SEELS Draft Survey of School Programs

May, 1999

	SPECIAL EDUCATION ELEMENTARY LONGITUDINAL STUDY (SEELS)

	DRAFT SURVEY OF SCHOOL PROGRAMS



	SRI Project 3421

THE SPECIAL EDUCATION ELEMENTARY LONGITUDINAL STUDY (SEELS)

Survey of Studentsí School Programs

Student name

ID Number

Birthdate

Dear Educator:

The Special Education Elementary Longitudinal Study (SEELS), funded by the U.S. Department of Education, is studying the school experiences and outcomes of a variety of students, including students in special education. The study will give educators, policy-makers, practitioners, and parents important information about studentsí experiences and how they contribute to student performance. A brochure describing SEELS is enclosed.

The student named on the label above is one of more than 14,000 students nationwide who are included in SEELS. They were in elementary and/or early middle school when SEELS began in the 1999-2000 school year; the study will follow these students through the 2003-2004 school year as they transition into middle and high school.

To understand studentsí educational experiences, this component of the study focuses on key features of studentsí school programs and performance (other surveys address studentsí language arts instruction and school characteristics). You have been identified as the school staff member who is best able to describe this studentís overall school program.

We urge you to take about XX minutes to complete this survey about the studentís school program. It may be helpful to have the studentís file available as you answer these questions. Please return the completed survey as soon as possible in the enclosed postage-paid envelope. A $XX (gift certificate/check) will be mailed to you when we receive the completed survey and you will be eligible to be chosen to receive a thank you gift ofÖÖÖÖ.

There are no right or wrong answers to the questions in this survey. Your honesty and candor are extremely important. Please be assured that your answers will be completely confidential. No information will be reported that identifies you or this school.

If you have any questions about the study or the survey, please feel free to call the SEELS hotline toll free at 1-800-XXX-XXXX, send e-mail to (address), or visit the SEELS Web site at (URL).

Thank you in advance for your contribution to this important study.

PLEASE TURN THE PAGE TO BEGIN THE SURVEY Ô Ô Ô Ô Ô Ô

Date: ______/_____/_____

MM DD YY

A. ABOUT THIS STUDENTíS SCHOOL PROGRAM

A1. What was the first date on which this student attended your school this school year? (This would be the first day of the school year if this student has attended your school all year, or the first day s/he moved to the school if s/he began attending it mid-year.) PLEASE ENTER DATE.

Date: _______/______/______

MM DD YY

A2. What is the current grade level placement of this student? Please circle ONE number.

0	Ungraded	4	4th grade	8	8^th grade
1	1st grade	5	5th grade	9	9^th grade
2	2nd grade	6	6th grade	10	10th grade
3	3rd grade	7	7^th grade	11	11th grade

A3a. In column A, please indicate whether this student received instruction in each of the subject areas this school year. PLEASE CIRCLE ONE NUMBER ON EACH LINE IN COLUMN A.

b. In column B, please indicate all the settings in which this student received instruction in each subject area circled in column A during this school year.

		A Receives instruction		B Setting(s) of Instruction
		No	Yes	General education class	Resource room	Self-contained special ed. class	Homebound Instruction
a.	Language arts	0	1 Ô	1	2	3	4
b.	Mathematics	0	1 Ô	1	2	3	4
c.	Science	0	1 Ô	1	2	3	4
d.	Social studies	0	1 Ô	1	2	3	4
e.	Art, music	0	1 Ô	1	2	3	4
f.	Physical education	0	1 Ô	1	2	3	4
g.	Life skills	0	1 Ô	1	2	3	4
h.	Study skills	0	1 Ô	1	2	3	4
i.	Vocational/prevocational training, industrial arts	0	1 Ô	1	2	3	4
j.	Social skills instruction	0	1 Ô	1	2	3	4
k.	Other (please specify:__________________)	0	1 Ô	1	2	3	4

A4. Does this student participate in any of the following? PLEASE CIRCLE ALL THAT APPLY.

1	Program for gifted and talented students
2	Chapter 1
3	Bilingual education or instruction for English-language learners
4	Summer school during the previous summer
5	Free/reduced price lunch program
6	None of these

NOTE: QUESTIONS SS6 THROUGH SS8 WILL BE INCLUDED ONLY IN THE VERSION OF THE QUESTIONNAIRE USED FOR STUDENTS AGES 14 OR OLDER. OTHER RESPONDENTS GO FROM HERE TO A5a, NEXT PAGE.

