Form 4 Attachment G: School Indicators

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) _____________________________________________________________________________________________________________________