AZDB Project Referral Form AZ Deafblind Registry Register a child or youth ages 0-22 Step 1 of 9 11% Person Making ReferralName First Last Email Your Role(parent/EI provider/teacher) Student InformationName First Last Gender Male Female Date of birth MM slash DD slash YYYY Address Street Address City State ZIP 1st Parent/Guardian Name First Last PhoneEmail Address Street Address City State ZIP 2nd Parent/Guardian Name First Last PhoneEmail Address Street Address City State ZIP School InformationHome District Home School Home County School of Attendance Child Receives Services From ASDB FBC District Ethnicity Not Hispanic Hispanic Race American Indian or Alaska Native Asian Black White Native Hawaiian/Pacific Islander Two or more races Unknown/Missing Living Setting Home:Parents Home:Extended Family Home: Foster Parents State Residential Facility Private Residential Facility Pediatric Nursing Home Community Residence (includes group home/supported apartment) Unknown/Missing Primary Language in Home English Spanish ASL Unknown/Missing ETIOLOGY (Hereditary/Chromosomal Syndromes and Disorders)Select one from the list belowHereditary/Chromosomal Syndromes and Disorders 101 Aicardi syndrome 102 Alport syndrome 103 Alstrom syndrome 104 Apert syndrome (Acrocephalosyndactyly, Type 1) 105 Bardet-Biedl syndrome (Laurence Moon-Biedl) 106 Batten disease 107 CHARGE association 108 Chromosome 18, Ring 18 109 Cockayne syndrome 110 Cogan Syndrome 111 Cornelia de Lange 112 Cri du chat syndrome (Chromosome 5p- syndrome) 113 Crigler-Najjar syndrome 114 Crouzon syndrome (Craniofacial Dysotosis) 115 Dandy Walker syndrome 116 Down syndrome (Trisomy 21 syndrome) 117 Goldenhar syndrome 118 Hand-Schuller-Christian (Histiocytosis X) 119 Hallgren syndrome 120 Herpes-Zoster (or Hunt) 121 Hunter Syndrome (MPS II) 122 Hurler syndrome (MPS I-H) 123 Kearns-Sayre syndrome 124 Klippel-Feil sequence 125 Klippel-Trenaunay-Weber syndrome 126 Kniest Dysplasia 127 Leber congenital amaurosis 128 Leigh Disease 129 Marfan syndrome 130 Marshall syndrome 131 Maroteaux-Lamy syndrome (MPS VI) 132 Moebius syndrome 133 Monosomy 10p 134 Morquio syndrome (MPS IV-B) 135 NF1 – Neurofibromatosis (von Recklinghausen disease) 136 NF2 – Bilateral Acoustic Neurofibromatosis 137 Norrie disease 138 Optico-Cochleo-Dentate Degeneration 139 Pfieffer syndrome 140 Prader-Willi 141 Pierre-Robin syndrome 142 Refsum syndrome 143 Scheie syndrome (MPS I-S) 144 Smith-Lemli-Opitz (SLO) syndrome 145 Stickler syndrome 146 Sturge-Weber syndrome 147 Treacher Collins syndrome 148 Trisomy 13 (Trisomy 13-15, Patau syndrome) 149 Trisomy 18 (Edwards syndrome) 150 Turner syndrome 151 Usher I syndrome 152 Usher II syndrome 153 Usher III syndrome 154 Vogt-Koyanagi-Harada syndrome 155 Waardenburg syndrome 156 Wildervanck syndrome 157 Wolf-Hirschhorn syndrome (Trisomy 4p) Pre-Natal/Congenital Complications 201 Congenital Rubella 202 Congenital Syphilis 203 Congenital Toxoplasmosis 204 Cytomegalovirus (CMV) 205 Fetal Alcohol syndrome 206 Hydrocephaly 207 Maternal Drug Use 208 Microcephaly 209 Neonatal Herpes Simplex (HSV) 207 Maternal Drug Use Post-Natal/Non-Congenital Complications 301 Asphyxia 302 Direct Trauma to the eye and/or ear 303 Encephalitis 304 Infections 305 Meningitis 306 Severe Head Injury 307 Stroke 308 Tumor 309 Chemically Induced Related to Prematurity 401 Complications of Prematurity Undiagnosed 501 No Determination of Etiology Documented Vision Loss 1. Low Vision (Visual acuity of 20/70 to 20/200 in the better eye with correction.) 2. Legally Blind (Visual acuity of 20/200 or less or field restriction of 20 degrees or less in the better eye with correction.) 