Adult Education Program

FY2014 Intake Assessment Form

Completion of this form is required for all adult learners in all programs. Required data is marked with an asterisk (*).

Please print legibly. All signatures should be in ink.

*Enrollment Date: ______*Entry Level: ______Class Site: ______

STUDENT DATA

Social Security Number: ______- ______- ______*Date of Birth: ______Age: ______

*Name: ______

Last First Middle/Former Name Suffix

*Hispanic/Latino: No, not Hispanic/Latino *Gender: Male Female

Yes, Hispanic/Latino

*Race: American Indian or Alaska Native Asian Black or African-American

(select one or more) Native Hawaiian or Other Pacific Islander White

*Highest Degree or Level of School Completed:

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Technical College System of Georgia , Office of Adult Education, Intake Assessment Form, Effective: July 1, 2013 (FY14).

No Schooling

1st grade

2nd grade

3rd grade

4th grade

5th grade

6th grade

7th grade

8th grade

9th grade

10th grade

11th grade

12th grade (no diploma)

High School Diploma

GED

Some College, no degree

Associate’s degree

Bachelor’s degree

Master’s degree

Specialist’s degree

Doctorate or Professional degree

Unknown

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Technical College System of Georgia , Office of Adult Education, Intake Assessment Form, Effective: July 1, 2013 (FY14).

*Where was this Degree or Level of School Completed? U.S. Based Schooling Non-U.S. Based Schooling

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/Former Name

Phone 1: (______)______Phone 2: (______)______Relationship: ______

STUDENT STATUS and SPECIAL POPULATIONS

*Labor Force Status: Employed

(select one) Unemployed and looking for work

Not working and not looking for work (e.g. homemaker, retiree, student, etc.)

*Receiving Public Assistance (TANF, Food Stamps): Yes No

*Special Populations: Low Income Displaced Homemaker Single Parent Dislocated Worker

(check all that apply) Learning Disabled Adult Physically Disabled Adult None of the above

Language spoken at home: ______Home Country: ______

Special Accommodations Notice

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 your disability.

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 (ink): ______*Date (ink): ______

STUDENT GOALS

Interviewer: Complete this page with the student at intake. At least one primary goal should be selected. Primary goals are not entered into GALIS. The student may also select secondary goals. Secondary Goals must be entered into GALIS and completion of those goals tracked and reported by the local program.

*Primary Goal(s) for this year:
Improve Basic Literacy Skills:
Reading
Math
Writing
Science
Social Studies / Improve English Language Skills:
Speaking
Listening
Reading
Writing / Get a job
Keep my job
Get a better job
Earn a GED diploma
Enroll in college
Enroll in a training program
Secondary Goal(s) for this year:
Achieve work-based project learning goal
Leave public assistance program
Achieve citizenship skills
Increase involvement in children's education
Increase involvement in children's literacy / Vote or register to vote
Increase involvement in community activities
Achieve U.S. citizenship (GA)
Achieve Georgia Work Ready Certificate (GA)
Other College, Career or Personal Goals: (optional)
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*Intake and Goal-setting Conference Notes:

(Note: Please use the Conference Notes section to update goal progress and completion.)

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*Student’s Signature (ink): ______*Date (ink): ______

*Interviewer’s Signature (ink): ______*Date (ink): ______

*TEST DATA

Hard copies of assessment records must be maintained in the student permanent record. Assessment records for each approved assessment include the following:

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Technical College System of Georgia , Office of Adult Education, Intake Assessment Form, Effective: July 1, 2013 (FY14).

·  BEST Literacy test book and scoring sheet

·  BEST Plus score report

·  GAIN score report

·  TABE answer sheet and score report

·  TABE CLAS-E answer book, writing folio, score report

·  WorkKeys score report

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Technical College System of Georgia , Office of Adult Education, Intake Assessment Form, Effective: July 1, 2013 (FY14).

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
General Assessment of Instructional Needs (GAIN)
English / Date / Type / Version (circle one) / Form (circle one) / Scale Score / GE / EFL
Pre / Online Paper/Pencil / A B
Post / Online Paper/Pencil / A B
Post / Online Paper/Pencil / A B
Math / Date / Type / Version (circle one) / Form (circle one) / Scale Score / GE / EFL
Pre / Online Paper/Pencil / A B
Post / Online Paper/Pencil / A B
Post / Online Paper/Pencil / A B
Test of Adult Basic Education (TABE)
Reading / Date / Type / Form (circle one) / Level (circle one) / Scale Score / GE / EFL
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
Math / Date / Type / Form (circle one) / Level (circle one) / Scale Score / GE / EFL
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
Language / Date / Type / Form (circle one) / Level (circle one) / Scale Score / GE / EFL
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
TABE Complete Language Assessment System – English (TABE CLAS-E)
Listening/
Speaking / Date / Type / Form (circle one) / Level (circle one) / Scale Score / EFL
Pre / A B / 1 2 3 4
Post / A B / 1 2 3 4
Post / A B / 1 2 3 4
Reading/
Writing / Date / Type / Form (circle one) / Level (circle one) / Scale Score / EFL
Pre / A B / 1 2 3 4
Post / A B / 1 2 3 4
Post / A B / 1 2 3 4
WorkKeys Assessment
Reading / Date / Type / Version (circle one) / Form / Scale Score / EFL
Pre / Internet Paper/Pencil
Post / Internet Paper/Pencil
Math / Date / Type / Version (circle one) / Form / Scale Score / EFL
Pre / Internet Paper/Pencil
Post / Internet Paper/Pencil

*CONFERENCE NOTES

Use the Conference Notes section to document interaction with the student. This interaction could include academic advisement, goal progress and completion, assessment results and diagnostics, and service referrals. At least one note is required per quarter of the program year.

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Technical College System of Georgia , Office of Adult Education, Intake Assessment Form, Effective: July 1, 2013 (FY14).