REL Midwest Data Collection Instruments—1

B-1. Draft Protocol—School-Level Survey 

(Treatment Contrast and Data-Informed Allocation of Dropout Prevention 

Interventions for Students)

Paperwork Burden Statement

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

information unless such collection displays a valid Office of Management and Budget (OMB) control 

number. The valid OMB control number for this information collection is XXXX-XXXX. The time required 

to complete this information collection is estimated to average 60 minutes per response. This information 

collection is voluntary. If you have any comments concerning the accuracy of the time estimate(s) or 

suggestions for improving this form, please write to: U.S. Department of Education, Washington, DC 20202–

4651. If you have comments or concerns regarding the status of your individual submission of this form, 

write directly to: Christopher Boccanfuso, U.S. Department of Education, Institute of Education Sciences, 

Room 506D, 555 New Jersey Ave. NW, Washington, DC 20208-5500.

Per the policies and procedures required by the Education Sciences Reform Act of 2002, Title I, Part E, 

Section 183, responses to this data collection will be used only for statistical purposes. The reports 

prepared for this study will summarize findings across the sample and will not associate responses with a 

specific district or individual. Any willful disclosure of such information for nonstatistical purposes, 

except as required by law, is a class E felony.

**This survey will be administered to both treatment and control schools to estimate the impact 

of EWIMS on school-level outcomes 

The purpose of this draft school-level survey is twofold: the first section documents current 

usage of an early warning system tool or the use of data to identify students who are at risk of 

academic failure, disengagement, and/or dropping out of high school, and will be used to 

measure the treatment contrast in the EWIMS impact study. We will use this information to 

document the treatment contrast. Measures are adapted from the REL Appalachia survey in an 

attempt to coordinate data collection across RELs on similar EWS implementation studies.

These second section collects consistent information from treatment and control schools about 

the types of dropout interventions they are implementing and whether and how they use student 

data to allocate those dropout interventions. This section will be used to answer school-level 

research question 2a: What is the impact of EWIMS on data-informed allocation of dropout 

prevention interventions for students? Items are based on up-to-date input from the Dropout 

Prevention Research Alliance members’ input, as well as a collaboration between REL 

Appalachia and REL Midwest to develop similar tools for EWS implementation studies. The 

study team plans to continue to review and populate these response options prior to 

administration and in collaboration with alliance members to reflect the most up-to-date local.

These items are still in draft form and will be finalized with input from REL Midwest’s Dropout 

Prevention Alliance. 
REL Midwest Data Collection Instruments—2

Section I: Treatment Contrast—Use of an Early Warning System

1. Is your high school using an early warning system (EWS) to identify students who may be at 

risk of not graduating from high school on time? 

o Yes, we are implementing EWS in my high school 

If yes, what is the name of your early warning system? ________________________.

o No, my high school is not currently implementing EWS in any high schools (IF NO, 

SKIP TO QUESTION 5)

2. Please tell us when you began implementing an early warning system in your school, and the 

degree of implementation in each school year.

Time Period Degree of Implementation

Before the 2010–11 school year Drop down menua

2010–11 school year Drop down menua

2011–12 school year Drop down menua

2012–13 school year Drop down menua

2013–14 school year Drop down menua

Other (Please specify) Drop down menua

aDrop down menu: Beginning stages, In progress, Mastered the tool and 

process

3. How do you use the early warning system? (Please check all that apply)

o To identify students at risk based on attendance

o To identify students at risk based on course failure

o To identify students at risk based on behavior 

o To target resources to support off-track students before they drop out

o To assign students to intervention(s)

o To monitor student progress or students’ response to intervention(s)

o To examine patterns and identify school climate issues

o Other (please specify) _____________________________________________________

4. What kinds of reports does your early warning system generate? (Please check all that apply)

o Student-level reports that show lists of students and risk status 
REL Midwest Data Collection Instruments—3

o School-level, or graphical, reports that show trends in student risk status across the school 

or time 

o Reports (student or school level) for key subgroups (e.g., students with disabilities) of 

students

o Intervention-level reports that allow us to monitor the effectiveness of our interventions

