New York Deaf-Blind Collaborative Referring a Child

New York Deaf-Blind Collaborative Referring a Child NYDBC Overview The New York Deaf-Blind Collaborative (NYDBC) is statewide grant that provides technical assistance to improve services for children and youth who are deaf-blind between the ages 0-21. The NYDBC is housed at Queens College but is responsible for outreach throughout New York State. NYDBC is funded by the United States Department of Education, Office of Special Education Programs (OSEP). NYDBC is designed to complement the educational programming of the student and does not interfere or replace existing services. All support and training is provided free of cost. To Refer a Child To refer a child to NYDBC, complete the following steps (*required): Child Count Form* Release of Educational Information* Hearing Report* Vision Report* IEP* Consent to Video (optional) Consent to Photo (optional) TA Request Form Staff or related service providers can assist in the completion of the Child Count form but it must be signed by a family member or authorized caregiver. Training to the educational team and related service providers is not contingent on family consent. Forms can be faxed or scanned and emailed to the following: Email: nydbc@qc.cuny.edu Fax: 718-997-4883 Phone: 718-997-4856

Degree of Hearing Loss Eligibility Chart: Combinations of Vision and Hearing Loss Degree of Vision Loss 0 25 db Normal 26 40 db Mild 41 55 db Moderate 56 70 db Moderate to Severe 71 90 db Severe > 91 db Profound Normal 20/20 Acuity 20/70 20/200 Peripheral Fields <20 degrees Acuity 20/200 20/400 Acuity 20/400 20/1000 Light Perception Only/No Vision At Risk - Consult with NYDBC Children/young adults with dual sensory loss as a result of congenital infections, hereditary syndromes and post-natal complications (see NYDBC Child Count Form) are at risk for compromised access to learning. Eligible for Services Refer to NYDBC Children/young adults with more severe hearing & vision loss will experience difficulty accessing spoken language and the visual world around them. Accommodations must be made in order to provide adequate access to learning. Impairment Cortical Visual Impairment: Phase III Phase II Phase I At Risk: Consult with NYDBC Eligible for Services: Refer to NYDBC New York Deaf-Blind Collaborative P: 718-997-4856 F: 718-997-4883 E: nydbc@qc.cuny.edu

