School Records Form

APPENDIX B
SCHOOL RECORDS FORMS

OMB No.: 1850-0812
Expiration Date: 03/31/2009

AFFIX SCHOOL LABEL HERE

SCHOOL INFORMATION FORM (2007-2008)
National Evaluation of Reading Comprehension Programs
1.

2.

For what grade levels does this school offer instruction? (CHECK ALL THAT APPLY)
1

c Pre-kindergarten

5

c 3rd grade

9

c 7th grade

2

c Kindergarten

6

c 4th grade

10

c 8th grade

3

c 1st grade

7

c 5th grade

10

c Other (specify):

4

c 2nd grade

8

c 6th grade

15

c Ungraded (including ungraded special ed. students)

What was the total number of students enrolled
in this school around the first of October 2007?................................ .$$$.$$$.$$$.$$$. Students enrolled

3.

How many students were absent on the most recent school day? .......... .$$$.$$$.$$$. Students absent

4.

During the 2006-2007 academic year or summer, approximately
how many students transferred from your school?.................................. .$$$.$$$.$$$. Student transfers
Exclude students who graduated to a middle or high school.

5.

What percentage of students in the 2007-2008 academic year are:
a. Eligible for the federally funded free or reduced- price lunch program? ... .$$$.$$$.$$$. % of students
b. Classified as limited English proficient (LEP)? ....................................... .$$$.$$$.$$$. % of students

6.

How many students enrolled in this school are:
a. Hispanic or Latino ..................................................................................... .$$$.$$$.$$$.$$$. Students
b. Not Hispanic or Latino ............................................................................... .$$$.$$$.$$$.$$$. Students

7.

How many students enrolled in this school are (please select
one or more categories for each student):
a. American Indian or Alaska Native.............................................................. .$$$.$$$.$$$.$$$. Students
b. Asian......................................................................................................... .$$$.$$$.$$$.$$$. Students
c. Black or African American ......................................................................... .$$$.$$$.$$$.$$$. Students
d. Native Hawaiian or other Pacific Islander................................................... .$$$.$$$.$$$.$$$. Students
e. White ........................................................................................................ .$$$.$$$.$$$.$$$. Students
Please complete the other side.

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 1850-0812. The time required to complete
this information collection is estimated to average 10 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,
D.C. 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, Planning and Evaluation Services, Washington, D.C. 20208-5651.

Prepared by Mathematica Policy Research, Inc.

School Information Form (2007-2008)

OMB No.: 1850-0812
Expiration Date: 03/31/2009
How many teachers are employed at this school? ............................. .$$$.$$$.$$$. Teachers employed
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 shortterm substitute teachers.

8.

9.

How many fifth grade students were enrolled in
this school around the first of October 2007?................................. .$$$.$$$.$$$.$$$. 5th-grade students

10. How many fifth-grade classes do you have?.............................................. .$$$.$$$. 5th-grade classes
11. What type of school is this? (CHECK ONE)
1 c Regular
2 c Special Program Emphasis (science/math school, talented/gifted school, foreign language
immersion school, etc.)
3 c Special Education (primarily serves students with disabilities)
4 c Other (specify):
12. Does this school offer a magnet program? ..............................1 c Yes

0

c No

13. Is this a charter school? .........................................................1 c Yes

0

c No

14. a. Is this a Title I school? .......................................................1 c Yes

0

c No

b. If yes: Is it school-wide Title I? ...........................................1 c Yes

0

c No

15. Is your school participating in any comprehensive school reform?
1

c Yesà Please describe:

0

c No

16. Please complete the table below for the most current average reading and math standardized test
scores for this school’s fourth- and fifth-grade students.
Grade
Level

Test

Publisher

Month/
Year

Reading

Math

Standard
Nat’l
Standard
Nat’l
Score* Percentile Score* Percentile

4th
4th
5th
5th
*If standard scores are not available, check here if reporting:

1
2

c Scaled Scores
c Raw Scores

1
2

c Scaled Scores
c Raw Scores

Please return this form to Mathematica in the postage-paid envelope provided
or by faxing it to 202-863-1763, attention Melissa Dugger. Thank you very much.
Prepared by Mathematica Policy Research, Inc.

School Information Form (2007-2008)

OMB No.: 1850-0812
Expiration Date: 03/31/2009

AFFIX STUDENT BAR-CODED
LABEL HERE

STUDENT RECORDS FORM (2007-08)
NATIONAL EVALUATION OF READING COMPREHENSION PROGRAMS
1. What is this student’s date of birth?

.$$$.$$$. .$$$.$$$.

/

/ .$$$.$$$.

MONTH DAY

2.

Is this student male or female?

1

3.

What is the student’s ethnicity?

1

4.

What is this student’s race?
(PLEASE SELECT ONE OR MORE)

c Male

YEAR

2

c Female

c Hispanic or Latino
0 c Not Hispanic or Latino
9 c Don’t know

c American Indian/Alaska Native
2 c Asian
3 c Black or African American
4 c Native Hawaiian or other Pacific Islander
5 c White
9 c Don’t know
1

5. How many days was this student absent during the 2007-08 school year? (WRITE “0” IF NO ABSENCES)
a.

.$$$.$$$.$$$.

Total days absent in the 2007-08 school year

b.

.$$$.$$$.$$$.

Unexcused days absent in the 2007-08 school year (WRITE “NA” IF NOT AVAILABLE)

6. Is this student… (CHECK ONE IN EACH ROW )
YES

a. Classified as limited English proficient (LEP)? ............................................ 1 c
b. Eligible for the federally funded free or reduced-price lunch program? ......... 1 c

NO
0

c

0

c

7. For which of the following disability categories has this student been officially identified?
(CHECK ALL THAT APPLY)
1

c Autism

6

c Learning disability

11

c Traumatic brain injury

2

c Deaf-blindness

7

c Mental retardation

12

c Visual impairment

3

c Developmental delay

8

c Orthopedic impairment

13

c Other disability (SPECIFY):

4

c Emotional disturbance

9

c Other health impairment

5

c Hearing impairment

14

c None of the above

10

c Speech or language impairment

Please complete the other side.
Prepared by Mathematica Policy Research

Student Records Form 2006-07

8. Which of the following services does this student receive in reading? (CHECK ALL THAT APPLY)
1

c Reading support

2

c Speech/Language support

3

c English as a Second Language (ESL)/English for Speakers of Other Languages (ESOL), English

Language Development (ELD)
4

c Any other extra support or tutoring (i.e., Title I or other extra help to bring students up to grade-level

expectations)
5

c None of the above

9. In what grade was this student enrolled in the 2007-08 school year?

.$$$$.

Grade

10. What was this student’s enrollment status on the last day of the 2007-08 school year? (CHECK ONE)
If the student transferred, was expelled, or left for another reason, please fill in the box to the right.
1

c Enrolled at this school on the last day

of the 2007-08 school year

.$$$.$$$. .$$$.$$$.

/

Last day of attendance:

MONTH DAY

2

c Transferred to another school..........

3

c Expelled..........................................

Name of new school:

4

c Other (SPECIFY)

New school’s address:
CITY

....

/ .$$$.$$$.
YEAR

STATE

11. Has this student been promoted to the next grade for the 2008-09 school year? (CHECK ONE)
If the student will attend a new school next year, please fill in the box to the right.
1

c Yes

0

c No

9

c Don’t know

Promoted to grade:

.$$$$$.

If attending a new school next year:
Name of new school:
New school’s address:
CITY

STATE

Please return this form to Mathematica Policy Research, Inc., in the postage-paid envelope provided
or by faxing it to 202-863-1763, attention Melissa Dugger.

Thank you very much.

Prepared by Mathematica Policy Research

Student Records Form 2007-08