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  5. Confidential Parent Survey 2012/2013
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PAK
Parents Advocating for Kids (Butte)
Confidential Parent Survey 2012/2013

Please respond to the following statements. Circle the one that most accurately reflects your experience with your child’s educational program(s). Thank you.
 
 
1. Name:
   
 
 
 
2. Email Address:
   
 
 
 
3. Your Child's School:
   
 
 
 
4. Child’s Grade Level:
(If you have more than one child receiving services, fill out the survey and answering the questions with only one child in mind. Please select the grade level of your child below.)
 
Preschool
 
Elementary
 
Junior High
 
Senior High
 
Alternative Program
 
N/A
 
 
 
5. Please indicate below that which describes your child’s educational programs/services:
 
Early Childhood Program (prior to 5 years old)
 
Therapy Only (Occupational, Speech, Physical Therapy, etc.)
 
Special Education at Neighborhood School
 
Special Education/Self Contained Program
 
Special Education & Therapy
 
504 plan
 
Unsure
 
N/A
 
My child doesn’t have an IEP or a 504 plan. If so, please note if you feel services are needed.
 

 
 
6. On a scale of 1 to 4 (1 = Strongly Agree | 4 = Strongly Disagree, 5 = Don't Know), please indicate the number that best describes your opinion to the following statements:
1
Strongly Agree 		2 3 4
Strongly Disgree 		Don't Know
a. The people who work with my child are open and communicate a caring attitude toward my child and family.
b. I have had the opportunity to become actively involved in my child’s program.
c. I have had the opportunity to give my input in my child’s program.
d. When I’ve had a concern about my child’s program, the school staff is understanding and responds in a timely manner.
e. I am informed on my child’s progress, services, and activities.
f. Overall, the program(s) and services are appropriate for my child’s needs.
 
 
 
7. What will improve your child's program?
   
 
 
 
8. What do you see as the strengths of your child’s program?
   
 
 
 
9. What is the greatest challenge to you as a parent/guardian of a special education student?
   
 
 
 
10. What are some topics you may be interested in learning more about? Please check all that apply below:
 
Understanding Your Child’s IEP
 
Transition Planning
 
District Special Education Services & Options
 
Autism/Asperger’s
 
Behavioral Issues
 
Parent Rights & Responsibilities
 
Learning Disabilities
 
Community and School Resources
 
Recreation Opportunities
 
State Service Agencies
 
Physical Therapy
 
ADD/ADHD
 
Speech
 
Inclusion
 
Occupational Therapy
 
Communication: School & Family
 
Other
 

 
 
 
10. Would you need childcare in order to attend meetings?
 
Yes
 
No
 
N/A
 
 
 
11. What are good times for you to attend meetings?
(Check all that apply)
 
6:00 PM
 
6:30 PM
 
7:00 PM
 
Other (please explain preference)
 

 
 
 
12. How often would you like to see the meeting occur?
(Check all that apply)
 
Monthly
 
Every two months
 
Quarterly
 
No Preference

 
 
 
13. What was the most useful part of this presentation today?
   
 
 
 
14. What did you gain from attending this session today?
   
 
 
 
15. Are you interested in being a core team of the PAK to help facilitate and support the mission of this group?
 
Yes
 
No
 
 
 
If yes, please provide your name(s) and phone number(s).
   
 
 
 
Other Comments:
   
 
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