Form 1 Data Collection Checklist - NYPANS

H. Data Collection Checklist and Make-up List and Instructions

Form Approved

OMB No.: 0920-XXXX

Expiration Date: XX/XXX/XXXX

DATA COLLECTION CHECKLIST – NYPANS

School Name: ____________________________________________ Date of Survey Administration: _____________________ Teacher: __________________________________ Grade(s): _____ Class: ______________________ Period: ______

	Total Number of Students Enrolled in Class Minus Ineligible* Students	Number of Non Participating Eligible Students (Code as A – Absent; ISS - In School Suspension; SR – Student Refusal; or NFR – No Form Returned)				Number of Parent Refusals (PR)	Number of Completed Surveys
		A	ISS	SR	NFR
Females
Males
Total

* The following non-participation codes should be used to identify why students are not eligible to participate in the survey. Do not include these students in the enrollment totals or on the Make-Up List.

CCI – Cannot Complete Independently DS – Dropped School EA – Extended Absence MA – Moved Away TAC – Took in Another Class

DC – Dropped Class E – Expelled H – Homebound OSS – Out of School Suspension

Please Print

Student Name or Identifier

Grade

Gender

(M/F)

Date Reminder Sent

Check if Permission

Form was Returned

“No”

Check if Permission

Form was Returned “Yes”

If Student Did NOT Participate

Record Eligibility Code

If Eligibility Code is:

A, ISS, SR

or NFR

• Student IS Eligible for Make-Up

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Public reporting burden for this collection of information is estimated to average 15 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. 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 Reports Clearance Officer, 1600 Clifton Road, NE, MS D-74, Atlanta, GA 30333, ATTN:PRA (0920-xxxx).

Please Print Student Name or Identifier	Grade	Gender (M/F)	Date Reminder Sent	Check if Permission Form was Returned “No”	Check if Permission Form was Returned “Yes”	If Student Did NOT Participate Record Eligibility Code	If Eligibility Code is: A, ISS, SR or NFR Student IS Eligible for Make-Up
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MAKE-UP LIST
School Name: ________________________ State:_______ Grades(s): _____			Teacher Name(s):_______________________________ Class:__________________________Period:_______
Dear Teacher: Students who were selected to participate but did NOT complete the survey and are eligible for a make-up are listed below. The list includes students who were coded as: A: Absent; ISS: In-School Suspension; SR: Student Refusal; and NFR: No Form Returned. Students coded as NFR must have returned a signed parental permission form, with the “yes” box checked, to be surveyed as part of a make-up session. Students who initially refused to take the survey (SR) but voluntarily changed their mind and decide to participate, also may be surveyed. You are asked to administer a make-up with all students who meet the above criteria for a make-up survey administration. An adequate supply of survey booklets, student envelopes, and pencils is enclosed. When administering the survey, please follow the enclosed make-up survey administration guide closely. When you have completed the make-ups, please place each student’s sealed envelope containing his/her questionnaire, in the white, business reply, pre-paid envelope marked MAKE-UPS along with this form. Please enter your name, school name and address on the envelope prior to mailing. For any student(s) not completing a make-up survey, please note the reason (if known) next to the student’s name below. Please return any unused survey booklets and envelopes. Please do NOT send back pencils. Important: If a student for all practical purposes has ceased to come to class or attend school and you cannot conduct a make-up, mark a capital “D” next to his/her name. Thank you again for your help. If you have any questions, please call us toll-free at 1-800-675-9727. PLEASE PRINT NAMES CLEARLY.
Males Needing Make-ups	Code* (See list of codes below)	Females Needing Make-ups		Code* (See list of codes below)

NON-PARTICIPATION CODES*

A = Absent

ISS = In School Suspension

SR = Student Refusal

NFR = No Form Returned