My Blueprint Survey
Student Profile
MY BLUEPRINT
Fill out this survey to help us build your perfect school year.
NAME:
DATE:
Part 1: My Interests & Hobbies
- My favorite thing to do when I am not at school is...
When I am not at school, I love to
- In school, I am really good at...
A school subject or skill I feel confident in is
- How much do you like working in groups?
Not at all
1 2 3 4 5
Love it
- How much do you like working alone?
Not at all
1 2 3 4 5
Love it
- One cool topic or subject I want to learn more about is...
I want to learn more about
Part 2: Sensory & Learning Preferences
- When the classroom gets noisy, it is hard for me to focus.
Yes No
- How do you learn best? (Check your favorite ONE)
See pictures
Listen details
Hands-on/Move
- How helpful are visual checklists or daily schedules for you?
Not helpful
1 2 3 4 5
Very helpful
- I like using tools like fidgets or headphones to help me concentrate.
Yes No
- When I get stuck on a difficult assignment, I usually...
If an assignment feels too hard, I usually
Self-Advocacy Blueprint | My Blueprint Survey Page 1 of 2
MY BLUEPRINT
Section 2: Support & Future Goals
Part 3: Social-Emotional & Coping Strategies
- When I feel frustrated, I can easily feel it in my body.
Yes No
- A coping strategy that always helps me calm down is...
When I feel overwhelmed, it helps me to
- I feel happy and safe at school when...
I feel safe when my teacher or classmates
- How comfortable are you asking a teacher for help when you are confused?
Shy/Hard
1 2 3 4 5
Easy/Ready
- One thing that makes me feel nervous or stressed in class is...
I sometimes get stressed when
Part 4: IEP Transition & Life Skills Goals
- My goal for after high school (future career or job) is to...
When I grow up, I want to work as a
- How well can you keep your own binder and school supplies organized?
Hard for me
1 2 3 4 5
I got this!
- One important life skill I want to learn to do on my own is...
I want to learn how to
- I know what accommodations are on my IEP and how they help me learn.
Yes No
- The most important thing my teachers can do to help me succeed is...
My teachers can best support me by
Self-Advocacy Blueprint | My Blueprint Survey Page 2 of 2
Blueprint Survey Teacher Guide
Teacher Resource
SURVEY TEACHER GUIDE
Translating student survey results into actionable accommodations and IEP goals.
Use alongside the
My Blueprint Survey
Administration Tips
- Pacing: Allow students to complete this in two 15-minute segments to prevent sensory fatigue.
- Read Aloud: Read questions aloud or provide text-to-speech tools for students with decoding accommodations.
- Scribe Option: Allow students to dictate sentence-starter answers if they have fine motor or handwriting goals.
Accommodation Mapping
- Sensory Tools (Q6, Q9): Positive "Yes" indicates a need for proactive sensory toolkit access (headphones, alternate seating).
- Visual Schedules (Q8): High score (4-5) justifies adding visual planners/checklists to daily routines.
- Learning Modality (Q7): Direct indicator of classroom presentation adjustments (visual vs. oral).
IEP & Transition Translation Rubric
| Survey Focus / Q# | What the Student's Response Reveals | Actionable IEP Transition / Accommodations Goal Idea |
|---|
| Group vs. Individual | | |
| (Q3 & Q4) | Preferences in collaborative vs. independent environments. Highlights social-emotional and functional fatigue. | "By [date], when working in a small group, the student will use self-advocacy strategies to request a 2-minute break or independent task..." |
| Self-Advocacy & Coping | | |
| (Q10, Q12, Q14) | Indicates comfort levels with asking for assistance and awareness of physical stress signals. | "The student will independently initiate a request for support from teachers or peers using a visual help card in 4 out of 5 opportunities..." |
| Transition Goals | | |
| (Q16, Q18) | Provides direct, compliant indicators of student-centered post-secondary career and independent living goals. | "Based on student's expressed interest in [Career from Q16], the student will research [career field] and identify 3 high school courses to support this..." |
| Executive Functioning | | |
| (Q17) | Highlights baseline executive functioning limits and organizational needs. |