Teacher Surveys

OMB Appendix K.
NLTS 2012 Baseline School Program Questionnaire

OMB No: xxxx-xxxx
App. Exp: xx/xx/xxxx

NLTS-2012
STUDENT’S SCHOOL PROGRAM QUESTIONNAIRE
Thank you in advance for the time spent completing this questionnaire—it is vital to the success of this important
U.S. Department of Education study. Study findings will be critical as federal, state and local agencies work to improve
the quality of services and outcomes for youth with and without disabilities.
Be assured that your answers will be completely confidential; no information will be reported that identifies you or your
student.
For the NLTS-2012, Mathematica Research Policy and DIR are authorized to collect data under law
20 U.S.C. 123g;34CFR Part 99.
This questionnaire is to be completed by the teacher, counselor, or other school staff member who knows most about
the special education program of the student identified below. If you are not that person, please give this questionnaire
to the appropriate staff member and email us at XXX@XXXXX to tell us to whom you gave the questionnaire.

STUDENT NAME
If you prefer to complete the questionnaire on our secure website, you may do so at XXXXXX.XXX. Your log-in and
password are XXXXXXX XXXXXXX. You may also call XXX-XXX-XXXX to complete the questionnaire by telephone or
if you have any questions about the study or the participation of your school, staff, or students. Alternately, you may
email us at XXXXXXX, or visit our web site at XXXXXXXX.

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 1850-0882. The time required to complete
this information collection is estimated to average 30 minutes, including the time to review instructions, search existing data sources, gather the
data needed and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate or
suggestions for improving this form, please write to: U.S. Department of Education, Washington, DC 20201-4651.

Prepared by Mathematica Policy Research

A. Student’s Program

Please answer about the student whose name appears on the first page of this questionnaire.
A1.

(NLTS2
SSPSDa1D1c modified)

Which of the following responses describe this student? This student…
MARK AS MANY RESPONSES AS APPLY
1

□

Does not have an IEP for special education or related services or a Section 504 plan

2

□

Had a Section 504 plan that was discontinued during the |

3

□

Has a current Section 504 plan

4

□

Had an IEP that was discontinued before this school year

5

□

Has a current IEP or an IEP that was discontinued during this school year

|

|

|

|-|

|

|

|

|

|

|

|

|

|-|

|

|

|

SCHOOL YEAR

ENTER SCHOOL YEAR SECTION 504 PLAN WAS DISCONTINUED

|

ENTER SCHOOL YEAR IEP WAS DISCONTINUED

ANSWER THIS QUESTIONNAIRE ONLY IF THIS STUDENT HAS A CURRENT IEP OR ONE THAT WAS
DISCONTINUED DURING THIS SCHOOL YEAR.
IF THE STUDENT DOES NOT HAVE A CURRENT IEP OR ONE THAT WAS DISCONTINUED DURING THIS
SCHOOL YEAR, GO TO THANK YOU ON PAGE 23.
IF YOU ARE NOT SURE, PLEASE ASK THE TEACHER OR COUNSELOR WHO KNOWS MOST ABOUT THIS
STUDENT’S SPECIAL EDUCATION PROGRAM TO COMPLETE THE QUESTIONNAIRE.

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4

A2.
(NLTS2
SSPSD2ab,
rev)

In column A, please indicate ALL of the student’s disabilities. Then, in column B, please mark the student’s
one primary federal disability category.
MARK ONE FOR
EACH ROW

MARK ONE
ONLY

Column A

Column B

All Disabilities
Yes

h. Orthopedic impairment ...........................................................................................

□
1□
1□
1□
1□
1□
1□
1□

i. Other health impairment (including Attention Deficit Disorder /Attention Deficit
Hyperactivity Disorder) ...........................................................................................

1

a. Autism .....................................................................................................................
b. Deaf-blindness ........................................................................................................
c. Deafness.................................................................................................................
d. Emotional disturbance ............................................................................................
e. Hearing impairment, excluding deafness ...............................................................
f. Intellectual disability (formerly called mental retardation) ......................................
g. Multiple disabilities ..................................................................................................

j. Specific learning disability ......................................................................................
k. Speech or language impairment.............................................................................
l. Traumatic brain injury .............................................................................................
m. Visual impairment, including blindness ..................................................................
n. Other – Specify: .....................................................................................................

