Form G Attachment G: School Indicators

Evaluation of Dating Matters: Strategies to Promote Healthy Teen Relationships

Atmt G Parent Outcome Survey School Indicators

School Indicators

OMB: 0920-0941

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Form Approved

OMB No. 0920-XXXX

Exp. Date:

Public Reporting burden of this collection of information is estimated at 15 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 Reports Clearance Officer, 1600 Clifton Road NW, MS D-24, Atlanta, GA 30333; Attn: PRA (0920-XXXX).















Attachment G:

School Indicators



Dating Matters: Strategies to Promote Healthy Teen Relationships™ Initiative



Division of Violence Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention





Student ID number:

School ID number:

Date:

Program Year:


School Data Extractor

Dating Matters School Coding Sheet

No

Questions

Coding Categories


1

SEX (please circle one) Male female transgendered


2

RACE (you may mark one or more races, as appropriate)

american indian or alaska native asian black or african american native hawaiian or other pacific islander white other: _________________________________________

is the child hispanic or latino? (circle one) yes no



3

NUMBER OF OUT-OF-SCHOOL SUSPENSIONS IN THE LAST 12 MONTHS: _______________

(PLEASE CIRCLE ALL REASONS FOR OUT-OF-SCHOOL SUSPENSIONS THAT APPLY)

Assault / Battery / fighting Obscenity

weapons Disruption / defiance / disrespect

drugs / alcohol / controlled substances Sexual harassment

tobacco / nicotine Hate Violence

robbery / extortion / THEFT bullying / threats / intimidation

vANDALISM Other : _______________________________________


4

NUMBER OF OUT-OF-SCHOOL SUSPENSIONS IN THE PAST 12 MONTHS THAT REQUIRED BOARD REVIEW: _____________


5

NUMBER OF IN-SCHOOL SUSPENSIONS IN THE LAST 12 MONTHS: _______________

(PLEASE CIRCLE ALL REASONS FOR IN-SCHOOL SUSPENSIONS THAT APPLY)

Multiple unexcused Absences / tardies bullying / threats / intimidation

pushing / shoving profanity / name calling

Disruption / defiance / disrespect Cell phone use

vANDALISM Other : _______________________________________


6

HAS THIS STUDENT BEEN EXPELLED IN THE LAST 12 MONTHS?

(please circle one)

Yes

No



7

HAS THIS STUDENT BEEN SENT TO AN ALTERNATIVE SCHOOL IN THE LAST 12 MONTHS? (please circle one)

Yes

No



8

IS THIS CHILD IN THE SAME GRADE THIS YEAR AS HE/SHE WAS LAST YEAR?

Yes

No


9

TEST SCORES FROM NO CHILD LEFT BEHIND ACT

rEADING SCORE FOR THIS YEAR:

mATH sCORE FOR THIS YEAR:


10

STUDENT’S CURRENT GRADE POINT AVERAGE: _____________________


11

IS THIS STUDENT CURRENTLY ELIGIBLE FOR FREE OR REDUCED LUNCH? (please circle one)

Yes

No



12

NUMBER OF UNEXCUSED ABSENCES IN THE PAST 12 MONTHS: _____________________


13

HAVE THIS STUDENT’S PARENTS BEEN CALLED IN TO SPEAK WITH TEACHERS OR ADMINISTRATORS BECAUSE OF BEHAVIOR ISSUES WITH THE STUDENT IN THE LAST 12 MONTHS? (please circle one)

Yes

No



14

OTHER DISCIPLINARY ACTIONS IN THE LAST 12 MONTHS: (please fill in) _____________________________________________________________________________________________________________________





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