# School Name: _____________________________________

School ID: _____________

School Year: ________________

Individual Completing this form: __________________________________

Date: ______________________________

**Student ID Student Name** **M a** **l e** **F e** **m a** **l e** **N o** **t A** **v a** **i l** **a b** **l e** 



# MM/DD/YYYY**Y e** **s N** **o N** **o t** **A v** **a i** **l a** **b l** **e Y** **e s** **N o** **N o** **t A** **v a** **i l** **a b** **l e** **Y e** **s N** **o N** **o t** **A v** **a i** **l a** **b l** **e #** **o f** **E x** **c u** **s e** **d A** **b s** **e n** **c e** **s #** **o f** **U n** **e x** **c u** **s e** **d A** **b s** **e n** **c e** **s T** **o t** **a l** **# o** **f A** **b s** **e n** **c e** **s #** **o f** **E x** **c u** **s e** **d T** **a r** **d i** **e s** **# o** **f U** **n e** **x c** **u s** **e d** **T a** **r d** **i e** **s T** **o t** **a l** **# o** **f T** **a r** **d i** **e s** **# o** **f I** **n -** **S c** **h o** **o l** **S u** **s p** **e n** **s i** **o n** **s #** **o f** **O u** **t -** **o f** **- S** **c h** **o o** **l S** **u s** **p e** **n s** **i o** **n s** **# o** **f T** **r u** **a n** **c i** **e s** **# o** **f E** **x p** **u l** **s i** **o n** **s T** **o t** **a l** **# o** **f D** **i s** **c i** **p l** **i n** **a r** **y A** **c t** **i o** **n s** **Y e** **s N** **o N** **o t** **A v** **a i** **l a** **b l** **e Y** **e s** **N o** **N o** **t A** **v a** **i l** **a b** **l e** 



# Yes or No - Moved out DC

- Went to public school

- Went to another

private school

- Dropped out

- Expelled

- Unknown

- Other ______________

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 20

minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is mandatory (citing

authority)/required to obtain or retain benefit (citing authority) or voluntary. 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,

400 Maryland Ave., SW, Washington, DC 20210-4537 or email ICDocketMgr@ed.gov and reference the OMB Control Number XXXX-XXXX. Note: Please do not return the completed XXXX (cite form or other applicable reporting mechanism) application to this

address. **If 12th grader;**

**Anticipated High**

**School**

**Graduation for**

**2013** 

# DC CHOICE PROGRAM EVALUATION

**Student Outcome Records Form**

**Currently**

**Enrolled Was student** 

**Retained for**

**2012-2013 Free/** 

**Reduced**

**Lunch Limited** 

**English**

**Proficient IEP**  **Birth Date** 

# Attendance during the current school year

**If not enrolled, Reason**

**Left School New School Name**  

# Enrollment

**Gender**

**Disciplinary Actions Tardies**  **Absences**