TPSID Evaluation Form

Question Text
PROGRAM DEMOGRAPHICS

Response Choices - Choose one response questions have a list.
Checkbox items say Checkbox and the text in column A is the
choice

PD11. Please provide the number of applicants, as well as the number accepted to your program for this year:
PD11_a1. Number of in-state applicants (accepted or rejected)
PD11_a2. Number of in-state applicants who were accepted
PD11_b1. Number of out-of-state applicants (accepted or rejected)
PD11_b2. Number of out-of-state applicants who were accepted

Open end numeric
Open end numeric
Open end numeric
Open end numeric

PD11_C. What are the reasons students are not accepted (e.g. disability label, need housing (not available), lack of funding, family
support, student level of support needs)

Open end text

PD3. Is your TPSID affiliated with a particular school, college, or academic department within your IHE?
PD6a_1. What is your TPSID program's total operating expenses? $____________
PD6b. What was the total operating expense for TPSID personnel this year?
PD7. Does your TPSID operate during the summer months?
PD9. (Ask in first year only) Did your IHE serve and/or support students with ID prior to receiving the TPSID grant?
Based on your staff data entry, the total number of FTEs for your program this year was:
PD12. Is the number above an accurate representation of the total number of FTEs needed to operate your program
PD13. (If no to PD12) How many FTEs were used to operate your TPSID this year?

-Yes
-No
Open end numeric
-Yes
-No
-Yes
-No
Calculated field
-Yes
-No
Open end numeric

STAFF – This information is reported for each TPSID staff person

Staff1. What type of employee best describes this staff member’s job?

Staff2_1. Please enter the average number of hours per week this person works for the TPSID program
ACADEMIC ACCESS

-Full professor
-Associate, Assistant, or adjunct professor
-Dean or other Administrator
-Research staff
-Program staff
-Administrative staff
-Graduate student
-Undergraduate students
Open end numeric box

Question Text
AA1. Are TPSID students required to take placement or ability to benefit tests in order to register for classes at your IHE?
AA2a. Please provide a link to a webpage for your IHE's certificate/credential approval process:
AA2. What types of credentials are available to students who attend your TPSID? Check all that apply.
We do not offer a credential
Associate degree granted by the Institution of Higher Education available to both TPSID and non-TPSID students Skip to question AA4
Bachelor s degree granted by the Institution of Higher Education available to both TPSID and non-TPSID students Skip to question
AA4
Certificate granted by the Institution of Higher Education available to both TPSID and non-TPSID students Skip to question AA4
Has this credential been approved through the IHE governance structure and is it officially awarded and recognized by the host IHE?
Which of the following best describes this credential?
Is this certificate aligned with an existing labor market certification? Then if yes, name it.
Certificate specifically for TPSID students granted and approved by the Institution of Higher Education and not available to other
students
Has this credential been approved through the IHE governance structure and is it officially awarded and recognized by the host IHE?
Which of the following best describes this credential?
Is this certificate aligned with an existing labor market certification? Then if yes, name it.
Specialized certificate or other exit document specifically for TPSID students granted and approved by the TPSID program (Not the
hosting IHE) and not available to other students
Has this credential been approved through the IHE governance structure and is it officially awarded and recognized by the host IHE?
Which of the following best describes this credential?
Is this certificate aligned with an existing labor market certification? Then if yes, name it.
Specialized certificate designed for TPSID students issued from the local education agency not available to other students
Has this credential been approved through the IHE governance structure and is it officially awarded and recognized by the host IHE?
Which of the following best describes this credential?
Is this certificate aligned with an existing labor market certification? Then if yes, name it.
Another credential not listed (Please specify :__________).
Has this credential been approved through the IHE governance structure and is it officially awarded and recognized by the host IHE?

Response Choices - Choose one response questions have a list.
Checkbox items say Checkbox and the text in column A is the
choice
-Yes
-No
Open end text
Checkbox
Checkbox
Checkbox
Checkbox
-Yes
-No
-This an existing credential at the IHE?
-This was a newly developed credential.

-Yes
-No
Checkbox
-Yes
-No
-This an existing credential at the IHE?
-This was a newly developed credential.

-Yes
-No
Checkbox
-Yes
-No
-This an existing credential at the IHE?
-This was a newly developed credential.

-Yes
-No
Checkbox
-Yes
-No
-This an existing credential at the IHE?
-This was a newly developed credential.