I. Information About the Individual (Child/Young Adult) CHILD ID#: P.1 SCHOOL ID#: 1.*First Name: Last Name: Middle Initial: 2.*Gender: Male Female 3.*Child s Date of Birth: month day year 4. Child s County of Residence: 5. Parent/Guardian Name: Address: City/Town: Zip Code: Phone: Fax: Email: 6. Primary Identified Etiology (Enter one numeric code in the box from the list below.) HEREDITARY/CHROMOSAL SYNDROMES AND DISORDERS 101 Alcardi Syndrome 102 Alport Syndrome 103 Altrom Syndrome 104 Apert Syndrome (Acrocephalosyndactyly, Type I) 105 Bardet-Biedi Syndrome (Laurence Moon-Biedi) 106 Betten Disease 107 CHARGE Syndrome 108 Chromosome 18, ring 18 109 Cockayne Syndrome 110 Cogan Syndrome 111 Cornelia de Lange Syndrome 112 Cri du chat Syndrome (Chromosome 5p Syndrome) 113 Crigler-Najjar Syndrome 114 Crouzan Syndrome (Craniofacial Dysotosis) 115 Dandy Walker Syndrome 116 Down Syndrome (Trisomy 21 Syndrome) 117 Goldenhar Syndrome 118 Hand-Schuller-Christian 119 Hallgren Syndrome 120 Herpes-Zoster (or Hunt) 121 Hunter Syndrome (MPS II) 122 Hurler Syndrome (MPS I-H) 123 Kearns-Sayre Syndrome 124 Klippel-Fell Sequence 125 Klippel-Trenaunay-Weber Syndrome 126 Kniest Dysplasia 127 Leber Congenital Amaurosis 128 Leigh Disease 129 Marfan Syndrome 7. Ethnicity 1.American Indian or Alaskan Native 2.Asian CHILD COUNT FORM 130 Marshall Syndrome 131 Maroteaux-Larry Syndrome (MPS VI) 132 Moebius Syndrome 133 Monosomy 10p 134 Morquio Syndrome (MPS IV-B) 135 NF1-Neurofibromatosis (von Recklinghausen disease) 136 NF2-Bilateral Acoustic Neurofibromastosis 137 Norrie Disease 138 Optico-Cochleo-Dentate Degeneration 139 Pfieffer Syndrome 140 Prader-Willi 141 Pierre-Robbin Syndrome 142 Refsum Syndrome 143 Scheie Syndrome (MPS I-S) 144 Smith-Lemli-Optiz (SLO) Syndrome 145 Stickler Syndrome 146 Sturge-Weber Syndrome 147 Treacher Collins Syndrome 148 Trisomy 13 (Trisomy 13-15, Patau Syndrome) 149 Trisomy 18 (Edwards Syndrome) 150 Turner Syndrome 151 Usher Syndrome, Type I 152 Usher Syndrome, Type II 153 Usher Syndrome, Type III 154 Vogt-Koyanagi-Harada Syndrome 155 Waardenburg Syndrome 156 Wildervanck Syndrome 157 Wolf-Hirschorn Syndrome (Trisomy 4p) 199 Other: (Indicate the numeric code in the box above and specify in this space) 3.Black/African American PRE-NATAL/CONGENITAL COMPLICATIONS 201 Congenital Rubella 202 Congenital Syphilis 203 Congenital Toxoplasmosis 204 Cytomeglovirus (CMV) 205 Fetal Alcohol Syndrome 206 Hydrocephaly 207 Maternal Drug Use 208 Microcephaly 209 Neonatal Herpes Simplex (HSV) 299 Other: (Indicate the numeric code in the box above and specify in this space) POST-NATAL/NON CONGENITAL COMPLICATIONS 301 Asphyxia 302 Direct Trauma to the eye and/or ear 303 Encephalitis 304 Infections 305 Meningitis 306 Severe Head Injury 307 Stroke 308 Tumors 309 Chemically Induced 399 Other: (Indicate the numeric code in the box above and specify in this space) RELATED TO PREMATURITY 401 Complications to Prematurity UNDIAGNOSED 501 No determination of Etiology 4.Hispanic 5.White 6. Native Hawaiian/ Pacific Islander 7. Two or more races II. Information about Vision, Hearing, and Other Impairments 1.* Documented Vision Loss Select ONE that best describes the individual s: A. Documented degree of vision loss with correction, or B. Indicate that further testing is needed (testing must be complete prior to the next census submission) or C. Indicate that the student has a documented functional vision loss. 1.Low Vision 2.Legally Blind 3.Light Perception Only 4.Totally Blind 6.Diagnosed Progressive Loss 7.Further Testing Needed 9.Documented Functional Vision Loss 2.* Documented HEARING LOSS Select ONE that best describes the individual s: A. Documented degree of hearing loss with correction, or B. Indicate that further testing is needed (testing must be complete prior to the next census submission) or C. Indicate that the student has a documented functional hearing loss. 1.Mild (26-40 db loss) 2.Moderate (41-55 db loss) 3.Moderately Severe (56-70 db loss) 4.Severe (71-90 db loss) 5.Profound (91+ db loss) 6.Diagnosed Progressive Loss 7.Further Testing Needed 9.Documented Functional Hearing Loss

CHILD ID#: P.2 NYDBC Child Count Form 3. Does the child have any of the following: 4. Indicate all other documented impairments, in addition to vision and hearing impairments: Auditory Neuropathy Central Auditory Processing Disorder (CAPD) Cochlear Implant Cortical Visual Impairment Other: Other: Yes No Unknown Yes No Unknown Physical Impairments Cognitive Impairments Behavior Disorder Complex Health Care Needs Speech and Language Other: III. Reporting, Funding and Placement Information 1. Part C Reporting Category. If the child is 0-2 years of age please enter the category under which the child was reported within the Early Intervention program (Department of Health). [Select one] At-risk for developmental delay Developmentally Delayed Not reported under Part C 2. Part B Reporting Category Code. If the child is 3-21 years of age indicate the primary category code under which the individual was reported on Part B, IDEA Child Count. [Select one] 1.Mental Retardation 6.Orthopedic Impairment 10.Multiple Disabilities 2.Hearing Impairment (includes deafness) 7.Other Health Impairment 11.Autism 3.Speech or Language Impairment 8.Specific Learning Disability 12.Traumatic Brain Injury 4.Visual Impairment (includes blindness) 9.Deaf-Blindness 14.Non-Categorical 5.Emotional Disturbance 13.Developmentally Delayed (ages 3 through 9) 888 Not reported under Part B of IDEA 3. Early Intervention Setting (0-2). Please specify where the child receives services. 1.Home 2.Community-Based Setting Other [please specify]: 4. Educational setting 3-5 years of age. Please choose the one which best describes which type of program the child attends. 1.Attending a regular early childhood program at least 80% of the time. 2.Attending a regular early childhood program 40% to 79% of the time. 3.Attending a regular early childhood program less than 40% of the time. 4.Attending a separate class. 5.Attending a separate school. 6.Attending a residential facility. 7.Service provider location. 8.Home 5. Educational setting 6-21 years of age. Please choose the one which best describes the type of program the child attends. 9.Inside the regular class 80% or more of the day 10.Inside the regular class 40% to 79% of the day 11.Inside the regular class less than 40% of the day 12.Separate school 13.Residential Facility 14.Homebound/Hospital 15.Correctional Facilities 16.Parentally placed in private school 6.Participation in Statewide Assessments: Please indicate what assessment system the child participates in. 1.Regular grade-level State assessment. 2.Regular grade-level State assessment with accommodations. 4.Alternate assessments (NYSAA) based on alternate achievement standards. 6.Not required at age or grade level. 7. Special Education Status/Part C (0-2) Exiting. Please indicate the ONE code that best describes the individual s special education program status. 0.In a Part C early intervention program. 1.Completion of IFSP prior to reaching maximum age for Part C. 2.Eligible for IDEA, Part B 3.Not eligible for Part B, referral t other program. 4.Not eligible for Part B, exit without referrals. 5.Part B eligibility not determined. 6.Deceased. 7.Moved out of state. 8.Withdrawal by parent/guardian. 9.Could not contact parent.

