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pdfPre-Elementary Education Longitudinal Study
Elementary School Teacher
Questionnaire
KINDERGARTEN
school
ELEMENTARY
W4
Pre
school
S
PE E
L
Funded by the U.S. Department of Education
Institute of Education Sciences
National Center for Special Education Research
W4
Pre-Elementary Education Longitudinal Study
Elementary School Teacher
Questionnaire
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.
The study is following the children as they move through preschool, kindergarten, and into
the early elementary school years. This questionnaire is the only source of information about
this year’s school programs and experiences for this child. Because of this, your participation is
vitally important.
Please complete this questionnaire and return it in the postage-paid envelope within 3 weeks.
Answer all questions to the best of your knowledge and use your best guess when answering
questions for which you are not quite sure of the answer. However, try as best you can to avoid
responses that represent complete guesses. If necessary, please consult with colleagues in
answering questions. Be assured that your answers will be completely confidential, and no
information will be reported that identifies you, this child, or this school. We have enclosed
$10 as a token of our appreciation.
Before beginning this questionnaire, you may want to gather the following information so that
you will be able to complete the questionnaire more quickly:
●
●
●
The school file for the child whose name is on the label, including, if applicable,
the most recent Individualized Education Program (IEP);
Attendance records for this child during October of this school year; and
Child’s previous school records.
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 so much for your contribution to this very important study.
Sincerely,
Elaine Carlson
Project Director, PEELS
Questions?
Dear Teacher:
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
Section A:
Who should complete this questionnaire?
This questionnaire should be completed by the teacher or service provider who knows the child
whose name appears on the label and can describe the elementary education or special education and
related services for this child.
●
Can you tell us about the child whose name appears on the label?
1
2
●
2
2
A1. What is the current grade-level placement of this child? PLEASE
0
1
3
Yes
4
5
✓CHECK ONE.
Ungraded
1st grade
2nd grade
3rd grade
4th grade
Other (Specify: _________________________)
No
Can you tell us about special services this child receives (e.g., speech therapy)?
1
REMINDER: “This child” refers to the child whose name appears on the label.
2
No
Can you tell us about this child’s elementary school program?
1
●
Yes
ELEMENTARY SCHOOL PROGRAM AND CHILD PROGRESS
A2. Approximately how much school time per week does this child currently spend in
the following settings? PLEASE INDICATE EITHER MINUTES OR HOURS PER WEEK.
Number of
minutes/week
Yes
No
OR
Number of
hours/week
a. Regular education classroom
b. Special education setting
If you answered NO to ALL three questions:
DO NOT COMPLETE THIS QUESTIONNAIRE. PLEASE PASS THE QUESTIONNAIRE ON TO THE PERSON
WHO IS BEST ABLE TO DESCRIBE THIS CHILD’S ELEMENTARY EDUCATION PROGRAM OR SPECIAL
SERVICES.
If you answered YES to ANY of the three questions:
PLEASE PROCEED TO SECTION A ➜
c. Therapy/special service setting
(office, small room, etc.)
d. Setting outside of the classroom for other
remediation or assistance (e.g., Title I,
English as a second language [ESL])
e. Home instruction
A3. Which of the settings below is considered to be this child’s main education setting?
PLEASE
01
02
03
note:
04
✓CHECK ONE.
Regular education classroom
Special education setting
Home
Other (Specify:________________________________)
All references to “this child” mean the child whose name appears on the label. “IEP” refers to an
Individualized Education Program for a child with a disability. “Special education setting” and “special
education classroom” could be a self-contained day classroom or a resource room.
2
3
A4. In what capacity (or capacities) are you involved with this child?
