Multi-site Study Child School Record Abstraction Form

Attachment 18c.

Form Approved

OMB No. 0923-XXXX

Exp. Date xx/xx/201x xx/xx/20xxExDaxx/xx/20xx

Exp. Date xx/xx/20xx

Multi-site Study

ATSDR estimates the average public reporting burden for this collection of information as 20 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-xxxx).

Child School Record Abstraction Form

If the parent reports that the child has a developmental disability (e.g., ADHD, autism, or a learning disability), then ATSDR/[institution name] seeks to abstract the special education records for the child including the individualized education program (IEP), the IEP evaluation report (“Full Individual Evaluation” or “FIE”), and if available, the Independent Educational Evaluation. ATSDR seeks this information only if the child’s parent or legal guardian has signed the consent to release student information.

ATSDR/[institution name] has received parental or guardian permission to obtain the specified school records for the child named below:

Name of Student (print): ______________________________________ Student ID No. _____________ Date of Birth: [mm/dd/yyyy]

Address of Student: ____________________________________________________________________

City: ________________________________ State: ___________ Zip Code: _______________________

Name of Parent or Guardian (print): _______________________________________________________

Mail the completed form (using the enclosed pre-addressed return envelope) to:

[Investigator’s Name]

[Institution Name]

[Address]

Does the student have one or more of the following disabilities?

DISABILITY	FINDING	IF YES,
Autism	Yes No	How diagnosed?
Developmental Disability	Yes No	Specify___________________ How diagnosed?
Intellectual/Cognitive Impairment	Yes No	Specify___________________ How assessed?
Sensory-Hearing, Vision, Deaf-Blind	Yes No	Specify___________________
Neurological Disability	Yes No	Specify___________________ How assessed?
Other	Yes No	Specify___________________ How assessed?

DISABILITY	FINDING		IF YES,
Specific Learning Disability		Yes No		Specify___________________ How assessed?
Attention Deficit Hyperactivity Disorder (ADHD)		Yes No		How diagnosed?
Social/Emotional/Behavioral Disorder		Yes No		Specify___________________ How diagnosed?
Adaptive Behavior		Yes No		Specify___________________ How diagnosed?
Language Disability		Yes No		Specify [__] receptive [__] expressive [__] auditory processing How diagnosed?

Verbatim description of deficiencies noted in the Present Levels of Academic Achievement and Functional Performance (including deficiencies in social skills and behavior):

Note the following if found:

Services: Special Education	Yes No	Specify___________________
Psychometric Test Results	Yes No	IQ [__________] Reading Level [___________]

Other Test Results:

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