1



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

INTRO SCREEN **If identi fied from the district contact** **: You are receiving this survey because you have been**  **identif ied by your**  **district special education administrator as someone who**  **works , on at least a weekly basis,**  **with children or youth**  **with deafblindness (also known as Dual Sensory Impairment).**  **On the next screen , we will ask you to confirm**  **that you d o**  **work on at least a weekly basis**  **with children or youth**  **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 yo u have been identified by your state project, [Project name], as**  **someone who has**  **received child -** **specific support from that project related to serving**  **children and youth**  **with deafblindness (also known as Dual Sensory Impairment)**  **. H ere is some brief informat**  **ion about this study.**  **Please note: If you have already received and completed this survey, you do not need to complete it**  **again. Click here.**  **What is this survey about?** This survey is about the experiences of people who provide services in school and related settings to children and youth with deafblindness. The questions will ask about your background, your experiences working with children and youth with deafblindness generally, and about your experiences with the [Project name] . You will not be asked to share any personally identifiable or confidential information about the children and youth with whom you work
. **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. **Is this survey voluntary?** Your participation in this survey is completely voluntary. You may choose to decline to participate in the survey and there will be no negative effect on you or your school. **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 se nt 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 children and youth with deafblindness. There is no direct benefit to your school, or any child or youth you work with, but the findings will inform decisions that have to do with children and the settings where they are served.3

**What will happen with the infor mation I provide? Will it have a negative effect on my school or on me?**  Survey responses will be used only for research purposes. The study team will analyze respondents’ responses as a whole and will not focus on specific individuals or schools. We will a sk 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. **How long will it take to comp lete?**  Depending on your responses, t he survey contains between 20 and 32 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
- 279 , Section 183). Information that could identify an individual or institution will be separated from the su rvey 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 provide rs, 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 informat ion unless such collectio n 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 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 information collection. **If you have any comments concerning the accuracy of the time estimate(s) or suggestions f or 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:**  Meredith Bachman , U.S. Department of Education, Institute of Education Sciences, 555 New Jersey Avenue, NW, Suite 500J, Washington, D.C. 20208, or email Meredith.Bachman@ed.gov. If you have any questions, contact: Tamara Daley, 1
-888
-xxx-xxxx E
- mail: TADEval@westat.com4

SCREENER **PROVIDER SCREENER: Only Providers (not Customers)**  **will get the following screener :**  **For the purpose of verification, do you currently provide services on at least a weekly basis**  **to children**  **or youth with deafblindness or Dual Sensory Impairment?** 

 By deafbli ndness, we mean children or youth who have a combination of vision and hearing loss, also called a dual
- sensory impairment.  Few children who are considered deafblind have total vision and hearing l osses. Children may have losses in varying degrees of severity. For example, one child may have low vision and mild to moderate hearing loss, and another child may be both legally blind and have severe or profound deafness. For the purpose of this survey, both children are considered deafblind.  The children do not need to be eligible for services under the IDEA category of deafblindness to answer “yes” to this question. **Select the best answer:** O Yes, I work on at least a weekly basis with children or youth with deafblindness.  Will continue to survey O No, I do not work on a weekly basis with children or youth with deafblindness.  Will not receive the survey and this generates a “not eligible” status in the management system O I am unsure if I work with a child or youth with deafblindness
.  Generates an “uncertain eligibility” in the management system and will receive follow up

**CUSTOMER SCREENER: Only Customers (not Providers) will be asked the following**  **“current status” question and then, regardless of**  **the response, proceed to the survey Before proceeding to the survey, please indicate**  **: D**  **uring the current school year (2014** **- 15)** **, are**  **you work** **ing (or expect ing**  **to work) with**  **children or youth with deafblindness**  **?** O Yes O No5 **Frequently Asked Questions (FAQs) Navigating the Survey**  Navigate through the survey by answering each question and clicking the 'Save and Continue' button. When you click the 'Save and Continue' button, it will save your response and forward you to the next question. You may return to a prior question at any time by clicking on the appropriate question on the Section Guide to the left of the screen. When you reach the final submission page, please review your responses on the completed survey before the data are submitted. You cannot chan ge your responses after the completed survey has been submitted. After submitting the data, you will be directed to the final screen so that you can print a copy of your completed survey for your records. **Navigation Key:**

**PLEASE NOTE:**

 **The 'back' arrow on your browser has been disabled. Use the 'Save & Continue' button and the question guide to move through the survey.**   **Your session will time out after 30 minutes of inactivity and you will be returned to the login screen. Do I have to complete the survey all at one time?**  No. You can sign in and out of the website as many times as needed to complete the survey. However, if you need to stop before finishing the survey, please be sure to click on the 'Save & Continue' button b efore signing out so that your responses(s) on that page will be saved. Once you have finished and submitted your survey, you will no longer have access to it. **Can I skip a question?** Yes, you may skip any question in the survey that you cannot or do not wish to answer. To skip a question, leave the question blank and then click the 'Save & Continue' button to proceed. **Can I go back to a question that I have already answered or skipped?** Yes. You may return to any answered or skipped question by clicking on the appropriate question on the question guide found on the left side of the screen. If you wish to change your response, be sure to click the 'Save & Continue' button after you make any changes.6

**Can I print individual questions?** Yes. You may print an individual page at any time by using your computer’s usual method of printing (e.g. using the Command
- P or Ctrl
- P key combination). **Do I have to answer all the questions?** You will automatically be skipped past some questions that do not apply to your si tuation, depending upon your answer to an earlier question. **Can I print a copy of the questionnaire when I am finished?** Yes. Once you have completed the survey, you will have the option to print a copy of your responses before submitting it to Westat. Th is will allow you to review all your answers and make any necessary changes. You will also be able to print a copy for your records after submitting it electronically to Westat. **Can I obtain a paper version of the questionnaire?** Yes. If you would like to see a paper version for reference purposes, you can download a PDF version by clicking the link at the top of the page that says 'Download Blank PDF of S urvey.' **Is the system secure?** System security is ensured through the following steps: 1) Login and p assword validation for entry into the system, 2) The use of Secure Socket Layers (SSL) for encryption of data packets, and 3) Data storage in a Data Zone that is not accessible throu gh the Westat Firewall system. **Who should I contact if I have a question?** The Westat project team can be reached at TADEval@westat.com or by phone at 1
- 888
-xxx-xxxx. When sending emails, in addition to the question, please be sure to include your name and a phone number where you can be reached
.7

FOLLOW UP PAGE FOR “NO” AND “ UNSURE” PROVIDERS You are seeing this screen because you indicated that you either do not work on a weekly basis with children or youth with deafblindness or you are unsure whether you work with a child or youth 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 ? Please provide a brief explanation for your “unsure” response

CONTACT PAGE FOR INDIVIDUALS WHO HAVE ALREADY COMPLETED SURVEY You are seeing this screen because you indicated that you have already completed this survey. 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?8 

## Information about you and your experiences **Please provide a phone number**  **where we can rea**  **ch you in case of technical difficulties with your survey**  **.** Phone Number (xxx
-xxx-xxxx):

**1. Which of the following best describes your**  **professional role during the current**  **school year (2014** **- 15)**  **? If you play**  **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 (2014** **- 15)** **, across your entire caseload of children and youth**  **?** [a] schools located in [b] district(s)9

**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 disab ilities O Residential school for students with disabilities O In the home O Other:
**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 about only**  **the children and youth with deafblindness**  **with whom you work , 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 In the home O Other:
**6. Do**  **you work exclusively with individuals**  **with deafblindness?** O Yes O No

**7. How many**  **children and youth with deafblind**  **ness all together**  **do you work with**  **(or expect to work with)**  **during the school day**  **this school**  **year (2014** **- 15)**  **?** [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 youth10

**9. How long have you worked in the field of special**  **education or with people with disabilities?** [a] years [b] m onths

**10. Do you consider yourself primarily to be a service provider for children**  **and youth with**  **deafblindness?** O Yes O No
**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:
**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**  

