8/13/2019 1746 AppKCensus Form

1/3

Complete one for each student

New

Update

No Changes

Delete

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

2/3

/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

3/3

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&