"Student Data Summary Form - Sample" - Florida

Student Data Summary Form - Sample is a legal document that was released by the Florida Department of Education - a government authority operating within Florida.

Form Details:

  • Released on October 24, 2019;
  • The latest edition currently provided by the Florida Department of Education;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Florida Department of Education.

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Date Form Completed:
Student Data Summary Form
Last Name:
First Name:
Middle Name:
Maiden Name:
Student Email:
Social Security #:
Date of Birth:
Address:
Street or PO Box
City:
State:
ZIP Code:
County:
Phone:
Alternate Phone:
Gender:  Male
 Female
Ethnicity:  Latino or Hispanic Origin
Race – Select all that apply:
 American Indian or Alaskan Native  Asian
 Black or African American
 Native Hawaiian or other Pacific Islander
 White
Highest School Grade Completed (Select One):
 No school grades completed
 Completed some college, but did not earn a certificate
or degree
 Completed at least part of 1
st
th
through 11
grade
 Earned a Career Certificate
Highest grade completed:
 Earned an Associate of Applied Sciences degree
 Completed the twelfth grade, but did not attain a
 Earned an Associate of Science degree
diploma or equivalency
 Earned a high school diploma
 Earned an Associate of Arts degree
 Earned a high school equivalency
 Earned a Bachelor’s degree
 Have a disability and attained a special diploma or
 Attained beyond a Bachelor’s degree
high school certificate of attendance/completion from
completing an Individual Education Plan (IEP)
Where this level was achieved:  U.S. based school  Not U.S. based school
Military Status (Select One – For State Reporting Purposes):
 Active Duty Personnel
 Active Member of the Reserves
 Eligible Dependent (spouse/child)
 Veteran (Prior Service, Service Prior to 9/11/2001)
 Veteran (Prior Service, Service Dates Unknown)
 Veteran (Prior Service, Service on or after 9/11/2001)
 Active Member of the National Guard
 No Military History
Citizenship (For State Reporting Purposes):
 Non-Resident Alien
 U.S. Citizen
 Permanent Resident Alien
Revised October 24, 2019
Page 1
Date Form Completed:
Student Data Summary Form
Last Name:
First Name:
Middle Name:
Maiden Name:
Student Email:
Social Security #:
Date of Birth:
Address:
Street or PO Box
City:
State:
ZIP Code:
County:
Phone:
Alternate Phone:
Gender:  Male
 Female
Ethnicity:  Latino or Hispanic Origin
Race – Select all that apply:
 American Indian or Alaskan Native  Asian
 Black or African American
 Native Hawaiian or other Pacific Islander
 White
Highest School Grade Completed (Select One):
 No school grades completed
 Completed some college, but did not earn a certificate
or degree
 Completed at least part of 1
st
th
through 11
grade
 Earned a Career Certificate
Highest grade completed:
 Earned an Associate of Applied Sciences degree
 Completed the twelfth grade, but did not attain a
 Earned an Associate of Science degree
diploma or equivalency
 Earned a high school diploma
 Earned an Associate of Arts degree
 Earned a high school equivalency
 Earned a Bachelor’s degree
 Have a disability and attained a special diploma or
 Attained beyond a Bachelor’s degree
high school certificate of attendance/completion from
completing an Individual Education Plan (IEP)
Where this level was achieved:  U.S. based school  Not U.S. based school
Military Status (Select One – For State Reporting Purposes):
 Active Duty Personnel
 Active Member of the Reserves
 Eligible Dependent (spouse/child)
 Veteran (Prior Service, Service Prior to 9/11/2001)
 Veteran (Prior Service, Service Dates Unknown)
 Veteran (Prior Service, Service on or after 9/11/2001)
 Active Member of the National Guard
 No Military History
Citizenship (For State Reporting Purposes):
 Non-Resident Alien
 U.S. Citizen
 Permanent Resident Alien
Revised October 24, 2019
Page 1
Employment Status: (Select One – To be completed upon entry for each term/semester)
 Employed
 Not Employed (looking and eligible for employment)
 Employed but with Notice of Termination or in transition out of military service
 Not in Labor Force (incarcerated, not eligible for employment, or not seeking employment)
Background (Select all that apply – To be completed upon entry for each term/semester):
The school system and the Florida College System provides services for persons with disabilities. If you need assistance
in the course of your studies, please notify a school or college administrator.
 Youth in Foster Care (including aged-out)
 Single Parent
 Single Pregnant Woman
 Perceived employment barriers
 Previously or currently subject to any stage of the criminal justice process
 Low-income individual (or their dependent) employed primarily in farming currently unemployed or finding difficulty
obtaining work for 12 months out of the last two years
 Migrant or seasonal farmworker (or their dependent)  Homeless without a fixed, regular nighttime residence
 Homeless but staying in non-traditional housing (ex: park, abandoned building, or bus station)
 Child of migrants who have changed school districts in the last 3 years due to parents’ seasonal employment
 Previously unemployed or underemployed while caring for home and family (unpaid)
 Previously supported by public assistance or family, and now unemployed or underemployed
 Parent of a child within two years of no longer receiving TANF (formerly AFDC)
 Unemployed dependent spouse of a member of the Armed Forces on active duty or is deceased or disabled as a result
of military service
Income Status (Select all that apply – To be completed upon entry for each term/semester):
 Student currently eligible to receive Temporary Assistance for Needy Families (TANF) under Part A Title IV of the
Social Security Act, however the student’s eligibility will be exhausted within two years of current reporting year
 Student has been unemployed for 27 weeks or more at the time of entry in the current reporting year
 Student self-identifies as having a low income at the time of entry in the current reporting year under any of the
following:
Student or immediate family receive benefits under Supplemental Nutritional Assistance Program (SNAP),
Temporary Assistance for Needy Families (TANF), Supplemental Security Income (SSI), or other state public
assistance
Total family income does not exceed the higher of the poverty line or 70% of the lower living standard
income level
Student is current in a foster program
Student has a disability and has personal income at or below the poverty line, regardless of family income
Student is a youth living in a high-poverty area
Revised October 24, 2019
Page 2
This Section to be Completed by Adult General Education Agency
Enrollment Date:
Separation Date:
Signed Release of Information on File:  Yes  No
Program Enrollment Type – Select all that apply:
 ABE
 ESOL
 ASE (AHS, High School Equivalency Program)
If Adult High School, indicate the diploma program:
 18 credit ACCEL HS diploma (s. 1002.3105 F.S.)
 24 credit HS diploma (s. 1003.4282 F.S.)
Institutional Programs:
 Correctional Facility  Community Correctional Program
 Other Institutional Settings
Assessment – Pretest within first 12 hours of instruction
Assessment name:
Date:
Scale
Form
Level
Scores
Class Information
Reading
Online Asynchronous
Math
Class Site:
Expected Attendance Hours/Dates
Language
(Weekly/Monthly):
Listening
Revised October 24, 2019
Page 3
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