+-----------------------+-----------------------+-----------------------+
| ###### **SC           | SCHOOLWIDE RECORDS    | ###                   |
| HOOL IDENTIFICATION** | COLLECTION FORM       | ## OMB No.: 1850-0818 |
|                       |                       |                       |
| #####                 |                       | Expiration Date:      |
| # (ATTACH LABEL HERE) |                       | MM/DD/YY              |
|                       |                       |                       |
| School Name:          |                       |                       |
|                       |                       |                       |
| School Address:       |                       |                       |
+-----------------------+-----------------------+-----------------------+

Name of person completing this form:
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

Phone of person completing this form: (\_\_ \_\_ \_\_) **\_\_ \_\_
\_\_ - \_\_ \_\_ \_\_ \_\_**

1\. Please record today's date: \| \| \| / \| \| \| / \| \| \| \| \|

Month Day Year

2\. Which of the following best describes this school? **CHECK ONE
RESPONSE**

1  Regular public school

2  Alternative public school

3  Charter school

4  Special Program Emphasis (for example, science/math school,
talented/gifted school, etc.)

5  Special Education (primarily serves students with disabilities)

[6  Other *(Please specify)*]{.underline}

+-------------------------------------------------+---------+----------+
| 3\. How many teachers are employed at this      | \_\_    | (Enter   |
| school?                                         | \_\_\_\ | Number)  |
|                                                 | _\_\_\_ |          |
| *Include all full and part-time regular         |         |          |
| classroom teachers, special area or resource    |         |          |
| teachers, long-term substitute teachers, and    |         |          |
| itinerant teachers. Do not include student      |         |          |
| teachers, teachers' aides, or short-term        |         |          |
| substitute teachers.*                           |         |          |
+-------------------------------------------------+---------+----------+
| 4\. As of October 1, 2006, what was the total   | \_\_    | (Enter   |
| number of students enrolled in this school?     | \_\_\_\ | Number)  |
|                                                 | _\_\_\_ |          |
+-------------------------------------------------+---------+----------+
| 5\. How many students were ABSENT on the most   | \_\_    | (Enter   |
| recent school day?                              | \_\_\_\ | Number)  |
|                                                 | _\_\_\_ |          |
+-------------------------------------------------+---------+----------+
| 6\. How many students were TARDY on the most    | \_\_    | (Enter   |
| recent school day?                              | \_\_\_\ | Number)  |
|                                                 | _\_\_\_ |          |
+-------------------------------------------------+---------+----------+
| 7\. What percentage of current students at this | \| \|   | (Enter   |
| school are male?                                | \| \|   | Percent) |
+-------------------------------------------------+---------+----------+
| 8\. What percentage of current students at this | \| \|   | (Enter   |
| school are Hispanic or Latino?                  | \| \|   | Percent) |
+-------------------------------------------------+---------+----------+
| 9\. What percentage of current students at this |         |          |
| school are:                                     |         |          |
+-------------------------------------------------+---------+----------+
| American Indian/Alaska Native                   | \| \|   | (Enter   |
|                                                 | \| \|   | Percent) |
+-------------------------------------------------+---------+----------+
| Asian                                           | \| \|   | (Enter   |
|                                                 | \| \|   | Percent) |
+-------------------------------------------------+---------+----------+
| Black or African American                       | \| \|   | (Enter   |
|                                                 | \| \|   | Percent) |
+-------------------------------------------------+---------+----------+
| Native Hawaiian or Other Pacific Islander       | \| \|   | (Enter   |
|                                                 | \| \|   | Percent) |
+-------------------------------------------------+---------+----------+
| White                                           | \| \|   | (Enter   |
|                                                 | \| \|   | Percent) |
+-------------------------------------------------+---------+----------+
| 10\. What percentage of current students at     |         |          |
| this school fit the following criteria?         |         |          |
+-------------------------------------------------+---------+----------+
| 10a. Are approved for free or                   | \| \|   | (Enter   |
|                                                 | \| \|   | Percent) |
| reduced-price school meals?                     |         |          |
+-------------------------------------------------+---------+----------+
| 10b. Are limited English Proficient (LEP) or    | \| \|   | (Enter   |
|                                                 | \| \|   | Percent) |
| English Language Learners (ELL)?                |         |          |
+-------------------------------------------------+---------+----------+
| 10c. What percentage of students have an        | \| \|   | (Enter   |
| Individual Education Plan (IEP) for students    | \| \|   | Percent) |
| receiving special education services under the  |         |          |
| Individuals with Disabilities Education Act     |         |          |
| (IDEA) or a Services Agreement for students     |         |          |
| receiving services under Section 504 of the     |         |          |
| Rehabilitation Act of 1973?                     |         |          |
+-------------------------------------------------+---------+----------+

11\. During THIS school year (2006-2007), has it been the practice of
this school to do the following?

+-------------------------------------------------+---------+---------+
|                                                 | >       |         |
|                                                 | **CHECK |         |
|                                                 | > "YES" |         |
|                                                 | > OR    |         |
|                                                 | >       |         |
|                                                 |  "NO"** |         |
|                                                 | >       |         |
|                                                 | > **ON  |         |
|                                                 | > EACH  |         |
|                                                 | >       |         |
|                                                 |  LINE** |         |
+-------------------------------------------------+---------+---------+
|                                                 | >       | >       |
|                                                 | **Yes** |  **No** |
+-------------------------------------------------+---------+---------+
| a\. Control access to school *buildings* during | 1      | 0      |
| school hours (e.g., locked or monitored doors   |         |         |
+-------------------------------------------------+---------+---------+
| b\. Control access to school *grounds* during   | 1      | 0      |
| school hours (e.g. locked or monitored gates)   |         |         |
+-------------------------------------------------+---------+---------+
| c\. Require students to pass through metal      | 1      | 0      |
| detectors each day                              |         |         |
+-------------------------------------------------+---------+---------+
| d\. Perform random metal detector checks on     | 1      | 0      |
| students                                        |         |         |
+-------------------------------------------------+---------+---------+
| e\. Require that all or most students stay on   | 1      | 0      |
| campus during lunch                             |         |         |
+-------------------------------------------------+---------+---------+
| f\. Require students to wear uniforms           | 1      | 0      |
+-------------------------------------------------+---------+---------+
| g\. Enforce a strict dress code                 | 1      | 0      |
+-------------------------------------------------+---------+---------+
| h\. Require clear book bags or ban book bags on | 1      | 0      |
| school grounds                                  |         |         |
+-------------------------------------------------+---------+---------+
| i\. Require students to wear badges or picture  | 1      | 0      |
| IDs                                             |         |         |
+-------------------------------------------------+---------+---------+
| j\. Use one or more security cameras to monitor | 1      | 0      |
| the school                                      |         |         |
+-------------------------------------------------+---------+---------+
| k\. Maintain a daily presence of police or      | 1      | 0      |
| security personnel                              |         |         |
+-------------------------------------------------+---------+---------+

12\. During THIS school year (2006-2007), how often has this school used
random dog sniffs to check for drugs?

1  At least once a week

2  At least once a month

3  On occasion

4  Never **GO TO 13**

12a. In how many instances were drugs or drug paraphernalia found during
the most recent dog sniff?

*If none, please write in "0."*

\_\_\_\_\_ NUMBER OF INSTANCES

13\. During THIS school year (2006-2007), how often has this school
performed random sweeps for contraband (e.g., drugs or weapons), but
*not including dog sniffs*?

1  At least once a week

2  At least once a month

3  On occasion

4  Never **GO TO 14**

13a. If this school does perform random sweeps for contraband, in how
many instances were contraband found during the most recent search?

*If none, please write in "0."*

  ------------------------------------------------------ ------------------
                                                         **NUMBER OF
                                                         INSTANCES**

  a\. Drugs and/or drug paraphernalia were found         \_\_\_\_\_\_\_\_

  b\. Alcohol was found                                  \_\_\_\_\_\_\_\_

  c\. Weapons were found                                 \_\_\_\_\_\_\_\_

  d\. Total number of instances any contraband was found \_\_\_\_\_\_\_\_
  ------------------------------------------------------ ------------------

14\. For each of the following time periods, how **many students** were
expelled (i.e., removed or transferred for at least the remainder of the
school year) from this school?

*If none, please write in "0."*

+----------------------------------+-----------------------------------+
| **Last School Year (2005-2006)** | **Current School Year             |
|                                  | (2006-2007)**                     |
+----------------------------------+-----------------------------------+
| \_\_\_\_\_\_\_\_                 | \_\_\_\_\_\_\_\_                  |
|                                  |                                   |
| NUMBER OF STUDENTS               | NUMBER OF STUDENTS                |
+----------------------------------+-----------------------------------+

15\. For each of the following time periods, what was the **total number
of** suspensions in this school? Please include in-school and
out-of-school suspensions. Please count each individual suspension
(e.g., if one student received 10 suspensions, all 10 would be included
on this line).

*If none, please write in "0."*

+----------------------------------+-----------------------------------+
| **Last School Year (2005-2006)** | **Current School Year             |
|                                  | (2006-2007)**                     |
+----------------------------------+-----------------------------------+
| \_\_\_\_\_\_\_\_                 | \_\_\_\_\_\_\_\_                  |
|                                  |                                   |
| NUMBER OF SUSPENSIONS            | NUMBER OF SUSPENSIONS             |
+----------------------------------+-----------------------------------+

16\. For each of the following time periods, please provide the **total
number of incidents** this school recorded for each of the offenses
listed below.

*If none, please write in "0."*

+--------------------------------------+---------------+---------------+
|                                      | **Last School | **Current     |
|                                      | Year**        | School Year** |
|                                      |               |               |
|                                      | **            | **            |
|                                      | (2005-2006)** | (2006-2007)** |
+--------------------------------------+---------------+---------------+
| a.  Use/possession of a              | \_\           | \_\           |
|     firearm/explosive device         | _\_\_\_\_\_\_ | _\_\_\_\_\_\_ |
+--------------------------------------+---------------+---------------+
| b.  Use/possession of a weapon other | \_\           | \_\           |
|     than a firearm                   | _\_\_\_\_\_\_ | _\_\_\_\_\_\_ |
+--------------------------------------+---------------+---------------+
| c.  Distribution, possession, or use | \_\           | \_\           |
|     of illegal drugs                 | _\_\_\_\_\_\_ | _\_\_\_\_\_\_ |
+--------------------------------------+---------------+---------------+
| d.  Distribution, possession, or use | \_\           | \_\           |
|     of alcohol                       | _\_\_\_\_\_\_ | _\_\_\_\_\_\_ |
+--------------------------------------+---------------+---------------+
| e.  Physical attacks or fights       | \_\           | \_\           |
|                                      | _\_\_\_\_\_\_ | _\_\_\_\_\_\_ |
+--------------------------------------+---------------+---------------+

17\. During each of the following time periods, did this school have any
formal programs **[intended to]{.underline}** **[prevent or reduce
tobacco, alcohol and/or drug use]{.underline}** that included the
following components for students?

+---------------------------------------+------+------+-------+-------+
|                                       | **C  |      |       |       |
|                                       | HECK |      |       |       |
|                                       | "    |      |       |       |
|                                       | YES" |      |       |       |
|                                       | OR   |      |       |       |
|                                       | "N   |      |       |       |
|                                       | O"** |      |       |       |
|                                       |      |      |       |       |
|                                       | **ON |      |       |       |
|                                       | EACH |      |       |       |
|                                       | LINE |      |       |       |
|                                       | FOR  |      |       |       |
|                                       | EACH |      |       |       |
|                                       | TIME |      |       |       |
|                                       | PERI |      |       |       |
|                                       | OD** |      |       |       |
+---------------------------------------+------+------+-------+-------+
|                                       | **   |      | *     |       |
|                                       | Last |      | *Curr |       |
|                                       | Sc   |      | ent** |       |
|                                       | hool |      |       |       |
|                                       | Ye   |      | **S   |       |
|                                       | ar** |      | chool |       |
|                                       |      |      | Y     |       |
|                                       | **(  |      | ear** |       |
|                                       | 2005 |      |       |       |
|                                       | -200 |      | **(20 |       |
|                                       | 6)** |      | 06-20 |       |
|                                       |      |      | 07)** |       |
+---------------------------------------+------+------+-------+-------+
|                                       | **Y  | **   | **    | *     |
|                                       | es** | No** | Yes** | *No** |
+---------------------------------------+------+------+-------+-------+
| a\. Prevention curriculum,            | 1   | 0   | 1    | 0    |
| instruction, or training for students |      |      |       |       |
+---------------------------------------+------+------+-------+-------+
| b\. Behavioral or behavior            | 1   | 0   | 1    | 0    |
| modification intervention for         |      |      |       |       |
| students                              |      |      |       |       |
+---------------------------------------+------+------+-------+-------+
| c\. Counseling, social work,          | 1   | 0   | 1    | 0    |
| psychological, or therapeutic         |      |      |       |       |
| activity for students                 |      |      |       |       |
+---------------------------------------+------+------+-------+-------+
| d\. Recreational, enrichment, or      | 1   | 0   | 1    | 0    |
| leisure activities for students       |      |      |       |       |
+---------------------------------------+------+------+-------+-------+
| e\. Hotline/tipline for students to   | 1   | 0   | 1    | 0    |
| report problems                       |      |      |       |       |
+---------------------------------------+------+------+-------+-------+
| f\. Information line for students to  | 1   | 0   | 1    | 0    |
| obtain information about alcohol      |      |      |       |       |
| and/or drug use                       |      |      |       |       |
+---------------------------------------+------+------+-------+-------+
| g\. Health fair, including            | 1   | 0   | 1    | 0    |
| component(s) related to alcohol       |      |      |       |       |
| and/or drug                           |      |      |       |       |
| use.............                      |      |      |       |       |
| ..................................... |      |      |       |       |
+---------------------------------------+------+------+-------+-------+
| h\. Student assemblies, speaking      | 1   | 0   | 1    | 0    |
| engagements............               |      |      |       |       |
+---------------------------------------+------+------+-------+-------+
| i\. Alcohol and/or drug resource      | 1   | 0   | 1    | 0    |
| center........................        |      |      |       |       |
+---------------------------------------+------+------+-------+-------+
| j\. Brochures or                      | 1   | 0   | 1    | 0    |
| posters......                         |      |      |       |       |
| ..................................... |      |      |       |       |
+---------------------------------------+------+------+-------+-------+
| k\. Other programs intended to        |      |      |       |       |
| prevent or reduce alcohol and/or drug |      |      |       |       |
| use? *(Please list)*                  |      |      |       |       |
+---------------------------------------+------+------+-------+-------+
|                                       | 1   | 0   | 1    | 0    |
+---------------------------------------+------+------+-------+-------+
|                                       | 1   | 0   | 1    | 0    |
+---------------------------------------+------+------+-------+-------+
|                                       |      |      |       |       |
+---------------------------------------+------+------+-------+-------+

18\. During each of the following time periods, which of the following
trainings for classroom teachers or aides did this school or district
provide?

+---------------------------------------+------+------+-------+-------+
|                                       | **C  |      |       |       |
|                                       | HECK |      |       |       |
|                                       | "    |      |       |       |
|                                       | YES" |      |       |       |
|                                       | OR   |      |       |       |
|                                       | "N   |      |       |       |
|                                       | O"** |      |       |       |
|                                       |      |      |       |       |
|                                       | **ON |      |       |       |
|                                       | EACH |      |       |       |
|                                       | LINE |      |       |       |
|                                       | FOR  |      |       |       |
|                                       | EACH |      |       |       |
|                                       | TIME |      |       |       |
|                                       | PERI |      |       |       |
|                                       | OD** |      |       |       |
+---------------------------------------+------+------+-------+-------+
|                                       | **   |      | *     |       |
|                                       | Last |      | *Curr |       |
|                                       | Sc   |      | ent** |       |
|                                       | hool |      |       |       |
|                                       | Ye   |      | **S   |       |
|                                       | ar** |      | chool |       |
|                                       |      |      | Y     |       |
|                                       | **(  |      | ear** |       |
|                                       | 2005 |      |       |       |
|                                       | -200 |      | **(20 |       |
|                                       | 6)** |      | 06-20 |       |
|                                       |      |      | 07)** |       |
+---------------------------------------+------+------+-------+-------+
|                                       | **Y  | **   | **    | *     |
|                                       | es** | No** | Yes** | *No** |
+---------------------------------------+------+------+-------+-------+
| a\. School-wide discipline policies   | 1   | 0   | 1    | 0    |
| and practices related to alcohol      |      |      |       |       |
| and/or drug use                       |      |      |       |       |
+---------------------------------------+------+------+-------+-------+
| b\. Recognizing signs of students     | 1   | 0   | 1    | 0    |
| using/abusing alcohol and/or drugs    |      |      |       |       |
+---------------------------------------+------+------+-------+-------+
| c\. Other programs? *(Please list)*   |      |      |       |       |
+---------------------------------------+------+------+-------+-------+
|                                       | 1   | 0   | 1    | 0    |
+---------------------------------------+------+------+-------+-------+
|                                       | 1   | 0   | 1    | 0    |
+---------------------------------------+------+------+-------+-------+
|                                       | 1   | 0   | 1    | 0    |
+---------------------------------------+------+------+-------+-------+

19\. During each of the following time periods, how many students
transferred to and from your school after the school year had started?
Please report on the total mobility, not just transfers due to
disciplinary actions.

*(If a student transferred more than once in the school year, count each
transfer separately. If no transfers, please record zero \[0\].)*

+---------------------------------+------------------+-----------------+
|                                 | **Last School    | **Current       |
|                                 | Year**           | School Year**   |
|                                 |                  |                 |
|                                 | **(2005-2006)**  | **(2006-2007)** |
+---------------------------------+------------------+-----------------+
| a\. Total number of transfers   | \_\_\_\_         | \_\_\_\_\_\     |
| *to* the school                 | \_\_\_\_\_\_\_\_ | _\_\_\_\_\_\_\_ |
+---------------------------------+------------------+-----------------+
| b\. Total number of transfers   | \_\_\_\_         | \_\_\_\_\_\_\   |
| *from* the school               | \_\_\_\_\_\_\_\_ | _\_\_\_\_\_\_\_ |
+---------------------------------+------------------+-----------------+

20\. The last question is about the most current average reading and
math test scores for students in this school. For each grade and subject
listed below please indicate:

\(1\) whether students were tested, (2) date of test, (3) test name, (4)
publisher name, (5) raw score, and (6) percentile.

+-----------+---+---+-----+-----+----------+---------+------+-------+
|           | * |   | *   |     | **(3)**  | **(4)** | **(  | **    |
|           | * |   | *(2 |     |          |         | 5)** | (6)** |
|           | ( |   | )** |     |          |         |      |       |
|           | 1 |   |     |     |          |         |      |       |
|           | ) |   |     |     |          |         |      |       |
|           | * |   |     |     |          |         |      |       |
|           | * |   |     |     |          |         |      |       |
+-----------+---+---+-----+-----+----------+---------+------+-------+
|           | * |   | **D |     |          |         |      |       |
|           | * |   | ate |     |          |         |      |       |
|           | S |   | of  |     |          |         |      |       |
|           | t |   | Tes |     |          |         |      |       |
|           | u |   | t** |     |          |         |      |       |
|           | d |   |     |     |          |         |      |       |
|           | e |   |     |     |          |         |      |       |
|           | n |   |     |     |          |         |      |       |
|           | t |   |     |     |          |         |      |       |
|           | s |   |     |     |          |         |      |       |
|           | * |   |     |     |          |         |      |       |
|           | * |   |     |     |          |         |      |       |
|           |   |   |     |     |          |         |      |       |
|           | * |   |     |     |          |         |      |       |
|           | * |   |     |     |          |         |      |       |
|           | t |   |     |     |          |         |      |       |
|           | e |   |     |     |          |         |      |       |
|           | s |   |     |     |          |         |      |       |
|           | t |   |     |     |          |         |      |       |
|           | e |   |     |     |          |         |      |       |
|           | d |   |     |     |          |         |      |       |
|           | ? |   |     |     |          |         |      |       |
|           | * |   |     |     |          |         |      |       |
|           | * |   |     |     |          |         |      |       |
+-----------+---+---+-----+-----+----------+---------+------+-------+
| **Grade** | * | * | **M | **  | **Test   | **Pu    | *    | **Pe  |
|           | * | * | ont | Yea | Name**   | blisher | *Raw | rcent |
|           | Y | N | h** | r** |          | Name**  | Sco  | ile** |
|           | e | o |     |     |          |         | re** |       |
|           | s | * |     |     |          |         |      |       |
|           | * | * |     |     |          |         |      |       |
|           | * |   |     |     |          |         |      |       |
+-----------+---+---+-----+-----+----------+---------+------+-------+
| a.  **9th |   |   |     |     |          |         |      |       |
|           |   |   |     |     |          |         |      |       |
|   Grade** |   |   |     |     |          |         |      |       |
+-----------+---+---+-----+-----+----------+---------+------+-------+
| Math      | 1 | 0 | \|  | \|  | \_\_\_\_ | \       | \_   | \| \| |
|           |  |  | \|  | \|  | \_\_\_\_ | _\_\_\_ | \_\_ | \| \| |
|           |   |   | \|  | \|  | \_\_\_\_ | \_\_\_\ | \_\_ |       |
|           |   |   |     |     |          | _\_\_\_ | \_\_ |       |
|           |   |   | Mo  | Y   |          |         |      |       |
|           |   |   | nth | ear |          |         |      |       |
+-----------+---+---+-----+-----+----------+---------+------+-------+
| Reading   | 1 | 0 | \|  | \|  | \_\_\_\_ | \       | \_   | \| \| |
|           |  |  | \|  | \|  | \_\_\_\_ | _\_\_\_ | \_\_ | \| \| |
|           |   |   | \|  | \|  | \_\_\_\_ | \_\_\_\ | \_\_ |       |
|           |   |   |     |     |          | _\_\_\_ | \_\_ |       |
|           |   |   | Mo  | Y   |          |         |      |       |
|           |   |   | nth | ear |          |         |      |       |
+-----------+---+---+-----+-----+----------+---------+------+-------+
| b\.       |   |   |     |     |          |         |      |       |
| **10^th^  |   |   |     |     |          |         |      |       |
| Grade**   |   |   |     |     |          |         |      |       |
+-----------+---+---+-----+-----+----------+---------+------+-------+
| Math      | 1 | 0 | \|  | \|  | \_\_\_\_ | \       | \_   | \| \| |
|           |  |  | \|  | \|  | \_\_\_\_ | _\_\_\_ | \_\_ | \| \| |
|           |   |   | \|  | \|  | \_\_\_\_ | \_\_\_\ | \_\_ |       |
|           |   |   |     |     |          | _\_\_\_ | \_\_ |       |
|           |   |   | Mo  | Y   |          |         |      |       |
|           |   |   | nth | ear |          |         |      |       |
+-----------+---+---+-----+-----+----------+---------+------+-------+
| Reading   | 1 | 0 | \|  | \|  | \_\_\_\_ | \       | \_   | \| \| |
|           |  |  | \|  | \|  | \_\_\_\_ | _\_\_\_ | \_\_ | \| \| |
|           |   |   | \|  | \|  | \_\_\_\_ | \_\_\_\ | \_\_ |       |
|           |   |   |     |     |          | _\_\_\_ | \_\_ |       |
|           |   |   | Mo  | Y   |          |         |      |       |
|           |   |   | nth | ear |          |         |      |       |
+-----------+---+---+-----+-----+----------+---------+------+-------+
| c\.       |   |   |     |     |          |         |      |       |
| **11^th^  |   |   |     |     |          |         |      |       |
| Grade**   |   |   |     |     |          |         |      |       |
+-----------+---+---+-----+-----+----------+---------+------+-------+
| Math      | 1 | 0 | \|  | \|  | \_\_\_\_ | \       | \_   | \| \| |
|           |  |  | \|  | \|  | \_\_\_\_ | _\_\_\_ | \_\_ | \| \| |
|           |   |   | \|  | \|  | \_\_\_\_ | \_\_\_\ | \_\_ |       |
|           |   |   |     |     |          | _\_\_\_ | \_\_ |       |
|           |   |   | Mo  | Y   |          |         |      |       |
|           |   |   | nth | ear |          |         |      |       |
+-----------+---+---+-----+-----+----------+---------+------+-------+
| Reading   | 1 | 0 | \|  | \|  | \_\_\_\_ | \       | \_   | \| \| |
|           |  |  | \|  | \|  | \_\_\_\_ | _\_\_\_ | \_\_ | \| \| |
|           |   |   | \|  | \|  | \_\_\_\_ | \_\_\_\ | \_\_ |       |
|           |   |   |     |     |          | _\_\_\_ | \_\_ |       |
|           |   |   | Mo  | Y   |          |         |      |       |
|           |   |   | nth | ear |          |         |      |       |
+-----------+---+---+-----+-----+----------+---------+------+-------+
| d\.       |   |   |     |     |          |         |      |       |
| **12^th^  |   |   |     |     |          |         |      |       |
| Grade**   |   |   |     |     |          |         |      |       |
+-----------+---+---+-----+-----+----------+---------+------+-------+
| Math      | 1 | 0 | \|  | \|  | \_\_\_\_ | \       | \_   | \| \| |
|           |  |  | \|  | \|  | \_\_\_\_ | _\_\_\_ | \_\_ | \| \| |
|           |   |   | \|  | \|  | \_\_\_\_ | \_\_\_\ | \_\_ |       |
|           |   |   |     |     |          | _\_\_\_ | \_\_ |       |
|           |   |   | Mo  | Y   |          |         |      |       |
|           |   |   | nth | ear |          |         |      |       |
+-----------+---+---+-----+-----+----------+---------+------+-------+
| Reading   | 1 | 0 | \|  | \|  | \_\_\_\_ | \       | \_   | \| \| |
|           |  |  | \|  | \|  | \_\_\_\_ | _\_\_\_ | \_\_ | \| \| |
|           |   |   | \|  | \|  | \_\_\_\_ | \_\_\_\ | \_\_ |       |
|           |   |   |     |     |          | _\_\_\_ | \_\_ |       |
|           |   |   | Mo  | Y   |          |         |      |       |
|           |   |   | nth | ear |          |         |      |       |
+-----------+---+---+-----+-----+----------+---------+------+-------+