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Distribution: Student Record (IEP Team Meeting Documents folder)
Parent'Questionnaire
!
'
!
Department'of'Special'Education'and'Student'Services
!
HOWARD'COUNTY'PUBLIC'SCHOOL'
SYSTEM'
Ellicott'City,'MD'21042
!
Please return to
at school by .
(Date)
The information on this form will be used to assist the school team in understanding your child’s educational needs. Fill out
the form as completely as possible; however, you have the right to not respond to any item you believe may invade your
privacy. If you are unable to recall or supply some of the information requested, note that on the form.
If you have any questions, call
.
(Name and title)
STUDENT
BIRTHDATE / / GRADE
Family Information
Household Members
Relationship
Age
Education
(Highest grade completed)
Occupation
(If appropriate)
What are your child’s strengths?
In what areas do you see your child needing support or help?
Is English the usual language spoken at home? Yes No
If No, other language:
Page 1 of 5
Distribution: Student Record (IEP Team Meeting Documents folder)
Parent'Questionnaire
!
'
!
Department'of'Special'Education'and'Student'Services
!
HOWARD'COUNTY'PUBLIC'SCHOOL'
SYSTEM'
Ellicott'City,'MD'21042
!
PREGNANCY AND BIRTH
Describe any serious health problems the mother experienced during the pregnancy.
In what month(s) of the pregnancy did these problems occur?
Birth weight
Apgar Scores (if known)
Did any of the following occur during the birth process?
Pre
mature Transfusion Caesarian section Fetal distress
Breech birth Prolonged labor Breathing problem Blood Incompatibility (RH factor)
Describe any birth problems, concerns or any difficulties your child had in learning to eat, sleep, sit, walk, or talk.
Briefly describe any traumatic or recent events that your child has experienced, for example, death of a close relative,
divorce, family crisis or school situation.
MEDICAL HISTORY
Check below any illnesses or problems that your child has had:
Allergies Ear problems Hepatitis Serious accident or injuries
Food Allergies Epilepsy, seizures Lead poisoning Sickle cell anemia
Asthma Eye problems Meningitis/encephalitis Speech problems
Attention deficit Frequent colds or Operations Temperatures above 104˚
hyperactivity disorder sore throats Physical problem Tuberculosis
Cerebral Palsy Headaches Reactions to immunizations
 Diabetes Heart disease
Dietary problems Other:
Describe any of the problems checked above.
Describe any school related or major medi
cal problems other family members have experienced.
Page 2 of 5
September 2013
Distribution: Student Record (IEP Team Meeting Documents folder)
Parent'Questionnaire
!
'
!
Department'of'Special'Education'and'Student'Services
!
HOWARD'COUNTY'PUBLIC'SCHOOL'
SYSTEM'
Ellicott'City,'MD'21042
!
SOCIAL AND BEHAVIORAL CHARACTERISTICS - Check the statements which describe your child:
Gets ideas quickly Remembers most information once learned
Doesn’t seem to understand questions or directions Has difficulty remembering information
Has difficulty expressing thoughts and ideas Is creative or imaginative
Takes time to understand ideas but retains it later Has short attention span
Enjoys reading Is organized
Enjoys listening to stories Is disorganized
Has difficulty with letter sounds and reading Has difficulty with changes in routine
Enjoys writing tasks Has difficulty completing jobs and activities
Has difficulty with paper and pencil tasks Is overactive
Enjoys math tasks Is under active
 Has difficulty using numbers Is motivated
Is self-confident Lacks motivation
Seldom follows directions Shows inconsistent moods or behaviors
Is cooperative Has difficulty making and keeping friends
Shows aggression toward others Is shy or withdrawn
Is not always truthful Is fearful
 Frequently talks to self Spends a lot of time alone
Doesn’t take responsibility for behavior Has nervous habits or tics
Is likeable
Comment on any behaviors that particularly concern you.
List any private Evaluation Reports that you will provide to the school and attach the reports.
Type of Evaluation Date of Evaluation Name of Evaluator
Page 3 of 5
September 2013
Distribution: Student Record (IEP Team Meeting Documents folder)
Parent'Questionnaire
!
'
!
Department'of'Special'Education'and'Student'Services
!
HOWARD'COUNTY'PUBLIC'SCHOOL'
SYSTEM'
Ellicott'City,'MD'21042
!
When learning a new task my child likes: to work alone  to work with others  to have supervision.
My child likes to express thoughts and ideas througK
writing talk
ing movement singing
other
What
are your child’s interests outside of school?
Does your child readily do homework? Yes  No
Does your child have an established homework routine? Yes  No
If
yes, exp
lain:
What do you like best about your child?
What do you find are effective ways of disciplining your child?
What is the most challenging aspect of raising your child?
Do you have concerns about the appropriateness of your child’s friends? Yes No
If
yes, exp
lain.
Is there anything else you would like to tell us about your child?
Page 4 of 5
September 2013
Distribution: Student Record (IEP Team Meeting Documents folder)
Parent'Questionnaire
!
'
!
Department'of'Special'Education'and'Student'Services
!
HOWARD'COUNTY'PUBLIC'SCHOOL'
SYSTEM'
Ellicott'City,'MD'21042
!
Name any other persons outside your household that have a significant impact on your child’s life (for example, mentor,
other family member):
Please make suggestions as to how the school can best meet your child’s school or emotional needs.
I give my permission for the school team to use the information provided on this form to assist in identifying my child’s
educational needs. I understand that this information will be kept confidential and cannot be read by anyone other than
Howard County Public School officials who have a legitimate educational interest. I am also aware that this information
may not be sent to anyone outside of the Howard County Public School System without my permission, and that I may
request that this information be removed from my child’s folder if it is inaccurate, misleading, or otherwise in violation of
the privacy or other rights of my child. I am also aware that I may request a copy of this completed form for my own
records.
Signature Date Signature of Recorder Date
Relationship to student:
(When appropriate)
Page 5 of 5
September 2013
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