1

Appendix A.

State Deaf-Blind Project 

Grantee Questionnaire
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Thank you for logging on to complete the State Deaf-Blind Project survey.

As you know, this survey is being conducted as part of the National Evaluation of the Technical 

Assistance and Dissemination (TA&D) Program. We are gathering the same information from all 

State Deaf-Blind Projects in order to describe the activities of the project, who you serve and 

how you identify children and youth for services, your work in different initiatives, and 

collaboration both with other state projects and with other agencies and organizations.

All information gathered for this study will be kept confidential and will only be used for 

research purposes. 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 (Public Law 107-279, Section 183).

We estimate that this survey will take approximately 45 minutes to complete. 

You can start and stop at any time and your information will be saved.

As you respond to questions, please keep the following in mind: 

 By child-specific technical assistance, we mean assistance that was centered on a particular 

child and which was provided either on site or through distance technology. Please do not 

include consultation provided exclusively by phone or email when responding to questions 

about child-specific TA.

 While some activities of your project may have existed prior to the new funding cycle, 

please focus on the time period of October 2013 through now in responding to general 

questions about your project.

 If you are uncertain how to answer any particular question, at any time, feel free to contact 

the project at TADEval@westat.com or toll-free at 1-800-XXX-XXXX and the survey specialist 

assigned to your state will get back to you right away.

Thank you for making this evaluation a success!

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 45 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. 
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A. Project Structure and Model of TA

1. Which of the following best describes the administrative location of your state project? Select 

one.

O Housed in the SEA

O Housed in a university

O Housed in a private agency or center

O Housed in a state school for the deaf and/or blind

O Other: 

2. Which best describes the way in which your project provides child-specific TA in schools and 

homes? Select one.

O Our project does not provide child-specific TA in homes or schools 

O Child-specific TA is delivered primarily by project staff

O Child-specific TA is delivered primarily by individuals who are not project staff (e.g., regional 

teams not funded by the project)

O Child-specific TA is delivered equally by project and non-project staff

O Other: 

3. Check whether your project receives any of the following in-kind support from your SEA (if it is 

not your home agency) or from other entities, such as community partners. 

 If this support varies from year to year, think about the first year of your project.

 Include only support that comes to your project, or passes through your project (e.g., if 

your state supports parents to attend trainings but provides these stipends to parents 

directly, do not include them below, but if they sponsor families and provide this money 

to the project to distribute, it should be included.

From your 

project’s fiscal 

agent or home 

agency

From the SEA, if SEA 

is not your project’s 

fiscal agent or home 

agency

From another 

entity

a. FTEs for program-related staff (e.g., 

Project directors, TA team members, 

family specialists, etc.)

  

b. FTEs for administrative and clerical staff   

c. FTEs for consultants   

d. Benefits   

e. Infrastructure (e.g., computer 

equipment, office space, photocopying, 

telephone, etc.)

  

f. Travel   

g. Professional development for project 

staff   

h. Other (specify):   
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B. Child Count Data

4. Based on the data you submitted to NCDB for the Child Count in May 2014, please indicate how 

many children and youth with deafblindness your state had in each of these categories:

Age birth-2

3-5 

6-11 

12-17

18-21

Over 21

5. Since October 2013, how many children and youth have received child-specific TA, either in 

person or through distance technology, from your project?

Age birth-2

3-5 

6-11 

12-17

18-21

Over 21
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C. TA Recipients

6. Below is a list of possible individuals who may be served by your Project. Please check any to 

whom you have provided child-specific TA since October 2013. Note that your response to this 

question is not expected to include TA or dissemination products that might be accessed 

without your knowledge. 

