken and have not yet passed

Taken and awaiting test results

Not applicable

Draft
8

* Including the condition formerly classified as mental retardation

11. Have you ever taken a college course in the following areas? MARK YES OR NO ON EACH ROW.

Yes No

a. Early childhood education

b. Early childhood special education

c. Elementary education

d. Child development

e. English as a Second Language ﴾ESL﴿ or teaching English

 language learners

f. General special education

g. Learning disabilities

h. Intellectual disability *

i. Orthopedic impairments

l. Blindness and vision

k. Deafness and hearing

j. Serious emotional disturbance

m. Communication disorders

n. Infants and toddlers with disabilities

o. Physical therapy

p. Occupational therapy

q. School psychology

r. Classroom management

Draft
9

12. Have you ever taken a college course that addressed issues related to the following? MARK YES

OR NO ON EACH ROW.

13. Which of the following best describes your current position in this school? MARK ONE RESPONSE.

Special education teacher

Special education teacher consultant

General education teacher

Special education classroom aide

Speech‐language pathologist

Physical therapist

Physical therapy assistant or aide

Occupational therapist

Occupational therapy assistant or aide

School psychologist

School counselor

School social worker

Other ﴾PLEASE SPECIFY﴿

Yes No

a. Using published research evidence to identify and select effective

interventions and supports for students

b. Using formal assessment data to inform the choice of READING

interventions and supports for students

c. Using formal assessment data to inform the choice of MATH

interventions and supports for students

d. Using data to inform the choice of behavioral interventions and

supports for students

Draft
10

14. How do you classify your main assignment at this school, that is, the activity at which you spend

most of your time during this school year? MARK ONE RESPONSE.

Regular full‐time teacher/service provider

Regular part‐time teacher/service provider

Itinerant teacher/service provider ﴾that is, your assignment requires you to provide

Long‐term substitute ﴾that is, your assignment requires that you fill the role of a

Teacher aide

Other ﴾PLEASE SPECIFY﴿

instruction/related services at more than one school﴿

teacher on a long‐term basis, but you are still considered a substitute﴿

15. During this school year, where have you worked with children with IEPs? INCLUDE ONLY

CHILDREN WHO ATTEND THIS SCHOOL. MARK YES OR NO ON EACH ROW.

Yes No

a. In a general education classroom

b. In a special education classroom

c. In a non‐classroom space ﴾for example, office, therapy

room, small work space, mobile van, etc.﴿

d.In a location outside of the school setting ﴾for example,

a child's home, a private clinic, etc.﴿

e.Other ﴾PLEASE SPECIFY﴿

Draft
11

17. During the school year, how many children with IEPs have you worked with or provided services

for, on average, each week? ﴾Include children you work with directly, as well as children for whom

you consult with the general education teacher and/or another special education teacher/service

provider.﴿ MARK ONE RESPONSE.

16. Please indicate the extent to which you agree or disagree with each of the following statements. 

MARK ONE RESPONSE ON EACH ROW.

1‐10

11‐20

21‐40

More than 40

Don't know

18. Date questionnaire completed:

Strongly

disagree Disagree

Neither

disagree

nor agree Agree

Strongly

agree

b. I am certain I am making a

 difference in the lives of the

 children I work with.

c. If I could start over, I would

choose this career again.

d. I am satisfied with my class

 size/caseload.

a. I really enjoy my present job.

THANK YOU FOR YOUR COOPERATION!

MONTH DAY YEAR

2015

Draft
12

Draft
13

Draft
14

Draft
15

For Office Use Only

Comp

Ref

Draft
16

Draft
1

Spring 2015

Special Education Teacher

Questionnaire B

Child Level

RETURN THIS COMPLETED QUESTIONNAIRE IN THE SEALED

TYVEK® ENVELOPE DIRECTLY TO YOUR SCHOOL COORDINATOR

OR AN ECLS‐K:2011 STAFF MEMBER. DO NOT MAIL THIS

QUESTIONNAIRE UNLESS YOU ARE ASKED TO DO SO BY STUDY

STAFF AND ARE PROVIDED WITH AN ENVELOPE FOR MAILING.

Use a black or blue ball point pen to complete this questionnaire.

Rockville, Maryland

Westat

National Center for Education Statistics by:

Prepared for the U.S. Department of Education

S_ID T_ID

C_ID

T

C

According to the Paperwork Reduction Act of 1995, no persons are required 

to respond to a collection of information unless it displays a valid OMB 

control number. The valid OMB control number for this voluntary survey is 

1850‐XXXX. Approval expires XX/XX/XXXX. The time required to complete this 

survey is estimated to average 20 minutes per response, including the time to 

review instructions, search existing data resources, gather the data needed, 

and complete and review the survey. If you have any comments concerning 

the accuracy of the time estimate or suggestions for improving this survey, or 

any comments or concerns regarding the status of your individual submission 

of this survey, please write to: Early Childhood Longitudinal Study, National 

Center for Education Statistics, 1990 K Street, N.W., Washington, D.C. 20006‐

5574.

The collection of information in this survey is authorized by 20 U.S. 

Code, Section 9543. Participation is voluntary. You may skip questions 

you do not wish to answer; however, we hope that you will answer as 

many questions as you can. Your responses are protected from 

disclosure by federal statute ﴾20 U.S. Code, Section 9573﴿. All 

responses that relate to or describe identifiable characteristics of 

individuals may 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. Data will be combined to produce statistical reports. 

No individual data that links your name, address, telephone number, 

or identification number with your responses will be included in the 

statistical reports. 

15

Draft
2

Draft
3

Dear Special Education Teacher/Related Services Provider,

This questionnaire is an important part of a major longitudinal study of children's early

educational experiences beginning with kindergarten and continuing through grade 5. The

Early Childhood Longitudinal Study, Kindergarten Class of 2010‐11 ﴾ECLS‐K:2011﴿ is

collecting information from the special education teachers/related service providers of

sampled children who have Individualized Education Programs ﴾IEPs﴿. We are gathering

information from these children's regular classroom teachers as well. Our purpose is to

investigate the relationship between the children's academic progress and various school,

classroom, teacher, and home characteristics. This questionnaire collects information on the

special education/related services received by the child identified on the cover of this

questionnaire.

Taking part in the study is voluntary. You may stop at any time or choose not to answer a

question you do not want to answer. However, only you can provide this information.

Although we realize you are very busy, we urge you to complete this questionnaire as

completely and accurately as possible. You may find at least some of the information we are

asking for in the child's IEP. All information you provide is being collected for research

purposes only and will be protected from disclosure to the fullest extent allowable by law

﴾Education Sciences Reform Act of 2002, 20 U.S.C. § 9573﴿. Information from multiple

individuals will be combined to produce statistical reports; no information that identifies you

will be included in any reports or provided to students, their parents, or other school staff.

THANK YOU VERY MUCH FOR YOUR HELP.

Draft
4

Draft
5

3. In what capacity or capacities do you teach or provide services to this child? MARK YES OR NO

ON EACH ROW.

a. Provide instruction directly to the child

b. Provide related services directly to the child

c. Provide consultation services directly to the child

d.Provide indirect consultation services ﴾for example, consultation

to the child's teacher﴿

e. Provide case management

f. Other ﴾PLEASE SPECIFY﴿

4. When was this child first determined eligible for special education or related services? MARK

ONE RESPONSE.

Before kindergarten

During kindergarten

During first grade

During second grade

During third grade

During fourth grade

Other ﴾PLEASE SPECIFY﴿

Don't know

1. Is this child currently receiving gifted/talented services through an IEP, or has the child received

such services during this school year? MARK ONE RESPONSE.

2. Is this child currently receiving special education services through an IEP due to a disability or

has the child received such services during this school year? MARK ONE RESPONSE.

Yes

No

﴾SKIP TO Q 34﴿

Yes

No

Yes No

Draft
6

﴾SKIP TO Q 10﴿

7. To what extent were you involved in planning the transition from last year's special education

program to this year's special education program for this child? MARK ONE RESPONSE.

Not at all

Somewhat

Extensively

5. Is this the first school year that the child has been receiving special education services? MARK

ONE RESPONSE.

Yes

No

6. When did this child first start receiving special education or related services? MARK ONE

RESPONSE.

8. To what extent did you communicate with the person﴾s﴿ who provided special education for

this child last year? MARK ONE RESPONSE.

Not at all

Somewhat

Extensively

I provided special education for this child last year.

Before kindergarten

During kindergarten

During first grade

During second grade

During third grade

Other ﴾PLEASE SPECIFY﴿

Don't know

Draft
7

* Including the condition formerly classified as mental retardation

9. Have you reviewed this child's records related to special education services provided before

this school year? MARK ONE RESPONSE.

Yes

No, I don't have access to the records.

No, I have access to the records, but have not reviewed them.

No, I provided special education to this child last year.

10. What is this child's primary disability as identified on the child's IEP? PLEASE SELECT THE

CATEGORY BELOW INTO WHICH THE CHILD'S PRIMARY DISABILITY FITS BEST. MARK ONE RESPONSE.

Speech or language impairments

Specific learning disabilities

Emotional disturbance

Intellectual disability *

Developmental delay

Visual impairments ﴾including blindness﴿

Hearing impairments ﴾including deafness﴿

Orthopedic impairments

Other health impairments

Autism

Traumatic brain injury

Deaf‐blindness

Multiple disabilities ﴾children included in this category should be those who have more than

No classification is given

one primary disability which do not include deaf‐blindness or developmental delay﴿

Draft
8

11. During this school year, for which of the following disabilities has this child received special

education or related services, whether for the child's primary disability or another of his/her

disabilities? MARK YES OR NO ON EACH ROW.

12. During this school year, has this child received any special education or related services

because of a diagnosed Attention Deficit Disorder ﴾ADD﴿ or Attention Deficit Hyperactivity

Disorder ﴾ADHD﴿? MARK ONE RESPONSE.

Yes

No

* Including the condition formerly classified as mental retardation

a. Speech or language impairments

b. Specific learning disabilities

c. Emotional disturbance

d. Intellectual disability *

e. Developmental delay

f. Visual impairments ﴾including blindness﴿

g.Hearing impairments ﴾including deafness﴿

h. Orthopedic impairments

i. Other health impairments

l. Deaf‐blindness

k. Traumatic brain injury

j. Autism

m. Multiple disabilities ﴾children included in this category should

be those who have more than one primary disability which do

not include deaf‐blindness or developmental delay﴿

n. No classification given

THE REST OF THE ITEMS IN THIS QUESTIONNAIRE REFER TO THIS CHILD'S SPECIAL EDUCATION

EXPERIENCE DURING THE CURRENT SCHOOL YEAR.

Yes No

Draft
9

13. During this school year, which of the following describe﴾s﴿ the IEP goals for this child? MARK

YES OR NO ON EACH ROW.

Academics

Speech and language

a. Reading

b. Mathematics

c. Language Arts

d. Science

Social

Life skills

Physical/Mobility

Other

e. Auditory processing

f. Listening comprehension

g. Oral expression

h. Voice/speech articulation

i. Language pragmatics

j. Social skills

k. General appropriateness of behavior

l. Adaptive behavior or self‐help skills

m. Fine motor skills

n. Gross motor skills

o. Orientation and mobility

p. Other ﴾PLEASE SPECIFY﴿

Yes No

Draft
10

14. During this school year, which of the following related services have been provided through the

school to this child? MARK YES OR NO ON EACH ROW.

a. Audiology

b. Counseling services

c. Occupational therapy

d. Physical therapy

e. Psychological services

f. Health services

g. Social work services

h. Special transportation

i. Speech or language therapy

j. Orientation services

m.Other ﴾PLEASE SPECIFY﴿

l. Rehabilitation services

k. Mobility services

Yes No

Draft
11

15. During this school year, has this child received any of the following? MARK YES OR NO ON EACH

ROW.

16. During this school year, has this child's primary placement been a general education classroom?

MARK ONE RESPONSE.

