Form S-1 Parent Survey -- Special Education

IA Form #S-1

OMB Control Number 1040-0001
Expiration Date 03/31/2012

Parent Survey – Special Education
This is a survey for parents of students receiving special education services. Your response will help guide efforts to
improve services and results for children and families. For each statement below, please select one of the following
response choices: very strongly disagree, strongly disagree, disagree, agree, strongly agree, very strongly agree. You
may skip any item you feel does not apply to you or your child.
Use pencil only

Fill in circle completely

Schools Efforts to Partner with Parents
1) I am considered an equal partner with teachers and
other professionals in planning my child’s program.
2) I was offered special assistance (such as child care)
so that I could participate in the Individualized
Educational Program (IEP) meeting.
3) At the IEP meeting, we discussed how my child
would participate in statewide assessments.
4) At the IEP meeting, we discussed accommodations
and modifications that my child would need.
5) All of my concerns and recommendations were
documented on the IEP.
6) Written justification was given for the extent that
my child would not receive services in the regular
classroom.
7) I was given information about organizations that
offer support for parents of students with disabilities.
8) I have been asked for my opinion about how well
special education services are meeting my child’s
needs.
9) My child’s evaluation report is written in terms I
understand.
10) Written information I receive is written in an
understandable way.
11) Teachers are available to speak with me.
12) Teachers treat me as a team member.
13) Teachers and administrators seek out parent input.
14) Teachers and administrators show sensitivity to
the needs of students with disabilities and their
families.
15) Teachers and administrators encourage me to
participate in the decision-making process.
16) Teachers and administrators respect my cultural
heritage.
17) Teachers and administrators ensure that I have
fully understood the Procedural Safeguards [the rules
in federal law that protect the rights of parents].

Very
Strongly
Disagree

Strongly
Disagree

Disagree

Agree

Strongly
Agree

Very
Strongly
Agree

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Schools Efforts to Partner with Parents
18) The school has a person on staff who is available to
answer parents’ questions.
19) The school communicates regularly with me
regarding my child’s progress on IEP goals.
20) The school gives me choices with regard to
services that address my child’s needs.
21) The school offers parents training about special
education issues.
22) The school offers parents a variety of ways to
communicate with teachers.
23) The school gives parents the help they may need
to play an active role in their child’s education.
24) The school provides information on agencies that
can assist my child in the transition from school.
25) The school explains what options parents have if
they disagree with a decision of the school.

State of Residence
Child’s Grade
O
Child’s Age in Years

Child’s Age When First Referred to
Early Intervention or Special Education
O Under 1 year OR Age in years
Is the child Hispanic or Latino/Latina
Yes
No (circle one)
Child’s Race (Select one or more)
1 O White
2 O Black / African American
3 O Asian
4 O Native Hawaiian or Pacific Islander
5 O American Indian or Alaska Native

Very
Strongly
Disagree

Strongly
Disagree

Disagree

Agree

Strongly
Agree

Very
Strongly
Agree

O

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Child’s Primary Exceptionality / Disability
(Bubble only one)
O Autism
O Deaf-Blindness
O Deafness
O Developmental Delay
O Emotional Disturbance
O Hearing Impairment
O Mental Retardation
O Multiple Disability
O Orthopedic
O Other Health
O Specific Learning Disability
O Speech or Language Impairment
O Traumatic Brain Injury
O Visual Impairment

THANK YOU FOR YOUR
PARTICIPATION !!

Paperwork Reduction Act Statement: This information is collected to properly identify each student’s instructional and residential program classification. The
information is supplied by a respondent to obtain or retain a benefit that is to provide appropriate schooling. It is estimated that responding to the request will take an
average of 20 minutes to complete. This includes the amount of time it takes to gather the information and fill out the form. If you wish to make comments on the form,
please send them to the Information Collection Clearance Officer-Indian Affairs, 1849 C Street, NW, Washington, DC 20240. NOTE: Comments, names and
addresses of commenters are available for public review during regular business hours. If you wish us to withhold this information you must state this prominently at
the beginning of your comment. We will honor your request to the extent allowable by law. In compliance with the Paperwork Reduction Act of 1995, as amended, this
collection has been reviewed by the Office of Management and Budget and assigned OMB Control #1040-0001 and an expiration date of March 31, 2012. Please
note that an agency may not conduct or sponsor, and a person is not required to report to, a collection of information unless there is a valid OMB control number.