CHILD COUNT 2023- DUE Friday, March 22, 2024

Student Information
CHILD COUNT Kansas DB Project (December 2, 2022 to December 1, 2023). Please answer all relevant questions.

Due by Friday, March 22, 2024

Questions?
Joy Gabel - cgabel@kssdb.org
Student's Name*

First NameLast Name
Student's Date of Birth*

MonthDayYear
Date
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Mother/Guardian's Name *

First NameLast Name
Mom's Phone Number

Area CodePhone Number
Mother's Email
example@example.com
Father/Guardian's Name

First NameLast Name
Father's Phone Number

Area CodePhone Number
Father's Email
example@example.com
School/District Information
Student's School Name*
School address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School district or CO-OP Name*
USD Number
School Contact Person*

First NameLast Name
School contact person title/position*
School contact person email*
example@example.com
Name of TSVI (Teacher of Students with Visual Impairment). Write none, if there is no TSVI.
Name of TOD/HH (Teacher of the Deaf/Hard of Hearing). Write none, if there is no TOD/HH
DB Project Status in Dec 2, 2022- Dec 1, 2023*

0. Eligible to receive services from the DB Project:1. No longer eligible to receive services from the DB Project
Student's Medical Background/Information
GENDER*

0 - Male1 - Female2 - Other
Ethnicity*

0 - Not Hispanic1 - Hispanic/Latino
Race*

1 - American Indian or Alaska Native2. Asian3. Black or African American5. White6. Native Hawaiian/Pacific Islander7. Two or more races999 - Unknown/Missing
Living Setting: Please select setting that best describes where the student resides the majority of the year.*

1- Home: Parents2- Home: Extended family3- Home: Foster parents4- State Residential Facility5- Private Residential Facility9- Pediatric Nursing Home10- Community Resident (includes group home/supported apartment)555 - Other999 - Unknown/missing
Primary Language in the Home*

1 - English2 - Spanish3 - ASL999 - Unknown/MissingOther
PRIMARY IDENTIFIED ETIOLOGY: Hereditary/Chromosomal Syndromes and Disorders*

101 Aicardi syndrome102 Alport syndrome103 Alstrom syndrome104 Apert syndrome (Acrocephalosyndactyly, Type 1)105 Bardet-Biedl syndrome (Laurence Moon-Biedl)106 Batten disease107 CHARGE Syndrome108 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 syndrome152 Usher II syndrome153 Usher III syndrome154 Vogt-Koyanagi-Harada syndrome155 Waardenburg syndrome156 Wildervanck syndrome157 Wolf-Hirschhorn syndrome (Trisomy 4p)N/AOther
Pre-Natal/Congenital Complications*

201 Congenital Rubella202 Congenital Syphilis203 Congenital Toxoplasmosis204 Cytomegalovirus (CMV)205 Fetal Alcohol syndrome206 Hydrocephaly207 Maternal Drug Use208 Microcephaly209 Neonatal Herpes Simplex (HSV)299 OtherN/AOther
Post-Natal/Non-Congenital Complications*

301 Asphyxia302 Direct Trauma to the eye and/or ear303 Encephalitis304 Infections305 Meningitis306 Severe Head Injury307 Stroke308 Tumors309 Chemically Induced399 OtherN/AOther
Related to Prematurity*

401 Complications of PrematurityN/A
Undiagnosed*

501 No Determination of EtiologyN/A
Documented Vision Loss (Items 5 and 8 are intentionally not used and they are unavailable as an option)*

1. Low Vision2. Legally Blind3. Light Perception Only4. Totally Blind6. Diagnosed Progressive Loss7. Further Testing Needed (1 year only)9. Documented Functional Vision Loss
Cortical Vision Impairment*

0. No1. Yes2. Unknown
Corrective Lenses*

0 - No1 - Yes2 - Unknown
Documented Hearing Loss (Item 8 is intentionally not used and it is unavailable as an option)*

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 Loss7. Further Testing Needed (1 year only)9. Documented Functional Hearing Loss
(CAPD) Central Auditory Processing Disorder*