1

□
1□
1□
1□
1□
1□

No

□
0□
0□
0□
0□
0□
0□
0□
0

□
0□
0□
0□
0□
0□
0

Primary
Disability

□
1□
1□
1□
1□
1□
1□
1□
1

□
1□
1□
1□
1□
1□
1

_______________________________________________________________

IF THIS STUDENT IS IN A SCHOOL SERVING ONLY STUDENTS WITH DISABILITIES, PLEASE SKIP TO ITEM A4.
ELSE CONTINUE TO A3.

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5

A3.

Some students may take a subject in multiple settings. Please indicate all the settings in which this student
is now taking each subject listed below. Mark “not applicable” if the student does not take a subject.

(NLTS2
SSPS A3
modified)

PLEASE MARK ALL SETTINGS THAT APPLY FOR EACH SUBJECT

Subject

General education
classroom (with or
without resource
room support)

j. Career exploration ......................

□
1□
1□
1□
1□
1□
1□
1□
1□
1□

k. Career and technical education
(including computer skills)...........

1

a. Language arts .............................
b. Mathematics ................................
c. Science .......................................
d. Social studies/history ..................
e. Foreign language ........................
f. Art, music, drama ........................
g. Physical education ......................
h. Life skills, social skills .................
i. Study skills ..................................

l. Other Subject – Specify: .............

Special education
classroom

□
2□
2□
2□
2□
2□
2□
2□
2□
2□

1

2

□
1□

□
2□
2

_________________________

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6

Individual
instruction
(e.g., home/
hospital/ treatment
center)

□
3□
3□
3□
3□
3□
3□
3□
3□
3□
3

□
3□
3

Community
setting

□
4□
4□
4□
4□
4□
4□
4□
4□
4□
4

□
4□
4

Not Applicable
(Student does not
take this class)

□
n□
n□
n□
n□
n□
n□
n□
n□
n□
n

□
n□
n

IF THIS STUDENT IS IN A SCHOOL SERVING ONLY STUDENTS WITH DISABILITIES, PLEASE COMPLETE A4.
ELSE, SKIP TO B1.
A4.
(NLTS2
SSPS A3
modified)

Some students may take subjects in multiple settings. Please indicate all the settings in which this
student is now taking each subject listed below. Mark “not applicable” if the student does not take a
subject.
PLEASE MARK ALL SETTINGS THAT APPLY FOR EACH SUBJECT

Subject

Class at this school

j. Career exploration ......................

□
1□
1□
1□
1□
1□
1□
1□
1□
1□

k. Career and technical education
(including computer skills)...........

1

a. Language arts .............................
b. Mathematics ................................
c. Science .......................................
d. Social studies/history ..................
e. Foreign language ........................
f. Art, music, drama ........................
g. Physical education ......................
h. Life skills, social skills .................
i. Study skills ..................................

l. Other Subject – Specify: .............

Class at another
location

□
2□
2□
2□
2□
2□
2□
2□
2□
2□

1

2

□
1□

□
2□
2

_________________________

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7

Individual
Instruction (e.g.
home or hospital)

□
3□
3□
3□
3□
3□
3□
3□
3□
3□
3

□
3□
3

Community
Setting

□
4□
4□
4□
4□
4□
4□
4□
4□
4□
4

□
4□
4

Not Applicable
(Student does not
take this class)

□
n□
n□
n□
n□
n□
n□
n□
n□
n□
n

□
n□
n

B. Access to Accommodations, Supports, and Services

The next questions are about the various types of school accommodations, supports, and services that are
provided to this student.
B1.

(NLTS2
SSPS D-3)

Which of the following accommodations or modifications are provided to this student?
MARK ONE FOR EACH ROW

Yes

No

a. More time in taking tests ...................................................................................................

1

□

0

□

b. Tests read to student ........................................................................................................

1

□

0

□

c.

Modified tests ....................................................................................................................

1

□

0

□

d. Alternate tests or assessments ........................................................................................

1

□

0

□

e. Modified grading standards ..............................................................................................

1

□

0

□

f.

Slower-paced instruction ..................................................................................................

1

□

0

□

g. Additional time to complete assignments .........................................................................

1

□

0

□

h. Shorter or different assignments ......................................................................................

1

□

0

□

i.

More frequent feedback ....................................................................................................

1

□

0

□

j.

Physical adaptations (e.g., modifications to the classroom, special desks) .....................

1

□

0

□

k.

Large print or Braille books ...............................................................................................

