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Greetings, families! You have been asked to complete this survey because your child (age 0-21) is registered with the Pennsylvania Deaf-Blind Project. As our Project plans upcoming activities, we would like input from families throughout the state to ensure we meet the needs of families and children on our registry. Please respond by April 15, 2021. If you have any questions, please do not hesitate to reach out to your PA Deaf-Blind Project Family Engagement Consultants, Patti McGowan at pmcgowan@pattan.net or Molly Black at mblack@pattan.net. Thank you for your time and input!!

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* 1. Name of family member completing the survey:

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* 2. Email address:

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* 3. Phone: 

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* 4. Early Intervention Agency, if applicable: 

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* 5. School District (or N/A if not applicable):

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* 6. Intermediate Unit (or N/A if not applicable):

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* 7. Do you give permission to be contacted by a Family Engagement Consultant of the PA Deaf-Blind Project to receive more information on the resources, supports, and services available to your child and family?

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* 8. What are the top 3 needs you have for your child (select from the following list or add your own)?

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* 9. In what areas do you need to increase your knowledge and skills or would like training (select all that apply)?

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* 10. Are current family training opportunities in your state meeting your needs?

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* 11. Please explain how current training opportunities could be improved.

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* 12. What service providers—public or private—have worked with your child in the past or are currently working with your child? (please select all that apply)

The next set of questions relate to your experiences with other agencies and organizations that we sometimes refer families to for support and training, as well as the Pennsylvania Deaf-Blind Project. We want to ensure that other agencies and our Project are responsive to your needs.

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* 13. Are you aware of or have you sought or received support from any of the following?

  1 - Yes, they were responsive and helpful 2 - Yes, they were responsive, but not helpful 3 - Yes, but they were not responsive or helpful 4 - I have not interacted with this agency 5 - I was not aware of or referred to this agency
Etiology/Disability Specific Organization (if so, please enter name below)
Families to the MAX
Family Connections for Language and Learning – Affiliate of Parent to Parent
Helen Keller National Center
HUNE
ICanConnect
National Family Association for the Deaf-Blind
Pennsylvania Partnership for the Deafblind
Office of Development Programs (ODP)
Office of Vocational Rehabilitation (OVR)
Children’s Services
Bureau of Blind and Visual Services (BBVS)
PA Family Network
Pennsylvania Education and Leadership Center (PEAL) State PTI

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* 14. What Pennsylvania Deaf-Blind Project supports have been most helpful? (select all that apply)

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* 15. Have you used the Pennsylvania Deaf-Blind Project webpage located on the PaTTAN website?

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* 16. Where do you go for information and resources? 

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* 17. How would you like information about resources from the PA Deaf-Blind Project to be shared with you? (select all that apply)

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* 18. Would you like to have your email address added to the PA Family and Interested Professional Deaf-Blind Listserv to get information and updates about upcoming events, opportunities, and more?

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* 19. Are you aware of the National Center on Deaf-Blindness (NCDB)? www.Nationaldb.org

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* 20. Are you presently volunteering for or serving on boards or committees of any local, state, or national organizations? If yes, please list the name of the organization and your role. 

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* 21. Are you interested in participating in future advocacy opportunities at the following levels (check all that apply)?

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* 22. How many times per month, on average, do you have an opportunity to communicate with another family member of a person who is deaf-blind?

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* 23. Would you like to be connected to other families of children with deaf-blindness or increase your current connections?

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* 24. If you would like to be connected with other families of children with deaf-blindness, do we have your permission to share your above name and contact information with others interested in connecting with a family or individual who is deaf-blind?

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* 25. Do you feel that you have a good understanding of your child's diagnosis?

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* 26. What is your child’s age?

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* 27. What is/are the primary language(s) spoken in your home?

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* 28. Please share any additional comments you have regarding the PA Deaf-Blind Project and its services:

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