# 21st CCLC 20 **1 5** 

**Annual Performance Report :**  **Paper Forms for Centers Public Burden Statem**  **ent:** According to the Paperwork Reduction Act of 1 995, 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 comple ting and reviewing the collection of information. T he 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 - 62 00 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 **201 5**  **U.S. Departm ent 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 P age (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 ................................ ................................ ................................ ....................... 35Form 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 ................................ ................................ ................................ ........... 5821st CCLC 2015 Annual Performance Report: Paper Forms for Centers

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

L earning Centers (21st CCL C) 20 1 5 Annual Performance Report (APR) . An y questions may be directed to the 21st CCL C 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 alway s 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 ente red at that level or sent to contract personnel . Provide all information to the best of your abili ty . 

## Instructions **Operations (Form A)** Complete the table on Form A (see page 15) b y identifying the ty pical 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 CCL C

– funded activiti es during the entire span of the summer of 20 14 and/or the entire span of the 20 14

– 1 5 school ye ar. Centers operating only for a portion of the summer or onl y for a portion of the school year (i.e., for onl y 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 onl y report the ty pical number of hours the center spent actually operating programs that served participating students or adul t 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

defin ition, a 21st CCL C center should be characterized by defined hours of operation that should be relativel y consistent across the school year or summer (e.g., 3

– 6 p.m., Monday

– Thursday). Special, nonrecurring, or episodic events, field trips, or programmin g would not be considered ty pical 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 b y the c enter. In some instances, centers may be characterized by

recurring periods of operation or programming that take place on an ongoing basis but less frequentl y than weekl y. For example, a center may

be open on the fourth Saturday of every month in additio n to a regular weekl y schedule of 3:00 p.m. to 6:00 p.m. Monday through Thursday . In this case, in order to report on ty pical hours of operation, the center may want to consider adding up the total hours of operation for a t ypical month for the timeframe i n question (in this case Weekends during the school year) and dividing b y 4.3 to obtain a weekl y average that can be used to report on ty pical hours of21st CCLC 2015 Annual Performance Report: Paper Forms for Centers

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operation for that timeframe. A similar approach can be taken to reporting on the ty pical number of day s a center was t ypically open per week. Note also that one of the categories is for activities that take place during the school day . The 21st CCL C 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, holiday s, summer). However, activities targeting prekindergarten children and adult family

members may

take place during regular school hours since these times may b e 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 day s per week that the center was open during the school year and/or summer.21st CCLC 2015 Annual Performance Report: Paper Forms for Centers

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### 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 regularl y staffi ng 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 teac hers 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 regularl y 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 onl y worked at special, nonrecurring, or episodic events, field trips, or programming should not be counted in this sec tion of the APR. Staff not directl y funded by the state administered 21st CCL C grant should also be counted if they regularl y staffed activities provided to 21st CCL C participants. Please also note that a single staff person can be counted in both columns related to the school ye ar 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 t yp e category . When an individual staff member can be classified in more than one category , the following hierarch y should be employed in determining in what staff ty pe 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 pai d staff or volunteer staff member who: I s not certified as a school - day teacher; Is not employed during the school day

in some other capacit y (e.g., librarian, school counselor) by one or more of the feeder schools and/or districts associated with the 21st CCL C; 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, c lergy) 9. Other non - school - day staff with some or no college 10. Other21st CCLC 2015 Annual Performance Report: Paper Forms for Centers

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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 thi s category of staff appears higher in the above - outlined hierarch y. 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 o n Form B, indicate the number of paid staff regularl y staffing the center during the reporting period that were not funded directl y b y the 21st CCL C grant. Only count paid staff that received no compensation from funds associated with the 21st CCL C grant. On the second line below the tables, report the number of paid staff who regularl y 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

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### Activities (Forms C **- 1**  **– C**  **- 7)**  For APR reporting purposes, an activit y is defined as a discrete program offering that took place according to a defined schedule (e.g., Tuesday s and Thursday s from 4:00 to 5:00 p.m.) on a sustained and ongoing basis during the reporting period. Normall y, the a ctivities 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 tut oring activity . Center activities supported by a funding source other than 21st CCL C but attended by 21st CCL C participants should also be reported on as well. Activity - related information needs to be supplied separatel y for activities undertaken during th e 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 discr etion 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 newl y 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 b y adult fam ily

members. Please utilize the one that is most reflective of activit y participants. **Submitting Aggregated Activities Information** This section asks for the following three types of information about the activities provided at this center during the sch ool 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 b y the activities provided at this center For each of thes e three way s 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 typ e was ty picall y 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 studying21st CCLC 2015 Annual Performance Report: Paper Forms for Centers