Yes

No

a. Adaptive physical education

b.Assistance from classroom aides ﴾for example, teacher aide, 

behavioral assistant, special education aide﴿

c. Interpreter for the deaf or hard of hearing ﴾oral or sign﴿

d. Teacher used Braille to provide instruction

e. Child was taught how to use Braille

f. Teacher used American Sign Language to provide instruction

g. Child was taught how to use American Sign Language

h. Teacher used Manual English to provide instruction

i. Child was taught how to use Manual English

j. Teacher used Cued Speech to provide instruction

m. Tutoring/remediation from special education teacher

l. Mental health services, personal/group counseling, therapy, or 

psychiatric care provided to the child

k. Child was taught how to use Cued Speech

n. Training, counseling, and other supports/services provided to 

this child's family

Yes No

Draft
12

17. During this school year, approximately how many hours per week of direct special education

and related services ﴾that is, service provided directly to the child, from a teacher or another

adult﴿ has this child received? WRITE NUMBER IN BOX.

Hours per week

18. Of the hours of direct special education and related services reported above, approximately

how many of those hours per week were the instruction/services provided outside of a general

education classroom but within the school setting? WRITE NUMBER IN BOX.

Hours per week

19. During this school year, what teaching practices and methods have you and/or other special

education service providers used with this child? MARK ONE RESPONSE ON EACH ROW.

a. One‐on‐one instruction

b.Small‐group instruction

c. Large‐group instruction

d.Co‐teaching ﴾see definition above﴿

e. Cooperative learning

f. Peer tutoring

g. Computer‐based instruction

h. Direct instruction

i. Cognitive strategies

j. Self‐management

k. Behavior management

Don't

Yes No know

l. Instruction received through a sign interpreter

PLEASE NOTE THE FOLLOWING DEFINITION

THAT IS RELEVANT TO QUESTION 19 BELOW:

Co‐teaching is when a general education teacher and a special education service provider share the

teaching responsibility, with the special education service provider providing specialized differentiated

lessons for students with special needs. The two teachers participate in lesson or activity planning

together and work together in the same classroom to instruct both students with and without disabilities.

Draft
13

20. During this school year, which of the following best describes the curriculum materials used

with this child in the general education classroom? MARK ONE RESPONSE.

General education curriculum materials were used without modification

General education curriculum materials were used with some modifications

General education curriculum materials were used with substantial modifications

Specially‐designed commercial materials were used

Teacher‐designed materials were used

Child not in this setting

Don't know

General education curriculum materials were used without modification

General education curriculum materials were used with some modifications

General education curriculum materials were used with substantial modifications

Specially‐designed commercial materials were used

Teacher‐designed materials were used

Child not in this setting

Don't know

21. During this school year, which of the following best describes the curriculum materials used

with this child in the special education classroom/program? MARK ONE RESPONSE.

22. During this school year, has this child had the assistance of a service animal while at school? A

service animal is any guide dog, signal dog, or other dog individually trained to provide assistance to

an individual with a disability. Service animals can be used full time or in‐school only as part of a

program such as animal assisted therapy ﴾AAT﴿.

Yes, this child has been assisted by his/her own service dog at school

Yes, this child has been assisted by a service dog provided by a school program

No, this child has not been assisted by a service dog at school

Draft
14

23. During this school year, which of the following assistive technologies and devices has this child

used? MARK YES OR NO ON EACH ROW.

Mobility aids

a. Vans, vehicles

b. Wheelchair

c. Walker

d. White cane

e. Electronic with voice output ﴾for example, Touch Talker﴿

f. Electronic without voice output ﴾for example, device with

visual display or printed speech output﴿

g. Non‐electronic ﴾for example, manual printing board﴿

Communication aids

Hearing assistance

Visual aids

Learning aids ﴾non‐computer﴿

r. Tape recorder

s. Calculator

t. Electronic spelling devices

h. Hearing aids

i. FM loops

j. TTYs/TDDs

k. Cochlear implants

l. Real‐time captioning

m. Braille texts

n. Electronic Braille devices

o. Digital texts

q. Close‐captioned television ﴾CCTV﴿

p. Magnifying devices

Yes No

Draft
15

23. ﴾CONTINUED﴿ During this school year, which of the following assistive technologies and devices

has this child used? MARK YES OR NO ON EACH ROW.

