ASEPAC - SURVEY

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ASEPAC

ASEPAC SURVEY

ATTLEBORO SPECIAL EDUCATION PARENT ADVISORY COUNCIL

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Please print out this form, answer all of the questions, mail or fax it to the ASEPAC office. (see contact information for details).
ASEPAC Assessment Survey

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 PDP’s for attending 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 ASEPAC 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 ___________________________

School ________________________

Phone # ___________________________

E-mail _________________________

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

a. Preschool

b. Elementary

c. Middle School

d. High School

7. If you have not attended ASEPAC 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 ASEPAC 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 Guest Speakers

____ School Personnel/Parent Speakers

____ Workshops

____ Video Presentations

____ Support Group/adults

____ Networking with other ASEPACs

____ School Programs for Students

____Support Group/students

____ Other

_____________________________________________________

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

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