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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 o therwise 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 specificall y to the mode of service delivery (e.g., mentoring, tutoring, community service/service learning, etc.). The table is split into two ty

pes 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 t ypically are dedicated to an activi ty 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 activit y 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 l evel, 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 ty pical 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 respon dent. For example, if five hours per week typically are dedicated to an activity that specificall y targets students who are habitually truant and are performing below grade level, five hours should be reported for both activity ty pes in the table. **The thir d 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 ty pical number of hours per week activities addressing a particular subject area were provided during the school ye ar, a given activit y **should be counted across each of the categories** in which the activit y can be classified b y the respondent. For example, if five hours per week typically are dedicated to an activity that specificall y addressed mathematics and science, five hours should be reported for both activity

t ypes in the table.21st CCLC 2015 Annual Performance Report: Paper Forms for Centers

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**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 ty pical number of hours per week this activity was provided should be reported as 2 (i.e., 2 day s 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 CCL Cs 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 full y to parents, administrators, and other stakeholders. If a center has not fully articulated the rationale behind wh y 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

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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 studen ts, but they also impart knowledge. They allow the participants to apply knowledge and skills stressed in school to real - life experiences. Activities for Limited - English proficient 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 - an d violence prevention, 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. Expan ded 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

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**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 f amily 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 academi c 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 - secto r 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

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### Feeder Schools ( **Form D)** A feeder school is an y s chool 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 an y 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. Incompleting 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 . Incompleting the table, also consider all students served b y the center for the ti me 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. 

### Attenda **nce (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) b y indicating the number of participants (students and adults) served during the reporting period, the characteristics associated with the student population served b y 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 CCL C 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 an y student characteristic that is l ess 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

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### Impact Categories (Form F) The Impact Categories section is intended to measure what effects the program has had on participants (specific all y 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 . I f you do not know which categories to complete, contact your state lia ison 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 r egular attendees, compare the student s’ 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 meet ing 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 onl y have either mathematics or readi ng/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); other wise, 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 b y the center in the reporting period. If you are using a 100 - point scale, a half - grade change is a decrease or incre ase of five points. If you are using an A

–F scale, a half - grade change is any

decrease or increase in the letter grade (e.g., A to A - is a decrease and C+ to B - is an increase). If you are using an E - S - U (Excellent Satisfactory - Unsatisfactory) or similar non - A

–F letter - grade scale, a half - grade change is a decrease or increase from one letter grade to another (e.g., S to E is an increase and S to U is a decrease).21st CCLC 2015 Annual Performance Report: Paper Forms for Centers

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### 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 catego ries. 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 b y 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 sec tions of the state assessment on the tables on Form 2. It is realized that most states currentl y 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 b y this center in the reporting period. 

### State Assessment**— Cross**  **- Year Disaggregated (Forms F**  **- 3a and F**  **- 3b)**  These sections require yo u to compare a student’s 20 13 - 1 4 state assessment results with 201 4

– 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 onl y 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 yo u 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 attendee s 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 tot al of the cells in the table should be equal to the number of regular attendees you identified as being served b y 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 ye ar that represented a higher level of achievement than the category they scored in when taking the assessment during the 201 3

– 1 4 school year. For example, you would count stu dents as having improved if they scored in the basic category in 201 3

– 1 4 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

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### Te **acher 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 r eport 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 day s 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 CCL C program staff, it is preferable to survey teachers who are not. There should be one te acher 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 onl y in center - related activities during summer 2014 should not be included in the r eporting of teacher survey results.21st CCLC 2015 Annual Performance Report: Paper Forms for Centers

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### 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 an y s ections 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 comm ents 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 b y contacting your SEA liaison. Please review the associated forms to ensure that you have included all necessary information. If you have not completed an y 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 sy stem or send th e paper cop y on to contracted personnel .21st CCLC 20 15 Annual Performance Report: Paper Forms for Centers: Form A

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## 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 ye ar **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?

___________________________ Wh at was the ty

pical number of day s per week the center was open during the school year?

___________________________ What was the ty

pical number of day s per week the center was open during the summer?

____________________________21st CCLC 20 15 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

________________________________________ Totals2 1st CCLC 20 15 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 regularl y staffing the center during the reporting period that were not funded directly by the 21 st CCLC grant:

________________________ The number of paid staff that regularl y 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 20 15 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. Mentoring21st CCLC 20 15 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 20 15 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 th ese 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 15 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 - English proficient students 3. Students who have been truant, suspended, or expelled 4. Students with special needs or disabilities 5. Other: ____________

__________________

__________________21st CCLC 20 15 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 nutrition related activities 9. Other: _____________

__________________ 

### Activity **Description (Optional)** If you would like, provide a description of one of the school - ye ar activities here. This section is optional and is not required to complete your APR.21st CCLC 20 15 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 services21st CCLC 20 15 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. Examp les 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 - English proficient students 3. Students who have been truant, suspended, or expelled 4. Students with special needs or disabilities 5. Other: ____________

