NACCAS Annual Report Change Request Form

Ref #: ______

NACCAS Annual Report Change Form

School Name:
Reference #: / Date of Request:
Owner ID#: / Annual Report Year:
Person Submitting Request:
# of Programs to be Changed:

Please check one:

□ Request voluntarily submitted by institution (supporting documentation must be attached in order to process this request)

1. For institutions not currently on Annual Report Monitoring/Low Outcomes Monitoring:

a. Completed Cohort Grids in support of the requested changes must be attached.

2. For institutions currently on Annual Report Monitoring/Low Outcomes Monitoring:

a. Full backup documentation (as listed in the Annual Report Instructions) in support of the institution’s proposed changes must be attached.

b. Completed Cohort Grids in support of the requested changes must be attached.

□ Request required by NACCAS as a result of:

□ An on-site visit □ Annual Report Monitoring/Low Outcomes Monitoring/CARD

(Use 2nd page for changes to additional programs)

Please explain the reason for the above change(s). Use additional sheets if necessary:

(Supporting documentation must be attached in order to process this request)

I request these revisions of my institution’s Annual Report and certify that this new data is correct:

Signature (School Representative) / Print Name / Position / Date

NACCAS Annual Report Change Request Form

Additional Programs

Include this page if you need to make changes to more than one program. Use as many copies as you need.

Current Data
Program:______/ Revised Data
Program:______
Enrollment / Starts for Reporting Year / Starts for Reporting Year
Students Enrolled as of Jan. 1st of Reporting Year / Students Enrolled as of Jan. 1st of Reporting Year
Completion / Item 1 – Scheduled to complete in report year / Item 1 – Scheduled to complete in report year
Item 2 – Students from Item 1 who completed / Item 2 – Students from Item 1 who completed
Placement / Item 3 – Completers in report year who are eligible for placement / Item 3 – Completers in report year who are eligible for placement
Item 4 – Completers from Item 3 who were employed in the field / Item 4 – Completers from Item 3 who were employed in the field
Licensure / Item 5 – Sat for licensure exam in report year / Item 5 – Sat for licensure exam in report year
Item 6 – Students from Item 6 who passed exam / Item 6 – Students from Item 6 who passed exam
Current Data
Program:______/ Revised Data
Program:______
Enrollment / Starts for Reporting Year / Starts for Reporting Year
Students Enrolled as of Jan. 1st of Reporting Year / Students Enrolled as of Jan. 1st of Reporting Year
Completion / Item 1 – Scheduled to complete in report year / Item 1 – Scheduled to complete in report year
Item 2 – Students from Item 1 who completed / Item 2 – Students from Item 1 who completed
Placement / Item 3 – Completers in report year who are eligible for placement / Item 3 – Completers in report year who are eligible for placement
Item 4 – Completers from Item 3 who were employed in the field / Item 4 – Completers from Item 3 who were employed in the field
Licensure / Item 5 – Sat for licensure exam in report year / Item 5 – Sat for licensure exam in report year
Item 6 – Students from Item 6 who passed exam / Item 6 – Students from Item 6 who passed exam

School Representative Initials: ______

Please explain the reason for the above changes. Use additional sheets if necessary:

(Supporting documentation must be attached in order to process this request)

(NACCAS Use Only Below)

The requested changes [□ are verified □ are not verified] by the supporting documentation.

Changes Verified By:

Signature / Print Name / Position / Date

Annual Report Updated By:

Signature / Print Name / Position / Date
Outcome Rates based on Current Annual Report Data / Outcome Rates based on Revised Data
Completion Rate / Completion Rate
Placement Rate / Placement Rate
Licensure Rate / Licensure Rate

NOTES:

SUBMIT REQUEST FORM TO:

NACCAS

Attn: Jason Tiezzi or Alex Kim

4401 Ford Avenue Suite 1300

Alexandria, VA 22302

Fax: 703-379-2200

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