FAMILY QUESTIONNAIRE
Purpose of the Questionnaire
An important outcome of Project CATS is to include family and parent input in making decisions about the environments and travel methods in which their children travel. This questionnaire is used to describe family members' and parents' perceptions of their children's placement and travel opportunities. The consortium recognizes that parents and family members have valuable information regarding themselves, their children, and their school communities, which may be beneficial to other parents and professionals as they seek to assist children who are deafblind, including those with additional disabilities, who travel in their home, school, and community environments.

Directions for Completing the Questionnaire
The questionnaire should be completed by a parent or family member who has direct responsibility in developing, designing, or selecting an educational program for the child and the consortium member facilitator or team leader. Please review the protocol in advance of the interview or meeting.

1. Questions 1-3 & 9 require checking the answer or circling a number which best applies.

2. Questions 4-8 and the second part of Question 9 require brief statements to explain the answer.

If the questions do not apply to this parent, family or student,
indicate "N/A" non-applicable.
_______________________________________________________

The original questionnaire was developed by the National Task Force of the Full Inclusion Project for Students who are Deaf-Blind (OSERS/SEP #H025D30013; Dr. Lori Goetz, Project Director) of the California Research Institute at San Francisco State University, 612 Font Blvd., San Francisco, CA 94132

It is adapted (1999) with permission from: Goetz, L. (1997). Including deaf-blind students: A report from a national task force. San Francisco: California Research Institute.

FAMILY QUESTIONNAIRE

Student's Initials or Code___________ Age____________

Model Site_______________________ State______________________


1. How much time does your child usually spend in a general education program each day? (Please check one. Do not include time spent in special education programs).

_____a. less than one hour

_____b. 1 hour to 1 hour and 59 minutes

_____c. 2 hours to 2 hours and 59 minutes

_____d. 3 hours to 3 hours and 59 minutes

_____e. 4 hours or more

2. How much time does your child travel every day in your community and/or at home?

_____a. less than one hour

_____b. 1 hour

_____c. 2 hours

_____d. 3 hours

_____e. 4 hours

3. Do you feel that you have a good knowledge of the following terms?

TERMS
YES
NO
NOT SURE
Inclusion . . .
Orientation & Mobility . . .
Travel Skills/Methods . . .


4. Why do you want your child to have more opportunities in your home, school, and community?






5. Are there specific places in your home, school and community where you want your child to travel?









6. Which people outside of your family currently help your child travel in your home, school, and community environments?









7. What do you think needs to happen to help your child travel safely in your home, school, and community?








8. What type of assistance do you think you will need in the future in order to have your child continue travel instruction in your home, school, and community?











9. (a) Please rate how satisfied you currently are with your child's travel instruction:

Very Well Satisfied Not At All Satisfied
5 4 3 2 1

(b) If you marked 1, 2, or 3, please tell us what needs to be improved with your child's travel instruction:

Your Home:



Your School



Your Community:



(c) What are two things you like best about your child's travel instruction in your home, school, and community environments?

Home

1.

2.


School

1.

2.


Community

1.

2.