Schoolwide Records Collection Form

Appendix C Schoolwide Records Collection Form

SCHOOL IDENTIFICATION (ATTACH LABEL HERE) School Name: School Address:

SCHOOLWIDE RECORDS COLLECTION FORM

OMB No.: 1850-0818 Expiration Date: MM/DD/YY

Name of person completing this form: ________________________________________

Phone of person completing this form: (__ __ __) __ __ __ - __ __ __ __

1. Please record today’s date: | | | / | | | / | | | | |

Month Day Year

2. Which of the following best describes this school? CHECK ONE RESPONSE

1  Regular public school

2  Alternative public school

3  Charter school

4  Special Program Emphasis (for example, science/math school, talented/gifted school, etc.)

5  Special Education (primarily serves students with disabilities)

6  Other (Please specify)

3. How many teachers are employed at this school? Include all full and part-time regular classroom teachers, special area or resource teachers, long-term substitute teachers, and itinerant teachers. Do not include student teachers, teachers’ aides, or short-term substitute teachers.	_________	(Enter Number)
4. As of October 1, 2006, what was the total number of students enrolled in this school?	_________	(Enter Number)
5. How many students were ABSENT on the most recent school day?	_________	(Enter Number)
6. How many students were TARDY on the most recent school day?	_________	(Enter Number)
7. What percentage of current students at this school are male?	| | | |	(Enter Percent)
8. What percentage of current students at this school are Hispanic or Latino?	| | | |	(Enter Percent)
9. What percentage of current students at this school are:
American Indian/Alaska Native	| | | |	(Enter Percent)
Asian	| | | |	(Enter Percent)
Black or African American	| | | |	(Enter Percent)
Native Hawaiian or Other Pacific Islander	| | | |	(Enter Percent)
White	| | | |	(Enter Percent)
10. What percentage of current students at this school fit the following criteria?
10a. Are approved for free or reduced-price school meals?	| | | |	(Enter Percent)
10b. Are limited English Proficient (LEP) or English Language Learners (ELL)?	| | | |	(Enter Percent)
10c. What percentage of students have an Individual Education Plan (IEP) for students receiving special education services under the Individuals with Disabilities Education Act (IDEA) or a Services Agreement for students receiving services under Section 504 of the Rehabilitation Act of 1973?	| | | |	(Enter Percent)

11. During THIS school year (2006-2007), has it been the practice of this school to do the following?

Source: Modified from Principal Questionnaire, SAS SURVEY 03-04, Q35

	CHECK “YES” OR “NO” ON EACH LINE
	Yes	No
a. Control access to school buildings during school hours (e.g., locked or monitored doors	1 	0 
b. Control access to school grounds during school hours (e.g. locked or monitored gates)	1 	0 
c. Require students to pass through metal detectors each day	1 	0 
d. Perform random metal detector checks on students	1 	0 
e. Require that all or most students stay on campus during lunch	1 	0 
f. Require students to wear uniforms	1 	0 
g. Enforce a strict dress code	1 	0 
h. Require clear book bags or ban book bags on school grounds	1 	0 
i. Require students to wear badges or picture IDs	1 	0 
j. Use one or more security cameras to monitor the school	1 	0 
k. Maintain a daily presence of police or security personnel	1 	0 

12. During THIS school year (2006-2007), how often has this school used random dog sniffs to check for drugs?

1  At least once a week

2  At least once a month

3  On occasion

4  Never GO TO 13

12a. In how many instances were drugs or drug paraphernalia found during the most recent dog sniff?

If none, please write in “0.”

_____ NUMBER OF INSTANCES

13. During THIS school year (2006-2007), how often has this school performed random sweeps for contraband (e.g., drugs or weapons), but not including dog sniffs?

1  At least once a week

2  At least once a month

3  On occasion

4  Never GO TO 14

13a. If this school does perform random sweeps for contraband, in how many instances were contraband found during the most recent search?

If none, please write in “0.”

	NUMBER OF INSTANCES
a. Drugs and/or drug paraphernalia were found	________
b. Alcohol was found	________
c. Weapons were found	________
d. Total number of instances any contraband was found	________

1

Source: Modified from Principal Questionnaire SAS SURVEY

03-04, Q33

4. For each of the following time periods, how many students were expelled (i.e., removed or transferred for at least the remainder of the school year) from this school?

If none, please write in “0.”

Last School Year (2005-2006)	Current School Year (2006-2007)
________ NUMBER OF STUDENTS	________ NUMBER OF STUDENTS

1

Source: Modified from Principal Questionnaire

SAS SURVEY

03-04, Q34

5. For each of the following time periods, what was the total number of suspensions in this school? Please include in-school and out-of-school suspensions. Please count each individual suspension (e.g., if one student received 10 suspensions, all 10 would be included on this line).

If none, please write in “0.”

