Child Data File Extraction

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

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.