Families/Caregivers

 Parents/guardians

 Siblings

 Extended family members (e.g., grandparents)

 Non-familial caregivers (e.g., day care or after school providers)

School/Campus level

 School/campus administrators 

 Special education teachers

 General education teachers

 Related service providers (e.g., PT, OT, SLP, nurses, social workers, interpreters)

 Paraprofessionals /Paraeducators and support service providers (excluding trained

Interveners)

 Interveners

 Peers of students

District/county/regional level

 District Special Education Directors and other administrators

 Itinerant vision and hearing staff and/or audiologist employed by and working at the 

district level

 Local early intervention service providers

 Administrators of local Part C programs 

 County Service Agencies

 Staff of state early intervention/Part C lead agencies

 Regional consultants

State level and others

 State Department of Education (SEA) Part B personnel

 State Part C lead agency personnel

 Agencies/organizations serving children or youth who are deafblind (includes parent 

organizations)

 Private day care providers

 Hospitals or pediatric medical day cares

 University administrators, faculty, and students

 Researchers

 Other:
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7. Looking at all the customers you checked, which are the three customers that have received 

your greatest time and financial resources for child-specific TA since October 2013? [Respondent 

will only see the items checked from the question above]

Families/Caregivers

 Parents/guardians

 Siblings

 Extended family members (e.g., grandparents)

 Non-familial caregivers (e.g., day care or after school providers)

School/Campus level

 School/campus administrators 

 Special education teachers

 General education teachers

 Related service providers (e.g., PT, OT, SLP, nurses, social workers, interpreters)

 Paraprofessionals /Paraeducators and support service providers (excluding trained

Interveners)

 Interveners

 Peers of students

District/county/regional level

 District Special Education Directors and other administrators

 Itinerant vision and hearing staff and/or audiologist employed by and working at the 

district level

 Local early intervention service providers

 Administrators of local Part C programs 

 County Service Agencies

 Staff of state early intervention/Part C lead agencies

 Regional consultants

State level and others

 State Department of Education (SEA) Part B personnel

 State Part C lead agency personnel

 Agencies/organizations serving children or youth who are deafblind (includes parent 

organizations)

 Private day care providers

 Hospitals or pediatric medical day cares

 University administrators, faculty, and students

 Researchers

 Other:
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8. For children and youth age 6-21 only, how are children and youth referred to your project for 

child-specific TA? For each of these options, please estimate the percentage of all referrals that 

are generated this way. 

Percentage

a. Parents contact us directly %

b. School/campus administrators or providers contact us %

c. District/county/regional staff contact us %

d. We initiate contact based on identification through Child Count %

e. Other (Specify) %

Total 100%

9. For many reasons, children and youth identified with deafblindness may not receive technical 

assistance from state projects. For your project, please indicate how true each of these reasons 

is in explaining why a child or youth may not receive child-specific technical assistance.

Not at all 

true

Occasionally 

true

Often 

true

Very often 

true

a. Service providers and parents are 

not aware of or do not understand 

project services

O O O O

b. The school or district staff feel they 

do not need assistance O O O O

c. Parents are not interested in the 

child or youth receiving services 

from our project

O O O O

d. We cannot initiate contact with a 

student; we must wait until contact 

is initiated with us

O O O O

e. Following a referral, the district 

failed to participate in the TA 

process

O O O O

f. There are geographical barriers in 

reaching the child/youth in his 

home or school

O O O O

g. The finite resources of our project 

restrict the number of 

children/youths who are served

O O O O
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D. TA Activities

10. Please check all products or services that your project provides.

Product Development and Dissemination

 Information on our website or Facebook page

 Product development

 Listserves or e-lists

 Email or telephone consultation

 Dissemination of CD/DVDs

 Online training modules 

 Newsletters

Technical Assistance and Training

 Child-specific TA in the home

 Child-specific TA in classrooms

 Child-specific TA through distance technology

 Assistance in identification of children and youth who are deafblind

 Assistance in IEP and IFSP development

 Statewide or regional training (e.g., inservice, workshops, workgroups, seminars, 

symposia, institutes, forums) 

 Training via web-conferencing, webinars

 Family leadership or family-focused training

 Family support

 Assistance in connecting families with one another 

 Participate on task forces and advisory boards
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11. From among the services and activities your project provides, check those for which demand 

exceeds your resources? [Respondent will only see the items checked from the question above]

Product Development and Dissemination

 Information on our website or Facebook page

 Product development

 Listserves or e-lists

 Email or telephone consultation

 Dissemination of CD/DVDs

 Online training modules 

 Newsletters

Technical Assistance and Training

 Child-specific TA in the home

 Child-specific TA in classrooms

 Child-specific TA through distance technology

 Assistance in identification of children and youth who are deafblind

 Assistance in IEP and IFSP development

 Statewide or regional training (e.g., inservice, workshops, workgroups, seminars, 

symposia, institutes, forums) 

 Training via web-conferencing, webinars

 Family leadership or family-focused training

 Family support

 Assistance in connecting families with one another 

 Participate on task forces and advisory boards

12. Among all the activities and initiatives that your project undertakes, please briefly describe the 

two that reflect work you view as “signature” activities of your project.

