Special Education Program and Related Services

KINDERGARTEN

school
ELEMENTARY
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Section B:
SPECIAL EDUCATION PROGRAMS AND RELATED SERVICES

PE E S
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grow

Pre

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Pre-Elementary Education Longitudinal Study

Section B:

Elementary School Teacher
Questionnaire

SPECIAL EDUCATION PROGRAMS AND RELATED SERVICES
REMINDER: “This child” refers to the child whose name appears on the label.

B1. What are this child’s disabilities?

Your school district is participating in an important U.S. Department of Education study called
the Pre-Elementary Education Longitudinal Study (PEELS). The child named on the label is
one of more than 3,000 children nationwide who are taking part in PEELS. This questionnaire
is the only source of information about this child’s special education and related services.
Because of this, your participation is vitally important.
Please complete Section B of this questionnaire and return it in the self-mailer within 3 weeks.
To use the self-mailer, simply fold the questionnaire in half, affix the seal to secure it, and drop
it in your mailbox. Be assured that your answers will be confidential, and no information will
be reported that identifies you, this child, or this school.
In completing this questionnaire, you may need to refer to the child’s most recent
Individualized Education Program (IEP). If you have any questions about the study or the
questionnaire, please feel free to call the PEELS toll-free hot line at 1-888-534-8348, send
an email to [email protected], or visit the PEELS web site at www.peels.org.
Thank you in advance for your contribution to this very important study.
Sincerely,

Elaine Carlson
Project Director, PEELS

Questions?

Dear Education Professional:

Call the PEELS
toll-free hot line:
1-888-534-8348

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number.
The valid OMB control number for this information collection is 1850-0809. The time required to complete this information collection is estimated to average 20 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. 20202-4651. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: National Center for Special
Education Research, Institute of Education Sciences, U.S. Department of Education, 555 New Jersey Ave., NW, Washington, D.C. 20208.

OMB Control # 1850-0809, Expiration date: 1/31/08

PLEASE
PLEASE

✓CHECK ALL THAT APPLY IN COLUMN A.
✓CHECK ONE PRIMARY DISABILITY IN COLUMN B.
A
All disability
categories
applicable to
this child

B
This child’s
primary
disability
category

Check all that apply

Check one

01

a. Autism

02

b. Deaf/blindness
c. Deafness

02

03

03

05

05

04

d. Developmental delay
e. Emotional disturbance/behavior disorder

04

06

f. Hearing impairment

06

07

g. Learning disability

07

08

h. Mild mental retardation
i. Moderate/severe mental retardation

08

09

09

11

11

10

10

j. Multiple disabilities
k. Orthopedic impairment
l. Other health impairment

12

12

14

14

13

m. Speech or language impairment
n. Traumatic brain injury

13

15

o. Visual impairment/blindness
p. Other (Specify: _________________________)

15

16

16

98

q. Not sure

01

98

B2. Does this child use any medical devices that require school staff attention
during any part of the school day? (Medical devices could include suctioning
equipment, oxygen, catheters, etc. Do not include nonmedical devices such as
communication devices, electronic equipment, etc.) PLEASE
CHECK ONE.
1

2

✓

Yes
No
27

B6. In which of the following settings does this child receive special education and
related services? Please think about all the settings in which this child receives
CHECK ALL THAT APPLY.
services. PLEASE

B3. Who participated in the most recent IEP or 504 plan development or
CHECK ALL THAT APPLY.
review for this child? PLEASE
01

02
03
04
05
06
07
08
09
10
11

98

✓

a. Regular education academic subject teacher(s)

01

b. Regular education vocational teacher(s)

02

c. Special education teacher(s)

03

d. School administrator (e.g., principal, special education
director, program coordinator)

04
05

e. School counselor or psychologist

06

f. Related services personnel (e.g., speech therapist,
physical therapist, nutritionist)

07
08

g. Parent/guardian(s)

09

h. Child
i. Staff of outside service agency or outside consultant

✓

a. Regular education classroom
b. Regular education program but outside the classroom
c. Special education classroom
d. Special education setting, but not a classroom
e. Therapy site for special services located at a regular elementary school
f. An outpatient medical service facility, clinic, or therapy site
g. Child’s home
h. Someone else’s home (e.g., a babysitter)
i. Other (Specify: _____________________________)

j. Advocate
k. Other (Specify: ____________________________________________________)
l. Don’t know

B7. Which of the following are provided to this child as part of his/her IEP or 504 plan?
PLEASE

✓CHECK ALL THAT APPLY.