1

□

0

□

l.

Other accommodation or modification – Specify: .............................................................

1

□

0

□

______________________________________________________________________

Prepared by Mathematica Policy Research

8

B2.

Which of the following kinds of additional supports or assistance are provided to this student?
MARK ONE FOR EACH
ROW

(NLTS2
SSPS D-3)

Yes

No

a. Reader or interpreter, including sign language .....................................................................

1

□

0

□

b. Teacher’s aide, instructional assistant, or other personal aide .............................................

1

□

0

□

c.

Student progress monitored by special education teacher or related service provider ........

1

□

0

□

d. Peer tutors .............................................................................................................................

1

□

0

□

e. Tutoring by an adult ...............................................................................................................

1

□

0

□

f.

Behavior management program ............................................................................................

1

□

0

□

g. Learning strategies/study skills assessment .........................................................................

1

□

0

□

h. Self-determination and self-advocacy skills training ..............................................................

1

□

0

□

B3.

Which of the following learning aids are provided to this student?

(NLTS2
SSPS D-3)

MARK ONE FOR EACH
ROW

Yes

No

a. Books on CD, tape, or podcasts ............................................................................................

1

□

0

□

b. Use of a calculator for activities not allowed other students (such as during tests) ..............

1

□

0

□

Use of computers for activities not allowed other students (such as use of spell checker
when other students do not use one) ....................................................................................

1

□

0

□

d. Computer software designed for students with disabilities....................................................

1

□

0

□

e. Computer-based assistive technology. Examples may include: alternative keyboards,
Co:Writer, database software, graphic organizers and outlining managers, Inspiration,
optical character recognition, speech-recognition programs, speech synthesizers,
variable-speed tape recorders, or word-prediction programs................................................

1

□

0

□

f.

Captioned media....................................................................................................................

1

□

0

□

g. Manipulatives .........................................................................................................................

1

□

0

□

h. Other learning aid – Specify: .................................................................................................

1

□

0

□

c.

Prepared by Mathematica Policy Research

9

B4.

(NLTS2
SSPS A4a
and A4b)

Please indicate in Column A whether this student has received or will receive any of the following from or
through the school system during this school year (2011-2012).
For any activity this student does not receive, please indicate in Column B whether you believe he or she
could benefit from it.
Column A
Received?

Activity

Yes

No

Column B
Could benefit?
Yes

No

a. Reproductive health education or services .......................................

1

□

0

□

1

□

0

□

b. Teen parenting instruction .................................................................

1

□

0

□

1

□

0

□

c.

Child care for children of parenting teens ..........................................

1

□

0

□

1

□

0

□

d. Conflict resolution, anger management, violence prevention ...........

1

□

0

□

1

□

0

□

e. Substance abuse counseling or education ........................................

1

□

0

□

1

□

0

□

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10

B5.
(NLTS2 SSPS
D6 and D7
Modified)

Which of the following services has been provided to this student from or through the school system
during this school year (2011-2012), including services the school contracted from other agencies?

MARK ONE FOR EACH ROW

Service provided?
Yes

No

Don’t
Know

a. Adaptive physical education ............................................................................................

1

□

0

□

d

□

b. Assistive technology services/devices .............................................................................

1

□

0

□

d

□

c.

Audiology .........................................................................................................................

1

□

0

□

d

□

d. Behavioral intervention/specialist ....................................................................................

1

□

0

□

d

□

e. Speech or language therapy ............................................................................................

1

□

0

□

d

□

Communication services (e.g. instruction in sign/ manual communication or lip
reading, Braille, and other types of augmentative communication devices) ...................

1

□

0

□

d

□

g. Health services (e.g., administering medication, oxygen) ...............................................

1

□

0

□

d

□

h. Literacy services ..............................................................................................................

1

□

0

□

d

□

Monitoring of a medical device that requires staff attention during the school day (e.g.,
suctioning equipment, catheter) .......................................................................................

1

□

0

□

d

□

j.

Mental health services, personal/group counseling, therapy, or psychiatric care ...........

1

□

0

□

d

□

k.

Mobility training ................................................................................................................

1

□

0

□

d

□

l.

Occupational therapy .......................................................................................................

1

□

0

□

d

□

m. Physical therapy...............................................................................................................

1

□

0

□

d

□

n. Service coordination/case management..........................................................................

1

□

0

□

d

□

o. Social work services ........................................................................................................

