Strategies for Young Children with Dual Sensory Disabilities The Sooner the Better

For Families and Service Providers – Birth-to-Three and Preschool

Section 5: A Few Handy Forms

• Checklist: B-3 Content on Deaf-Blindness

• Communication Consistency

• Communication Dictionary [template and example]

• Deaf-Blind Census Form

• Likes/Dislikes [template]

• Release of Information (WSDS ROI)

• Routines [template]

• Use of Sensory Channels [template]

B-3 and Preschool Content Checklist: Deaf-Blindness

Child’s Name Date of Birth

Assessment Date Comment Update Comment

Likes/Dislikes Form

Communication Matrix

Preferred Sensory Channels

Home Talk

Home/School Inventory of Problem-Solving Skills

Other:

Building a Foundation Date Comment Update Comment

Access to People, Objects, Activities

Bonding/Relationships

Importance of Routines

Likes/Dislikes

Sensory Channels

Touch

Strategy Introduced Date Comment Update Comment

Active Learning

Choice Making

Co-Active Movement

Cues

1. Touch Cues

2. Object Cues

Greeting/Leaving Rituals

Hand-Under-Hand

Name Cues/Identifiers

Wait Time and Pacing

Other Forms Date Comment Update Comment

Release of Information

Deaf-Blind Census Form

COMMUNICATION CONSISTENCY FORM

Child: ________________________ Date: __________________

Activity Spoken Message Signed Message Object Cue Touch Cue

Communication Consistency/FORMS [Rev. 03/2006]

Communication Dictionary

What she does What we think it means How we respond

Communication Dictionary (Example)

What he does What we think it means How we respond

Head turn, make eye contact, over- exaggerated blink

• In response to “Are you ready?”: he is indicating “yes”

• When initiated it means: “I want to connect.”

In response: you initiate the activity you’ve asked if he is ready for.

When he initiated: initiate interaction.

Look and rapid blink • Typically questioning something: o It may be for reassurance in

unfamiliar settings/situations, “What’s going on?”

o It also might be asking “What’s that?”

o Can also be excitement

Respond to him by describing what’s going on.

Tickling hand with finger when you present your hand to him

Initiation for interaction, might mean: “I’m ready to engage.”

Signing with him and initiating play.

Lifts shoulders, without lifting hands (jerky movements typically-- you might see muscle effort)

“I want to continue this interaction.” Continue interaction using sign and verbal language.

Lifting one hand up Again, this might be inquiry, he might be checking in about a new experience, shows he’s engaged.

Give information about the experience.

Lifting both hands and shoulders up from elbows—hands end in air, curled up

This is a seizure. Provide some verbal reassurance:

“It’s almost done.”

“You’re back.”

Turn toward a person “I’m thinking about you and want to connect with you”—showing he’s engaged.

Give wait time for him to fully turn, then respond with verbal and sign to initiate interaction.

His eyes are almost closed, sneaky peeks

• “I’m tired” or

• “Not yet fully engaged” or

• “I’m not sure about this” or

• “I don’t want to interact”

Be big about engagement (increase volume, big hand movements, motherese—lots of intonation).

Cue him by saying, “Big boy eyes” with gesture.

Use tactile contact with him.

Communication Dictionary (Example) Page 2

What he does What we think it means How we respond

His eyes are almost closed, sneaky peeks (continued)

This also could be a time to acknowledge that he may need the interaction to be a bit slower.

For someone he’s not comfortable with, it might mean slowing down, quieting, being present and stepping back a bit to tactile connection (as you mentioned below), or connection around movement or a visual object or person of interest.

Vocalizing without movement “ah” or “wuh” or exhale sound

His response in a conversation, this happens after he’s engaged.

Communication partner should stop talking and give him the “air time”—allow multiple seconds for him to get it out and then respond.

Communication partner should acknowledge it as his conversational turn.

“Uh” in rhythmic manner

Initiating discomfort. Provide reassurance and check for discomfort.

Change in breathing, a pause in his breathing

“I’m getting ready to talk”—Then the inhale, then he can vocalize.

Listen quietly and wait for him to vocalize.

Holding his breath (this might be at midline)

Not quite sure what this means, he sometimes gets stuck but sometimes seems to do it purposely.

Encourage him to keep moving head to his side.

Let him know you’re listening (i.e., if it’s on purpose what is he trying to tell us? Let him know we are there/curious).

Sweeping with his left arm

Can move arm out but not back in.

[Adapted from Vermont Sensory Access Project, 9/18/16]

⃝New ⃝ Male

⃝ Update

⃝ No change ⃝ Female

FORM TO BE COMPLETED BY THE STUDENT'S TEACHER OR TEAM MEMBER

⃝No longer in district. Moved to: Student’s Last Name Student’s First Name School District _______________________________

⃝SSID#_______________________ Address (10 digit student ID#)

Date of Birth:

City State Zip Code / /

Month Day Year

Parent(s)/Guardian Phone

PRIMARY IDENTIFIED ETIOLOGY: Select ONE from the list below that best describes

the etiology of the individual’s primary disability.

Hereditary/Chromosomal Syndromes and Disorders

101 Aicardi syndrome

102 Alport syndrome

103 Alstrom syndrome

104 Apert syndrome (Acrocephalosyndactyly, Type 1)

105 Bardet-Biedl syndrome (Laurence Moon-Biedl)

106 Batten disease

107 CHARGE association

108 Chromosome 18, Ring 18

109 Cockayne syndrome

110 Cogan Syndrome

111 Cornelia de Lange

112 Cri du chat syndrome (Chromosome 5p-syndrome)

113 Crigler-Najjar syndrome

114 Crouzon syndrome (Craniofacial Dysotosis)

115 Dandy Walker syndrome

116 Down syndrome (Trisomy 21 syndrome)

117 Goldenhar syndrome

118 Hand-Schuller-Christian (Histiocytosis X)

119 Hallgren syndrome

120 Herpes-Zoster (or Hunt)

121 Hunter Syndrome (MPS II)

122 Hurler syndrome (MPS I-H)

123 Kearns-Sayre syndrome

124 Klippel-Feil sequence

125 Klippel-Trenaunay-Weber syndrome

126 Kniest Dysplasia

127 Leber congenital amaurosis

128 Leigh disease

129 Marfan syndrome

130 Marshall syndrome

131 Maroteaux-Lamy syndrome (MPS VI)

132 Moebius syndrome

133 Monosomy 10p

134 Morquio syndrome (MPS IV-B)

135 NF1 - Neurofibromatosis (von Recklinghausen disease)

136 NF2 - Bilateral Acoustic Neurofibromatosis

137 Norrie disease

138 Optico-Cochleo-Dentate Degeneration

139 Pfeiffer syndrome

140 Prader-Willi

141 Pierre-Robin syndrome

142 Refsum syndrome

143 Scheie syndrome (MPS I-S)

144 Smith-Lemli-Opitz (SLO) syndrome

145 Stickler syndrome

146 Sturge-Weber syndrome

147 Treacher Collins syndrome

148 Trisomy 13 (Patau syndrome, Trisomy 13-15)

149 Trisomy 18 (Edwards syndrome)

150 Turner syndrome

151 Usher I syndrome

152 Usher II syndrome

153 Usher III syndrome

154 Vogt-Koyanagi-Harada syndrome

155 Waardenburg syndrome

156 Wildervanck syndrome

157 Wolf-Hirschhorn syndrome (Trisomy 4p)

199 Other __________________________

Pre-Natal/Congenital Complications Post-Natal/Non-Congenital Complications

201 Congenital Rubella Syndrome

202 Congenital Syphilis

203 Congenital Toxoplasmosis

204 Cytomegalovirus (CMV)

