We want to know more about your and your family. We are particularly interested in your experiences with the education of your blind or visually impaired child in Utah, and are seeking to address concerns in this area. Please list any specific concerns you have related to your child’s education. We are also very interested in hearing about positive elements that have supported your child’s educational success.
Please cut and paste this survey in word format, complete, save and send to palmermommy@comcast.net
I am looking forward to hearing from you soon!
Marla Palmer
President, Utah Parents of Blind Children of Utah
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Utah Parents of Blind Children
Family/Child Needs Survey
Family/Child Needs Survey
Parent Name (s)/Address/Phone/E-mail:
____________________________________________________________________________________________________________________________________________________________
Child(ren) Name (s)/Age/Grade/Type and Degree of Vision Loss
____________________________________________________________________________________________________________________________________________________________
My child is educated in (check one)
___ our local public school
___ a private school
___ home schooled
___ USDB
___ other (please specify):___________________________
My child has (check one)
My child has (check one)
___ An IEP
___ an IFSP
___ a 504 plan
___ Not Sure
___ No individualized plan
My child reads (check all that apply)
My child reads (check all that apply)
___ regular print
___ large print
___ Braille
___ does not read
What’s Working Well?
Please rate the statements as follows: 1= working well; 2= working ok; 3= moderate problem; 4=serious problem or NA=not applicable
Please rate the statements as follows: 1= working well; 2= working ok; 3= moderate problem; 4=serious problem or NA=not applicable
RATING
____ My child receives the educational support services he/she needs to attain and maintain age and grade appropriate skills.
____ My child reads well in print, Braille, or both.
____ My child receives travel training (O & M) that allows him/her to travel safely and efficiently in home, school, and community.
____ I have good knowledge of the wide varieties of assistive technology available to assist my visually impaired/blind child with school work.
____ My child has access at home and at school to a variety of assistive technology devices to aide learning.
____ My child’s Braille or large print textbooks are provided at the same time as the rest of the class.
____ My child has received good individualized evaluations that have helped develop good educational support plans.
____ My child has additional disabilities that have been identified and are being addressed in a good educational support plan.
Parent/Child/Family Interests
Please rate the statements as follows: 1= strong interest; 2= moderate interest; 3= mild interest; 4= no interest
RATING
____ I would like opportunities for social activities with other UPOBC families.
____ I would like to have more opportunities for my child and family to meet and interact with blind adults.
____ I would like more opportunities for social and recreational activities for my child.
____ I would like more opportunities for educational and life skills development activities for my child.
____ I would like to receive written materials on child development and education issues.
____ I am interested in college scholarship opportunities for my child.
____ I would like more parent training opportunities.
____ I would like a parent advocate to discuss my child’s educational program with me and possibly attend school meetings such as IEP.
Utah Parents of Blind Children typically honors an educator in Utah on an annual basis for outstanding service to blind and visually impaired students. Do you know someone we should consider? Yes No
If yes, who:________________________________
May we include you on our mailing list? Yes No
Feel free to add any additional statements, information, or suggestions survey that will help us better understand the needs of your blind/visually impaired child and related family issues.
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