National Census Form

National Census of Infants, Children & Youth With Deaf-Blindness in North Dakota	Office Use Only: IDNUM:______________ KIDCODE: ___________

Instructions: Please check and update all information for accuracy.
Once you fill out all fields, we recommend you to print of a hard copy.

Child's Name: (first, middle initial, surname)	Date of Birth: (mth/day/yr) Male Female
Child's Home Special Education Unit:	Phone #:
School/Agency Serving Child:	Address:
Parent/Guardian Name:	Address:
Home Phone #:	Work Phone #:
Primary language used in home:

Does the child reside on an Indian Reservation?	Yes No
Fort Berthold Indian Reservation	Yes
Standing Rock Sioux Tribe Indian Reservation	Yes
Turtle Mountain Band of Chippewa Indian Reservation	Yes
Spirit Lake Indian Reservation (Devils Lake Sioux Tribe)	Yes

Person completing this form: (please fill out completely)

Name/Title:	Phone #:
School/Agency:	E-mail Address:
Address:

Etiology: Check the etiology code that best represents the major identified cause of Deaf-Blindness for the individual from only ONE of the following areas.
Please specify etiologies not listed.

Primary Identified Etiology
Hereditary/Chromosomal Syndromes And Disorders
101 Aicardi syndrome	130 Marshall syndrome
102 Alport syndrome	131 Maroteaux-Lamy syndrome (MPS VI)
103 Alstrom syndrome	132 Moebius syndrome
104 Apert syndrome (Acrocephalosyndactyly, Type 1)	133 Monosomy 10p
105 Bardet-Biedi syndrome (Laurence Moon-Biedi)	134 Morquio syndrome (MPS IV-B)
106 Batten disease	135 NF1 - Neurofibromatosis (von Recklinghausen disease)
107 CHARGE association	136 NF2 - Bilateral Acoustic Neurofibromatosis
108 Chromosome 18, Ring 18	137 Norrie disease
109 Cockayne syndrome	138 Optico-Cochleo-Dentate Degeneration
110 Cogan syndrome	139 Pfieffer syndrome
111 Cornelia de Lange	140 Prader-Willi
112 Cri du chat syndrome (Chromosome 5p- syndrome)	141 Pierre-Robin syndrome
113 Crigler-Najjar syndrome	142 Refsum syndrome
114 Crouzon syndrome (Craniofacial Dysotosis)	143 Scheie syndrome (MPS I-S)
115 Dandy Walker syndrome	144 Smith-Lemli-Opitz (SLO) syndrome
116 Down syndrome (Trisomy 21 syndrome)	145 Stickler syndrome
117 Goldenhar syndrome	146 Sturge-Weber syndrome
118 Hand-Schuller-Christian (Histiocytosis X)	147 Treacher Collins syndrome
119 Hallgren syndrome	148 Trisomy 13 (Trisomy 13-15, Patau syndrome)
120 Herpes-Zoster (or Hunt)	149 Trisomy 18 (Edwards syndrome)
121 Hunter syndrome (MPS II)	150 Turner syndrome
122 Hurler syndrome (MPS I-H)	151 Usher I syndrome
123 Kearns-Sayre syndrome	152 Usher II syndrome
124 Klippel-Feil sequence	153 Usher III syndrome
125 Klippel-Trenaunay-Weber syndrome	154 Vogt-Koyanagi-Harada syndrome
126 Kniest Dysplasia	155 Waardenburg syndrome
127 Leber congenital amaurosis	156 Wildervanck syndrome
128 Leigh Disease	157 Wolf-Hirschhorn syndrome (Trisomy 4p)
129 Marfan syndrome	199 Other

Pre-Natal/Congenital Complications	Post-Natal/Non-Congenital
201 Congenital Rubella	301 Asphyxia
202 Congenital Syphilis	302 Direct Trauma to the eye and/or ear
203 Congenital Toxoplasmosis	303 Encephalitis
204 Cytomegaiovirus (CMV)	304 Infections
205 Fetal Alcohol syndrome	305 Meningitis
206 Hydrocephaly	306 Severe Head Injury
207 Maternal Drug Use	307 Stroke
208 Microcephaly	308 Tumors
209 Neonatal Herpes Simplex (HSV)	309 Chemically Induced
299 Other	399 Other
Related to Prematurity	Undiagnosed
401 Complication of Prematurity	501 No Determination of Etiology

Race/Ethnicity (Please select one that BEST describes the individual
1. American Indian or Alaska Native	4. Hispanic or Latino
2. Asian or Pacific Islander	5. White (not Hispanic)
3. Black or African American (not Hispanic)

Visual Impairment For the purposes of this part, the term, “Functional Vision Assessment,” means a non-clinical assessment carried out by a trained vision specialist using commonly accepted assessment tools, checklists and measures for the purpose of making educated judgments about the functional use of vision.
(1) Date of most recent Ophthalmologic Exam:	Month	Year:
(2) Date of most recent Functional Vision Test:	Month	Year:

Primary Classification of Visual Impairment (Please select only ONE)
1. Low Vision (Visual Acuity of 20/70 to 20/200 in the better eye with correction.)	5. Cortical Visual Impairment
2. Legally Blind (Visual acuity of 20/200 or less or field restriction of 20 degrees or less in the better eye with correction.)	6. Diagnosed Progressive Loss
3. Light Perception Only	7. Further Testing Needed to Determine Visual Impairment
4. Totally Blind	8. Tested - Results Non-conclusive

Hearing Impairment For the purposes of this part, the term, “Functional Hearing Assessment,” means a non-clinical assessment carried out by a trained hearing specialist using commonly accepted assessment tools, checklists and measures for the purpose of making educated judgments about the functional use of hearing.
(1) Date of most recent Audio logical Exam:	Month	Year:
(2) Date of most recent Functional Hearing Test:	Month	Year:
(3) Central Auditory Processing Disorder:	Yes:	No:

Primary Classification of Hearing Impairment (Please select only ONE)
1. Mild (26-40 dB loss)	5. Profound (91+ dB loss)
2. Moderate (41-55 dB loss)	6. Diagnosed Progressive Loss
3. Moderately Severe (56-70 dB loss)	7. Further Testing Needed to Determine Hearing Impairment
4. Severe (71-90 dB loss)	8. Tested - Results Non-conclusive

Central Auditory Processing Disorder

(0) No

(1) Yes:

(5) Not Tested

Other Impairments:
Physical Impairments:	Yes:	No:	Explain:
Cognitive Impairments:	Yes:	No:	Explain:
Behavioral Disorder:	Yes:	No:	Explain:
Complex Health Care Needs:	Yes:	No:	Explain:
Other (Specify):	Yes:	No:	Explain:

Funding Category (Please select only ONE)
1. IDEA Part B (3-21)	2. IDEA Part C (0-2) Previously Part H	3. Not Reported under Part B or Part C

Part B Category Codes (Please select only ONE)
0. Not Applicable - Individual is under 3 years old	8. Emotionally Disturbed
1. Autistic	9 . Specific Learning Disability
2. Hearing Impaired (includes deafness)	10.Speech or Language Impairment
3. Deaf-Blind	11.Traumatic Brain Injury
4. Mental Retardation	12.Visually Impaired (includes blindness)
5. Multi-disabled	13.Developmentally Delayed – *( Optional category for age 3 through 9)**
6. Other Health Impairment	14.Non-Categorical
7. Orthopedic Impairment	888.Not Reported under Part B of IDEA

Educational Setting (Please select only ONE)
Birth through Age 2	Ages 3 - 5
101 Program Designed for Children With Developmental Delays or Disabilities	201 Early Childhood Setting
102 Home	202 Early Childhood Special Education Setting
103 Combination of Center Based and Home Based EI	203 Part EC Setting & Part ECSE Setting
104 Service Provider Location	204 Home
105 Daycare/Childcare	205 Residential Facility
106 Hospital (inpatient)	206 Separate School
107 Not Receiving Early Intervention (EI) Services	207 Itinerant Service Outside the Home
108 Program Designed for Typically Developing Children	208 Reverse Mainstream Setting
109 Residential Facility	255 Misc. Other (Specify)
155 Misc. Other (Specify)

Ages 6- 21
301 Regular Class	308 Homebound/Hospital
302 Resource Room	310 Home School Program
303 Separate Class	311 Post-secondary Program
304 Public Separate School	312 Vocational Program
305 Private Separate School	313 Not in Educational Setting
306 Public Residential Facility	355 Misc Other (Specify)
307 Private Residential Facility
401(please check) Individual is age 22-28	*Reporting is optional for individuals over the age of 21

Part B Exiting
0. In Special Education Program	7. Moved, Not Known to be Continuing
1. No Longer Receives Special Education/Returned to Regular Education	8. Dropped Out
2. Graduation with Regular Diploma	9. No Longer Receives Special Education, but Still Receiving State DB Project Services
3. Received a Certificate	10. Received a Modified Diploma
4. Reached Maximum Age	11. No longer meets deaf-blind criteria
5. Deceased
6. Moved, Known to be Continuing

Living Setting (Please select only ONE)
1. Home: Birth/Adoptive Parents	6. Group Home (less than 6 residents)
2. Home: Extended Family	7. Group Home (6 or more residents)
3. Home: Foster Parents	8. Apartment (with non-family person(s)
4. State Residential Facility	9. Pediatric Nursing Home
5. Private Residential Facility	555. Other (Specify)

Cochlear Implant
Cochlear Implant	(0) No	(1) Yes

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