Accommodations/modifications
B4. For this school year, what are the three most important IEP goals for this child?
PLEASE
01

02
03
04
05
06
07
08
09
10

98

✓CHECK UP TO THREE.

a. Not applicable —the child does not have an IEP.

➜

Go to Question B7

b. Improve overall school readiness

01

02
03
04

a. Modified grading standards
b. Slower-paced instruction
c. Additional time to complete assignments
d. Modified assignments

c. Improve academic performance in a specific area: _________________________

05

d. Improve social skills

Learning aids
06

e. Improve appropriateness of general behavior

07

f. Improve adaptive behavior or self-help skills

08

g. Improve speech/communication skills

09

h. Improve fine motor skills

10

i. Improve gross motor skills
j. Other (Specify: ____________________________________________________)
k. Don’t know

B5. Which of the following best describes the amount of progress this child has made in
CHECK ONE.
this school year with regard to the goals specified in the IEP? PLEASE

✓

11
95

e. Physical adaptations (e.g., preferential seating, special desks)
f. Books on tape
g. Communication aids (e.g., Touch Talker, manual printing board)
h. Use of spell checker
i. Computer software designed for children with disabilities
j. Computer hardware adapted for child’s unique needs
(e.g., alternative keyboards, switch interface)
k. Other (Specify: _________________________________________________)
No accommodations/modifications or learning aids provided
(NOT ANY of items a. through k., above)

This child has made:
1

2
3
4
5
8

Much more progress than expected
More progress than expected
As much progress as expected
Less progress than expected
Much less progress than expected
Don’t know
28

29

B8. Were any of the following services provided to this child through the school
system during the current school year? (Include services the school contracted from
other agencies.) PLEASE
CHECK ALL THAT APPLY.

●
●

IF YOU COMPLETED SECTION A, please go to the back cover.
IF SOMEONE ELSE COMPLETED SECTION A, please continue with B9.

✓

01

02
03
04
05
06
07
08
09
10
11

12
13
14
15
16
17
18
19

20
21

22
23
24

a. Adaptive physical education
b. Assistive technology services/devices
c. Audiology
d. Augmentative or alternative communication system
e. Behavior management program
f. Health services (e.g., administering of medication, oxygen, tracheostomy
care, tube feeding, catheterization)
g. Instruction in American Sign Language
h. Instruction in Manual English or Cued Speech
i. Instruction in Braille

B9. In what capacity (or capacities) are you involved with this child?
PLEASE
01

✓CHECK ALL THAT APPLY.

a. Provide instruction directly to this child

02

b. Provide related services directly to this child

03

c. Provide consultation services to child’s teacher(s)

04

d. Provide case management (e.g., program monitoring) for this child

05

e. Serve as program administrator or supervisor

06

f. Supervise instructional assistant or para-educator assigned to
work with this child

07

g. Other (Specify: ____________________________________________________)

j. Learning strategies/study skills assistance by a special educator
k. Mental health services, personal/group counseling, therapy, or psychiatric
care provided to this child
l. Occupational therapy
m.One-to-one para-educator/assistant (e.g., teacher aide, nurse’s aide, fullinclusion assistant, behavioral assistant)
n. Physical therapy

B10. We want to know what you think about special education for young children.
In the space provided, please print any suggestions or concerns you have regarding
the provision of special education services for young children. (Be assured that your
answers will be confidential.)
________________________________________________________________________________________
________________________________________________________________________________________

o. Reader or interpreter
p. Service coordination/case management
q. Social work services
r. Special transportation because of disability (e.g., help in travel or special
equipment such as lifts, ramps)
s. Specialized computer software or hardware
t. Speech or language therapy
u. Training, counseling, and other supports/services provided to this child’s family
v. Tutoring/remediation by a special education teacher
w. Vision services
x. Other (Specify: _______________________________)

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Thank you for completing
this questionnaire.
Date Completed: ____/____/____
mm dd yy

Please provide your name and contact information below,
so that we can reach you if we have questions.

Your Name:

School/Program Name:

Address:

Phone:

(

)

Email:

30

Please continue to the back cover.

31

Thank you for completing
this questionnaire.

When you have completed this portion of the
questionnaire, please seal it with the label
below and place it in your local mailbox.

National Center for
Special Education Research

WESTAT

PEELS 8089.03.09

BUSINESS REPLY MAIL
FIRST-CLASS

PERMIT NO.433

ROCKVILLE, MD

POSTAGE WILL BE PAID BY ADDRESSEE

PEELS • Pre-Elementary Education
Longitudinal Study
Westat • RW2634
1650 Research Blvd.
Rockville, MD 20850-9973

21467.1206.80890309

thank you!