| DC CHOICE PROGRAM EVALUATION |
| Student Outcome Records Form |
| School Name: _____________________________________ |
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| School ID: _____________ |
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| School Year: ________________ |
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| Individual Completing this form: __________________________________ |
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| Date: ______________________________ |
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Enrollment |
Gender |
Birth Date |
IEP |
Limited English Proficient |
Free/ Reduced Lunch |
Attendance during the current school year |
Was student Retained for 2012-2013 |
If 12th grader; Anticipated High School Graduation for 2013 |
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Currently Enrolled |
If not enrolled, Reason Left School |
New School Name |
Absences |
Tardies |
Disciplinary Actions |
| Student ID |
Student Name |
Male |
Female |
Not Available |
MM/DD/YYYY |
Yes |
No |
Not Available |
Yes |
No |
Not Available |
Yes |
No |
Not Available |
# of Excused Absences |
# of Unexcused Absences |
Total # of Absences |
# of Excused Tardies |
# of Unexcused Tardies |
Total # of Tardies |
# of In-School Suspensions |
# of Out-of-School Suspensions |
# of Truancies |
# of Expulsions |
Total # of Disciplinary Actions |
Yes |
No |
Not Available |
Yes |
No |
Not Available |
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Yes or No |
- Moved out DC |
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- Went to public school |
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- Went to another private school |
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- Dropped out |
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- Expelled |
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- Unknown |
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- Other ______________ |
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| 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. The valid OMB control number for this information collection is xxxx-xxxx. Public reporting burden for this collection is estimated to average 40 hours for the school response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. The obligation to respond to this collection is required to obtain or retain benefits. “The authorizing statute includes an expectation that the mandated evaluation, in collaboration with the program operator, “ensure that the parents of each student who applies for a scholarship under this division… and the parents of each student participating in the scholarship program under this division, agree that the student will participate in the measurements given annually by the Institute of Education Sciences…” SOAR Act Sec. 3009(a)(3)(C). The program operator has determined that to meet this requirement, participants are obligated to participate in the measurements (data collection) or they could lose their scholarship award.” 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 Avenue, S.W., LBJ, Room 2E117, Washington, DC 20210-4537 or send electronically through the Federal eRulemaking Portal at http://www.regulations.gov by selecting the Docket ID number. |