###     
SKIP INSTRUCTIONS:

 If CUSTOMER SCREENER=1, proceed to Question 13
 If CUSTOMER SCREENER=0, skip to Question 19.11

**In responding to Q uestion**  **s 13 -**  **15 below,**  **please think about**  **all the**  **children and youth with**  **deafblindness with whom you are working during the current**  **school year (2014** **- 15)**  **. 13.**  **What a re**  **the 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 s**  **of the student** **s with deafblindness with whom you**  **wo rk** **? 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 approx** **imate communication level of those student** **s? Check all that apply**  **.**  **Pre -** **symbolic communication** (use primarily behaviors, signals to request, reject, or comment), limited ability to initiate participation in routines without support  **Emerging symbolic communication** (use behaviors, signals, gestures, pictures, object symbols along with very limited s igns or speech to request, reject, or comment), partial ly participate in routines and instructional activities  **Symbolic communication in familiar routines** ( use more formal signals, gestures, some sign language, tactile symbols, pictures; emerg ing print or Braille), initiate interactions with others  **Symbolic communication** (use primarily speech, signs, fingerspelling, pictu res, print, or Braille), engage in instructional activities at or near grade
- level12 

## 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 children and youth**  **with deafblindness? Check yes or no for each topic. You can see more**  **information by holding your cursor over each topic.** Yes, I need support on this topic No, I do not

need support on this topic Adaptive living/Self
- care skills O O Assessment O O Assistive technology O O Behavioral issues and behavioral management O O Cochlear i mplants 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 In structional strategies (How to teach) O O Orientation and Mobility (O&M) O O Parent/family support O O Socialization, leisure and recreation O O State and local policies O O Teachers’ roles, credentialing and competencies O O Transition (early childhood) O O Transition (secondary) O O Visual and tactile accommodations to sign language O O
**17. Do**  **you need information or support**  **in any other**  **topic areas in order to provide services to a**  **child or youth**  **who is deafblind?**13

**18. To what extent**  **is your need for**  **information and support to serve children and youth with**  **deafblindness being met through resources currently available to you** **, from any source ?** 

**1 Not at all**  **met 2** 

**Somewhat met 3**  **Mostly met 4** 

**Completely or nearly completely met**  O O O O



## Knowledge and Receipt of **Support 19.**  **Where do you usually turn**  **for information or support**  **on how to work with children and youth**  **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 the child or youth  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: **20. Do you have any familiarity with the [Name of state deafblind proje** **ct?] Check all that apply.**  a. I have not heard of this center/project before.  b. I have heard about this center/project, but have never had any interaction with it.  c. I interacted with this center/project in some way in the past, but not last year (2013
- 14) or this year (2014
- 15)
.  d. I had interaction with this center/project during the 2013

- 14 school year
.  If this or the following response option is checked, respondent will go to Question 21; otherwise, resp ondent will go to the Thank You & Contact page .  e. I have interacted with this center/project during the current school year (2014
- 15)
.  If this or the previous response option is checked, respondent will go to Question 21; otherwise, resp ondent will go to the Thank You & Contact Information page . SKIP INSTRUCTIONS:

 If 20 d and/or 20 e are selected, go to Question 2 1 .  If 20a or 20b or 20c are selected, go to Thank You & Contact page.14

**21. Please indicate all of the kinds of contact you had with [P**  **roject name] during the previous school**  **year (2013**  **- 14)**  **or the current school year (2014 -**  **15). Check all that apply.**  a. I received child
-specific support. Child
- specific support means assistance that was focused on a particular child or children with deafblindness, and took place either in person or t hrough the use of distance technology. OR I received staff

-specific support . Staff
- specific support means intensive, individualized assistance that was focused on helping me to serve deafblind children , but which was not focused on a specific child or children. This support took pl a ce either in person or through distance technology.  If this is checked, respondent will go to Question 24
.  b. Attended an in
- person training conducted by the project/center (e.g., workshops, workgroups, seminars, symp osia, institutes, forums)  If this is checked and the first response option is not checked, resp ondent will go to Question 22
.  c. Participated in web
- based training  If this is checked and the first response option is not checked, resp ondent will go to Question 22 .  d. Downloaded information or materials from the project website  e. Received information or materials through mail  f. Received information through email or telephone  g. Received a newsletter  h. Other: If n one of the fir

st three response options is checked, respondent will go to Thank You & Contact Information page . SKIP INSTRUCTIONS:

