NEDP Intake & Update Model Form NEDP

REPLACE WITH YOUR PROGRAM NAME HERE

SECOND LINE AVAILABLE HERE

FY 14NATIONAL EXTERNAL DIPLOMA PROGRAMLEARNER’S INTAKE and UPDATE FORM

Directions: / Complete this information in pencil. Ask for help if you need something explained to you.
County / Provider / Assessor / Advisor / Program Enrollment Date
M / D / Y
Social Security Number orAssigned LWIS Number / – / –
NAME: First / Middle / Last
Address / City / State / Zip
Date of Birth
Home Phone / Work Phone / M / D / Y

Email Address (if available)______

Checkone of these boxes. /

Male?

Female?

Are you Hispanic or Latino? Check one of these boxes. / Yes / No
Do you have any children?
Write in how many are / No matter what you checked above, circle the numbers in one or more boxes to indicate what describes you.
0-5 years old / 1 / American Indian/Alaska Native / 4 / Native Hawaiian/Other Pacific Islander
6-13 years old / 2 / Asian / 5 / White
14-21 years old / 3 / Black or African American

If other than U.S., what is your native country?______Native Language?______

Indicateyour highest level of education in USA or foreign country  / USA / Foreign / Checkonly one below.
If USA, indicate grade you completed from 0-12 (no diploma). / NA /  / Employed-Full Time
If USA, indicate grade you completed from 0-12 if Special Ed. / NA
If USA, check if you were in Special Ed. but don’t know grade. / NA /  / Employed-Part Time
If Foreign, indicate grade you completed from 0 through 16. / NA
If Foreign & you completed higher than Grade 16, check here. / NA /  / Employed-Multiple Jobs
Check if you received a High School Diploma or alternate credential.
Check if you received a GED®. / NA /  / Unemployed
Check if you attended college, but received no degree.
Check if you completed college or a professional degree. /  / Not in Labor Force
Check if your highest education level is unknown.

WRITE Your Name Here______Put Today’s Date Here_____/_____/_____

Month DayYear

Stop here! Someone will help you complete the next two sections.

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Name______

Entry Status: Someone will help you with this section and the next section. Check  all that apply.

 / Community Corrections /  / FL-Judy Center /  / Military Spouse
 / Crossroads Café /  / FL-Other Family Literacy Partnership /  / One Stop Center Referral
 / Disabled /  / GED-i (i-Pathways) /  / Other Public Assistance
 / Dislocated Worker /  / Homeless /  / Single Parent
 / Displaced Homemaker /  / Immigrant/Refugee /  / TANF
 / FL-Early Head Start/Head Start /  / Incarcerated /  / TV 411
 / FL-Even Start /  / Institutionalized /  / WIA/Title 1
 / FL-Even Start-Local Continuation /  / ITA (Individual Training Account) /  / Other
 / FL-Family Support Center /  / Madison Heights /  / None of the above

Check only onePrimary Goal. In addition, checkall Secondary and Additional Goals that apply.

Primary Goals:Must check only one.

/ Secondary Goals:Check all that apply.
 / Education-High School Diploma (NEDP) /  / Economic-Advance on Job
 / Education-Skills Upgrade /  / Economic-Get Job
 / Economic-Retain a Job
 / Education-Enter Post-Secondary Ed
or Occupational Skills Training

Additional Goals: Check all that apply. Check None if no additional goals apply.

 / None-Check if no additional goals /  / Education-Computer Skills
 / Economic-Career Exploration /  / Education-English Speaking Skills
 / Economic-Reduced Public Assistance /  / Education-Higher Education Options
 / Economic-Unsubsidized Job /  / Education-Math Skills
 / Economic-Work Readiness Skills /  / Education-Reading Skills
Select ENTRY level. Check only one level. Entry level is determined by Pre-Screening Test.
 / ABE Beginning Literacy (200 & below) /  / ABE Intermediate Low (211-220) /  / ASE Low (236-245)
 / ABE Beginning Basic Ed (201-210) /  / ABE Intermediate High (221-235) /  / ASE High (246 & above)
If Pre-Screening was not successful, stop here and complete pages 3and 4to exit learner.
ENTERED NEDP? Enter the appropriate dates and check the appropriate boxes.
M / D / Y /

SUCCESSFUL?

