HSAC District Forms and Letters

STUDY OF SECONDARY MATH TEACHERS FROM
ALTERNATIVE ROUTES TO CERTIFICATION
SCHOOL RECORDS DATA REQUEST EXAMPLE
DISTRICT: [PREFILL]
TEACHER [PREFILL]
Item
(6)

03/06/95

635

621

650

645

0

Mass, Bill

M

0000002

02/17/95

550

535

555

540

0

Smith,
Tom

M

0000003

12/06/94

560

535

540

535

0

Rosada,
Jorge

M

0000020

11/08/95

540

520

525

515

1

Thompson,
Ashley

F

0000005

07/18/95

610

585

600

605

0

Hodges,
Emily

F

0000008

05/12/95

580

605

550

610

1

Morris,
Michael

M

0002345

11/25/95

510

525

450

515

0

Hogan,
Renee

F

0000004

05/26/95

600

610

600

580

Kim, June

F

0000045

10/15/95

510

515

520

515

0

Martz,
Josh

M

0000004

04/18/95

610

600

550

600

0

1

1
1
1

1

1
1
1

[PREFILL]
[PREFILL]
Item
(9)

Item
(10)

Item
(11)

As of
June
2009, was
this
student
promoted
to the
next
grade?

During the
2009-2010
school
year, was
this
student
eligible for
free or
reducedprice
school
lunch?

During the
2009-2010
school
year, was
this
student
classified
as English
Language
Learner
(ELL)?

Yes=1,
No=0

Yes=1,
No=0

Yes=1
No=0

8

1

0

0

8

1

0

0

0

8

1

1

0

1

8

1

0

0

0

8

1

0

0

1

8

1

1

0

1

8

1

0

0

0

7

1

1

0

0

8

0

0

1

0

8

1

1

0

0

During
the 20092010
school
year, in
what
grade
was this
student?

Asian

0000001

(Enter 1 for all codes that
apply)
Native Hawaiian or
Other Pacific Islander

F

mm/dd/yy

Item
(8)

What is the student’s racial
identity?

White or Caucasian

Yes=1,
No=0

Lake, Ann

M /F

Item
(7)

American Indian or
Alaskan Native

Please provide student’s
score on the state or
district math test for:

Is the
student
of
Hispanic
or
Latino
origin?

Spring 2007

Please
provide
student’s
date of
birth
(mm/dd/yy)

Item
(5)

Spring 2008

Please
provide
student’s
district
ID

Item
(4)

Spring 2009

Please
correct
gender if
necessary
or provide
if missing

Item
(3)

Spring 2010

Student
Name
Last, First

Item
(2)

Black or African
American

Item
(1)

SCHOOL:
SCHOOL ADDRESS:

Item
(12)
During the
2009-2010
school year,
did this
student
have an
Individual
Education
Plan (IEP)
or 504
plan?

Yes=1
No=0