1810_0060_3 optional state agency form for sea use

ATTACHMENT 3: SAMPLE WORKSHEET

INSTRUCTIONS

PART I - INSTITUTION AND STATE AGENCY

Enter the names of the institution and State agency. A separate form must be completed for each institution.

PART II - BASIS FOR ELIGIBILITY

Respond “yes” or “no” to each of the three questions. If the answer is no to any one of these questions, the institution or community day program does not qualify.

• In question 1 a “regular program of instruction” means an education program (not beyond grade 12) in an institution or a community day program for neglected or delinquent children that consists of classroom instruction in basic school subjects such as reading, mathematics, and vocationally oriented subjects, and that is supported by non-Federal funds. Neither the manufacture of goods within the institution nor activities related to institutional maintenance are considered classroom instruction.

• In question 2 a “State agency” means an agency of State government responsible for providing free public education for children in institutions for neglected or delinquent children, community day programs for neglected or delinquent children, and adult correctional institutions.

• In question 3, which applies only to institutions for neglected children and institutions for delinquent children, an “average length of stay” is calculated by determining the length of time each child entering the institution stays and dividing that number by the total number of children passing through that institution during a given year. The average length of stay for all children in the institution must equal at least 30 days. An individual child in an institution, however, would not necessarily have to stay for 30 days.

PART III - TYPE OF INSTITUTION AND ENROLLMENT

Category

Check the category that fits the definition of the institution. Do not report institutions that do not meet any of the four definitions.

Enrollment

For the category of institution checked, furnish the number of children under 21, through age 20, enrolled in a State-funded regular program of instruction on a date in calendar year 2023 specified by the State agency. The date specified by the State agency must be consistent for all institutions or community day programs operated by the State agency, and the date must represent a school day within calendar year 2023.

In order to be counted as enrolled, a child must be enrolled in a State-funded regular program of instruction for at least:

• 20 hours per week if in an institution for neglected or delinquent children or a community day program for neglected or delinquent children; or

• 15 hours per week if in an adult correctional institution.

PART IV - ADJUSTED ENROLLMENT TO REFLECT THE RELATIVE LENGTH OF THE STATE AGENCY’S ANNUAL PROGRAM

Multiply the enrollment determined in Part III by the number of days in the year that the educational program operates. Divide that number by 180 to determine the adjusted enrollment.

PART V - CERTIFICATION

The appropriate institution and State agency official should sign certifying that the information provided meets the requirements of Title I, Part D, Subpart 1, and is complete and accurate. (Note, because these data will generate Federal funds, they are subject to audit and must be supportable from documented records.)

SAMPLE WORKSHEET

ANNUAL REPORT OF CHILDREN IN STATE-OPERATED INSTITUTIONS FOR NEGLECTED OR DELINQUENT CHILDREN, COMMUNITY DAY PROGRAMS FOR NEGLECTED OR DELINQUENT CHILDREN, OR ADULT CORRECTIONAL INSTITUTIONS

PART 1- INSTITUTION AND STATE AGENCY

Name and address of neglected or delinquent institution, community day program, or adult correctional institution

Name and address of State agency

PART II – BASIS FOR ELIGIBILITY (CHECK YES OR NO)

1. Is a regular program of instruction provided for the children in the neglected or delinquent institution, community day program, or adult correctional institution?

☐ Yes

☐ No

2. Is the State agency responsible for providing free public education in the neglected or delinquent institution, community day program, or adult correctional institution?

☐ Yes

☐ No

3. In the case of a neglected or delinquent institution, is the average length of stay at least 30 days? (Please note that this question does not apply to community day programs or adult correctional facilities.)

☐ Yes

☐ No

FOR A NEGLECTED OR DELINQUENT INSTITUTION, IF THE ANSWER TO THE THREE QUESTIONS IS YES, GO TO PART III.

FOR A COMMUNITY DAY PROGRAM OR ADULT CORRECTIONAL INSTITUTION, IF THE ANSWER TO THE FIRST TWO QUESTIONS IS YES, GO TO PART III.

PART III – TYPE OF INSTITUTION AND ENROLLMENT

		Number of children under 21 years of age enrolled in a regular program of instruction supported by State funds for at least:
(Check one)	Type of Institution	20 hours per week	15 hours per week
	Institution for neglected children: a public or private residential facility, other than a foster home, that is operated for the care of children who have been committed to the institution or voluntarily placed in the institution under applicable State law, due to abandonment, neglect, or death of their parents or guardians.
	Institution for delinquent children: a public or private residential facility for the care of children who have been adjudicated to be delinquent or in need of supervision.
	Community day program: a regular program of instruction provided by a State agency at a community day school operated specifically for neglected or delinquent children and youth.
	Adult correctional institution: facility in which persons (including persons under 21 years of age) are confined as a result of a conviction for a criminal offense.

PART IV – ADJUSTED ENROLLMENT TO REFLECT THE RELATIVE LENGTH OF THE

STATE AGENCY’S ANNUAL PROGRAM

Enrollment (from Part III):

Multiplied by the number of days per year that program operates:

Divided by:

180 days

Equals the adjustment enrollment:

PART V – CERTIFICATION

I certify that the State agency has implemented a system of internal controls and taken the steps necessary to ensure that the data provided meet the requirements of Title I, Part D, Subpart 1 of the ESEA and are, to the best of my knowledge, valid and reliable. I understand that any knowingly and willingly submitted false statement provided herein that I have made is subject to fine or imprisonment pursuant to 18 U.S.C. 1001.

_______________________________________ __________________________________

(Typed name of institution official) (Signature and date)