Appendix I - School Records Form

APPENDIX I
STUDENT RECORDS

TITLE I EARLY CHILDHOOD LANGUAGE DEVELOPMENT STUDY

Student Records

August 1, 2011

Notice of Confidentiality

Information collected for this study come under the confidentiality and data protection requirements of the Institute of Education Sciences (The Education Sciences Reform Act of 2002, Title I, Part E, Section 183). Information that could identify an individual or institution will be separated from the survey responses submitted, kept in secured locations, and be destroyed as soon as they are no longer required. Survey responses will be used only for research purposes. The reports prepared for the study will summarize findings across individuals and institutions and will not associate responses with a specific district, school, or person.

Conducted by: Mathematica Policy Research

www.mathematica-mpr.com

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain a benefit(Education Department General Administrative Regulations Section 76.591). Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Education, 400 Maryland Ave., SW, Washington, DC 20210-4537 or email ICDocketMgr@ed.gov and reference the OMB Control Number 1850-0871. Note: Please do not return the completed questionnaire to this address.

AFFIX STUDENT LABEL	STUDENT RECORDS	OMB No.: 1850-0871
		Expiration Date: xx/xx/xxxx

STUDENT CHARACTERISTICS, ATTENDANCE, AND SERVICES

1. Is this student Hispanic or Latino(a)?

1 □ Hispanic or Latino(a)

0 □ Not Hispanic or Latino(a)

2. What is this student’s race?

MARK (X) ALL THAT APPLY

1 □ American Indian/Alaska Native

2 □ Asian

3 □ Black or African American

4 □ Native Hawaiian or other Pacific Islander

5 □ White

3. What is this student’s date of birth?

(If the school does not provide full DOB please provide the month and year.)

| | | / | | | / | | | | |

Month Day Year

4. What is this student’s gender?

1 □ Male

2 □ Female

5. Please provide the month and year this student first enrolled at this school.

| | | / | | | | |

Month Year

6. What grade(s) has this student attended at this school? Include this student’s current grade as well as those attended in previous years.

MARK (X) ALL THAT APPLY

1 □ Prekindergarten

2 □ Kindergarten

3 □ 1st grade

4 □ 2nd grade

5 □ 3rd grade

6 □ Ungraded

ATTENDANCE

7. What was this student’s enrollment status on the last day of the 2011-2012 school year?

1 □ Enrolled at this school for the entire 2011-2012 school year. GO TO Q.8

2 □ Started after the beginning of the school year.

Date of Arrival: | | | / | | | / | | | | |

Month Day Year

3 □ Left before the end of the school year.

Date Left: | | | / | | | / | | | | |

Month Day Year

8. How many days was this student absent during the 2011-2012 school year?

IF NONE, ENTER “0”

| | | NUMBER OF DAYS ABSENT

9. Has this student been promoted to the next grade for the 2012-2013 school year?

1 □ Yes, promoted to grade: | | |

0 □ No

10. Prior to this school year (2011-2012), has this student ever been retained in a grade?

1 □ Yes

0 □ No GO TO Q.12

11. If yes, what grade(s) did this student repeat?

1 □ Prekindergarten

2 □ Kindergarten

3 □ 1st Grade

4 □ 2nd Grade

5 □ 3rd Grade

6 □ Ungraded

TEST SCORES

Please indicate whether state or district standardized test scores are available for this student in Question 12 below. If test scores are available, please provide this student’s grade 3 standardized assessment scores in reading in the table provided in Question 13. Instructions for completing Question 13 are provided along with an example showing how the table is to be completed.

12. Are standardized test scores available for this student?

1 □ Yes

0 □ No GO TO Q.14

13. For each reading standardized test administered to this student during the 2010-2011 school year and 2011-2012 school year, please provide the following information on the table on the next page. Please review the examples below before completing the table for the student.

1. Month it was administered.

2. Test name and publisher or name of state or district developed test (e.g., ITBS, TerraNova, Stanford 9, FCAT, VA SOL, NY ELA and Math, TAAS, PSSA, ESPA, GEPA, California State Standards).

3. Form and/or level of test administered.

4. Specific reading test components administered.

5. Student’s standard score (for individual test components and overall reading score). If standard scores are not used for this test, you can provide the scale score or raw score, indicating which type of score you are providing by checking the blank at the bottom of the table entry.

6. Student’s percentile (for individual test components and overall reading score).

EXAMPLE

Year/Month	Test/Publisher/Edition	Form/ Level	Reading Test Component	Standard Score*	National Percentile
2010-11 Jan.	Stanford 9 Achievement Test/ Harcourt Brace	Primary 3	Reading Comprehension Reading Vocabulary Total Reading	622 603 613	73% 54% 65%
*If standardized scores are not available, use an X to indicate if reporting scale scores _X_ or raw scores ___
2011-12 May	New Mexico Standards Based Assessment (NMSBA)	Grade 3	Reading	30	N/A
*If standardized scores are not available, use an X to indicate if reporting scale scores ___ or raw scores _X_

TEST SCORE TABLE (Use this table to enter the scores for this student)

Year/Month	Test/Publisher/Edition	Form/ Level	Reading Test Component	Standard Score*	National Percentile
*If standardized scores are not available, use an X to indicate if reporting scale scores__ or raw scores ___
*If standardized scores are not available, use an X to indicate if reporting scale scores___ or raw scores ___
*If standardized scores are not available, use an X to indicate if reporting scale scores ___ or raw scores ___
*If standardized scores are not available, use an X to indicate if reporting scale scores ___ or raw scores ___
*If standardized scores are not available, use an X to indicate if reporting scale scores ___ or raw scores ___
*If standardized scores are not available, use an X to indicate if reporting scale scores ___ or raw scores ___

SPECIAL EDUCATION SERVICES

14. Does the student have an Individualized Education Program (IEP) or an Individualized Family Service Program (IFSP) 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?

1 □ Student receives services under an IEP/IFSP

2 □ Student receives services under a Services Agreement

3 □ Neither of the above applies for this student