-Yes
-No
Checkbox
-Yes
-No

Question Text

Response Choices - Choose one response questions have a list.
Checkbox items say Checkbox and the text in column A is the
choice

Which of the following best describes this credential?

-This an existing credential at the IHE?
-This was a newly developed credential.

Is this certificate aligned with an existing labor market certification? Then if yes, name it.

-Yes
-No

AA4_New. Has your program developed a satisfactory academic progress policy?
AA4_Document. If Yes to AA4_New, Please upload a copy of your policy here:
EMPLOYMENT AND CAREER DEVELOPMENT

- Yes
- No

EC1. Who provides the employment services or work-related direct supports for the students in your TPSID program? Check all that
apply
We do not provide employment services or direct supports for the students in our TPSID program
Career Services staff available to all students attending the IHE
Peer mentors or supports
LEA transition staff for dually-enrolled students
State Vocational Rehabilitation Staff
State Intellectual and Developmental Disability agency staff
Separate/Contracted employment service provider, e.g. Community Rehab Provider
Supervisors at the worksite
Coworkers at the worksite
Other (please specify: __________)

-Job search services
-Employment support services
-Job search services
-Employment support services
-Job search services
-Employment support services
-Job search services
-Employment support services
-Job search services
-Employment support services
-Job search services
-Employment support services
-Job search services
-Employment support services
-Job search services
-Employment support services
-Job search services
-Employment support services

PLANNING AND ADVISING
PA1. Does the TPSID use Person Centered Planning with students in the program?
PA4. What is the TPSID using for an academic advising process? Check one.

-Yes
-No
-Regular advising system used by all students
-Separate advising system for TPSID students
-Both

Question Text
SOCIAL OPPORTUNITIES
SO1. Are TPSID students allowed to join registered student organizations at the IHE? Y/N
SO2. Have any of your students joined a registered student organization? Y/N
SO3. Are TPSID students allowed to attend social events on campus that are only available to students at the IHE? Y/N
SO4. Have any of your students attended social events on campus that are only available to students at the IHE? Y/N

Response Choices - Choose one response questions have a list.
Checkbox items say Checkbox and the text in column A is the
choice

-Yes
-No
-Yes
-No
-Yes
-No
-Yes
-No

RESIDENTIAL ACCESS
*We will provide information about whether or not the institution has housing for students.
RA2. Do TPSID students have the opportunity to access this housing?

-Yes
-No

RA2_1. Why are students unable to access this housing?

-Concerns from IHE
-Students are not regularly matriculated students and cannot access
housing
-Insufficient student housing availability
-Planning for housing – will be available in future
-Other

RA3. (If RA2 = Yes) Which of the following residential supports do students who live in IHE housing receive? Check all that apply.
¨ None
¨ Roommate/suitemate who receives compensation
¨ An uncompensated roommate/suitemate who provides supports
¨ Residential Assistant or Advisor who provides supports
¨ Continuous staff support
¨ Intermittent or on-call staff support
¨ Other support (please specify:__________)

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PEER SUPPORTS
PS1. Does your TPSID use peer mentors?
PS2. In which areas do peer mentors support TPSID students? Check all that apply.
Social
Academic

-Yes
-No
Checkbox
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Question Text
Independent living
Employment
Transportation
Other (please specify: __________)

Response Choices - Choose one response questions have a list.
Checkbox items say Checkbox and the text in column A is the
choice
Checkbox
Checkbox
Checkbox
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INTEGRATION WITH INSTITUTION OF HIGHER EDUCATION
IIHE1. Do any TPSID staff participate in existing IHE professional development?
IIHE7. Do TPSID students follow the academic calendar used by the IHE?
IIHE8. Are TPSID students held to the IHE’s code of conduct?
IIHE9. How is this code of conduct shared with TPSID students? Check all that apply.
Reviewed with student
Student is given a copy of the code of conduct
Code of conduct is available but is not reviewed with or given directly to students
Other (Please specify:____________)

IIHE_10_New. What types of strategies are used to communicate with family members of students attending this TPSID?

IIHE11. Do TPSID students receive a transcript? Select one.

IIHE12_New. Are students issued an official student ID from the IHE?
IIHE 15_1. Do student attend the regular orientation for new students at the IHE?
IIHE 15_2. Do family members of students attend the regular orientation for new students at the IHE?
IIHE 15_3. Do you provide a special orientation for students?
IIHE 15_4. Do you provide a special orientation for family members of students?