SS6. Please indicate which of the following services this student received from or through the school system during this school year. PLEASE CIRCLE ALL THAT APPLY.

1	A formal assessment of career skills or interests
2	Career counseling
3	Job readiness or prevocational training
4	Work exploration
5	Work experience
6	Specific job skills training
7	Referrals to potential employers
8	Instruction in looking for jobs
9	School staff worked with employer to modify jobs for this student
10	School staff contacted student or employer to monitor performance on the job
11	None of these

SS7. What percentage of this studentís school day is currently being spent in the two activities below (do not include after school employment)? PLEASE CIRCLE ONE NUMBER ON EACH LINE.

	None	1-24%	25-49%	50-74%	75-99%	100%	Donít Know
School-based work experience	0	1	2	3	4	5	8
Community-based work experience	0	1	2	3	4	5	8

SS8. Which of the following best describes the primary goal of this studentís educational program for the period immediately following high school? Please circle ONE number.

1	Attend a 2 or 4 year college
2	Attend a postsecondary vocational training program
3	Get competitive employment (includes military)
4	Get into sheltered employment (where most other workers are also disabled)
5	Get supported employment (similar to competitive employment, but where supervision/training is provided by an agency/individual other than the employer)
6	Employment or postsecondary education is not a goal for this student. The educational program goal is to help this student become as self-sufficient as possible
7	Other (please describe): _____________________________________________________
8	No goal as yet for this student beyond high school

A5a. Has this student made any of the following transitions within the past 9 months? Please circle ONE number.

1	Elementary to middle school.
2	Middle school to high school PLEASE CONTINUE WITH A5b
3	No transitions this past year Ô Ô PLEASE GO TO QUESTION A7

b. Which of the following were provided to support this student's transition? PLEASE CIRCLE ALL THAT APPLY.

1	Staff or students from your school visited the sending school to meet with groups of students who were preparing for the transition.
2	Groups of transitioning students visited your school before school started.
3	Information was provided to your school staff by the sending school about this student (e.g., student performance information ,disability awareness).
4	Your school staff met with staff of the sending school specifically about this student.
5	Parent and/or student met with staff of this school before starting school here.
6	Preparatory strategies were developed specifically for this student (e.g., behavior plans, school scheduling modifications, etc.)
7	Other:______________________________________________________________
8	None of these
9	Donít know

c. How would you rate the amount of planning and support that was provided this student during this transition? Please circle ONE number.

1	It was more than he/she needed.
2	It was appropriate to the needs of this student.
3	This student could have benefited from more transition support.
9	Don't know

A6a. Will this student be involved in any of the following transitions at the end of this school year?

1	Elementary to middle school.
2	Middle school to high school PLEASE CONTINUE WITH A6b
3	No transitions this year Ô Ô PLEASE GO TO QUESTION A7

b. Which of the following are being or will be provided to support this student's transition? PLEASE CIRCLE ALL THAT APPLY.

1	Groups of transitioning students visit their next school before school starts.
2	Information is provided to the receiving school about this student (e.g., student performance information, disability awareness).
3	Your school staff met with receiving school staff specifically about this student.
4	Parent and/or student meet with staff of the receiving school individually before starting school there.
5	Preparatory strategies are developed specifically for this student (e.g., behavior plans, school scheduling modifications, etc.).
6	Other:______________________________________________________________
7	None of these
8	Donít know

A7. Does this student currently have either an Individualized Education Plan (IEP) for special education or related services (which might include monitoring by special education staff) or a "504 plan" for students with disabilities? PLEASE CIRCLE ONE NUMBER

Yes, this student has an IEP

for special education services PLEASE GO TO SECTION B, PAGE 6

Yes, this student has a 504 plan

No Ô Ô Ô Ô Ô Ô PLEASE CONTINUE WITH QUESTION A8

A8a. Did this student ever have and Individualized Education Plan (IEP) for special education or related services?

Yes, this student had an IEP

for special education services Ô Ô PLEASE CONTINUE WITH A8b.

