Get documents about "Adult Education Program
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Adult Education Program
Intake Assessment Form
Form Completion is required for ALL Adult Learners and ALL Programs. Required data is marked with an asterisk (*).
Enrollment Date: _________________ Entry Level: __________________ Class Site: ________________________
STUDENT DATA
Social Security Number: ___________ - _________ - ____________ *Date of Birth: __________________________
*Name: __________________________________________________________________________________________
Last First Middle/Former Name Suffix
*Ethnicity: Are you Hispanic/Latino? Yes *Gender: Male Female
No
*Race: American Indian or Alaska Native Asian Black or African-American
Native Hawaiian or Other Pacific Islander White
*Highest Educational Level Completed:
No Formal School 4th grade 8th grade 12th grade (no diploma) Bachelors
1st grade 5th grade 9th grade High School Diploma Masters
2nd grade 6th grade 10th grade GED Diploma Specialists
3rd grade 7th grade 11th grade Associates Doctorate
How did you hear about the program? Print Media Friend TV Radio Referral Internet Family
Previous Enrollment Previous Enrollment in another program: If so, which one? ___________________________
Special Enrollment: Technical College certificate/diploma/degree program Compass/Asset Review
WIA/Economic Development/Work Ready Georgia High School Graduation Test Other ___________________
STUDENT CONTACT INFORMATION
Address: _________________________________________________________________________________________
Street Address/ Apartment Number / PO Box *City *State *Zip
*County of residence: ___________________________ Email Address: ______________________________________
Phone 1: (______)_________________ Phone 2: (______)_________________ Phone 3: (______)________________
EMERGENCY CONTACT INFORMATION
Name: __________________________________________________________________________________________
Last First Middle/Maiden
Address: ________________________________________________________________________________________
Street Address/ Apartment Number / PO Box City State Zip
Relationship: Parent Child Spouse Friend Sibling Other ____________________
Phone 1: (______)_________________ Phone 2: (______)_________________ Phone 3: (______)________________
STUDENT STATUS
*Labor Force Status: Employed *Receiving Public Assistance: Yes
(Select one) Unemployed (i.e. TANF, Food Stamps, Medicaid) No
Not in Labor Force
SPECIAL POPULATIONS/NEEDS
*Special Populations: Low Income Displaced Homemaker Single Parent Dislocated Worker
(Check all that apply) Learning Disabled Adult Physically Disabled Homeless Other _______________
Language spoken at home: __________________________________________________________________________
*Special Needs: If you have a disability and desire any special accommodation for instruction or testing, it is your
responsibility to notify the program administrative office and provide professional documentation of disability. Is there a
need for special accommodations? Yes No Unknown
Requested Accommodations: _______________________________________________________________________
Provided Accommodations: _______________________________________________________________________
Technical College System of Georgia, Office of Adult Education, Intake Assessment Form, Effective: July 1, 2010 1
►The Student Goals page is to be completed by the student and teacher after initial assessment and updated
throughout the year. Goals should be attainable within the reporting period. Please check all goals that apply.