-Yes
-No
-Yes
-No
-Yes
-No
Checkbox
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Checkbox
e sa e co

u cat o st ateg es used o a stude ts at t e
IHE
- Communication strategies specifically for family members of
students attending the TPSID
- Both
- We do not communicate with family members of students
attending the TPSID
- Yes, an official transcript from the IHE
- Yes, a transcript from the TPSID program
- Yes, both an official transcript and a transcript from the TPSID
program
- No, they do not receive a transcript
- Yes
- No
- Yes
- No
- Yes
- No
- Yes
- No
- Yes
- No

Question Text

Response Choices - Choose one response questions have a list.
Checkbox items say Checkbox and the text in column A is the
choice

IIHE16. To the best of your knowledge, have TPSID students used any of the following IHE resources in the past year? Check all that
apply.
Health center/counseling services
Career services
Registrar, Bursar, or financial aid office
Tutoring services
Library
Bookstores
Computer lab/Student IT services
Sports and recreational facilities or Arts/cultural center
Student center or Dining hall
Disability services office
Residential Life
Off-campus housing services
Students did not use any of these resources this year.

- Yes
- No
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IIHE16a. Does the enrollment status of TPSID students impact their access to any privileges or processes that apply to matriculated
students at the IHE?
If yes, what impact? Check all that apply.
Register for classes after matriculated students
Limits access to student organizations
Which organizations?
Limits access to campus services, such as health services
Which services?
Not allowed to participate in graduation
Not awarded an IHE approved credential
Not considered alumni of the IHE
OTHER – text box

- Yes
- No

IIHE17. Does your IHE host a TRIO, GEAR UP or other college access program? Check all that apply
TRIO
GEAR UP
Other college access program (please specify)
IIHE18. If TRIO is checked, do you collaborate with this TRIO program?
IIHE19. If TRIO is Checked, do your students receive services from this TRIO program?

Checkbox
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Checkbox
- Yes
- No
- Yes
- No

Question Text
IIHE18. If GEAR UP is checked, do you collaborate with this GEAR UP program?
IIHE19. If GEAR UP is Checked, do your students receive services from this GEAR UP program?
IIHE18. If other college access program is checked, do you collaborate with this program?
IIHE19. If other college access program is checked, do your students receive services from this program?

Response Choices - Choose one response questions have a list.
Checkbox items say Checkbox and the text in column A is the
choice
- Yes
- No
- Yes
- No
- Yes
- No
- Yes
- No

COLLABORATION WITH OTHER PARTNERS – Report this information for each partner

CP1_New. Please select the organization the TPSID has an active partnership with: Add a tool tip about other possible ones like PTICs
and Private foundations

If VR is selected
CP_VR1. Does your TPSID collaborate with your state Vocational Rehabilitation services to provide pre-employment transition
services?
If yes:
In collaboration with state VR services do you provide to your TPSID participants:
CP_VR1a. Self-advocacy instruction
CP_VR1b. Work-based learning experiences
CP_VR1c. Social skills and work place skills development

CP2. How frequently does the TPSID interact with this organization? Check one.

-Education Agencies (K-12, Local, and Regional)
-Vocational Rehabilitation
-Community Rehabilitation Provider(s)
-State intellectual/Developmental Disability (IDD) services agency
-Advocacy Groups
-Employers
-University Centers for Excellence in Developmental Disabilities
(UCEDDs)
-Developmental disability councils (DD Councils)
-Other
- Yes
- No

- Yes
- No
- Yes
- No
- Yes
- No
-Annually
-Bi-annually
-Quarterly
-Monthly
-Weekly
-Daily

Question Text
CP3: What functions does this partner serve? Check all that apply.
Advisory board/consultant
Provides direct service to TPSID students
Provides training to TPSID staff
Provide career development opportunities for students
Provide paid jobs for students
Other (please specify:____________)
CP4 . Does this partner provide any of the following? Check all that play?
Funds for student tuition
Funds for other students expenses (fees, room, board, etc.)
Funds for other program expenses (operating expenses)
FUNDING SOURCES
FS1. Other than the funding you received from the Office of Postsecondary Education, which of the following sources of funds are you
using to support the development & implementation of your TPSID program (e.g. to pay TPSID staff & other expenses)? Check all that
apply
IHE resources
Medicaid
Local Education Agency (LEA)
Other government-funded grants
Private foundation grants
Funding from state budget
State intellectual/developmental disability (IDD) services agency funds
State Vocational Rehabilitation agency funds
Student Tuition and Fees
Individual and/or corporate donors
FS2. How is your program meeting the match requirements for this the grant? Check all that apply.
FS2_1. If FS2 = "in-kind" to in-kind which kinds you received? Check all that apply
faculty/staff time
rent
physical space
materials
waving overhead
rent for space
VR drawdown
Other
FS2_2. What types of other monetary contributions?"

