Readiness to Learn Form M – Master List Project: ___________
School Year: 2004–2005 Component: _____________ Site: _____________
Staff: _____________________
Instructions: Use this form to record the code numbers assigned to each child and family. Keep this form in a safe place. Do
not submit this form to RMC Research. Do not reassign previously used codes.
Code Child Family
School Year: 2004–2005
Readiness to Learn Form 1A – Family Services Family Code: ____________ Project: _______
School Year: 2004–2005 Staff: _______________________ Component: _________ Site: _________
Instructions: For each service provided between July 1, 2004, and June 30, 2005, circle the role of RTL, indicate the number of
family members who received the service, and indicate the number of times the service was delivered or referred.
SERVICES
Number Number of times
Education of Child Receiving service delivered or
Role Service referred
A Early childhood education 1 2
B Academic counseling 1 2
C Tutoring 1 2
D Alternative school program 1 2
E Student advocacy 1 2
F Behavior interventions 1 2
G Adult or peer mentors 1 2
H Peer support groups 1 2
I After-school/evening activities 1 2
J Summer activities 1 2
K School supplies or fees 1 2
L Other 1 2
Number Number of times
Parent Engagement Receiving service delivered or
Role Service referred
A Behavior management training 1 2
B Parent/child involvement activities 1 2
C Parent/school involvement activities 1 2
D Parenting education 1 2
E Parent support groups/mentors 1 2
F Parent advocacy (relationship building) 1 2
Number Number of times
Adult Education/Employment Receiving service delivered or
Role Service referred
A Adult education (ABE, ASE, GED) 1 2
B English as Second language (ESL) 1 2
C Job counseling/placement 1 2
D Other (specify): 1 2
KEY for ROLE of RTL
1 Linked/referred family to service
2 Provided direct service or paid for service
School Year: 2004–2005
Readiness to Learn Form 1B – Family Services, cont. Family Code: ____________ Project: _______
School Year: 2004–2005 Component: _________ Site: _________
Instructions: For each service provided between July 1, 2004, and June 30, 2005, circle the role of RTL, indicate the number of
family members who received the service, and indicate the number of times the service was delivered or referred.
SERVICES, cont.
Number Number of times
Basic Needs Receiving service delivered or
Role Service referred
A Food assistance (food bank, food stamps, WIC) 1 2
B School lunch or breakfast program 1 2
C Clothing assistance 1 2
D Transportation to appointments 1 2
E Child care 1 2
F Public assistance (AFDC, SSI) 1 2
G Legal assistance 1 2
H Translation 1 2
I Housing (emerg. shelter, rent, utilities) 1 2
J Holiday food or gift basket 1 2
K Other 1 2
Number Number of times
Health Receiving service delivered or
Role Service referred
A Health insurance (including Medicaid) 1 2
B Health screening 1 2
C Correct hearing/vision problems 1 2
D Dental care 1 2
E Immunizations 1 2
F Other medical care 1 2
G Nutrition counseling/education 1 2
H Other (specify): 1 2
Number Number of times
Family Functioning/Mental Health Receiving service delivered or
Role Service referred
Child counseling (individual or group, anger,
A 1 2
depression)
B Parent counseling 1 2
C Family counseling 1 2
Alcohol/drug support groups/ counseling/
D 1 2
treatment—child
Alcohol/drug support groups/ counseling/
E 1 2
treatment—parent
Referral to Child Protective Services
F 1 2
(CPS)
G Other (specify): 1 2
School Year: 2004–2005
Readiness to Learn Form 1C - Family Outcomes Family Code: ____________ Project: _______
School Year: 2004–2005 Component: _________ Site: _________
Instructions: For each service provided between July 1, 2004, and June 30, 2005, indicate the number of family members who
achieved each outcome.
OUTCOMES
Number Achieving
Education of Child
Outcome
1 Enrolled in preschool
2 Improved educational plan
3 Improved academic skills
4 Enrolled in alternative program
5 Improved attendance
6 Improved behavior at school
7 Returned to school
8 Graduated from high school
9 Involved in positive activities (community and/or school)
Number Achieving
Parent Engagement
Outcome
1 Family has very little or no contact with school
2 Family has talked with school staff about concerns
Family has increased contact with school staff at conferences
3
or other school events
4 Family has volunteered for school events or activities
5 Family supports and participates in their child’s education
6 Linked to school activities
7 Improved school relationships
Number Achieving
Community Resources
Outcome
1 Family is unwilling or unable to take action to help themselves
2 Family is able to talk about strengths/needs
3 Family is willing and able to accept support to meet their needs
Family is able to identify and utilize community resources with
4
support
Family is able to identify and utilize community resources
5
independently
School Year: 2004–2005
Readiness to Learn Form 2 – Child Background Child Code: ____________ Project: _______
School Year: 2004–2005 OSPI School Code: _______ Component: _________ Site: _________
Instructions: Complete this form for all children served by RTL this school year. Do not report siblings of target child unless they
were subsequently referred. Submit by June 30, 2005 attached to the Child and Family Services Forms
(Records 1A–1C).
Characteristics of Child
Status
Describe the characteristics of the child at the point of first contact
Continuing services from last year with the child or family this school year.
(do not complete box below)
Student referred to RTL for the first time Birthdate ___/___/___ Grade _____ or
(complete box below) 1 Under age 5 or
2 Not enrolled in school
New Referral to RTL Gender
1 Male
2 Female
Date of referral _____/_____ (month/year)
Source of referral (check one):
1 Teacher Ethnic background (check all that apply)
2 Administrator 1 Asian/Pacific Islander
3 Counselor 2 Native American
4 Psychologist 3 Hispanic
5 Other school staff 4 Black (not of Hispanic origin)
6 Legal system 5 White (not of Hispanic origin)
7 Public health 6Ukrainian
8 Service provider
9 Self-referral (child or parent)
Child is currently participating in the following special services:
10 School team
(check all that apply)
11 Other ___________________
1 English Language Limited/ELL
Primary reasons for referral (check all that apply): 2 Title I or Learning Assistance Program (LAP)
1 Poor attendance 3 Special Education
2 Academic problems 4 None of the above
3 Limited English Proficiency 5 Local program
4 School behavior problems
5 Low interest in school What is the living situation for this child? (check one)
6 Health needs for student (medical, dental) 1 Both parents
7 Reported physical/sexual abuse 2 Parent and stepparent
8 Other mental health needs 3 Single parent (may include joint custody or unmarried
9 Family basic needs (food, clothing, housing, partner)
child care transportation, etc.) 4 Relatives (grandparents, aunt/uncle)
10Student basic needs 5 Foster care/out-of-home placement
11 Family substance abuse 6 Alone or with friends/significant other
12Student substance abuse 7 Other ___________________
13 Domestic safety concerns
14At risk of being homeless
15 Other ___________________
Year-End Status
Approximately how many days during the school year
did RTL staff work with this student or family (about this What is the current status of this student?
1 Discontinued, declined further participation
student): ______
2 Discontinued, moved or transferred
Number of family members in household: ______ 3 Still working with student
Did this student transfer to or from another school during the 4 Completed work with student
school year? 1 No 2 Yes 5 Other (specify) ___________________
School Year: 2004–2005
Readiness to Learn Form 3A – Elementary Success Child Code: ____________ Project: _______
School Year: 2004–2005 Component: _________ Site: _________
RTL Staff: ______________________ Grade: _____
Complete Records 3A, 3B, and 3C for elementary students who: a) were intensively served (served 3 or more times), and
b) began RTL services this year. Use Record 4 to report outcomes for middle and high school students.
When the student is first referred to RTL, ask the referring teacher to complete Initial Teacher Rating (Record 3B). (This
process becomes automatic if you can attach Record 3B to your referral form).
At the end of the school year (or when the student moves or leaves the program), ask the referring teacher to complete the
Follow-up Teacher Rating (Record 3C).
At the end of the school year, enter student attendance data on Record 3A from school records. Data for two points in time
must be recorded in order to assess changes in attendance and behavior over time. Use spring term 2004 data as the
baseline (i.e., status prior to involvement with RTL). If spring term 2004 data are unavailable, it may be necessary to use fall
term 2004 data. For the first year follow-up, record spring 2005 data.
Use N/A to indicate missing data. Use zero to indicate no days absent or no behavioral incidents.
Data Collected Baseline Prior to RTL First Year Follow-Up Second Year Follow-Up
Achievement, Attendance, and Behavior
Grading period for attendance is:1 Baseline reported for:
(check one) (check one)
Spring term 2005
Quarter (preferred) Spring term 2004 for for new students
new students or
Semester/trimester
Fall term 2004 Submit second year
School year (least preferred) (only if spring unavailable)
follow-up for students
Number of days enrolled in school served 2003–2004 on
computer forms provided
Number of days absent2 by RMC Research in
spring 2005
Number of days tardy
Number of days suspended2
Number of office referrals or
detentions2
1
Use the same length of grading period for grades, attendance, and disciplinary actions for baseline and follow-up. Use spring quarter
if possible (otherwise use semester data). At baseline, report the spring term data from the prior school year (use fall term data from
this year if spring term data from last year are unavailable).
2
Enter N/A if data are not available. Enter a 0 if no incidents were recorded during the term.
School Year: 2004–2005
Readiness to Learn Form 3B – School Success Child Code: ____________ Project: _______
School Year: 2004–2005 Component: _________ Site: _________
RTL Staff: ______________________ Grade: _____
Initial Teacher Rating
Fall 2004
Dear _________________ Date ___/___/___
Please take a minute to help us monitor the progress of this student as part of the evaluation of our Readiness to Learn program.
Please rate this student's academic performance and school behavior based on your observations in the classroom over the past 30
days. Please write any comments on a separate page. Thank you for your time!
Academic Performance School Behavior Parent/School Partnership
How has this child performed in the past How has this child behaved in the past 30 During the past three months, have the
30 days? days? parent(s) of this student:
Class participation and attentiveness Disruptive behavior in class Attended parent/teacher conference,
1 Much below average 1 Not a problem open house, or other school event
1 No
2 Below average 2 Mild problem
2 Once
3 Average 3 Moderate problem
3 Two or more times
4 Above average 4 Serious problem
4 No opportunity to observe or not
5 Much above average
Aggressive behavior or fighting applicable
Class assignments 1 Not a problem
Volunteered to help with a school event
1 Much below average 2 Mild problem
or activity
2 Below average 3 Moderate problem
1 No
3 Average 4 Serious problem
2 Once
4 Above average
Poor attendance or tardiness 3 Two or more times
5 Much above average
1 Not a problem 4 No opportunity to observe or not
Class performance and grades 2 Mild problem applicable
1 Much below average 3 Moderate problem
Discussed with you how this child is
2 Below average 4 Serious problem performing or behaving in school
3 Average 1 No
4 Above average 2 Once
5 Much above average 3 Two or more times
Reading achievement 4 No opportunity to observe or not
1 Much below average
applicable
2 Below average
3 Average Assets/Protective Factors
4 Above average How often does this student:
How often is this student:
5 Much above average
Motivated to do well in school Demonstrate ability to plan ahead and
Math achievement make appropriate choices
1 Never
1 Much below average 1 Never
2 Sometimes
2 Below average 2 Sometimes
3 Often
3 Average 3 Often
4 Always
4 Above average 4 Always
5 Much above average Actively engaged in learning
Communicate effectively in social
1 Never
situations
2 Sometimes
1 Never
3 Often
2 Sometimes
4 Always
3 Often
Cooperative and flexible 4 Always
1 Never
2 Sometimes
3 Often
4 Always
School Year: 2004–2005
Readiness to Learn Form 3C – School Success Child Code: ____________ Project: _______
School Year: 2004–2005 Component: _________ Site: _________
RTL Staff: ______________________ Grade: _____
Follow-Up Teacher Rating
Spring 2005
Dear _________________ Date ___/___/___
Please take a minute to help us monitor the progress of this student as part of the evaluation of our Readiness to Learn program.
Please rate this student's academic performance and school behavior based on your observations in the classroom over the past 30
days. Thank you for your time!
Academic Performance School Behavior Parent/School Partnership
How has this child performed in the past How has this child behaved in the past 30 During the past three months, have the
30 days? days? parent(s) of this student:
Class participation and attentiveness Disruptive behavior in class Attended parent/teacher conference,
1 Much below average 1 Not a problem open house, or other school event
1 No
2 Below average 2 Mild problem
2 Once
3 Average 3 Moderate problem
3 Two or more times
4 Above average 4 Serious problem
4 No opportunity to observe or not
5 Much above average
Aggressive behavior or fighting applicable
Class assignments 1 Not a problem
Volunteered to help with a school event
1 Much below average 2 Mild problem
or activity
2 Below average 3 Moderate problem
1 No
3 Average 4 Serious problem
2 Once
4 Above average
Poor attendance or tardiness 3 Two or more times
5 Much above average
1 Not a problem 4 No opportunity to observe or not
Class performance and grades 2 Mild problem applicable
1 Much below average 3 Moderate problem
Discussed with you how this child is
2 Below average 4 Serious problem performing or behaving in school
3 Average 1 No
4 Above average 2 Once
5 Much above average 3 Two or more times
Reading achievement 4 No opportunity to observe or not
1 Much below average
applicable
2 Below average
3 Average
Assets/Protective Factors
4 Above average How often is this student: How often does this student:
5 Much above average
Motivated to do well in school Demonstrate ability to plan ahead and
Math achievement 1 Never
make appropriate choices
1 Much below average 1 Never
2 Sometimes
2 Below average 2 Sometimes
3 Often
3 Average 3 Often
4 Always
4 Above average 4 Always
Actively engaged in learning
5 Much above average Communicate effectively in social
1 Never
situations
2 Sometimes
1 Never
3 Often
2 Sometimes
4 Always
3 Often
Cooperative and flexible 4 Always
1 Never
2 Sometimes
3 Often
4 Always
School Year: 2004–2005
Readiness to Learn Form 4 – Middle & High School Success Child Code: ____________ Project: _______
School Year: 2004–2005 Component: _________ Site: _________
RTL Staff: ______________________ Grade: _____
Complete the Baseline and First Year Follow-Up columns only for newly intensively served students (3 or more contacts) who began
RTL services this year and were enrolled in a middle school or high school.
Data Collected Baseline Prior to RTL First Year Second Year
Follow-Up Follow-Up
Achievement, Attendance, and Behavior
Observation period1 (check one)
(check one)
Quarter (preferred) Spring term 2004 for new students or
Spring term 2005
Semester/trimester Fall term 2004
for new students
School year (least preferred) (only if spring unavailable)
Number of days enrolled in school
Number of days absent2
Number of days tardy2
Number of days suspended2
Number of office referrals or detentions2
Grade Point Average (GPA)
Educational and Employment Status (High School Age Only) Submit second year
follow-up for
High School status 1 Dropped out 1 Dropped out students
(check one) 2 Still enrolled 2 Still enrolled served in 2003–2004
3 Graduated/diploma 3 Graduated/diploma on computer forms
4 Moved 4 Moved provided
5Returned to school 5Returned to school by RMC Research in
spring 2005.
GED or other alternative diploma 1 Not working toward 1 Not working toward
(if no HS diploma) 2 Working toward 2 Working toward
3 Completed 3 Completed
4Returned to school 4Returned to school
Post secondary education 1 Applied 1 Applied
(check one) 2 Accepted 2 Accepted
3 Attending 3 Attending
4Returned to school 4Returned to school
Vocational training 1 Applied 1 Applied
(check one) 2 Attending 2 Attending
3 Completed 3 Completed
4Returned to school 4Returned to school
Employment status 1 Not looking 1 Not looking
(check one) 2 Actively looking 2 Actively looking
3 Job program 3 Job program
4 Part time/seasonal 4 Part time/seasonal
5 Full time 5 Full time
Cumulative High School credits completed End of spring 2003___ . ___ End of spring 2004 ___.___ Total credits needed
for graduation at this
school: _____
1
Use the same length of observation period for grades, attendance, and disciplinary actions for baseline and follow-up. Use spring quarter if possible
(otherwise use semester date). At baseline, report the spring term data from the prior school year (use full term data from this year if spring term data from
last year are unavailable). 2Enter N/A if data are not available. Enter a 0 if no incidents were recorded during the term.
School Year: 2004–2005
Readiness to Learn Form G – Group Services Log Project: _______
School Year: 2004–2005 Component: _________ Site: _________
Contact Person: ______________________ School: _________________
Instructions: Record only events, activities, or services that are coordinated or provided by RTL and are not targeted to specific
families and thus would not be reported on the Child and Family Records. If a class or other activity meets several times
with the same participants, record it once. Specify only one purpose code and one participant type per group service.
Date or Primary Type of Average Times Met (or
Time Purpose1 Participant2 Number of Number of
(Select one) (Select one)
Period Brief Description of Service Participants Sessions)
1 2
Purpose 01 Outreach/inform about RTL 07 Improve parenting skills Participant 1 Students
Codes: 02 Inform about community resources 08 Improve academic skills Type: 2 Parents
03 Provide for basic family needs (homework club, tutoring) 3 Families
04 Improve physical or mental health 09 Provide social/recreational 4 Community
05 Reduce substance abuse or activity for students 5 School personnel
violence (after school or summer)
06 Increase family involvement 10 Coordination meetings with
in school other agencies
School Year: 2004–2005
Readiness to Learn Form L – Calling Log for Client Satisfaction Project: _______
School Year: 2004–2005 Component: _________ Site: _________
Staff: ______________________ School: __________________
Instructions: Use this log to record all of the calls made for the Client Satisfaction Interviews. Interviewers should record the family
codes for the sample of families selected to participate in the survey. Entries in the log should contain the date and time
of the call, the name of the interviewer, whether the family was reached, messages left, whether the interview occurred,
and explanations if it did not.
Explanation if
Date & Time Interview Not
of Call(s) & Was the Date Completed
Name of family Interview (nonrespondent
Family Code Interviewer reached? Messages Left Completed or refusal)
School Year: 2004–2005
Readiness to Learn Form S – Client Satisfaction Family Code: ________________ Project: _______
School Year: 2004–2005 Component: ________________ Site: ____________
RTL Service Provider: _____________________ Interviewer: ____________________ Interview Date: ________
Introductory statement: I am talking with some of the parents who have participated in, or whose children have participated in,
[the Readiness to Learn Program] to see what they think about the program. You will help us improve [the
Readiness to Learn Program] by answering some questions about the services you have received. We
are interested in your honest opinions, whether they are positive or negative.
Awareness of Program Services
1. How many times have you or your child been in contact with [title or name of family worker] since June, 2004? __________
2. To which community agencies or programs were you referred by the [Readiness to Learn Program]?
3. What did you or your child like most about the support you received?
4. What could the [Readiness to Learn Program] do to provide more effective support to you or your child?
Rating Satisfaction
5. Has your child done better in school because of the support you received?
Yes, definitely
1
Probably
2
3 Probably not
4 No, definitely not
6. How satisfied are you with the amount of support you or your child received?
Very satisfied
1
2 Satisfied
3 Dissatisfied
4 Very dissatisfied
7. Would you be willing to assist and support other families in your community?
School Year: 2004–2005
School Year: 2004–2005