LPPFinalReport2010 11

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					                                      THE STATE EDUCATION DEPARTMENT
                                  Office of K-16 Initiatives and Access Programs
                                  Pre-Collegiate Preparation Programs Unit, LPP
                                       89 Washington Avenue Rm 965 EBA
                                                Albany, NY 12234
                         Liberty Partnerships Program (LPP)
           2010 – 2011 Final Report Due Friday September 30, 2011, 12noon

           Please return one original report and one (1) copy to the address
                  above. Also, email the electronic excel version to
                               ktorner@mail.nysed.gov

Name of institution:                                                       Date report submitted:



Name of LPP project:                                                       Project number:




Mailing address:




Contracted # of students to be served:
Actual # of students enrolled:




Name of LPP Director:                                                      E-mail address:



                                                                           Telephone number (include area
Fax number:                                                                code & extension):




                                         Names and Signatures


LPP Director/Date                                                             Chief Executive Officer/Date
LPP INSTITUTION:

DATE:
                                        BASIC STUDENT INFORMATION




                                          School/GED
        Last Name   M.I.   First Name      Program       DOB MM/DD/YYYY
LPP INSTITUTION:

DATE:
                                                 BASIC STUDENT INFORMATION




        Last Name   M.I.   First Name   Gender                  Race/Ethnicity
LPP INSTITUTION:

DATE:

                                                                           LPP PARTICIPATION INFORMATION



                                        Term
                                        Student
                                        Participat Date of First Entry into Grade Level at of start Current Grade Level
        Last Name   M.I.   First Name   ed in:     LPP                      of LPP                  for 2010-2011         Student Status
LPP INSTITUTION:

DATE:
                                                                    LPP PARTICIPATION INFORMATION
                                                        Student Risk Factors (Place the number "1" in all that apply)




                                                                                                                  Family/Peers Have
                                                                  Inconsistent or Poor     Behavior/ Disciplinary History of Dropping
        Last Name   M.I.   First Name   Poor Academic Performance Attendence               Problems               out of School
LPP INSTITUTION:

DATE:
                                                                      LPP PARTICIPATION INFORMATION
                                                          Student Risk Factors (Place the number "1" in all that apply)




                                        Negative Change in History of Child Abuse or Foster Care/ Homeless/ History of Substance
        Last Name   M.I.   First Name   Family Circumstances Neglect                 Residence in a Shelter Abuse
LPP INSTITUTION:

DATE:
                                                                      LPP PARTICIPATION INFORMATION
                                                          Student Risk Factors (Place the number "1" in all that apply)




                                        Limited English        Teen Pregnancy and/or
        Last Name   M.I.   First Name   Proficiency            Parenting             Negative Peer Pressure Other (Explain)
LPP INSTITUTION:

DATE:
                                        LPP PARTICIPATION INFORMATION




                                        Primary Eligibility
        Last Name   M.I.   First Name   Factor
LPP INSTITUTION:

DATE:
                                                                       Report of Student Services
                                                     Number of hours students received each of the following services:




                                                                       College, Career,
                                        Parent        Academic         Financial Aid          Personal/Family     Workforce
        Last Name   M.I.   First Name   Engagement    Counseling       Counseling             Counseling          Preparation
LPP INSTITUTION:

DATE:
                                                                            Report of Student Services
                                                          Number of hours students received each of the following services:




                                        Cultural                                                    Part-time/Summer Recruitment,
                                        Enrichment/                                                 Employment       Retention and
        Last Name   M.I.   First Name   Sports Programs      Mentoring Services Service-Learning    Preparation      Follow-up
LPP INSTITUTION:

DATE:
                                            Report of Student Services
                                         Number of hours students received




                                        Explanation of   Number of hours
                                        Other services   on other services
        Last Name   M.I.   First Name   provided         provided
LPP INSTITUTION:

DATE:
                                                                          Outcomes
                                                                          Graduation




                                        Did student
                                        advance in grade    Did student
        Last Name   M.I.   First Name   level by Aug. 31?   graduate?          Type of Diploma Graduate Received
LPP INSTITUTION:

DATE:
                                                                  OUTCOMES
                                                          Postsecondary Education Plans




                                        Type of               Name of               Start date at
                                        College/University    College/University    postsecondary
        Last Name   M.I.   First Name   Student will Attend   Student will Attend   institution
LPP INSTITUTION:

DATE:
                                                                                OUTCOMES
                                                Not Pursuing College Graduation Plans




                                        Not Pursuing College
        Last Name   M.I.   First Name   Graduation Plans        Other (Explain)            Type of employment
LPP INSTITUTION:

DATE:
                                                 Premature Exit from Program
                                                                   Reason for Separation




                                                             Reason for
        Last Name   M.I.   First Name   Date of Exit         Separation Other
LPP INSTITUTION:

DATE:

                                                               Student Promotion




                                        Was the Student Promoted by
                                        August 31st of the program    What grade level was the student
        Last Name   M.I.   First Name   year?                         promoted or remitted to?
Section: 2
                                          CUMULATIVE INFORMATION REPORT
GENERAL INFORMATION
         Institution:
                                                                                             12            2011
                                                                                            MONTH    DAY   YEAR
4. Total Number of Enrollees:                                                 0
CUMULATIVE INFORMATION
FREQENCIES OF STUDENTS BY DEMOGRAPHIC CHARACTERISTICS
                                                GRADE LEVEL
Gender Ethnicity                      5 6    7     8   9   10            11       12        TOTALS
                                                                                       GED (13)
       African American               0 0    0     0   0    0             0        0    0       0
       White, non-hispanic            0 0    0     0   0    0             0        0    0       0
       Hispanic/Latino(a)             0 0    0     0   0    0             0        0    0       0
       American Indian/Alaskan Native 0 0    0     0   0    0             0        0    0       0
  Males




       Asian                          0 0    0     0   0    0             0        0    0       0
       Hawaiian or Pacific Islander   0 0    0     0   0    0             0        0    0       0
       Bi-racial or Multi-racial      0 0    0     0   0    0             0        0    0       0
       Other                          0 0    0     0   0    0             0        0    0       0
            Subtotal                             0   0   0   0   0   0   0        0     0     0
            African American                     0   0   0   0   0   0   0        0     0     0
            White, non-Hispanic                  0   0   0   0   0   0   0        0     0     0
            Hispanic/Latino                      0   0   0   0   0   0   0        0     0     0
            American Indiatn/Alaskan Native      0   0   0                                    0
  Females




                                                             0   0   0   0        0     0
            Asian                                0   0   0   0   0   0   0        0     0     0
            Hawaiian or Pacific Islander         0   0   0   0   0   0   0        0     0     0
            Bi-racial or Multi-racial            0   0   0   0   0   0   0        0     0     0
            Other                                0   0   0   0   0   0   0        0     0     0
            Subtotal                             0   0   0   0   0   0   0        0     0     0
                                        TOTALS   0   0   0   0   0   0   0        0     0     0
                                Reason for Referral:                                Total Hours of Services Provided:
                       Poor Academic Performance           0                                      Parent Engagement       0
                   Inconsistent or Poor Attendance         0                                     Academic Counseling      0
                    Behavior/Disciplinary Problems         0                 College, Career, Financial Aid Counseling    0
Family/Peers Have history of Dropping out of School        0                               Personal/Family Counseling     0
          Negative Change in Family Circumstances          0                                   Workforce Preparation      0
                   History of Child Abuse or Neglect       0                    Cultural Enrichment/ Sports Programs      0
       Foster Care/Homeless/Residence in a Shelter         0                                       Mentoring Services     0
                         History of Substance Abuse        0                                         Service-Learning     0
                         Limited English Proficiency       0             Part-time/Summer Employment Preparation          0
                  Teen Pregnancy and/or Parenting          0                                               Afterschool #REF!
                             Negative Peer Pressure        0                    Recruitment, Retention and Follow-up      0
                                              Other        0                   Explanation of Other services provided     0
                                                                         Number of hours on other services provided       0
                                             TOTAL         0                                                   TOTAL #REF!


ADVANCEMENT RECORDS                                    Count   %        REASONS FOR SEPARATION
Students who advanced to the next grade                    0   ######   Employment                               0
Student who did not advance to next grade level            0   ######   Family responsibility                    0
Students who graduated                                     0   ######   Withdrew from school                     0
Students who did not graduate                              0   ######   Transferred into another LPP             0
                                                                        Transferred out of service area          0
                                                                        Medical                                  0
                                                                        Dissatisfied                             0
                                                                        Involved in other activities             0
                                                                        Other                                    0
                                                                                                       TOTAL     0
LPP Durable Goods Inventory                     Institution Name:
September 1, 2009 - August 31, 2011