0. No1. Yes2. Unknown
Auditory Neuropathy*

0. No1. Yes2. Unknown
Cochlear Implant*

0. No1. Yes2. Unknown
Assistive Listening Device*

0 - No1 - Yes2 - Unknown
Other: Orthopedic/Physical Impairments*

0. No1. Yes2. Unknown
Other: Intellectual/Cognitive Disabilities*

0. No1. Yes2. Unknown
Other: Emotional/Behavioral Disorders*

0. No1. Yes2. Unknown
Other Health Impairment/Complex Health Care Needs*

0. No1. Yes2. Unknown
Other - Communication, Speech/Language Impairments*

0. No1. Yes2 - Unknown
Other Impairments or Conditions*

0. No1. Yes2. Unknown
Additional Assistive Technology*

0. No1. Yes2. Unknown
Intervener*

0. No1. Yes2. Unknown777. Not Applicable
IDEA Services*

1. IDEA Part C2. IDEA Part B3. Not reported under Part B or C4. 504 Plan
PART C CATEGORY CODE (birth through 36 months of age)
Part C Category Code

1. At-risk for developmental delays (as defined by the state's Part C Lead Agency)2. Developmentally Delayed777. Not Reported Under Part C of IDEA
Early Intervention Part C Setting

1. Home2. Community-based settings3. Other Settings777. Not applicable/Not served under Part C of IDEA
Part C Exiting

0. Not exited - In a Part C early intervention program1. Completion of IFSP prior to reaching maximum age for Part C2. Eligible for IDEA, Part B3. Not eligible for Part B, exit with referrals to other programs4. Not eligible for Part B, exit with no referrals5. Part B eligibility not determined6. Deceased7. Moved out of state8. Withdrawal by parent (or guardian)9. Attempts to contact the parent and/or child were unsuccessful777. Not Applicable888 Not Part COther
PART B CATEGORY CODE (school-aged children (3 through 21 years of age)

Required if IDEA Part B is selected.
Part B Disability

1. Intellectual Disability2. Hearing Impairment (includes deafness)3. Speech or Language Impairment4.Visual Impairment (includes blindness)5. Emotional Disturbance6. Orthopedic Impairment7. Other Health Impairment8. Specific Learning Disability9. Deaf-blindness10. Multiple Disabilities11. Autism12. Traumatic Brain Injury13. Developmentally Delayed-age 3 through 9 Also included for Child Count reporting purposes are14. Non-Categorical888. Not Reported under Part B of IDEA
PART B Educational Environment (school-aged children (3 through 21 years of age)

Each question is required below if IDEA Part B is selected.
Ages 3-5

301 - Services in Regular Early Childhood Program (10+ hours)302 - Other location regular early childhood program (10+ hours)303 - Services in regular early childhood program (304 - Other Location Regular Early Childhood Program (305 - Attending a separate class306 - Attending a separate school307 - Attending a residential facility309 - Home, at public expense310 - Home, not a public expense888 - N/A Not served under Part B999 - Unknown/Missing
Ages 6 - 21

610 - Inside the regular class 80% or more of day611 - Inside the regular class 40% to 79% of day612 - Inside the regular class less than 40% of the day613 - Separate school614 - Residential facility615 - Homebound/Hospital616 - Correctional facilities617 - Parentally placed in private schools620 - Home school/remote learning, at public expense621 - Home school/remote learning, NOT at public expense888 - N/A Not served under Part B999 - Unknown or missing
Participation in statewide assessment

1. Regular grade-level state assessment2. Regular grade-level state assessment with accommodations3. Alternate asssessments6. Not required at age or grade level7. Parent opt out
Part B Exiting (School-aged children 3 through 21 years old)

0. In special education program1. Transferred to regular education2. Graduated with regular high school diploma22. Graduated with alternate diploma3. Received a certificate4. Reached maximum age5. Died6. Moved, known to be continuing8. Dropped out888. N/A Not served by Part B
Thank you for completing the census. Please keep a copy for your reference.

If you have any questions, please contact:

Joy Gabel

cgabel@kssdb.org
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