21st CCLC 2015

Annual Performance Report: 

Paper Forms for Centers

Public Burden Statement:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of

information unless such collection displays a valid OMB control number. Public reporting burden for this collection 

of information is estimated to average 24 hours per response, including time for reviewing instructions, searching 

existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of 

information. The obligation to respond to this collection is required to obtain or retain benefit (20 U.S. Code 

§§7171). Send comments regarding the burden estimate or any other aspect of this collection of information, 

including suggestions for reducing this burden, to the U.S. Department of Education, 21stCCLC Program, AITQ, 

Office of Elementary and Secondary Education, U.S. Department of Education, 400 Maryland Avenue, S.W., LBJ/FB-6, 

3E210, Washington, D.C. 20202-6200 or email ICDocketMgr@ed.gov and reference the OMB Control Number 

1810-0668. Note: Please do not return the completed APR to this address.

 

March 2015

U.S. Department of Education

21st Century Community Learning Centers (21st CCLC)
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
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers—1

Introduction

This is a paper version of the center-level forms for the 21st Century Community Learning 

Centers (21st CCLC) 2015 Annual Performance Report (APR). Any questions may be directed 

to the 21st CCLC APR Help Desk at 21stcclc_apr@thetactilegroup.com. 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 to contract personnel.

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 2014 and/or the entire span 

of the 2014–15 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 2014–15 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 
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers—2

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.
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers—3

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 non-school-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 non-school-day staff with some or no college

10. Other
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers—4

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. 
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers—5

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 2014–15 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 online, 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 
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers—6

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. 
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers—7

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.
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers—8

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 

learning programs

Enrichment activities expand on students’ learning in 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 

Limited-Englishproficient students

These activities specifically target students with limited English proficiency and 

are designed to further enhance students’ ability to utilize the English language.

Activities that target 

truant, expelled, or 

suspended students

These activities specifically target truant, expelled, or suspended students and 

are designed to reengage 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 service-learning 

programs

These activities performed by students are 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 violenceprevention, 

counseling, and 

character-education 

programs

These activities are designed to prevent youths from engaging in high-risk 

behaviors, including the use of drugs and alcohol; amelioration of the causal 

factors 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 hours

The 21st CCLC funds are used specifically to expand, 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.
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers—9

Activity Type Definition and Description

Programs promoting 

parental 

involvement 

These activities specifically target adult family members of youths participating 

in the 21st CCLC program and are designed to more actively engage 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 

promote family 

literacy

These activities specifically target adult family members of youths participating 

in the 21st CCLC 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 

activities

These activities are not academic in nature, but rather 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 

educational services

Supplemental Educational Services are a component of Title I of the Elementary 

and Secondary Education Act (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 

promote youth 

leadership 

These activities intentionally promote youth leadership through skill 

development and the provision of formal leadership opportunities 

designed to foster and inspire leadership aptitude in participating youth. 
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers—10

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 either 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. 
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers—11

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 2014 mathematics and reading/language arts grades with the students’ last set of spring 

2015 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 2014–15 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 2014 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 (ExcellentSatisfactory-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). 
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers—12

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 2013-14 state assessment results with 

2014–15 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 2014–15 school 

year that represented a higher level of achievement than the category they scored in when 

taking the assessment during the 2013–14 school year. For example, you would count students 

as having improved if they scored in the basic category in 2013–14 and improved to proficient 

when taking the 2014–15 assessment. A similar approach should be taken when identifying the 

number of students who witnessed a decline in performance. 
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers—13

Teacher Survey (Form F-4)

In the table on Form F-4 (see pages 55-56), record the results from the 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 2014 should not be included 

in the reporting of teacher survey results.
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers—14

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 2015 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. 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 contracted personnel.
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form A—15

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? ____________________________
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form B—16

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 non-school-day staff 

with a college degree or higher

Other non-school-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
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form B—17

Type of Staff Member

Summer

Paid Volunteer

School-day teachers (including former and substitute teachers)

Center administrators and coordinators

Youth development workers or other non-school-day staff 

with a college degree or higher

Other non-school-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 21st 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: ________________________
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form C-1—18

Form C-1: School Year Activities by Category

For instructions, see page 5.

________________________________ ________________________________

Grantee Name Center Name

EXAMPLE

Activity or Service

Typical 

Number 

of Hours 

Per Week

Typically, How Often Was This Type of 

Activity Provided?

Was This 

Type of 

Activity 

Provided 

Across the 

Whole 

School 

Year?

4–5 

Times a 

Week

1–3 

Times a 

Week

1–3 

Times a 

Month

Less 

Than 

Once a 

Month

1. Academic 

improvement or 

remediation 

programs 

10 x Yes

Activity or Service

Typical 

Number 

of Hours 

Per Week

Typically, How Often Was This Type of

Activity Provided?

Was This 

Type of 

Activity 

Provided 

Across the 

Whole 

School 

Year?

4–5 

Times a 

Week

1–3 

Times a 

Week

1–3 

Times a 

Month

Less 

Than 

Once a 

Month

Activities Targeting Student Attendees

1. Academic 

enrichment 

learning programs

2. Tutoring 

3. Homework help 

4. Mentoring
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form C-1—19

Activity or Service

Typical 

Number 

of Hours 

Per Week

Typically, How Often Was This Type of 

Activity Provided?

Was This 

Type of 

Activity 

Provided 

Across the 

Whole 

School 

Year?

4–5 

Times a 

Week

1–3 

Times a 

Week

1–3 

Times a 

Month

Less 

Than 

Once 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: ___________

_________________

_________________
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form C-1—20

Activity or Service

Typical 

Number 

of Hours 

Per Week

Typically, How Often Was This Type of 

Activity Provided?

Was This 

Type of 

Activity 

Provided 

Across the 

Whole 

School 

Year?

4–5 

Times a 

Week

1–3 

Times a 

Week

1–3 

Times a 

Month

Less 

Than 

Once 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.
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form C-2—21

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

For instructions, see page 5.

Activity or Service

Typical 

Number 

of Hours 

Per Week

Typically, How Often Was This Type of 

Activity Provided?

Was This 

Type of 

Activity 

Provided 

Across the 

Whole 

School 

Year?

4–5 

Times a 

Week

1–3 

Times a 

Week

1–3 

Times a 

Month

Less 

Than 

Once 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-Englishproficient students

3. Students who 

have been truant, 

suspended, or expelled

4. Students with special 

needs or disabilities

5. Other: ____________

__________________

__________________
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form C-3—22

Form C-3: School Year Activities by Subject Area

For instructions, see page 5.

Activity or Service

Typical 

Number 

of Hours 

Per Week

Typically, How Often Was This Type of 

Activity Provided?

Was This 

Type of 

Activity 

Provided 

Across the 

Whole 

School 

Year?

4–5 

Times a 

Week

1–3 

Times a 

Week

1–3 

Times a 

Month

Less 

Than 

Once 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 nutritionrelated 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.
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form C-4—23

Form C-4: Summer Activities by Category

For instructions, see page 5.

Activity or Service

Typical 

Number 

of Hours 

Per Week

Typically, How Often Was This Type of 

Activity Provided?

Was This 

Type of 

Activity 

Provided 

Across the 

Whole 

School 

Year?

4–5 

Times a 

Week

1–3 

Times a 

Week

1–3 

Times a 

Month

Less 

Than 

Once 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
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form C-4—24

Activity or Service

Typical 

Number 

of Hours 

Per Week

Typically, How Often Was This Type of 

Activity Provided?

Was This 

Type of 

Activity 

Provided 

Across the 

Whole 

School 

Year?

4–5 

Times a 

Week

1–3 

Times a 

Week

1–3 

Times a 

Month

Less 

Than 

Once 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.
21st CCLC 20 Annual Performance Report: Paper Forms for Centers: Form C-5—25

Form C-5: Summer Activities by Student Populations Targeted

For instructions, see page 5.

Activity or Service

Typical 

Number 

of Hours 

Per Week

Typically, How Often Was This Type of 

Activity Provided?

Was This 

Type of 

Activity 

Provided 

Across the 

Whole 

School 

Year?

4–5 

Times a 

Week

1–3 

Times a 

Week

1–3 

Times a 

Month

Less 

Than 

Once 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-Englishproficient students

3. Students who 

have been truant, 

suspended, or expelled

4. Students with special 

needs or disabilities

5. Other: ____________

__________________

__________________
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form C-6—26

Form C-6: Summer Activities by Subject Area

For instructions, see page 5.

Activity or Service

Typical 

Number 

of Hours 

Per Week

Typically, How Often Was This Type of 

Activity Provided?

Was This 

Type of 

Activity 

Provided 

Across the 

Whole 

School 

Year?

4–5 

Times a 

Week

1–3 

Times a 

Week

1–3 

Times a 

Month

Less 

Than 

Once 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 nutritionrelated 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.
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form C-7—27

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.

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
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form C-7—28

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: __________________________________________________________________
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form C-7—29

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
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form C-7—30

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.

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form D—31

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.
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form D—32

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.

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form D—33

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 

School 

Active

Percentage of Center Participants

Y N 1–25% 26–50% 51–75% 76%+ N/A

Wright Elementary X X

School Year

School Name

Feeder 

School 

Active

Percentage of Center Participants

Y N 1–25% 26–50% 51–75% 76%+ N/A
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form D—34

Summer

School Name

Feeder 

School 

Active

Percentage of Center Participants

Y N 1–25% 26–50% 51–75% 76%+ N/A
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form E—35

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 Served All Adults 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
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form E—36

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 Attendees Regular Student 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 Attendees Regular Student Attendees

Male

Female

Data not provided

Student Characteristics—Special Services or Programs

Special Service or Program - Limited 

English Proficiency Total Student Attendees Regular Student Attendees

Students with limited English proficiency

Students for whom limited English 

proficiency status could not be determined.
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form E—37

Student Characteristics—Special Services or Programs

Special Service or Program - Free or 

Reduced-Price Lunch Total Student Attendees Regular Student 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 - Special 

Needs or Disabilities Total Student Attendees Regular Student Attendees

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 Attendees Regular Student Attendees

Prekindergarten

Kindergarten

First grade

Second grade

Third grade

Fourth grade

Fifth grade

Sixth grade

Seventh grade

Eighth grade

Ninth grade

10th grade

11th grade

12th grade

Unknown
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form F—38

Form F: Impact Categories

For instructions, see page 11. 

________________________________ ________________________________

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
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form F-1a—39

Form F-1a: Grades (Gradation)

For instructions, see pages 11. 

________________________________ ________________________________

Grantee Name Center Name

Grades Data Overview

Indicate the number of regular attendees for which:

Number of 

Regular 

Attendees

You have both mathematics and reading/language arts grades for fall 2014 and 

spring 2015. 

You have only mathematics grades for fall 2014 and spring 2015. 

You have only reading/language arts grades for fall 2014 and spring 2015. 

You have neither mathematics nor reading/language arts grades for fall 2014 and 

spring 2015. 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 who: 

Regular Attendees by 

Number of Days Attended

30–59 Days 60–89 Days 90+ 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.
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form F-1a—40

Indicate the number of regular attendees who: 

Regular Attendees by 

Number of Days Attended

30–59 Days 60–89 Days 90+ 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.
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form F-1b—41

Form F-1b: Grades (Combined)

For instructions, see pages 11. 

________________________________ ________________________________

Grantee Name Center Name

Grades Data Overview

Indicate the number of regular attendees for which:

Number of 

Regular 

Attendees

You have both mathematics and reading/language arts grades for fall 2014 and 

spring 2015. 

You have only mathematics grades for fall 2014 and spring 2015. 

You have only reading/language arts grades for fall 2014 and spring 2015. 

You have neither mathematics nor reading/language arts grades for fall 2014 and 

spring 2015. 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 who: 

Regular Attendees 

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.
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form F-1b—42

Reading/Language Arts Grades

Indicate the number of regular attendees who: 

Regular Attendees 

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.
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form F-2—43

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

For instructions, see page 10. 

________________________________ ________________________________

Grantee Name Center Name

State Assessment Proficiency Results—Overview

Indicate the number of regular attendees for which: 

Regular Attendees 

You have both mathematics and reading/language arts 

results for the state proficiency test administered during 

the 2014–15 school year. 

You have only mathematics results for the state proficiency 

test administered during the 2014–15 school year. 

You have only reading/language arts results for the state 

proficiency test administered during the 2014–15 school 

year. 

You have neither mathematics nor reading/language arts 

results for the state proficiency test administered during the 

2014–15 school year. 

Totals

State Assessment Proficiency Results—Mathematics Performance

Indicate the number of regular 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.)

Regular Attendees 

Total (Mathematics)
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form F-2—44

State Assessment Proficiency Results—Reading/Language Arts Performance

Indicate the number of regular 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.)

Regular Attendees 

Total (Reading/Language Arts)
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form F-3a—45

Form F-3a: State Assessment—Cross-Year 

(Disaggregated, Gradation)

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 2013–14 and 2014–15 school years. 

You have only mathematics assessment results for proficiency tests administered 

during the 2013–14 and 2014–15 school years. 

You have only reading/language arts assessment results for proficiency tests 

administered during the 2013–14 and 2014–15 school years. 

You have neither mathematics nor reading/language arts assessment results for 

proficiency tests administered during the 2013–14 and 2014–15 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.

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.

Example

1. Advanced

2. Proficient

3. Basic

4.

5.
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form F-3a—46

Mathematics Proficiency Test Results—Changes in Performance Level

Indicate the number of regular attendees in each level 

who: 

Regular Attendees by 

Number of Days Attended

30–59 Days 60–89 Days 90+ Days

Level 1 (Highest) 

Witnessed no change in performance level on the proficiency 

test administered during the 2014–15 school year. 

Witnessed a decrease in performance level on the proficiency 

test administered during the 2014–15 school year. 

Total for Level 1

Level 2

Witnessed an increase in performance level on the 

proficiency test administered during the 2014–15

school year. 

Witnessed no change in performance level on the proficiency 

test administered during the 2014–15 school year. 

Witnessed a decrease in performance level on the proficiency 

test administered during the 2014–15 school year. 

Total for Level 2

Level 3

Witnessed an increase in performance level on the 

proficiency test administered during the 2014–15

school year. 

Witnessed no change in performance level on the proficiency 

test administered during the 2014–15 school year. 

Witnessed a decrease in performance level on the proficiency 

test administered during the 2014–15 school year. 

Total for Level 3

Level 4

Witnessed an increase in performance level on the 

proficiency test administered during the 2014–15

school year. 

Witnessed no change in performance level on the proficiency 

test administered during the 2014–15 school year. 

Witnessed a decrease in performance level on the proficiency 

test administered during the 2014–15 school year. 

Total for Level 4
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form F-3a—47

Indicate the number of regular attendees in each level 

who: 

Regular Attendees by 

Number of Days Attended

30–59 Days 60–89 Days 90+ Days

Level 5 (Lowest)

Witnessed an increase in performance level on the 

proficiency test administered during the 2014–15

school year. 

Witnessed no change in performance level on the proficiency 

test administered during the 2014–15 school year. 

Total for Level 5

Total (Mathematics)

Reading/Language Arts Proficiency Test Results—Changes in Performance 

Level

Indicate the number of regular attendees in each level 

who: 

Regular Attendees by 

Number of Days Attended

30–59 Days 60–89 Days 90+ Days

Level 1 (Highest)

Witnessed no change in performance level on the proficiency 

test administered during the 2014–15 school year. 

Witnessed a decrease in performance level on the proficiency 

test administered during the 2014–15 school year. 

Total for Level 1

Level 2

Witnessed an increase in performance level on the 

proficiency test administered during the 2014–15

school year. 

Witnessed no change in performance level on the proficiency 

test administered during the 2014–15 school year. 

Witnessed a decrease in performance level on the proficiency 

test administered during the 2014–15 school year. 

Total for Level 2

Level 3

Witnessed an increase in performance level on the 

proficiency test administered during the 2014–15

school year. 

Witnessed no change in performance level on the proficiency 

test administered during the 2014–15 school year. 

Witnessed a decrease in performance level on the proficiency 

test administered during the 2014–15 school year. 

Total for Level 3
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form F-3a—48

Indicate the number of regular attendees in each level 

who: 

Regular Attendees by 

Number of Days Attended

30–59 Days 60–89 Days 90+ Days

Level 4

Witnessed an increase in performance level on the 

proficiency test administered during the 2014–15

school year. 

Witnessed no change in performance level on the proficiency 

test administered during the 2014–15 school year. 

Witnessed a decrease in performance level on the proficiency 

test administered during the 2014–15 school year. 

Total for Level 4

Level 5 (Lowest)

Witnessed an increase in performance level on the 

proficiency test administered during the 2014–15

school year. 

Witnessed no change in performance level on the proficiency 

test administered during the 2014–15 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 who: 

Number of 

Regular 

Attendees 

Number of regular attendees who witnessed a jump from a category two levels below 

proficient to the proficient 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 proficient performance level or above on the proficiency test.
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form F-3a—49

Reading/Language Arts Proficiency Test Results—Significant Changes in 

Performance Level

Indicate the number of regular attendees in each level who: 

Number of 

Regular 

Attendees 

Number of regular attendees who witnessed a jump from a category two levels below 

proficient to the proficient 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 proficient performance level or above on the proficiency test.
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form F-3b—50

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 2013–14 and 2014–15 school years. 

You have only mathematics assessment results for proficiency tests administered 

during the 2013–14 and 2014–15 school years. 

You have only reading/language arts assessment results for proficiency tests 

administered during the 2013–14 and 2014–15 school years. 

You have neither mathematics nor reading/language arts assessment results for 

proficiency tests administered during the 2013–14 and 2014–15 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.

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.

Example

1. Advanced

2. Proficient

3. Basic

4.

5.
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form F-3b—51

Mathematics Proficiency Test Results—Changes in Performance Level

Indicate the number of regular attendees in each level 

who: 

Regular Attendees 

Level 1 (Highest) 

Witnessed no change in performance level on the proficiency 

test administered during the 2014–15 school year. 

Witnessed a decrease in performance level on the proficiency 

test administered during the 2014–15 school year. 

Total for Level 1

Level 2

Witnessed an increase in performance level on the 

proficiency test administered during the 2014–15

school year. 

Witnessed no change in performance level on the proficiency 

test administered during the 2014–15 school year. 

Witnessed a decrease in performance level on the proficiency 

test administered during the 2014–15 school year. 

Total for Level 2

Level 3

Witnessed an increase in performance level on the 

proficiency test administered during the 2014–15

school year. 

Witnessed no change in performance level on the proficiency 

test administered during the 2014–15 school year. 

Witnessed a decrease in performance level on the proficiency 

test administered during the 2014–15 school year. 

Total for Level 3

Level 4

Witnessed an increase in performance level on the 

proficiency test administered during the 2014–15

school year. 

Witnessed no change in performance level on the proficiency 

test administered during the 2014–15 school year. 

Witnessed a decrease in performance level on the proficiency 

test administered during the 2014–15 school year. 

Total for Level 4
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form F-3b—52

Indicate the number of regular attendees in each level 

who: 

Regular Attendees 

Level 5 (Lowest)

Witnessed an increase in performance level on the 

proficiency test administered during the 2014–15

school year. 

Witnessed no change in performance level on the proficiency 

test administered during the 2014–15 school year. 

Total for Level 5

Total (Mathematics)

Reading/Language Arts Proficiency Test Results—Changes in Performance 

Level

Indicate the number of regular attendees in each level 

who: 

Regular Attendees 

Level 1 (Highest)

Witnessed no change in performance level on the proficiency 

test administered during the 2014–15 school year. 

Witnessed a decrease in performance level on the proficiency 

test administered during the 2014–15 school year. 

Total for Level 1

Level 2

Witnessed an increase in performance level on the 

proficiency test administered during the 2014–15

school year. 

Witnessed no change in performance level on the proficiency 

test administered during the 2014–15 school year. 

Witnessed a decrease in performance level on the proficiency 

test administered during the 2014–15 school year. 

Total for Level 2

Level 3

Witnessed an increase in performance level on the 

proficiency test administered during the 2014–15

school year. 

Witnessed no change in performance level on the proficiency 

test administered during the 2014–15 school year. 

Witnessed a decrease in performance level on the proficiency 

test administered during the 2014–15 school year. 

Total for Level 3
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form F-3b—53

Indicate the number of regular attendees in each level 

who: 

Regular Attendees

Level 4

Witnessed an increase in performance level on the 

proficiency test administered during the 2014–15

school year. 

Witnessed no change in performance level on the proficiency 

test administered during the 2014–15 school year. 

Witnessed a decrease in performance level on the proficiency 

test administered during the 2014–15 school year. 

Total for Level 4

Level 5 (Lowest)

Witnessed an increase in performance level on the 

proficiency test administered during the 2014–15

school year. 

Witnessed no change in performance level on the proficiency 

test administered during the 2014–15 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 who: 

Number of 

Regular 

Attendees 

Number of regular attendees who witnessed a jump from a category two levels below 

proficient to the proficient 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 proficient performance level or above on the proficiency test.
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form F-3b—54

Reading/Language Arts Proficiency Test Results—Significant Changes in 

Performance Level

Indicate the number of regular attendees in each level who: 

Number of 

Regular 

Attendees 

Number of regular attendees who witnessed a jump from a category two levels below 

proficient to the proficient 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 proficient performance level or above on the proficiency test.
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form F-4—55

Form F-4: Teacher Survey

For instructions, see pages 13. 

________________________________ ________________________________

Grantee Name Center Name

In the following table, record the results from the 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 2014 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.
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form F-4—56

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 Behaviors 

on Which Teachers 

Reported:

Number of Regular Attendees

Did Not 

Need to 

Improve

Acceptable Level of Functioning Not Demonstrated Early in School Year—

Improvement Warranted 

Significant 

Improvement

Moderate 

Improvement

Slight 

Improvement

No 

Change

Slight 

Decline

Moderate 

Decline

Significant 

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
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form G—57

Form G: Comments

For instructions, see page 14.

________________________________ ________________________________

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.

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________
21st CCLC 2015 Annual Performance Report: Paper Forms for Centers: Form H—58

Form H: Confirmation Page

For instructions, see page 14.

________________________________ ________________________________

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