For RMC Use Only
Site __________________
Batch ___________________
PI ___________________
Washington State Prevention and Intervention Services Program
Prevention/Intervention Specialist Submission Summary
Date: ____/____/____
Month / Day / Year
To: Grant coordinator
From:_______________________________________________________
(Please print your name clearly.)
One copy of this form must accompany all data forms submitted each month. Please
submit this form even if you have no presentation logs or scan sheets to submit (write
"0" for the number of logs or scan sheets). This alerts your grant coordinator that you
have not forgotten to submit your data.
Included in this month’s submission are:
____ Number of completed Intake and Services scan sheets.
Completed Program Evaluation scan sheets in confidentiality envelopes.
(Check here if any sent this month.)
Since my last submission I have seen:
____ Dropin students (Enter a "0" if you have seen no drop-ins. A blank will be
considered incomplete.)
(Drop-in refers to a student who stops to talk or observe program activities but does not
participate. Do not complete an Intake and Services scan sheet for drop-in students. If
you complete a scan sheet on a student, do not count them as a drop-in.)
Prevention and Intervention Services Program Specialists' Form 1 OSPI 9/01
Washington State Prevention and Intervention Services Program
Confidential Student Master List
School:___________________________________ Specialist:____________________________
School Year: ___ 99–00 ___ 00–01 ___ 01–02 ___ 02–03 School Code: __ __ __ __ (see Appendix C)
Important Instructions: Use this form as a master list of student names during this and future school years. Code numbers must remain unique
within the entire school district. Keep the same code number for the same student every year, even when a student changes schools within the
district. Always code birth date on forms to allow verification of the code number. Use the last four columns of this sheet to maintain a record of
data submitted. Submit this form to your grant coordinator at the end of the school year, so that the next specialist in this school will know the
code numbers. Do not submit to RMC Research or OSPI. Please refer to the Guide to Data Collection for complete instructions on the use of
this form.
Month Forms Submitted
Intake and Service
Birth Sheet At Any At Program
Student Name Code Number Date Number Intake Updates Exit Evaluation
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/ /
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/ /
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Prevention and Intervention Services Program Specialists' Form 2 OSPI 9/01
Confidentiality Envelope
Student Instructions
Today I would like to ask you to tell us what impact our prevention and intervention
program has had on your life. We are asking all students who participated in
counseling or support groups to complete the Program Evaluation Form. This survey
asks you several questions about your feelings and the things you do. It asks you to
say how you feel now and how you felt at the beginning of the school year before you
participated in counseling or support groups.
Your participation in this survey is voluntary and confidential. When you are done with
the survey, insert your answer sheet into this envelope. I will not look at how you
answer these questions. When all the students have completed the form, I will send this
envelope to RMC Research in Portland, Oregon for processing. They will combine your
answers with those of other students from this school and around the state. Then they
will destroy your answer sheet when they are done with them.
__________________________________________
Prevention and Intervention Specialist
___________________________
Project
Prevention and Intervention Services Program Specialists' Form 3 OSPI 9/01
Teacher Ratings of Prevention/Intervention Students
In Elementary and Alternative Schools
For ____________________________________
(student name)
To aid the evaluation of our school’s Prevention and Intervention Services Program, I
would like to gain a perspective of this student’s classroom activities. Please take a
minute to rate the class performance, behavior in school, and attendance of this
student at two points in time.
The ratings you give me will be transferred to a coded data sheet, which will be sent to
the evaluation contractor for processing. They will combine the ratings of students from
this school and around the state for the evaluation. This sheet is the only place where
the student’s name will be shown. It will stay with my records or be destroyed.
Thank you for your assistance.
Please rate the class performance, behavior in school, and attendance of this student
during September (or the first month the student attended your class).
Satisfactory Unsatisfactory
Class performance .........
Behavior in school .........
Attendance ......................
Now rate the class performance, behavior in school, and attendance of this student
during the past month as compared to the beginning of the year. Check one box per
line.
Much Somewhat About Somewhat Much
Improved Improved the Same Worse Worse
Class performance ......
Behavior in school ......
Attendance ...................
Please return to
(prevention and intervention specialist)
Prevention and Intervention Services Program Specialists' Form 4 OSPI 9/01
Washington State Prevention and Intervention Services Program
Grant Coordinator’s Monthly Submission Cover Sheet
Date: ____/____/____
Month Day Year For RMC Use Only
Site __________________
To: Annie Argento Batch ___________________
RMC Research Corporation Date ___________________
522 SW Fifth Avenue, Suite 1407
Portland, OR 97204
From: _______________________________________________________
Contact (Grant coordinator or alternative contact person)
_______________________________________________________
Project (Name of agency receiving grant)
You are the final check to ensure that the data we receive is complete and accurate. Please
complete this cover sheet and submit it with your data each month. This sheet will help guide
you in preparing the submission for mailing and will ensure that our data clerk has all the
information needed to process the data.
Please organize the mailing as follows:
1. Grant Coordinator Cover Sheet
2. Listing of Prevention and Intervention Specialists (Sent for all specialists at the
beginning of the year. In later months submit updates for new specialists or changes in
school assignments.)
3. Intervention Specialists’ Data:
a. Prevention/Intervention Specialist Submission Summary.
b. Intake and Services Form scan sheets. Only the new pink and green sheets.
c. Program Evaluation Form scan sheets. Keep these in their confidentiality envelopes.
Please ensure that the scan sheets are complete:
All forms include school code, code number, and birth date so students are properly
identified. (No blanks are allowed. Use leading zeros. For example: 9/5/99 should be
09/05/99 and student 2-3 should be 002-0003.)
School codes are accurate. (Verify against the list we provide.)
Please ensure that the scan sheets can be processed:
Scan sheets are bundled using paper clips or, for large bundles, rubber bands (not
stapled) and placed in large envelopes or boxes (not folded). (Try not to use manila
envelopes. They sometimes get destroyed in the mail.)
Marks are dark and all bubbles filled.
Codes are completely filled in, including zeros. This is important for both the Intake and
Services form and the Program Evaluation survey form.
Prevention and Intervention Services Program Coordinators' Form 1 OSPI 9/01
Washington State Prevention and Intervention Services Program
Prevention and Intervention Specialists
Project: ________________________________
Instructions: Submit this form by September 30 for all specialists and again any month you hire new specialists or assignments change. List each specialist once.
Only include specialist paid by the state prevention/intervention grant or with funds counted as matching funds in the grant request. Next to each person’s name circle
their funding source(s). If they have an e-mail address, please write that in the third column. We will use e-mail for reminders and special notices. Lastly, list the schools
you anticipate each specialist to be working in and the number of days per week they will be in each school. Take as many lines as needed, one school name per line.
Under “days per week” estimate the number of days each week they will be in that school. For example, write “2.5” if they work full time, splitting their time equally
between two schools. Write “1” if they are in the school every Friday. For schools where a specialist is on call and may visit only rarely, write “.01”.
Funding Name of School(s)
Source(s)* Assigned to Days Per
(Circle all that apply, (Please write one name per Week at That
Specialist’s Name once per specialist.) E-mail Address line.) School
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
* Funding Sources:
1. Prevention and Intervention Grant 2. Federal Drug Free Schools Grant 3. Local District/County Support 4. Other source(s)
Prevention and Intervention Services Program Coordinators' Form 2 OSPI 9/01