205 Fetal Alcohol Syndrome

206 Hydrocephaly

207 Maternal Drug Use

208 Microcephaly

209 Neonatal Herpes Simplex (HSV)

299 Other_______________________

301 Asphyxia

302 Direct Trauma (to the eye and/or ear)

303 Encephalitis

304 Infections

305 Meningitis

306 Severe Head Injury

307 Stroke

308 Tumors

309 Chemically Induced

399 Other _______________________

Related to Prematurity Undiagnosed

401 Complications of Prematurity 501 No Determination of Etiology

National Deaf-Blind Census: Individual Entry Form

RACE ETHNICITY: CHECK ONE BOX ONLY

⃝1. American Indian or Alaska Native ⃝ 3. Black or African American ⃝ 5. White ⃝ 7. Two or more races

⃝2. Asian ⃝ 4. Hispanic/Latino ⃝ 6. Native Hawaiian or Pacific Islander

VISUAL IMPAIRMENT: PRIMARY CLASSIFICATION OF VISUAL IMPAIRMENT

CHECK ONE BOX ONLY

⃝1. Low Vision (visual acuity of 20/70 to 20/200 or more in the better eye with correction.)

⃝2. Legally Blind (visual acuity of 20/200 or less or field restriction of 20 degrees or less in the

better eye with correction.)

⃝3. Light Perception Only

⃝4. Totally Blind

⃝6. Diagnosed Progressive Loss

⃝7. Further Testing Needed to Determine Visual Impairment

⃝9. Documented Functional Vision Loss

CHECK IF APPLICABLE

Cortical Vision Impairment

⃝ 1. Yes

⃝ 0. No

⃝ 2. Unknown

HEARING IMPAIRMENT: PRIMARY CLASSIFICATION OF HEARING IMPAIRMENT

CHECK ONE BOX ONLY

⃝1. Mild (26-40 dB loss)

⃝2. Moderate (41-55 dB loss)

⃝3. Moderately Severe (56-70 dB loss)

⃝4. Severe (71-90 dB loss)

⃝5. Profound (91+ dB loss)

⃝6. Diagnosed Progressive Loss

⃝7. Further Testing Needed to Determine Hearing Impairment

⃝9. Documented Functional Hearing Loss

CHECK EITHER “NO,” “YES,” OR “UNKNOWN”

Central Auditory Processing Disorder

⃝1. Yes ⃝ 0. No ⃝ 2. Unknown

Auditory Neuropathy

⃝ 1. Yes ⃝ 0. No ⃝ 2. Unknown

Cochlear Implant

⃝ 1. Yes ⃝ 0. No ⃝ 2. Unknown

Other Impairments: Indicate impairments, in addition to the individual’s hearing and visual impairments, that have a

significant impact on the individual’s development or educational progress.

CHECK ALL CATEGORIES AS EITHER “NO” OR “YES”

1. Orthopedic/Physical Impairments ⃝ 1. Yes ⃝ 0. No

2. Cognitive Impairments ⃝ 1. Yes ⃝ 0. No

3. Behavioral Disorders ⃝ 1. Yes ⃝ 0. No

4. Complex Health Care Needs ⃝ 1. Yes ⃝ 0. No

5. Communication, Speech and/or Language ⃝ 1. Yes ⃝ 0. No

6. Other Impairment(s) ⃝ 1. Yes ⃝ 0. No (Specify)

PART C (BIRTH THROUGH 2 YRS.) CATEGORY CODES: CHECK ONE BOX ONLY

⃝ 1.At-risk for developmental delays (as defined by the state’s Part C Lead Agency)

⃝ 2. Developmentally Delayed

⃝ 888. Not Reported under Part C of IDEA

PART B (3 THROUGH 21 YRS.) CATEGORY CODES*: CHECK ONE BOX ONLY

⃝1. Intellectual Disability

⃝2. Hearing Impaired/Deaf

⃝3. Speech or Language Impairment

⃝4. Visually Impaired/Blind

⃝5. Emotional/Behavioral

⃝6. Orthopedic Impairment

⃝7. Other Health Impairment

⃝8. Specific Learning Disability

⃝9. Deaf-Blindness

⃝10. Multiple Disabilities

⃝11. Autism

⃝12. Traumatic Brain Injury

⃝13. Developmentally Delayed (age 3 to 9)

⃝14. Non-Categorical

⃝888. Not Reported under Part B of IDEA

*As child was reported on December 1 Child Count

EDUCATIONAL SETTING: CHECK ONE BOX ONLY

Birth through Age 2

⃝1. Home ⃝2. Community-based settings ⃝3. Other settings (specify): Ages 3 - 5

⃝1. Attending a regular early childhood program at least 80% of the time

⃝2. Attending a regular early childhood program 40% to 79% of the time

⃝3. Attending a regular early childhood program less than 40% of the

time

⃝4. Attending a separate class

⃝5. Attending a separate school

⃝6. Attending a residential facility

⃝7. Service provider location

⃝8. Home

Ages 6 – 21 ⃝9. Inside the regular class 80% or more of day

⃝10. Inside the regular class 40% to 79% of the day

⃝11. Inside the regular class less than 40% of the day

⃝12. Separate School

⃝13. Residential facility

⃝14. Homebound/Hospital

⃝15. Correctional facilities

⃝16. Parentally placed in private schools, including home

schooled

PARTICIPATION IN STATEWIDE ASSESSMENTS: CHECK ONE BOX ONLY ~ TAKEN FROM THE LAST STATEWIDE ASSESSMENT ⃝1. Regular grade-level state assessment

⃝2. Regular grade-level state assessment with

accommodations

⃝3. Alternate assessments aligned with grade-level

achievement standards

⃝4. Not Used

⃝5. Not Used

⃝6. Not yet required

⃝7. Parent Opt Out

PART C (BIRTH THROUGH 2 YRS.) EXITING: CHECK ONE BOX ONLY

NOTE: CHILDREN WHO HAVE TURNED AGE 3 AND TRANSITIONED FROM PART C TO PART B DURING THE REPORTING PERIOD MAY BE

REPORTED UNDER BOTH PART C AND PART B.

⃝ 0. In a Part C early intervention program

⃝ 1. Completion of IFSP prior to reaching maximum age for Part C

⃝ 2. Eligible for IDEA, Part B

⃝ 3. Not eligible for Part B, exit with referrals to other programs

⃝ 4. Not eligible for Part B, exit with no referrals

⃝ 5. Part B eligibility not determined

⃝ 6. Deceased

⃝ 7. Moved out of state

⃝ 8. Withdrawal by parent (or guardian)

⃝ 9.Attempts to contact parent and/or child were unsuccessful

PART B (3 YRS. THROUGH 21 YRS.) EXITING: CHECK ONE BOX ONLY

NOTE: CHILDREN WHO HAVE TURNED AGE 3 AND TRANSITIONED FROM PART C TO PART B DURING THE REPORTING PERIOD MAY BE

REPORTED UNDER BOTH PART C AND PART B.

⃝0. In ECSE or school-aged special education program

⃝1. Transferred to regular education

⃝2. Graduated with regular diploma

⃝3. Received a certificate

⃝ 4. Reached maximum age

⃝ 5. Deceased ⃝ 6. Moved, known to be continuing.

School district moved to:

⃝ 8. Dropped out

DEAF-BLIND PROJECT EXITING STATUS: CHECK ONE BOX ONLY

⃝ 1. Eligible to receive services from the deaf-blind project ⃝ 2. No longer eligible to receive services from the deaf-blind project

LIVING SETTING: CHECK ONE BOX ONLY

⃝1. Home: Birth/Adoptive Parents

⃝2. Home: Extended Family

⃝3. Home: Foster Parents

⃝4. State Residential Facility

⃝5. Private Residential Facility

⃝6. Group Home (less than 6 residents)

⃝7. Group Home (6 or more residents)

⃝8. Apartment (with non-family person(s))

⃝9. Pediatric Nursing Home

⃝555. Other (Specify)

ASSISTIVE DEVICES: CHECK EITHER “NO,” “YES,” OR “UNKNOWN”

Glasses or contact lenses used:

⃝1. Yes ⃝ 0. No ⃝ 2. Unknown

Hearing aids, FM system or other listening device used:

⃝1. Yes ⃝ 0. No ⃝ 2. Unknown

Additional assistive technology other than corrective lenses or

assistive listening devices:

⃝ 1. Yes ⃝ 0. No ⃝ 2. Unknown

Student’s Name: Date Completed:

*Intervener services are provided by an individual, typically a paraeducator, who has received specialized

training in deaf-blindness and the process intervention.

Person Completing Form: (Please fill out #1 and #2 below.)

1. Your Name: Title:

Agency Name:

Address: City: Zip:

Phone: ( ) Email:

District: ESD:

Home School District (if different from serving district):

2. Teacher’s Name: Title:

School Name:

School Address: City: Zip:

Teacher’s Phone: ( ) Email:

District: ESD:

Home School District (if different from serving district): Revised 01/15/2016

RETURN FORM TO:

WA State Services for Children with Deaf-Blindness

Puget Sound ESD/WSDS

800 Oakesdale Avenue SW

Renton, WA 98057-5221

Phone: (800) 572-7000 (in-state); (425) 917-7827

- OR –

FAX to: (425) 917-7838

EMAIL to: wsds@psesd.org

Intervener*: 0. No ⃝ 1. Yes ⃝ 2. Unknown

Intervener Services: Check either “NO,” “YES,” or “UNKNOWN”

WEB Rev 12/12

“LIKES” INFORMATION

Child: Date:

FOODS

taste/ texture

SMELLS

TOUCH

texture/ hugs/ fabrics light - heavy

MOVEMENT

rock/ bounce swing

VIBRATION

car ride toys/ appliances

SIGHTS

lights/colors

SOUNDS voices/ music

pitch/ loudness environmental

MUSCLES

push - pull bear weight

PEOPLE PLACES ACTIVITIES TOYS SELF STIMULATION BEHAVIORS

OTHER

Page 1 of 2

WEB Rev 12/12

“DISLIKES” INFORMATION

Child: Date:

FOODS

taste/ texture

SMELLS

TOUCH

texture/ hugs/ fabrics light - heavy

MOVEMENT

rock/ bounce swing

VIBRATION

car ride toys/ appliances

SIGHTS

lights/colors

SOUNDS voices/ music

pitch/ loudness environmental

MUSCLES

push - pull bear weight

PEOPLE PLACES ACTIVITIES TOYS SELF STIMULATION BEHAVIORS

OTHER

Page 2 of 2

Washington Sensory Disabilities Services 9/28/2015

Authorization for Release of Records

PURPOSE: As a parent, guardian or student (aged 18 or older), you have the right to give, or not give, permission for the release of your child’s records to other persons or agencies. This request provides you with the opportunity to approve or not approve such a request, unless release of records is allowed under one of the exceptions under the rules implementing the Family Education Rights and Privacy Act, FERPA.

CHILD’s NAME Male Female CHILD’S DOB

SCHOOL DISTRICT/AGENCY STATE STUDENT ID # (10 digits)

I HEREBY AUTHORIZE THE EXCHANGE OF INFORMATION VERBALLY, IN WRITING, OR ELECTRONICALLY BETWEEN WSDS PROJECT STAFF AND THE AGENCIES/PERSONS LISTED BELOW FOR THE FOLLOWING PURPOSE(S):

Check one or more:

☐ Determining eligibility for WSDS project services ☐ Sharing evaluation/assessment results, progress notes

☐ Developing an appropriate IFSP/IEP ☐ Other (specify)

Washington Sensory Disabilities Services (WSDS) and Name of agency/person Name of agency/person

800 Oakesdale Ave. SW

Street address Street address

Renton, Washington 98057

City, State, Zip City, State, Zip

(425) 917-7827 or (800) 572-7000 (425 ) 917-7838 ( ) ( )

Phone # Fax # Phone # Fax #

and

Name of agency/person

Street address

City, State, Zip

( ) ( )

Phone # Fax #

and

Name of agency/person

Street address

City, State, Zip

( ) ( )

Phone # Fax #

and

Name of agency/person

Street address

City, State, Zip

( ) ( )

Phone # Fax #

THE RECORDS TO BE EXCHANGED INCLUDE:

(check all that apply)

☐ Reports/Assessment for:

Vision Hearing

☐ IFSP/IEP

☐ Relevant medical records

☐ Other (specify)

FOR QUESTIONS, CONTACT WSDS STAFF:

Puget Sound ESD:

800-572-7000 (or) 425-917-7827

North Central ESD:

509-665-2619

Central Washington University:

509-963-1131

wsds@psesd.org

www.wsdsonline.org

Washington Sensory Disabilities Services 9/28/2015

I understand that this information obtained will be treated in a confidential manner by Washington Sensory

Disabilities Services project staff under the provisions of the Family Education Rights and Privacy Act (FERPA).

FERPA prohibits disclosure of personally identifiable information without consent except in limited circumstances.

Neither treatment nor payment is dependent on a signed authorization.

Information disclosed may be subject to re-disclosure by an authorized recipient and privacy laws may no longer

protect your information.

The following information is protected via HIPPA. Check each item below that you wish to be released:

☐ HIV (AIDS virus) ☐ Sexually transmitted diseases

☐ Drug or alcohol abuse ☐ Psychiatric disorder or mental health

☐ This authorization is valid for one year. Specify end date:

☐ If less than one year, this authorization is valid from: to

Date Date

Requesting Records: From: To:

Date Date

I understand that my consent for the release of records is voluntary and I can withdraw my consent at any time in

writing. Should I withdraw my consent, it does not apply to information that has already been provided under the

prior consent for release.

Parent Signature Date Relationship to Child

Father’s Name (if appropriate) Mother’s Name (if appropriate)

Parent/Guardian Address Child’s Address (if different)

City, State, Zip City, State, Zip

( ) ( )

Phone(s) Phone(s)

Email Email

Adapted from Donta, N. & Purvis, B. (2005). NTAC Handout.

Routine

INITIATION:

1.

2.

3.

PREPARATION:

1.

2.

3.

CORE:

1.

2.

3.

TERMINATION:

1.

2.

3.

Other Comments:

________

USE OF SENSORY CHANNELS

Student: Has glasses/contacts? Yes No Has hearing aids? R L Wearing them now? Yes No Wearing aids now? R L

Setting/Activity:____________________________________________________________________

Date: ___________________________ Observer:_______________________________________

Observed Behavior Sensory Channel V T A O/G P/V V T A O/G P/V V T A O/G P/V V T A O/G P/V V T A O/G P/V V T A O/G P/V V T A O/G P/V V T A O/G P/V V T A O/G P/V V T A O/G P/V V T A O/G P/V V T A O/G P/V V T A O/G P/V V T A O/G P/V V T A O/G P/V V T A O/G P/V V T A O/G P/V V T A O/G P/V V T A O/G P/V V T A O/G P/V V T A O/G P/V V T A O/G P/V V T A O/G P/V V T A O/G P/V

V T A O/G P/V

V T A O/G P/V

V T A O/G P/V

V T A O/G P/V

V T A O/G P/V

Totals

Probable Primary Channel:

Secondary Sensory Channel(s):

KEY: V = Visual

T = Tactual

A = Auditory

O/G = Olfactory/Gustatory

P/V = Proprioceptive/Vestibular

Adapted from Koenig & Holbrook/TSBVI (1993) in collaboration with Arizona Schools for the Deaf & Blind. [Rev. 8/2005]