3. Light Perception Only 4. Totally Blind 6. Diagnosed Progressive Loss 7. Further Testing Needed (may only be used the first year of referral) 9. Documented Functional Vision Loss Documented Vision Loss (Primary Classification of Visual Impairment) Note: Lines 5 and 8 are purposely not used.Cortical Visual Impairment No Yes Unknown Corrective lenses? No Yes Unknown Documented Hearing Loss 1. Mild (26-40 dB loss) 2. Moderate (41-55 dB loss) 3. Moderately Severe (56-70 dB loss) 4. Severe (71-90 dB loss) 5. Profound (91+ dB loss) 6. Diagnosed Progressive Loss 7. Further Testing Needed (may only be used the first year of referral) 9. Documented Functional Hearing Loss Documented Hearing Loss (Primary Classification of Hearing Impairment) Note: Line 8 is purposely not used.Central Auditory Processing Disorder No Yes Unknown Auditory Neuropathy No Yes Unknown Cochlear Implants No Yes Unknown Assistive Listening Device No Yes Unknown Orthopedic or Physical Impairment No Yes Unknown Cognitive Impairment No Yes Unknown Behavior Disorder No Yes Unknown Complex Health Care Needs No Yes Unknown Communication/Speech Language Impairment No Yes Unknown Other No Yes Unknown Other No Yes Unknown Additional Assistive Technology No Yes Unknown Intervener Services No Yes (from an individual with the title and function of an intervener OR from an individual with a function of an intervener working under a different title) Unknown Not Applicable IDEA Services IDEA Part C (0-3) IDEA Part B (3-21) Not reported under Part B or C 504 Plan Part C Category Code At risk for developmental delays Developmentally delayed Not reported under Part C of IDEA Early Intervention Part C Setting Home Community-based settings Other Settings N/A Not served under Part C of IDEA Part C Exiting Status Not exited – In a Part C Early Intervention Program Completion of IFSP prior to reaching maximum age for Part C Eligible for IDEA, Part B Not eligible for Part B, exit with referrals to other programs Not eligible for Part B, exit with no referrals Part B eligibility not determined Deceased Moved out of state Withdrawal by parent (or guardian) Attempts to contact the parent and/or child were unsuccessful N/A Not served under Part C Part B Disability Code Intellectual Disability Hearing Impairment (includes Deafness) Speech or Language Impairment Visual Impairment (included blindness) Emotional Disturbance Orthopedic Impairment Other Health Impairment Specific Learning Disability Deaf-blindness Multiple Disabilities Autism Traumatic Brain Injury Developmentally Delayed – allowed for only ages 3-9 when defined by the state Non-categorical Not Reported under Part B of IDEA CURRENT EDUCATIONAL SETTING (check only the section that applies to the student this year)Ages 3-5 Early Childhood Education Environment Services in Regular Early Childhood Program (10+ hours) Other Location Regular Early Childhood Program (10+ hours) Services in Regular Early Childhood Program (<10 hours) Other Location Regular Early Childhood Program (<10 hours) Separate Class Separate School Residential Facility Home, at public expense Home, NOT at public expense N/A Not Served Under Part B Ages 6-21 (School-Aged) Educational Environment Inside regular class 80% or more of the day Inside regular class 40% through 79% of the day Inside regular class less than 40% of the day Separate School Residential Facility Homebound/Hospital Correctional Facilities Parentally placed in private school Home School/Remote Learning, at public expense* Home School/Remote Learning, NOT at public expense N/A Not Served under Part B Participation in Statewide Assessments Regular grade-level state assessment Regular grade-level state assessment with accommodations Alternate assessment Not required at age or grade level Parent Opt Out Not required to be reported by state Part B Exiting Status Not Exited – In special education program Exited Part B – Transferred to regular education Exited Part B – Graduated with regular high school diploma Exited Part B – Graduated with an alternate diploma Exited Part B – Received a certificate Exited Part B – Reached maximum age Exited Part B – Died Not Exited – Moved, known to be continuing Exited Part B – Dropped out Records Upload Drop files here or Select files Max. file size: 400 MB. Note: Vision records include ophthalmological and functional vision assessments. Hearing records include audiograms, audiological records, and functional hearing assessmentsFor questions in the Tucson area or around the state, please call (520) 770-3268 For questions in the Phoenix area only, call (602) 771-5237CommentsThis field is for validation purposes and should be left unchanged.
