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 byAgencyPhoneFaxEmail Child InformationName First Last Date of birth Date Format: MM slash DD slash YYYY GenderAddress Street Address City State ZIP RACE/ETHNICITYAmerican Indian or Alaska NativeAsian or Pacific IslanderBlack (not Hispanic)HispanicWhite (not Hispanic)CHILD’S RESIDENTIAL/LIVING SETTINGHome: ParentsHome: Extended FamilyHome: Foster ParentsState Residential FacilityPrivate Residential FacilityGroup 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 homeEmail IDEA INFORMATION - How the Child is Reported and FundedFunding CategoryIDEA Part C (Birth –2)C IDEA Part B (3-21)Not reported under Part B or Part CAZEIP Category Code For Part C if child under three years old: (birth through two years old)At RiskDevelopmentally DelayedNot Reported under Part CPrimary 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 Disorders101 Aicardi syndrome102 Alport syndrome103 Alstrom syndrome104 Apert syndrome (Acrocephalosyndactyly, Type 1)105 Bardet-Biedl syndrome (Laurence Moon-Biedl)106 Batten disease107 CHARGE association108 Chromosome 18, Ring 18109 Cockayne syndrome110 Cogan Syndrome111 Cornelia de Lange112 Cri du chat syndrome (Chromosome 5p- syndrome)113 Crigler-Najjar syndrome114 Crouzon syndrome (Craniofacial Dysotosis)115 Dandy Walker syndrome116 Down syndrome (Trisomy 21 syndrome)117 Goldenhar syndrome118 Hand-Schuller-Christian (Histiocytosis X)119 Hallgren syndrome120 Herpes-Zoster (or Hunt)121 Hunter Syndrome (MPS II)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 syndrome130 Marshall syndrome131 Maroteaux-Lamy syndrome (MPS VI)132 Moebius syndrome133 Monosomy 10p134 Morquio syndrome (MPS IV-B)135 NF1 - Neurofibromatosis (von Recklinghausen disease)136 NF2 - Bilateral Acoustic Neurofibromatosis137 Norrie disease138 Optico-Cochleo-Dentate Degeneration139 Pfieffer syndrome140 Prader-Willi141 Pierre-Robin syndrome142 Refsum syndrome143 Scheie syndrome (MPS I-S)144 Smith-Lemli-Opitz (SLO) syndrome145 Stickler syndrome146 Sturge-Weber syndrome147 Treacher Collins syndrome148 Trisomy 13 (Trisomy 13-15, Patau syndrome)149 Trisomy 18 (Edwards syndrome)150 Turner syndrome151 Usher I syndrome152 Usher II syndrome153 Usher III syndrome154 Vogt-Koyanagi-Harada syndrome155 Waardenburg syndrome156 Wildervanck syndrome157 Wolf-Hirschhorn syndrome (Trisomy 4p)Pre-Natal/Congenital Complications201 Congenital Rubella202 Congenital Syphilis203 Congenital Toxoplasmosis204 Cytomegalovirus (CMV)205 Fetal Alcohol syndrome206 Hydrocephaly207 Maternal Drug Use208 Microcephaly209 Neonatal Herpes Simplex (HSV)207 Maternal Drug UsePost-Natal/Non-Congenital Complications301 Asphyxia302 Direct Trauma to the eye and/or ear303 Encephalitis304 Infections305 Meningitis306 Severe Head Injury307 Stroke308 Tumor309 Chemically InducedRelated to Prematurity401 Complications of PrematurityUndiagnosed501 No Determination of Etiology DEGREE OF VISUAL IMPAIRMENT1. 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 Only4. Totally Blind6. Diagnosed Progressive Loss7. Further Testing Needed (may only be used the first year of referral)9. Documented Functional Vision LossDocumented Vision Loss (Primary Classification of Visual Impairment) Note: Lines 5 and 8 are purposely not used.Does the child have a cortical visual impairment?NoYesUnknownCorrective lenses?NoYesUnknown DEGREE OF HEARING IMPAIRMENT1. 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 Loss7. Further Testing Needed (may only be used the first year of referral)9. Documented Functional Hearing LossDocumented Hearing Loss (Primary Classification of Hearing Impairment) Note: Line 8 is purposely not used.Does the child have a central auditory processing disorder?NoYesUnknownDoes the child have auditory neuropathy?NoYesUnknownDoes the child have a cochlear implant?NoYesUnknownDoes the child use assistive listening devices?NoYesUnknownSpecify OTHER IMPAIRMENTS OR CONDITIONS (check all that apply) Physical/Ortho Impairment Cognitive Impairment Behavioral Disorder Communication/Speech/Language Impairments Other SpecifyDoes the child use any additional assistive technology?NoYesUnknown CURRENT EDUCATIONAL SETTING (check only the section that applies to the student this year)Birth Through Age 21. Home2. Community-based settings.Third ChoiceAges 3 - 51. Attending a regular early childhood program at least 80% of the time2. Attending a regular early childhood program 40% to 79% of the time3. Attending a regular early childhood program less than 40% of the time4. Attending a separate class5. Attending a separate school6. Attending a residential facility7. Service provider location8. HomeAges 6 -219. Inside the regular class 80% or more of day10. Inside the regular class 40% to 79% of day11. Inside the regular class less than 40% of day12. Separate school13. Residential facility14. Homebound/Hospital15. Correctional facility16. Parentally placed in private schoolsPARTICIPATION IN STATEWIDE ASSESSMENTS in their last statewide assessment1. Regular grade-level state assessment4. Alternate assessments based on alternate achievement standards6. Not yet required (too young) PROGRAM INFORMATIONIf Receiving Early Intervention services:Program NamePhoneName 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 ResidenceSpecial Education DirectorAddress Street Address City State ZIP PhoneFaxEmail Name of School Child AttendsSchool Address Street Address City State ZIP PhoneFaxEmail Classroom TeacherAddress 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 COOPERATIVESDesert Valley Regional CoopEastern Highland Regional CoopNorth Central Regional CoopSoutheast Regional CoopSouthwest Regional CoopDoes the student have an intervener?YesNoInterveners NamePhoneEmail STUDENT COUNT CONTACT: (Who does the Deafblind Project contact regarding the annual Student Count?)Student Count Contact Person First Last PositionAddress Street Address City State ZIP PhoneFaxEmail Records Upload Drop files here or 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) 771-5237EmailThis field is for validation purposes and should be left unchanged.