[open-ended]

13. Since October 1, 2013, what has been the greatest challenge your project has experienced in 

providing services to children, youth and families? 

[open-ended]
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E. National Initiatives

Items 15 – 20 ask about work you may have done related to the national initiatives of Intervener 

Services, Early Identification and Referral, Technology Solutions, Family Engagement, and Literacy.

14. In the area of Intervener Services, are any of the following activities part of your project? For 

each row, select one option.

Have worked 

on this since 

October 2013 

Have not 

worked on this

yet, but plan to 

do so by 

completion of 

project

Not part of 

our project

a. Disseminate information intended to increase 

recognition/understanding of intervener 

services.

O O O

b. Provide intervener training/professional 

development to interveners or people 

interested in becoming interveners. 

O O O

c. Provide training/professional development 

about intervener services to administrators and 

educational team members.

O O O

d. Develop intervener learning modules. O O O

e. Participate in a credentialing process at the 

state level.

O O O

f. Develop other products related to intervener 

services (e.g., definition, IEP guidelines).

O O O

g. Present webinars on intervener services. O O O

h. Pilot an intervener model in selected districts. O O O

i. Other O O O

[Specify other if selected]
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15. In the area of Early Identification and Referral, are any of the following activities part of your 

project? For each row, select one option.

Have worked 

on this since 

October 2013 

Have not 

worked on this

yet, but plan to 

do so by 

completion of 

project

Not part of 

our project

a. Develop or modify products/training on early 

identification and referral O O O

b. Conduct outreach to Part C staff, medical 

professionals, or other service providers to 

increase knowledge about early identification 

and referral (e.g. conference presentations, 

dissemination of project information through 

website or other means)

O O O

c. Provide training on early identification and 

referral to early intervention providers O O

O

d. Provide in-person mentoring/coaching for early 

intervention providers O O O

e. Accompany and support families during initial 

visits and assessments O O O

f. Maintain a community of practice on early 

identification and referral (e.g. share materials, 

group problem solving) 

O O O

g. Other O O O

[Specify other if selected]
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16. In the area of Technology Solutions, are any of the following activities part of your project? For 

each row, select one option.

Have worked 

on this since 

October 2013 

Have not 

worked on this

yet, but plan to 

do so by 

completion of 

project

Not part of 

our project

a. Implement distance mentorship activities with 

teams in my state O O O

b. Maintain a listserv for families and/or service 

providers O O O

c. Distribute assistive technology equipment to 

families and/or service providers O O O

d. Make use of web-based training tools including 

webinars, video conferencing, and video 

streaming

O O O

e. Offer or link to training or informational videos 

on the project’s website O O O

f. Use video to record and playback sessions with 

children with deafblindness O O O

g. Other:

O O O

[Specify other if selected]
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17. In the area of Family Engagement, are any of the following activities part of your project? For 

each row, select one option.

Have worked 

on this since 

October 2013 

Have not 

worked on this

yet, but plan to 

do so by 

completion of 

project

Not part of 

our project

a. Promote or establish a network for parents of 

children with deafblindness O O O

b. Conduct a needs assessment with families in 

our state

O O O

c. Disseminate information on evidenced-based 

practices and resources on deafblindness to 

families, PTIs and other family organizations.

O O O

d. Conduct training, coaching or mentoring to 

parents through in-person training O O O

e. Conduct training, coaching or mentoring to 

parents through web-based techniques O O O

f. Promote or establish collaborative partnerships 

between our project and the state parent 

center.

O O O

g. Other: O O O

[Specify other if selected]
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18. In the area of Literacy, are any of the following activities part of your project? For each row, 

select one option.

