Critical School Events (elementary, middle)

OMB No: Exp Date:

Parent Critical Events Form Elementary and Middle School
D ate	I D #
We would like to learn how your child’s school year is going and about any problem(s) he/she is experiencing. Also, we would like to know about any contact and communication you have had with your child’s school.
1. General Information A. Child’s current grade: PreK K 1st 2nd 3rd 4th 5th 6th 7th 8th 9th B. Child’s school: ___________________________ C. Child’s teacher: ___________________________	2. Attendance A. Has your child been absent from school this school year? This does NOT include suspensions or expulsions. Y es No Don’t Know B. If YES, How many days has he/she missed? _______ days 3. Detentions A . Has your child been in detention this school year? Yes No Don’t Know B. If YES, How many different times was he/she in detention? _______ times C. Can you tell me why your child was put in detention? Behavioral Problems Academic Problems Other Problems Don’t Know
Public reporting burden of this collection of information is estimated to average6 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 (???).

4. Suspensions A . Has your child been suspended or received in-school suspension this school year? Yes No Don’t Know B. How many different times has he/she received suspension/in-school suspension? ______ times C. Can you tell me why your child received suspension? Behavioral Problems Academic Problems Other Problems Don’t Know 5. Expulsions A . Has your child been expelled this school year? Yes No Don’t Know B. How many times was your child expelled? ______ times C. Can you tell me why your child was expelled? Behavioral Problems Academic Problems Other Problems Don’t Know

D. Has he/she been sent to another school this school year as a result of the expulsion Y es No Don’t Know E. What is the name of the school that your child goes to? _______________ F. What type of school is it? Regular Alternative Other Don’t Know 6. Transfers A . Has your child changed schools this school year? Yes No Don’t Know B. How many times has he/she changed schools this school year? ______ times C. Can you please give me the history? School Name Start Date Stop Date _____________ ________ ________ _____________ ________ ________ D. Why did your child change schools? Family moved Child expelled Zoning changes Overcrowded classes/child did not receive attention Other Don’t Know

7. 504 Plan A . Does your child have a 504 Plan for this school year? Yes No Don’t Know B. Can you tell me about your child’s 504 plan? (What changes have been made for him/her?) ______________________________________________________ C. Can you tell me why your child has a 504 plan? Behavioral Problems Academic Problems Other Problems Don’t Know 8. IEP Plan A . Does your child have an IEP Plan for this school year? Yes No Don’t Know B. Can you tell me about your child’s IEP plan? (What types of changes have been made for him/her?) ___________________________ C. What type of program is it? ___________________________

D. Can you tell me why your child has an IEP plan? Behavioral Problems Academic Problems Other Problems Don’t Know 9. Resource/Special Ed A. Is your child in any resource or special education classes this school year? Yes No Don’t Know B. How many hours per week is he/she in a resource or special education class? ________ #hrs/week C. Can you please list the resource or special education classes that your child takes? ______________________________________________________