A r c h i v e d  I n f o r m a t i o n

Appendix A3
Student Instructional Status and
Attendance Form

1. Current Program Status:

____ Active: Received one or more hours of instruction (Go to 3)
____ Inactive: Received no instruction (Go to 2) and stop

2. Reason for Not Receiving Instruction

____ Student no longer attends, reason unknown
____ Completed instructional program, not interested in going further
____ Completed highest level of instruction offered
____ Completed requirements of employer/other agency/other program
____ Forced to leave by personal circumstances--moved, changed job, health, family obligations, etc.
____ Did not complete program, but left expressing satisfaction
____ Did not complete program and left expressing dissatisfaction
____ Transferred to another site/program
____ Participation ended for other reasons

3.	Learning Environment(s)		4.	Support Services Used (Mark All That Apply)
____	Class with teacher only		____	Child care
____	Class with teacher and aide		____	Transportation
____	Computer assisted lab		____	Health Services
____	Vocational lab		____	Counseling
____	Learning Lab		____	Job Search assistance
____	Individual tutor		____	Translator services
____	Self-study, no instructor		____	Financial assistance
____	Other

5. Approximate Class Size
____________________

6. Days and Hours Scheduled or Attendance Pattern for Typical Student

	Days Scheduled		Hours Scheduled
	Per Week:		Per Week:
	____		____

7. Monthly Student Attendance Record

Month:____

Month:____

Month:____

Total Days Attended	Total Hours Attended	Total Days Attended	Total Hours Attended	Total Days Attended	Total Hours Attended
_______	_______	_______	_______	_______	_______

Month:____

Month:____

Month:____

Total Days Attended	Total Hours Attended	Total Days Attended	Total Hours Attended	Total Days Attended	Total Hours Attended
_______	_______	_______	_______	_______	_______

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Appendix A2. Program Profile

Appendix A4. Student Follow-Up Telephone Survey