Have worked 

on this since 

October 2013 

Have not 

worked on this

yet, but plan to 

do so by 

completion of 

project

Not part of 

our project

a. Work with the SEA to incorporate literacy into 

the Common Core Standards for all children, 

including those with deafblindness

O O O

b. Develop products related to literacy O O O

c. Provide training on literacy instruction O O O

d. Disseminate evidence-based practices for 

literacy instruction 

O O O

e. Offer assistive technologies for literacy 

instruction 

O O O

f. Develop a model of literacy instruction for 

children with deafblindness

O O O

g. Other: O O O

[Specify other if selected]
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F. TA in the Area of Systems Capacity Building

19. Please check whether, during your current grant cycle, you have worked or plan to work with 

your SEA in any of the following areas: 

20. Does anyone from your project participate on a state task force or advisory committee related 

to deafblindness?

O No

O Yes

Development or refinement of state policies or 

practices related to...

We have worked 

with the SEA in this 

area since October 1, 

2013

We have not yet 

worked with the SEA 

in this area, but we 

plan to over the 

course of the project

State definition of deafblind O O

Increasing identification of children with deafblindness O O

Reporting related to Child Count O O

Incorporating the expanded core curriculum O O

Intervener policies and practices O O

Teachers of deafblind O O

Early screening policies and practices O O

Transition planning policies and practices O O

Other: O O

Other: O O
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G. Content of TA

21. Below is a list of content areas that State Deaf-Blind Projects may cover with their technical 

assistance and dissemination activities. Please check all areas for which you offer any type of 

technical assistance as it relates to deafblindness. To see what sub-topics might be covered 

through these areas, you can roll your cursor over the topic name. [Rollover only possible in webversion; See list at end of document]

Adaptive living / Self-care skills 

Assessment 

Assistive technology 

Behavioral issues & behavioral management 

Cochlear Implants 

Collaboration among providers 

Communication 

Community and independent living 

Curriculum (What to teach) 

Deafblindness overview 

Etiology 

IEP/IFSP development and implementation 

Inclusion 

Intervener roles and competencies 

Instructional strategies (How to Teach) 

Orientation and Mobility (O&M) 

Parent/family support 

Socialization, leisure & recreation 

State and local policies 

Teachers roles, credentialing and competencies 

Transition (early childhood) 

Transition (secondary) 

Visual and tactile accommodations to sign language 
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22. From among the areas you checked in the previous question, what are the five topic areas for

which your project receives the greatest demand for TA? Check only five. [Respondent will only 

see the areas checked in previous question]

Adaptive living / Self-care skills 

Assessment 

Assistive technology 

Behavioral issues & behavioral management 

Cochlear Implants 

Collaboration among providers 

Communication 

Community and independent living 

Curriculum (What to teach) 

Deafblindness overview 

Etiology 

IEP/IFSP development and implementation 

Inclusion 

Intervener roles and competencies 

Instructional strategies (How to Teach) 

Orientation and Mobility (O&M) 

Parent/family support 

Socialization, leisure & recreation 

State and local policies 

Teachers roles, credentialing and competencies 

Transition (early childhood) 

Transition (secondary) 

Visual and tactile accommodations to sign language 
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H. Collaboration

We are looking at two types of collaboration: 1) How projects assist one another, and 2) How projects 

collaborate within and outside their state with entities other than state projects.

The matrix that appears on the next screen lists all the State Deafblind Projects funded in October 2013. 

To complete the matrix, you will indicate which other state projects you and your staff work with or use 

for various purposes. Please consult staff from your project if their input is needed to complete the 

matrix accurately. 

The columns in the matrix are not intended to represent a hierarchy, nor are the columns mutually 

exclusive. Instead, they simply represent some of the types of interactions that occur in a network of TA 

providers. Please check all appropriate boxes in each row, leaving blank the row for your own state or 

for any state with which you had no significant interaction. Specifically, please check the appropriate 

boxes in the matrix if staff from your project worked with or used another state project to do any of the 

following since October 1, 2013:

1. Obtained information, materials, or services, excluding training

Examples:

 Your staff downloaded information or materials from the website of another state project 

on assisting parents with IEPs, and used them (or adapted them for use) in your state.

 You requested and received an example of a needs assessment form that was used in 

another state.

2. Received training (in-person or using technology) from another state project.

Examples:

 Your staff received an inservice training on the use of the distance mentorship model being 

used in another state

 Staff from your state participated in a webinar by a well-known expert that was hosted and 

paid for by another state project.