1

□

0

□

d

□

p. Special transportation because of disability ....................................................................

1

□

0

□

d

□

q. Training, counseling, or other supports/services provided to student’s family ................

1

□

0

□

d

□

r.

1

□

0

□

d

□

f.

i.

Other – Specify: ...............................................................................................................

Prepared by Mathematica Policy Research

11

B5aa. Did/does this student get any services funded by Vocational Rehabilitation Services this school year
(2011-2012)?
1

□

Yes

0

□

No

d

□

Don’t know

GO TO B6

B5bb. Which of the following services did/does this student get from Vocational Rehabilitation Services?
MARK YES, NO, OR
DON’T KNOW ON EACH ROW

Service provided?
Yes
a. Career counseling ............................................................................................................
b. Goal setting and career planning .....................................................................................
c.

Job assessment and appraisal ........................................................................................

d. Health advice and promotion that supports working........................................................
e. Case management, referral, and service co-ordination ...................................................
f.

Interventions to remove environmental, employment and attitudinal barriers .................

g. Other (Please specify) .....................................................................................................

□
1□
1□
1□
1□
1□
1□
1

No

□
0□
0□
0□
0□
0□
0□
0

Don’t
Know

□
d□
d□
d□
d□
d□
d□
d

The next questions are about assistive technology. Assistive technology is any item, piece of equipment, or
product that is used to increase, maintain, or improve functional capabilities of individuals with disabilities.
B6.

Does this student’s IEP require assistive technology?

□
0□
1

Yes
No

GO TO B9

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12

B7.

What technology does this student use? What is the device called? If this student uses more than one
device, please tell us about the one specified in the IEP or most important for his/her education.
(Please specify)
Please reference the device named in B7 above for B8 and B8a

B8.

Is this student able to use this device effectively for its intended purpose?

□
0□
1

Yes

GO TO B9

No

B8a. Why not?
MARK ALL THAT APPLY

□ Device is not the right size, shape, or strength for this student
2 □ Student is still learning how to use the device
3 □ Student has been unable to learn how to use the device
4 □ Device cannot go with student to the places where it is needed
5 □ Device does not suit the student’s actual needs
95 □ Other reason(s) (Please specify)
1

B9.

Have you personally been trained on …
MARK ONE FOR
EACH ROW

Yes
a. How to serve students with assistive technology needs? .......................................................
b. Legal issues related to assistive technology? .........................................................................
c.

How to write IEPs for students who require use of assistive technology devices? .................

d. Resources to contact for information on assistive technology? ..............................................
e. How to use a variety of assistive technologies? ......................................................................

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13

□
1□
1□
1□
1□
1

No

□
0□
0□
0□
0□
0

C. IEP and Transition Planning

The next questions focus on this student’s IEP and transition planning.
C1.
(NEW)

C2.

(NLTS2
SSPS E1,
REV)

When was the most recent IEP meeting for this student?
| | |/|
MONTH

□
0□
d□

(NLTS2
SSPS E2)

C4.
(NLTS2
SSPS E3)

Yes
No

GO TO D1 (PAGE 21)

Don’t know

PLEASE WORK WITH THE TEACHER OR COUNSELOR MOST FAMILIAR WITH THE STUDENT’S
IEP OR TRANSITION PLAN TO COMPLETE THIS SECTION OF THE QUESTIONNAIRE.

What age or grade level was this student when transition planning first started for him or her?
|

|

| AGE OR |

|

| GRADE

Has this student received instruction specifically focused on transition planning (e.g., a specialized
curriculum designed to help students assess options and develop strategies for leaving secondary
school and transitioning to adult life)?

□
0□
1

C5.

| MONTH AND YEAR OF THE MOST RECENT IEP MEETING

Has there been any planning for transition to adult life for this student? In other words, have school staff, a
parent, or the student begun to explore options the student might consider for life, work, or education after
high school?
1

C3.

| | |
YEAR

Yes
No

For this school year, what are the primary IEP goals for this student?

(NLTS2
SSPS D4)
Modified)

MARK ONE FOR
EACH ROW

Yes
a. Improve overall academic performance ..................................................................................
b. Improve academic performance in specific area(s) ................................................................
c.

Build social skills .....................................................................................................................

d. Improve appropriateness of general behavior ........................................................................
e. Increase functional or life skills ...............................................................................................
f.

Improve fine or gross motor skills, mobility, or other physical functioning ..............................

g. Enhance skills for self-advocacy and self-determination ........................................................
h. Improve speech and communication skills..............................................................................
i.

Define career goals .................................................................................................................

j.

Develop occupational and technical skills ...............................................................................

k.

Prepare for postsecondary education .....................................................................................

l.

Other (Please specify) .............................................................................................................

Prepared by Mathematica Policy Research

14

□
1□
1□
1□
1□
1□
1□
1□
1□
1□
1□
1□
1

No

□
0□
0□
0□
0□
0□
0□
0□
0□
0□
0□
0□
0

C6.

Is there a measurable indicator for one or more of this student’s primary IEP goals listed in item C5?

□
2□
3□
1

C7.

All
Some
None

For the period following high school, what are the primary goals of this student’s educational program?
MARK ONE FOR EACH ROW

(NLTS2
SSPS E4
Modified)

Yes

No

Don’t
Know

a. Attend a 2- or 4-year college? .....................................................................................

1

□

0

□

d

□

b. IF C7a= NO, ASK: Attend a career or technical school or training program? ........

1

□

0

□

d

□

Get competitive employment (includes military)? .......................................................

1

□

0

□

d

□

d. IF C7c= NO, ASK: Get supported employment (paid work in a community
setting for those needing continuous support and for whom competitive
employment is unlikely)? ............................................................................................

1

□

0

□

d

□

e. IF C7d= NO, ASK: Get into sheltered employment (where most workers have
disabilities)? .................................................................................................................

1

□

0

□

d

□

Live independently?.....................................................................................................

1

□

0

□

d

□

g. IF C7f= NO, ASK: Maximize functional independence? ............................................

1

□

0

□

d

□

h. Enhance social/interpersonal relationships and satisfaction? ...............................

1

□

0

□

d

□

Other educational program goal, not listed above (Please specify) ........................

1

□

0

□

d

□

c.

f.

i.

C8.
(NLTS2
SSPS E5)

Does this student’s transition plan or IEP specifically state what course of study or kinds of classes the
student should pursue in order to meet his/ her post school transition goal(s)?

□
0□
1

Yes
No

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15

C9.

The next set of questions apply to students in specific grades. What is this student’s current grade level
this school year (2011-2012)?

(NLTS2
SSPSA1)

MARK ONE ONLY

□
2□
3□
4□
5□
6□
7□
8□
1

7th grade
8th grade

GO TO D1 (PAGE 21)

9th grade
10th grade
11th grade
12th grade
Ungraded high school equivalent
Ungraded less than high school equivalent

GO TO D1 (PAGE 21)

C10. In Column A, indicate who has actively participated in the student’s transition planning. We define active
(NLTS2
participation as being involved in discussions regarding services or goals. Then, in Column B, indicate
SSPS E8
who actually attended the IEP meeting.
Modified)

INDIVIDUALS

MARK ONE FOR
EACH ROW

MARK ONE FOR
EACH ROW

Column A
Participated in
Process

Column B
Attended
Meeting

Yes

a. A general education academic subject teacher ...........................................

1

b. A general education career and technical teacher or work study
coordinator ...................................................................................................

1

c.

A special education teacher ........................................................................

d. A school administrator (e.g. principal, special education administrator) .....
e. A school guidance counselor, social worker, or psychologist .....................
f.

A related services personnel (e.g. speech pathologist, occupational
therapist ) .....................................................................................................

g. A parent or guardian ....................................................................................
h. The student ..................................................................................................
i.

A representative of post secondary educational institution .........................

j.

An employer.................................................................................................

k.

A counselor from the vocational rehabilitation agency ................................

l.

A representative from the Social Security Administration (SSA) .................

m. An adult health-care representative.............................................................
n. Other (Please specify) .................................................................................

Prepared by Mathematica Policy Research

16

□

□
1□
1□
1□
□
1□
1□
1□
1□
1□
1□
1□
1□
1

No
0

□

□
0□
0□
0□
0

□
0□
0□
0□
0□
0□
0□
0□
0□
0

Yes
1

□

□
1□
1□
1□
1

□
1□
1□
1

No
0

□

□
0□
0□
0□
0

□
0□
0□
0

C11. Did this student’s parents or guardians actively participate in the transition process? (See C10g, Column A
above.)

□
0□
1

(NEW)

C12.