Yes No

24. Does this child have a computer, laptop, or word processing device assigned to him/her for use

full time this school year? MARK ONE RESPONSE.

Yes

No

25. During this school year, on average, how often have you met with general education teacher﴾s﴿

to discuss this child's program or progress? MARK ONE RESPONSE.

w. Reading

x. Writing

y. Mathematics

Other assistive technologies or devices

z. Other ﴾PLEASE SPECIFY﴿

Computer software designed for children with disabilities

Computer hardware designed or adapted for children with

disabilities ﴾for example, alternate keyboards, switch interface﴿

u. Used solely by individual child

v. Shared with other children

Not applicable because I am the child's general education teacher

Not applicable to my work with this child

Every day or several times a week

Once a week or several times a month

Once a month

A few times over the school year

Once during this school year

Never during this school year ﴾SKIP TO Q 27﴿

﴾SKIP TO Q 27﴿

﴾SKIP TO Q 27﴿

Draft
16

27. During this school year, approximately how often have you communicated with this child's

parents about this child's program or progress ﴾by phone, in person, or in writing, including

e‐mail﴿? MARK ONE RESPONSE.

Every day or several times a week

Once a week or several times a month

Once a month

A few times over the school year

Once during this school year

Never during this school year

28. During this school year, has this child received formal individual evaluations in any of the

following areas for purposes of developing IEP goals? MARK YES OR NO ON EACH ROW.

26. On average, how long were the meetings with the general education teacher﴾s﴿ to discuss this

child's program or progress? MARK ONE RESPONSE.

1 to 15 minutes

16 to 30 minutes

31 to 45 minutes

46 to 60 minutes

More than 60 minutes

a. Psychological

b. Speech/language

c. Vision

d. Hearing

e. Learning style

f. Motor skills

g. Academics

h.Other ﴾PLEASE SPECIFY﴿

Yes No

Draft
17

29. To what extent is this child expected to achieve the same general education goals as other

children at his/her grade level this school year? MARK ONE RESPONSE.

30. What percentage of this child's current IEP goals have been met or nearly met at this point in

the school year? MARK ONE RESPONSE.

76 to 100 percent

51 to 75 percent

26 to 50 percent

1 to 25 percent

0 percent

31. Which of the following best expresses the likelihood that this child will continue to receive

some level of special education services ﴾through an IEP﴿ in the next school year? MARK ONE

RESPONSE.

Child is expected to attain grade level achievement for all of the academic content standards.

Child is expected to attain grade level achievement for some of the academic content

Child is expected to attain grade level achievement for only a few of the academic content

Child is not expected to attain grade level achievement for any of the academic content

There are no academic content standards at this grade level.

Don't know

standards.

standards.

standards.

not continue in special education ﴾will be dismissed from services﴿

Definitely will continue in special education

Very likely to continue in special education

Rather likely to continue in special education

Rather unlikely to continue in special education

Very unlikely to continue in special education

Definitely will

Draft
18

32. During this school year, to what extent has this child participated in any grade‐level assessment

administered as part of the school's testing program? MARK ONE RESPONSE.

33. Did this child receive special accommodations to participate in the school's regular testing or

assessment program this school year? MARK ONE RESPONSE.

Yes

No

Don't know

34. In which grade is this child enrolled? MARK ONE RESPONSE.

Kindergarten

First grade

Second grade

Third grade

Fourth grade

Fifth grade or higher

This child is in an ungraded classroom

35. Date Questionnaire Completed:

THANK YOU FOR YOUR COOPERATION!

MONTH DAY YEAR

2015

Child did not participate in the school's testing or assessment program.

Child participated in alternate assessments and no regular assessments.

Child participated in some alternate assessments and some regular assessments.

Child participated fully in the school's regular testing or assessment program.

There is no testing or assessment program at this grade level.

Don't know

﴾SKIP TO Q 34﴿

﴾SKIP TO Q 34﴿

﴾SKIP TO Q 34﴿

﴾SKIP TO Q 34﴿

Draft
19

For Office Use Only

Comp

Ref

Draft
20

Draft