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#18-009009-0018
Supplemental Questionnaire

Last Name
First Name
1.

Please check the box below to indicate your American Sign Language skill level:

Polite (able to greet and exchange pleasantries; indicate or understand an emergency)
Literate (understands a conversation and can respond)
Fluent (is your native language or can converse in the language as if it was your native language)
Do not speak sign language.
2.

Do you have experience working with Students who are deaf or hard of hearing? If yes, please explain below

3.

Do you currently hold a Teacher Certification?  If so, from what state?

4.

Have you previously obtained Highly Qualified status from a school district?

Yes No

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