Student Information Form / Texas
Juvenile Justice Department
STUDENT PERSONAL DATA
- First Name
5. SS# / 6. DOB / 7. Race
Black Asian
White Hispanic
American Indian Other /
- Gender
Male
Unknown / 9. TSDS #
STUDENT ADMISSION DATA
10. County Number / 11. PID # / 12. Referral # / 13. PIEMS Student ID14. Expulsion Date / 15. Campus ID / 16. Offense Cite
17. Entrance Date / 18. Grade Level / 19. Math
- Tested Grade Level:
a. Tested Grade Level:
b. Standard Score:
21. Special Education
Yes
No / 22. Special Education Type (Choose the primary disability)
Autism Deaf-Blindness
Developmental Delay Emotional Disturbance
Hearing Impairment Intellectual Disability/Mental Retardation
Multiple Disabilities Orthopedic Impairment
Other Health Impairment Specific Learning Disability
Speech/Language Impairment Traumatic Brain Injury
Visual Impairment Unknown
STUDENT EXIT DATA
23. Exit Date /24. Juvenile Court Disposition (Choose only 1)
Prosecution Refused Adjudicated-Placed on Probation Adult – Non-ApplicableCourt Found Not Guilty Pending Not Applicable
Supervisory Caution Dismissed by Court Deferred Prosecution
25. Math
a. Tested Grade Level:
b. Standard Score:
/26. Reading
a. Tested Grade Level:
b. Standard Score:
/27. Expulsion Expired
YesNo /
28. Probation Expired
YesNo
29. Total Days Attended: / 30. Total Days Absent:
31. Exit Reason (Choose only 1)
Completed GED (GED) Completed program/term of expulsion and probation expired(RTRS)Graduated (GRAD) Other (OTHR)
Completed program/term of expulsion expired (EXPX)Left Program Incomplete (INCO)
Completed program/term of probation expired (PRBX) ARD exit/ Special ed. needs could not be met in JJAEP (ARD)
INSTRUCTIONS FOR STUDENT INFORMATION FORM
1.First NameIndicate student’s first name.
2.Middle NameIndicate student’s middle name.
3.Last NameIndicate student’s last name.
4.Suffix Indicate the child’s name suffix (i.e. Jr. III).
5.DOBIndicate student’s date of birth.
6.SS#Indicate student’s social security number.
7.RaceIndicate student’s race.
8.GenderIndicate whether the student is male or female.
9.TSDS #Texas Student Data Number - Unique identification number (10 digits) by Texas Education Agency.
10.County NumberIndicate county number.
11.PID #Juvenile department tracking number (Caseworker number).
12.Referral #Juvenile probation referral number that coincides with the offense for which the juvenile entered the JJAEP.
13.PIEMS Student IDUnique number used to identify the student in the (TEA)PIEMS system.
14.Expulsion DateDate which a school district officially expelled a student.
15.Campus IDNine digit campus number assigned a school district by TEA. Number should be the campusfrom which astudent was expelled.
16.Offense Cite List whether the offense cite as listed in the Education Code was:
37.007(a)(1)37.007(a)(1)(A)
37.007(a)(2)(A)
37.007(a)(2)(B)
37.007(a)(2)(C)
37.007(a)(2)(D)
37.007(a)(2)(E)
37.007(a)(2)(F)
37.007(a)(2)(G)
37.007(a)(2)(H)
37.007(a)(2)(I)
37.007(a)(3)
37.007(b1)(D)
37.007(b1)(E)
37.007(b2)(A1)
37.007(b2)(A1)(B)
37.007(b)(2)(A2)
37.007(b)(2)(A3) / - Unlawful Weapons(PC 46.02- (A-C))
Prohibited Weapon (PC 46.05- (A-I))
-Agg Asslt, Agg Sex Asslt, Sex Asslt
- Arson
- Murder, Capital Murder, Att Murder
- Indecency with a Child
- Aggravated Kidnapping
- Aggravated Robbery
- Manslaughter
- Criminally Negligent Homicide
- Continuous Sex Abuse of A Young Child or children (Penal Code 21.02)
- Felony Drug
- False Alarm
- Terroristic Threat
- Mis Marihuana
- Mis Cont Sub
- Mis Dangerous Drug
- Mis Alcohol / 37.007(b)(2)(B)
37.007(b)(2)(C)
37.007(b)(2)(D)
37.007(b)(3)
37.007(b)(4)
37.007(b)(5)
37.007(c)
37.007(d)
37.007(e)
37.007(f)
37.0081
37.0081
37.309 / - Glue, Aerosol Paint
- Asslt on Teacher/Sch Employee
- Deadly Conduct
- Non-Schl; Student/Student
- 300ft. Rule MandatoryOffense
- Breach of Computer Security/Hacking
- Serious Misconduct
- Retaliation
- Fed Firearm
- Fed Criminal Mischief
- Title 5 Felony Offenses
{23 Offenses}
- Off Campus Aggravated Robbery {37.0081(Y)}
- Registered Sex Offender
Select appropriate offense for which the student was officially expelled or other reason that student was placed in the JJAEP (i.e. Probation Placement/Court Order or Voluntary School Placement).
17.Entrance DateDate of student’s first attendance day in the JJAEP.
18.Grade LevelGrade student currently is enrolled.
19.Matha. Grade Level - Number should reflect the student’s tested entrance level in math (i.e. 3.6).
b. Standard Score - Number should reflect the student’s tested standardized score.
20.Readinga. Grade Level - Number should reflect the student’s tested entrance level in reading (i.e. 3.6).
b. Standard Score - Number should reflect the student’s tested standardized score.
21.Special EducationIndicate if the student has been diagnosed as a special education student.
22.Special Education TypeIf student has been diagnosed as needing special education, choose the primary disability, usually the first one listed in Sp. Ed. Paperwork. 504 is NOT Special ed.
23.Exit DateStudent’s last date of attendance in the JJAEP.
24.Juvenile Court DispositionIndicate the juvenile court disposition pertinent to the student from list.
25.Matha. Grade Level - Number should reflect the student’s tested exit level in math (i.e. 4.6).
b. Standard Score - Number should reflect the students tested standardized score.
26.Readinga. Grade Level - Number should reflect the student’s tested exit level in reading (i.e. 4.6).
b. Standard Score - Number should reflect the student’s tested standardized score.
27.Expulsion ExpiredIndicate upon exit if student’s term of expulsion had expired.
28.Probation ExpiredIndicate upon exit if student’s term of probation had expired.
29.Total Days AttendedTotal number of full days student was in attendance at JJAEP.
30.Total Days AbsentTotal number of days student was absent while enrolled in the JJAEP.
31.Exit ReasonStudent exiting program should be accounted for in only one eligiblecategory from list.
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