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Florida Department of Education
Bureau of Instructional Support and Community Services
Usher Syndrome Screening Survey
Name:
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District:___________________________ _______
Address:
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Telephone:________________________________
Email:________________________________________________________________________
1.
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What is your district’s current procedure for implementing the Usher Syndrome
Screening requirement according to State Board of Education Rule 6A-6.03013 (3)(d)?
Please check the appropriate box.
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No procedures in place at this time
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Current procedures are unclear
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Procedures in place. Please describe: ____________________________
2.
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Who is responsible for oversight of the screening implementation?
Name_______________________________ Title? ______________________________
3.
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When does Usher Syndrome Screening usually occur (i.e. Fall of 6
th
grade)?
4.
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What follow-up actions take place (or would take place) should a child have a positive
screening? ______________________________________________________________
5.
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Do you feel that you could use more training or technical assistance regarding the Usher
Syndrome Screening requirement? Circle one:
yes no
Additional Comments: _____________________________________________________
Please return to Dawn Saunders by April 7, 2004.
Mailing address: 325 West Gaines Street, Suite 601
Tallahassee, Florida 32399
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Fax: 850-245-0955
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