PLEASE
01
02
03
04
05
06
07
✓CHECK ALL THAT APPLY.
a. Provide instruction directly to this child
b. Provide related services directly to this child
c. Provide consultation to this child’s teacher(s)
2
3
4
✓
✓
APPLICABLE IF CHILD DOES NOT RECEIVE INSTRUCTION IN A SUBJECT AREA.
d. Provide case management (e.g., program monitoring) for this child
Regular
education
classroom
e. Program administrator/supervisor for this child’s program
f. Supervise instructional assistant assigned to work with this child
Special
education
setting
Pull-out
program
(not special
education)
Homebound
instruction
Not
applicable
a. Language arts
1
2
3
4
5
b. Mathematics
1
2
3
4
5
c. Science
1
2
3
4
5
Special education teacher
d. Social studies
1
2
3
4
5
Related service provider (Specify: ______________________)
e. Art, music
1
2
3
4
5
f. Physical education
1
2
3
4
5
g. Self-help skills
1
2
3
4
5
h. Social skills
1
2
3
4
5
i. Other (Specify:
_________________)
1
2
3
4
5
g. Other (Specify: ___________________________________________)
A5. What is your main role in this school? PLEASE
1
A8. Please indicate all the settings in which this child currently receives instruction for
each subject listed here. (NOTE: Some children may receive instruction in a subject
area in multiple settings, such as a special education setting and a general education
classroom.) PLEASE
CHECK ALL THAT APPLY IN EACH ROW. PLEASE
CHECK NOT
✓CHECK ONE.
Regular education classroom teacher
Other (Specify: ______________________)
A6. How many years have you been teaching or working in your current
professional capacity?
Number of years
A7. Approximately how many TOTAL hours per week does this child attend school?
(If this child does not attend school [e.g., home schooled], indicate approximately
how many total hours of instruction he/she receives in a typical week.)
A9. Does this child participate in the following? PLEASE
✓CHECK ONE IN EACH ROW.
TOTAL hours per week child attends school or receives instruction
4
Yes
No
Don’t
know
a. Program for gifted and talented students
1
2
8
b. Title I
1
2
8
c. Bilingual education or instruction for English language
learners (ELL) (e.g., ESL or limited English proficient [LEP])
1
2
8
d. Program for children with behavioral or
emotional problems
1
2
8
e. Free/reduced-price lunch program
1
2
8
5
A10. How many of the following people are usually in the room during the majority of
this child’s time in your classroom?
PLEASE ENTER ONE NUMBER ON EACH LINE. ENTER “0” IF NONE.
A14. During October of this school year, how many days was this child absent?
PLEASE ENTER THE NUMBER OF DAYS.
Number of days absent
Number
of people
a. Regular education teachers
A15. How many of these were unexcused absences?
PLEASE ENTER THE NUMBER OF DAYS.
b. Special education teachers
Number of unexcused absences
c. One-to-one assistants or aides assigned to this child
d. One-to-one assistants or aides assigned to any other
child in this child’s class
A16. Which of the following best describes the curriculum materials for this child?
PLEASE
1
e. Teacher aides
2
f. Other specialists
3
g. Adult volunteers
4
A11. What are the total numbers of children with IEPs and without IEPs enrolled in this
child’s main class? PLEASE ENTER ONE NUMBER ON EACH LINE. IF THE CHILD IS
ENROLLED IN MORE THAN ONE CLASS, PLEASE RESPOND FOR THE CLASS IN WHICH
THE CHILD SPENDS THE MOST TIME.
Number of children with IEPs in child’s class
Number of children without IEPs in child’s class
}
If “0,” go to
Question A13
A12. Among the children without IEPs in this child’s main classroom, how many are
currently under formal review for special education services?
PLEASE ENTER ONE NUMBER.
Number of children under formal review
✓CHECK ONE.
Regular education grade-level curriculum materials are used
without modification.
Some modifications in regular education curriculum materials have been made.
Substantial modifications in regular curriculum materials have been made.
Specialized curriculum or materials are used.
A17. What percentage of the day does this child spend in the following activities?
THE PERCENTAGES YOU PROVIDE SHOULD TOTAL 100%. PLEASE EXCLUDE TIME FOR
LUNCH AND RECESS IN CALCULATING PERCENTAGES.
a. Instructional or therapy services outside the classroom
%
b. Adult-directed whole class activities
%
c. Adult-directed small group activities
%
d. Adult-directed individual activities
%
e. Child-selected activities
%
f. Other (Specify: ____________________________________)
%
100%
A13. Has this child missed 2 or more weeks of school this year because of a health
CHECK ONE.
problem? PLEASE
1
2
8
✓
Yes
No
Don’t know
6
7
A18. Which of the following teaching practices and methods are used with this child on a
CHECK ONE IN EACH ROW.
regular basis? PLEASE
✓
Yes
No
Don’t
know
SOCIAL SKILLS RATING SYSTEM
This questionnaire is designed to measure how often a student exhibits certain social skills.
