CENSUS 2021

2020 Kansas DB Project Census

Due by April 9, 2021

Questions? Email Erin Kelly - ekelly@kssdb.org
Please verify that you are human *
Student Information
Student's Name *

First Name Last Name
Student's Date of Birth *

Month Day Year
Date
Home Address *

Street Address

Street Address Line 2

City State / Province

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

First Name Last Name
Mom's Phone Number *

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

First Name Last Name
Father's Phone Number

Area Code Phone Number
Father's Email
example@example.com
Primary language spoken at home: *
School/District Information
Student's School Name *
School address *

Street Address

Street Address Line 2

City State / Province

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

First Name Last 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 2020 *

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 - Male 1 - Female 2 - Other
Ethnicity *

0 - Not Hispanic 1 - Hispanic/Latino
Race *

1 - American Indian or Alaska Native 2. Asian 3. Black or African American 5. White 6. Native Hawaiian/Pacific Islander 7. Two or more races 999 - Unknown/Missing
Living Setting: Please select setting that best describes where the student resides the majority of the year. *

1- Home: Parents 2- Home: Extended family 3- Home: Foster parents 4- State Residential Facility 5- Private Residential Facility 9- Pediatric Nursing Home 10- Community Resident (includes group home/supported apartment) 555 - Other 999 - Unknown/missing
Primary Language in the Home *

1 - English 2 - Spanish 3 - ASL 9 - Other 999 - Unknown/Missing
PRIMARY IDENTIFIED ETIOLOGY: Hereditary/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 Syndrome 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 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) N/A
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) 299 Other N/A
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 Tumors 309 Chemically Induced 399 Other N/A
Related to Prematurity *

401 Complications of Prematurity N/A
Undiagnosed *

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

1. Low Vision 2. Legally Blind 3. Light Perception Only 4. Totally Blind 6. Diagnosed Progressive Loss 7. Further Testing Needed (1 year only) 9. Documented Functional Vision Loss
Cortical Vision Impairment *

0. No 1. Yes 2. Unknown
Corrective Lenses *

0 - No 1 - Yes 2 - 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 Loss 7. Further Testing Needed (1 year only) 9. Documented Functional Hearing Loss
(CAPD) Central Auditory Processing Disorder *

0. No 1. Yes 2. Unknown
Auditory Neuropathy *

0. No 1. Yes 2. Unknown
Cochlear Implant *

0. No 1. Yes 2. Unknown
Assistive Listening Device *

0 - No 1 - Yes 2 - Unknown
Other: Orthopedic/Physical Impairments *

0. No 1. Yes 2. Unknown
Other: Intellectual/Cognitive Disabilities *

0. No 1. Yes 2. Unknown
Other: Emotional/Behavioral Disorders *

0. No 1. Yes 2. Unknown
Other Health Impairment/Complex Health Care Needs *

0. No 1. Yes 2. Unknown
Other - Communication, Speech/Language Impairments *

0. No 1. Yes 2 - Unknown
Other Impairments or Conditions *

0. No 1. Yes 2. Unknown
Additional Assistive Technology *

0. No 1. Yes 2. Unknown
Intervener *

0. No 1. Yes 2. Unknown 888. Not Applicable
IDEA Services *

1. IDEA Part C 2. IDEA Part B 3. Not reported under Part B or C 4. 504 Plan
PART C CATEGORY CODE
Part C Category Code

1. At-risk for developmental delays (as defined by the state's Part C Lead Agency) 2. Developmentally Delayed 888. Not Reported Under Part C of IDEA
Early Intervention Part C Setting

1. Home 2. Community-based settings 3. Other Settings 888. Not applicable/Not served under Part C of IDEA
Part C Exiting

0. Not exited - In a Part C early intervention program 1. Completion of IFSP prior to reaching maximum age for Part C 2. Eligible for IDEA, Part B 3. Not eligible for Part B, exit with referrals to other programs 4. Not eligible for Part B, exit with no referrals 5. Part B eligibility not determined 6. Deceased 7. Moved out of state 8. Withdrawal by parent (or guardian) 9. Attempts to contact the parent and/or child were unsuccessful 888. NA Not Part C
PART B CATEGORY CODE
Part B Disability

1. Intellectual Disability 2. Hearing Impairment (includes deafness) 3. Speech or Language Impairment 4.Visual Impairment (includes blindness) 5. Emotional Disturbance 6. Orthopedic Impairment 7. Other Health Impairment 8. Specific Learning Disability 9. Deaf-blindness 10. Multiple Disabilities 11. Autism 12. Traumatic Brain Injury 13. Developmentally Delayed-age 3 through 9 Also included for Child Count reporting purposes are 14. Non-Categorical 888. Not Reported under Part B of IDEA
PART B Educational Environment
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 class 306 - Attending a separate school 307 - Attending a residential facility 309 - Home, at public expense 310 - Home, not a public expense 888 - N/A Not served under Part B 999 - Unknown/Missing
Ages 6 - 21

610 - Inside the regular class 80% or more of day 611 - Inside the regular class 40% to 79% of day 612 - Inside the regular class less than 40% of the day 613 - Separate school 614 - Residential facility 615 - Homebound/Hospital 616 - Correctional facilities 617 - Parentally placed in private schools 620 - Home school/remote learning, at public expense 621 - Home school/remote learning, NOT at public expense 888 - N/A Not served under Part B 999 - Unknown or missing
Participation in statewide assessment

1. Regular grade-level state assessment 2. Regular grade-level state assessment with accommodations 3. Alternate asssessments 6. Not required at age or grade level 7. Parent opt out 19. Not required to be reported by state
Part B Exiting

0. In special education program 1. Transferred to regular education 2. Graduated with regular high school diploma 22. Graduated with alternate diploma 3. Received a certificate 4. Reached maximum age 5. Died 6. Moved, known to be continuing 8. Dropped out 888. N/A Not served by Part B
Thank you for completing the census. Please keep a copy for your record. You may send it electronically or print this document and send it by mail.

If you have any questions, please contact:

Erin Kelly

ekelly@kssdb.org

913-305-3061

Mailing address:

Kansas State School for the Blind

1100 State Ave., Kansas City, KS 66102
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