1



# Appendix A. **State Deaf** **- B**  **lind Project**  **Grantee Questionnaire**2



## Thank you for logging on to complete the **S tate**  **D eaf** **- B**  **lind P**  **roject 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 (Publ ic 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 -** **spe cific 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 questi ons 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 co ntrol 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 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:**  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.34 

## 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 p roject 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 p roject and non
- project staff O Other: **3. Check whether your project receives any of**  **the following in -**  **kind support from your**  **SEA (if it**  **i s**  **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. T ravel    g. Professional development for project staff    h. Other (specify):   5 

## 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**  **you r state had**  **in each of these categories:** Age birth
- 2 3
- 5 6
- 1 1 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 216 

## C. **TA Recipients**

**6. Below is a list of po** **ssible 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)  I nterveners  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 e arly 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:7

**7. Looking at**  **all the customers you checke** **d, 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)  I nterveners  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 e arly 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:8

**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 percen tage 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, p**  **lease indicate how true each of these reasons is**  **in explain**  **ing 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 O9 

## 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  E mail or telephone consultation  Disseminat ion of CD/DVDs  Online training modules  N ewsletters **Technical Assistance and Training**   C hild
-specific TA in the home  C hild
-specific TA in classrooms  C hild
-specific TA through distance technology  Assistance i n 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 boards10

**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]11 

## 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]12

**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 i ntervention 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]13

**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 m entorship 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]14

**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]15

**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]16 

## 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 I ntervener policies and practices O O Teachers of deafblind O O E arly screening policies and practices O O Transition planning policies and practices O O Other: O O Other: O O17 

## G **. Content of TA** 

**21. Below is a list of content areas that**  **S tate**  **D eaf** **- B**  **lind P**  **rojects may cover with their technical**  **assistance and disse mination**  **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 web
version; 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 18

**22. From among th**  **e areas you checked in the previous question , what are the**  **five topic areas**  **for which your proje** **ct 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 19 

## 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. P lease 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. P lease check **all** appropria te 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 proje ct to do any of the following since October 1, 2013 : 1. Obtain ed 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. Create d or provide d 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
. ”20

**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   21

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 No22

**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 p**  **lan 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:  23



### 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 a nd 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 wh o 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?**       24 

# 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 p ositive behavior support Cochlear i mplants 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; developi ng and extending conversations Community and independent living Strategies to improve community and independent living skills; self
- determination Curriculum (What to teach) What to teach and target; ideas for teaching meaningful skills for the student’s age; teaching skills in the natural environment/setting Deafblindness overview Overview of deaf
- blindness, vision and hearing loss, gaining more information about a child’s diagnosed condition Etiology Usher Syndrome; CHARGE Syndrome ; 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;25



### Topic **Areas of TA May Include...** Inclusion Appropriate adaptations for i nclusive education; accessing general education curriculum; targeting appropriate skills for inclusive education; effective strategies for teaching in inclusive settings Intervener roles and competencies (Interveners are people who have specialized training in deafblindness to work consistently and one
-to - one with a child who is deafblind). Topics could include the role of the intervener; Council for Exceptional Children competencies for interveners Instructional strategies (How to Teach) How to use visual cues or auditory cues; hand
- under
hand; physical assistance with children/students who have multiple 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; t ravel and nav igation 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 T ransition (early childhood) Tra nsition from early intervention to preschool; from preschool program to kindergarten program T ransition (secondary) Transition from school to adult services, including college, work, rehabilitation, group homes, vocational training/employment Visual and tactile accommodations to sign language Assessing the students’ need for accommodations; training staff in specific strategies (tactile, signing, coactive signing)