Delinquent Institution Contact Information
(One form must be completed for each facility receiving Title I, Part D funding)
Name of Institution / USD(Name and Number)
Person Submitting Report / Title
Phone / Email
Participant Information
Juvenile Corrections / AdultCorrections
1.Number of students receiving Title I, Part D services (7/1/15 – 6/30/16)
2. Number of students from Question 1receiving transition services as part of the Title I, Part D service (7/1/15 – 6/30/16)
(i.e., transition back to school or post-secondary, employment programs, counseling services, placement services for university/college/junior college, job placement services, assistance with student financial aid, coordination of services for the family, counseling, assistance in accessing drug and alcohol abuse prevention programs, tutoring, family counseling, etc.,)
3. Number of studentsfrom Question 1with IEPs or 504 plans (IDEA)
4. Number of students from Question 1 identified as Limited English Proficient (LEP)
5. Number of Title I, Part D participants (Question 1) by area of instruction (may be duplicated count). (7/1/15 – 6/30/16)
Reading/Language Arts
Mathematics
Writing
Science
English
GED
Other
If “Other”, Specify

2.4.1.1. PROGRAMS & FACILITIES

Facility type
/ # of facilities/ programs / *Avg. length of stay (days) / Unduplicated
count of students
Juvenile Corrections (JC)-- Any program servingadjudicated youth. Including non-secure facilities and group homes.
Adult Corrections (AC)-- An adult correctional institution is a facility in which persons, including persons 21 or under, are confined as a result of conviction for a criminal offense.

*You must calculate the average length of stay. Do not put what the ‘normal stay’ is in this column. Calculating the “Average length of stay”: The average length of stay should be weighted by the number of students and should include the number of days, per visit, for each student enrolled during the reporting year, regardless of entry or exit date (within the July 1, 2015- June 30, 2016 date range). Students who entered the facility multiple times during the reporting year can be included.

The Average Length of Stay in days cannot exceed 365.

Refer to NDTAC’s Creating a Weighted Average Length of Stay Reporting Tool ( for information on how to calculate a weighted average.

2.4.1.2 STUDENT DEMOGRAPHICS

NOTE: The Total Unduplicated Student, Total Race/Ethnicity, Total Gender, & Total Agecategories must all be equal.

Juvenile Corrections / Adult Corrections
Total Unduplicated Students Served
Long-term Students Served
(90 or more consecutive days)
Race/Ethnicity / Juvenile Corrections / Adult Corrections
American Indian or Alaskan Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or other Pacific Islander
White (non-Hispanic)
Two or More Races
TOTAL
Gender / Juvenile Corrections / Adult Corrections
Male
Female
TOTAL
Age / Juvenile Corrections / Adult Corrections
3-5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
TOTAL

2.4.1.3.1 Student Re-Entry Data and Planning

Student Re-Entry Data and Planning
1. Are delinquent facilities in your district able to collect data on student outcomes after exit? / (Enter: Yes or No)
If no to above question, explain why.
Juvenile Corrections / Adult Corrections
2. Number of students receiving Title I, Part D services that have a re-entry and/or discharge plan.
3. Using the count from Question 2, the number of plans that specifically address school re-entry and/or employment.

Please complete the table below according to classification of your facility designation (Juvenile Corrections or Adult Corrections)

2.4.1.3.2 Academic/Vocational Outcomes

Academic & Vocational Outcomes (Please use Unduplicated Count)
Juvenile Corrections / Adult Corrections
Number of students who attained outcomes(s)
WHILEenrolled / Number of Students who attained outcome(s)
Up to 90 Days After Exit / Number of students who attained outcomes(s)
WHILEenrolled / Number of Students who attained outcome(s)
Up to 90 Days After Exit
Enrolled in their local district school
Earned high school course credits
Enrolled in a GED program
Earned a GED
Obtained high school diploma
Accepted and/or enrolled into post-secondary education
Enrolled in job training courses/programs
Obtained employment

2.4.1.6.1 (Reading) and 2.4.1.6.2 (Math)ACADEMIC PERFORMANCE IN READING & MATH

Performance Data
(Based on most recent
pre/post-test data) / Number of long-term students
Only report those students in placement for
at least 90 calendar days between
July 1, 2015- June 30, 2016
Reading / Math
JC / AC / JC / AC
The total of Rows 3-6 below should equal the number reported in Row 1.
  1. Number of students who were in placement from July 1, 2015 to June 30, 2016.

  1. Number of students from Row 1 who tested below grade level upon entry.

  1. Number of students from Row 1 who took both the pre-test and post-test exams.

  1. Number of students from Row 1 who took a pre-test but not a post-test.

  1. Number of students from Row 1 who took a post-test but not a pre-test.

  1. Number of students from Row 1 who took neither a pre-test or post-test.

The total of questions 7-10 below should equal the number of students reported in Row 3 above.
7. Number of students from Row 3 who showed negative grade level change from the pre-test to post-test exams.
8. Number of students from Row 3 who showed no change in grade level from the pre-test to post-test exams.
9. Number of students from Row 3 who showed improvement ofup to one full grade levelfrom the pre-test to post-test exams.
10. Number of students from
Row 3 who showed
improvement of more
than one full grade level
from the pre-test to post-
test exams.
Name of assessment(s) used for student data in Table 2.4.1.6.1 and/or 2.4.1.6.2
Name of Pretest used for Reading
Name of Post-test used for Reading
Name of Pretest used for Math
Name of Post-test used for Math

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