Ratings of problem behaviors are also requested.
Read each of the items on A19 and A20 and think about this student’s behavior during the
past month or two. Decide how often the student does the behavior described.
a. One-on-one instruction
1
2
8
b. Small-group instruction
1
2
8
c. Large-group instruction
1
2
8
d. Cooperative learning
1
2
8
e. Peer tutoring
1
2
8
f. Computer-based instruction
1
2
8
g. Direct instruction
1
2
8
Shows empathy for peers.
0
1
h. Cognitive strategies
1
2
8
i. Self-management
1
2
8
Asks questions of you when
unsure of what to do in
schoolwork.
0
1
j. Behavior management
1
2
8
k. Not applicable, you do not deliver regular
instruction to this child
1
2
8
•
•
•
If the student never does this behavior, check the 0.
If the student sometimes does this behavior, check the 1.
If the student very often does this behavior, check the 2.
Here are two examples:
How Often?
Never
Sometimes
Very
Often
2
✓
✓
2
This student very often shows empathy for classmates. Also,
this student sometimes asks questions when unsure of schoolwork.
Please do not skip any items. In some cases you may not
have observed the student perform a particular behavior. Make an
estimate of the degree to which you think the student would
probably perform that behavior.
Social Skills Rating System (SSRS) Teacher Questionnaire by Frank Gresham and Stephen Elliott ©1990 American Guidance Service, Inc., 4201 Woodland
Road, Circle Pines, MN 55014-1796. Permission to reproduce granted to Westat for research purposes only. All rights reserved. www.agsnet.com
8
9
A19. Social Skills
PLEASE
CHECK ONE IN EACH ROW TO INDICATE HOW OFTEN THE STUDENT DOES
THE BEHAVIOR DESCRIBED.
How Often?
✓
How Often?
Never
Sometimes
1
2
16. Produces correct schoolwork.
0
1
2
17. Appropriately tells you when
he or she thinks you have
treated him or her unfairly.
0
1
2
18. Accepts peers’ ideas for
group activities.
0
1
2
19. Gives compliments to peers.
0
1
2
20. Follows your directions.
0
1
2
21. Puts work materials or
school property away.
0
1
2
2
22. Cooperates with peers
without prompting.
0
1
2
0
1
2
1
2
2. Introduces herself or himself to
new people without being told.
0
1
2
4. Compromises in conflict
situations by changing own
ideas to reach agreement.
5. Responds appropriately to
peer pressure.
6. Says nice things about himself
or herself when appropriate.
0
0
0
1
1
1
1
Very
Often
0
Very
Often
0
0
Sometimes
15. Uses time appropriately
while waiting for help.
1. Controls temper in conflict
situations with peers.
3. Appropriately questions
rules that may be unfair.
Never
2
2
2
7. Invites others to join in
activities.
0
1
2
23. Volunteers to help peers
with classroom tasks.
8. Uses free time in an
acceptable way.
0
1
2
24. Joins ongoing activity or group
without being told to do so.
0
1
2
9. Finishes class assignments
within time limits.
0
1
2
25. Responds appropriately when
pushed or hit by other children.
0
1
2
26. Ignores peer distractions
when doing class work.
0
1
2
27. Keeps desk clean and neat
without being reminded.
0
1
2
28. Attends to your instructions.
0
1
2
29. Easily makes transition
from one classroom activity
to another.
0
1
2
30. Gets along with people
who are different.
0
1
2
10. Makes friends easily.
0
1
2
11. Responds appropriately to
teasing by peers.
0
1
2
12. Controls temper in conflict
situations with adults.
0
1
2
13. Receives criticism well.
0
1
2
14. Initiates conversations
with peers.
0
1
2
Social Skills Rating System (SSRS) Teacher Questionnaire by Frank Gresham and Stephen Elliott ©1990 American
Guidance Service, Inc., 4201 Woodland Road, Circle Pines, MN 55014-1796. Permission to reproduce granted to
Westat for research purposes only. All rights reserved. www.agsnet.com
continued >
Social Skills Rating System (SSRS) Teacher Questionnaire by Frank Gresham and Stephen Elliott ©1990 American
Guidance Service, Inc., 4201 Woodland Road, Circle Pines, MN 55014-1796. Permission to reproduce granted to
Westat for research purposes only. All rights reserved. www.agsnet.com
10
11
A20. Problem Behaviors
PLEASE
CHECK ONE IN EACH ROW TO INDICATE HOW OFTEN
THE STUDENT DOES THE BEHAVIOR DESCRIBED.
