Child School Record Abstraction

Human Health Effects of Drinking Water Exposures to Per- and Polyfluoroalkyl Substances (PFAS) at Pease International Tradeport, Portsmouth, NH (The Pease Study)

P_Att20c ChildSchoolRecordAbstractionForm 20190813 clean

Child School Record Abstraction

OMB: 0923-0061

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Attachment 20c.

Shape1

Form Approved

OMB No. 0923-XXXX

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

Exp. Date xx/xx/20xx



Pease Study

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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 shall obtain and 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.


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___________________



DISABILITY

FINDING

IF YES,

Neurological Disability

Yes

No

Specify___________________

How assessed?

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


IQ [__________]

Reading Level [___________]




Other Test Results:










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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorBove, Frank J. (ATSDR/DTHHS/EEB)
File Modified0000-00-00
File Created2021-01-13

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