appendix

A set of three Questionnaires were prepared for each hearing impaired child. One to be filled by the parents, one to be filled by the regular teacher and one to be filled by the professional providing special services i.e. Special Educator / Speech Therapist / Resource Teacher. These questionnaires are as follows.  

Questionnaire No 1

All the information in the questionnaire will be kept strictly confidential. You may send your questionnaire in a sealed envelope  

Questionnaire for the parents

Full Name of the child:________________________________________________

Age:_______________   D.O.B. ___________________     Sex: ______________

Average Hearing loss: _______db. Hearing aids used: _______________________

Address:  Residence: _________________________________________________

Tel. No._________________   E-mail: __________________________________

Name and address of the school presently studying in: ______________________  

__________________________________________________________________

__________________________________________________________________

Q.1. Since when does your child suffer from the hearing loss? (Since birth / age)

A.1. ______________________________________________________________

Q.2. When was the problem first detected? By whom?

A.2. ______________________________________________________________

Q.3. When was the child first fitted with the hearing aids?

A.3. ______________________________________________________________

Q.4. On an average, how many hours per day does the child wear the hearing aids?

A.4. ______________________________________________________________

Q.5. Which schools has the child attended so far? Give names and no. of years.

A.5. ______________________________________________________________

       ______________________________________________________________

       _____________________________________________________________

Q.6. Does the child have additional help? Tic [ x ] where applicable.

A.6. a) Regular teacher _____ b) Special educator _______ c) Parent _____

        d)  Speech therapist _______ e) Any other (specify) _______________

Q.7. How exactly do you help your child to cope up in a regular school?

A.7. ______________________________________________________________       

        ______________________________________________________________

        ______________________________________________________________

Q.8. Which are the specific areas where your child finds difficulty in coping in inclusive set up?  Tic [ x ] where applicable  

A.8. Particular subjects (specify) ________________________________________          

        Communicating with others ________________________________________

        Social and emotional adjustment ____________________________________

        Any other (specify) ______________________________________________      

Q.9. In your opinion, what extra facilities should be given to such children in regular schools?

A.9. ______________________________________________________________

       ______________________________________________________________

       ______________________________________________________________

Q.10. What is it about the school that your child does not like and wish that it would change?

A.10. _____________________________________________________________ 

         _____________________________________________________________

Q. 11.  Does your child suffer from any illness or other disability? If yes, write details.

A.   11.  ___________________________________________________________

       ___________________________________________________________

       ___________________________________________________________

Q. 12.  Your views / suggestions on inclusive educational setup that you may wish to share with us.  

A. 12.  ____________________________________________________________

            ____________________________________________________________

            ____________________________________________________________

            ____________________________________________________________    

Questionnaire No 2  

All the information in the questionnaire will be kept strictly confidential. You may send your questionnaire in a sealed envelope 

Questionnaire for class teacher in regular school  

Full Name of the child: _______________________________________________  

Name of the school: ____________________________________ Std: _________  

Name of the teacher: _________________________________________________  

Tel No: ___________________ E-mail: __________________________________  

Q. 1. Since how long have you been teaching the child?  

A. 1.  ________ years _________ months.  

Q. 2. How many hours is the child with you in the classroom everyday?  

A. 2. ________ hours.  

Q. 3. Does the child co-operate with you? Tic [ x ] the correct answer.  

A. 3. Never____, Rarely____, Occasionally_____, Frequently_____, Always____,  

Q. 4. What is the mode of communication used by the child? Tic [ x ] the correct answer.  

A. 4. Only verbal ______, Verbal with gestures / signs _____, Only signs _____,

         Tic [ x ] the correct Answer.  