__________________

__________________21st CCLC 20 15 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 nutrition related activities 9. Other:

_____________

__________________ 

### Activity Description (Optional) If you would like, provide a description of one of the summer activities here. This section is optional and is not required to complete your APR.21st CCLC 20 15 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 exampl e: 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 PPI CS. 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 Tue sday 's and Thursday 's from 4:00 to 5:00. These should be entered as different activities given that they were scheduled differentl y during the course of the week and ran for different lengths during the reporting period. If you are concerned that the appli cation 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 PPI CS Help Desk at 21stcclc@contact.learningpt.org . Activity Name: _________________________________________________________________ Participant Ty

pe: 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 Summer21st CCLC 20 15 Annual Performance Report: Paper Forms for Centers: Form C - 7

—28



### Activity Categories Id entify 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 Expande d 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 Communi ty

service or service learning Activity to promote youth leadership Other: __________________________________________________________________21st CCLC 20 15 Annual Performance Report: Paper Forms for Centers: Form C - 7

—29



### St **udent Populations Targeted by the Activity** Indicate whether the activity specificall y 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 Id entify whether an academic subject area was addressed during the provision of the activity . Check all that appl y. 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 Ty pical number of day s provided per week Ty pical number of hours provided per day21st CCLC 20 15 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 concurrentl y or at multiple times to different groups of participants during the course of a week. If either of these circumstances were true for thi s 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 co ncurrently 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 Tuesday s, 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 Tuesday s to students in grade 4 and Thursday s to students in grade 5)? Was this activity

t ypically offered less frequentl y than weekl y during the period it was offered (for example, was the activity provided every

other Saturday

or one Saturday

a month)? Yes, this activity

t ypically was offered 1

– 3 times a month. Yes, this activity

t ypically was offered less than once a month. No, this activity

ty picall y was offered every week during the period it was offered. 

### Number of Participants Indicate the typical number of participants (students or adults) served b y this activity per day . Do not include instructors, volunteer tutors, and other staff. Only those being served should be i ncluded. 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 20 15 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 i n 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 lik el y 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 Id entify 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 20 15 Annual Performance Report: Paper Forms for Centers: Form D

— 32 Total number of weeks provided Ty pical number of day s provided per week Ty pical number of hours provided per day It 's also common for a given activity to be offered in multiple sessions concurrentl y 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 Tuesday s, with one session for adult family members of students in grade 4 and a second session for adult famil y 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 Tuesday s to adult famil y members of students in grade 4 and Thursd ay s to adult family members of students in grade 5)? Was this activity

offered less than weekl y during the period it was offered (e.g., was the activity provided every

other Saturday

or one Saturday

a month)? Yes, this activity

t ypically was offered 1

– 3 times a month. Yes, this activity

t ypically was offered less than once a month. No, this activity

ty picall y was offered every week during the period it was offered. 

### Number of Participants Indicate the typical number of participants (students or adults) served b y 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 20 15 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 20 15 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 20 15 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 ye ar only , the summer onl y, or both. If your center keeps an attendance list for each activity and people can attend more than one activity , count attendees onl y 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 c enter 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, o r 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 day s during the reporting period, and (2) the number who attended 30 day s or more during the reporting period. Any student who attended 30 day s 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 Total21st CCLC 20 15 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

describ es 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 appl y. 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 al l 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 20 15 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 10 th grade 11 th grade 12 th grade Unknown21st CCLC 20 15 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 ye ar’s APR. The specific forms you need to fill out ar e 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, f

ill 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 - 421st CCLC 20 15 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 Overvie w **Indicate the number of regular attendees for which: Number of**  **Regular Attendees**  You have both mathematics and reading/language arts grades for fall 20 1 4 and spring 2015 . You have only mathematics grades for fall 20 1 4 and spring 2015 . You have only reading/language arts grades for fall 20 1 4 and spring 2015 . You have neither mathematics nor reading/language arts grades for fall 20 1 4 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. T otal 

### 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 20 15 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 20 15 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 Overvie w **Indicate the number of regular attendees for which: Number of**  **Regular Attendees**  You have both mathematics and reading/language arts grades for fall 20 1 4 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 20 15 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 hi ghest grade possible * Total (Reading/Language Arts) *Figures reported in this row should not be counted toward the column totals.21st CCLC 20 15 Annual Performance Report: Paper Forms for Centers: Form F - 2

—43



## Form F **- 2: State Assessm**  **ent –**  **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 201 4

– 1 5 school year. You have only mathematics results for the state proficiency test administered during the 201 4

– 1 5 school year. You have only reading/language arts results for the state proficiency test administered during the 201 4

– 1 5 school year. You have neither mathematics nor reading/language arts results for the state proficiency test administered during the 20 1 4

– 1 5 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 20 15 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 20 15 Annual Performance Report: Paper Forms for Centers: Form F - 3a