Yes

GO TO C13

No

To the best of your knowledge, why did this student’s parent or guardian not actively participate in the
transition planning process?

(NEW)

MARK ONE FOR EACH ROW

Was this a reason?

Yes

a. No transition planning meetings were held .........................................................
b. Student did not want parent/guardian to participate ............................................
c.

Parent or guardian had work obligations .............................................................

d. Parent or guardian was ill or was taking care of others.......................................
e. Parent or guardian does not speak English, has language barrier .....................
f.

Parent or guardian was not in area or did not have transportation to school ......

g. Parent or guardian was not interested in participating ........................................
h. School had difficulty reaching parent or guardian to schedule meeting ..............
i.

Parent did not show up for meeting .....................................................................

j.

Other (Please specify) .........................................................................................

□
1□
1□
1□
1□
1□
1□
1□
1□
1□
1

No

□
0□
0□
0□
0□
0□
0□
0□
0□
0□
0

Don’t
Know

□
d□
d□
d□
d□
d□
d□
d□
d□
d□
d

C13. Which of the following best describes this student’s role in his or her transition?
(NLTS2
SSPS E9

MARK ONE ONLY

□
2□
3□
4□
1

Student has not attended planning meetings or participated in the process
Student has been present in the discussions but participated very little or not at all
Student has provided some input into transition planning as a moderately active participant

GO TO C15

Student has taken a leadership role in the transition planning process, defining goals and identifying program
or service needs
GO TO C15

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17

C14. To the best of your knowledge, why didn’t this student participate (or participate more fully) in the
transition planning process?
(NEW)

MARK ONE FOR EACH ROW

Was this a reason?

Yes

a. No transition planning meetings were held .......................................................
b. Student was not invited to the planning meetings .............................................
c.

Student was not interested in participation ........................................................

d. Student forgot about meeting ............................................................................
e. Student was too ill to participate ........................................................................
f.

Student had another appointment or work obligation at time of meeting ..........

g. Student had no transportation to get to meeting ...............................................
h. Parent preferred student not attend...................................................................
i.

Other reason – Specify: ___________________________________

C15.
(NLTS2
SSPS E10
Modified)

□
0□
0□
0□
0□
0□
0□
0□
0□

□
d□
d□
d□
d□
d□
d□
d□
d□

0

d

MARK ONE FOR EACH ROW

a. Colleges (2- or 4-year) .......................................................................
b. Career and technical schools or training institutions .........................
Support service personnel at college or technical training schools ...

d. Vocational Rehabilitation Agency ......................................................
e. U.S. military .......................................................................................
f.

□
1□
1□
1□
1□
1□
1□
1□
1□
1

Have the following been contacted this school year about the students’ activities when he/she leaves
high school?

Yes

c.

Don’t
Know

No

Potential competitive employers ........................................................

g. Job placement programs or agencies ...............................................
h. Supported employment programs .....................................................
i.

Sheltered workshops .........................................................................

j.

Mental health agencies ......................................................................

k.

Social Security Administration ...........................................................

l.

Congregate care facilities or institutions ............................................

m. Supervised residential support agencies ...........................................
n. Adult day programs............................................................................
o. Other social service agencies ............................................................
p. Other agencies (Please specify) ........................................................

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□
1□
1□
1□
1□
1□
1□
1□
1□
1□
1□
1□
1□
1□
1□
1□
1

No

□
0□
0□
0□
0□
0□
0□
0□
0□
0□
0□
0□
0□
0□
0□
0□
0

Don’t
know

□
d□
d□
d□
d□
d□
d□
d□
d□
d□
d□
d□
d□
d□
d□
d□
d

Not Appropriate
for Student

□
n.a. □
n.a. □
n.a. □
n.a. □
n.a. □
n.a. □
n.a. □
n.a. □
n.a. □
n.a. □
n.a. □
n.a. □
n.a. □
n.a. □
n.a. □
n.a.

C16. Has information about services available after high school related to this student’s disability been provided
(either verbally or in writing), to his or her parents/guardians?
(NLTS2

SSPS E11,
modified)

MARK ONE ONLY

□
1□
2□
0□
d□
n

Not applicable; this student does not need services after high school
Yes
Not yet; information will be provided before the student graduates
No
Don’t know

C17. What service or program needs were identified for this student for after high school in his or her IEP or
transition plan?

