1. Citizenship

Lawfully Admitted Alien

U.S. Citizen

No Response

Appropriate box should be marked; however, learner does not have to answer this question. If no answer is given, check “No Response.”

2. Gender

Male

Female

Check appropriate box.

3. Ethnicity

American Indian/Alaskan Native: person having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition.

Asian: person having origins in ay of the original peoples of the Far East, Southeast Asia or the Indian subcontinent, i.e., China, India, Japan, Korea.

Native Hawaiian/Other Pacific Islander: person having origins as a native of the Hawaiian Islands or the other islands of the Pacific, such as the Philippine Islands and Samoa.

Black /African American: person having origins in any of the Black racial groups of Africa, but not of Hispanic culture or origin.

Hispanic/Latino: person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.

White: person having origins in any of the original peoples of Europe, North Africa, or the middle East, but not of Hispanic culture or origin.

Check appropriate box. 

4. Native Language

English: speaks native English

Non-English: does not speak native English

Check appropriate box.

5. Last Grade Completed

    and Last Year Attended

Highest level of education learner has completed.

Write in the last grade that was completed by the learner.  If possible, put last year of attendance.

6. Contact Type

ABE: (Adult Basic Education Program)-program designed for adults who lack competence in reading, writing, speaking, problem solving, or computation at a level necessary to function in society, on a job or in the family.

ESL: (English as a second Language Program)-program designed to help adults who are limited in English proficiency to achieve competence in the English language.

Check ABE if learner is in a regular Adult Education class (assessment is with TABE), or ESL if the learner is in an ESL class (assessment is with BEST or CASAS)

7. Primary/Secondary

    Core Indicator

Earn GED Certificate

Earn High School Diploma

Placement in Postsecondary Education or Training

Placement in Unsubsidized Employment

Retention in Employment

The learner should choose at least one goal (Core Indicator). Check  one appropriate box under Primary and one under Secondary (Secondary if applicable).

8. Secondary Reasons

Vote or registered to vote…-learner registers to vote or votes for the first time during instruction anytime during the program year.

Achieve citizenship skills-learner attains the skills needed to pass the U.S. citizenship test.

Increased involvement in community affairs…-learner increases involvement in attending/organizing meetings of neighborhood, community or political organizations; volunteers to work for such organizations; contributes to the support of such organizations; and volunteers to work on community improvement activities.

Increased involvement in children’s ed…-learner increases involvement in the education of dependent children under his/her care, including helping more frequently with schoolwork, increased contact hours with children’s teacher to discuss children’s education, and more involved with children’s school, such as by attending school activities and volunteering to work on school projects.

Increased involvement in children’s literacy…-learner increases involvement in the literacy-related activities of dependent children under his/her care, including reading to children, visiting the library, and purchasing books or magazines for children.

Mark any that are appropriate.

9. Referral Source

Vocational Education

Welfare-work/TANF

Vocational Rehab

Newspaper/Magazine

Literacy Hotline

Pamphlet/Brochure

Radio/TV

Employer

Friend/Family

Web Site

Internet News Group

HS/College

Other

Check appropriate box.

10. Selective Service

All 18-25 year old males must be advised of their obligation to register with the Selective Service.

11. Living Area

Rural Residency Status: learner who resides in a place with a population less than 2,500 and outside an urbanized area. An urbanized area includes a population of 50,000 or more in a city and adjacent areas of high density.

Check Urban if learner lives in Shelby county or St. Clair county.  All others are Rural.

12. Employment

      Status

Yes, full time

Yes, part time

No, currently unemployed

Not in the labor market

Check appropriate box.

13. Public Assistance

Yes

No

Check whether or not the learner is receiving public assistance.

14. Status:

Low Income: learner receives or is a member of a family that received a total family income in the six months prior to enrollment of 70 percent of the income level standard for a family of that size; or if the learner is receiving or is a member of a family that is receiving cash assistance payments from Federal or state agencies or Food Stamps.

Displaced Homemaker: learner has been providing unpaid services to family members in the home and has been dependent on the income of another family member but is no longer supported by that income; and is unemployed or underemployed and is experiencing difficulty in obtaining or upgrading employment.

Single Parent: learner has sole custodial support of one or more dependent children.

Dislocated Worker: leaner who received an individual notice of pending or actual layoff from a job, or an individual who received a publicly announced notice of pending or actual layoff.

Check appropriate box if applicable.

16. Diagnosed learning

      disability

Learner has a record of, or is regarded as having, any type of physical or mental impairment, including a learning disability, that substantially limits or restricts one or more major life activities, including seeing, hearing, speaking, learning, and working.

Check if applicable. You cannot ask the student this question; this information  must be voluntarily given.

17. Diagnosed physical

      disability

Learner has a record of, or is regarded as having, any type of physical or mental impairment, including a learning disability, that substantially limits or restricts one or more major life activities, including seeing, hearing, speaking, learning, and working.

Check if applicable. You cannot ask the student this question; visual confirmation is allowed.

20. Support Needed

Child Care

Job Placement

Transportation

Health Services

Check appropriate box(es), if applicable