No Ô Ô PLEASE GO TO SECTION B, PAGE 6

b. In what school year was this student no longer a special education student, but was still attending school? PLEASE RECORD SCHOOL YEAR OR CIRCLE CODE.

____________

School year removed from special education:

888 Not applicable, this student has not been in special education

999 Donít know

B. About this studentís Special Education and 504 plan services

Please complete this section only for students with an IEP for special education services or a 504 plan. For other students, please go to Section C, page 10.

B1a. Approximately how many hours per week does this student receive instruction?

__________

Number of Hours/Week

B1b. Approximately how much time per week does this student currently spend in the following instructional settings?

Number of Minutes/Week

or

Number of Hours/Week

__________

__________

General education classroom

__________

__________

Special education self contained classroom

__________

__________

Special education resource classroom

__________

__________

Individual instruction (e.g., homebound)

B2a. In column A, please circle all of this students disabilities. PLEASE CIRCLE ALL THAT APPLY in column a.

b. In column B, please circle the studentís primary disability. PLEASE CIRCLE ONE NUMBER IN COLUMN B.

A

All disability categories
B

Primary disability category

1

1

Autism

2

2

Deaf-blindness

3

3

Developmental delay

4

4

Emotional or behavioral impairment

5

5

Hearing impairment/deafness

6

6

Learning disability

7

7

Mental retardation

8

8

Orthopedic impairment

9

9

Other health impairment

10

10

Multiple disabilities

11

11

Speech or language impairment

12

12

Traumatic brain injury

13

13

Visual impairment/blindness

14

14

Other:___________________________________

B3. For this school year, what are the primary goals for this student? PLEASE CIRCLE ALL THAT APPLY.

1	Improve overall academic performance
2	Improve academic performance in a specific area:___________________________
3	Build social skills
4	Improve appropriateness of general behavior
5	Increase functional skills
6	Improve speech and communication skills
7	Vocational preparation
8	Postsecondary education preparation
9	Other (please specify:_________________________________________________)
99	Donít know

B4. Which of the following are provided this student as part of his/her IEP or 504 plan? Please circle All that apply.

	Accommodations/modifications
1	More time in taking tests
2	Test read to student
3	Modified tests
4	Modified grading standards
5	Slower-paced instruction
6	Additional time to complete assignments
7	Shorter assignments
8	Physical adaptations (e.g., preferential seating, special desk)
	Additional Supports & Assistance
9	Reader or interpreter
10	Teacher aides or instructional assistants
11	Student progress monitored by special education teacher
12	Tutoring by special education teacher
13	Behavior management program
14	Learning strategies/study skills assistance
	Learning Aids
15	Books on tape
16	Communication aids (e.g., Touch Talker, manual printing board)
17	Use of spell checker
18	Computer software designed for students with disabilities
19	Computer hardware adapted for studentís unique needs (e.g. alternative keyboards, switch interface)
20	Other:___________________________________________________________
21	None of these provided

B5a. Does the student 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 devices, electronic equipment, etc.)

1	Yes
2	No

b. Is there an emergency medical plan for this student?

1	Yes
2	No

B6. Which of the following services has this student received from or through the school system during the current school year, including services contracted from other agencies? In column A, circle ALL the services that this student has received this school year. In column B, indicate the approximate number of minutes per week that service is provided.

		A Service provided this school year		B Approximate minutes per week service provided
		No	Yes
a.	Adaptive physical education	0	1 Ô
b.	Audiology	0	1 Ô
c.	Communication services (e.g., instruction in sign language, Braille, or lip reading)	0	1 Ô
d.	Family training, counseling, and other support	0	1 Ô
e.	Health services (e.g., oxygen, tracheostomy care, tube feeding, catheterization)	0	1 Ô
f.	Mental health services, personal/group counseling, therapy, or psychiatric care	0	1 Ô
g.	Nursing services	0	1 Ô
h.	Occupational therapy	0	1 Ô
i.	One-to-one paraeducator/assistant (e.g., full inclusion assistant, behavioral assistant, nurseís aide)	0	1 Ô
j.	Physical therapy	0	1 Ô
k.	Social work services	0	1 Ô
l.	Speech or language therapy	0	1 Ô
m	Tutoring	0	1 Ô
n.	Vision services	0	1 Ô
o.	Special transportation because of disability (e.g., help in travel or special equipment such as lifts, ramps)	0	1 Ô
p.	Other (specify)	0	1 Ô
q.	Assistive technology services/devices.	0	1
r.	Service coordination/case management	0	1
s.	Diagnostic testing (e.g., psychological)	0	1

B7a. During the current school year, to what extent did this student participate in any standardized test[s] or performance assessments administered as part of a school-, district-, or state-wide testing program? Please circle ONE number.