Pre-Screening 1 / Date of Pre-Screening 1 / Yes / No
M / D / Y /

SUCCESSFUL?

Pre-Screening 2 / Date of Pre-Screening 2 / Yes / No
M / D / Y /

SUCCESSFUL?

Pre-Screening 3 / Date of Pre-Screening 3 / Yes / No
CHECK IF ENTERED DIAGNOSTICS / CHECK  IF ENTERED ASSESSMENT

Name______

Social Security Number or
Assigned LWIS Number / – / –
NEDP TASKS COMPLETED: Check  / NOTES/COMMENTS 
One / Two / Three / Four / Five

UPDATE AT END OF QUARTER

CHECK CURRENT QUARTER /  / Q1 /  / Q2 /  / Q3 /  / Q4
If ABE or ASE, select level at End of Quarter. Check only one level.
 / ABE Beginning Literacy (200 & below) /  / ABE Intermediate Low (211-220) /  / ASE Low (236-245)
 / ABE Beginning Basic Ed (201-210) /  / ABE Intermediate High(221-235) /  / ASE High (246 & above)
NUMBER / EXIT STATUS AT END OF QUARTER /  / REASON FOR WITHDRAWAL
#1 / Completed Level & Continuing at Higher Level
(Enter Completed Diagnostics Date.) /  / Administratively Separated
 / Changed Address or Left Area
#2 / Completed Level & Left
(Enter Exit Date.) /  / Child Care Problems
 / Deceased
#3 / Withdrew without Completing Level
(Enter Exit Date Check Reason for Withdrawal. ) /  / Disciplinary Segregation (jail)
 / Disciplined by School
#4 / Terminated
(Enter Exit Date.) /  / Family Problems
 / Health Problems
#5 / Transferred to Another NEDP Program
(Enter Exit Date.) /  / Incarcerated
 / Job Related
#6 / Transferred to Another Literacy/Adult Ed Program
(Enter Exit Date.)
(Enter Exit Date.) /  / Lack of Interest
 / Lack of Progress
#7 / Remained within Same Level & Continuing
(Do not enter an Exit Date.) /  / Location of Instruction
 / Paroled
QUARTER / CONTACT HOURS / # OF EXIT STATUS  / EXIT or LEVEL
COMPLETION DATE /  / Released
 / Time Instruction was Scheduled
Q1-July-Sept /  / To Take a Job
 / To Take Institutional Job
Q2-Oct-Dec /  / Transferred (Local jail or MD DOC only)
 / Transportation Problems
Q3-Jan-Mar /  / Other-Briefly describe:______
Q4-Apr-June
PROGRESS/STATUS: Check all that apply.
 / Demonstrated NEDP Competency/ies /  / Met Educational Goal
 / Entered NEDP from ABE/ESL/Tutoring /  / No Measurable Progress
 / Re-enrolled in High School

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ACHIEVEMENT:Check all that apply.
 / Entered Apprenticeship /  / Gained Computer Skills
 / Entered Military /  / More Involved in Community Activities
 / Entered Post-Sec. Ed or Occupational Skills Training /  / Obtained Driver’s License or Permit
 / FL-Increased Acquisition of Books or Magazines for Children /  / Obtained EL & Civics/Citizenship Skills
 / FL-Increased Assistance w/Children’s Education (Class/Hmwk) /  / Received Citizenship
 / FL-Increased Contact with Children’s Teachers /  / Reduced Public Assistance
 / FL-Increased Involvement in Children’s School Activities /  / Removed from Public Assistance
 / FL-Increased Reading Time with Children /  / Voted for First Time or Registered to Vote
 / FL-Increased Visits to Library with Children /  / Other: