Special Education Programs and Related Services

KINDERGARTEN

school
ELEMENTARY
W4

Pre

school
W4

Section D:
SPECIAL EDUCATION PROGRAMS AND RELATED SERVICES

PE E S
L

grow

Pre-Elementary Education Longitudinal Study

Section D:

Early Childhood Teacher
Questionnaire

SPECIAL EDUCATION PROGRAMS AND RELATED SERVICES
REMINDER: “This child” refers to the child whose name appears on the label.

D1. What are this child’s disabilities?
PLEASE
PLEASE

Your school district is participating in an important U.S. Department of Education study called
the Pre-Elementary Education Longitudinal Study (PEELS). The child named on the label is one
of more than 3,000 children nationwide who are taking part in PEELS. This questionnaire is
the only source of information about this child’s special education and related services.
Because of this, your participation is vitally important.
Please complete Section D of this questionnaire and return it in the self-mailer within 3 weeks.
To use the self-mailer, simply fold the questionnaire in half, affix the seal to secure it, and drop
it in your mailbox. Be assured that your answers will be confidential, and no information will
be reported that identifies you, this child, or this school.
In completing this questionnaire, you may need to refer to the child’s most recent
Individualized Education Program (IEP). If you have any questions about the study or the
questionnaire, please feel free to call the PEELS toll-free hot line at 1-888-534-8348, send
an email to questions@peels.org, or visit the PEELS web site at www.peels.org.
Thank you in advance for your contribution to this very important study.

Sincerely,

Elaine Carlson
Project Director, PEELS

Questions?

Dear Early Childhood Professional:

Call the PEELS
toll-free hot line:
1-888-534-8348

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number.
The valid OMB control number for this information collection is 1850-0809. The time required to complete this information collection is estimated to average 20 minutes per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington,
D.C. 20202-4651. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: National Center for Special
Education Research, Institute of Education Sciences, U.S. Department of Education, 555 New Jersey Ave., NW, Washington, D.C. 20208.

OMB Control # 1850-0809, Expiration date: 1/31/08

✓CHECK ALL THAT APPLY IN COLUMN A.
✓CHECK ONE PRIMARY DISABILITY IN COLUMN B.
A
All disability
categories
applicable to
this child

B
This child’s
primary
disability
category

Check all that apply

Check one

01

a. Autism

02

b. Deaf/blindness
c. Deafness

e. Emotional disturbance/behavior disorder

03

05

05

06

f. Hearing impairment

07

g. Learning disability
h. Mild mental retardation

j. Multiple disabilities

m. Speech or language impairment

10

o. Visual impairment/blindness
p. Other (Specify: _________________________)

11

12

13

15

15

16

98

q. Not sure

09

13
14

n. Traumatic brain injury

07

10

12

l. Other health impairment

06

08

11

k. Orthopedic impairment

04

08
09

i. Moderate/severe mental retardation

02

03
04

d. Developmental delay

01

14

16

98

D2. Does this child use any medical devices that require school staff attention during
any part of the school day? (Medical devices could include suctioning equipment,
oxygen, catheters, etc. Do not include nonmedical devices, such as communication
devices, electronic equipment, etc.) PLEASE
CHECK ONE.
1

2

✓

Yes
No

27

D3. Were any of the following services provided to this child through the school system
during the current school year? Include services the school contracted from other agencies.
PLEASE

✓CHECK ALL THAT APPLY.

01

a. Adaptive physical education

02
03
04
05
06
07
08
09
10
11

12
13
14
15
16
17
18
19

20
21

22
23
24

b. Assistive technology services/devices
c. Audiology
d. Augmentative or alternative communication system
e. Behavior management program
f. Health services (e.g., administering of medication, oxygen, tracheostomy
care, tube feeding, catheterization)

D4. In which of the following settings does this child receive special education and
related services? Please think about all the settings in which this child receives
CHECK ALL THAT APPLY.
services. PLEASE
01