      Director / Date                           Direct Superviser / Date

      Phone #                                   Phone #

      Email                                     Email

Please Note: All goods purchased with LPP funds are the property of the State and shall be returned to the
Department if the LPP program is discontinued.
Property purchased pursuant to this AGREEMENT is deemed to be the property of the STATE. For
purposes of this form please list electronic items, furniture, musical instruments, durable goods, etc that have
been purchased within the current funding cycle, 9/1/2009-8/31/2011.
 #               Item/Model           Quanity                Serial #            Vendor            Invoice #       Total Cost $
 1
 2
 3
 4
 5
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 7
 8
 9
 10
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 29
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 40
 41
 42
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 44
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 46
 47
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 49
 50
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 52
 53
LPP Durable Goods Inventory                     Institution Name:
September 1, 2009 - August 31, 2011



      Director / Date                           Direct Superviser / Date

      Phone #                                   Phone #

      Email                                     Email

Please Note: All goods purchased with LPP funds are the property of the State and shall be returned to the
Department if the LPP program is discontinued.
Property purchased pursuant to this AGREEMENT is deemed to be the property of the STATE. For
purposes of this form please list electronic items, furniture, musical instruments, durable goods, etc that have
been purchased within the current funding cycle, 9/1/2009-8/31/2011.
 #               Item/Model           Quanity                Serial #            Vendor            Invoice #       Total Cost $
 54
 55
 56
 57
 58
 59
 60
 61
 62
 63
 64
 65
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 80
 81
 82
 83
 84
 85
 86
 87
 88
 89
 90
 91
 92
 93
 94
 95
 96
 97
 98
 99
100
LPP INSTITUTION:
                                Post HS Follow Up                            Post HS Follow Up

                                                      Not Pursuing College
# Last Name        First Name      College Activity   Graduation Plans       Full or Part-Time Employment
 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
LPP INSTITUTION:
                                Post HS Follow Up                            Post HS Follow Up

                                                      Not Pursuing College
# Last Name        First Name      College Activity   Graduation Plans       Full or Part-Time Employment
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
LPP INSTITUTION:
                                Post HS Follow Up                            Post HS Follow Up

                                                      Not Pursuing College
# Last Name        First Name      College Activity   Graduation Plans       Full or Part-Time Employment
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
LPP INSTITUTION:
                                Post HS Follow Up                            Post HS Follow Up

                                                      Not Pursuing College
# Last Name        First Name      College Activity   Graduation Plans       Full or Part-Time Employment
82
83
84
85
86
87
88
89
90
91
92
93
94
95
LPP INSTITUTION:
                                     HS HS Follow
                                PostPostFollow Up Up


   Last Name       First Name      Type of Job Field (Explain)
LPP INSTITUTION:
                                     HS HS Follow
                                PostPostFollow Up Up


   Last Name       First Name      Type of Job Field (Explain)
LPP INSTITUTION:
                                     HS HS Follow
                                PostPostFollow Up Up


   Last Name       First Name      Type of Job Field (Explain)
LPP INSTITUTION:
                                     HS HS Follow
                                PostPostFollow Up Up


   Last Name       First Name      Type of Job Field (Explain)
       Expenditures incurred between:                                         Institution Name:
                                        Statrt Date   End Date
                                                      LPP Year Expenditure Budget Summary

                                                      ROUND CENTS TO THE NEAREST DOLLAR

Line
                                                       Code
                                                                  LPP            Institution           Other Sources
No.    Expenditure Category                                        (1)                (2)                   (3)
 1     Salaries for Professional Personnel              15
 2     Salaries for Non-Professional Personnel          16               $0                       $0               $0
          a. Clerical/Secretarial
          b. Student Assistants
          c. Other
 3     Purchased Services                               40
 4     Supplies & Materials                             45               $0                       $0               $0
          a. Instructional
          b. Other
 5     Travel Expenses                                  46               $0                       $0               $0
          a. Student/Programmatic
          b. Staff/Administrative
 6     Employee Benefits                                80               $0                       $0               $0
          a. Professional
          b. Clerical/Secretarial
          c. Student Assistants
          d. Other
 7     SUBTOTAL (of Lines 1-6)                                           $0                   $0                  $0

 8     Indirect Cost*                                   90

 9     BOCES Services                                   49

10     Minor Remodeling                                 30
11     Equipment                                        20
12     GRAND TOTAL (Lines 7-11)                                          $0                   $0                  $0
       Number of Students Served                                        0
       Cost Per Student                                          #DIV/0!

               ALL AMENDMENTS TO THE BUDGET MUST BE SUBMITTED BY MAY 30, 2009
TOTAL
 (4)
        $0
        $0
       $0
       $0

       $0
       $0
       $0
       $0

       $0
       $0
       $0

       $0
       $0
       $0
       $0
       $0

       $0

       $0

       $0

       $0

       $0
       $0
       $0

				
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