—45 

## Form F **- 3a: State Assessm**  **ent —**  **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 201 3

– 1 4 and 201 4

– 1 5 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 b y 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, s eparated 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, yo u would indicate that a student in the proficient level witnessed an in crease in performance between the two ye ars. **Example** 1. Advanced 2. Proficient 3. Basic 4. 5.21st CCLC 20 15 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 201 4

– 1 5 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 421st CCLC 20 15 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 321st CCLC 20 15 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 21 st CCL C 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 sy stem. 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 ye ar’s assessment and have now scored proficien t or above on the current assessment. NOTE: You only will need to complete the following tables if your state assessment sy stem has two or more proficiency

levels the fall below proficient. 

### Mathematics Proficiency Test Results **— Significant Changes in Perfo**  **rmance Level**  **Indicate the number of regular attendees in each level who: Number of**  **Regular Attendees**  Number of regular attendees who witnessed a j ump from a category two levels below proficient to the p roficient performance level or above on the proficiency test. Number of regular attendees that witnessed a jump from a category three levels below proficient to the p roficient performance level or above on the proficiency test.21st CCLC 20 15 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 j ump from a category two levels below proficient to th e p roficient performance level or above on the proficiency test. Number of regular attendees that witnessed a jump from a category three levels below proficient to the p roficient performance level or above on the proficiency test.21st CCLC 20 15 Annual Performance Report: Paper Forms for Centers: Form F - 3b

— 50



## Form F **- 3b: State Assessm**  **ent —**  **Cross -**  **Year (Disaggregated, Com**  **bined)** 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 20 13

– 14 and 2014

– 15 school years. You have only mathematics assessment results for proficiency tests administered during the 20 1 3

– 14 and 2014

– 15 school years. You have only reading/language arts assessment results for proficiency tests administered during the 20 1 3

– 1 4 and 2014

– 15 school years. You have neither mathematics nor reading/language arts assessment results for proficiency tests administered during the 20 1 3

– 14 and 2014

– 15 school years. Total 

### State Performance Levels Indicate the performance levels used b y 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 ye ar and moved to the advanced level the next, yo u would indicate that a student in the proficient level witnessed an increase in performance between the two ye ars. **Example** 1. Advanced 2. Proficient 3. Basic 4. 5.21st CCLC 20 15 Annual Performance Report: Paper Forms for Centers: Form F - 3b

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### Mathematics Proficiency Test Results **— Changes in Performance Level**  **Indicate the number of regular a ttendees 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 421st CCLC 20 15 Annual Performance Report: Paper Forms for Centers: Form F - 3b

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**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 321st CCLC 20 15 Annual Performance Report: Paper Forms for Centers: Form F - 3b

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**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 CCL C 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 pro ficiency 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 sy stem. 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 ye ar’s assessment and have now scored proficient or above on the current assessment. NOT E: You only will need to complete the following tables if your state assessment sy stem 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 j ump from a category two levels below proficient to the p roficient performance level or above on the proficiency test. Number of regular attendees that witnessed a jump from a category three levels below proficient to the p roficient performance level or above on the proficiency test.21st CCLC 20 15 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 j ump from a category two levels below proficient to the p roficient performance level or above on the proficiency test. Number of regular attendees that witnessed a jump from a category three levels below proficient to the p roficient performance level or above on the proficiency test.21st CCLC 20 15 Annual Performance Report: Paper Forms for Centers: Form F - 4

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## 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 s urvey asks school - day

teachers to report whether regular attendees’ behavior improved or did not improve in certain areas. I f 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 day s 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 teac hers who also are serving as 21st CCL C 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 onl y in center - related activities during summer 2014 should not be included in the reporting of teacher survey results. The number of survey s 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 20 15 Annual Performance Report: Paper Forms for Centers: Form F - 4

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### Survey 30

– 59 Day s 60

– 89 Days 90+ Day s Combined 1.1 Total number of survey s given out: ___________________ 1.2 Total number of survey s completed: ___________________ **Changes in Behaviors on Which Teachers**  **Reported: Numb**  **er 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 V olunteering (e.g., extra credit, more responsibilities) Attending class regularly B eing attentive in class Behaving well in class Performing academically Coming to school motivated to learn Getting along well with other students21st CCLC 20 15 Annual Performance Report: Paper Forms for Centers: Form G

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## Form G: Comments For instructions, see page 14.

________________________________ ________________________________ Grantee Name Center Name Provide an y additional information you believe to be pertinent to this APR. If you are not able to complete an y sections of the APR for an y 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 20 15 Annual Performance Report: Paper Forms for Centers: Form H

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## 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 associ ated forms to ensure that yo u 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 hereb y state that all the information Ihave provided is complete and accurate to the best of m y knowledge.

________________________________ Signature