02
03
04
05
06
07

✓

a. Early childhood classroom (regular education)
b. Early childhood special education classroom
c. Therapy site for special services outside the classroom
d. Outpatient medical service facility, clinic, or therapy site
e. Child’s home
f. Someone else’s home (e.g., a babysitter)
g. Other (Specify: ________________________________)

g. Instruction in American Sign Language
h. Instruction in Manual English or Cued Speech
i. Instruction in Braille
j. Learning strategies/study skills assistance by a special educator
k. Mental health services, personal/group counseling, therapy, or psychiatric
care provided to this child
l. Occupational therapy
m.One-to-one para-educator/assistant (e.g., teacher aide, nurse’s aide, fullinclusion assistant, behavioral assistant)

D5. For this school year, what are the three most important IEP goals for this child?
PLEASE
01

02
03
04
05
06
07

n. Physical therapy
o. Reader or interpreter
p. Service coordination/case management
q. Social work services
r. Special transportation because of disability (e.g., help in travel or special
equipment such as lifts, ramps)
s. Specialized computer software or hardware
t. Speech or language therapy
u. Training, counseling, and other supports/services provided to this child’s family
v. Tutoring/remediation by a special education teacher
w. Vision services
x. Other (Specify: _______________________________)

08
09

98

a. Improve overall school readiness
b. Improve pre-academic performance in a specific area: ____________________
c. Improve social skills
d. Improve appropriateness of general behavior
e. Improve adaptive behavior or self-help skills
f. Improve speech/communication skills
g. Improve fine motor skills
h. Improve gross motor skills
i. Other (Specify: ____________________________________________________)
j. Don’t know

D6. Which of the following best describes the amount of progress this child has made in
this school year with regard to the goals specified in the IEP? PLEASE
CHECK ONE

✓

This child has made:
1

2
3
4
5
8

28

✓CHECK UP TO THREE.

Much more progress than expected
More progress than expected
As much progress as expected
Less progress than expected
Much less progress than expected
Don’t know

29

●
●

IF YOU COMPLETED SECTIONS A,B, and C, please go to the back cover.
IF SOMEONE ELSE COMPLETED SECTIONS A,B, and C, please continue with
Question D7.

✓CHECK ALL THAT APPLY.

________________________________________________________________________________________

a. Provide instruction directly to this child

________________________________________________________________________________________

D7. In what capacity (or capacities) are you involved with this child?
PLEASE
01

02
03
04
05
06
07

D9. We want to know what you think about special education for young children.
In the space provided, please print any suggestions or concerns you have regarding
the provision of special education services for young children. (Be assured that your
answers will be confidential.)

________________________________________________________________________________________

b. Provide related services directly to this child
c. Provide consultation services to this child’s teacher(s)
d. Provide case management (e.g., program monitoring) for this child
e. Program administrator or supervisor

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

f. Supervise instructional assistant or para-educator
assigned to work with this child
g. Other (Specify: _________________________________________________)

D8. What are your main roles in this school or program?
PLEASE
01

02
03
04
05
06
07
08

✓CHECK ALL THAT APPLY.

a. Early childhood teacher, not special education
b. Special education teacher
c. Related service provider (e.g., speech therapist)
d. Program specialist (e.g., full inclusion specialist)
e. Case manager/service coordinator
f. School psychologist
g. School counselor
h. Other (Specify: _________________________________________________)

Thank you for completing
this questionnaire.
Date Completed: ____/____/____
mm dd yy

Please provide your name and contact information below,
so that we can reach you if we have questions.

Your Name:

School/Program Name:

Address:

Phone:

(

)

Email:

Please continue to the back cover.
30

31

Thank you for completing
this questionnaire.

When you have completed this portion of the
questionnaire, please seal it with the label
below and place it in your local mailbox.

WESTAT

PEELS 8089.03.09

BUSINESS REPLY MAIL
FIRST-CLASS

PERMIT NO.433

ROCKVILLE, MD

POSTAGE WILL BE PAID BY ADDRESSEE

PEELS • Pre-Elementary Education
Longitudinal Study
Westat • RW2634
1650 Research Blvd.
Rockville, MD 20850-9973

21468.1206.80890309

thank you!

National Center for
Special Education Research