 Your state used an online training module in early identification developed by another 

project

3. Created or provided a product, program, or service that required joint planning, shared decision 

making, or pooling of monetary or staff resources

Examples:

 Your state worked with another state to provide intervener training to providers in both 

states.

 Your state worked with another state to create a joint website to disseminate information.

 Your state and five other states identified notable speakers and arranged for conferences in 

several of the states as a “speaker circuit.”
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23. Please check all appropriate boxes if, since the start of your grant in October 2013, staff from 

your project have worked with or used the state DB project listed on the left to do any of the 

following activities. 

State DB project 1. Obtained information, 

materials or services 

(excluding training)

2. Received training 

(in-person or using 

technology) from another 

state project

3. Created or provided a 

product, program, or service 

that required joint planning, 

shared decision making, or 

pooling of monetary or staff 

resources

Alabama   

Alaska   

Arizona   

Arkansas   

California   

Colorado   

Connecticut   

Delaware   

District of Colombia   

Florida   

Georgia   

Hawaii   

Idaho   

Illinois   

Indiana   

Iowa   

Kansas   

Kentucky   

Louisiana   

Maine   

Maryland   

Massachusetts   

Michigan   

Minnesota   

Mississippi   

Missouri   

Montana   

Nebraska   

Nevada   

New Hampshire   

New Jersey   

New Mexico   

New York   

North Carolina   

North Dakota   

Ohio   

Oklahoma   
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Oregon   

Pennsylvania   

Puerto Rico   

Rhode Island   

South Carolina   

South Dakota   

Tennessee   

Texas   

Utah   

Vermont   

Virginia   

Washington   

West Virginia   

Wisconsin   

Wyoming   

24. Is your state project part of any formal group or consortium with other states? 

O Yes O No  Skips to collaboration with other projects

25. [If yes] What is the name of that group?

26. [If yes] Who are the other members?

27. What is the focus or topic of that group?

28. Is there a Memorandum of Understanding for that group?

 Yes  No

29. Does your state project belong to any other formal groups or consortiums?

O Yes O No

30. [If yes] What is the name of that group?

31. [If yes] Who are the other members?

32. What is the focus or topic of that group?

33. Is there a Memorandum of Understanding for that group?

O Yes O No
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34. Since the start of your current project (or based on your plans), have you collaborated with any 

of the following? By “collaborated” we mean worked together on a common activity or goal. For 

the purpose of this question, receiving information from or providing information without any 

shared activity or goal does not constitute collaboration.

Have 

collaborated 

with since 

October 1, 2013

Have not yet 

collaborated, 

but plan to 

work with over 

the course of 

the project

a. NCDB – National Center on Deaf-Blindness  

b. Helen Keller National Center  

c. Perkins School for the Blind  

d. National family/parent organizations related to 

deafblindness (such as NFADB or CHARGE Syndrome 

foundation)

 

e. National Parent Technical Assistance Center (NPTAC)  

f. Associations or organizations serving professionals  

g. Your regional Parent Technical Assistance Center  

h. Your state Parent Training and Information center (PTI) or 

Community Parent Resource Center 

 

i. Your state Department of Education, Special Education 

Section

 

j. Your state Early Hearing Detection and 

Intervention Program (EHDI)

 

k. Your state Department of Health and Welfare, Infant 

Toddler Program (Part C)

 

l. State family/parent organizations (other than the federally 

funded PTI)

 

m. A school or private institute for children who are deaf, blind 

or deafblind in your state

 

n. University programs, including personnel preparation or 

leadership projects

 

o. Other:  
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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. 

Please take a minute to indicate who completed the survey, so we can follow up as needed. List 

the people involved in completing the survey. If there was more than one person, please 

indicate the person who had the greatest role in answering questions.

When you are done, hit ‘SUBMIT’ and your survey will be sent.

If you have any questions, please feel free to contact us at TADEval@westat.com or toll-free at 

1-800-xxx-xxxx. Thank you again for your time and effort in completing this survey!

Name Email Greatest 

role?












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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 among providers 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; 
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Topic Areas of TA May Include...

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-underhand; physical assistance with children/students who 

have multiple 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

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)