FORM

NEW JERSEY DEPARTMENT OF EDUCATION

Division of Programs and Operations

Office of Title I

Immigrant Student Count Summary Verification Form (Form A)

Winter 2011- 12

*Please note: this form must be submitted to the NJDOE.

School District: ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ _______________________________________ District Code:_______________________

County: _____________________________________________ County Code:_______________________

Contact Person: ______________________________________ Phone No.:_________________________

E-mail:______________________________________________

Federal regulations define immigrant students as those who:

· are age 3 to 21;

· were not born in any State, and

· have not been attending one or more schools in any one or more States for more than three full academic years.

Students from Puerto Rico and the U.S. Virgin Islands are NOT considered immigrants.

Immigrant Student Count

A) Number of eligible public school immigrant students (Pre-K – 12) ­­_______________________

B) Number of eligible immigrant students enrolled in nonprofit, nonpublic schools within the district

(Please list each school separately). This form may be duplicated if there are more than five nonpublic schools.

County Code School Code Name of School Nu mber o f

Immigrant Students

__________ ________ _______________________ _________________________

__________ ________ _______________________ _________________________

__________ ________ _______________________ _________________________

__________ ________ _______________________ _________________________

__________ ________ _______________________ ________________________

C) Total number of immigrant students
(Totals of section A and B) ________________________

Statement of Assurance

The certifying official for the district (chief school administrator) verifies that immigrant students have been identified

using the following criteria:

· are age 3 to 21;

· were not born in any State, and

· have not been attending one or more schools in any one or more States for more than three full academic

years.

Students from Puerto Rico and the U.S. Virgin Islands are NOT considered immigrants.

I hereby certify that the above information is true and accurate and supporting district documentation/records regarding

Immigrant students are maintained in (indicate where records are kept)_________________________________________.

___________________________________________________ Date ______________________

Chief School Administrator Signature

FORM B

NEW JERSEY DEPARTMENT OF EDUCATION

Division of Programs and Operations

Office of Title I

Immigrant Student Count

Winter 2011-12

Nonpublic School Data Collection Form

The Nonpublic School Verification Form may be duplicated and must be completed by each nonpublic/nonprofit school

within the jurisdiction of the district. This information will be forwarded to the district and recorded in the Immigrant Student

Count Summary Verification (Form A) which will be submitted to the New Jersey Department of Education.

Please Note: This form should be retained on file at the district . D o not forward the Nonpublic School Data Collection F orm to the New Jersey Department of Education.

For each language, please provide the number of eligible immigrant students enrolled in nonprofit, nonpublic schools within the district. Please include the native language for each immigrant student, and indicate the number of immigrant students reported in column 1 who have been identified as limited English proficient (LEP).

County Code and Name of School Language Nu mber Of LEP Immigrant

Immigrant Students Students

School Code

__________ ________________ __________________ _____________ _____

________________ _____________ ______

________________ _____________ ______

________________ _____________ ______

________________ _____________ ______

_________________ _____________ ______

________________ _____________ ______

________________ _____________ ______

________________ _____________ ______

________________ _____________ ______

Statement of Assurance

I hereby certify that the above information is true and accurate and represents the total number of immigrant students in _______________________ nonpublic/nonprofit school.

________________________________________________________ Date ___________________

Certifying Official for Nonpublic/Nonprofit School Signature