✓
How Often?
Never
Sometimes
Very
Often
1. Fights with others.
0
1
2
2. Has low self-esteem.
0
1
2
3. Threatens or bullies others.
0
1
2
4. Appears lonely.
0
1
2
5. Is easily distracted.
0
1
2
6. Interrupts conversations
of others.
0
1
2
7. Disturbs ongoing activities.
0
1
2
8. Shows anxiety about being
with a group of children.
0
1
2
9. Is easily embarrassed.
0
1
2
10. Doesn’t listen to what
others say.
0
1
2
11. Argues with others.
0
1
2
12. Talks back to adults
when corrected.
0
1
2
13. Gets angry easily.
0
1
2
14. Has temper tantrums.
0
1
2
15. Likes to be alone.
0
1
2
16. Acts sad or depressed.
0
1
2
17. Acts impulsively.
0
1
2
18. Fidgets or moves
excessively.
0
1
2
Social Skills Rating System (SSRS) Teacher Questionnaire by Frank Gresham and Stephen Elliott ©1990 American
Guidance Service, Inc., 4201 Woodland Road, Circle Pines, MN 55014-1796. Permission to reproduce granted to
Westat for research purposes only. All rights reserved. www.agsnet.com
12
Items A21 and A22 omitted.
ACADEMIC RATING SCALE
The Academic Rating Scale is separated into two areas: (1) language and literacy and (2) mathematical thinking. You are asked to rate the child’s skills, knowledge, and behaviors within each
of these areas based on your experience with this child. This is NOT a test and should not
be administered directly to the child. Each question includes examples that are meant to help
you think of the range of situations in which the child may demonstrate similar skills and
behaviors. The examples do not exhaust all the ways that a child may demonstrate what
he/she knows or can do.
The following five-point scale is used for each of the questions. It reflects the degree to which
a child has acquired/chooses to demonstrate the targeted skills, knowledge, and behaviors.
1
=
Not yet
Child has not yet demonstrated skill, knowledge, or behavior.
2
=
Beginning
Child is just beginning to demonstrate skill, knowledge,
or behavior but does so very inconsistently.
3
=
In progress
Child demonstrates skill, knowledge, or behavior
with some regularity but varies in level of competence.
4
=
Intermediate
Child demonstrates skill, knowledge, or behavior with
increasing regularity and average competence but is
not completely proficient.
5
=
Proficient
Child demonstrates skill, knowledge, or behavior
competently and consistently.
N/A =
Not applicable Skill, knowledge, or behavior has not been introduced
in classroom setting.
Rate only the child’s current achievement or motivation. Rate each child compared to other
children of the same age level. Please use the full range of ratings. If the skill, knowledge, or
behavior has been introduced in the classroom, please rate the child using the numbers 1
through 5. Check “NA” only if the skill, knowledge, or behavior has not been introduced in
your classroom setting.
Children with limited English proficiency: Please answer the question based on your
knowledge of this child’s skills. If the child does not yet demonstrate skills in English but does
demonstrate them in his/her native language, please answer the questions with the child’s
native language in mind.
Children with special needs: It may be necessary to consider adaptations for some questions
to make them more inclusive for this child’s skills/use of adaptive equipment. Some children
may utilize alternative forms of verbal communication (e.g., sign language, communication
boards) or written communication (e.g., word processors, Braille, dictation). Please answer the
questions with these adaptations in mind.
13
A23. Language and literacy
PLEASE
A24. Mathematical thinking
✓CHECK ONE IN EACH ROW.
THIS CHILD…
a. Contributes relevant information
to classroom discussions (e.g.,
during a class discussion, can express
an idea or a personal opinion on
a topic and the reasons behind
the opinion).
b. Understands and interprets a
story or other text read to him/
her (e.g., by writing a sequel to a
story, dramatizing part of a story,
or posing a question about why
a particular story event occurred
as it did).
c. Reads words with regular vowel
sounds (e.g., reads “coat,” “junk,”
“lent,” “chimp,” “halt,” or “bite”).