0	Not applicable; there is no such testing at this grade level

1	Student participated in the full testing program without modifications

2	Student participated in part of the Ô Ô PLEASE GO TO QUESTION B8 testing program without modifications
3	Student did not take such tests
4	Student participated in the testing Ô Ô PLEASE CONTINUE WITH program with modifications QUESTION B7b

b Which of the following accommodations, if any, were provided to this student to participate in the standardized tests? PLEASE CIRCLE ALL THAT APPLY.

0	No accommodations were provided this student
1	Given test orally; reader provided
2	Dictated responses
3	Shortened test
4	Alternative setting
5	Additional time
6	Alternative format for responding (e.g., pointing, typing, etc.)
7	Braille/large print version of test
8	Other:______________________________________________________________

B8. Who participated in the most recent IEP or 504 plan development or review for this student? PLEASE CIRCLE ALL THAT APPLY.

1	General education academic subject teacher(s)
2	General education vocational teacher(s)
3	Special education teacher(s)
4	School administrator (e.g., principal, special education director)
5	School counselor or psychologist
6	Related services personnel (e.g., speech therapist/pathologist, occupational therapist).
7	Parent/guardians
8	Student
9	Staff of outside service agency (Please specify type of staff:__________________)
10	Outside consultant (Please specify type of consultant :_______________________)
11	Employer
12	Representative from postsecondary institution
13	Advocate
14	Other (Please specify:_________________________________________________)

NOTE: QUESTIONS SS10 THROUGH SS12 WILL BE INCLUDED ONLY IN THE VERSION OF THE QUESTIONNAIRE USED FOR STUDENTS AGES 14 OR OLDER.

SS10. Has anyone at the school done postsecondary transition planning for this student during this school year?

1	Yes PLEASE GO ON TO QUESTION SS10b
2	No PLEASE GO TO SECTION C
9	Don't Know

SS10b. Is the studentís transition plan written?

1	Yes
2	No

c. Who has actively participated in the transition planning for this student during this school year (for example, by being involved in discussions on choosing services or goals)? PLEASE CIRCLE ALL THAT APPLY.

1	General education academic subject teacher(s)
2	General education vocational teacher(s)
3	Special education teacher(s)
4	School administrator (e.g., principal, special education director)
5	School counselor or psychologist
6	Parent/guardian
7	Student
8	Vocational Rehabilitation agency staff
9	Staff of outside agencies:_______________________________________
10	Employer or representative of postsecondary education
11	Other:_____________________________________________________________
12	Donít know

C. ABOUT THIS STUDENTíS PERFORMANCE AND FAMILY SUPPORT

C1a. During the month of February of this year, how many days was this student absent, excluding days suspended? If days aren't available, please indicate the number of classes the student was absent. PLEASE RECORD ONE NUMBER ON EACH LINE.

Number of days	or	Number of classes
__________		__________	Excused absences
__________		__________	Unexcused absences

C1b. Was this above, below, or about the same level as the February absenteeism rate of peers?

1	Same level as peers
2	Below the level of peers
3	About the same level as peers

C2. During this school year, how many times has the student experienced the following disciplinary actions? PLEASE RECORD ONE NUMBER ON EACH LINE OR CIRCLE "999". RECORD "0" FOR NONE.

Number of Days	Number of Incidents
	__________	Disciplinary actions (e.g., referral to the office, detentions, etc.), excluding suspensions or expulsions.
_________ OR	__________	Suspensions (may include in-school suspensions).
999	999	Donít know

C3a. What grade level in reading and mathematics has this student achieved as of the most recent assessment(s)? PLEASE Circle one number for reading and one number for math.

