De-identifying Registration Form

If you have any difficulties with this form, please email Michelle Clyne.

Please click Submit at the end of this form.

Submitter's Information

Submitter's role (required)

Family MemberProject StaffSpecial Education TeacherVI Teacher/Coordinator/Orientation and Mobility SpecialistHI Teacher/CoordinatorCase ManagerDT-VisionDT-HearingCFC Service CoordinatorEarly Intervention ProviderAudiologistOptometrist/OphthalmologistNurseSocial WorkerSpeech and Language TherapistOccupational TherapistPhysical TherapistQIDPAgency AdministratorOther

Other Role Detail   

Relationship to child/youth being reported (required) 

CaregiverRelativeOn IFSP TeamOn Educational TeamOn Medical TeamOther

Submitter’s First Name (required)

Submitter’s Last Name (required)

Submitter's Phone (required)

Submitter's Email (required)

Program/Agency/School Name (if applicable)

Street Address (required)

City (required)

Zip Code (required)

Child's Information

Some information is required, only enough so that a unique count to the National Deaf-Blind Child Count can be made. The individual child will NOT be identified, and the child’s family is not being made eligible for ILDBP services. ILDBP services CAN be accessed through the "Referral for Eligibility" process at any time the family wishes.

Child's Initials (required)

Directions: Use the first two initials of the first name, and the first two initials of the last name. For example, Mary Smith would be MASM.

Date of Birth (required)

Gender (required)

MaleFemaleOther

Ethnicity: Is this student Hispanic/Latino?

No, not Hispanic/LatinoYes, Hispanic/Latino

Race

American Indian or Alaskan NativeAsianBlack or African AmericanWhiteNative Hawaiian or Other Pacific IslanderTwo or more races

Primary Language used in Student's Home (required)

EnglishSpanishASLOther

Cause of DeafBlindness (required)

Aicardi syndromeAlport syndromeAlstrom syndromeApert syndrome/Acrocephalosyndactyly, Type 1Bardet-Biedl syndrome (Laurence Moon-Biedl)Batten diseaseCHARGE SyndromeChromosome 18, Ring 18Cockayne syndromeCogan SyndromeCornelia de LangeCri du chat syndrome (Chromosome 5p- synd)Crigler-Najjar syndromeCrouzon syndrome (Craniofacial Dysotosis)Dandy Walker syndromeDown syndrome (Trisomy 21 syndrome)Goldenhar syndromeHand-Schuller-Christian (Histiocytosis X)Hallgren syndromeHerpes-Zoster (or Hunt)Hunter Syndrome (MPS II)Hurler syndrome (MPS I-H)Kearns-Sayre syndromeKlippel-Feil sequenceKlippel-Trenaunay-Weber syndromeKniest DysplasiaLeber congenital amaurosisLeigh DiseaseMarfan syndromeMarshall syndromeMaroteaux-Lamy syndrome (MPS VI)Moebius syndromeMonosomy 10pMorquio syndrome (MPS IV-B)NF1 - Neurofibromatosis (von Recklinghausen dis)NF2 - Bilateral Acoustic NeurofibromatosisNorrie diseaseOptico-Cochleo-Dentate DegenerationPfieffer syndromePrader-WilliPierre-Robin syndromeRefsum syndromeScheie syndrome (MPS I-S)Smith-Lemli-Opitz (SLO) syndromeStickler syndromeSturge-Weber syndromeTreacher Collins syndromeTrisomy 13 (Trisomy 13-15, Patau syndrome)Trisomy 18 (Edwards syndrome)Turner syndromeUsher I syndromeUsher II syndromeUsher III syndromeVogt-Koyanagi-Harada syndromeWaardenburg syndromeWildervanck syndromeWolf-Hirschhorn syndrome (Trisomy 4p)OTHER: Hereditary Syndromes/ DisordersCongenital RubellaCongenital SyphilisCongenital ToxoplasmosisCytomegalovirus (CMV)Fetal Alcohol syndromeHydrocephalyMaternal Drug UseMicrocephalyNeonatal Herpes Simplex (HSV)OTHER: Pre-Natal/ Congenital ComplicationsAsphyxiaDirect Trauma to the eye and/or earEncephalitisInfectionsMeningitisSevere Head InjuryStrokeTumorsChemically InducedOTHER: Post-Natal/ Non-CongenitalComplication of PrematurityNo Diagnosis

Vision Status (required)

Low vision (visual acuity of 20/70 to 20/200)Legally blind (visual acuity of 20/200 or less or visual field restriction of 20 degrees or lessLight perception onlyTotal blindnessDiagnosed progressive vision lossFurther testing neededDocumented functional vision loss

Does this child have Cortical/Neurological Visual Impairment? (required)

NoYesUnknown

Hearing Status (required)

Mild (26 – 40 dB hearing loss)Moderate (41 – 55 dB hearing loss)Moderately Severe (56 – 70 dB hearing loss)Severe (71 – 90 dB hearing loss)ProfoundDiagnosed Progressive LossFurther Testing NeededDocumented Functional Hearing Loss

Does this child have Central Auditory Processing Disorder? (required)

NoYesUnknown

Does this child have Auditory Neuropathy? (required)

NoYesUnknown

If the child is birth – 2, how are Part C services provided?

HomeCommunityOther SettingsNot applicable/not served under Part C

If the child is age 3 – 5, where/how are educational services provided?

Services in regular early childhood program 10+ hoursOther location regular early childhood program 10+ hoursServices in regular early childhood program less than 10 hoursOther location regular early childhood program less than 10 hoursAttending a separate classAttending a separate schoolAttending a residential facilityHome, at public expenseHome, not at public expenseNot served under Part B

If the child is age 6 – 22, where/how are educational services provided?

Inside the regular education class 80% or more per dayInside the regular education class 40% - 79% per dayInside the regular education class less than 40% per dayAttending a separate schoolAttending a residential facilityHomebound/hospitalCorrectional facilityParentally placed in private schoolHome school/remote learning, at public expenseHome school/remote learning, not at public expenseN/A, not served under Part BUnknown/Missing

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