Alternative Education Program Student Data Form

  1. Student Name (First, Middle Initial, Last) ______
  2. Student Testing Number (10-digit number) ______
  3. Student Date of Birth (MM/DD/YYYY) ______
  4. Student Grade Level Upon Entry

Pre-KindergartenGrade 6

KindergartenGrade 7

Grade 1Grade 8

Grade 2Grade 9

Grade 3Grade 10

Grade 4Grade 11

Grade 5Grade 12

  1. Student Gender (Please select one.)

MaleFemale

  1. Student Ethnicity (Please select one.)

Hispanic or Latino OriginNot of Hispanic or Latino Origin

  1. Student Race (Please select all that apply.)

American Indian or Alaskan NativeNative Hawaiian or Pacific Islander

AsianWhite

Black or African American

  1. Is this student on an Individualized Education Program (IEP)?

YesNo

  1. Student’s Home School County Code- The county code is a two-digit code between 01 and 77.

______

  1. Student’s Home School District Code - The district code is a four-character code beginning with a letter followed by three digits. Ex. C001

______

  1. Student’s Home School Site Code - The school side code is a three-digit code. Ex. 705

______

  1. Alternative Education Enrollment Date (MM/DD/YYYY) - If the student is returning from last school yearenter the first day of school as the enrollment date. ______
  2. Alternative Education Exit Date (MM/DD/YYYY)- If the student is still enrolled in the Alternative Program at the end of the school yearenter the last day of school as the exit date. ______
  3. Reason for Alternative Education Program Referral (Please select all that apply.)

Academic deficienciesFinancial issues

AbsenteeismPhysical/mental health issues

Behavioral difficultiesSubstance abuse

Family issuesJuvenile justice involvement

Pregnant/Parenting teenDropout Recovery

Court orderedOther, please describe

  1. Alternative Education Exit Status (Please select one option.)

Graduated from high schoolSuspended through the end of the year

Returned to traditional schoolDropped out

Continuing in the alternative programIncarcerated

Earned GED (certificate in folder)Deceased

MovedUnknown

Entered homeschoolingOther, please describe

Entered virtual school

  1. End-of-Instruction (EOI) Exams Passed (For High School students only; Use highest score available) - Select the EOI exams for which the student has received a Satisfactory or Advance score. Do NOT include competency by alternate tests and/or methods.

Algebra IU.S. History

BiologyEnglish III

English IIAlgebra II

GeometryThe student has not passed any EOIs

  1. ACE Alternate Exams or Methods (For High School students only; Use highest score available) - Select the areas in which the student has demonstrated competency through approved alternate exams and/or end-of-course projects.Use drop down box for alt tests and project

Algebra IU.S. History

BiologyEnglish III
English IIAlgebra II

GeometryThe student has not demonstrated competency through alternate methods

Entry Student Information

  1. Pre-Entry Absences – Enter the total number of days absent in the most recent complete semester prior to Alternative Education program enrollment. _____
  2. Classes Attempted – Enter the total number of class attempts prior to Alternative Education program. _____
  3. Classes Passed – Enter the total number of classes passed prior to Alternative Education program. _____
  4. Pre-Entry Grade Point Average (GPA) – Enter the total unweighted GPA (4.0 scale) for the most recent semester prior to Alternative Education program enrollment. _____
  5. Pre-Entry Days In-School Suspension – Enter the total number of days suspended in a school setting in the most recent semester prior to Alternative Education program enrollment. _____
  6. Pre-Entry Days Out-of-School Suspension – Enter the total number of days suspended out of school in the most recent semester prior to Alternative Education program enrollment. _____

Exit Student Information

  1. Post-Exit Absences – Enter the total number of days absent in the Alternative Education program this school year. _____
  2. Classes Attempted – Enter the total number of class attempts in Alternative Education program this school year. _____
  3. Classes Passed – Enter the total number of classes passed Alternative Education program in this school year. _____
  4. Post-Exit Grade Point Average (GPA) – Enter the total unweighted GPA (4.0 scale) for all classes taken while enrolled in the Alternative Education program this school year. _____
  5. Post-Exit Days In-School Suspension – Enter the total number of days suspended in a school setting in the Alternative Education program this school year. _____
  6. Post-Exit Days Out-of-School Suspension – Enter the total number of days suspended out of school in the Alternative Education program this school year. _____
  7. Enrolled in a Career Tech Fall Spring
  8. Passed classes in a Career TechFall How Many? Spring How Many?
  9. Total Number of Counseling Hours

Individual Counseling _____

Group Counseling _____

Family Counseling _____
Crisis Counseling _____
Guidance ______What topics taught?

Home Visits _____ Why?