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Participate in the Family Survey

Your Path: Circle of Inclusion Home Page --> Family Survey
Click here for a printable verison
If you are a parent or guardian of a child with a disability, please complete the survey below. (See Privacy Statement) Then a link will be provided so you may view the aggregated results that you and other parents have submitted. If you are not a parent/guardian or have already filled out the survey, please view the survey results here. The purpose of this survey is to gain a better understanding of the parent/guardian perspective of needs in infant/toddler or early childhood settings. The information you provide will only be presented in aggregate, and will never be used to invade your privacy or the privacy of your child. Thank you for your participation.

1. What type of challenges does your child have (check all that apply):

      Visual       Attention
      Hearing       Seizure
      Physical       Eating/Feeding
      Speech/Language       Communication
      Behavioral       Sensory
      Emotional       Motoric
      Cognitive       Multiple

2. What is the age of your child with a disability?

      0-2 years       13-18 years
      3-5 years       19-21 years
      6-8 years       22 and older years
      9-12 years

3. Is your child       Male            Female

4. What services does your child currently receive (check all that apply)?

      Physical Therapy (PT)       Hippotherapy
      Occupational Therapy (OT)       Counseling
      Speech/Language       Behavioral Therapy
      Communication       Sensory Integrative Therapy
      Assistive Technology (AT)       Mobility Training
      Cognitive/Educational       Music Therapy

5. How often does you child receive services?
      Weekly
      Bi-Weekly
      Monthly

6. Is your child in a current program? (check all that apply)
      In-Home Program
      Community-Based Program
      Center-Based Program
      Clinic/Hospital Program
      School-Based Program

7. Check child's current plan:
      Individual Family Service Plan (IFSP)
      Individual Education Plan (IEP)
      Neither

8. Is your child in an inclusive setting?       Yes            No

9. If you answered "No" to #8, what is the reason?
      Requested but Denied
      Did Not Request
      Did Not Want
      Requested but Told Not Available

10. If you answered "Yes" to #8, what portion of your child's day is spent in the inclusive setting?

      100 %       25-49 %
      75-99 %       1-24 %
      50-74 %       0 %

11. What is your geographic location?
      Urban
      Suburban
      Rural

12. What types of information are you most interested in having? (check all that apply)

      Advocacy       Positive Behavior Support
      Legal Issues       Communication
           Insurance       Educational Issues
           Medical       Developmental Issues
           Estate Planning       Motor Development
           Education       Occupational/Physical Therapy
      Specific Disability Information       Web-site Addresses
      Community Resources       Assistive Technology
      Play/Recreation       Speech/Language Development
      Building Friendships       Daily Skills
      Parent/School Relationships       Sibling Supports
      Collaboration with Professionals       Respite Care
      Extended Family Supports       Use of Visual Supports
      Mobility Training       Braille Training
      Sign Language       Parent Support Group

13. Where do you access the Internet? (check all that apply)
      Home
      Work
      Public library
      School
      Other

Optional Information:
Name:       E-mail:

Please be sure that you have correctly filled out the survey.


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Copyright © 2002, University of Kansas, Circle of Inclusion Project. Permission for reproduction of these materials for non-profit use with proper citation is granted. Please send your comments and questions to questions@circleofinclusion.org.