Register 3-22 Register a child or youth ages 3-22 AZ Deafblind Registry Register a child or youth ages 3-22 Step 1 of 14 7% Referral InformationReferred by Agency PhoneFaxEmail Child InformationName First Last Date of birth MM slash DD slash YYYY Gender Address Street Address City State ZIP RACE/ETHNICITY American Indian or Alaska Native Asian or Pacific Islander Black (not Hispanic) Hispanic White (not Hispanic) CHILD’S RESIDENTIAL/LIVING SETTING Home: Parents Home: Extended Family Home: Foster Parents State Residential Facility Private Residential Facility Group Home (less than 6 residents) Group Home (6 or more residents) Apartment (with non-family person(s)) Pediatric Nursing Home 1st Parent/Guardian Name First Last PhoneAddress Street Address City State ZIP 2nd Parent/Guardian Name First Last PhoneAddress Street Address City State ZIP Primary Language in the home Email IDEA INFORMATION - How the Child is Reported and FundedFunding Category IDEA Part C (Birth –2) C IDEA Part B (3-21) Not reported under Part B or Part C AZEIP Category Code For Part C if child under three years old: (birth through two years old) At Risk Developmentally Delayed Not Reported under Part C Primary Disability Code reported to ADE (AZ Dept. of Ed) for 3 - 22 years oldsCheck one box only unless you are checking BOTH vision and hearing Not Applicable - Child is under 3 years old Mental Retardation Hearing Impairment (includes deafness) Speech or Language Impairment Visual Impairment (includes blindness) Emotional Disturbance Orthopedic Impairment Other Health Impairment Specific Learning Disability Deaf-blindness (combined, co-existing vision and hearing loss) Multiple Disabilities (please check and circle here if MDSSI) Autism Traumatic Brain Injury Developmentally Delayed (optional category for ages 3-9) Non-Categorical Not Reported under Part B of IDEA ADE SAIS Number (if over 3 years of age) PRIMARY IDENTIFIED ETIOLOGY or MAJOR CAUSE OF DEAFBLINDNESSSelect 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 DEGREE OF VISUAL IMPAIRMENT 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.Does the child have a cortical visual impairment? No Yes Unknown Corrective lenses? No Yes Unknown DEGREE OF HEARING IMPAIRMENT 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.Does the child have a central auditory processing disorder? No Yes Unknown Does the child have auditory neuropathy? No Yes Unknown Does the child have a cochlear implant? No Yes Unknown Does the child use assistive listening devices? No Yes Unknown Specify OTHER IMPAIRMENTS OR CONDITIONS (check all that apply) Physical/Ortho Impairment Cognitive Impairment Behavioral Disorder Communication/Speech/Language Impairments Other Specify Does the child use any additional assistive technology? No Yes Unknown CURRENT EDUCATIONAL SETTING (check only the section that applies to the student this year)Birth Through Age 2 1. Home 2. Community-based settings. Third Choice Ages 3 - 5 1. Attending a regular early childhood program at least 80% of the time 2. Attending a regular early childhood program 40% to 79% of the time 3. Attending a regular early childhood program less than 40% of the time 4. Attending a separate class 5. Attending a separate school 6. Attending a residential facility 7. Service provider location 8. Home Ages 6 -21 9. Inside the regular class 80% or more of day 10. Inside the regular class 40% to 79% of day 11. Inside the regular class less than 40% of day 12. Separate school 13. Residential facility 14. Homebound/Hospital 15. Correctional facility 16. Parentally placed in private schools PARTICIPATION IN STATEWIDE ASSESSMENTS in their last statewide assessment 1. Regular grade-level state assessment 4. Alternate assessments based on alternate achievement standards 6. Not yet required (too young) PROGRAM INFORMATIONIf Receiving Early Intervention services:Program Name PhoneName of El Coordinator First Last PhoneEmail Address Street Address Address Line 2 City State ZIP Name of Early Interventionist or PA First Last PhoneEmail Address Street Address Address Line 2 City State ZIP If Receiving Special Education services (3 – 21 yrs old):School District of Residence Special Education Director Address Street Address City State ZIP PhoneFaxEmail Name of School Child Attends School Address Street Address City State ZIP PhoneFaxEmail Classroom Teacher Address Street Address City State ZIP PhoneFaxEmail IF STUDENT RECEIVES SERVICES FROM A TEACHER OF THE VISUALLY IMPAIRED (VI)VI Teacher's Name First Last PhoneFaxEmail Amount of Service Provided(Specify time per day / week / month / quarter) IF STUDENT RECEIVES SERVICES FROM A TEACHER OF THE HEARING IMPAIRED (HI)HI Teacher's Name First Last PhoneFaxEmail Amount of Service Provided(Specify time per day / week / month / quarter) CHECK IF RECEIVING SERVICES THROUGH ONE OF THE ASDB REGIONAL COOPERATIVES Desert Valley Regional Coop Eastern Highland Regional Coop North Central Regional Coop Southeast Regional Coop Southwest Regional Coop Does the student have an intervener? Yes No Interveners Name PhoneEmail STUDENT COUNT CONTACT: (Who does the Deafblind Project contact regarding the annual Student Count?)Student Count Contact Person First Last Position Address Street Address City State ZIP PhoneFaxEmail Records Upload Drop files here or Select files Max. file size: 2 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) 771-5237PhoneThis field is for validation purposes and should be left unchanged.
