Census Form

Introduction
Status of this Individual’s Report
Part I: Information About Individual with Deaf-Blindness
Select the ONE that best describes the individual’s race/ethnicity
Select the ONE setting that best describes where the individual resides the majority of the year
Part II: Individual’s Medical Background/Disabilities
Select the ONE that best describes the primary classification of the individual’s visual impairment
Select the ONE that best describes the primary classification of the individual’s hearing impairment
Please list the ONE etiology that best describes the primary CAUSE of the individual’s primary disability. Please indicate “Unknown” if you do not know the exact cause of the primary disability
Part III: IDEA
Please indicate the category which the individual was eligible for the Part C/Early Intervention services. Select only ONE
Please indicate the ONE code that best describes the individual’s special education program status
Assistive Technology
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  • Ideas that Work: U.S. Office of Special Education Programs

    The contents of this website were developed under a grant from the US Department of Education, #H326T130023. However, these contents do not necessarily represent the policy of the US Department of Education, and you should not assume endorsement by the Federal Government. Project Officer, Susan Weigart.


  • Contact Us

    Mellanie Lee
    Project Director/Education Specialist
    Pacific Outreach Initiative
    Phone: (808) 753-0981
    Email: mellanie@hawaii.edu

    Jennifer Tarnay
    Program Coordinator/Speech-Language Pathologist
    Phone: (808) 753-2351
    Email: jtarnay@hawaii.edu

    Stella Chang
    Family Specialist
    Phone: (808) 222-8466
    Email: yhchang@hawaii.edu