Form 19 UCEDD: Self-administered Form

DEVELOPMENTAL DISABILITIES PROGRAM

INDEPENDENT EVALUATION

UNIVERSITY CENTERS FOR EXCELLENCE IN DEVELOPMENTAL DISABILITIES EDUCATION, RESEARCH, AND SERVICE (UCEDDs)

SELF-ADMINISTERED FORM

INSTRUCTIONS:

In addition to questions that can be answered through personal interview, there is some information that is best collected with a form like this. For the most part, the information requested requires consolidation of information you are already collecting.

The form is divided into separate sections, one section for each of the key functions¹ that all UCEDDs implement. We would appreciate it if you would provide us with information that responds to the questions for each key function. When documentation² is required, please append to this form.

So that data from all UCEDDs can be rolled up to the national level, it is important that all centers that complete this form use the same time period [REPORTING PERIOD]. Therefore, please answer all questions using the following REPORTING PERIOD:

From [to be completed by _____]

M M D D Y Y Y Y

To [to be completed by_____}

M M D D Y Y Y Y

We are providing you with a CD that contains this form, as well as a paper copy of the form. Please feel free to complete this form by computer or with a pen. If you complete this form by computer, please save it as a Word file and send it to _________________ as an attachment. Documentation should be sent to _________ in the self-addressed envelope we have provided.

If you complete this form in hard copy, please return the form with all documentation to _________________ in the self-addressed envelope we have provided.

If you have any questions, please do not hesitate to call ____________ at ____________.

ID Number

[Completed by _________]

Name of Program ___________________________________________________­­­______

­­­

Executive Director ________________________________________________________

Name and contact information of person (people) completing form:

Name	Section Completed	Telephone Number	Email
	5-year Planning
	Interdisciplinary Pre-service Preparation and Continuing Education
	Basic and/or Applied Research
	Dissemination
	Governance and Management

A. 5-year Planning

All questions in this section refer to the following reporting period:

From [to be completed by _____]

M M D D Y Y Y Y

To [to be completed by_____}

M M D D Y Y Y Y

1. What are the goals and objectives stated in the approved UCEDD 5-year plan and adjustments to the plan that pertains to this reporting period?

PLEASE LIST.

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

2. What were the major undergraduate and graduate teaching and continuing education activities implemented by the UCEDD during the reporting period (e.g., courses taught to interdisciplinary pre-service students, curricula and syllabi developed, development of disability content into other courses)?

PLEASE LIST.

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

ID Number

[Completed by _________]

3. What were the major basic and/or applied research activities implemented by the UCEDD during the reporting period (e.g., writing grant proposals, implementing research project, writing up results for publication)? PLEASE LIST.

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

ID Number

[Completed by _________]

4. What were the major community services activities (including direct services, technical assistance, and training) implemented by the UCEDD during the reporting period? PLEASE LIST.

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

5. What were the major dissemination activities implemented by the UCEDD during the reporting period? PLEASE LIST.

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

ID Number

[Completed by _________]

2. Interdisciplinary Pre-service Preparation and Continuing Education

All questions in this section refer to the following reporting period:

From [to be completed by _____]

M M D D Y Y Y Y

To [to be completed by_____}

M M D D Y Y Y Y

6. How many faculty and staff were affiliated with the UCEDD during the reporting period?³

Don’t know [CHECK, IF APPLICABLE.]

7. What disciplines were represented among UCEDD faculty and staff affiliated during the reporting period?

PLEASE LIST EACH DISCIPLINE AND THE NUMBER OF FACULTY OR STAFF MEMBERS WHO FALL WITHIN EACH DISCIPLINE.

Discipline	No. of faculty or staff

8. What disciplines were represented among interdisciplinary pre-service students during the reporting period?

PLEASE LIST EACH DISCIPLINE AND THE NUMBER OF STUDENTS WHO FALL WITHIN EACH DISCIPLINE.

Discipline	No. of students

9. What major fields were represented among students participating in a disability studies program within the past academic calendar year?

PLEASE LIST EACH MAJOR FIELD AND THE NUMBER OF STUDENTS THAT FALL WITHIN EACH FIELD.

Major fields	No. of students

There is no disabilities studies program. [CHECK IF APPLICABLE.]

10. What departments were represented among students who took courses infused with disability content during the reporting period?

PLEASE LIST EACH DEPARTMENT AND THE NUMBER OF STUDENTS WHO FELL WITHIN EACH DEPARTMENT.

Departments	No. of students

11. What types of professionals (e.g., teachers, occupational therapists, audiologists) were represented among people who took UCEDD-supported continuing education courses during the reporting period?

PLEASE LIST EACH TYPE OF PROFESSION AND THE NUMBER OF PEOPLE WHO FELL WITHIN EACH TYPE OF PROFESSION.

Types of professionals	No.

12. How effective was UCEDD faculty and staff teaching rated during the reporting period?

PLEASE PROVIDE DOCUMENTATION.⁴

Extremely effective

Very effective

Effective

Somewhat effective

Not at all effective

Don’t know [CHECK, IF APPLICABLE.]

13. How many interdisciplinary pre-service students graduated or completed their program during the reporting period?

Don’t know [CHECK, IF APPLICABLE.]

14. How many interdisciplinary pre-service students who graduated or completed their program during the reporting period were working in a position that would benefit people with developmental disabilities?