(NLTS2
SSPS E12
Modified)

MARK ONE FOR EACH ROW

Yes

No

Don’t
Know

a. Education accommodations to help pursue post secondary education ..............

1

□

0

□

d

□

b. Audiology .............................................................................................................

1

□

0

□

d

□

c.

Behavioral intervention ........................................................................................

1

□

0

□

d

□

d. Mental health services .........................................................................................

1

□

0

□

d

□

e. Mobility training ....................................................................................................

1

□

0

□

d

□

f.

Nursing or other medical services .......................................................................

1

□

0

□

d

□

g. Occupational therapy ...........................................................................................

1

□

0

□

d

□

h. Physical therapy ..................................................................................................

1

□

0

□

d

□

i.

Social work services ............................................................................................

1

□

0

□

d

□

j.

Speech, sign language, or communication therapy or services ..........................

1

□

0

□

d

□

k.

Supported living arrangement .............................................................................

1

□

0

□

d

□

l.

Transportation assistance ...................................................................................

1

□

0

□

d

□

m. Vision services .....................................................................................................

1

□

0

□

d

□

n. Vocational training, placement or support ...........................................................

1

□

0

□

d

□

o. Assistive technology ............................................................................................

1

□

0

□

d

□

p. Literacy services ..................................................................................................

1

□

0

□

d

□

q. Other service or program (Please specify) ..........................................................

1

□

0

□

d

□

Prepared by Mathematica Policy Research

19

C18. How much progress do you believe this student is making toward each kind of goal for the transition to
adulthood?
MARK ONE FOR EACH ROW

(NLTS2
SSPS E6)

No
Progress

□
0□
0□

a. Defining employment goals ........................................

0

b. Defining career goals ..................................................
c.

Goals for postsecondary education and training ........

d. Functional independence and independent living
goals ...........................................................................

□
0□
0□
0□
0□
0

e. Behavior management goals ......................................
f.

Social/interpersonal goals ..........................................

g. Self-advocacy .............................................................
h. Other type of goal – Specify: ......................................

A Little
Progress

□
1□
1□
1

□
1□
1□
1□
1□
1

Some
Progress

□
2□
2□
2

□
2□
2□
2□
2□
2

A Lot of
Not
Progress Applicable

□
3□
3□
3

□
3□
3□
3□
3□
3

□
n□
n□
n

□
n□
n□
n□
n□
n

__________________________________________
C19. How well suited do you believe this student’s school program is for preparing him or her to achieve his or
her transition goals?

(NLTS2
SSPS E7)

MARK ONE ONLY

□
□
3□
4□
1
2

Not at all well suited; the school program does not prepare him/her to achieve transition goals
Some what well suited; the school program provides a little preparation for achieving transition goals
Fairly well suited; the school program prepares him/her fairly well to achieve transition goals
Very well suited; the school program provides very good preparation for achieving transition goals

Prepared by Mathematica Policy Research

20

The next set of questions address challenges this student may face as he/ she prepares for the transition to adult
life. For each challenge described below, please check the box to show whether this is a challenge for this
student in securing a paid, job, obtaining post-secondary education, or living independently.
C20. To what extent is the student facing the following challenges?
(NEW)

MARK ALL THAT APPLY FOR EACH ROW
Getting a paid
job

Obtaining
postsecondary
education

Living
Independently

Not
applicable

a. Parental expectations..........................................

1

□

2

□

3

□

n

□

b. Student’s confidence in his / her own abilities ....

1

□

2

□

3

□

n

□

Student’s personal skills - including use of
transportation. .....................................................

1

□

2

□

3

□

n

□

d. Student’s behavior problems ..............................

1

□

2

□

3

□

n

e. Insufficient accommodations or supports............

1

□

2

□

3

□

f.

1

□

2

□

3

□

c.

Lack of awareness of available options ..............

□
d□
d

d

□

□

d

□

n

□

d

□

n

□

d

□

d

□

d

□

d

□

g. Insufficient support identifying or applying to
jobs, post-secondary schools, or independent
housing arrangements ........................................

1

□

2

□

3

□

n

□

h. Limited access to social or health services
(including health insurance) ................................

1

□

2

□

3

□

n

□

i.

1

□

2

□

3

□

n

□

Poor coordination with adult service providers ...

Don’t
Know

C21. The next challenge applies only to jobs. Is fear of losing public benefits a barrier for this student getting a
(NEW)
paid job?

□
0□
d□
1

Yes
No
Don’t Know

C22. The next challenge applies only to further education. Are insufficient financial resources and access to
(NEW)
financial aid a barrier to this student continuing his / her education?

□
0□
d□
1

Yes
No
Don’t Know

C23. Are there any other challenges you know this student is facing in his / her transition to adult life?
(NEW)

□
0□
d□
1

Yes – Please specify: _____________________________
No
Don’t Know

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21

D. Demographics
The next questions are about you.
D1.

(NLTS2
SSPS F1
modified)

What are your one or two main roles in this school?
MARK ONE FOR EACH ROW

Yes

□
1□
1□
1□
1□
1□
1□
1□
1□

a. General education classroom teacher ...................................................................

Resource room teacher..........................................................................................

d. Related services provider (e.g., speech therapist) ................................................
e. Program or transition specialist ..............................................................................
f.

Case manager ........................................................................................................

g. School psychologist ...............................................................................................
h. School guidance counselor ....................................................................................
i.

Other (Please specify)............................................................................................

D2.

MARK ONE FOR EACH ROW

Yes

□
0□
0□
0□
0□

1

b. Provide related services directly to this student .........................................................
Provide consultation services to student’s teacher(s) ................................................

d. Provide case management (e.g., program monitoring) for this student .....................
e. Program administrator/supervisor ..............................................................................
Supervise instructional assistant or para-educator assigned to work with this
student ........................................................................................................................

0

□
1□

□
0□

1

g. Other (Please specify) ................................................................................................

D3.

No

□
1□
1□
1□
1□

a. Provide instruction directly to this student ..................................................................

f.

0

In what capacity (or capacities) are you involved with this student?

(NLTS2
SSPS F2)

c.

□
0□
0□
0□
0□
0□
0□
0□
0□

1

b. Special education classroom teacher ....................................................................
c.

No

0

Please indicate the extent to which you agree or disagree with each of the following statements.

(NLTS2F3)

MARK ONE FOR EACH ROW

Strongly
Disagree
a. The school leadership has high expectations and standards for all
students and teachers ..........................................................................
b. The principal promotes instructional improvement among school
staff.......................................................................................................
c.

This school is a safe place for students ...............................................

d. I feel well prepared to work with students with disabilities ...................
Prepared by Mathematica Policy Research

22

1

□

□
1□
1□
1

Disagree
2

□

□
2□
2□
2

Agree
3

□

□
3□
3□
3

Strongly
Agree
4

□

□
4□
4□
4

D4.
(New)

Are you Hispanic or Latino?

□
0□
1

Yes – Hispanic or Latino
No – Not Hispanic or Latino

D5.

Which best describes your race?

(New)

MARK ALL THAT APPLY

□
2□
3□
4□
5□
1

D6.

(NLTS2
SSPS F5)

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

To the best of your knowledge, what do you expect this student’s school enrollment status to be for the
next school year (2012-2013)?
ANSWER YES OR NO FOR EACH ROW AND COMPLETE THE INFORMATION FOR EACH YES ANSWER.
Yes

No

a. The student is expected to attend your school next year ..............................................

1

□

0

□

b. The student is expected to attend a different secondary school next year ...................

1

□

0

□

1

□

0

□

1

□

0

□

NAME OF SCHOOL:
CITY:
STATE:
c.

The student is not expected to attend your school because he or she will:

□
2□
3□
4□
1

(MARK ALL THAT APPLY)

Graduate
Move
Exceed the age limit for services
Drop out

d. The student is not expected to attend any school next year .........................................

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23

THANK YOU AGAIN FOR COMPLETING THIS QUESTIONNAIRE.
AS SOON AS WE RECEIVE THIS QUESTIONNAIRE, WE WILL SEND YOUR $25 THANK YOU.

PLEASE ENTER THE ADDRESS TO WHICH WE SHOULD SEND THE CHECK:
Name:
Address:
City:
State:

ZIP Code:

May we also have your email and telephone number in case we have any questions about your responses?
Email:

@

Phone: (_______) Area Code

-

Number

PLEASE RETURN THE QUESTIONNAIRE IN THE POSTAGE-PAID ENVELOPE.
IF YOU DO NOT HAVE THE ENVELOPE, YOU MAY FAX THE QUESTIONNAIRE TO:
xxxxxxxx at xxx-xxx-xxxx OR MAIL IT TO: NLTS-2012 STUDY

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24