o Other (please specify) _____________________________________________________

~~~~~~~~~~~~~~~~~~~~~~Skip Pattern from Question 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~

The following questions ask about how your school uses data to identify students who may 

be at risk for not graduating on time.

5. Do teachers in your school have access to student data that identifies students at risk of not 

graduating?

o Yes, and all teachers access it regularly

o Yes, and some teachers access it regularly

o Yes, and some teachers access it occasionally

o Yes, but very few teachers actually access it

o Yes, but no teachers actually access it

o No, teachers do not have access to this type of data

o Other (please specify) _____________________

6. Does your school review student attendance data to determine which students may be at risk 

(i.e., missing more than # days per year)?

o Yes 

o No (IF NO, SKIP TO QUESTION 9)
REL Midwest Data Collection Instruments—4

7. For which grades do you examine student attendance data? (Please check all that apply.)

o Grade 9

o Grade 10

o Grade 11

o Grade 12

8. How often do you review these data?

o Daily 

o Weekly

o Monthly

o 4 times per year (once per quarter)

o 3 times per year

o 2 times per year

o 1 time per year

9. How often do you use attendance data to assign students to specific interventions or support 

services?

o Never

o Rarely

o Sometimes

o Always

10. Tell us a little bit about how you use attendance data in your school:

11. Does your school review student course performance data (including course failures, credit 

deficiencies) to determine which students may be at risk? 

o Yes

o No (IF NO, SKIP TO QUESTION 15)
REL Midwest Data Collection Instruments—5

12. For which grades do you examine course performance data (including course failures, credit 

deficiencies)? (Please check all that apply).

o Grade 9

o Grade 10

o Grade 11

o Grade 12

13. How often do you review these data?

o Daily 

o Weekly

o Monthly

o 4 times per year (once per quarter)

o 3 times per year

o 2 times per year

o 1 time per year

14. Tell us a little bit about how you use course performance data (including course failures, 

credit deficiencies) data in your school:
REL Midwest Data Collection Instruments—6

15. What other kinds of student data do you look at, and for which grades? (Please check all that 

apply.)

We do 

not use

We use in these grades

Grade 9 Grade 10 Grade 11 Grade 12

Behavior referrals     

Behavior suspensions     

Grade point average (GPA)     

State assessment results     

Other:     

Other:     

Other:     

Other:     

The following questions ask about the structure of data review in your high school, 

focusing on the group of individuals who use student data to identify students who may be 

at risk of not graduating from high school on time. These individuals may be part of a

distinct early warning system team or part of another team that is responsible for

examining these data.

16. Does your school have a team or group of individuals that reviews student data to support

students who are identified as at risk of not graduating from high school? (e.g., building- or 

teacher-level teams, Student Success Teams, Data Review Teams)

o Yes, we have a dedicated school-based team.

If yes, what is the goal or purpose of this team? ___________________________ 

_________________________________________________________________

o No, we do not have a dedicated school-based team.

o Other (please specify)
REL Midwest Data Collection Instruments—7

17. How often does your team meet to review student data?

o Weekly

o Monthly

o 4 times per year (once per quarter)

o 3 times per year

o 2 times per year

o 1 time per year

18. How often does your team meet to assign students at risk to support and/or interventions?

o Weekly

o Monthly

o 4 times per year (once per quarter)

o 3 times per year

o 2 times per year

o 1 time per year

19. Describe the members of the team at the high school level (if applicable). (Please check all 

that apply.)

o School principal

o Assistant principal

o Representative from feeder middle schools

o Guidance counselors

o Content area teachers

o Special education teachers

o English language learner instructors

o District office representative

o Community service providers 

o Community members

o Other (please specify) _____________________________________________________
REL Midwest Data Collection Instruments—8

20. To what extent do you agree with the following statement: “Implementing an early warning 

system will lead to improved graduation rates.”

o Strongly disagree

o Disagree

o Agree

o Strongly agree

21. How often does your school reflect on the process of identifying and assigning students at

risk to interventions?

o More than twice a year

o Twice a year

o Once a year

o We do not have this opportunity
REL Midwest Data Collection Instruments—9

Section II: Data-Informed Allocation of Dropout Prevention Interventions for Students

1. Does your school offer targeted academic interventions (e.g., tutoring, reading remediation, 

study skills) for students?

o Yes

o No (IF NO, SKIP TO QUESTION 3)
REL Midwest Data Collection Instruments—10

2. Please name the targeted academic interventions that the school offers. In the table below, indicate which programs are available, 

the number of students who participated during the school year, and the grade level of students who participated. 

Program 

name

Focus of the 

intervention

How is this 

program 

delivered?

Who delivers 

this program?

# of 

participating 

students

Grade 

level(s) of 

students

Who refers 

students for 

this program?

What criteria are 

used to select 

students for 

participation in 

targeted academic 

interventions?

What data do you 

use to determine 

whether an 

intervention/ 

support is 

working?

Write in

Drop down 

menu (reading, 

mathematics, 

science, 

tutoring, 

remediation, 

study skills, 

other please 

specify)

Drop down 

menu 

(individually 

to students, via 

small group, 

via large 

group, 

schoolwide, 

other please 

specify)

Drop down 

menu (teachers, 

administrators, 

guidance 

department, 

community 

members, 

parents, peers 

[other students], 

other please 

specify)

Drop down 

menu 

(from 1 to 999)

Drop down 

menu 

(from 

grade 9 to 

grade 12)

Drop down menu 

allowing 

checking all that 

apply 

(administrator, 

counselor, parent, 

teacher, data 

team, student, 

[self], other 

please specify)

Drop down menu 

allowing checking all 

that apply (course 

failure [e.g., failing 

Algebra], grade point 

average [GPA], number 

of credits, student 

attendance [e.g., 

missing a number of 

days of school or 

class], student behavior 

[e.g., office referrals, 

suspensions], no 

criteria, other please 

specify)

Drop down menu 

allowing checking all 

that apply (attendance, 

behavior, course 

performance, core 

course performance, 

GPA, credits earned, 

behavior referrals, 

behavior suspensions, 

no criteria, other 

please specify)
REL Midwest Data Collection Instruments—11

3. Does your school offer targeted behavior interventions (e.g., social skill training, character education) for students?

o Yes

o No (IF NO, SKIP TO QUESTION 4)

a. Please name the targeted behavior interventions at the school. In the table below, indicate which programs are available, the

number of students who participated during the school year, and the grade level of students who participated. 

Program 

name

Focus of the 

intervention

How is this 

program 

delivered?

Who delivers 

this 

program?

# of 

participating 

students

Grade 

level(s) of 

students

Who refers 

students for 

this program?

What criteria are used 

to select students for 

participation in 

targeted behavior 

interventions?

What data do you 

use to determine 

whether an 

intervention/ 

support is 

working?

Write in

Drop down 

menu (social 

skill training, 

character 

education, 

other please 

specify)

Drop down 

menu 

(individually 

to students, 

via small 

group, via 

large group, 

schoolwide, 

other please 

specify)

Drop down 

menu (teachers, 

administrators, 

guidance 

department, 

community 

members, 

parents, peers 

[other students], 

other please 

specify)

Drop down 

menu 

(from 1 to 999)

Drop down 

menu (from 

grade 9 to 

grade 12)

Drop down menu 

allowing 

checking all that 

apply 

(administrator, 

counselor, parent, 

teacher, data 

team, student, 

[self], other 

please specify)

Drop down menu 

allowing checking all that 

apply (course failure [e.g., 

failing Algebra], grade 

point average [GPA], 

number of credits, student 

attendance [e.g., missing a 

number of days of school 

or class], student behavior 

[e.g., office referrals, 

suspensions], no criteria, 

other please specify)

Drop down menu 

allowing checking all 

that apply (attendance, 

behavior, course 

performance, core 

course performance, 

GPA, credits earned, 

behavior referrals, 

behavior suspensions, 

no criteria, other 

please specify)
REL Midwest Data Collection Instruments—12

4. Does your school offer targeted attendance/truancy interventions (e.g., attendance monitor) for students?

o Yes

o No (IF NO, SKIP TO QUESTION 5)

a. Please name the targeted attendance/truancy interventions that the school offers. In the table below, indicate which programs

are available, the number of students who participated during the school year, and the grade level of students who participated. 

Program 

name

Focus of the 

intervention

How is this 

program 

delivered?

Who delivers 

this program?

# of 

participating 

students

Grade 

level(s) of 

students

Who refers 

students for 

this program?

What criteria are 

used to select 

students for 

participation in 

targeted behavior 

interventions?

What data do you 

use to determine 

whether an 

intervention/ 

support is 

working?

Write in

Drop down 

menu 

(attendance 

monitoring, 

contacting

truancy 

officers, 

automated 

contact with 

families, 

conferences 

with families 

and students, 

other please 

specify)

Drop down 

menu 

(individually 

to students, via 

small group, 

via large 

group, 

schoolwide, 

other please 

specify)

Drop down 

menu (teachers, 

administrators, 

guidance 

department, 

community 

members, 

parents, peers 

[other students], 

other please 

specify)

Drop down 

menu 

(from 1 to 999)

Drop down 

menu 

(from 

grade 9 to 

grade 12)

Drop down menu 

allowing 

checking all that 

apply 

(administrator, 

counselor, parent, 

teacher, data 

team, student, 

[self], other 

please specify)

Drop down menu 

allowing checking all 

that apply (course failure 

[e.g., failing Algebra], 

grade point average 

[GPA], number of 

credits, student 

attendance [e.g., missing 

a number of days of 

school or class], student 

behavior [e.g., office 

referrals, suspensions], 

no criteria, other please 

specify)

Drop down menu 

allowing checking all 

that apply 

(attendance, 

behavior, course 

performance, core 

course performance, 

GPA, credits earned, 

behavior referrals, 

behavior 

suspensions, no 

criteria, other please 

specify)
REL Midwest Data Collection Instruments—13

5. Does your school offer credit or content recovery (e.g., online programs such as Apex, K12, Plato, or another district program)?

o Yes 

o No (IF NO, SKIP TO QUESTION 6)

a. Please name the credit recovery programs that your school offers. In the table below, indicate which programs are available, 

the number of student who participated during the school year, and the grade level of students who participated.

Program 

name

Focus of the 

intervention

How is this 

program 

delivered?

Who 

delivers this 

program?

# of 

participating 

students

Grade 

level(s) 

of 

students

Who refers 

students for 

this 

program?

What criteria are used to 

select students for 

participation in targeted 

behavior interventions?

What data do you 

use to determine 

whether an 

intervention/ support 

is working?

Write in

Drop down 

menu (reading, 

mathematics, 

science, 

tutoring, 

remediation, 

study skills, 

other please 

specify)

Drop down 

menu 

(individually 

to students, 

via small 

group, via 

large group, 

schoolwide, 

other please 

specify)

Drop down 

menu 

(teachers, 

administrators, 

guidance 

department, 

community 

members, 

parents, peers 

[other 

students], other 

please specify)

Drop down 

menu 

(from 1 to 999)

Drop 

down 

menu 

(from 

grade 9 to 

grade 12)

Drop down 

menu allowing 

checking all that 

apply 

(administrator, 

counselor, 

parent, teacher, 

data team, 

student, [self], 

other please 

specify)

Drop down menu allowing 

checking all that apply (course 

failure [e.g., failing Algebra], 

grade point average [GPA], 

number of credits, student 

attendance [e.g., missing a 

number of days of school or 

class], student behavior [e.g., 

office referrals, suspensions], 

no criteria, other please 

specify)

Drop down menu 

allowing checking all 

that apply (attendance, 

behavior, course 

performance, core course 

performance, GPA, 

credits earned, behavior 

referrals, behavior 

suspensions, no criteria, 

other please specify)
REL Midwest Data Collection Instruments—14

6. Does your school offer student mentoring programs (e.g., Check & Connect, Check In/Check Out)?

o Yes

o No (IF NO, SKIP TO QUESTION 7)

a. Which of the following mentoring programs does the school offer or do students have access to in the community? In the table 

below, indicate which programs are available, the number of students who participated during the school year, and the grade 

level of students who participated. 

Program 

name

Focus of the 

intervention

How is this 

program 

delivered?

Who delivers 

this 

program?

# of 

participating 

students

Grade 

level(s) of 

students

Who refers 

students for 

this program?

What criteria are used 

to select students for 

participation in 

targeted behavior 

interventions?

What data do you 

use to determine 

whether an 

intervention/ 

support is working?

Write in

Drop down menu 

(academic mentoring, 

school adjustment 

mentoring [e.g., 9th grade 

transition program, reentry 

from adjudication], career 

mentoring, project-based 

and community-based 

mentoring, group-specific 

mentoring, peer mentoring, 

other please specify)

Drop down 

menu 

(individually 

to students, 

via small 

group, via 

large group, 

schoolwide, 

other please 

specify)

Drop down 

menu (teachers, 

administrators, 

guidance 

department, 

community 

members, 

parents, peers 

[other students], 

other please 

specify)

Drop down 

menu 

(from 1 to 999)

Drop down 

menu (from 

grade 9 to 

grade 12)

Drop down menu 

allowing 

checking all that 

apply 

(administrator, 

counselor, 

parent, teacher, 

data team, 

student, [self], 

other please 

specify)

Drop down menu allowing 

checking all that apply 

(course failure [e.g., failing 

Algebra], grade point 

average [GPA], number of 

credits, student attendance 

[e.g., missing a number of 

days of school or class], 

student behavior [e.g., office 

referrals, suspensions], no 

criteria, other please 

specify)

Drop down menu 

allowing checking all 

that apply (attendance, 

behavior, course 

performance, core 

course performance, 

GPA, credits earned, 

behavior referrals, 

behavior suspensions, 

no criteria, other please 

specify)

Check & 

Connect

Check In 

Check Out 

Gear Up
REL Midwest Data Collection Instruments—15

7. Does your school offer a student internship or school-related work-preparation program (such as Job Corp, MACC Project, or 

career and technical education classes or programs)?

o Yes

o No (IF NO, SKIP TO QUESTION 8)

a. Which of the following student internship or school-related work-preparation programs does the school offer? In the table 

below, indicate which programs are available, number of student who participated during the school year, and the grade level 

of students who participated. 

Program name

Focus of the 

intervention

How is this 

program 

delivered?

Who delivers 

this 

program?

# of 

participating 

students

Grade 

level(s) of 

students

Who refers 

students for 

this program?

What criteria are used to 

select students for 

participation in targeted 

behavior interventions?

What data do you 

use to determine 

whether an 

intervention/ 

support is working?

Write in

Drop down 

menu 

(internship, 

work-prep, 

other please 

specify)

Drop down 

menu 

(individually 

to students, 

via small 

group, via 

large group, 

schoolwide, 

other please 

specify)

Drop down 

menu (teachers, 

administrators, 

guidance 

department, 

community 

members, 

parents, peers 

[other students], 

other please 

specify)

Drop down 

menu 

(from 1 to 999)

Drop down 

menu 

(from 

grade 9 to 

grade 12)

Drop down menu 

allowing 

checking all that 

apply 

(administrator, 

counselor, parent, 

teacher, data 

team, student, 

[self], other 

please specify)

Drop down menu allowing 

checking all that apply (course 

failure [e.g., failing Algebra], 

grade point average [GPA], 

number of credits, student 

attendance [e.g., missing a 

number of days of school or 

class], student behavior [e.g., 

office referrals, suspensions], 

no criteria, other please 

specify)

Drop down menu 

allowing checking all 

that apply (attendance, 

behavior, course 

performance, core 

course performance, 

GPA, credits earned, 

behavior referrals, 

behavior suspensions, 

no criteria, other please 

specify)

Job Corps

AmeriCorps 

Post-Secondary Enrollment 

Options program at Kent State 

University

Career and technical 

education program(s) (e.g., 

culinary arts)

Career and technical 

education class(es) that are not 

part of a program 

Other—please describe:
REL Midwest Data Collection Instruments—16

8. Does your school offer student college preparation programs (such as AVID or Gear Up)?

o Yes

o No (IF NO, SKIP TO QUESTION 9)

a. Which of the following college preparation programs does the school offer? In the table below, indicate which programs are 

available, the number of students who participated during the school year, and the grade level of students who participated. 

Program

name

Focus of the 

intervention

How is this 

program 

delivered?

Who delivers 

this 

program?

# of 

participating 

students

Grade 

level(s) of 

students

Who refers 

students for 

this program?

What criteria are used 

to select students for 

participation in 

targeted behavior 

interventions?

What data do you 

use to determine 

whether an 

intervention/ 

support is working?

Write in

Drop down menu (general 

college prep, financial aid 

assistance, application 

process assistance, support 

for college entrance exams, 

academics, other please 

specify)

Drop down 

menu 

(individually 

to students, 

via small 

group, via 

large group, 

schoolwide, 

other please 

specify)

Drop down 

menu (teachers, 

administrators, 

guidance 

department, 

community 

members, 

parents, peers 

[other students], 

other please 

specify)

Drop down 

menu 

(from 1 to 999)

Drop down 

menu (from 

grade 9 to 

grade 12)

Drop down menu 

allowing 

checking all that 

apply 

(administrator, 

counselor, 

parent, teacher, 

data team, 

student, [self], 

other please 

specify)

Drop down menu allowing 

checking all that apply 

(course failure [e.g., failing 

Algebra], grade point 

average [GPA], number of 

credits, student attendance 

[e.g., missing a number of 

days of school or class], 

student behavior [e.g., office 

referrals, suspensions], no 

criteria, other please 

specify)

Drop down menu 

allowing checking all 

that apply (attendance, 

behavior, course 

performance, core 

course performance, 

GPA, credits earned, 

behavior referrals, 

behavior suspensions, 

no criteria, other please 

specify)

Early College 

High School

AVID 

Gear Up

Talent 

Development 
REL Midwest Data Collection Instruments—17

9. In what other ways do you assign students to intervention, or support programming?

o Demographics (such as free or reduced-price lunch)

o We use teacher recommendations or referrals

o Other types of data (please specify)