Q. 5. Do you have difficulty in communicating with the child? Tic [ x ] the correct Answer

A. 5. Never____, Rarely____, Occasionally_____, Frequently_____, Always____,  

Q. 6. Does the child have difficulty in communicating with you? Tic [ x ] the correct Answer.

A. 6. Never____, Rarely____, Occasionally_____, Frequently_____, Always____,

Q. 7. Which are the specific areas that you find most difficult to teach? Specify.

A. 7. Particular subjects _______________________________________________

        Communication _________________________________________________

        Social skills ____________________________________________________

        Any other ______________________________________________________  

Q. 8. What is it that you would like to change to make learning easier for the child?

A. 8. ______________________________________________________________

         ______________________________________________________________

         ______________________________________________________________  

Q. 9. Does the child mix with other children and participate in group activities? Tic [ x ] the correct Answer.

A. 9. Never____, Rarely____, Occasionally_____, Frequently_____, Always____,

Q.10. What are your expectations from the parents to help the child cope in regular school and learn better?  

A.10 ______________________________________________________________

        ______________________________________________________________

        ______________________________________________________________

Q. 11.  Your views / suggestions on inclusive educational setup that you may wish to share with us.  

A. 11.  ____________________________________________________________

            ____________________________________________________________

            ____________________________________________________________

            ____________________________________________________________

 Questionnaire No 3

All the information in the questionnaire will be kept strictly confidential.You may send your questionnaire in a sealed envelope  

Questionnaire for Special Educator / Speech Therapist / Resource Teacher

Full Name of the child: _______________________________________________  

Name of the Special Educator / Speech Therapist / Resource Teacher: __________________________________________________________________

Tel No: ___________________ E-mail: __________________________________

Q. 1. Since how long have you been teaching the child?

A. 1.  ________ years _________ months.  

Q. 2. How many hours do you teach the child in a week?  

A. 2. ________ hours.  

Q. 3. Does the child co-operate with you? Tic [ x ] the correct answer.  

A. 3. Never____, Rarely____, Occasionally_____, Frequently_____, Always____,  

Q. 4. What is the mode of communication used by the child? Tic [ x ] the correct answer.  

A. 4. Only verbal ______, Verbal with gestures / signs _____, Only signs _____,  

Q. 5. Do you have difficulty in communicating with the child? Tic [ x ] the correct  answer.  

A. 5. Never____, Rarely____, Occasionally_____, Frequently_____, Always____,  

Q. 6. Does the child have difficulty in communicating with you? Tic [ x ] the correct answer.  

A. 6. Never____, Rarely____, Occasionally_____, Frequently_____, Always____,

Q. 7. In which areas do you train the child? Tic [ x ] all the areas applicable.  

A. 7. 1) Language _____              2) Speech _______       3) Lip reading _____
         
        4) Auditory Training ______ 5) Sign Language _____6) Subjects ______

        7) Any other / Specify ___________  

Q. 8. Among the areas in answer 7 in which you train the child, which are the most

         difficult to teach? Specify.  

A. 8. ______________________________________________________________

         ______________________________________________________________

         ______________________________________________________________

Q. 9.  What are the factors that you consider before mainstreaming the child in inclusive educational set up?  Specify.    

A. 9.  _____________________________________________________________

          _____________________________________________________________

          _____________________________________________________________

Q.10. What are your expectations from the parents to help the child cope in regular school and learn better?  

A.10 _____________________________________________________________

         ______________________________________________________________

         ______________________________________________________________  

Q. 11.  Does the child suffer from any other disability? If yes, write details.  

B.    11.  ___________________________________________________________

       ___________________________________________________________  

Q. 12.  Your views / suggestions on inclusive educational setup that you may wish to share with us. 

A. 12.  ____________________________________________________________

            ____________________________________________________________

            ____________________________________________________________

            ____________________________________________________________  

  

Contact Details:

Nilam Patel Bahushrut Foundation

SF-Riverdale Apartment,Opp. Sun Moon Park

Akota, Vadodara 390 020

Telephone: 91-0265-2357124

E-mail: nilampatel62@gmail.com

 Website: www.bahushrutfoundation.org

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