Grade Level in:

Reading

Mathematics

999

999

No grade level determined

00

00

Preschool

0

0

Kindergarten

1

1

Grade 1

2

2

Grade 2

3

3

Grade 3

4

4

Grade 4

5

5

Grade 5

6

6

Grade 6

7

7

Grade 7

8

8

Grade 8

9

9

Grade 9

10

10

Grade 10

11

11

Grade 11

12

12

Grade 12 or above

b. Most recent year of reading assessment: __________________ (year)

c. Most recent year of math assessment: ___________________ (year)

C4. This school year, has this studentís parent/guardian(s) attended parent/teacher conferences or "back-to-school" night? Please circle ONE number.

1	Yes
2	No
3	We do not have parent conferences or "back-to-school" night.
9	Don't know

C5. Approximately how often have you communicated with this studentís parent/guardian(s) during this school year about this studentís progress (by phone, in person, or in writing)?

Please circle ONE number.

0	Never
1	Once
2	A few times over the school year
3	Once every other month
4	Once a month
5	Once a week or several times a month
6	Every day or several times a week

C6. How involved is this studentís parent/guardian(s) in his/her school experiences (e.g., monitoring homework or studentís progress in school)? Please circle ONE number.

1	Not at all involved
2	Not very involved
3	Fairly involved
4	Very involved
9	Donít know

C7a. What is the primary language spoken by this studentís parent/guardian(s)? Please circle ONE number.

A language other than English. PLEASE CONTINUE WITH QUESTION C7b

Please specify: ________________________

English

Donít know PLEASE GO TO SECTION D, NEXT PAGE

b. Are you proficient in the language other than English spoken by this family?

1	Yes
2	No

D. ABOUT YOU

If you also filled out the Language Arts Teacher Survey for this student, please go to page .

D1. In what capacity(ies) are you involved with this student? PLEASE CIRCLE ALL THAT APPLY.

1	Provide instruction directly to this student
2	Provide related services directly to this student
3	Provide consultation services to studentís teacher(s)
4	Provide case-management (i.e., program monitoring) for this student
5	Program administrator
6	Other:______________________________________________________________

D2. Approximately how often do you currently have contact with this student? Please circle ONE number.

1	Daily
2	2 to 3 times per week PLEASE CONTINUE WITH QUESTION D2b.
3	Once a week
4	Less than once per week
5	Once per month
6	Once every two to six months PLEASE GO TO QUESTION D3
7	Very rarely

b. How much time do you currently have contact with this student each day in a typical week? Please write ONE number in each box. if you do not see this student on a particular day, please write in "0".

Monday

Tuesday

Wednesday

Thursday

Friday

Minutes
OR

Hours

Minutes
OR

Hours

Minutes
OR

Hours

Minutes
OR

Hours

Minutes
OR

Hours

D3. What is the highest level of education you have completed? Please circle ONE number.

1	Bachelorís degree
2	At least 1 year of course work beyond a bachelorís but not a graduate degree
3	Masterís degree
4	Education specialist or professional diploma with at least 1 year of course work past a masterís degree
5	Doctorate degree
6	Other (please specify) ________________________________________________

D4. Which of the following certificates, credentials, or licenses do you hold in this state? PLEASE CIRCLE ALL THAT APPLY.

1	General education credential
2	Disability-specific credential or endorsement
3	Special education credential or endorsement (for more than one disability category)
4	Speech/language certification
5	Physical therapy license
6	Occupational therapy license
7	Other:____________________________________________________________________
9	None of these

D5. Which best describes you? PLEASE CIRCLE ALL THAT APPLY.

1	African-American or Black
2	American Indian or Alaskan Native
3	Asian
4	Caucasian or white
5	Hispanic, Latino, or other Spanish origin
6	Native Hawaiian
7	Other Pacific Islander
8	Other:________________________________________________________

D6. What is your main role in this school? Please circle All That apply.

1	General education classroom teacher
2	Special education classroom teacher PLEASE CONTINUE WITH QUESTION D7
3	Resource room teacher
4	Related services provider (e.g., speech therapist)
5	Program specialist (e.g., full inclusion specialist)
6	Case manager PLEASE GO TO END OF SURVEY, PAGE 19
7	School psychologist
8	School counselor
9	Other:___________________________________

THE REMAINING QUESTIONS IN THIS SECTION ARE FOR CLASSROOM TEACHERS. IF YOU ARE NOT A TEACHER, PLEASE GO TO THE END OF THE SURVEY, PAGE 19.

