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#1 02

 
	 3

	
IRM -,, , ..-..---, SASS-5 (11-:~-a?) ----- OME Na. lWKM15Xl! Annroval Exnires 12/31

NOTICE - Tnis report is authorized by law (20 U.S. Code 1221e). Your answers will be kept strictly

canfidentiai. Results from this survey will appear in summary or statistical form only, so that

individuals cannot be identified.

1a. Exciuding homeroom, za. Excluding homeroom, sa. Exc!uding homeroom,

study hails, and free study halis, and free study hails, and free

periods, was this student periods, was this student periods, was this student

taught by taught by taught by

.*

7 ?

m

’00 I ❑ IYes

[

‘“ I ❑ IYes

[

’80 I ❑ IYes

20No + GOtoitsm2a 2 ❑ No + GO to ;tem”3a

[

2UN0 + GOtoltem4

b. ::dIII:yi te::ci:isf tie b. ~ddh#~l ~::ch:isf the b. ~ddh::~l te::c!$isf tie

day? day? day?

105 ; ~:os + GO to ikam 2a 145 : ~ :OS + GO to ;tem 3a 185 ; :;.s + GO to item 4

$ $ $

C. List the ciasaes that hehhe C. Ust the ciasses that hehhe C. List the ciaases that he/she

taught this student on or tiught this student on or taught this student on or

about the date shown about the date shown about the date shown

above. Record the number above. Record the number above. Record the number

of times per week that of times per week that of times per week that

each ciass met. Do not each cjasa met. Do not each class met. Do not

inciude homeroom, study include homeroom, study inciude homeroom, study

halis, and free periods. halls, and free periods. hails, and free periods.

CIass name

Meetings Class name Meetings Class name Meeting

per week per week

110

per wee

. .- 2 1 Sll !55 3C ~ 95

! 2: .: . , -L-t> =: - - -

- ~ ,4. .-..5

-.

,.

,.. . . . -:

., .“, ,/,

. . I —
& 1s this student maie or femaie?

~ Male

Q female

5. What is this student’s date of birth?

IIlcmmil

Month Day Year

6. What is this student’s courmy of bifih?

❑ USA

~ Other

y& What is this student’s race or ethnicity?

v DAmerican Indian or Alaska Native

I

b.

c.

d

e.

a Asian or Pacific Islander

D Hispanic, regardless of race

❑ Black, not of Hispanic origin

b

GO to

item 8a

~ White, not of Hispanic origin

What American Indian tribe or Alaska

Native village is this student a member of?

Specify .—h

I

(Office Use Only)

a Don’t know

Is this student enrolled in that tribe or

viilage?

•l Yes

~ No

O Don’t know

1s this student cwrwrdy enrolled in a

ciass taught by an American Indian or

Alaska Native teacher?

U Not currentJy enrolled at this school

tlYes

D No

At this school, is this student current!y

rscaiving counseling from an American

Indian or Alaska Native counselor?

a Not currently enrolled at this school

Cl Yes

❑ No

8a. Has this student ever dropped out of or

withdrawn from this school?

Do nor /nclude rrans?ers to another schooi.

F

C! Yes

~ No + GO tu item 9

b. For which of the following reasons did

this student drop out or withdraw?

. . .

. .

.,

. .

.,.

. . .

..:

-..

.

.:

J;

. . .

:,,.

.-=

-u.

~.,:

-..,

-.

..:

>.

. . .

.-.

Mark (X) all that apply.

@Alcohol or drug abuse

. ~ Alienation or isolation

❑ Did not like school, teachers, or

other students

- ~ Discrimination

~ Employment

❑ Family problems

~ Friends withdrew or dropped out

: ❑ Parenthood or pregnancy

$ ❑ Poor grades

: ~ Other -Speci& =

~ ~ ❑ Don’t know

9. Has this student ever been suspended or

expelled from this school due to alcohol

or drug abuse?

:.;)!t 5 ,

-. : .-. ❑ Yes

10. What is this student’s CURRENT status

at this school? .- ___ _

{

❑ Enrolled

. ~ Suspended

another school

2 uVV:;:vy/::P&JJJ

I

r

GO to next

student

definition below}

J

11. Prior to this school, which of the followina

types of schools did this student attend? -

Mark (X) all that apply.

❑ Public school

❑ Private school

❑ 8ureau of Indian Affairs-funded school

U No other school attended

D Don’t know

,’

DEFINITION

Question 10- Withdrawn/Dropout/Chronic Truant - An individual who has not been in school for 4

consecutive weaks or more and is not absent due to illness or injury.
12. What is the primary language spoken in 17. At this schooI, which of the foiiowing

this student’s home? JAark (X) only one box. types of counseling services is this

~ Engiish student currently receiving? .:.

C! Spanish

Mark [X) ail that apply.

~ American Indian or Alaska Native ::;

❑ School or academic counseling

language : •l Career counseling

•l Other :..: ❑ Family counseling

J: D Alcohoi or drug abuse counseling

13. Is this student classified as limited Engiish ‘~’~ ; ❑ Psychological or mental health counse

proficient (i&P)? (See definition below) .25 a American Indian or Alaska Native

~!:; •l Yes counseling

:UNO

. . . :.* l., - ❑ Other counseling

=-= .u - ~ a None

14. Does this student receive free or

reducad-price iunches through the 18a. How many days were in the iast compie

Nationai School Lunch Program? grading period, that is, the iaet quatier,

.-.

- •l Yes

semester, or other unit this schooi uses

. . .

:~No

designate a grading period?

15. Which of the foilowing services does this 5!: Total days in grading per

student receive? Mark (X) all that apply.

~~ : ❑ Gifted and talented b. Of)feytea&s~At#ow many days was this

-- - am. : n Remedial education

: ❑ Chapter 1

.

%5

~=- .- -

- ❑ Before-school or atier-schooi care ---

: ❑ Indian Education Act (I%ie V)

.>

Days absent :: .: at: 3.. .

*+,:. : ❑ English as a Second Language (ESL)/

English for Speakem of Other Languages 1 ga. ~:ds+ie student ever been retained in a

(ESOL) (See definition beiow)

<: - ❑ Bilingual education (See definition below) 52C

~:: “ ❑ None of the above

16a. IS this student receiving special

[B!ltknowl+ ‘oro;remzo

education services under the Individuals b. In what grades has this student been

with Disabilities Education Act (IDEA)? retained? Mark (X) all that app/y. ..=-.

r

Cl Yes --- ❑ Ungraded

- ❑ No +GO to ;tan 17

~.o

:-

--2 ❑ Prekindergafien

.-. 3< a ❑ Kindergarten

b. Which of the following disabilities does := ❑ 11st

this student have? Mark [Xl all that apply. 5@ ❑ 2nd

~:~ - ❑ Learning disability j ~~

~ ❑ 3rd

i

-:

.- : a Emotional disturbance --- :=3 - ❑ 4th

.

.: ❑ Mentai retardation --- :zJ ❑ 5th

u~ : ❑ Speech or language impairment .:55 - ❑ 6th

. . . . --, - ❑ Hearing impairment :-* ❑ 7th

: Cl Visual impairment

---

=: ~-.. “~~

❑ ORhopedic impairment

..-

:+. . ~:..

:::. ❑ Autism -.:. D 10th

:: ❑ Traumatic brain injury .-. ❑ Ilth

❑ Other health impairment ❑ 12th

DEFINITIONS

Question 13- limited English Proficient - Students whose native or dominant language is other than English and who

have sufficient dificul~ speaKing, reading, writing, or understanding the English Ianguag& as to deny them the

oppomunity to learn success:~ily in an English-speaking-only c!assroom.

Question 15- English as a Second Idnguage (ESL1/English for Speakers of Other Languages (ESOLI - Students with

limited English proficiency are prcvided with intensive instruction in English.

Biiingual Education - Native language is used to va~ing degrees in instructing students with limited English proficiency.
I

I

20. What is this student’s CIJRREFIT grade level? 23. At this schooi, inciuding this school yea

0{.; ❑ Ungraded

i

which of the foilowing types of courses

: ❑ Kindergaflen

has this student EVER been enroiled in?

Mark (X) all that appiy.

c..

. . .5 @ Ist mc I ❑ American Indian or Alaska Native histo~

; ~ ::: GO to next 6Z5 ? ❑ American Indian or Alaska Native langua student 6s0 3 ❑ American Indian or Alaska Native culture

. ❑ 4th 6!+5 J D k#can Indian or Alaska Native arts an

‘a5th

‘a6th 700 5 ❑ American Indian tribal government or

i

Alaska Native village government

- ❑ 7th 705 G ❑ Multicultural education with an America

‘aath Indian or Alaska Native emphasis

no 9th 7% T ❑ Social studies with an American Indian o

Wa 10th

Alaska Native emphasis

I:tl llth

715 s H 2 or more of the above topics are

I:D 12th

integrated into the entire cum’culum

720 0 ❑ None of the above

z~. In which math course is this studant

CURRENTLY enrolled? Mark (Yrdy one box. /f If this student is in grade 9 or above,

this student is currentty enrolled in more than one CONTINUE with item 24. Otherwise, GO

math course, mark the box for the highest level in to the next student.

which this student is currently enrolled.

310 I ❑ Remedial math

: ❑ General or regular math 24. How many Advanced Placament (AP)

.? ❑ Business or consumer math courses is this student CIJRREiUTLY

An Pre-aigebra or enriched math

enroiled in?

sO Algebra I

~ ❑ Geometry 725 on None o r A? courses

~~ Algebra II

: U Trigonometry 25. How many Advanced Placament (AP)

: ❑ Algebra ll~rigonomet~

coursas has this student COMPLETED?

‘: •l Pre-calcuius

‘~ •l Calculus 730 0 ❑ None or AP courses

I: ❑ Advanced Placement (AP) Calculus

:: ~ ;.:: 26a. What is this student’s cumulative grade

point average (GPA) for the current scho

year? Report answer to the nearest tenth.

=. In which scienca course(s) is this student

CURRENTLY enroiled? Mark (X) all that app/y. 735~@A

6:5 : ❑ Generai science

6:!3 : ❑ EaRh science b. VUAl~~psd&i~A~ie is used to compute t

6Z5 : u Environmental science

5:3 ~ D Physical science 7~ 1 •1 0.0 to 4.0

52: : ❑ Anatomy/Phwiology :Cl 0.0 to 5.0

tj:: ~~ •l Biology :Cloto loo

.,.- =- . ‘n Advanced Placement (AP) Biology :DAto Eor Ato F

~: . ❑ Chemistry “• Other

,:=. ., ❑ Advanced Placement (AP) Chemist~

❑ Physics .: 27. How many transcripts have been sent to

❑ Advanced Placement (AP) Physics

colleges or universities for this student?

❑ Other

~ None D None or Transcripts


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