Not yet
1
PLEASE
Beginning
2
2
1
1
2
In
progress
3
3
3
Intermediate
4
4
4
Proficient
5
5
5
Not
applicable
THIS CHILD…
0
a. Demonstrates an understanding
of place value (e.g., explaining
that 14 is 10 plus 4, or using two
stacks of 10 and 5 single cubes to
represent the number 25).
0
b. Models, reads, writes, and
compares whole numbers
(e.g., recognizing that 30 is the
same quantity if it is 30 rabbits or
30 tallies or 15 + 15 red dots, or
describing that the number 25 is
smaller than 41).
0
c. Counts change with two different
types of coins (e.g., two quarters
and a nickel, or three dimes and
two pennies).
d. Reads words with irregular
vowel sounds (e.g., reads
“through,” “point,” “enough,”
or “shower”).
1
2
3
4
5
0
e. Reads first grade books
independently with
comprehension (e.g., reads most
words correctly and answers
questions about what was read,
makes predictions while reading,
and retells story after reading).
1
2
3
4
5
0
f. Reads first grade books fluently
(e.g., easily reads words in
meaningful phrases rather than
reading word by word).
1
2
3
4
5
0
g. Composes a story with a clear
beginning, middle, and end.
1
2
3
4
5
0
h. Demonstrates an understanding
of some of the conventions of
print (e.g., appropriately using
question marks, exclamation
points, and quotation marks).
1
2
3
4
5
0
i. Uses the computer for a variety
of purposes (e.g., by writing a
page for a class book, looking up
information on a topic of interest,
solving math problems, or
recording a scientific observation).
1
2
3
4
5
0
14
✓CHECK ONE IN EACH ROW.
d. Surveys, collects, and organizes
data into simple graphs (e.g.,
making tally marks to represent the
number of children who want to
play jump rope at recess, or making
a picture, bar, line, or circle graph
to show the different kinds of fruit
children bring to school and the
quantity of each type).
e. Makes reasonable estimates
of quantities (e.g., looking at a
group of objects and deciding if it
is more than 10, about 50, or less
than 100).
f. Measures to the nearest whole
number using common
instruments (e.g., rulers, or tape
measures, or thermometers, or scales).
g. Uses a variety of strategies to
solve math problems (e.g., using
manipulative materials, using trial
and error, making an organized list
or table, drawing a diagram, looking
for a pattern, acting out a problem,
or talking with others).
Not yet
Beginning
In
progress
Intermediate
Proficient
Not
applicable
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
15
A25. Overall, how would you rate this child’s academic skills compared to typical children
CHECK ONE.
of the same grade level? PLEASE
1
2
3
4
5
✓
Far below average
Below average
2
3
4
5
03
Above average
04
Far above average
05
✓
A lot less active than most
2
3
4
5
1
2
3
4
8
07
08
09
✓
a. Impressions based on experience with child and written notes
about specific events
b. Direct observation with general anecdotal notes
c. Direct observation with checklist of skills
d. Direct assessment or testing
e. Test developed to accompany published curriculum
f. Teacher-developed tests
g. Video/audio recording
h. Portfolios of child’s work samples
i. Other (Specify: __________________________________________________)
j. Child progress is not formally monitored
About the same as most
A little more active than most
A30. During the current school year, to what extent will this child participate in any
mandated standardized test(s) administered as part of a school-, district-, or statewide
CHECK ONE.
testing program? PLEASE
A lot more active than most
✓
Far fewer than most
Fewer than most
0
1
2
3
As many as most
More than most
4
Far more than most
A28. Overall, how appropriate do you think this child’s placement is in your classroom?
PLEASE
06
10
A little less active than most
A27. Compared to his/her classmates, how many friends does this child have in your
CHECK ONE.
classroom? PLEASE
1
01
02
Average
A26. How does this child compare with other children in the class in terms of physical
activity? PLEASE
CHECK ONE.
1
A29. Which of the following methods do you commonly use to assess how well this child
CHECK ALL THAT APPLY.
is doing in your class? PLEASE
✓CHECK ONE.
5
✓
There is no such testing at this grade level.
