PARENT QUESTIONNAIRE ONLINE ORDER FORM

Office of Special Education
The State Education Dept./The University of the State of New York/Albany, NY 12234

Instructions:
1. Please answer all questions. Do not leave any blank fields.
2. Do not over-order surveys. If you are unsure how many surveys you need to order for.your district, click on the Survey Calculator.

If you experience technical difficulties with this web site or with any of the online surveys, please contact the Potsdam Institute for Applied Research (PIAR) at SUNY Potsdam at 315-267-3466 or 888-419-2698 (toll free) or send an e-mail to parentsurvey@potsdam.edu.

REQUISITION FORMS & REPORTS
Part I: Contact Information
Please provide the following Information regarding the person filling in this form so that we may contact you if any clarification of this information is required.
Surveys ordered by:
  Mr. Mrs. Ms. Dr.
Name
Phone
Ext.
Fax
Email

Part II: Stakeholder Review (Distribution & Demographics)

Please provide the following Information regarding the school district participating in this survey and the name of the individual to whom the surveys will be shipped.

Surveys ordered for:

District
Send the surveys I am ordering to the attention of:
  Mr. Mrs. Ms. Dr.
Name
Title
School or Bldg Name
Address

City, State, Zip
Phone
Ext
Fax
Email

Part III: Ordering Parent Surveys

This survey is available in multiple languages. The default/standard version Is In English and Spanish. Please order the other language options only when necessary.

Important! Do not over-order surveys. If you are unsure how many surveys you need to order for your district, click on the Survey Calculator.

Language
Quantity 
English/Spanish
English/Chinese
English/Russian
English/Haitian Creole
English/Urdu
English/Bengali
English/Korean
English/Arabic
English/Yiddish