D7. How many years have you been a teacher?

_________

Years in teaching

D8. How many years have you had special education students in your classroom?

_________

Years in teaching special education students

D9. Which of the following best describes your current teaching job? Please circle ONE number.

1	Full-time teacher
2	Part-time teacher
3	Itinerant teacher (i.e., you provide instruction at more than one school)
4	Long-term substitute (i.e., fills the role of a regular teacher on a long-term basis, but still considered a substitute)
5	Other:_____________________________________________________________

D10. Which of the following types of credentials do you hold in this state for your current teaching job? Please circle ONE number.

1	Regular or standard or advanced certificate
2	Probationary certificate
3	Provisional (or other type given to persons who are still participating in an "alternative certification program")
4	Temporary certificate (requires some additional coursework and/or student teaching)
5	Emergency certificate or waiver
6	Other: ___________________________________________________________________

D11. During the past 3 years, have you had in-service training totaling at least 8 hours to help you do the following?

Please circle All that apply.

1	Teach in your subject matter area
2	Work with students who are considered to be "at-risk"
3	Work with students with disabilities
4	Classroom management
5	None of these

D12. How would you rate your current ability to do each of the following?

Please circle ONE number on each line.

		Very good	Good	Adequate	Limited
a.	Motivate students to participate in academic tasks	1	2	3	4
b.	Use computers in instruction	1	2	3	4
c.	Adapt instruction and/or materials to address varying needs and achievements of individual students	1	2	3	4
d.	Monitor student progress and adjust instruction accordingly	1	2	3	4
e.	Manage behavior	1	2	3	4

D13. Please indicate the extent to which you agree or disagree with each of the following statements. Please circle ONE number on each line.

		Strongly Agree	Agree	Disagree	Strongly Disagree	Not Applicable
a.	I am given the support I need to teach students with special needs	1	2	3	4	8
b.	I have adequate training for teaching students with disabilities.	1	2	3	4	8
c.	The school leadership has high expectations and standards for students and teachers	1	2	3	4	8
d.	The principal promotes instructional improvement among school staff.	1	2	3	4	8
e.	This school is a safe place for students.	1	2	3	4	8

Thank you for your help! We would like to express our appreciation to you for taking the time to complete this survey by sending you a $XX (check/gift certificate). In addition, returning the completed questionnaire will make you eligible for a "thank you" gift, which will be sent to one teacher, selected randomly from those who complete the questionnaire. To whom should we send the check and the thank-you gift, if you are chosen as its recipient?

Name:___________________________________________________________________

Street address:_____________________________________________________________

City/state/zip code:_________________________________________________________

Thank you again. Please return the completed questionnaire in the enclosed postage-paid envelope to:

The Special Education Elementary Longitudinal Study

SRI International

Center for Education and Human Services

333 Ravenswood Avenue

Menlo Park, CA 94025

SEELS DESIGN DOCUMENTS

Number of Minutes/Week	or	Number of Hours/Week
__________		__________	General education classroom
__________		__________	Special education self contained classroom
__________		__________	Special education resource classroom
__________		__________	Individual instruction (e.g., homebound)

A All disability categories	B Primary disability category
1	1	Autism
2	2	Deaf-blindness
3	3	Developmental delay
4	4	Emotional or behavioral impairment
5	5	Hearing impairment/deafness
6	6	Learning disability
7	7	Mental retardation
8	8	Orthopedic impairment
9	9	Other health impairment
10	10	Multiple disabilities
11	11	Speech or language impairment
12	12	Traumatic brain injury
13	13	Visual impairment/blindness
14	14	Other:___________________________________

Grade Level in:
Reading	Mathematics
999	999	No grade level determined
00	00	Preschool
0	0	Kindergarten
1	1	Grade 1
2	2	Grade 2
3	3	Grade 3
4	4	Grade 4
5	5	Grade 5
6	6	Grade 6
7	7	Grade 7
8	8	Grade 8
9	9	Grade 9
10	10	Grade 10
11	11	Grade 11
12	12	Grade 12 or above

Monday	Tuesday	Wednesday	Thursday	Friday
Minutes OR Hours	Minutes OR Hours	Minutes OR Hours	Minutes OR Hours	Minutes OR Hours