Multi-site Study Child School Record Abstraction Form

Human Health Effects of Drinking Water Exposures to Per- and Polyfluoroalkyl Substances (PFAS): A Multi-site Cross-sectional Study

M_Att18c_ChildSchoolRecordAbstractionForm 20191212

Child School Record Abstraction

OMB: 0923-0063

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Attachment 18c.


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Form Approved

OMB No. 0923-XXXX

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

Exp. Date xx/xx/20xx



Multi-site 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/[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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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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