Child did not take such tests or is not expected to take them.
Child participated in some of the testing program without
accommodations or modifications or is expected to do so.
Child participated in most or all of the testing program
without accommodations or modifications or is expected
to do so.
Child participated in some of the testing program with
accommodations or modifications or is expected to do so.
Child participated in most or all of the testing program with
accommodations or modifications or is expected to do so.
}
}
Go to
Question A33
Continue with
Question A31
Very appropriate
A31. Which of the following accommodations/modifications were provided to this child
CHECK ALL THAT APPLY.
to participate in mandated standardized tests? PLEASE
Somewhat appropriate
Not very appropriate
01
Not at all appropriate
02
Don’t know
03
04
05
06
07
08
09
16
✓
a. Given test orally
b. Reader provided
c. Dictated responses
d. Shortened test
e. Alternative setting
f. Additional time
g. Alternative format for responding (e.g., pointing, typing)
h. Braille/large-print version of test
i. Other (Specify: _________________________________________)
17
A32. For what type(s) of test were the above accommodations provided?
PLEASE
1
2
3
A36. How do you communicate with the parents or guardians of this child?
✓CHECK ALL THAT APPLY.
PLEASE
01
a. Math assessments
02
b. Reading/language assessments
03
c. Other (Specify: ______________________________)
04
A33. What grade level in reading and mathematics has this child achieved as of the most
CHECK ONE FOR READING AND ONE FOR MATH.
recent assessment(s)? PLEASE
✓
Grade level in:
Reading
Mathematics
No grade level determined
95
95
Preschool/Kindergarten
00
00
Grade 1
01
01
Grade 2
02
02
Grade 3
03
03
Grade 4
04
04
Grade 5
05
05
Grade 6 or above
06
06
A34. Date of most recent reading assessment:
Month/year
05
06
07
08
1
2
3
4
0
b. I regularly give parents report cards for this child.
c. I call them on the phone, send email, or send notes home.
d. I speak with parents before or after school when this child is
being dropped off or picked up.
e. We have regularly scheduled parent-teacher meetings.
f. We share a daily or weekly journal for this child.
g. There is a regular system for communicating with parents
(e.g., newsletter or phone tree).
h. Parents have access to the school’s web site with information
specifically for parents.
✓
At least once a week
A few times a month
About once a month
Less than once a month
Never
A38. How involved are this child’s parents or guardians in his/her school experiences
(e.g., monitoring homework or child’s progress in school)? PLEASE
CHECK ONE.
2
3
4
8
Month/year
a. I give parents regular written progress reports.
A37. During this school year, approximately how often have you and this child’s parents
or guardians communicated (by phone, in person, or in writing) about his/her
CHECK ONE.
progress, excluding routine progress reports or report cards? PLEASE
1
A35. Date of most recent math assessment:
✓CHECK ALL THAT APPLY.
✓
Not at all involved
Not very involved
Fairly involved
Very involved
Don’t know
A39. During this school year, did this child’s parents or guardians attend a parent-teacher
CHECK ONE.
conference or “back-to-school night”? PLEASE
1
2
3
8
18
✓
Yes
No
Not applicable; we do not have parent conferences
or “back-to-school night”
Don’t know
19
A40. To what extent were you involved in planning this child’s transition into your class?
PLEASE
1
2
3
0
✓CHECK ONE.
A45. How are this child’s IEP goals and objectives primarily addressed in the regular
CHECK THE ONE THAT BEST DESCRIBES HOW
education classroom? PLEASE
✓
GOALS AND OBJECTIVES ARE PRIMARILY ADDRESSED.
01
Not at all
02
Somewhat
Extensively
03
Not applicable—transition planning not done
04
A41. How easy was it for this child to make the transition into your class or program?
PLEASE
1
2
3
4
✓CHECK ONE.
06
Very easy
07
Somewhat easy
1
2
8
Very difficult
1
2
3
✓CHECK ONE.
Yes
➜
No
Don’t know
}
2
3
8
2
4
8
Go to Question A44
0
✓
Not at all
The regular education teacher or aide works individually with the child
on special tasks.
Related services personnel work individually with the child on special tasks.
Related services personnel work with the child in group activities.
The goals and objectives are embedded in common classroom activities.
