**21st CCLC 2007\
Annual Performance Report:\
Paper Forms for Centers**

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>
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> form, write directly to:*** 21stCCLC Program, AITQ, Office of
> Elementary and Secondary Education*, U.S. Department of Education, 400
> Maryland Avenue, S.W.,* LBJ/FB-6, 3W211*, Washington, D.C.
> 20202-*6200*.*

**March 2007**

#### *U.S. Department of Education 21st Century Community Learning Centers (21st CCLC)*

![](media/image1.jpeg){width="2.986111111111111in"
height="0.6840277777777778in"}

> 1120 East Diehl Road, Suite 200
>
> Naperville, IL 60563-1486
>
> 800-356-2735 630-649-6500
>
> www.learningpt.org

Copyright © 2006 Learning Point Associates, sponsored under government
Analytic Support for Evaluation and Program Monitoring, OMB number
1810-0668. All rights reserved.

 

This work was originally produced in whole or in part with funds from
the U.S. Department of Education under Analytic Support for Evaluation
and Program Monitoring, OMB number 1810-0668. The content does not
necessarily reflect the position or policy of the Department of
Education, nor does mention or visual representation of trade names,
commercial products, or organizations imply endorsement by the federal
government.

**Contents**

**Page**

Introduction 1

Instructions 1

> Operations (Form A) 1
>
> Staffing (Form B) 3
>
> Activities (Forms C-1--C-7) 5
>
> Feeder Schools (Form D) 10
>
> Attendance (Form E) 10
>
> Impact Categories (Form F) 11
>
> Grades (Form F-1) 11
>
> State Assessment--Current Year (Form F-2) 12
>
> State Assessment--Cross-Year (Forms F-3a and F-3b) 12
>
> Teacher Survey (Form F-4) 13
>
> Comments (Form G) 14
>
> Confirmation Page (Form H) 14

Form A: Operations 15

Form B: Staffing 16

Form C-1: School Year Activities by Category 18

Form C-2: School Year Activities by Student Populations Targeted 21

Form C-3: School Year Activities by Subject Area 22

Form C-4: Summer Activities by Category 23

Form C-5: Summer Activities by Student Populations Target 25

Form C-6: Summer Activities by Subject Area 26

Form C-7: Individual Activities Form 27

Form D: Feeder Schools 33

Form E: Attendance 35

Form F: Impact Categories 38

Form F-1a: Grades (Gradation) 39

Form F-1b: Grades (Combined) 41

Form F-2: State Assessment---Current Year (Combined) 43

Form F-3a: State Assessment---Cross-Year Disaggregated (Gradation) 45

Form F-3b: State Assessment---Cross-Year Disaggregated (Combined) 50

Form F-4: Teacher Survey 55

Form G: Comments 57

Form H: Confirmation Page 58

# Introduction

This is a paper version of the center-level forms for the 21st Century
Community Learning Centers (21st CCLC) 2007 Annual Performance Report
(APR) available on the *Profile and Performance Information Collection
System (PPICS)* website at **http://ppics.learningpt.org/ppics/**. Any
questions may be directed to the 21st CCLC Help Desk at 866-356-2711 or
21stcclc@contact.learningpt.org. It is highly recommended to fill out
the forms online, but it is understood that this may not always be
possible for every center. If opting to complete the paper forms, send
them to the grantee-level contact for your program so\
they may be entered at that level or sent on to Learning Point
Associates.

Provide all information to the best of your ability.

# Instructions

**Operations (Form A)**

Complete the table on Form A (see page 15) by identifying the typical
number of hours per week that the center was open for each of the time
periods.

Only complete this form if the center was active during the reporting
period. If the center was not in operation during this time please
answer no to the first listed question. A center would have been
considered active during the reporting period if the center in question
were providing 21st CCLC--funded activities during the entire span of
the summer of 2006 and/or the entire span of the 2006--07 school year.
Centers operating only for a portion of the summer or only for a portion
of the school year (i.e., for only one semester or less) are not
required to submit APR data for the 2006--07 reporting period.

When reporting hours of operation at this center during the reporting
period, please only report the typical number of hours the center spent
actually operating programs that served participating students or adult
family members. Hours spent only on administrative or planning tasks
should not be counted when completing the tables outlined below.

*Typical* is defined as the *usual* or *characteristic* attributes
associated with center operation and programming. By definition, a 21st
CCLC center should be characterized by defined\
hours of operation that should be relatively consistent across the
school year or summer\
(e.g., 3--6 p.m., Monday--Thursday). Special, nonrecurring, or episodic
events, field trips, or programming would not be considered typical
attributes associated with center operation and should not be considered
when reporting information associated with the typical hours and days of
center operation nor when reporting the typical activities provided by
the center.

In some instances, centers may be characterized by recurring periods of
operation or programming that take place on an ongoing basis but less
frequently than weekly. For example, a center may be open on the fourth
Saturday of every month in addition to a regular weekly schedule of 3:00
p.m. to 6:00 p.m. Monday through Thursday. In this case, in order to
report on typical hours of operation, the center may want to consider
adding up the total hours of operation for a typical month for the
timeframe in question (in this case Weekends during the school year) and
dividing by 4.3 to obtain a weekly average that can be used to report on
typical hours of operation for that timeframe. A similar approach can be
taken to reporting on the typical number of days a center was typically
open per week.

Note also that one of the categories is for activities that take place
during the school day. The 21st CCLC statute specifically indicates that
services are to be provided outside the regular school day or during
periods when school is not in session (e.g., before school, after
school, evenings, weekends, holidays, summer). However, activities
targeting prekindergarten children and adult family members may take
place during regular school hours since these times may be the most
suitable for serving these populations.

On the lines following the table on Form A, indicate the total number of
weeks and number of days per week that the center was open during the
school year and/or summer.

**Staffing (Form B)**

In the table on Form B (see page 16), enter the *number* of staff from
each category who worked with students and adult family members
participating in activities at the center. Respondents should record the
number of individuals involved in regularly staffing the center during
the reporting period (both school year and summer, separately), not the
number of positions associated with the center's operation (e.g., if you
have one teaching position for the same activity that meets on different
days and two teachers share the position, you would record 2 staff
members).

In this instance, an individual, whether a paid employee or a volunteer,
would be considered to have regularly staffed the center if they worked
at the center according to a defined schedule on an ongoing basis and
had a defined function or role to perform during the periods in which
they were staffing the center. Individuals who only worked at special,
nonrecurring, or episodic events, field trips, or programming should
*not* be counted in this section of the APR.

Staff not directly funded by the state administered 21st CCLC grant
should also be counted if they regularly staffed activities provided to
21st CCLC participants.

Please also note that a single staff person can be counted in both
columns related to the school year and summer if the individual in
question regularly staffed the center during both periods of center
operation. However, a single staff person should only be counted once in
the school year or summer column.

A single individual only should be classified as falling within one
staff type category. When an individual staff member can be classified
in more than one category, the following hierarchy should be employed in
determining in what staff type category they should be counted:

1.  School-day teachers (include former and substitute teachers)

2.  Center administrators and coordinators

3.  Youth development workers and other nonschool-day staff with a
    college degree or higher. Please note that a Youth Development
    Worker is defined as any paid staff or volunteer staff member who:
    Is not certified as a school-day teacher; Is not employed during the
    school day in some other capacity (e.g., librarian, school
    counselor) by one or more of the feeder schools and/or districts
    associated with the 21st CCLC; and Has a nonteaching-based college
    degree or higher.

4.  Other nonteaching school-day staff (e.g., librarians, guidance
    counselors, aides)

5.  Parents

6.  College students

7.  High school students

8.  Other community members (e.g., business mentors, senior citizens,
    clergy)

9.  Other nonschool-day staff with some or no college

10. Other

In this regard, if a staff member is both a parent of a child attending
the center and a school-day teacher, the respondent should classify the
person as being a school-day teacher because this category of staff
appears higher in the above-outlined hierarchy.

Finally, if a staff person was both a volunteer and a paid staff person
during either the school or summer, please count them in the paid column
only.

On the first line below the tables on Form B, indicate the number of
paid staff regularly staffing the center during the reporting period
that were not funded directly by the 21st CCLC grant. Only count paid
staff that received *no* compensation from funds associated with the
21st CCLC grant. On the second line below the tables, report the number
of paid staff who regularly staffed the center during the reporting
period who left the program and were replaced during the reporting
period with a new staff person.

**Activities (Forms C-1--C-7)**

For APR reporting purposes, an activity is defined as a discrete program
offering that took place according to a defined schedule (e.g., Tuesdays
and Thursdays from 4:00 to 5:00 p.m.) on a sustained and ongoing basis
during the reporting period. Normally, the activities listed on a
center's monthly activity calendar will meet these criteria. Activities
provided only once during the reporting period should not be included
here. Examples of activities would be an arts and crafts class, an
astronomy club, and a tutoring activity.

Center activities supported by a funding source other than 21st CCLC but
attended by 21st CCLC participants should also be reported on as well.
Activity-related information needs to be supplied separately for
activities undertaken during the school year and the summer associated
with the reporting period. Activities should only be included if they
were actually attended by participants during the school year and/or
summer

For the 2006-07 reporting period, states have been afforded the
discretion to select one of two options for the reporting of APR
activities information:

1.  States can opt to continue to report ***aggregated*** activity
    information through a revised version of the APR Activities page
    found in PPICS in previous APR years, OR

2.  States can opt to implement a newly developed APR Activities page
    that allows for data to be collected at the level of an
    ***individual*** activity offered during the reporting period.

Be sure to check with your state liaison to determine if you should be
completing the Aggregated Activities forms (C-1--C-6) (see pages 18-26)
or the Individual Activities form (C-7) (see pages\
27-32). The instructions for the aggregated forms are included in this
section. The directions for\
the individual activities form are provided on the form itself. Print
and fill out Form C-7 for each activity you offer. Separate tables are
provided for activities attended by students and those attended by adult
family members. Please utilize the one that is most reflective of
activity participants.

**Submitting Aggregated Activities Information**

This section asks for the following three types of information about the
activities provided at this center during the school year and summer:

-   The category of activities provided at this center

-   The extent to which activities were provided that targeted specific
    student populations

-   The academic subject areas addressed by the activities provided at
    this center

For each of these three ways of reporting **school year and summer**
activity information, please indicate if a given type of activity was
provided, how many hours a week the activity type was typically
provided, and how often a given type of activity was provided. Note that
a single activity can be classified according to each of the areas:
category, target population, and subject area. For example, a center may
offer a rocketry club targeting students performing below average in
science in which participants learn to build and launch rockets while
also studying astronomy. In this case, the activity would be
classifiable as an *Academic Enrichment Learning Program* in the first
table; it would be identified as targeting *Students not performing at
grade level, are failing, or otherwise are performing below average in
the second table*; and as a *Science Educational Activity* in the third
table.

Where it is possible to do so, it is also highly encouraged that a
description be provided of at least one activity provided in a given
category

Please note that the typical number of hours an activity was provided
per week cannot exceed the total number of hours the center was
identified as being open per week during the school year or summer on
the APR Operations section of the APR.

**The first table** that appears on the Activities page refers
specifically to the mode of service delivery (e.g., mentoring, tutoring,
community service/service learning, etc.). The table is split into two
types of activities - (1) those targeting student attendees and (2)
those targeting adult family members. *Every activity (with the
exception of snack) provided by the center should be classifiable into
one or more of the categories identified in this table. NOTE:* When
attempting to calculate the typical number of hours per week a category
of activities was provided during the school year, a given activity only
**should be counted as falling within a single activity** category in
the table. For example, if five hours per week typically are dedicated
to an activity that has both tutoring and mentoring components, five
hours should be reported for either mentoring or tutoring in the table,
but not both. In this regard, respondents should identify the primary
category in which a given activity can best be classified when
completing the table.

**The second table** that appears on the Activities page specifically
relates to activities intentionally designed to exclusively provide
services to one or more specified target population (e.g., students
performing below grade level, habitually truant students, students with
limited English proficiency, etc.). *Not every activity provided by a
center needs to target one or more of the identified groups outlined in
the second table on the Activities page. NOTE:* When attempting to
calculate the typical number of hours per week activities targeting a
particular student population were provided during the school year, a
given activity **should be counted across each of the categories** in
which the activity can be classified by the respondent. For example, if
five hours per week typically are dedicated to an activity that
specifically targets students who are habitually truant *and* are
performing below grade level, five hours should be reported for both
activity types in the table.

**The third table** that appears on the Activities page specifically
relates to the academic subject area (e.g., reading/language arts,
mathematics, science, etc.) that is addressed in a given activity. *It
may be possible that a given activity may not have an academic subject
area associated with it, and therefore will not be classifiable in
relation to the academic subject areas referenced in the third table on
the Activities page. NOTE:* When attempting to calculate the typical
number of hours per week activities addressing a particular subject area
were provided during the school year, a given activity **should be
counted across each of the categories** in which the activity can be
classified by the respondent. For example, if five hours per week
typically are dedicated to an activity that specifically addressed
mathematics *and* science, five hours should be reported for both
activity types in the table.

#### Reporting on Activities Provided in Sessions During the Reporting Period

If the center provided some activities in sessions during the reporting
period, information submitted for (1) the typical number of hours per
week the activity was provided and (2) how often the activity was
provided should be reported in terms of what characterized the activity
during the period in which it was provided. For example, a center may
have provided career- or job-training activities for youth two times per
week one hour per day for eight weeks during the school year. In this
example the typical number of hours per week this activity was provided
should be reported as 2 (i.e., 2 days per week 1 hour per day). In
addition, the activity should be identified as having been provided 1-3
times per week, and the checkbox that signifies that the activity was
provided across the whole school year should be left unendorsed.

**Intentionality of Program Design**

The 21st CCLCs are encouraged to articulate the reasoning behind the
activities they implemented during the reporting period. Designing
activities with intentionality creates\
better, more focused programs for children and allows program staff to
explain the value of\
the activities more fully to parents, administrators, and other
stakeholders. If a center has not fully articulated the rationale behind
why the programming they offered during the reporting period was
provided, they are encouraged to do so prior to completing the
Activities page. Going through this exercise will help ensure that a
center is not underreporting the breadth of activities they provided
during the reporting period. Also note that one activity may fall within
more than one category. In this regard, all appropriate activity
categories associated with that activity should be endorsed.

Table 2 provides definitions that will help in determining which
categories are appropriate for the activities.

#### Table 2. Terms Related to Activity Types by Category

  ---------------------------- -------------------------------------------------------
  **Activity Type**            **Definition and Description**

  Academic enrichment\         Enrichment activities expand on students' learning in
  learning programs            ways that differ from\
                               the methods used during the school day. They often are
                               interactive and project focused. They enhance students'
                               education by bringing new concepts to light or by using
                               old concepts in new ways. These activities are fun for
                               the students, but they also impart knowledge. They
                               allow the participants to apply knowledge and skills
                               stressed in school to real-life experiences.

  Activities for               These activities specifically target students with
  Limited-English-proficient   limited English proficiency and are designed to further
  students                     enhance students' ability to utilize the English
                               language.

  Activities that target       These activities specifically target truant, expelled,
  truant, expelled, or         or suspended students and are designed to reengage
  suspended students           these students in educational services and through
                               counseling and support address academic attainment or
                               behavioral issues\
                               that have estranged these students from traditional
                               educational settings.

  Career or job training       These activities may target either youths and adults
                               participating in the 21st CCLC program and are designed
                               to support the development of a defined skill set
                               directly transferable to a specific vocation, industry,
                               or career. For youths participating in center
                               programming, activities that are designed to expose
                               youths to various types of careers and help inform
                               youths of the skills needed\
                               to obtain a given career also could be considered in
                               this activity category.

  Community service or         These activities performed by students are
  service-learning programs    characterized by defined service tasks that address a
                               given community need and provide for structured
                               opportunities that link tasks to the acquisition of
                               values, skills, or knowledge\
                               by participating youths.

  Drug- and                    These activities are designed to prevent youths from
  violence-prevention,         engaging in high-risk behaviors, including the use of
  counseling, and              drugs and alcohol; amelioration of the causal factors
  character-education programs that may have led youths to participate in such
                               activities through counseling and support; and/or the
                               cultivation of core, ethical values, such\
                               as caring, honesty, fairness, responsibility, and
                               respect for self and others\
                               that are likely to contribute to prevention efforts.

  Expanded library service     The 21st CCLC funds are used specifically to expand,
  hours                        beyond normal operation, the number of hours a library
                               is open.

  Homework help                This refers to program time dedicated to assisting
                               students in working independently on homework, with or
                               without assistance from staff,\
                               volunteers, or older peers.

  Mentoring                    These activities primarily are characterized by
                               matching students with one or more adult role models,
                               often from business or the community, for guidance\
                               and support.
  ---------------------------- -------------------------------------------------------

  --------------- -------------------------------------------------------
  **Activity      **Definition and Description**
  Type**          

  Programs        These activities specifically target adult family
  promoting       members of youths participating in the 21st CCLC
  parental        program and are designed to more actively engage
  involvement     parents\
                  in supporting the educational attainment of their
                  children. Activities in this category should require
                  ongoing and sustained participation by the adult\
                  family member in order to achieve the acquisition of
                  knowledge or a skill\
                  meant to be imparted through participation in the
                  service or activity.

  Programs that   These activities specifically target adult family
  promote family  members of youths participating in the 21st CCLC
  literacy        program and are designed to enhance the literacy skills
                  of adult family members. Activities in this category
                  should require ongoing and sustained participation by
                  the adult family member in order to achieve the
                  acquisition of knowledge or a skill meant to be
                  imparted through participation\
                  in the service or activity.

  Recreational    These activities are not academic in nature, but rather
  activities      allow students time\
                  to relax or play. Sports, games, and clubs fall into
                  this category. Occasional academic aspects of
                  recreational activities can be pointed out, but the
                  primary lessons learned in recreational activities are
                  in the areas of social skills, teamwork, leadership,
                  competition, and discipline.

  Supplemental    Supplemental Educational Services are a component of
  educational     Title I of the Elementary and Secondary Education Act
  services        (ESEA), as reauthorized by the No Child Left Behind Act
                  (NCLB). These services are meant to provide extra
                  academic assistance to increase the academic
                  achievement of eligible students in schools that have
                  not met State targets for increasing student
                  achievement (adequate yearly progress). These services
                  may include tutoring and after-school services. They
                  may be offered through public- or private-sector
                  providers that are approved by the state, such as
                  public schools, public charter schools, local education
                  agencies, educational service agencies and faith-based
                  organizations. Students from low-income families who
                  remain in Title I schools that fail to meet state
                  standards for at least three years are eligible to
                  receive supplemental educational services.

  Tutoring        These activities involve the direct provision of
                  assistance to students in order to facilitate the
                  acquisition of skills and knowledge related to concepts
                  addressed during the school day. Tutors or teachers
                  directly work with students individually and/or in
                  small groups to complete their homework, prepare for
                  tests, and work specifically on developing an
                  understanding and mastery of concepts covered during
                  the school day. Please note that tutoring services
                  directly supported through Supplemental Educational
                  Services provided under the auspices of Title I of the
                  Elementary and Secondary Education Act (ESEA), as
                  reauthorized by the No Child Left Behind Act (NCLB),
                  should be counted in the Supplemental Educational
                  Service activity category.

  Activities to   These activities intentionally promote youth leadership
  promote youth   through skill development and the provision of formal
  leadership      leadership opportunities\
                  designed to foster and inspire leadership aptitude in
                  participating youth.
  --------------- -------------------------------------------------------

**Feeder Schools (Form D)**

A feeder school is any school that provided students to the center
during the reporting period. Fill out the table on Form D (see pages
33-34) for any feeder schools identified in your online Grantee Profile
or in your original grant application as well as any new schools you may
be serving. It is important to note that every center must have at least
one feeder school associated with it, even if the center and the feeder
school are the same entity.

On the right side of the table on Form D, indicate whether the center
provided services to students who attended one of the listed feeder
schools by entering an estimated percentage of center participants
served during the reporting period who were enrolled at an identified
school during the reporting period. In completing the table, consider
all students served by the center.

For students who participated in activities at the center both during
the school year and summer *or* during the summer only, consider such
students as having been enrolled in the school they attended during the
school year following the summer in question. Values greater than zero
but less than one should be rounded up and included in the 1-25%
category. In completing the table, also consider all students served by
the center for the time frame in question. This means that if a student
attended the center both during the school year and summer, they should
be considered when estimating both the school year and summer
percentages of students attending the center from that school.

**Attendance (Form E)**

The purpose of this section of the APR is to obtain information about
the participants served at this center during the reporting period.
Complete the eight tables on Form E (see pages 35-37) by indicating the
number of participants (students and adults) served during the reporting
period, the characteristics associated with the student population
served by the center, and the number of center participants meeting the
definition of *regular attendee*. A *regular attendee* is defined as a
student students that has attended a 21st CCLC program for at least 30
days (which do not have to be consecutive) during the reporting period.

To protect student confidentiality, if you have a value for any student
characteristic that is less than three, round that value down to zero.
If you have a value of three or four, round that value up to five.

**Impact Categories (Form F)**

The Impact Categories section is intended to measure what effects the
program has had on participants (specifically regular attendees). Your
state education agency has chosen the categories on which you must
report, and whether you need to provide gradient information\
for each impact category. If you do not know which categories to
complete, contact your state liaison and ask. On Form F (see page 38),
indicate which impact categories are required\
for your state. Once you have done so, skip to only those sections and
complete the forms as directed.

**Grades (Form F-1)**

To report on changes in grade performance for regular attendees, compare
the students' first set of fall 2006 mathematics and reading/language
arts grades with the students' last set of spring 2007 grades for those
participants who were regular attendees at this center during the
reporting period. If the grades you have for a given student do not span
the 2006--07 school year (e.g., the student only was enrolled in
mathematics or reading/language arts for one semester), do not report
grade results for the student in question. In addition, students meeting
the definition of a regular attendee who participated only in
center-related activities during summer 2006 should not be included in
grades reporting.

It is realized that there are some students for whom you may only have
either mathematics or reading/language arts grades for comparison, but
not both. In this case, report the change in student performance for the
grades you do have available.

If your state requires gradient information to be reported, fill out the
Form F-1a (see pages 39--40); otherwise, fill out the Form F-1b (see
pages 41--42). Answer the questions in the first table on the
appropriate form by indicating the number of *regular attendees* that
fall into each of the listed categories. Count a child only once
(unduplicated count) in the table. The total of each of the four cells
in the table should be equal to the number of regular attendees you
identified as being served by the center in the reporting period.

If you are using a 100-point scale, a half-grade change is a decrease or
increase of five points.\
If you are using an A--F scale, a half-grade change is any decrease or
increase in the letter grade (e.g., A to A- is a decrease and C+ to B-
is an increase). If you are using an E-S-U
(Excellent-Satisfactory-Unsatisfactory) or similar non-A--F letter-grade
scale, a half-grade change is a decrease or increase from one letter
grade to another (e.g., S to E is an increase and S to U\
is a decrease).

**State Assessment---Current Year (Form F-2)**

In order to provide State Assessment -- Current Year information, fill
out the Form F-2 (see pages 42--43). Answer the questions in the first
table on the appropriate form by indicating the number of regular
attendees that fall into each of the listed categories. Count a child
only once (unduplicated count) in the table. The total of each of the
four cells in the table should be equal to the number of regular
attendees you identified as being served by this center in the reporting
period.

The purpose of this section is to collect data on what proficiency
categories regular attendees\
fell within on the state assessment administered during the reporting
period. Report proficiency results for both the mathematics and
reading/language arts sections of the state assessment on the tables on
Form 2. It is realized that most states currently only test a subset of
grades. Report the performance of regular attendees on the state
assessment for the grades tested in your state.

As above, answer the questions on the tables by indicating the number of
regular attendees that fall into each of the listed categories. Count a
child only once (unduplicated count) in the table. The total of each of
the cells in the table should be equal to or less than the number of
regular attendees you identified as being served by this center in the
reporting period.

**State Assessment---Cross-Year Disaggregated (Forms F-3a and F-3b)**

These sections require you to compare a student's 2005-06 state
assessment results with\
2006--07 results for those participants who were regular attendees at
this center during the reporting period. It is realized that there are
some students for whom you may only have either mathematics or
reading/language arts assessment results for comparison, but not both.
In this case, report the change in student performance for the
assessment results you do have available.

Answer the questions in the first table on Form F-3a (gradations) or
Form F-3b (combined) by indicating the number of regular attendees that
fall into each of the listed categories. Count a child only once
(unduplicated count) in the table. The total of each of the four cells
in the table should be equal to the number of regular attendees you
identified as being served by the center in the reporting period.

Answer the questions in the remaining two tables on Form F-3a or Form
F-3b by indicating the number of regular attendees that fall into each
of the listed categories. Count a child only once (unduplicated count)
in each table. The total of the cells in the table should be equal to
the number of regular attendees you identified as being served by the
center in the reporting period.

You should count students as having witnessed an improvement in state
assessment results if they scored in a proficiency category when taking
the assessment during the 200--07 school year that represented a higher
level of achievement than the category they scored in when\
taking the assessment during the 2005--06 school year. For example, you
would count students\
as having improved if they scored in the *basic* category in 2005--06
and improved to *proficient* when taking the 2006--07 assessment. A
similar approach should be taken when identifying the number of students
who witnessed a decline in performance.

**Teacher Survey (Form F-4)**

In the table on Form F-4 (see pages 55-56), record the results from the
Learning Point Associates teacher survey. This survey should be
administered at the end of the school\
year associated with the reporting period. The survey asks school-day
teachers to report whether regular attendees' behavior improved, did not
improve, or did not need to improve in certain areas.

**Teacher Selection**

For every student you have identified as a regular attendee (30 days or
more), select one of his or her regular school-day teachers to complete
the teacher survey. For elementary school students, the teacher should
be the regular classroom teacher. For middle and high school students, a
mathematics or English teacher should be surveyed. Although you may
include in your sample the teachers who also are serving as 21st CCLC
program staff, it is preferable to survey teachers who are not. There
should be one teacher survey filled out for every student identified as
a regular attendee. In addition, note that students meeting the
definition of a regular attendee\
who participated only in center-related activities during summer 2006
should not be included\
in the reporting of teacher survey results.

**Comments (Form G)**

It is understood that some grantees and centers may have circumstances
that do not fit into the options that the APR provides. To obtain the
best information possible on all grantees, you should include any
further information pertinent to the APR on Form G (see page 57). Also,
if there are any sections of the APR you were not able to complete,
explain the omissions on this form. You may attach additional sheets if
necessary, but try to keep your comments concise and specific.

**Confirmation Page (Form H)**

On this form (see page 58), certify that you have completed all of the
required information\
for your 2007 APR. Put a checkmark next to the sections you have
completed. All of the standard sections (i.e., Operations, Staffing,
Activities, Feeder Schools, and Attendance) are required. Your state
education agency (SEA) has selected which impact categories are required
as well. You can find out what these are by contacting your SEA liaison
or by logging on to the PPICS online system at
**[http://ppics](http://ppics/)[.learningpt.org/ppics/]{.underline}**
and seeing which buttons are available in the Centers section of the APR
part of the site. Please review the associated forms to ensure that you
have included all necessary information. If you have not completed any
required section, give an explanation for the omission on Form G and
write "See comments" next to the section title. Once you have completed
and checked off all required sections, have the primary program contact
for your center sign the confirmation page and send the Forms section of
this document (pages 15-58) to your grantee, which may then enter the
information into the online system or send the paper copy on to Learning
Point Associates.

**Form A: Operations**

For instructions, see page 1.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Grantee Name Center Name

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Grantee State ID Number (if applicable) State Education Agency

Was the center active during the reporting period (Y/N)?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  ---------------------------------------------- ------------------------
  **Time Period**                                **Typical Hours Per
                                                 Week**

  **School Year**                                

  Weekday before school                          

  Weekday during school hours                    

  Weekday after school                           

  Weekend                                        

  Total for school year                          

  **Summer**                                     

  Weekdays                                       

  Weekday evenings                               

  Weekend                                        

  Total for summer                               
  ---------------------------------------------- ------------------------

What was the total number of weeks the center was\
open during the school year?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

What was the total number of weeks the center was\
open during the summer?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

What was the typical number of days per week the\
center was open during the school year?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

What was the typical number of days per week the\
center was open during the summer?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Form B: Staffing**

For instructions, see page 3.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Grantee Name Center Name

  ---------------------------------------------------------------------------------- ---------- ---------------
  **Type of Staff Member**                                                           **School   
                                                                                     Year**     

                                                                                     **Paid**   **Volunteer**

  School-day teachers (including former and substitute teachers)                                

  Center administrators and coordinators                                                        

  Youth development workers or other nonschool-day staff\                                       
  with a college degree or higher                                                               

  Other nonschoo-day staff with some or no college                                              

  Other nonteaching school staff (e.g., librarians, guidance counselors, aides)                 

  Parents                                                                                       

  College students                                                                              

  High school students                                                                          

  Other community members (e.g., business mentors,\                                             
  senior citizens, clergy)                                                                      

  Other                                                                                         
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_              

  Totals                                                                                        
  ---------------------------------------------------------------------------------- ---------- ---------------

  ---------------------------------------------------------------------------------- ------------ ---------------
  **Type of Staff Member**                                                           **Summer**   

                                                                                     **Paid**     **Volunteer**

  School-day teachers (including former and substitute teachers)                                  

  Center administrators and coordinators                                                          

  Youth development workers or other nonschool-day staff\                                         
  with a college degree or higher                                                                 

  Other nonschoo-day staff with some or no college                                                

  Other nonteaching school staff (e.g., librarians, guidance counselors, aides)                   

  Parents                                                                                         

  College students                                                                                

  High school students                                                                            

  Other community members (e.g., business mentors,\                                               
  senior citizens, clergy)                                                                        

  Other                                                                                           
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                

  Totals                                                                                          
  ---------------------------------------------------------------------------------- ------------ ---------------

The number of paid staff regularly staffing the center\
during the reporting period that were not funded\
directly by the 21^st^ CCLC grant:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

The number of paid staff that regularly staffed the center\
during the reporting period who left the program and were\
replaced during the reporting period with a new staff person:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Form C-1: School Year Activities by Category**

For instructions, see page 5.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Grantee Name Center Name

  ------------------- ----------- -------------- -------- --------- --------- ----------
  ***EXAMPLE***                                                               

  **Activity or       **Typical   **Typically,                                **Was This
  Service**           Number of   How Often Was                               Type of
                      Hours Per   This Type of                                Activity
                      Week**      Activity                                    Provided
                                  Provided?**                                 Across the
                                                                              Whole
                                                                              School
                                                                              Year?**

                                  **4--5 Times a **1--3   **1--3    **Less    
                                  Week**         Times a  Times a   Than Once 
                                                 Week**   Month**   a Month** 

  1\. Academic        10                                  x                   Yes
  improvement or                                                              
  remediation                                                                 
  programs                                                                    
  ------------------- ----------- -------------- -------- --------- --------- ----------

  ------------------- ----------- -------------- -------- -- -------- --------- --------- ----------
  **Activity or       **Typical   **Typically,                                            **Was This
  Service**           Number of   How Often Was                                           Type of
                      Hours Per   This Type of                                            Activity
                      Week**      Activity                                                Provided
                                  Provided?**                                             Across the
                                                                                          Whole
                                                                                          School
                                                                                          Year?**

                                  **4--5 Times a             **1--3   **1--3    **Less    
                                  Week**                     Times a  Times a   Than Once 
                                                             Week**   Month**   a Month** 

  **Activities                                                                            
  Targeting Student                                                                       
  Attendees**                                                                             

  1\. Academic                                                                            
  enrichment\                                                                             
  learning programs                                                                       

  2\. Tutoring                                                                            

  3\. Homework help                                                                       

  4\. Mentoring                                                                           
  ------------------- ----------- -------------- -------- -- -------- --------- --------- ----------

  ------------------------------------- ----------- -------------- -------- -- -------- --------- --------- ----------
  **Activity or Service**               **Typical   **Typically,                                            **Was This
                                        Number of   How Often Was                                           Type of
                                        Hours Per   This Type of                                            Activity
                                        Week**      Activity                                                Provided
                                                    Provided?**                                             Across the
                                                                                                            Whole
                                                                                                            School
                                                                                                            Year?**

                                                    **4--5 Times a             **1--3   **1--3    **Less    
                                                    Week**                     Times a  Times a   Than Once 
                                                                               Week**   Month**   a Month** 

  **Activities Targeting Student                                                                            
  Attendees**                                                                                               

  5\. Recreational activities                                                                               

  6\. Drug- and\                                                                                            
  violence-prevention, counseling, and                                                                      
  character-education programs                                                                              

  7\. Career or job training for youth                                                                      

  8\. Expanded library service hours                                                                        

  9\. Supplemental educational services                                                                     

  10\. Community service or                                                                                 
  service-learning programs                                                                                 

  11\. Activities to promote youth                                                                          
  leadership                                                                                                

  12\. Other: \_\_\_\_\_\_\_\_\_\_\_\                                                                       
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                                                                       
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                        
  ------------------------------------- ----------- -------------- -------- -- -------- --------- --------- ----------

  ------------------ ----------- -------------- -------- -- -------- --------- --------- ----------
  **Activity or      **Typical   **Typically,                                            **Was This
  Service**          Number of   How Often Was                                           Type of
                     Hours Per   This Type of                                            Activity
                     Week**      Activity                                                Provided
                                 Provided?**                                             Across the
                                                                                         Whole
                                                                                         School
                                                                                         Year?**

                                 **4--5 Times a             **1--3   **1--3    **Less    
                                 Week**                     Times a  Times a   Than Once 
                                                            Week**   Month**   a Month** 

  **Activities                                                                           
  Targeting Adult                                                                        
  Family Members\***                                                                     

  13\. Programs that                                                                     
  promote parental                                                                       
  involvement                                                                            

  14\. Programs that                                                                     
  promote family                                                                         
  literacy                                                                               

  15\. Career or                                                                         
  job\                                                                                   
  training for                                                                           
  adults                                                                                 
  ------------------ ----------- -------------- -------- -- -------- --------- --------- ----------

\*Activities targeting adult family members must require ongoing and
sustained participation by the adult family member in order to achieve
the acquisition of knowledge or a skill meant to be imparted through
participation in the service or activity. Examples of activities that
conform to these requirements would include general equivalency diploma
(GED) classes, classes on how to develop a resume, or a programming
series on effective parenting strategies. Episodic, nonrecurring, or
special events likely do not conform to these requirements. For example,
an open house night for the parents of children attending the center
that involves a meal and social activities would not conform to these
requirements.

**Form C-2: School Year Activities by Student Populations Targeted**

For instructions, see page 5.

  -------------------------------------------------------------------------- ----------- -------------- -------- --------- --------- ----------
  **Activity or Service**                                                    **Typical   **Typically,                                **Was This
                                                                             Number of   How Often Was                               Type of
                                                                             Hours Per   This Type of                                Activity
                                                                             Week**      Activity                                    Provided
                                                                                         Provided?**                                 Across the
                                                                                                                                     Whole
                                                                                                                                     School
                                                                                                                                     Year?**

                                                                                         **4--5 Times a **1--3   **1--3    **Less    
                                                                                         Week**         Times a  Times a   Than Once 
                                                                                                        Week**   Month**   a Month** 

  **Activities Targeting Specific Student Populations**                                                                              

  1\. Students who are not performing at grade level, are failing,\                                                                  
  or otherwise are performing below average                                                                                          

  2\. Limited-English-proficient students                                                                                            

  3\. Students who\                                                                                                                  
  have been truant, suspended, or expelled                                                                                           

  4\. Students with special needs or disabilities                                                                                    

  5\. Other: \_\_\_\_\_\_\_\_\_\_\_\_\                                                                                               
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                           
  -------------------------------------------------------------------------- ----------- -------------- -------- --------- --------- ----------

**Form C-3: School Year Activities by Subject Area**

For instructions, see page 5.

  -------------------------------------- ----------- --------- -------------- -------- -------- --------- --------- ----------
  **Activity or Service**                **Typical             **Typically,                                         **Was This
                                         Number of             How Often Was                                        Type of
                                         Hours Per             This Type of                                         Activity
                                         Week**                Activity                                             Provided
                                                               Provided?**                                          Across the
                                                                                                                    Whole
                                                                                                                    School
                                                                                                                    Year?**

                                                               **4--5 Times a          **1--3   **1--3    **Less    
                                                               Week**                  Times a  Times a   Than Once 
                                                                                       Week**   Month**   a Month** 

  **Activities Addressing a Specific                                                                                
  Subject Area**                                                                                                    

  1\. Reading or literacy education                                                                                 
  activities                                                                                                        

  2\. Mathematics\                                                                                                  
  education activities                                                                                              

  3\. Science education activities                                                                                  

  4\. Arts and music education                                                                                      
  activities                                                                                                        

  5\. Entrepreneurial education programs                                                                            

  6\. Telecommunications and technology                                                                             
  education programs                                                                                                

  7\. Cultural activities or social                                                                                 
  studies                                                                                                           

  8\. Health- or nutrition-related                                                                                  
  activities                                                                                                        

  9\. Other: \_\_\_\_\_\_\_\_\_\_\_\_\_\                                                                            
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                              
  -------------------------------------- ----------- --------- -------------- -------- -------- --------- --------- ----------

**Activity Description (Optional)**

If you would like, provide a description of one of the school-year
activities here. This section is optional and is not required to
complete your APR.

**Form C-4: Summer Activities by Category**

For instructions, see page 5.

  ---------------------- ----------- -------------- -------- -- -------- --------- --------- ----------
  **Activity or          **Typical   **Typically,                                            **Was This
  Service**              Number of   How Often Was                                           Type of
                         Hours Per   This Type of                                            Activity
                         Week**      Activity                                                Provided
                                     Provided?**                                             Across the
                                                                                             Whole
                                                                                             School
                                                                                             Year?**

                                     **4--5 Times a             **1--3   **1--3    **Less    
                                     Week**                     Times a  Times a   Than Once 
                                                                Week**   Month**   a Month** 

  **Activities Targeting                                                                     
  Student Attendees**                                                                        

  1\. Academic                                                                               
  enrichment\                                                                                
  learning programs                                                                          

  2\. Tutoring                                                                               

  3\. Homework Help                                                                          

  4\. Mentoring                                                                              

  5\. Recreational                                                                           
  activities                                                                                 

  6\. Drug- and\                                                                             
  violence-prevention,                                                                       
  counseling, and                                                                            
  character-education                                                                        
  programs                                                                                   

  7\. Career or job\                                                                         
  training for youth                                                                         

  8\. Expanded library                                                                       
  service hours                                                                              

  9\. Supplemental                                                                           
  educational services                                                                       
  ---------------------- ----------- -------------- -------- -- -------- --------- --------- ----------

  ------------------------------------- ----------- -------------- -------- -- -------- --------- --------- ----------
  **Activity or Service**               **Typical   **Typically,                                            **Was This
                                        Number of   How Often Was                                           Type of
                                        Hours Per   This Type of                                            Activity
                                        Week**      Activity                                                Provided
                                                    Provided?**                                             Across the
                                                                                                            Whole
                                                                                                            School
                                                                                                            Year?**

                                                    **4--5 Times a             **1--3   **1--3    **Less    
                                                    Week**                     Times a  Times a   Than Once 
                                                                               Week**   Month**   a Month** 

  **Activities Targeting Student                                                                            
  Attendees**                                                                                               

  10\. Community service or                                                                                 
  service-learning programs                                                                                 

  11\. Activities that promote youth                                                                        
  leadership                                                                                                

  12\. Other: \_\_\_\_\_\_\_\_\_\_\_\                                                                       
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                                                                       
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                        

  **Activities Targeting Adult Family                                                                       
  Members\***                                                                                               

  13\. Programs that promote parental                                                                       
  involvement                                                                                               

  14\. Programs that promote family                                                                         
  literacy                                                                                                  

  15\. Career or job\                                                                                       
  training for adults                                                                                       
  ------------------------------------- ----------- -------------- -------- -- -------- --------- --------- ----------

\*Activities targeting adult family members must require ongoing and
sustained participation by the adult family member in order to achieve
the acquisition of knowledge or a skill meant to be imparted through
participation\
in the service or activity. Examples of activities that conform to these
requirements would include general equivalency diploma (GED) classes,
classes on how to develop a resume, or a programming series on effective
parenting strategies. Episodic, nonrecurring, or special events likely
do not conform to these requirements. For example, an open house night
for the parents of children attending the center that involves a meal
and social activities would not conform to these requirements.

**Form C-5: Summer Activities by Student Populations Targeted**

For instructions, see page 5.

  -------------------------------------------------------------------------- ----------- -------------- -------- --------- --------- ----------
  **Activity or Service**                                                    **Typical   **Typically,                                **Was This
                                                                             Number of   How Often Was                               Type of
                                                                             Hours Per   This Type of                                Activity
                                                                             Week**      Activity                                    Provided
                                                                                         Provided?**                                 Across the
                                                                                                                                     Whole
                                                                                                                                     School
                                                                                                                                     Year?**

                                                                                         **4--5 Times a **1--3   **1--3    **Less    
                                                                                         Week**         Times a  Times a   Than Once 
                                                                                                        Week**   Month**   a Month** 

  **Activities Targeting Specific Student Populations**                                                                              

  1\. Students who are not performing at grade level, are failing,\                                                                  
  or otherwise are performing below average                                                                                          

  2\. Limited-English-proficient students                                                                                            

  3\. Students who\                                                                                                                  
  have been truant, suspended, or expelled                                                                                           

  4\. Students with special needs or disabilities                                                                                    

  5\. Other: \_\_\_\_\_\_\_\_\_\_\_\_\                                                                                               
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                           
  -------------------------------------------------------------------------- ----------- -------------- -------- --------- --------- ----------

**Form C-6: Summer Activities by Subject Area**

For instructions, see page 5.

  -------------------------------------- ----------- --------- -------------- -------- -------- --------- --------- ----------
  **Activity or Service**                **Typical             **Typically,                                         **Was This
                                         Number of             How Often Was                                        Type of
                                         Hours Per             This Type of                                         Activity
                                         Week**                Activity                                             Provided
                                                               Provided?**                                          Across the
                                                                                                                    Whole
                                                                                                                    School
                                                                                                                    Year?**

                                                               **4--5 Times a          **1--3   **1--3    **Less    
                                                               Week**                  Times a  Times a   Than Once 
                                                                                       Week**   Month**   a Month** 

  **Activities Addressing a Specific                                                                                
  Subject Area**                                                                                                    

  1\. Reading or literacy education                                                                                 
  activities                                                                                                        

  2\. Mathematics\                                                                                                  
  education activities                                                                                              

  3\. Science education activities                                                                                  

  4\. Arts and music education                                                                                      
  activities                                                                                                        

  5\. Entrepreneurial education programs                                                                            

  6\. Telecommunications and technology                                                                             
  education programs                                                                                                

  7\. Cultural activities or social                                                                                 
  studies                                                                                                           

  8\. Health- or nutrition-related                                                                                  
  activities                                                                                                        

  9\. Other: \_\_\_\_\_\_\_\_\_\_\_\_\_\                                                                            
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                              
  -------------------------------------- ----------- --------- -------------- -------- -------- --------- --------- ----------

**Activity Description (Optional)**

If you would like, provide a description of one of the summer activities
here. This section is optional and is not required to complete your APR.

**Form C-7: Activities Individual Form**

If you have questions about what level of detail is appropriate when
reporting activities information, please refer to the following example:
For example, a given center has a standing activity on its calendar
called Sports that runs from 4:00 to 5:00 every Tuesday and Thursday for
21 weeks and during this 21-week period different 7 weeks are spent on
Baseball and 7 weeks are spent on soccer and 7 weeks are spent on
Basketball, a single activity called Sports would be entered into PPICS.

Now, however, let\'s say that during a nine week period Baseball ran on
Monday\'s and Wednesday from 3:00 to 4:00 and during a 12 week period
Soccer ran on Tuesday\'s and Thursday\'s from 4:00 to 5:00. These should
be entered as different activities given that they were scheduled
differently during the course of the week and ran for different lengths
during the reporting period.

If you are concerned that the application of this approach to reporting
activity information as outlined here will be difficult for you to
undertake or you are concerned about the number of activities you will
need to report on, please contact the PPICS Help Desk at
[[21stcclc@contact.learningpt.org]{.underline}](mailto:21stcclc@contact.learningpt.org).

Activity Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Participant Type: Student Attendees

> Adult Family Members (for adult activities please use page )

**Student Attendees**

Was this activity provided during the reporting period? Yes No

Indicate whether this activity was provided in the summer or during the
school year (if the activity was conducted during both the summer and
school year, it should be listed twice with separate information for
both time periods).

School Year

Summer

**Activity Categories**

Identify the primary category in which the activity can be classified as
falling from the list below. Choose only one category.

Academic enrichment learning program

Tutoring

Homework help

Mentoring

Recreational activity

Career or job training for youth

Drug- and violence-prevention, counseling, or character education

Expanded library service hours

Supplemental education services

Community service or service learning

Activity to promote youth leadership

The activity had more than two program elements

If the activity intentionally was designed to incorporate other elements
beyond the primary category identified above, please select a secondary
category from the following list:

Academic enrichment learning program

Tutoring

Homework help

Mentoring

Recreational activity

Career or job training for youth

Drug- and violence-prevention, counseling, or character education

Expanded library service hours

Supplemental education services

Community service or service learning

Activity to promote youth leadership

Other:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Student Populations Targeted by the Activity**

Indicate whether the activity specifically was designed to exclusively
provide services to one or more of the following target populations.
Check all that apply.

Students who are not performing at grade level, are failing, or
otherwise are performing below average

Limited-English-proficient students

Students who have been truant, suspended, or expelled

Students with special needs or disabilities

Other:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

None of the above

**Activity Subject Areas**

Identify whether an academic subject area was addressed during the
provision of the activity. Check all that apply.

Reading or literacy

Mathematics

Science

Arts and music

Entrepreneurial education

Technology or telecommunications

Cultural activities or social studies

Health or nutrition

Other:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

None of the above

**Amount of Time Provided**

Describe the total number of weeks, the typical number of days per week,
and the typical number of hours per day this activity was provided.

  -------- --------------------------------------------------------------
           Total number of weeks provided

           Typical number of days provided per week

           Typical number of hours provided per day
  -------- --------------------------------------------------------------

It\'s also common for a given activity to be offered in multiple
sessions concurrently or at multiple times to different groups of
participants during the course of a week. If either of these
circumstances were true for this activity, please endorse the
appropriate option below (please note that completion of these fields is
optional).

Was this activity offered in multiple sessions that occurred
concurrently on the same day serving different groups of students (e.g,
there were two sessions of the activity that met from 4:00 to 5:00 p.m.
on Tuesdays, with one session for students in grade 4 and a second
session for students in grade 5)?

Was this activity offered multiple times during the course of the
typical week but to different groups of students on a given day (e.g.,
the activity was offered on Tuesdays to students in grade 4 and
Thursdays to students in grade 5)?

Was this activity typically offered less frequently than weekly during
the period it was offered (for example, was the activity provided every
other Saturday or one Saturday a month)?

Yes, this activity typically was offered 1--3 times a month.

Yes, this activity typically was offered less than once a month.

No, this activity typically was offered every week during the period it
was offered.

**Number of Participants**

Indicate the typical number of participants (students or adults) served
by this activity per day.\
Do not include instructors, volunteer tutors, and other staff. Only
those being served should be included.

  -------- --------------------------------------------------------------
           Total number of students per day

  -------- --------------------------------------------------------------

**Activity Description (Optional)**

If you would like, include a 1,000-word description of the activity
here. This section is optional and is not required to complete your APR.

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Adult Family Members**

It is important to note that activities Targeting Adult Family Members
must require ongoing and sustained participation by the adult family
member in order to achieve the acquisition of knowledge or a skill that
is meant to be imparted through participation in the service or
activity. Examples of activities that conform to these requirements
would include GED classes, classes on how to develop a resume, or a
programming series on effective parenting strategies. Episodic,
nonrecurring, or special events are likely not to conform to these
requirements. For example, an open house night for the parents of
children attending the center that involves a meal and social activities
would not conform to these requirements.

Was this activity provided during the reporting period? Yes No

Indicate whether this activity was provided in the summer or during the
school year (if the activity was conducted during both the summer and
school year, it should be listed twice with separate information for
both time periods).

School Year

Summer

**Activity Categories**

Identify the primary category in which the activity can be classified as
falling from the list below. Choose only one category.

Promotion of parental involvement

Promotion of family literacy

Career or job training for adults

The activity had more than two program elements

If the activity intentionally was designed to incorporate other elements
beyond the primary category identified above, please select a secondary
category from the following list:

Promotion of parental involvement

Promotion of family literacy

Career or job training for adults

Other:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Amount of Time Provided**

Describe the total number of weeks, the typical number of days per week,
and the typical number of hours per day this activity was provided.

  -------- --------------------------------------------------------------
           Total number of weeks provided

           Typical number of days provided per week

           Typical number of hours provided per day
  -------- --------------------------------------------------------------

It\'s also common for a given activity to be offered in multiple
sessions concurrently or at multiple times to different groups of
participants during the course of a week. If either of these
circumstances were true for this activity, please endorse the
appropriate option below (please note that completion of these fields is
optional).

Was this activity offered in multiple sessions that occurred
concurrently on the same day serving different groups of adult family
members (e.g, there were two sessions of the activity that met from 4:00
to 5:00 p.m. on Tuesdays, with one session for adult family members of
students in grade 4 and a second session for adult family members of
students in grade 5)?

Was this activity offered multiple times during the course of the
typical week but to different groups of adult family members on a given
day (e.g., the activity was offered on Tuesdays to adult family members
of students in grade 4 and Thursdays to adult family members of students
in grade 5)?

Was this activity offered less than weekly during the period it was
offered (e.g., Was the activity provided every other Saturday or one
Saturday a month)?

Yes, this activity typically was offered 1--3 times a month.

Yes, this activity typically was offered less than once a month.

No, this activity typically was offered every week during the period it
was offered.

**Number of Participants**

Indicate the typical number of participants (students or adults) served
by this activity per day.\
Do not include instructors, volunteer tutors, and other staff. Only
those being served should be included.

  -------- --------------------------------------------------------------
           Total number of adult family members per day

  -------- --------------------------------------------------------------

**Activity Description (Optional)**

If you would like, include a 1,000-word description of the activity
here. This section is optional and is not required to complete your APR.

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Form D: Feeder Schools**

For instructions, see page 10. Please add additional pages as needed.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Grantee Name Center Name

  --------------------- ---------- ------- ---------------- ------------- ------------- ---------- ---------
  ***School Year                                                                                   
  (Example)***                                                                                     

  **School Name**       **Feeder           **Percentage of                                         
                        School             Center                                                  
                        Active**           Participants**                                          

                        **Y**      **N**   **1--25%**       **26--50%**   **51--75%**   **76%+**   **N/A**

  Wright Elementary     X                                                               X          
  --------------------- ---------- ------- ---------------- ------------- ------------- ---------- ---------

  --------------------- ---------- ------- ---------------- ------------- ------------- ---------- ---------
  **School Year**                                                                                  

  **School Name**       **Feeder           **Percentage of                                         
                        School             Center                                                  
                        Active**           Participants**                                          

                        **Y**      **N**   **1--25%**       **26--50%**   **51--75%**   **76%+**   **N/A**

                                                                                                   

                                                                                                   

                                                                                                   

                                                                                                   

                                                                                                   

                                                                                                   

                                                                                                   

                                                                                                   

                                                                                                   
  --------------------- ---------- ------- ---------------- ------------- ------------- ---------- ---------

  --------------------- ---------- ------- ---------------- ------------- ------------- ---------- ---------
  **Summer**                                                                                       

  **School Name**       **Feeder           **Percentage of                                         
                        School             Center                                                  
                        Active**           Participants**                                          

                        **Y**      **N**   **1--25%**       **26--50%**   **51--75%**   **76%+**   **N/A**

                                                                                                   

                                                                                                   

                                                                                                   

                                                                                                   

                                                                                                   

                                                                                                   

                                                                                                   

                                                                                                   

                                                                                                   
  --------------------- ---------- ------- ---------------- ------------- ------------- ---------- ---------

**Form E: Attendance**

For instructions, see page 10.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Grantee Name Center Name

**Total Participants**

Indicate the number of participants (PK--12 students and adult family
members age 19 and older) who attended the program during the school
year only, the summer only, or both. If your center keeps an attendance
list for each activity and people can attend more than one activity,
count attendees only one time.

  ------------------------- ---------------------- ----------------------
  **Period of Attendance**  **All Students         **All Adults
                            Served**               Served\***

  School year only                                 

  Summer only                                      

  Both summer and school                           
  year                                             

  Total individual                                 
  participants served                              
  ------------------------- ---------------------- ----------------------

\*Adults only should be counted for APR reporting purposes if both of
the following are true:

1.  They are an adult family member age 19 years or older of a child
    that attended the center during the reporting period

2.  They participated in activities targeting adult family members that
    required ongoing and sustained participation by the adult family
    member in order to achieve the acquisition of knowledge or a skill\
    meant to be imparted through participation in the service or
    activity. Examples of activities that conform\
    to these requirements would include GED classes, classes on how to
    develop a resume, or a programming series on effective parenting
    strategies. Episodic, nonrecurring, or special events are not likely
    to conform to these requirements. For example, an open house night
    for the parents of children attending the center that involves a
    meal and social activities would not conform to these requirements.

**Regular Attendees**

Record in the following table: (1) the total number of student attendees
who attended the program fewer than 30 days during the reporting period,
and (2) the number who attended 30 days or more during the reporting
period. Any student who attended 30 days or more during the reporting
period is a *regular attendee*.

  ------------------------------------------ ----------------------------
  **Nature of Attendance**                   **Number of Student
                                             Attendees**

  1\. Attended fewer than 30 days during the 
  reporting period                           

  2\. Attended 30 days or more during the    
  reporting period                           

  Total                                      
  ------------------------------------------ ----------------------------

**Student Characteristics---Racial/Ethnic Group**

Please provide below, to the best of your ability, the number of
students who fit into each of the categories given in each
characteristic section. If you do not have enough information to
determine what category describes a student, list that student in the
*unknown* category for that section. In sections related to
*Racial/Ethnic Group* and *Student Services*, you may include a
duplicate count. That is, students may be counted in more than one
category (e.g., a student may have mixed ethnicity or have limited
English proficiency and may also be eligible for free or reduced price
lunch). For students who fit more than one category, you may count them
in as many categories as apply. For the grade level and gender sections,
count each student only once. For students that attended summer sessions
only during the reporting period, please count them in the grade they
would have been enrolled in during the school year following the summer
in question. You must use whole numbers for all answers.

To protect student confidentiality, a value for any student
characteristic that is less than three should be rounded down to zero;
for value of three or four, round it up to five.

  ------------------------------ ------------------- ---------------------
  **Racial/Ethnic Group**        **Total Student     **Regular Student
                                 Attendees**         Attendees**

  American Indian/Alaska Native                      

  Asian/Pacific Islander                             

  Black or African American                          

  Hispanic or Latino                                 

  White                                              

  For how many students                              
  attending the center do you                        
  not have racial/ethnic group                       
  data?                                              
  ------------------------------ ------------------- ---------------------

**Student Characteristics---Gender**

  ------------------------------ ------------------- ---------------------
  **Gender**                     **Total Student     **Regular Student
                                 Attendees**         Attendees**

  Male                                               

  Female                                             

  Data not provided                                  
  ------------------------------ ------------------- ---------------------

**Student Characteristics---Special Services or Programs**

  ------------------------------ ------------------- ---------------------
  **Special Service or Program - **Total Student     **Regular Student
  Limited English Proficiency**  Attendees**         Attendees**

  Students with limited English                      
  proficiency                                        

  Students for whom limited                          
  English proficiency status                         
  could not be determined.                           
  ------------------------------ ------------------- ---------------------

**Student Characteristics---Special Services or Programs**

  ------------------------------ ------------------- ---------------------
  **Special Service or Program - **Total Student     **Regular Student
  Free or Reduced-Price Lunch**  Attendees**         Attendees**

  Students eligible for free or                      
  reduced-price lunch                                

  Students for whom free or                          
  reduced-price lunch status                         
  could not be determined.                           
  ------------------------------ ------------------- ---------------------

  ------------------------------ ------------------- ---------------------
  **Special Service or Program - **Total Student     **Regular Student
  Special Needs or               Attendees**         Attendees**
  Disabilities**                                     

  Students with special needs or                     
  disabilities                                       

  Students for whom special                          
  needs or disabilities status                       
  could not be determined.                           
  ------------------------------ ------------------- ---------------------

**Student Characteristics---Grade Level**

  ------------------------------ ------------------- ---------------------
  **Grade Level**                **Total Student     **Regular Student
                                 Attendees**         Attendees**

  Prekindergarten                                    

  Kindergarten                                       

  First grade                                        

  Second grade                                       

  Third grade                                        

  Fourth grade                                       

  Fifth grade                                        

  Sixth grade                                        

  Seventh grade                                      

  Eighth grade                                       

  Ninth grade                                        

  10^th^ grade                                       

  11^th^ grade                                       

  12^th^ grade                                       

  Unknown                                            
  ------------------------------ ------------------- ---------------------

**Form F: Impact Categories**

For instructions, see page 11.

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\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Grantee Name Center Name

Put a checkmark beside the impact category or categories that your state
education agency has chosen for this year's APR. The specific forms you
need to fill out are determined by your state education agency.

Grades (see pages 8--9)

\_\_\_\_\_\_\_\_\_ Gradation Reporting (Form F-1a)

\_\_\_\_\_\_\_\_\_ Combined Reporting (Form F-1b)

State Assessment---Current Year (see pages 10)

\_\_\_\_\_\_\_\_\_ Combined Reporting (Form F-2)

State Assessment---Cross-Year Disaggregated (see pages 10--11)

\_\_\_\_\_\_\_\_\_ Gradation Reporting (Form F-3a)

\_\_\_\_\_\_\_\_\_ Combined Reporting (Form F-3b)

Teacher Survey (see page 11)

\_\_\_\_\_\_\_\_\_ (Form F-4)

To clarify, for each impact category you have marked, fill out the
associated form as follows:

> Grades Form F-1a or F-1b
>
> State Assessment---Current Year Form F-2
>
> State Assessment---Cross-Year (Disaggregated) Form F-3a or F-3b
>
> Teacher Survey Form F-4

**Form F-1a: Grades (Gradation)**

For instructions, see pages 11.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Grantee Name Center Name

**Grades Data Overvie**w

  ----------------------------------------------------------- -------------
  **Indicate the number of regular attendees for which:**     **Number of
                                                              Regular
                                                              Attendees**

  You have both mathematics *and* reading/language arts       
  grades for fall 2006 and\                                   
  spring 2007.                                                

  You have *only* mathematics grades for fall 2006 and spring 
  2007.                                                       

  You have *only* reading/language arts grades for fall 2006  
  and spring 2007.                                            

  You have *neither* mathematics *nor* reading/language arts  
  grades for fall 2006 and spring 2007. You also should count 
  in this category students meeting the definition\           
  of a regular attendee who participated only during the      
  summer and therefore should not be included in grades       
  reporting.                                                  

  Total                                                       
  ----------------------------------------------------------- -------------

**Mathematics Grades**

  ------------------------------------------ ------------ ---------- --------
  **Indicate the number of regular attendees **Regular               
  who:**                                     Attendees               
                                             by\                     
                                             Number of               
                                             Days                    
                                             Attended**              

                                             **30--59     **60--89   **90+
                                             Days**       Days**     Days**

  Increased their mathematics grade by half                          
  a grade or more.                                                   

  Decreased their mathematics grade by half                          
  a grade or more.                                                   

  Neither increased nor decreased their                              
  mathematics grade.                                                 

  Number of the above (i.e., neither                                 
  increased nor decreased) that could not                            
  improve given that they had obtained                               
  highest grade possible \*                                          

  Total (Mathematics)                                                
  ------------------------------------------ ------------ ---------- --------

\*Figures reported in this row should not be counted toward the column
totals.

  ------------------------------------------ ------------ ---------- --------
  **Indicate the number of regular attendees **Regular               
  who:**                                     Attendees               
                                             by\                     
                                             Number of               
                                             Days                    
                                             Attended**              

                                             **30--59     **60--89   **90+
                                             Days**       Days**     Days**

  Increased their reading/language arts                              
  grade by half a grade\                                             
  or more.                                                           

  Decreased their reading/language arts                              
  grade by half a grade or more.                                     

  Neither increased nor decreased their                              
  reading/language arts grade.                                       

  Number of the above (i.e., neither                                 
  increased nor decreased) that could not                            
  improve given that they had obtained                               
  highest grade possible \*                                          

  Total (Reading/Language Arts)                                      
  ------------------------------------------ ------------ ---------- --------

\*Figures reported in this row should not be counted toward the column
totals.

**Form F-1b: Grades (Combined)**

For instructions, see pages 11.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Grantee Name Center Name

**Grades Data Overvie**w

  ----------------------------------------------------------- -------------
  **Indicate the number of regular attendees for which:**     **Number of
                                                              Regular
                                                              Attendees**

  You have both mathematics *and* reading/language arts       
  grades for fall 2006 and\                                   
  spring 2007.                                                

  You have *only* mathematics grades for fall 2006 and spring 
  2007.                                                       

  You have *only* reading/language arts grades for fall 2006  
  and spring 2007.                                            

  You have *neither* mathematics *nor* reading/language arts  
  grades for fall 2006 and spring 2007. You also should count 
  in this category students meeting the definition\           
  of a regular attendee who participated only during the      
  summer and therefore should not be included in grades       
  reporting.                                                  

  Total                                                       
  ----------------------------------------------------------- -------------

**Mathematics Grades**

  ---------------------------------------------- ------------------------
  **Indicate the number of regular attendees     **Regular Attendees**
  who:**                                         

                                                 

  Increased their mathematics grade by half a    
  grade or more.                                 

  Decreased their mathematics grade by half a    
  grade or more.                                 

  Neither increased nor decreased their          
  mathematics grade.                             

  Number of the above (i.e., neither increased   
  nor decreased) that could not improve given    
  that they had obtained highest grade possible  
  \*                                             

  Total (Mathematics)                            
  ---------------------------------------------- ------------------------

\*Figures reported in this row should not be counted toward the column
totals.

**Reading/Language Arts Grades**

  ---------------------------------------------- ------------------------
  **Indicate the number of regular attendees     **Regular Attendees**
  who:**                                         

                                                 

  Increased their reading/language arts grade by 
  half a grade\                                  
  or more.                                       

  Decreased their reading/language arts grade by 
  half a grade or more.                          

  Neither increased nor decreased their          
  reading/language arts grade.                   

  Number of the above (i.e., neither increased   
  nor decreased) that could not improve given    
  that they had obtained highest grade possible  
  \*                                             

  Total (Reading/Language Arts)                  
  ---------------------------------------------- ------------------------

\*Figures reported in this row should not be counted toward the column
totals.

**Form F-2: State Assessment--Current Year (Combined)**

For instructions, see page 10.

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\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Grantee Name Center Name

**State Assessment Proficiency Results---Overview**

  ------------------------------------------ ----------------------------
  **Indicate the number of regular attendees **Regular Attendees**
  for which:**                               

                                             

  You have both mathematics *and*            
  reading/language arts results for the      
  state proficiency test administered        
  during\                                    
  the 2006--07 school year.                  

  You have *only* mathematics results for    
  the state proficiency test administered    
  during the 2006--07 school year.           

  You have *only* reading/language arts      
  results for the state proficiency test     
  administered during the 2006--07 school    
  year.                                      

  You have *neither* mathematics *nor*       
  reading/language arts results for the      
  state proficiency test administered during 
  the 2006--07 school year.                  

  Totals                                     
  ------------------------------------------ ----------------------------

**State Assessment Proficiency Results---Mathematics Performance**

+------------------------------------------+---------------------------+
| **Indicate the number of regular         | **Regular Attendees**     |
| attendees who scored\                    |                           |
| in the following levels on the state     |                           |
| proficiency test administered during the |                           |
| reporting period**                       |                           |
|                                          |                           |
| **(*NOTE:* Enter the proficiency levels  |                           |
| for your state\                          |                           |
| below from highest to lowest.)**         |                           |
+------------------------------------------+---------------------------+
|                                          |                           |
+------------------------------------------+---------------------------+
|                                          |                           |
+------------------------------------------+---------------------------+
|                                          |                           |
+------------------------------------------+---------------------------+
|                                          |                           |
+------------------------------------------+---------------------------+
|                                          |                           |
+------------------------------------------+---------------------------+
|                                          |                           |
+------------------------------------------+---------------------------+
|                                          |                           |
+------------------------------------------+---------------------------+
|                                          |                           |
+------------------------------------------+---------------------------+
|                                          |                           |
+------------------------------------------+---------------------------+
| Total (Mathematics)                      |                           |
+------------------------------------------+---------------------------+

**State Assessment Proficiency Results---Reading/Language Arts
Performance**

+------------------------------------------+---------------------------+
| **Indicate the number of regular         | **Regular Attendees**     |
| attendees who scored\                    |                           |
| in the following levels on the state     |                           |
| proficiency test administered during the |                           |
| reporting period**                       |                           |
|                                          |                           |
| **(*NOTE:* Enter the proficiency levels  |                           |
| for your state\                          |                           |
| below from highest to lowest.)**         |                           |
+------------------------------------------+---------------------------+
|                                          |                           |
+------------------------------------------+---------------------------+
|                                          |                           |
+------------------------------------------+---------------------------+
|                                          |                           |
+------------------------------------------+---------------------------+
|                                          |                           |
+------------------------------------------+---------------------------+
|                                          |                           |
+------------------------------------------+---------------------------+
|                                          |                           |
+------------------------------------------+---------------------------+
|                                          |                           |
+------------------------------------------+---------------------------+
|                                          |                           |
+------------------------------------------+---------------------------+
|                                          |                           |
+------------------------------------------+---------------------------+
|                                          |                           |
+------------------------------------------+---------------------------+
|                                          |                           |
+------------------------------------------+---------------------------+
| Total (Reading/Language Arts)            |                           |
+------------------------------------------+---------------------------+

**Form F-3a: State Assessment---Cross-Year\
(Disaggregated, Gradation)**

For instructions, see pages 12.

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Grantee Name Center Name

**State Assessment Proficiency Results---Changes in Performance Level
Overview**

  --------------------------------------------------------- -------------
  **Indicate the number of regular attendees for which:**   **Number of
                                                            Regular
                                                            Attendees**

  You have both mathematics *and* reading/language arts     
  assessment results for proficiency tests administered     
  during the 2005--06 and 2006--07 school years.            

  You have *only* mathematics assessment results for        
  proficiency tests administered during the 2005--06 and    
  2006--07 school years.                                    

  You have *only* reading/language arts assessment results  
  for proficiency tests administered during the 2005--06    
  and 2006--07 school years.                                

  You have *neither* mathematics *nor* reading/language     
  arts assessment results for proficiency tests             
  administered during the 2005--06 and 2006--07 school      
  years.                                                    

  Total                                                     
  --------------------------------------------------------- -------------

**State Performance Levels**

Indicate the performance levels used by your state assessment from high
to low (e.g., *advanced* to *basic*), with 1 being high. If you have
fewer than five categories, you can leave levels blank.

  -----------------------------------------------------------------------
  **Example**

  1\. Advanced

  2\. Proficient

  3\. Basic

  4\.

  5\.
  -----------------------------------------------------------------------

> 1\. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> 2\. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> 3\. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> 4\. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

5.  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

On the following pages, indicate the number of regular attendees that
fall into each of the listed categories, separated based on students'
performance on the first of the two tests. For example,\
if a student performed at the *proficient* level one year and moved to
the *advanced* level the next, you would indicate that a student in the
*proficient* level witnessed an increase in performance between the two
years.

**Mathematics Proficiency Test Results---Changes in Performance Level**

  ------------------------------------------ ------------ ---------- --------
  **Indicate the number of regular attendees **Regular               
  in each level who:**                       Attendees               
                                             by\                     
                                             Number of               
                                             Days                    
                                             Attended**              

                                             **30--59     **60--89   **90+
                                             Days**       Days**     Days**

  **Level 1 (Highest)**                                              

  Witnessed no change in performance level                           
  on the proficiency test administered                               
  during the 2006--07 school year.                                   

  Witnessed a decrease in performance level                          
  on the proficiency test administered                               
  during the 2006--07 school year.                                   

  Total for Level 1                                                  

  **Level 2**                                                        

  Witnessed an increase in performance level                         
  on the proficiency test administered                               
  during the 2006--07\                                               
  school year.                                                       

  Witnessed no change in performance level                           
  on the proficiency test administered                               
  during the 2006--07 school year.                                   

  Witnessed a decrease in performance level                          
  on the proficiency test administered                               
  during the 2006--07 school year.                                   

  Total for Level 2                                                  

  **Level 3**                                                        

  Witnessed an increase in performance level                         
  on the proficiency test administered                               
  during the 2006--07\                                               
  school year.                                                       

  Witnessed no change in performance level                           
  on the proficiency test administered                               
  during the 2006--07 school year.                                   

  Witnessed a decrease in performance level                          
  on the proficiency test administered                               
  during the 2006--07 school year.                                   

  Total for Level 3                                                  

  **Level 4**                                                        

  Witnessed an increase in performance level                         
  on the proficiency test administered                               
  during the 2006--07\                                               
  school year.                                                       

  Witnessed no change in performance level                           
  on the proficiency test administered                               
  during the 2006--07 school year.                                   

  Witnessed a decrease in performance level                          
  on the proficiency test administered                               
  during the 2006--07 school year.                                   

  Total for Level 4                                                  
  ------------------------------------------ ------------ ---------- --------

  ------------------------------------------ ------------ ---------- --------
  **Indicate the number of regular attendees **Regular               
  in each level who:**                       Attendees               
                                             by\                     
                                             Number of               
                                             Days                    
                                             Attended**              

                                             **30--59     **60--89   **90+
                                             Days**       Days**     Days**

  **Level 5 (Lowest)**                                               

  Witnessed an increase in performance level                         
  on the proficiency test administered                               
  during the 2006--07\                                               
  school year.                                                       

  Witnessed no change in performance level                           
  on the proficiency test administered                               
  during the 2006--07 school year.                                   

  Total for Level 5                                                  

  **Total (Mathematics)**                                            
  ------------------------------------------ ------------ ---------- --------

**Reading/Language Arts Proficiency Test Results---Changes in
Performance Level**

  ------------------------------------------ ------------ ---------- --------
  **Indicate the number of regular attendees **Regular               
  in each level who:**                       Attendees               
                                             by\                     
                                             Number of               
                                             Days                    
                                             Attended**              

                                             **30--59     **60--89   **90+
                                             Days**       Days**     Days**

  **Level 1 (Highest)**                                              

  Witnessed no change in performance level                           
  on the proficiency test administered                               
  during the 2006--07 school year.                                   

  Witnessed a decrease in performance level                          
  on the proficiency test administered                               
  during the 2006--07 school year.                                   

  Total for Level 1                                                  

  **Level 2**                                                        

  Witnessed an increase in performance level                         
  on the proficiency test administered                               
  during the 2006--07\                                               
  school year.                                                       

  Witnessed no change in performance level                           
  on the proficiency test administered                               
  during the 2006--07 school year.                                   

  Witnessed a decrease in performance level                          
  on the proficiency test administered                               
  during the 2006--07 school year.                                   

  Total for Level 2                                                  

  **Level 3**                                                        

  Witnessed an increase in performance level                         
  on the proficiency test administered                               
  during the 2006--07\                                               
  school year.                                                       

  Witnessed no change in performance level                           
  on the proficiency test administered                               
  during the 2006--07 school year.                                   

  Witnessed a decrease in performance level                          
  on the proficiency test administered                               
  during the 2006--07 school year.                                   

  Total for Level 3                                                  

  **Indicate the number of regular attendees **Regular               
  in each level who:**                       Attendees               
                                             by\                     
                                             Number of               
                                             Days                    
                                             Attended**              

                                             **30--59     **60--89   **90+
                                             Days**       Days**     Days**

  **Level 4**                                                        

  Witnessed an increase in performance level                         
  on the proficiency test administered                               
  during the 2006--07\                                               
  school year.                                                       

  Witnessed no change in performance level                           
  on the proficiency test administered                               
  during the 2006--07 school year.                                   

  Witnessed a decrease in performance level                          
  on the proficiency test administered                               
  during the 2006--07 school year.                                   

  Total for Level 4                                                  

  **Level 5 (Lowest)**                                               

  Witnessed an increase in performance level                         
  on the proficiency test administered                               
  during the 2006--07\                                               
  school year.                                                       

  Witnessed no change in performance level                           
  on the proficiency test administered                               
  during the 2006--07 school year.                                   

  Total for Level 5                                                  

  **Total (Reading/Language Arts)**                                  
  ------------------------------------------ ------------ ---------- --------

One of the goals of the 21^st^ CCLC program is to help students achieve
a level of *proficient* or above on state assessments. The federal
government has set three proficiency categories: *basic*, *proficient*,
and *advanced*. Each state has chosen three or more proficiency
categories for its own assessments. One of the state's categories
matches the federal category of *proficient* while the lower categories
connect to the *basic* level and the higher categories represent the
*advanced* level in the federal system. If your state has two or more
proficiency levels that fall below proficient, indicate the number of
students that scored at least two levels below *proficient* on the
previous year's assessment and have now scored *proficient* or above on
the current assessment. *NOTE:* You only will need to complete the
following tables if your state assessment system has two or more
proficiency levels the fall below proficient.

**Mathematics Proficiency Test Results---Significant Changes in
Performance Level**

  ----------------------------------------------------------- -------------
  **Indicate the number of regular attendees in each level    **Number of
  who:**                                                      Regular
                                                              Attendees**

  Number of regular attendees who witnessed a jump from a     
  category two levels below *proficient* to the *p*roficient  
  performance level or above on the proficiency test.         

  Number of regular attendees that witnessed a jump from a    
  category three levels below *proficient* to the             
  *p*roficient performance level or above on the proficiency  
  test.                                                       
  ----------------------------------------------------------- -------------

**Reading/Language Arts Proficiency Test Results---Significant Changes
in Performance Level**

  ----------------------------------------------------------- -------------
  **Indicate the number of regular attendees in each level    **Number of
  who:**                                                      Regular
                                                              Attendees**

  Number of regular attendees who witnessed a jump from a     
  category two levels below *proficient* to the *p*roficient  
  performance level or above on the proficiency test.         

  Number of regular attendees that witnessed a jump from a    
  category three levels below *proficient* to the             
  *p*roficient performance level or above on the proficiency  
  test.                                                       
  ----------------------------------------------------------- -------------

**Form F-3b: State Assessment---Cross-Year\
(Disaggregated, Combined)**

For instructions, see pages 12.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Grantee Name Center Name

**State Assessment Proficiency Results---Changes in Performance Level
Overview**

  --------------------------------------------------------- -------------
  **Indicate the number of regular attendees for which:**   **Number of
                                                            Regular
                                                            Attendees**

  You have both mathematics *and* reading/language arts     
  assessment results for proficiency tests administered     
  during the 2005--06 and 2006--07 school years.            

  You have *only* mathematics assessment results for        
  proficiency tests administered during the 2005--06 and    
  2006--07 school years.                                    

  You have *only* reading/language arts assessment results  
  for proficiency tests administered during the 2005--06    
  and 2006--07 school years.                                

  You have *neither* mathematics *nor* reading/language     
  arts assessment results for proficiency tests             
  administered during the 2005--06 and 2006--07 school      
  years.                                                    

  Total                                                     
  --------------------------------------------------------- -------------

**State Performance Levels**

Indicate the performance levels used by your state assessment from high
to low (e.g., *advanced* to *basic*), with 1 being high. If you have
fewer than five categories, you can leave levels blank.

  -----------------------------------------------------------------------
  **Example**

  1\. Advanced

  2\. Proficient

  3\. Basic

  4\.

  5\.
  -----------------------------------------------------------------------

> 1\. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> 2\. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> 3\. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> 4\. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

5.  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

On the following pages, indicate the number of regular attendees that
fall into each of the listed categories, separated based on students'
performance on the first of the two tests. For example, if a student
performed at the *proficient* level one year and moved to the *advanced*
level the next, you would indicate that a student in the *proficient*
level witnessed an increase in performance between the two years.

**Mathematics Proficiency Test Results---Changes in Performance Level**

  ------------------------------------------ ----------------------------
  **Indicate the number of regular attendees **Regular Attendees**
  in each level who:**                       

                                             

  **Level 1 (Highest)**                      

  Witnessed no change in performance level   
  on the proficiency test administered       
  during the 2006--07 school year.           

  Witnessed a decrease in performance level  
  on the proficiency test administered       
  during the 2006--07 school year.           

  Total for Level 1                          

  **Level 2**                                

  Witnessed an increase in performance level 
  on the proficiency test administered       
  during the 2006--07\                       
  school year.                               

  Witnessed no change in performance level   
  on the proficiency test administered       
  during the 2006--07 school year.           

  Witnessed a decrease in performance level  
  on the proficiency test administered       
  during the 2006--07 school year.           

  Total for Level 2                          

  **Level 3**                                

  Witnessed an increase in performance level 
  on the proficiency test administered       
  during the 2006--07\                       
  school year.                               

  Witnessed no change in performance level   
  on the proficiency test administered       
  during the 2006--07 school year.           

  Witnessed a decrease in performance level  
  on the proficiency test administered       
  during the 2006--07 school year.           

  Total for Level 3                          

  **Level 4**                                

  Witnessed an increase in performance level 
  on the proficiency test administered       
  during the 2006--07\                       
  school year.                               

  Witnessed no change in performance level   
  on the proficiency test administered       
  during the 2006--07 school year.           

  Witnessed a decrease in performance level  
  on the proficiency test administered       
  during the 2006--07 school year.           

  Total for Level 4                          
  ------------------------------------------ ----------------------------

  ------------------------------------------ ----------------------------
  **Indicate the number of regular attendees **Regular Attendees**
  in each level who:**                       

                                             

  **Level 5 (Lowest)**                       

  Witnessed an increase in performance level 
  on the proficiency test administered       
  during the 2006--07\                       
  school year.                               

  Witnessed no change in performance level   
  on the proficiency test administered       
  during the 2006--07 school year.           

  Total for Level 5                          

  **Total (Mathematics)**                    
  ------------------------------------------ ----------------------------

**Reading/Language Arts Proficiency Test Results---Changes in
Performance Level**

  ------------------------------------------ ----------------------------
  **Indicate the number of regular attendees **Regular Attendees**
  in each level who:**                       

                                             

  **Level 1 (Highest)**                      

  Witnessed no change in performance level   
  on the proficiency test administered       
  during the 2006--07 school year.           

  Witnessed a decrease in performance level  
  on the proficiency test administered       
  during the 2006--07 school year.           

  Total for Level 1                          

  **Level 2**                                

  Witnessed an increase in performance level 
  on the proficiency test administered       
  during the 2006--07\                       
  school year.                               

  Witnessed no change in performance level   
  on the proficiency test administered       
  during the 2006--07 school year.           

  Witnessed a decrease in performance level  
  on the proficiency test administered       
  during the 2006--07 school year.           

  Total for Level 2                          

  **Level 3**                                

  Witnessed an increase in performance level 
  on the proficiency test administered       
  during the 2006--07\                       
  school year.                               

  Witnessed no change in performance level   
  on the proficiency test administered       
  during the 2006--07 school year.           

  Witnessed a decrease in performance level  
  on the proficiency test administered       
  during the 2006--07 school year.           

  Total for Level 3                          
  ------------------------------------------ ----------------------------

  ------------------------------------------ ----------------------------
  **Indicate the number of regular attendees **Regular Attendees**
  in each level who:**                       

                                             

  **Level 4**                                

  Witnessed an increase in performance level 
  on the proficiency test administered       
  during the 2006--07\                       
  school year.                               

  Witnessed no change in performance level   
  on the proficiency test administered       
  during the 2006--07 school year.           

  Witnessed a decrease in performance level  
  on the proficiency test administered       
  during the 2006--07 school year.           

  Total for Level 4                          

  **Level 5 (Lowest)**                       

  Witnessed an increase in performance level 
  on the proficiency test administered       
  during the 2006--07\                       
  school year.                               

  Witnessed no change in performance level   
  on the proficiency test administered       
  during the 2006--07 school year.           

  Total for Level 5                          

  **Total (Reading/Language Arts)**          
  ------------------------------------------ ----------------------------

One of the goals of the 21st CCLC program is to help students achieve a
level of *proficient* or above on state assessments. The federal
government has set three proficiency categories: *basic*, *proficient*,
and *advanced*. Each state has chosen three or more proficiency
categories for its own assessments. One of the state's categories
matches the federal category of *proficient* while the lower categories
connect to the *basic* level and the higher categories represent the
*advanced* level in the federal system. If your state has two or more
proficiency levels that fall below proficient, indicate the number of
students that scored at least two levels below *proficient* on the
previous year's assessment and have now scored *proficient* or above on
the current assessment. *NOTE:* You only will need to complete the
following tables if your state assessment system has two or more
proficiency levels the fall below proficient.

**Mathematics Proficiency Test Results---Significant Changes in
Performance Level**

  ----------------------------------------------------------- -------------
  **Indicate the number of regular attendees in each level    **Number of
  who:**                                                      Regular
                                                              Attendees**

  Number of regular attendees who witnessed a jump from a     
  category two levels below *proficient* to the *p*roficient  
  performance level or above on the proficiency test.         

  Number of regular attendees that witnessed a jump from a    
  category three levels below *proficient* to the             
  *p*roficient performance level or above on the proficiency  
  test.                                                       
  ----------------------------------------------------------- -------------

**Reading/Language Arts Proficiency Test Results---Significant Changes
in Performance Level**

  ----------------------------------------------------------- -------------
  **Indicate the number of regular attendees in each level    **Number of
  who:**                                                      Regular
                                                              Attendees**

  Number of regular attendees who witnessed a jump from a     
  category two levels below *proficient* to the *p*roficient  
  performance level or above on the proficiency test.         

  Number of regular attendees that witnessed a jump from a    
  category three levels below *proficient* to the             
  *p*roficient performance level or above on the proficiency  
  test.                                                       
  ----------------------------------------------------------- -------------

**Form F-4: Teacher Survey**

For instructions, see pages 13.

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\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Grantee Name Center Name

In the following table, record the results from the Learning Point
Associates teacher survey. This survey is administered at the end of the
year. The survey asks school-day teachers to report whether regular
attendees' behavior improved or did not improve in certain areas. If a
student did not need to improve in a particular area, include that
student only in the Did Not Need to Improve column.

For every student you have identified as a regular attendee (30 days or
more), select one of his or her regular school-day teachers to complete
the teacher survey. For elementary school students, the teacher should
be the regular classroom teacher. For middle and high school students, a
mathematics or English teacher should be surveyed. Although you may
include in your sample the teachers who also are serving as 21st CCLC
program staff, it is preferable to survey teachers who are not. There
should be one teacher survey filled out for every student identified as
a regular attendee. In addition, note that students meeting the
definition of a regular attendee who participated only in center-related
activities during summer 2006 should not be included in the reporting of
teacher survey results.

The number of surveys given out should be equal to or less than the
number regular attendees you identified as being served by this center
in the reporting period on Form E. If your state requires gradation
information, print out Form F-4 for each of the three time period ranges
per student and check the appropriate box at the top of each survey for
the range of time it is addressing.

**Survey**

30--59 Days 60--89 Days 90+ Days Combined

1.1 Total number of surveys given out:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 1.2 Total number of surveys
completed: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  ------------------- ------------- --------------- --------------- --------------- ---------- ----------- ------------ ---------------
  **Changes in        **Number of                                                                                       
  Behaviors\          Regular                                                                                           
  on Which Teachers   Attendees**                                                                                       
  Reported:**                                                                                                           

                      **Did Not     **Acceptable                                                                        
                      Need to       Level of                                                                            
                      Improve**     Functioning Not                                                                     
                                    Demonstrated                                                                        
                                    Early in School                                                                     
                                    Year---\                                                                            
                                    Improvement                                                                         
                                    Warranted**                                                                         

                                    **Significant   **Moderate      **Slight        **No       **Slight    **Moderate   **Significant
                                    Improvement**   Improvement**   Improvement**   Change**   Decline**   Decline**    Decline**

  Turning in                                                                                                            
  homework\                                                                                                             
  on time                                                                                                               

  Completing homework                                                                                                   
  to your                                                                                                               
  satisfaction                                                                                                          

  Participating in                                                                                                      
  class                                                                                                                 

  Volunteering (e.g.,                                                                                                   
  extra credit, more                                                                                                    
  responsibilities)                                                                                                     

  Attending class                                                                                                       
  regularly                                                                                                             

  Being attentive in                                                                                                    
  class                                                                                                                 

  Behaving well in                                                                                                      
  class                                                                                                                 

  Performing                                                                                                            
  academically                                                                                                          

  Coming to school                                                                                                      
  motivated to learn                                                                                                    

  Getting along well                                                                                                    
  with other students                                                                                                   
  ------------------- ------------- --------------- --------------- --------------- ---------- ----------- ------------ ---------------

**Form G: Comments**

For instructions, see page 14.

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\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Grantee Name Center Name

Provide any additional information you believe to be pertinent to this
APR. If you are not able to complete any sections of the APR for any
reason, include an explanation for the omissions here. Be sure to state
the name of each incomplete section or specific questions to which you
are referring. Attach additional sheets as needed.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Form H: Confirmation Page**

For instructions, see page 14.

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\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Grantee Name Center Name

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Grantee State ID Number (if applicable) Center Address

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

State Education Agency Center City, State ZIP

Indicate which APR forms you have completed. The forms for Operations,
Staffing, Activities, Feeder Schools, and Attendance are required of all
centers. Your state education agency has selected which impact
categories are required. Please review the associated forms to ensure
that you have included all necessary information. If you have not
completed any required section, give an explanation for the omission on
Form G (Comments) and write "See comments" next\
to the section title below:

**Standard Categories**

\_\_\_\_\_\_\_\_\_\_ Operations (Form A)

\_\_\_\_\_\_\_\_\_\_ Staffing (Form B)

\_\_\_\_\_\_\_\_\_\_ Activities (Form C)

\_\_\_\_\_\_\_\_\_\_ Feeder Schools (Form D)

\_\_\_\_\_\_\_\_\_\_ Attendance (Form E)

\_\_\_\_\_\_\_\_\_\_ Impact Categories (Form F)

\_\_\_\_\_\_\_\_\_\_ Grades (Form F-1)

\_\_\_\_\_\_\_\_\_\_ State Assessment---Current Year (Form F-2)

\_\_\_\_\_\_\_\_\_\_ State Assessment---Cross-Year Disaggregated (Form
F-3)

\_\_\_\_\_\_\_\_\_\_ Teacher Survey (Form F-4)

I hereby state that all the information I have provided is complete and
accurate to the best of my knowledge.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature