ASPIRA Management Information System OJJDP General Intake Information

Transcription

1 ASPIRA Management Information System OJJDP General Intake Information Name: First Name Middle Name Last Name Nick Name Birth Date: (month/day/year) Address: Street Name Apt. # City State Zip Code Supplemental Address: Gender: Male Female Transgender Ethnicity: American Indian/Alaskan Native Asian Black/African American Hispanic/Latino Native Hawaiian or Pacific Islander Other Race White/Caucasian National Origin: Age: Household Information: Household Income: $0-15,315 $15,316-20,535 $20,536-25,755 $25,756-30,975 $30,976-36,195 $36,196-41,415 $41,416-46,635 $46,636-51,855 $51,856 and up How Many People in Your Household? Source of Income: (ex: Salary, pension, investments, TANF (welfare), social security benefits, unemployment benefits, general assistance, disability benefits, veterans compensation, child support) Page 1

2 ASPIRA Management Information System OJJDP Extended Intake Form Name: First Name Middle Name Last Name Communications preferences: Phone Post mail Program Participation: Select OJJDP Research Project Location: Urban Suburban Rural Contact Information: Home Phone: Cell Phone: Work Phone: (Area code + Number) (Area code + Number) (Area code + Number) Address: Emergency Contact Person: First Name Initial Last Name Relationship with Contact Person: Emergency Contact Phone Number: (Area code + Number) School District Student Name or Number: Immigration Status: U.S. Citizen: Yes No Immigration Status: OJJDP Baseline and Progress Data Education: Grade Level: Promoted to next grade level: Yes No Grade Point Average: (scale 1-4) School Name: Expected High School Graduation Date Page 2

3 School Level Elementary Middle High School Alternative Education Program (GED or adult education program) Post-secondary Drop out Status: Middle School High School Post-secondary N/A Educational status of high school seniors or equivalents: Received high school diploma Received high school equivalency credits Did not received high school diploma Other College entrance Exam type: SAT ACT CEEB N/A College Exam Prep: Academic Year Summer SAT combined score (verbal + math): (score) N/A Unknown SAT verbal score: (score) N/A Unknown SAT math score: (score) N/A Unknown ACT Score: N/A Unknown College (postsecondary education) application Applied to admissions Did not apply to admission College financial aid application: Received Financial Aid: Yes No Applied for financial aid Did not applied for financial aid Postsecondary enrollment: Enrolled into postsecondary institution t enrolled into postsecondary institution Other Page 3

4 Type of postsecondary institution enrolled: Public, two year institution Public, non-profit, two years institution Public, four year institution Public, non-profit, four year institution Public or non-profit vocational/technical institution Proprietary school Parents Educational Level: Father Educational Attainment (grade level): Father Completed High School: Yes No Father College Education: Yes No Mother Educational Attainment (grade level): Mother Completed High School: Yes No Mother College Education: Yes No Language Is English your primary language: Yes No If no please specify Limited English proficiency status at program entry: Yes Limited English proficiency status at program exit: Yes No No Justice Offender Status: At risk (no prior offense) First time offender Repeat offender Sex offender Status offender Violent offender Currently under probation: Residing in a juvenile aftercare group home Under supervision of juvenile authorities: Length of probation (Months) Gang member Page 4

5 Substance Abuser Adolescent parent Mental Health Issues Displays social behavior problems Improve Grade Point Average Passed GED Developed Cultural (Pride) Skills (Staff Reported) Improved communication and technology skills Teen Pregnancy If yes, how many children High School/College Reentry Improve Social Behavior Completed High School Displays/reports family relationship challenges Improved family relationships Increase in life skills/healthy behaviors Program Participation: Program Name Alcohol and Drug Abuse Prevention APEX Aspira Club Aspira Elementary School Aspira High School Aspira Middle School AYDP Entrepreneurship Financial Education Health Careers HIV Prevention Home Ownership Investment Education Math and Science Academy Mentoring Proyecto Casa x Research Youth Development Student Educational Services Talent Search Traffic Safety Upward Bound Regular Upward Bound Veterans Page 5

6 Date of entry into program (month/day/year) Program Activities Tutoring Personal Counseling Academic Advisement College Exam Prep Mentoring Study Skills Page 6

7 Cultural Activities Campus Visitation Assistance with College Admission Financial Aid Assistance Workshop Family Activity Community Service Page 7

8 Activity with Role Models Field Trip Internship Completed Program Yes No ASPIRA Clubs Club Officer Positions President Vice President Treasurer Secretary Completed the Areyto Ceremony Yes No Truancy School suspension In school suspension Out of school Suspension Number of school absences Pull down (1-50) Page 8