LEIS STUDENT OUTCOMES
NAME
(Last) (First) (MI/M) SOCIETAL ACHIEVEMENTS (Continued) Acquired Daily Living Skills 3. Obtained First Driver’s License 4. Obtained U.S. Citizenship 5. Recruited Other Students 6. Registered to Vote for First Time 7. Increased Involvement in Community Activities 8. Read More to Children 9. Greater Involvement in Children’s Education 10. Help More Frequently with School 11. Increased Contact with Children’s Teachers 12. More Involved in Children’s School Activities 13. Increased Involvement in Children’s Literacy 14. Activities 15. Visiting Library Reading to Children 16. Purchasing Books or Magazines 17. Other: Specify 18. 18. STUDENT DEFINED GOAL Student Defined Goal Achieved 1. Specify 3. SERVICES PROVIDED (Check All Applicable) Auxiliary Aids 1. Community Agency Referral 2. Computer-Assisted Instruction 3. Counseling 4. Day Care 5. Homebound Instructor 6. Interpreter Assigned 7. Job Referral 8. 9. Notetaker Assigned Reader Assigned 10. Telecourse 11. Training Referral 12. Transportation 13. Tutorial Instruction 14. 15. Other: Specify PROGRAMS/AGENCIES REFERRED TO (Check All Applicable) Admissions Office at This College 1. 2. Counselor at This College Department of Health 3. Department of Mental Health 4. Department of Social Services 5. PROGRAMS/AGENCIES REFERRED TO (Continued) Employment Security Commission 6. Four-Year College/University 7. Human Resources Development (HRD) 8. Job Training Partnership Act (JTPA) 9. Literacy Council 10. Other Community-Based Literacy Program 11. 12. Other Community/Junior College Private Educational/Industrial Training 13. Public School Program 14. Social Security Administration 15. Vocational Rehabilitation 16. Other: Specify 17. 11. AHS UNITS/EQUIV. COMPLETED 12. AHS UNITS TRANSFERRED OUT 13. DATE _ _ / _ _ / _ _ 14. FOLLOW-UP/REASONS FOR SEPARATION SEPARATION DATE _ _ / _ _ / _ _ (Check One) 20. Separation Reason Unknown 21. Follow-Up Attempted, No Information Available REASONS FOR SEPARATION BEFORE COMPLETING LEVEL OR GOAL (Check All Applicable) Changed Address or Left Area 1. Child-Care Problem 2. Class Closed 3. Death 4. Employment Conflict 5. Family Problem 6. Financial Problem 7. Health Problem 8. Instruction Not Helpful 9. 10. Lack of Interest Location of Class 11. Program Not Appropriate, Referred 12. 13. Time the Class or Program was Scheduled 14. Transferred, Inmate 15. Transferred, Military 16. Transferred, Other Institutionalized Adult 17. Transferred, Other Community College Transportation Problem 18. Other: Specify 19. 3. EDUCATIONAL ACHIEVEMENTS DATE _ _ / _ _ / _ _ (Check All Applicable) 1. Improved Basic Functional Skills Achieved Desired Level of Basic Functional Skills 2. 3. Learned to Read Improved Reading Skills/Comprehension 4. Achieved Desired Level of Reading Comprehension 5. Improved Oral Communication Skills 6. Achieved Desired Proficiency in Oral Communications 7. Improved Written Communication Skills 8. Achieved Desired Proficiency in Written 9. Communications Improved Math Skills 10. Acquired Desired Math Skills 11. Completed Current Level 12. Entered Curriculum/Extension at This College 13. Entered Postsecondary Educational/Training Program 14. 15. Obtained Adult High School Credits Re-entered High School 16. Obtained Adult High School Diploma 17. Passed At Least One GED Test 18. Passed At Least Three GED Tests 19. Passed GED 20. Completed Classwork/Test Pending 21. Improved Basic Skills for Personal Satisfaction and 22. Increased Self-Confidence Portfolio of Student Improvements Available 23. Other: Specify ________________________________ 24. 8. ECONOMIC ACHIEVEMENTS DATE _ _ / _ _ / _ _ (Check All Applicable) Achieved Work-Based Project Learning Goal 1. Progressing Toward Higher Level of Independent Living 2. Attained a Higher Level of Independent Living 3. 4. Documented Mastery of Employability/Life Skills Moved Off Public Assistance 5. Obtained a Job 6. Retained a Job 7. Obtained a Better Job or Promotion 8. Other: Specify _________________________________ 9. 13. SOCIETAL ACHIEVEMENTS DATE _ _ / _ _ / _ _ (Check All Applicable) Helped Children with School Work 1. Increased Daily Living Skills 2.
STUDENT SOCIAL SECURITY # _ _ _ - _ _ - _ _ _ _
DATE _________________________________
7.
Interview Conducted by Comments Student’s Signature
Interviewer’s SS/ID #
Date
(Revised 09/12/03)