CHILD ID#: P.3 NYDBC Child Count Form 8. Special Education Status/Part B Exiting. Please indicate the ONE code that best describes the individual s special education program status on December first of the current year. 0.In early childhood or school-age special education. 1.Transferred to regular education. 2.Graduated with regular high school diploma. 3.Received a certificate. 4.Reached maximum age. 5.Died 6.Moved, Know to be Continuing. 8.Dropped Out 9. Current living status: 1. Home: Parents 2. Home: Extended Family 3. Home: Foster Parents 4. State residential facility 5. Private residential facility 6. Group home (less than 6 residents) 7. Group home (6 or more residents) 8. Apartment (with non family) 9. Pediatric nursing home 555. Other 10. Does this individual use any of the following adaptive equipment? 0. Yes 1. No 2. Unknown Corrective Lenses Assistive Listening Devices (i.e. hearing aids or FM system) Additional Assistive Technology (other than corrective lenses or assistive listening devices) 11. School Information Agency/School Name: Street Address: City: State: Zip Code: Telephone Number: Fax Number: Teacher Name: Teacher s Email: 12. Is this individual receiving services from the New York Deaf-Blind Collaborative? Yes No Please return this form and the appropriate Release Form to: NYDBC Queens College Powdermaker 200 65-30 Kissena Blvd. Flushing, NY 11367 If you have any questions or need assistance in completing this form please contact us at: 718-997-4856 or email us at NYDBC@qc.cuny.edu.

Queens College, CUNY 65-30 Kissena Blvd., PH 200 Queens, NY 11367-1597 718-997-4856 T 718-997-4883 F Permission to Photograph I give the New York Deaf-Blind Collaborative permission to photograph or use photos of my child for one or more of the follow reasons: Check the ones(s) for which you give your permission. To be used by the project for the training of professionals and families, on different topics in the area of deaf-blindness in an electronic format, such as Power Point materials, that is accessible only to those families and professionals that the project staff gives specific permission to. To use photos in a publicly accessible manner, such as on our website or in another electronic format (i.e. brochure) to raise awareness of deaf-blindness in general or about specific topics in deaf-blindness. Child s Name: Parent/Guardian Name: Address: Phone: Email: X Signature Date

Queens College, CUNY 65-30 Kissena Blvd., PH 200 Queens, NY 11367-1597 718-997-4856 T 718-997-4883 F Permission to Videotape I give the New York Deaf-Blind Collaborative permission to videotape or use videos of my child for one or more of the follow reasons: Check the ones(s) for which you give your permission. To be used by the project for the training of professionals and families, on different topics in the area of deaf-blindness in an electronic format, such as Power Point materials, that is accessible only to those families and professionals that the project staff gives specific permission to. To use videos in a publicly accessible manner, such as in online learning modules to raise awareness of deaf-blindness in general or about specific topics in deaf-blindness. To use the video recording as a tool for analyzing the instruction and education that my child receives with the purpose of giving my child s teacher and educational staff feedback to improve their interactions with and instruction of my child. I understand that this videotape will be used in a closed setting with supervised use by NYDBC project staff. Child s Name: Parent/Guardian Name: Address: Phone: Email: X Signature Date

Queens College Powdermaker Rm. 200 65 30 Kissena Blvd. Flushing, NY 11367 1597 Release of Information and Education Records I hereby authorize (name of your child s school): to release (Your child s name): educational records, including evaluations, updates, IEP s, and other pertinent educational information to The New York Deaf Blind Collaborative in their role as technical assistance providers. Furthermore I authorize the staff of the school to discuss my child s educational program with staff from the Collaborative on an ongoing basis. Name of Parent(s) or Guardian: Signature: Address: Phone: If you have any questions about this release please contact: Susanne Morrow Project Director 718 997 4854 susanne.morrow@qc.cuny.edu