Last School Year (2005-2006)	Current School Year (2006-2007)
________ NUMBER OF SUSPENSIONS	________ NUMBER OF SUSPENSIONS

1

Source: Modified from School Survey on Crime & Safety Prevention 03-04, Q22

6. For each of the following time periods, please provide the total number of incidents this school recorded for each of the offenses listed below.

If none, please write in “0.”

	Last School Year (2005-2006)	Current School Year (2006-2007)
Use/possession of a firearm/explosive device	________	________
Use/possession of a weapon other than a firearm	________	________
Distribution, possession, or use of illegal drugs	________	________
Distribution, possession, or use of alcohol	________	________
Physical attacks or fights	________	________

17. During each of the following time periods, did this school have any formal programs intended to prevent or reduce tobacco, alcohol and/or drug use that included the following components for students?

Source: Modified from School Survey on Crime & Safety Prevention 03-04, Q3

	CHECK “YES” OR “NO” ON EACH LINE FOR EACH TIME PERIOD
	Last School Year (2005-2006)		Current School Year (2006-2007)
	Yes	No	Yes	No
a. Prevention curriculum, instruction, or training for students	1 	0 	1 	0 
b. Behavioral or behavior modification intervention for students	1 	0 	1 	0 
c. Counseling, social work, psychological, or therapeutic activity for students	1 	0 	1 	0 
d. Recreational, enrichment, or leisure activities for students	1 	0 	1 	0 
e. Hotline/tipline for students to report problems	1 	0 	1 	0 
f. Information line for students to obtain information about alcohol and/or drug use	1 	0 	1 	0 
g. Health fair, including component(s) related to alcohol and/or drug use…………………………………………..	1 	0 	1 	0 
h. Student assemblies, speaking engagements…………	1 	0 	1 	0 
i. Alcohol and/or drug resource center……………………	1 	0 	1 	0 
j. Brochures or posters…………………………………….	1 	0 	1 	0 
k. Other programs intended to prevent or reduce alcohol and/or drug use? (Please list)
	1 	0 	1 	0 
	1 	0 	1 	0 

1

Source: Modified from School Survey on Crime & Safety Prevention 03-04, Q12

8. During each of the following time periods, which of the following trainings for classroom teachers or aides did this school or district provide?

	CHECK “YES” OR “NO” ON EACH LINE FOR EACH TIME PERIOD
	Last School Year (2005-2006)		Current School Year (2006-2007)
	Yes	No	Yes	No
a. School-wide discipline policies and practices related to alcohol and/or drug use	1 	0 	1 	0 
b. Recognizing signs of students using/abusing alcohol and/or drugs	1 	0 	1 	0 
c. Other programs? (Please list)
	1 	0 	1 	0 
	1 	0 	1 	0 
	1 	0 	1 	0 

19. During each of the following time periods, how many students transferred to and from your school after the school year had started? Please report on the total mobility, not just transfers due to disciplinary actions.

(If a student transferred more than once in the school year, count each transfer separately. If no transfers, please record zero [0].)

	Last School Year (2005-2006)	Current School Year (2006-2007)
a. Total number of transfers to the school	____________	_____________
b. Total number of transfers from the school	____________	______________

2

Source: Eval. of the 21^st Century Community Learning Centers Program, School Records Form, Q11

0. The last question is about the most current average reading and math test scores for students in this school. For each grade and subject listed below please indicate:

(1) whether students were tested, (2) date of test, (3) test name, (4) publisher name, (5) raw score, and (6) percentile.

	(1)		(2)		(3)	(4)	(5)	(6)
	Students tested?		Date of Test
Grade	Yes	No	Month	Year	Test Name	Publisher Name	Raw Score	Percentile
9th Grade
Math	1 	0 	| | | Month	| | | Year	____________	___________	_______	| | | |
Reading	1 	0 	| | | Month	| | | Year	____________	___________	_______	| | | |
b. 10th Grade
Math	1 	0 	| | | Month	| | | Year	____________	___________	_______	| | | |
Reading	1 	0 	| | | Month	| | | Year	____________	___________	_______	| | | |
c. 11th Grade
Math	1 	0 	| | | Month	| | | Year	____________	___________	_______	| | | |
Reading	1 	0 	| | | Month	| | | Year	____________	___________	_______	| | | |
d. 12th Grade
Math	1 	0 	| | | Month	| | | Year	____________	___________	_______	| | | |
Reading	1 	0 	| | | Month	| | | Year	____________	___________	_______	| | | |

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is xxxx‑xxxx. The time required to complete this information collection is estimated to average 60 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collected. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, DC 20202-4651. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: U.S. Department of Education, Institute for Education Sciences, 555 New Jersey Avenue, Washington, DC 20208‑5651. This survey is authorized by law (INSERT LEGISLATION, IF APPLICABLE).

Prepared by Mathematica Policy Research, Inc.

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