STUDENT GOALS
Educational Gain/Academic Goals: Start date Completion date Comments
Improve reading ability
Improve writing ability
Improve spelling ability
Improve speaking ability
Improve math ability
Improve English language skills
Employment and Education Goals: Start date Completion date Comments
Enter employment
Retain employment
Enter postsecondary education/training program
Obtain a GED/Adult High School Diploma
EL/Civics and Citizenship Education Goals: Start date Completion date Comments
Achieve citizenship skills
Increase community life skills
Achieve US citizenship (optional)
Family Literacy Goals: Start date Completion date Comments
Increase involvement in children's education
Increase involvement in children's literacy
Community Goals: Start date Completion date Comments
Vote or register to vote
Increase involvement in community activities
Leave public assistance program
Health Literacy Goals: Start date Completion date Comments
Improve ability to read information about health
Increase understanding of healthcare delivery systems
Increase understanding of doctors' instructions
Work-Based Learning Goals: Start date Completion date Comments
Achieve Georgia Work Ready Certificate
Achieve workplace literacy and employability skills
Achieve customized workplace literacy goal
Achieve work-based project learning goal
Confidentiality Notice
This adult education program may release your student information for only specific reasons allowed under the Family
Educational Rights and Privacy Act (20 U.S.C. § 1232g; 34 CFR Part 99), such as program evaluation purposes. If you
do not wish this information to be disclosed, please check this box:
*Student’s Signature: __________________________________________ *Date: _________________
*Interviewer’s Signature: _______________________________________ *Date: _________________
Technical College System of Georgia, Office of Adult Education, Intake Assessment Form, Effective: July 1, 2010 2
Technical College System of Georgia
Office of Adult Education
Verification of Eligibility for Services
Name of Student: _
Birth date: Month__________________ Date __________________ Year__________________
Declaration (to be completed by the Student):
I am (check, if applicable, one of the following):
______a citizen of the United States or a legal permanent resident 18 years of age or older.
______a qualified alien, or nonimmigrant under the federal Immigration and Nationality Act, 18
years of age or older lawfully present in the United States.
Please provide the applicant’s Alien Number issued by a federal immigration agency:
___________________________________________________.
PHOTOCOPY of Alien Registration Card, Employment Authorization Document,
Form I-94 or other documentation as provided by the Department of Homeland
Security is attached (If printed on both sides, attach a copy of front and back).
By signing below, I represent that the information I have provided in this declaration is true and correct.
Print Student Name:
Student Signature: Date:
_______________________________________________
Notary Signature
Sworn to and subscribed before me:
This _____ day of (month) ____________, (year) ________
Notary Public
My Commission Expires: ________________________
(print)
Technical College System of Georgia, Office of Adult Education, Intake Assessment Form, Effective: July 1, 2010 3
TEST DATA and CONFERENCE NOTES
BEST Literacy
Date Type Version Form (circle one) Scale Score EFL
/ / Pre Print B C D
/ / Post Print B C D
/ / Post Print B C D
BEST Plus
Date Type Version (circle one) Form (circle one) Scale Score EFL
/ / Pre Computer Adaptive Print-Based N/A A B C
/ / Post Computer Adaptive Print-Based N/A A B C
/ / Post Computer Adaptive Print-Based N/A A B C
Test of Adult Basic Education (TABE)
Date Type Form (circle one) Level (circle one) Scale Score GE EFL
Reading
/ / Pre 9CB 10CB 9S 10S L E M D A
/ / Post 9CB 10CB 9S 10S L E M D A
/ / Post 9CB 10CB 9S 10S L E M D A
Date Type Form (circle one) Level (circle one) Scale Score GE EFL
/ / Pre 9CB 10CB 9S 10S L E M D A
Math
/ / Post 9CB 10CB 9S 10S L E M D A
/ / Post 9CB 10CB 9S 10S L E M D A
Date Type Form (circle one) Level (circle one) Scale Score GE EFL
Language
/ / Pre 9CB 10CB 9S 10S L E M D A
/ / Post 9CB 10CB 9S 10S L E M D A
/ / Post 9CB 10CB 9S 10S L E M D A
WorkKeys Assessment
Date Type Version (circle one) Form Scale Score EFL
Reading for
Information
/ / Pre Internet Paper/Pencil
/ / Post Internet Paper/Pencil
/ / Post Internet Paper/Pencil
Date Type Version (circle one) Form Scale Score EFL
Mathematics
Applied
/ / Pre Internet Paper/Pencil
/ / Post Internet Paper/Pencil
/ / Post Internet Paper/Pencil
Note: Conference notes reflect a dialogue between a teacher and student. They must be recorded at least once per quarter.
___________________________________________________________________________________________________________
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Technical College System of Georgia, Office of Adult Education, Intake Assessment Form, Effective: July 1, 2010 4
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