Response Choices - Choose one response questions have a list.
Checkbox items say Checkbox and the text in column A is the
choice

Checkbox
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Checkbox
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- In-kind contributions
- Other monetary contributions
Checkbox
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Text Box

Question Text
FS3. What is this program's Comprehensive Transition Program (CTP) status?
FS3_1_1. (If FS3 = We are an approved CTP ) When did you submit your application: mm/did/yyyy
FS3_1_2. (If FS3 = We are an approved CTP ) When did you receive approval: mm/dd/yyyy
FS3_2_1. (If FS3 = We have applied to become a CTP and are awaiting a response ) When did you submit your application: mm/dd/yyyy
FS3_2_2. (If FS3 = We are an approved CTP or We have applied to become a CTP and are awaiting a response) Did your program
experience challenges during the approval process, e.g. communication, applications components, etc.?
FS3_2_3. If yes, please describe these challenges: _______

Response Choices - Choose one response questions have a list.
Checkbox items say Checkbox and the text in column A is the
choice
-We are an approved CTP
-We have applied to become a CTP and are awaiting a response
- We are considering becoming a CTP
-We are not a CTP and have no plans to apply to become one
Date
Date
Date
-Yes
-No
Open end text

CHARGES TO STUDENTS

Which Type of Student Charges Structure are you reporting?

-All Students (use when charges to students do not vary based on
residential status)
-In-State
-Out-of-state
-In-County
-Out-of or Non-County
-City Resident
-Student who is NOT a city resident
-International Student
-Other Type of Student

What are the average total charges (including tuition, required fees, room and board) for this type of student to attend your program?

Open end numeric

If charges for this type of student are not broken out into individual categories because your Program charges a comprehensive fee that is
all inclusive check here and all that apply from the list below.
Tuition
Required Fees
Room
Board
Other (Please specify:)

Checkbox
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Checkbox
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Checkbox

Please indicate the categories for which you charge This type of student for each category selected.
Tuition
Required Fees
Room

Checkbox
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Checkbox

Question Text
Board

Response Choices - Choose one response questions have a list.
Checkbox items say Checkbox and the text in column A is the
choice
Checkbox

POST EXIT DATA COLLECTION EFFORTS
EA4. Does your IHE and/or TPSID program collect follow-up data on students who exited the TPSID program (with or without a
credential)? Select one.

-Yes
-No

EA5. For how long after exiting the program does the IHE and/or TPSID program collect data on students? Select one.

-1 year
-2 years
-3 years
-4 years
-5 or more years

EA6. Which follow-up data does the IHE and/or TPSID program collect? Check all that apply.
Type of job
Earnings
Hours worked per week
Length of employment
Volunteer or community service activities
Postsecondary graduation rate
Transfer to 2 or 4-year colleges and universities
Social or community involvement measures
Independent living measures
Quality of life measures
Other (please specify:__________)

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STUDENT CORE DATA
What was this student's first year in the TPSID program?
(Note: if this student attended your program prior to 2010-11, you should still enter 2010-11 since this is when your program first
received TPSID funding)

SC1. Student’s Age in Years as of 10/1/2015: ____________
SC2. Student’s gender.
SC3. What is this student’s ethnicity? Choose one.

-2009-10
-2010-11
-2011-12
-2012-13
-2013-14
-2014-15
-2015-16
-Male
-Female
-Hispanic or Latino
-Not Hispanic or Latino

Question Text
SC4. What is this person's race? Mark one or more races to indicate what this person considers himself/herself to be.
Asian
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
White
This student's race is unknown
SC5. What disabilities does this student have? Check all that apply
None of these disabilities
Autism
Deaf-blindness
Deafness
Developmental delay
Emotional disturbance
Hearing impairment
Intellectual disability
Multiple disabilities
Orthopedic impairment
Other health impairment
Specific learning disability
Speech or language impairment
Traumatic brain injury
Visual impairment, including blindness
SC5a. What documentation did you use to confirm this student has an intellectual disability?
ID was not confirmed through documentation
Neuropsychological or psychological examination report
Physician’s documentation of disability
Individualized Education Plan
SSA Disability Determination
Other (please specify:________________)
SC6. What types of benefits is this student receiving? Check all that apply.
None
SSI (Supplemental Security Income)
SSDI (Social Security Disability Insurance)
Medicaid Benefits
Other (please specify:________________)
Don’t Know

Response Choices - Choose one response questions have a list.
Checkbox items say Checkbox and the text in column A is the
choice

Checkbox
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Response Choices - Choose one response questions have a list.
Checkbox items say Checkbox and the text in column A is the
choice

Question Text
SC8. Which of the following best describes the curriculum and educational setting the student experienced in his/her high school prior to - Fully included (no special education classes)
entry into this program? Check one.
- Special education classes only
- Spent majority of their time in inclusive setting
- Spent majority of their time in special education classes
- Other
- Don't Know
SC10. Was this student ever employed for pay at or above minimum wage prior to entry into the TPSID program? Choose one.
SC13. Please indicate this student's total household income during 2015. Please include all income earners residing in this student's
household:

-Yes
-No
-<$25,000
-$25,000-$49,999
-$50,000-$74,999
-$75,000-$99,999
-$100,000-$149,999
-$150,000-$200,000
->$200,000

ACADEMIC STATUS
AS1. Is this student dually enrolled (receiving special education services under IDEA AND enrolled in a postsecondary program)?
AS2. What is the student’s high school graduation status? Choose one.

AS3 What was the student’s enrollment status in the IHE as of September 2016? Check all that apply.
Not enrolled
Enrolled as a TPSID program student
Enrolled as a special student
Matriculated as a regularly enrolled student at the IHE
Enrolled as a non-degree or continuing education student

-Yes
-No
-Received certificate of completion or attendance
-Received standard diploma
-Received modified or special diploma
-Received GED/high school equivalency certificate
-Dropped out
-Other
Checkbox
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Question Text

Response Choices - Choose one response questions have a list.
Checkbox items say Checkbox and the text in column A is the
choice

AS3A. What is the residency status of this TPSID student for the purposes of tuition and fees?

-In-State Student
-Out-of-state Student
-Other (Please Specify):

AS3B. Which of the following best described this student's enrollment status?

-Full time
-Part Time Matriculating
-Non Matriculating

AS3A_1. Did this individual exit the TPSID during this academic year?

-Yes
-No
-1st year
-2nd year
-3rd year
-4th year
-Beyond 4th year

AS4. What year of the TPSID program is the student in? Choose one.

AS5. Is this the student’s final year in the TPSID program?
AS6. Is this student seeking the meaningful credential offered by TPSID?
AS8. Is this student seeking a degree or certificate offered by the IHE other than a credential offered by the TPSID?
AS11_1. Does this student get any supports or accommodations from the Disability Services Office (DSO) on your campus?
AS11_2. If "Yes" to previous question, Please indicate the degree to which the DSO provides supports/ accommodations for this student
on-campus.

AS11_3. (If no to AS11_1) Was this student denied services from the DSO?
AS11_3txt. (If yes to AS11_3). Why were they denied services from the DSO?
COURSE ENROLLMENTS

-Yes
-No
-Yes
-No
-Yes
-No
-Yes
-No
- The DSO provides all of the supports/accommodations for this
student
- The DSO provides some of the supports/accommodations for this
student and other entities (program staff, faculty, peer mentors,
etc.) provide the rest.
-Yes
-No
Open end text

Question Text
BEGIINING IN FALL 2015 - WE WILL SPLIT THE COURSE DATA ENTRY INTO AREAS FOR INCLSUIVE AND
SPECIALIZED COURSES

Response Choices - Choose one response questions have a list.
Checkbox items say Checkbox and the text in column A is the
choice

TOOL TIP
An INCLUSIVE course is one which is available to regularly matriculated IHE students and is accessed via the regular registration
process at the IHE, lasts the length of an entire term, and is attended by regularly matriculated students.
A SPECIALIZED course is only available to TPSID students, not regularly matriculated students at the IHE, is developed/designed for
students with ID and attended primarily or exclusively by students with ID
CO1.What is the Course Title:
CO1_1. Does this course have prerequisites that must be met before the student can enroll in this course? E.g. declared major, completion - Yes
of lower level courses?
- No
CO2a_1. (for specialized courses only) How long do students attend this course?
-Students do not attend this course for a full academic term
- Students attend this course for the full academic term, e.g.
semester or quarter
CO2a_2. (If “less than full term to CO2a_1) please describe how frequently and for how many class meetings this course meets? i.e. how Enter the total number of weeks this course meets here (if it is
many weeks does the course meet? How many class meetings per week
easier for you to enter the total number class meetings, you may
skip this and enter it in the space below: ______
Enter total number of class meetings here: _____
CO2a_3. (for specialized courses only) Does this course appear on your IHE’s course catalog?
CO2a_4. Which of the following best describes the primary instructor for this course? Check one.

CO2b_new. What type of credits are awarded for students who complete this course?

CO3. (for specialized courses only) What subjects are covered in this course? Check all that apply.
Academic skills
Career preparation instruction
Independent Living Instruction

- Yes
- No
- IHE faculty (Full-time or Adjunct)
- Secondary school teacher
- TPSID staff person
- Graduate student
- Undergraduate student
- Volunteer
- Other, specify:_______
- Typical IHE credits that can be used towards a degree or
certificate
- Credits that are only available to TPSID students that CANNOT
be used towards a regular IHE degree or certificate
- Continuing education credits
- No credits are awarded to students who complete this course
Checkbox
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Question Text
Technology training/computer literacy
Social skills training
Travel training instruction
Other (please specify:________________)
Please report the following information for each course a student is taking.
AC1. Which of the following best describes the student's enrollment in this course? Choose one.

AC1_1. Does student earn credit towards their TPSID credential by taking this course?
AC1_2. Did this student receive a grade for this course?
AC1_3. What grade did the student receive in this course?
AC2. Why is the student taking this course? Check all that apply.
It is related to his/her career goals
It is related to his/her personal interest
It is required for credential
It is required for their degree/certificate

Response Choices - Choose one response questions have a list.
Checkbox items say Checkbox and the text in column A is the
choice
Checkbox
Checkbox
Checkbox
Checkbox

- Enrolled for standard IHE credit
- Enrolled as a non-credit student or auditing course
- Unofficially attending /sitting in on course
- Yes
- No
- Yes
- No
open end text
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FINANCING EDUCATION
Did this student receive any of the following forms of Federal Financial Aid this Year? Check all that apply.
Federal Work Study (not a State work study)

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Pell Grant
Supplemental Educational Opportunity Grant
Parent PLUS Loans

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F1. Which of the following funding sources are used to pay tuition for this TPSID student?
Check all that apply.
Tuition is waived for this student
Private pay (student and family)
Scholarships
State intellectual/developmental disability (IDD) services agency: state or local funds
Local Education Agency
Private student loans
Federal/State grant
Foundation/Private grant

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State Vocational Rehabilitation agency funds
State IDD Services Agency: Medicaid Home and Community-Based Services (HCBS) Waiver funds
Tuition Waivers via VR or Social Security
National Service grants
Social Security funds e.g. PASS plan
Other funding source (please specify: __________)
None of these sources are used to fund the students tuition
F2. Which of the following funding sources are used to pay for non-tuition expenses for this TPSID student? Check all that apply.
Private pay (student and family)
Scholarships
State intellectual/developmental disability (IDD) services agency: state or local funds
Local Education Agency
Private student loans
Federal/State grant
Foundation/Private grant
State Vocational Rehabilitation agency funds
State IDD Services Agency: Medicaid HCBS Waiver funds
Tuition Waivers via VR or Social Security
National Service grants
Social Security funds e.g. PASS plan
Other funding source (please specify: __________)
None of these sources are used to fund the student’s non-tuition expenses

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CAREER DEVELOPMENT/EMPLOYMENT
CDE1. Which of the following unpaid/volunteer experiences did the student participate in this year? Check all that apply.
This student did not participate in unpaid/volunteer experiences this year
Service learning opportunities
Unpaid internships (For credit and not for-credit)
Volunteering and/or Community service
Unpaid individual work training sites
Other unpaid/volunteer experience, please specify:________)
Please report the following information for each paid job the student has. Items with an * following them are updated each time the status
for this item changes for a particular job.
Name of the employer:______________
Student’s Job Title at this job: ___________________*
Job start date: mm/dd/yyyy
Job exit date: mm/dd/yyyy (entered only if student leaves this job)

