2019 Pearson Tactile Graphics Study: Phase 2 Student Recruitment Questionnaire

Contact Information and Questions

Please answer the following questions.

In the event you are (your child is) selected to participate in the study, the following information will allow us to contact you.

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* 1. What is your (the potential participant's) name (First, Last)?

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* 2. Please enter your contact information.

Telephone number:

Your name:

Email address:

Street address:

City:

State:

Zip:

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* 3. What is your (or your child's) gender?

Female

Male

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* 4. Please indicate your grade level (or the grade level of your child) for this 2019-2020 school year:

2nd

3rd

4th

5th

6th

7th

8th

9th

10th

11th

12th

Other (please specify)

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* 5. Are you (or has your child been) identified as an English Language Learner (ELL or ESL)?

Yes

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* 6. Do you (or your child) have an identified or documented visual impairment? (This could include a designation in a Section 504 Plan, an IEP under IDEA, or other primary diagnoses as having a visual impairment, including such conditions as blindness or low vision).

Yes

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* 7. How would you best describe your (or your child's) visual impairment?

Blind

Low Vision

Combination of blind and low vision that is dependent on the environment, context, or circumstances. Please explain below.

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* 8. Do you (or does your child) have any of the following conditions: severe hearing impairment, cognitive or intellectual disability, or a severe motor impairment?

Yes

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* 9. Are you (or Is your child) on grade level in math and science?

Yes, on or above grade level in math and science

No, 1-2 grade levels below in math and science

No, 3 or more grade levels below in math and science

Unsure

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* 10. Are you (Is your child) on grade level in ELA and social studies?

Yes, on or above grade level in ELA and social studies

No, 1-2 grade levels below in ELA and social studies

No, 3 or more grade levels below in ELA and social studies

Unsure

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* 11. Do you (or does your child) read braille or a combination of print and braille?

Yes

Other (please specify)

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* 12. How many years of experience do you have (has your child) with tactile graphics?

less than 1 year

1-3 years

3-5 years

5+ years

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100% of survey complete.