Post on 04-Jun-2018
8/13/2019 1746 AppKCensus Form
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Complete one for each student
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RACE/ETHNICITY
American Indian or Alaska Native
Asian or Pacific Islander
Black or African American (notHispanic
Hispanic or !atino
"hite (not Hispanic
#ther$ %pecif&
INSTRUCTIONAL STATUS INFORMATION
Continues in %pecial 'ducation & No !onger on Census %pecif& reason) ***********************************
No !onger +eceives %pecial 'ducation %pecif& reason) ***********************************
,raduated & Completing all +egular 'ducation +e-uirements (./
,raduated & Completing I'P +e-uirements$ Including Credit +e-uirements (.0$ (.1$ (.2
,raduated & Completing I'P +e-uirements and & +eaching 3a4imum Age for Part B %ervices (.5
+eached 3a4imum Age for Part B %ervices "ithout 3eeting I'P #6ectives
3oved$ in %tate to *******************
3oved$ #ut of %tate to ******************
Deceased
Dropped #ut
PARENTAL CONSENT No 7esParent Phone Numer ********************
8he district has otained specific consent from the parents9guardians of the student for the 8e4as 'ducation Agenc& and its contractors responsile forthe 8e4as Deaflind Census to release personall& identifiale education and statistical data from the annual census to specific agencies: 8his Consentmust e documented in the district on the 3arch ;..; 8'A Crigler?Na66ar s&ndrome//0 Crouon s&ndrome = (Craniofacia
D&sotosis//1 Dand& "alker s&ndrome//2 Down s&ndrome (8risom& ;/
s&ndrome//5 ,oldenhar s&ndrome//@ Hand?%chuller?Christian (Histioc&tosis // Hallgren s&ndrome/;.Herpes oster (or Hunt/;/ Hunter s&ndrome (3P% II/;; Hurler s&ndrome (3P% I?H/;> Eearns?%a&re s&ndrome/;0 Elippel? %cheie s&ndrome (3P% I?%/00 %mith?!emli?#pit (%!# s&ndrome/01 %tickler s&ndrome/02 %turge?"eer s&ndrome/05 8reacher Collins s&ndrome/0@ 8risom& /> (8risom&/>?/1$ Patau
s&ndrome/0 8risom& /@ ('dwards s&ndrome/1. 8urner s&ndrome/1/ Usher I s&ndrome/1; Usher II s&ndrome/1> Usher III s&ndrome/10 Fogt?Eo&anagi?Harada s&ndrome/11 "aardenurg s&ndrome/12 "ildervanck s&ndrome
Texas Deafblind Census !!"!!#
*************** **************!ast Name
8/13/2019 1746 AppKCensus Form
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/15 "olf?Hirschhorn s&ndrome (8risom& 0p/ #ther *************************
P(e"Na%al/C&n+eni%alC&$,li-a%i&ns;./ Congenital +uella;.; Congenital %&philis;.> Congenital 8o4oplasmosis;.0 C&tomegalovirus (C3F;.2 H&drocephal&;.@ 3icrocephal&;.Neonatal Herpes %imple4 (H%F
; #ther ****************** (indicate the numeric code in the o4
aove and specif& in this space
P&s%"Na%al/N&n"C&n+eni%alC&$,li-a%i&ns>./ Asph&4ia>.; Direct 8rauma to the e&e and9or ear>.> 'ncephalitis>.0 Infections>.1 3eningitis>.2 %evere Head In6ur&
>.5 %troke
>.@ 8umors>.Chemicall& Induced> #ther ******************
(Indicate the numeric code in the o4aove and specif& in this space
Rela%ed %& P(e$a%u(i%*0./ Complications of Prematurit&
Undia+n&sed1./ No Determination of 'tiolog&
Page /
.ISUAL IMPAIRMENT
Date of !ast #phthalmological9#ptometrical '4am
Date of !ast
8/13/2019 1746 AppKCensus Form
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Pa(% ' Ca%e+&(* C&de as (e,&(%ed in %)e De-e$be( 2 -&un% Select Only One01
Autism
Deaflind
Developmentall& Dela&ed
'motionall& Distured
Hearing Impaired (includes deafness
3ental +etardation
3ulti?disaled
Non?Categoricall&