Quarterly Update Events and Demographics (Parent)

OMB No: ???: Exp Date: ???

Q

Public reporting burden of this collection of information is estimated to average 1 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Clearance Officer; 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (???).

uarterly Update: Critical School Events

Quarterly update: Critical School Events 1. Detentions 1 A. Has your child been in detention in the last 3 months? Yes No Don’t Know 1B. How many different times was he/she in detention? ___________ times 1C. Can you tell me why your child was put in detention? Behavioral Problems Academic Problems Other Problems Don’t Know 2. Suspensions 2 A. Has your child been suspended or received in-school suspension in the last 3 months? Yes No Don’t Know 2B. How many different times has he/she received suspension/in-school suspension? ___________ times 2C. Can you tell me why your child received suspension? Behavioral Problems Academic Problems Other Problems Don’t Know

3. Expulsions 3 A. Has your child been expelled in the last 3 months? Yes No Don’t Know 3B. Can you tell me why your child was expelled? Behavioral Problems Academic Problems Other Problems Don’t Know 3C. Has he/she been sent to another school this school year as a result of the expulsion? Yes No Don’t Know 3D. If so, what is the name of the school that your child goes to? ________________ 3E. What type of school is it? Regular Alternative Other Don’t Know Questionnaire is continued on back

Quarterly update: Residence 1. Has your family moved in the last 3 months? Yes No 2. Has there been any change in your child’s custody? Yes If yes, please specify _________________________________ No 3. Has there been any change in your marital or relationship status? Yes If yes, please specify _________________________________ No

FOR STUDY USE ONLY
Date Interviewed	Month Day Year	Interviewed by