 If 2 1 a is checked regardless of any other boxes, go to Question 24
.  If 2 1 b or 2 1 c is checked and 2 1 a is not checked, go to Question 2 2 .  If none of the first three response options ( 2 1 a, 2 1 b, or 2 1 c ) i s chec ked, go to Thank You & Contact Information page.15

**22. Think**  **about the in -**  **person and/or web -**  **based training you received from [Project name] during the**  **previous school year**  **(2013 -**  **14) or**  **the current school year (2014 -**  **15). 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.**  Received support on this topic Did not

receive support o n this topic Adaptive living/Self

- care skills O O Assessment O O Assistive technology O O Behavioral issues and 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 and recreation O O State and local policies O O Teachers’ roles, credentialing and competencies O O Transition (early childhood) O O Transition (secondary) O O Visual and tactile accommodations to sign language O O
**23. Overall, how satisfied were you with**  **the in**  **- person and/or web** **- based training you received from**  **[Project name] during the previous**  **school year (2013** **- 14)**  **or th e current school year (2014** **- 15)?** 

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

**Somewhat dissatisfied 3**  **Somewhat satisfied 4**  **Very satisfied** O O O O
Skip to: Thank You & Contact Information page16

**24. Just to confirm**  **: During**  **the past two school**  **years (2013 -**  **14 and 2014** **- 15**  **), did you receive targeted**  **( child**  **- specific**  **and/or staff specific) support from anyone affiliated with [Name of state deafblind**  **project?]** Targeted support can include child
-specific support (i.e., assistance focused on a particular child) and/or staff

-specific support (i.e., support focused on helping you meet the needs of deafblind children generally) . Targeted support takes place either in
- person or through the use of distance technology. O Yes  Respondent continues to Question 25. O No  Survey is complete an d respondent will go to Thank You & Contact Information page
.



## TA Recipient Supplement **[These questions are received only by providers who are identified by the State Deaf** **- Blind**  **Project as receiving targeted support**  **]**

**25. Thinkin** **g about the previous school year (2013**  **- 14)**  **and the current school year (2014 -**  **15) , please**  **indicate the number of differ**  **ent children or youth with deafblindness for whom you have received**  **child -** **specific support from [Project Name].**  **If you did not receive support that was focused on a specific**  **child, enter ‘0’ below.** 

children or youth
**26. Please indicate**  **the locations you received**  **targeted support from [Project Name] during**  **the previous**  **school year (2013** **- 14)**  **or the current school year (2014** **- 15)**  **. Check all that apply.**   In a child’s home  In a school setting  In a child’s home using distance technology  In a school setting using distance technology  Other:
**27. 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 ago17

**28. 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 wit hin 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
. **29. 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 The child or youth ’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: **30. Think**  **about only**  **the targeted**  **support you received**  **from [Project name]**  **from the**  **2013 -**  **14 school**  **year onwards**  **. P**  **lease 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.** Received support on this topic Did not receive

support on this topic Adaptive living/Self
- care skills O O Assessment O O Assistive technology O O Behavioral issues and behavioral management O O Cochlear i mplants 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 In structional strategies (How to teach) O O Orientation and Mobility (O&M) O O Parent/family support O O Socialization, leisure and recreation O O State and local policies O O Teachers’ roles, credentialing and competencies O O Transition (early childhood) O O Transition (secondary) O O Visual and tactile accommodations to sign language O O18 

## Satisfaction with Support from **Project** 31. **Please rate how much you agree with each of the following statem ents about the**  **targeted support**  **you have**  **received from [ Project n**  **ame] , considering**  **any support you**  **received during the**  **previous school year**  **(2013 -**  **14) or**  **the current school year (2014 -**  **15) .**  **Strongly disagree**  **Somewhat**

**disagree Somewhat** 

**agree Strongly** 

**agree Not** 

**applicable** a. The information provided was **relevant and specific**  to the needs of the deafblind child or children I serve
. 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 informa tion in my work with a child or youth with deafblindness. O O O O
d. The information I received played a role in helping children w ith deafblindness **progress** . O O O O

e. I was able to use t he information in my work with children and youth with **other disabilities** 
. O O O O O
f. The consultant was **knowledgeable** in the area in which support was provided. O O O O g. The consultant was **non -** **judgmental** in his or her approach to providing support. O O O O h. The consultant was able to **explain and model**  practices and procedures effectively. O O O O
i. The consultant established a **collaborative partnership**  with me. O O O O j. The consultant took into account local **limitations in resources** when providing support. O O O O

**32. Overall, how satisfied were you with the**  **support you received from [Project name]**  **, considering any**  **support you received during the previous school year**  **(2013 -**  **14) or**  **the current school year (2014 -**  **15) ?**  **1 Very dissatisfied**  **2**

**Somewhat dissatisfied**  **3 Somewhat satisfied**  **4 Very satisfied**  O O O O19

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

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



## Thank You & **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 youth with deafblindness. While your responses are confidential, we do need your contact information to follow up to clarify responses if necessary and for tracking purposes. Please provide your information below and then click on the ‘Save & Continue’ button to proceed to the screen to submit your survey. 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. First Name: Last Name: Sex (for demographic purposes only) : O Male O Female Email Address: Name of district: Name of school or primary work setting: Best day and time to reach you, if needed?20

SUBMIT SCREEN **Instructions for submitting the survey:**
**You have completed the survey, but your data have not yet been submitted. By clicking the ‘Submit’ button, your data WILL BE SUBMITTED. You will be directed to the final screen so that you can**  **print a copy of your completed survey for your records.** 
To review or change any of your responses, please click on the ‘Return to Survey’ button or the relevant question in the Question Guide on the left. Questions highlighted in grey in the Question Gu ide were skipped based on a previous response.
After submitting your data, you will not be able to review and change your responses.
**Please click on the ‘Submit’ button to submit your data now.** Submit Return to Survey21

FINAL SCREEN Thank you! Your survey data have been submitted. We appreciate your taking the time to provide us with this important information. **Please print and keep a copy of this survey for your records using the link provided below.** If you have any questions, please contact us at TADEval@westat.com or toll
-free at 1
-800
-xxx-xxxx. For information on resources related to deafblindness through your state deaf
-blind project

, please click the link for your state below.

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# TA Topics [The information in the second column is what 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 ; a ssistive listening devices (hearing ai ds, FM systems), low vision devices Behavioral issues and behavioral management Behavioral issues, behavior management; help in identifying why the child/student engages in problem behaviors; functional behavioral analysis and positive behavior support C ochlear implants Eligibility questions related to cochlear implants; adapting Auditory Verbal Therapy; maintenance and use of the device Collaboration Teaming skills and transdisciplinary teams; collaborative team ing, 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 independ ent 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/settin g 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 app ropriate 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 interveners23

**Topic Areas of**  **TA May Include...** In structional strategies (How to teach) How to use visual cues or auditory cues; hand
- under
- hand; physical assistance with child ren/students who have multiple disabilities; d ocumenting child/student progress and modi fying instruction accordingly; l iteracy mode determination (use of Braille, large print, etc.); organizing a daily routine (s equence 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 ot her parents; increasing collaboration between family and school personnel; parent advocacy and leadership; sibling issues; wills, trusts and benefits; respite care Socialization, leisure and recreation Recreation and leisure skills, social
- emotional concerns (relationships with others); friendship facilitation State and local policies Alternate assessment; Common Core standards Teachers’ roles, credentialing and competencies Developing credentialing plans; defining the role of the teacher of deafbl ind students ; keeping teachers up to date; Council for Exceptional Children competencies for teachers of deafblind students; professional activities for continuing ed 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 t he students’ need for accommodations; training staff in specific strategies (tactile, signing, coactive signing)