Parent Needs Assessment Form

Please take a few moments of your time to complete & return this survey. Your feedback is necessary to help us in being more responsive to your particular needs and be a positive resource for our community. Thanks!

1. What is your relationship to Special Education?

a. Parent

b. School Administrator

c. Teacher

d. Advocate

e. Other __________________________

1b. Would you be interest in receiving certificates of attendance for workshops?

____yes ____no

2. What is your special needs area of interest or concern? (i.e.: learning, physical, behavior, neurological, developmental, speech/language, autism, LD, etc.)



3. Do you consider yourself to be a member of the special education parent advisory council at this time?

____yes ____no

4. If no, are you interested in becoming a member?

____yes ____no

5. If you answered yes to either question, please provide the following information

Name _____________________________Address_______________________

Address ___________________________School ________________________

Phone # ___________________________E-mail _________________________

6. What grade-level is of concern to you?

Preschool Elementary Middle School High School

7. If you have not attended special education parent advisory council meetings/workshops, what were the obstacles?

a. Inconvenient day/time

b. Inconvenient location

c. Lack of transportation

d. Lack of childcare

e. Lack of time

f. Not interested

g. Other ____________________________________

8. How often would you prefer special education parent advisory council to meet?

____monthly ____bi-monthly ____quarterly

9. Volunteers are needed on the following committees. Please check any that interest you:

By-laws ____ Web site ____

Speakers/Workshops ____ Fundraising ____

Elections/Membership ____ School Committee Liaison ____

Scholarships/Awards ____ Library Project ____

Annual Review/3-Year Plan ____ Public Relations/Marketing ____

Quarterly Newsletter ____ Support Group/Database ____

Childcare ____ Refreshments/Hosting ____

School Liaisons____ (one for each school)

Other _______________________

Disability Awareness_______ Inclusion _____________

10a. What topics are areas of interest to you and would motivate you to attend?

Identifying Special Needs ____ Basic Rights & The Laws ____

Early Intervention ____ Testing ____

IEP’s ____ Behavior Issues ____

Financial/Insurance ____ Environmental Adaptations ____

Sensory Processing/Integration ____ Communication Strategies ____

Speech & Language ____ Reading & Writing _____

Extracurricular/Summer Activities ____ Bus Driver Training _____

Homework ____ Family Issues ____

Inclusion ____ Mediation/Hearings ____

Other ________________________ Bullying and Teasing____

10b. Specific Disability Areas

ADD/ADHD ____ Autism/PDD ____

Downs Syndrome ____ Visual/Hearing Impaired ____

Developmental Disabilities ____ Physical Disabilities ____

Learning Disabilities____ Other ____________________ 

11. In what forum would you like to see these issues presented/addressed?

____ Outside GuestSpeakers ____ School Personnel/Parent Speakers

____ Workshops ____ Video Presentations

____ Support Group/adults ____ Networking with other SEPACs

____ School Programs for Students ____Support Group/students

____ Other _____________________________________________________

12. Provide any speakers or topics that may be of interest to others. Thank you!

Next: Parent to Parent Program Manual