1
3
Extensively
4
I provided special education services
8
✓
Yes, this child has an IEP for
special education services.
}
Yes, this child has a 504 plan.
Continue with Question A45
➜
Go to Question A46
No, this child does not have an IEP or 504 plan.
➜
Go to Question A46
➜
Go to Question A50
0
Very adequate
Somewhat adequate
Not very adequate
Not adequate at all
Don’t know
No support is needed
✓
Very adequate
Somewhat adequate
Not very adequate
Not adequate at all
Don’t know
No support is needed
A48. Does your program support social interaction between this child and
CHECK ONE.
children without disabilities? PLEASE
1
2
3
4
5
20
✓
A47. Overall, how adequate are the supports and resources that are provided
CHECK ONE.
to you for this child because of his/her disabilities? PLEASE
2
Somewhat
Don’t know.
1
3
Continue with Question A43
A44. Does this child currently have either an IEP or a 504 plan for children
CHECK ONE.
with disabilities? PLEASE
1
The special education teacher or aide works individually with the child
on special tasks.
A46. Overall, how adequate are the supports that are provided to this child because of
CHECK ONE.
his/her disabilities? PLEASE
A43. To what extent did you communicate with the person(s) who provided
special education for this child last year? PLEASE
CHECK ONE.
0
Not applicable—the child’s IEP goals are not addressed in the regular education
classroom; they are addressed elsewhere.
Somewhat difficult
A42. Did this child have an IEP during the year prior to this school year?
PLEASE
05
Not applicable—the child is not in a regular education classroom.
✓
Yes
➜
Continue with Question A49
Not applicable—we do not currently have children
without disabilities enrolled in this class or program.
Not applicable—this child does not have contact with
children without disabilities during our program.
Not applicable—no support is needed.
No
21
}
Go to Question A50
A49. Does your program use any of the following methods to support social interaction
CHECK ONE IN EACH ROW.
between this child and children without disabilities? PLEASE
✓
Yes
a. We present a specific disability awareness program
during group times.
1
b. We assign children without disabilities to be “helpers”
or “buddies” to this child.
1
No
2
2
c. We prompt and reinforce this child for initiating and
maintaining interactions with children without disabilities.
1
2
d. We prompt and reinforce the children without disabilities
for initiating and maintaining interactions with this child.
1
2
e. We structure play and task situations so that they require
interaction between this child and children without disabilities.
1
2
f. Other (Specify: _____________________________________)
1
2
A51. 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.)
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
A50. To the best of your knowledge, what school and grade level do you anticipate this
CHECK ONE.
child will be in next year? PLEASE
✓
1st
2nd
3rd
grade grade grade
a. Same school as this year
b. Different school next year
c. Don’t know
1
2
1
2
1
2
3
3
3
4th
grade
4
4
4
Other
(Specify: ________________)
(Specify: ________________)
(Specify: ________________)
Please write the name and address of the school (if known) if you expect
this child will attend a different school next year.
Name of new school: _________________________________________________
School address: _______________________________________________________
______________________________________________________________________
22
23
Instructions for Section B of this Questionnaire:
1. Section B of the questionnaire is to be completed only for children with IEPs or 504 plans.
Does this child have an IEP or 504 plan?
●
YES, this child DOES have an IEP or 504 plan. Please continue with next question.
●
NO, this child does NOT have an IEP or 504 plan. Please go to page 33 of this
questionnaire.
2. Section B is to be completed by the teacher or specialist most familiar with the child’s
special education and related services. Can you describe this child’s special services?
●
YES. Please continue with Section B on the next page.
●
NO. Please remove Section B and give it to the person who you feel could best answer
questions about this child’s special education or related services. Please provide this
person’s name and phone number below. When this person completes Section B,
please have him or her return it directly to Westat using the self-mailer.
Name:
Phone:
(
)
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:
24
33
Please continue to the back cover.
Thank you for completing
this questionnaire.
Please return this questionnaire
in the postage-paid envelope to:
Pre-Elementary Education Longitudinal Study
Westat
1650 Research Blvd.
Rockville, MD 20850
WESTAT
21467.1206.80890309
thank you!
National Center for
Special Education Research
| File Type | application/pdf |
| File Title | design 1 |
| File Modified | 2006-12-12 |
| File Created | 2006-12-12 |