Child Data File Extraction Form

Appendix L

A

OMB Number: xxxx-xxxx

Expiration Date: xx/xx/xx

ppendix L

Child Data File Extraction Form

Child ID
Child Name
Child’s Teacher ID
Child’s Grade
Child’s Teacher’s Name
Child’s School ID
Child’s School Name
Child’s Date of Birth
Child’s gender	 Female  Male
Child’s race	 White  African American  Asian/Pacific Islander  American Indian  Multiracial  Unknown
Child’s ethnicity	 Hispanic  Non-Hispanic  Unknown
Child has an IEP?	 Yes  No
If yes, indicate disability	 Developmental disability  Educational disability  Emotional disability  Hearing disability  Language/Speech disability  Other (Autism, Deaf-Blind, Traumatic Brain Injury)
Child in a remediation program?	 Yes  No
Area of remediation	 Reading  Math  Other (specify)________________
Retained in kindergarten?	 Yes  No
Currently receiving services for English Language Learners	 Yes  No
In past received services for English Language Learners	 Yes  No
Number of missed school days (current year)
Number of years in preschool

1

Responses to this data collection will be used only for statistical purposes. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific district or individual. We will not provide information that identifies you or your district to anyone outside the study team, except as required by law.