Don’t know [CHECK, IF APPLICABLE.]

15. How many students who participated in a disabilities studies program graduated during the reporting period?

Don’t know [CHECK, IF APPLICABLE.]

16. How many students who participated in a disabilities studies program and graduated during the reporting period were working in a position that would benefit people with developmental disabilities?

Don’t know [CHECK, IF APPLICABLE.]

17. How many students who participated in a disabilities studies program and graduated during the reporting period were accepted into a graduate program that could benefit people with developmental disabilities?

Don’t know [CHECK, IF APPLICABLE.]

18. When contacting students who were taught by UCEDD faculty and staff to determine their future plans, what response rate did the UCEDD achieve at the end of their program? PLEASE CONSIDER STUDENTS ENDING THEIR PROGRAM DURING THE REPORTING PERIOD.

% Response rate

Do not contact at end of program [CHECK, IF APPLICABLE.]

ID Number

[Completed by _________]

C. Basis and/or Applied Research

All questions in this section refer to the following reporting period:

From [to be completed by _____]

M M D D Y Y Y Y

To [to be completed by_____}

M M D D Y Y Y Y

19. How many faculty and staff were affiliated with the UCEDD during the reporting period?⁵

Don’t know [CHECK, IF APPLICABLE.]

20. How many UCEDD-affiliated faculty or staff published at least one disability-related research article in a peer-reviewed journal during the reporting period?

Don’t know [CHECK, IF APPLICABLE.]

21. How many UCEDD-affiliated faculty or staff authored or co-authored a disability-related technical report or article, or disability-related chapters in books during the reporting period?

Don’t know [CHECK, IF APPLICABLE.]

22. How many UCEDD-affiliated faculty or staff presented on their disability-related research (including public policy analysis and evaluation) at conferences or meetings held during the reporting period?

Don’t know [CHECK, IF APPLICABLE.]

23. How many UCEDD-affiliated faculty or staff served on disability-related advisory groups, boards of directors, commissions, Governor’s Councils, legislative committees, school boards, or other groups to study or advise on disability-related issues during the reporting period?

Don’t know [CHECK, IF APPLICABLE.]

24. How many UCEDD-affiliated faculty or staff gave public testimony, made presentations, or provided consultation to legislators and other public officials during the reporting period?

Don’t know [CHECK, IF APPLICABLE.]

25. How many UCEDD-affiliated faculty or staff participated in national or international task forces or other committees related to disability during the reporting period?

Don’t know [CHECK, IF APPLICABLE.]

26. How many UCEDD faculty or staff reviewed articles for a peer review journal, books or book chapters, or other publications during the reporting period?

Don’t know [CHECK, IF APPLICABLE.]

27. How many faculty or staff participated in a funding agency’s grant review committee during the reporting period?

Don’t know [CHECK, IF APPLICABLE.]

ID Number

[Completed by _________]

4. Community Services

No questions.

4. Dissemination

All questions in this section refer to the following reporting period:

From [to be completed by _____]

M M D D Y Y Y Y

To [to be completed by_____}

M M D D Y Y Y Y

28. To what extent were target audiences satisfied with UCEDD products they received?

Very satisfied

Satisfied

Neither satisfied nor dissatisfied

Not very satisfied

Dissatisfied

PLEASE DOCUMENT.⁶

Don’t know [CHECK, IF APPLICABLE.]

ID Number

[Completed by _________]

E. Governance and Management

All questions in this section refer to the following reporting period:

From [to be completed by _____]

M M D D Y Y Y Y

To [to be completed by_____}

M M D D Y Y Y Y

29. Please complete the following table on funding applied for by the UCEDD during the reporting period.

Name of project	Source	Amount	Date Submitted

29. Please complete the following table on funding received by the UCEDD during the reporting period.

Name of project funded	Source	Amount	Data funding began	Date funding ended

Please append all documentation and additional pages to this form and return it in the stamped, self-addressed envelope provided by _____________________.

Thank you for your assistance in completing this form.

1 Key functions are groups of activities carried out by each DD Network program. Taken together, they cover all key aspects of program activity.

2 Documentation is tangible evidence – such as a summary of survey results or a report sent to the CAC or other university administrator.

3Faculty and staff affiliated with the UCEEDD are individuals with a university or faculty appointment (tenure, non-tenure or adjunct) and who have a designated official role with the UCEDD (e.g., at least some proportion of their salary is funded under the UCEDD’s budget or a UCEDD grant or contract; works for a university academic department and is released from some of their departmental academic responsibilities in order to work with the UCEDD; is funded by the university fully or partially to be a UCEDD faculty member; works for an academic department but does some work for the UCEDD in addition to their departmental academic responsibilities).

4 Documentation is tangible evidence – such as a summary of survey results or a report to the CAC or university administrator.

5Faculty and staff affiliated with the UCEEDD are individuals with a university or faculty appointment (tenure, non-tenure or adjunct) and who have a designated official role with the UCEDD (e.g., at least some proportion of their salary is funded under the UCEDD’s budget or a UCEDD grant or contract; works for a university academic department and is released from some of their departmental academic responsibilities in order to work with the UCEDD; is funded by the university fully or partially to be a UCEDD faculty member; works for an academic department but does some work for the UCEDD in addition to their departmental academic responsibilities).

6 Documentation is tangible evidence – such as a summary of survey results.

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