This form is used to register a child on the statewide deafblind census, which is conducted yearly by the Ohio Center for Deafblind Education (OCDBE). Children being registered should be from birth through 21 years of age and have combined hearing and vision losses.

Anyone can register a child at any time. If you have more than one child to register, please complete a separate form for each one. Prior consent to disclose information is not required, however, we ask that if you are not the parent, you make the family aware that you are registering their child. All information disclosed on this form is confidential. Only non-identifiable information (such as hearing and vision levels, and etiology) will be shared with our national organization to create a national deafblind child count.

Information you will need to complete the form:

  • Parent and school contact information
  • Cause of hearing and vision loss (etiology)
  • Hearing loss and vision loss levels

Questions concerning this form should be directed to the Census Coordinator, Thomas Lather, by email at census@ohiodeafblind.org or by phone at 614.785.1163 ext. 103.

Thank you for your time and attention.

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Race/Ethnicity:

Select the ONE that best describes the individual's race/ethnicity.


Living Setting:

Select the ONE setting that best describes where the individual resides the majority of the year.


Primary Language:

Please indicate the primary language used by the child for the majority of communication.


Assistive Technology:

Please tell us more about the parent(s)/guardian(s) of the deafblind child. Contact information is not shared with any other entity and is used by OCDBE for the purpose of keeping families informed of resources and opportunities that can help them better support the development and education of their child.



If you would like to add an additional person as a guardian, please use the following fields:

Please tell us about a person in the child's overall support team who can serve as a contact person. Examples of such people include Special Education Coordinators, School Psychologists, Vision Specialists, Teachers of the Hearing Impaired, and many others. Along with receiving announcements about professional development opportunities in deafblindness, the designated contact person will also be the one to receive the census mailings requesting updates to the child's information in future years.


Professional Mailing Address Details:

Please provide information about the child's school or educational agency in which he or she is currently enrolled.


School/Educational Agency Details:


Services Provided:

Please mark ALL related services the child is currently receiving


Federal Quota:

Please indicate whether the child has been registered on the Federal Quota of Blind Students (paperwork submitted through CISAM).

Primary Cause of Deafblindness:

Please select the ONE item from the lists in this section that best describes the primary cause of the individual's deafblindness

Please complete the items below to help us better understand the nature of the child's hearing and vision losses.


Documented Vision Loss:

Please select the ONE option that best describes the child's vision loss with correction, or indicate that further testing is needed.

*Note:
If further testing is needed to verify and determine the nature of the child's vision loss, testing must be completed by March of the following year to guarantee continued inclusion in the Census registry.


Documented Hearing Loss:

Please select the ONE option that best describes the child's hearing loss, or indicate that further testing is needed.

*Note:
If further testing is needed to verify and determine the nature of the child's hearing loss, testing must be completed by March of the following year to guarantee continued inclusion in the Census registry.


Other Impairments or Conditions:

Please indicate any additional impairment or condition that has a significant impact on the individual's developmental or educational progress.

Funding Category:

Please indicate the funding category under which the child was receiving services as of December 1st of last year.

PART B

Please complete this section ONLY if the child was over 3 years of age and under 22 years of age on Dec. 1st of last year.

Part B Category Code:

Please indicate the primary category code under which the child was reported on the IDEA Part B Child Count.

Special Education Status/Part B Exiting:

Please select the code that best describes the child's special education program status as reported on the IDEA Part B Child Count.


Early Childhood Special Education Settings, Age 3-5:

Please select the ONE educational setting that was reported for the child on the IDEA Part B Child Count.

School-Aged Special Education Settings, Age 6-21:

Please select the ONE educational setting that was reported for the child on the IDEA Part B Child Count.


Participation in Statewide Assessments:

Please select the option that best describes the individual's participation in his or her most recent statewide assessment activities.

PART C

Please complete this section ONLY if the child was under 3 years of age on Dec 1st of last year.

Part C Category Code:

Please indicate the primary category code under which the child was reported on the IDEA Part C Child Count – select only ONE.

Special Education Status/Part C Exiting:

Please select the ONE code that best describes the child's special education program status as reported on the IDEA Part C Child Count.


Early Intervention Setting:

Please select the ONE early intervention setting that was reported for the individual on the IDEA Part C Child Count.