Deaf-Blind Child Census - Exceptional Children

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122 Hurler syndrome (MPS I-H)123 Kearns-Sayre syndrome124 Klippel-Feil sequence125 Klippel-Trenaunay-Weber syndrome126 Kniest Dysplasia127 Leber congenital amaurosis128 Leigh Disease129 Marfan syndromePre-Natal/Congenital Complications201 Congenital Rubella202 Congenital Syphilis203 Congenital Toxoplasmosis204 Cytomegalovirus (CMV)205 Fetal Alcohol syndrome206 Hydrocephaly207 Maternal Drug Use208 Microcephaly209 Neonatal Herpes Simplex (HSV)299 Other_______________________151 Usher I syndrome152 Usher II syndrome153 Usher III syndrome154 Vogt-Koyanagi-Harada syndrome155 Waardenburg syndrome156 Wildervanck syndrome157 Wolf-Hirschhorn syndrome (Trisomy 4p)199 Other __________________________Post-Natal/Non-Congenital Complications301 Asphyxia302 Direct Trauma to the eye and/or ear303 Encephalitis304 Infections305 Meningitis306 Severe Head Injury307 Stroke308 Tumors309 Chemically Induced399 Other _______________________Related to Prematurity401 Complications of Prematurity 501 No Determination of EtiologyUndiagnosedRace/EthnicityEnter the one race/ethnicity code from the list that best describes the individual. A child orstudent may only be reported in one race/ethnicity category.Possible selections include:1. American Indian or Alaska Native2. Asian3. Black4. Hispanic5. White6. Native Hawaiian /Pacific Islander7. Two or more racesThe following definitions of the seven categories of race/ethnicity have been adapted fromdefinitions appearing in the Final Guidance. Please note, in order to reduce coding changes wehave maintained the order of categories on the DB <strong>Child</strong> Count as previous years, adding thenew categories to the end of the numeric code list.1. American Indian or A person having origins in any of the original peoples of NorthAlaska Native and South America (including Central America) and whomaintains tribal affiliation or community attachment. (Does notinclude persons of Hispanic/Latino ethnicity.)2. Asian A person having origins in any of the original peoples of the FarEast, Southeast Asia, or the Indian subcontinent. This includes, for5
example, Cambodia, China, India, Japan, Korea, Malaysia,Pakistan, the Philippine Islands, Thailand, and Vietnam. (Does notinclude persons of Hispanic/Latino ethnicity.)3. Black or African A person having origins in any of the Black racial groups ofAmericanAfrica. (Does not include persons of Hispanic/Latino ethnicity.)4. Hispanic/Latino A person of Cuban, Mexican, Puerto Rican, South or CentralAmerican, or other Spanish culture or origin, regardless ofRace. Refers to Hispanic and/or Latino.5. White A person having origins in any of the original peoples of Europe,the Middle East, or North Africa. (Does not include persons ofHispanic/Latino ethnicity.)6. Native Hawaiian or A person having origins in any of the original peoples of Hawaii,Other Pacific Islander Guam, Samoa, or the Pacific Islands. (Does not include personsof Hispanic/Latino ethnicity.)7. Two or more races A person having origins in two or more of the race categorieslisted above. (Does not include persons of Hispanic/Latinoethnicity.)The following examples may be helpful in understanding how the reporting will work:• Example 1: A respondent self-identifies as Hispanic/Latino and as Asian. This respondentis reported only in the Hispanic/Latino category.• Example 2: A respondent self-identifies as Hispanic/Latino and as Asian and Black orAfrican American. This respondent is reported only in the Hispanic/Latino category.• Example 3: A respondent self-identifies as non-Hispanic/Latino and as Native Hawaiianor Other Pacific Islander. This respondent is reported in the Hawaiian Native or OtherPacific Islander category.• Example 4: A respondent self-identifies as non-Hispanic/Latino and as American Indianor Alaska Native and White. This respondent is reported in the two or more racescategory.Documented Vision LossIndicate the code that best describes the individual’s: a) documented degree of vision loss withcorrection, or b) indicates that further testing is needed (this testing must be completed prior tothe next child count submission date for continued inclusion in the census), or c) that the studenthas a documented functional vision loss.Please note: Items 5 and 8 are intentionally not used or available as an option.6
Page 1: Deaf-Blind CensusInstructions, Defi
Page 5: School NameIf child is enrolled in
Page 9 and 10: A Functional Hearing Assessment is
Page 11 and 12: For children who are birth through
Page 13 and 14: For school-aged students (6-21) set
Page 15 and 16: 1. Regular grade-level state assess
Page 17 and 18: 6. Moved, known to be continuing7.
Page 19 and 20: 1. Yes2. UnknownSurvey Page 5 Direc
Page 21: • None• Other• If “Other

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