Special Education Programs and Related Services

KINDERGARTEN

school
ELEMENTARY
W4

Section B:
SPECIAL EDUCATION PROGRAMS AND RELATED SERVICES

PE E S
L

Pre

school
W4

Pre-Elementary Education Longitudinal Study

Section B:

Kindergarten Teacher
Questionnaire

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

B1. What are this child’s disabilities?

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 B 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 Education 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

PLEASE
PLEASE

✓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

a. Autism

01

01

b. Deaf/blindness

02

02

c. Deafness

03

03

d. Developmental delay

04

04

e. Emotional disturbance/behavior disorder

05

05

f. Hearing impairment

06

06

g. Learning disability

07

07

h. Mild mental retardation

08

08

i. Moderate/severe mental retardation

09

09

j. Multiple disabilities

10

10

k. Orthopedic impairment

11

11

l. Other health impairment

12

12

m. Speech or language impairment

13

13

n. Traumatic brain injury

14

14

o. Visual impairment/blindness

15

15

p. Other (Specify: _________________________)

16

16

q. Not sure

98

98

27

B2. 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
CHECK ONE.
devices, electronic equipment, etc.) PLEASE
1

2

✓

Yes

01

02
03
04
05
06
07
08
09
10

98

✓

01

02

No

03

B3. For this school year, what are the three most important IEP goals for this child?
PLEASE

B5. 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.

CHECK UP TO THREE.

✓

a. Not applicable —the child does not have an IEP.

➜

Go to Question B6

b. Improve overall school readiness
c. Improve academic performance in a specific area: _________________________
d. Improve social skills

04
05
06
07
08
09
10

e. Improve appropriateness of general behavior

11

f. Improve adaptive behavior or self-help skills
g. Improve speech/communication skills

12

h. Improve fine motor skills

13

i. Improve gross motor skills
j. Other (Specify: ____________________________________________________)

14
15

k. Don’t know

16

B4. 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

Much more progress than expected

17
18
19

20
21

More progress than expected

22

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

28

23
24

a. Adaptive physical education
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)
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)
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: _______________________________)

29

B6. Which of the following are provided to this child as part of his/her IEP or 504 plan?
PLEASE

✓CHECK ALL THAT APPLY.

Accommodations/modifications
01

02
03
04
05

a. Modified grading standards

________________________________________________________________________________________

b. Slower-paced instruction
c. Additional time to complete assignments

________________________________________________________________________________________

d. Modified assignments

________________________________________________________________________________________

e. Physical adaptations (e.g., preferential seating, special desks)

________________________________________________________________________________________
________________________________________________________________________________________

Learning aids
06
07
08
09
10
11
95

●
●

B8. 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.)

________________________________________________________________________________________

f. Books on tape
g. Communication aids (e.g., Touch Talker, manual printing board)
h. Use of spell checker
i. Computer software designed for children with disabilities
j. Computer hardware adapted for child’s unique needs
(e.g., alternative keyboards, switch interface)
k. Other (Specify: _________________________________________________)
No accommodations/modifications or learning aids provided
(NOT ANY of items a. through k., above)

IF YOU COMPLETED SECTION A, please go to the back cover.
IF SOMEONE ELSE COMPLETED SECTION A, please continue with B7.

B7. 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 services to child’s teacher(s)

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.

d. Provide case management (e.g., program monitoring) for this child
e. Program administrator or supervisor

Your Name:

f. Supervise instructional assistant or paraeducator assigned to
work with this child

School/Program Name:

g. Other (Specify: ____________________________________________________)
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

21469.1206.80890309

thank you!

National Center for
Special Education Research