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JOB1. Please select the category that best describes this job setting:

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- Individual paid job
- Paid internship (For-credit or non-credit)
- Federal work-study
- Group paid work (Enclave or mobile crew)
- Work training site
- Sheltered workshop

Job1_2. Who pays the student at this Job? (Hide if Job 1 = Federal Work Study)

- The employer
- The TPSID program
- The host IHE
- Other (please specify)

JA1. Do you know this individual's exact hourly rate of pay?

-Yes
-No

JA1a. Please provide the student's hourly rate of pay:
JA1b. Please describe the wages earned at this job:

JA2. Do you know this individual's exact hours worked?
JA2a. Please provide this student s average hours worked per week
JA2b. How many hours per week on average does the individual work in this job?*

-Below minimum wage
-Minimum wage
-Above minimum wage
-Don’t know
-Yes
-No
-Under 5 hours per week
-Between 5 and 10 hours per week
-Between 11 and 20 hours per week
-Between 21 and 30 hours per week
-Between 31 and 40 hours per week
-Over 40 hours per week

JA2. continued. Why does this individual work no more than 20 hours per week? Please check all that apply.
Concerned about losing Social Security/Medicaid benefits
Health or disability status limits ability to work more hours
Unable to get more hours at current job
Attending postsecondary education
Family obligations
Other Reason. Please describe:

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JA6. Which of the following best describes this individual s field of employment?
Computer, mathematical, architecture, engineering, and science occupations
Education, training, and library occupations
Arts, design, entertainment, sports, media occupations
Healthcare practitioners and technical occupations

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Protective service occupations
Food preparation and serving related occupations
Building and grounds cleaning and maintenance occupations
Personal care and service occupations
Sales and related occupations
Office and administrative support occupations
Construction and extraction occupations
Installation, maintenance, and repair occupations
Production occupations
Transportation and material moving occupations
Military specific occupations
Other OCCUPATION. Please describe:

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WIOA IMPACT

WIOA1. Did this student receive services from a state VR program this year?
(If no to WIOA 1) WIOA1_1. Was this student denied services from a VR program this year? If yes, please explain why.
(If yes to WIOA 1) WIOA2. Please check which of the following services this student received from your state Vocational Rehabilitation
office during this year:
Benefits counseling
Self-advocacy instruction
Work-based learning experiences (e.g., internships, trial work experience)
social skills instruction
work place skills instruction
job coaching
supported employment
other (please specify) __
WIOA3. Is this student eligible for Medicaid?
WIOA4. Is this student receiving Medicaid services?

-Yes
-No
-Yes
-No

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-Yes
-No
-Yes
-No

WIOA5. If yes: What services or supports does Medicaid pay for (check all that apply):
Transportation
Day support

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Personal care attendant
Other (Please specify)

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SOCIAL PARTICIPATION
SP_New. This year, how much time did this student spend during a typical week doing the following activities?
SP_New1. Attending classes/labs

-None
-< 1 hr. per week
-1-2 hrs. per week
-3-5 hrs. per week
-6-10 hrs. per week
-11-15 hrs. per week
-16-20 hrs. per week
-Over 20 hrs. per week

SP_New2. Studying/homework

-None
-< 1 hr. per week
-1-2 hrs. per week
-3-5 hrs. per week
-6-10 hrs. per week
-11-15 hrs. per week
-16-20 hrs. per week
-Over 20 hrs. per week

SP_New3. Socializing with friends in person

-None
-< 1 hr. per week
-1-2 hrs. per week
-3-5 hrs. per week
-6-10 hrs. per week
-11-15 hrs. per week
-16-20 hrs. per week
-Over 20 hrs. per week

SP_New4. Exercising or sports

-None
-< 1 hr. per week
-1-2 hrs. per week
-3-5 hrs. per week
-6-10 hrs. per week
-11-15 hrs. per week
-16-20 hrs. per week
-Over 20 hrs. per week

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SP_New5. Student clubs and groups

Response Choices - Choose one response questions have a list.
Checkbox items say Checkbox and the text in column A is the
choice
-None
-< 1 hr. per week
-1-2 hrs. per week
-3-5 hrs. per week
-6-10 hrs. per week
-11-15 hrs. per week
-16-20 hrs. per week
-Over 20 hrs. per week

