Identification and Needs Assessment Form: Preschool and School Age

Children and Youth Living in Homeless Situations

(For use to facilitate needs determination, assessment, evaluation, and reporting.)

Preface

This Identification and Needs Assessment Form has been prepared for use by school districts in recording pertinent information regarding children and youths identified as living in homeless situations. This is not a required form and does not need to be submitted to the Department of Education. The form may be useful to school districts that are (1) establishing an electronic data management system for homeless children and youths and/or (2) conducting a study of homeless children and youths within their district.

The form has been developed for use by school districts. It can be used for a variety of purposes, including obtaining a cumulative count of the number of identified homeless children and youths; obtaining counts by grade level, ages, ethnic background, and other characteristics; maintaining and transferring information regarding individual homeless children and youths; determining individual educational and personal needs; determining educational and personal needs that are not being met by existing school and community programs and services; and developing summary reports of demographic data, characteristics, and needs of homeless children and youths.

Rather than limit the number of items on the form, there has been an attempt to include items that collect information that may be desired by school districts, especially if the District plans to conduct an extensive study of homeless children and youths. Since the form is prepared for use by schools, Districts that choose to use this form can modify it to meet their objectives.

The McKinney-Vento Homeless Assistance Improvement Act, Title X, Part C, No Child Left Behind Act requires school districts to collect and report information regarding Homeless Children and Youth. Information to be collected and reported is specified by the U. S. Department of Education and may be changed as the USDE receives input from states and localities. Therefore, the items on this form may be modified or added to conform to USDE requirements. Currently this form will satisfy all existing state and federal requirements.

The form is in text format allowing a separate form to be completed for each child or youth identified as homeless. The text format was used to facilitate modification into an electronic copy. The responses to the items on the form can be prepared as pull down menus on the electronic copy. An electronic copy permits entering data by computer directly into the form and forwards the form to a centralized data management system.

It is suggested that school districts planning to use this form determine if there is a person within the District or within the Area Education Agency that can convert the form into an electronic data management system adapted for use with the District’s centralized computer system.

This Identification and Needs Assessment Form includes all of the information that is included in the Iowa Homeless Population Form for Use by Schools that is on the Program Planning/Staff Development web page of the Department of Education Homeless Education web site. The latter form is in table format and ten children and youth can be entered on a single page. There are two disadvantages of the latter form, it needs to be completed manually and then entered into a computer program in order to analyze the data electronically and it does not include all of the items that are included in the text format form.

NOTE: Complete a separate form for each child/youth identified as living in a homeless situation.

Section One

New Student: Complete at the time of enrollment.

Student is Currently Enrolled: Complete when identified.

Child/Youth Not in School: Complete after follow up verifies homelessness. (Identifying homeless children/youth not in school is required by the McKinney-Vento Homeless Assistance Act, Title X, Part C).

If information for an item is not available, complete at a later date if/when the information becomes available. Leave the item unanswered when the information is not available.

School District: ____________________________ District Number: ____________

Building Name: ____________________________ Building Number: ___________

First four letters of child/youth’s last name: ________________(This facilitates reporting and enables screening out duplications when obtaining “counts”, while protecting privacy rights.)
Date of birth (Use numbers): Month _____Day _____Year _____
Age: _____
Male: _____ Female _____
School program (Check the answer that applies):

Enrolled in school (K-12)_____ Grade:____
Enrolled in preschool _____
Enrolled in head start _____
Enrolled in even start _____
Other preschool _____ Specify: _________________________________
Not enrolled in school _____

If the child/youth is new to your school, record the date of enrollment in your school (Use numbers): Month _____ Day _____ Year _____
Complete this item if the child/youth is new to your school and lives in a different attendance area within your district or in a different school district?

Specify the attendance area or the school district: __________________________

attends a special education class in our school _____
attends a program offered in our school ____ Specify the program: ___________________________________________________________
participates in a support service offered in our school ____ Specify the service: _____________________________________________________
attends an alternative program offered in our school ____ Specify the program: ________________________________________________
attends this school at the request of the parent/guardian ____
attends this school because it was determined to be in the best interests of this child/youth ____

If the child/youth has been attending your school, record the date the student was identified as being homeless (Use numbers): Month ____ Day ____ Year ____
Is this child/youth continuing attendance in your school after moving to another attendance area within your district? Yes ____ No ____
Is this child/youth continuing attendance in your school after moving to another school district? Yes ____ No ____
If the response to one of the items 7, 9, or 10 is yes, check the most frequently used mode of transportation:

additional or extended bus routes ____
public transportation ____
taxis ____
contracted transportation services ____
special education buses ____
non-school agency transportation ____
personal vehicles ____
reimbursing families for mileage ____
none ____
Other ____ Specify: __________________________________________

If the response to one of the items 7, 9, or 10 is yes and if an extra cost for transportation is incurred, estimate the school transportation cost per day: _________________________________________________________________
If you responded to item 12, estimate the total cost of school transportation for this child/youth (cost per day times total number of days transported): _________________________________________________________________
If the child/youth is not enrolled in school, record the date the child/youth was identified as being homeless (Use numbers): Month ____ Day ____ Year ____
If available, record the date the homeless situation ended: Month ____ Day ____ Year ____.
If the child/youth left your school while still homeless, record the discharge date: Month ____ Day ____ Year ____
Race (Check only one, if multiracial check the race the child/youth is most likely to be identified with):

White _____
African-American _____
Hispanic _____
Native American _____
Asian _____
Other _____ Specify: _____________________________

Child/youth status with respect to living/not living with parent/guardian (consider a guardian, stepmother, stepfather as a parent), (Check only one):

Unaccompanied (not with parent) _____
Accompanied by mother only _____
Accompanied by father only_____
Accompanied by both parents _____
Accompanied by mother and friend ____
Accompanied by father and friend ____
Other ____ Specify: _______________________________________

Current living situation of parent/guardian if the child/youth is living with parent/guardian (Check only one):

Emergency shelter _____
Transitional housing _____
Domestic violence center _____
Car, camper, abandoned building _____
On the street _____
Relatives _____
Friend or acquaintance _____
Unknown _____
Other_____ Specify:_______________________________________

Current living situation of child/youth, if the child/youth is not living with parent/guardian (Check only one):

Emergency shelter_____ If yes, facility name ___________________
Transitional housing _____ If yes, facility name _________________
Domestic violence center_____
Car, camper, abandoned building _____
On the street _____
Hotel/motel _____
Living with relation other than parent/guardian _____
Living with friend or acquaintance _____
Unknown _____
Other _____ Specify ____________________________
Shelter Care-court placed _____ If yes, facility name: ________________
Temporary placement in foster care due to lack of shelter care space ____
Homes for unwed mothers or pregnant youth _____
Hospital or other facility if abandoned by parent(s) _____
Other ____ Specify: ___________________________________________

Is the child/youth also identified as a migrant? Yes _____ No _____
If the child/youth is living with parent/guardian how many children, including this child/youth, are in this homeless family: ________ (Complete a separate copy of this Form for each child/youth attending your school and for each child/youth not attending school.)
Complete the following for children/youth (between 0 and 21) in this family who attend a school outside your attendance area (This will assist in identifying a child/youth who has not been identified as homeless by the school the child/youth is attending):

a. Age ____ Sex ____ School name ________________________

b. Age ____ Sex ____ School name ________________________

c. Age ____ Sex ____ School name ________________________

d. Age ____ Sex ____ School name ________________________

Were barriers encountered that delayed enrollment? If so, check all that apply:

No barriers were encountered _____
Residency requirements _____
Availability of school records _____
Birth certificates _____
Legal guardianship requirements _____
Transportation _____
School selection _____
Preschool programs not available_____
Immunization requirements _____
Physical examination records _____
Lack of parental cooperation _____
Language _____
Other_____ Specify:____________________________

Section Two

As data becomes available complete the following items and the Section One items above that were not completed earlier.

Were barrier(s) to attendance encountered? If so, check all that apply:

No barriers were encountered_____
Transportation _____
Health _____
Lack of parent cooperation _____
Other_____ Specify:_________________________________

Cause of homelessness as it applies to the parent/guardian when child/youth is living with parent/guardian:

Primary Reason (check only one):

Addiction _____
Divorce/family breakup _____
Domestic violence _____
Evicted within the past week _____
Family/personal illness _____
Jail/Prison of a parent _____
Moved to seek work _____
Physical/Mental Disability _____
Unable to pay rent/mortgage _____
Unemployment _____
Loss of FIP (Family Investment Plan)/TANF (Temporary Assistance to Needy Families) _____
Unknown _____
Other_____ Specify) ________________________________

Secondary Reason (check all that apply):

Addiction _____
Divorce/family breakup _____
Domestic violence _____
Evicted within the past week _____
Family/personal Illness _____
Jail/Prison of a parent _____
Moved to seek work _____
Physical/Mental Disability _____
Unable to pay rent/mortgage _____
Unemployment _____
Loss of FIP (Family Investment Plan)/TANF (Temporary Assistance to Needy Families) _____
Unknown _____
Other_____ Specify:________________________________

Cause of homelessness as it applies to the child/youth when child/youth is not living with parent/guardian (check only one reason):

Runaway (For whatever reasons) _____
Throwaway (Cast out by parent/guardian) _____
Abandoned by parent/guardian _____
Mother or mother to be (Not living with her parent/guardian or child’s father for whatever reason) _____
Parent/guardian unable to care for the child/youth _____ Specify the reason: ______________________________________________
Other _____ Specify: _________________________________________

School attendance (Check all that apply):

Significant indicates a negative effect on school progress.

Satisfactory attendance _____
Significant number of days missed due to illness _____
Significant number of days missed for reasons other than illness _____ Specify the reason: _________________________________________
Significant number of late arrivals _____ Specify the reason:__________________________________________________

Has the child/youth had difficulty gaining access to one or more of the following programs (Check all that apply):

Title 1 ____
Head Start ____
Even Start ____
Special Education ____
Bilingual Education ____
Safe and Drug Free Schools ____
Other: ____ Specify: _______________________________________

30. Based on your assessments and observations of this child/youth identify his/her educational needs. On the following list check all of the programs/services that would help to meet an educational need of this child/youth even if the program/service is not available. (It is important to respond to both questions 21 and 22. This permits identification of both “met” and “unmet” needs for a specific child or youth):

a. Title I

b. Head Start

c. Even Start

d. Preschool Program

e. Tutoring/Remedial

f. Summer School Academic Programs

g. Special Education

h. Gifted/Talented

i. Vocational Education

j. Work-Study

k. Alternative Education

l. Bilingual/Education as a Second Language (ESL)

m. School Transportation

n. Extra Curricular Activities

o. Counseling

p. Evaluations by School Staff to Determine Educational/Personal Needs

q. Free-Reduced Breakfast and/or Lunch

r. Parental Training Program

s. Parental Assistance Regarding Child’s Educational/Personal Needs

t. Parental Assistance Regarding Accessing Community Services

u. Assistance in Obtaining Records, Immunizations, Supplies, etc.

v. Other (Describe):

On the following list check the all of the programs/services that the school (or the community) provided to this child/youth: