Form 8 Classroom Report

Form Approved

OMB No. 0990-

Exp. Date XX/XX/20XX

Student Rosters & Administrative Data

Instructions:

1. At the beginning of the Fall 2019 semester, please pull the following data for each student who will be enrolled in grades [9 and/or 10] in Fall 2019 in your school. Please be certain to include all students in each grade. Label the data file with your school name and the date of download. For example, “George Washington High School – Sept 2 2019”

2. Share the data with MITRE by uploading it to this secure website: [insert SFTP link]

3. At the end of the Fall 2019 semester, repeat the above steps.

Data to include:

• Last name

• First name

• Student ID number

• Date of birth

• Grade (9 or 10) in Fall 2019

• Gender or Sex

• Race

• Ethnicity

• English as a Second Language (ESL)

• Grade Point Average (GPA) if available

• Homeroom teacher if available

• Individualized Education Plan (IEP) designation if available

Sample Student Roster:

A sample student roster with all the required data fields is provided below. However, you may share the data with MITRE in whatever format your school or district provides, as long as all the required data fields are included.

Last Name	First Name	Student ID number	Date of birth MM/DD/YY	Grade (9 or 10)	Homeroom Teacher	Gender	Race and ethnicity		GPA	ESL	IEP
							Race (circle all that apply)	Hispanic
1.						Male Female	White Black or African American Asian Native Hawaiian or Pacific Islander American Indian or Alaska Native	Yes No
2.						Male Female	White Black or African American Asian Native Hawaiian or Pacific Islander American Indian or Alaska Native	Yes No
3.						Male Female	White Black or African American Asian Native Hawaiian or Pacific Islander American Indian or Alaska Native	Yes No
…						Male Female	White Black or African American Asian Native Hawaiian or Pacific Islander American Indian or Alaska Native	Yes No

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-xxxx . The time required to complete this information collection is estimated to average 120 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

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