SP_New6. Household/childcare duties

-None
-< 1 hr. per week
-1-2 hrs. per week
-3-5 hrs. per week
-6-10 hrs. per week
-11-15 hrs. per week
-16-20 hrs. per week
-Over 20 hrs. per week

SP_New7. Commuting

-None
-< 1 hr. per week
-1-2 hrs. per week
-3-5 hrs. per week
-6-10 hrs. per week
-11-15 hrs. per week
-16-20 hrs. per week
-Over 20 hrs. per week

SP_New8. Online social networks (Facebook, Twitter, etc.)

-None
-< 1 hr. per week
-1-2 hrs. per week
-3-5 hrs. per week
-6-10 hrs. per week
-11-15 hrs. per week
-16-20 hrs. per week
-Over 20 hrs. per week

LIVING SITUATION
LS1. Where does this student live? Choose one.

- With Family
- In a residence provided by or associated with the IHE
- In another residence NOT provided by or associated with the IHE

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LS2. In which type of residence not provided by or associated with the IHE or TPSID program does the student live? Choose one.

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-Independent - on his/her own
-Supervised apartment or supported living situation
-Group home
-Other

LS3_1. Which type of residence offered by or associated with IHE or TPSID program does the student live? Select one.

- Residence hall
- On-campus apartment
- Off-campus apartment
- Other

LS3_2. Which of the following best describes this residence? Select one.

- Available to all IHE students
- Specifically for TPSID students

LS4. Which of the following residential supports does the student receive? Check all that apply.
¨ None
¨ Roommate/suitemate who receives compensation
¨ An uncompensated roommate/suitemate who provides supports
¨ Residential Assistant or Advisor who provides supports
¨ Continuous staff support
¨ Intermittent or on-call staff support
¨ Other support (please specify:__________)

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STUDENT EXIT SURVEY
EX1. What was this individual’s date of exit: mm/dd/yyyy
EX2. What were the reasons for the individual’s exit? Check all that apply
Completed TPSID program and earned TPSID credential skip to question EX3
Completed degree or certificate program available to TPSID and non-TPSID students skip to question EX3
Transferred to another postsecondary education program Go to EX2a and Skip EX3 and EX4-EX4d if they did not complete the
TPSID program or earn a degree
Student no longer wanted to attend TPSID program Please specify why: _______ then skip to question EX3a
Student was dismissed from TPSID program. Please specify why: _______ then skip to question EX3a
Unknown skip to question EX3a
Other reason, please specify: ________________ then skip to question EX3a
EX2a. Which type of program did the student indicate plans to transfer to?
A specialized postsecondary education program for students with ID:
A general postsecondary education program for students with and without ID:

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Academic Achievements
EX3. Which types of credential or credentials did this individual earn? Check all that apply and specify when checked
Associate degree granted by the Institution of Higher Education available to both TPSID and non-TPSID students
Bachelor’s degree granted by the Institution of Higher Education available to both TPSID and non-TPSID students
Certificate granted by the Institution of Higher Education available to both TPSID and non-TPSID students
Certificate specifically for TPSID students granted by the Institution of Higher Education and not available to other students
Specialized certificate or other exit document specifically for TPSID students granted by the TPSID program (Not the hosting IHE) and
not available to other students
Specialized certificate designed for TPSID students issued from the local education agency not available to other students
Another credential not listed (Please specify:__________).

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choice

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Employment/Career development
EX5. Which of the following unpaid/volunteer experiences was this individual participating in at program exit? Check all that apply
This individual did not participate in unpaid/volunteer experiences at the time of exit from the program
Service learning opportunities
Unpaid internships (for credit and not for-credit)
Volunteering and/or Community service
Unpaid individual work training sites
Other unpaid/volunteer experience, (please specify:________)
Residential
EX6. In which type of residence did the student live at program exit? Choose one

Benefits
EX7. What types of benefits was this student receiving at program exit? Check all that apply.
None
SSI (Supplemental Security Income)
SSDI (Social Security Disability Insurance)
Medicaid
Other (please specify:________________)
Don’t Know

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-With Family
-Independent - (alone or with roommates/partner)
-Supervised apartment or supported living situation
-Campus housing (if student transferred)
-Group home
-Other

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