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Montana DeafBlind Census Tips:

Before starting the survey, have the student’s most recent IEP and copy of last year’s census form (if applicable) close at hand. These will help you answer some of the questions.
After completing the census, you will receive an email containing the completed census. Please print a copy and retain it for your records. (This will help you in completing next year's form.)
If you need to stop part-way through the online survey, in most cases you will be able to return to it. If, however, your browser is set to automatically delete cookies, your progress will be lost.
Remember that the census is a "snapshot in time" based on what services looked like for this student on December 1, 2024.

Thank you for your assistance in identifying Montana children with dual sensory impairments!

Child’s ID Code

(4-digit UPPER CASE code, first 2 characters of the first and last names. For Hyphenated names use the first 2 characters of the first of the last names John Dodge-Smith =JODO )

Child Number

(This number remains the same over time. Children are assigned a number by the Montana DeafBlind Project upon being added to the census.)

DeafBlind Project Exiting Status

0 Eligible to receive services from DB project, regardless of their part C or part B status
1 No Longer eligible to receive services from DB Project

Gender

0 Male
1 Female
2 Other

Date of Birth: Month (mm)

Date of Birth: Day (dd)

Date of Birth: Year (yyyy)

Ethnicity

0 Not Hispanic
1 Hispanic / Latino

Race

1 American Indian or Alaskan Native
2 Asian
3 Black or African American
5 White
6 Native Hawaiian / Other Pacific Islander
7 Two or more races
999 Other or missing

Living Setting

1 Home: With Parents
2 Home: Extended Family
3 Home: Foster Parents
4 State Residential Facility
5 Private Residential Facility
9 Pediatric Nursing Home
10 Community Residence (includes group home/ supported apartment)
555 Other
999 Unknown/ missing

If you have chosen 'Other' for the Primary Language, please Specify:

Primary Identified Etiology (Indicate ONE etiology; choose the etiology that impacts deaf-blindness the most)

Hereditary/Chromosomal Syndromes and Disorders use options 101-199;
Pre-Natal/Congenital Complication use options 201-299;
Post-Natal/Non-Congenital Complication use options 301-399;
Related to Permaturity use option 401;
Undiagnosed use option 501

If you have chosen 'Other' for the Primary Identified Etiology, please explain:

Vision: Documented Vision Loss

(A Functional Vision Assessment is defined as: " a non-clinical assessment carried out by a trained vision specialist using commonly accepted assessment tools, checklists and measures for making educated judgements about the functional use of vision"

1 Low Vision (20/70-20/200)
2 Legally Blind (20/200 or less; field restriction 20E)
3 Light Perception Only
4 Totally Blind
6 Diagnosed Progressive Loss
7 Further Testing Needed (This option can only be used once. An assessment should be completed before the next census.)
9 Documented Functional Vision Loss

Vision: Cortical Vision Impairment?

0 No
1 Yes
2 Unknown

Vision: Corrective Lenses?

0 No
1 Yes
2 Unknown

Hearing: Documented Hearing Loss

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 (This option can only be used once. An assessment should be completed before the next census.)
9 Documented Functional Hearing Loss

Hearing: Central Auditory Processing Disorder

0 No
1 Yes
2 Unknown

Hearing: Auditory Neuropathy

0 No
1 Yes
2 Unknown

Hearing: Cochlear Implants

0 No
1 Yes
2 Unknown

Hearing: Assistive Listening Device

0 No
1 Yes
2 Unknown

Other Impairments: Orthopedic/ Physical

0 No
1 Yes
2 Unknown

Other Impairments: Intellectual/ Cognitive

0 No
1 Yes
2 Unknown

Other Impairments: Emotional/ Behavioral

0 No
1 Yes
2 Unknown

Other Impairments: Other Health Care Impairment/ Complex Health Care Needs

0 No
1 Yes
2 Unknown

Other Impairments: Communication/Speech/Language Impairments

0 No
1 Yes
2 Unknown

Other Impairments: Other (i.e., something that should be considered for planning purposes)

0 No
1 Yes
2 Unknown

If you have chosen 'Yes' for Other Impairments, please explain:

Educational Supports: Additional Assistive Technology

0 No
1 Yes
2 Unknown

Educational Supports: Intervener Services

0 No
1 Yes
2 Unknown
777 Not Applicable

Services: IDEA Services

1 IDEA Part C
2 IDEA Part B
3 Not reported under Part B or C
4 504 Plan

Services: Part C Category

(Only answer for children who are birth-age 2 at the time of reporting; Dec. 1, 2024)

1 At-Risk for developmental delays as defined by Part C
2 Developmentally Delayed
888 not reported under Part C of IDEA

Services: Early Intervention Part C Setting (Birth-2)

(Only answer for children who are birth-age 2 at the time of reporting; Dec. 1, 2024)

1 Home
2 Community-based settings (alongside students without disabilities)
3 Other Settings (specialized class, clinic, not community-based)
888 Not Applicable/ Not served under Part C

Services: Participation in Statewide Assessments

1 Regular grade-level state assessment
2 Regular grade-level state assessment with accommodations
3 Alternate assessments
6 Not required at age or grade level
7 Parent Opt Out

Name of Individual Completing Form

Email of Individual Completing Form (a copy of the survey will be sent to this email address)

Date Completed

Contact Person's Name

Contact Person's Email

Contact Person's Phone Number

Community in which Child Resides