Student Profile - 400A
ü Required … Completion of these sections of the “paper Student Profile” is mandatory and MUST be maintained in the individual student
folders. Once completed, all information should be input/updated in AEMIS by the 10th of the following month, per the program assurances/grant
award.
üKey Information
üClass Information... PY 2015-16
RESA ____Grantee ____________________
üFirst Name:________________________
Last Name:
Class Site ____________________________
Class Name __________________________
Middle Name:
______ Maiden Name:____________________
Class # __________-2016-______________
Signed Release of Information on File: o YES (valid for 2 program years)
WVAdultEd Technology Use Policy: o YES
Social Security Number (SSN): ____________-_________-____________
Division of Corrections (DOC) #:______________________
Gender: o Male o Female
Continuing Next PY o Yes
o No
o Yes
o No
Withdraw
o Misdemeanor
üDate of Birth: ___ ___ / ___ ___ / ___ ___ ___ ___
üAddress :_______________________________________________________________________________________________
Street / PO Box
__________________________________________________________________________________________________________
City
State
E-mail:_____________________________
üEthnicity: Answer both parts of the
County
Phone: (______)_______-_________
Zip
Alt Phone: (______)_______-__________
2. What is your race? (Choose one or more)
ethnicity question.
1.
o American Indian or Alaska Native
o Asian
Are you Hispanic / Latino?
(Choose only ONE)
o Black or African American
o Native Hawaiian or Other Pacific Islander
o NO
o White
o Hispanic / Latino
o YES
üStudent Type – select all that apply
o Receiving Public Assistance
o Documented Disability (confidential file)
o Single Parent
o Work Release
o TANF
o SPOKES
o Workplace
üEmployment Status –
o Homeless
o HSE Registrant (upon entry)
o Computer Literacy - student is receiving
computer literacy instruction as a
stand-alone skill
o Family Literacy / Even Start
o ESL
o Maintain Driver’s License (formerly SB14)
select one upon entry
üHighest Degree or Level of
School Completed Upon Entry
o Employed (Unsubsidized)
o Unemployed, in labor force
1. Select one:
· make specific efforts to look for unsubsidized
employment
· are available for work
· includes subsidized employment
o Not in labor force
o US Based Schooling
o Non-US Based Schooling
o Court-Ordered
o Career Tech Ed (CTE) / Higher Ed
o WIA Registrant
o EL Civics
o College Prep
o Career Exploration
o Day Report
o Distance Learner
2. Select one:
o No Schooling
o Some college, no degree
o Grades 1-5
o College or professional degree
o Grades 6-8
o Unknown
o Grades 9-12 (no diploma)
o High School Diploma or alternate credential
o GED or High School Equivalency
· has not looked for work in the last 4 weeks
üReferral Source – select one
o Local Job Service / Workforce WV
o Job training program
o Community Action Agency
o HRDF/ROSS (out-of-school Youth Program)
o Adult Education Hotline – 1.800.642.2670
o Library
o Division of Rehab. Services
o DHHR
o Career Tech Ed (CTE) / Higher Ed
o Judicial System (i.e. Court Order, Day Report)
o Counselor
o Employer
o High School (Official Withdrawal Letter on file)
o Family member / Friend
o I attended before
o Literacy WV
o Military
o Other
o TV
o Radio
o Online
o Newspaper
o Brochure
o Billboard
o Home School (Official Withdrawal Letter on file)
Disability Screening – select all that apply
o Screening Questions (Required 3 questions) ü
1. Have you ever had special help or special classes?
2. Do you think you have trouble learning new information or new skills?
3. What kind of things do you have trouble with?
o WV Learning Needs Screening (13 questions)
o Payne Learning Needs Inventory (46 questions)
o PowerPath Big 4 Screenings
05/28/2015... LM
PY 2015-16
Student Profile/400B
Class Number_________-2016-____________
ü Required … Completion of these sections of the “paper Student Profile” is mandatory and MUST be maintained in the individual student folders. Once
completed, all information should be input/updated in AEMIS by the 10th of the following month, per the program assurances/grant award.
üKey Information
Last Name:
Goals for Attending
o
o
o
o
o
First Name:___________________________ Date of Birth: __ __ / __ __ / __ __ __ ___
NOT Used for NRS purposes - Select all that apply for the current program year
o
o
o
o
o
Improve English skills (non-native students)
Pass the High School Equivalency
Enter post-secondary education or job training
Obtain a job
Complete a short-term (12-30hrs) work-based project
üAssessment Information
Complete High School Equivalency Readiness Assessment
Complete a Career Exploration Activity
Complete a College Preparation Activity
Retain current job
OTHER: Personal Goal
o CASAS
o ESL / CASAS
o TABE
o Survey
o Complete Battery
o TABE Large Print Survey
o TABE Audio
o TABE Braille Complete Battery
o TABE Braille Survey
o Citizenship
o Life & Work
o Life Skills
o ESL / BEST
o BEST Plus
o Literacy
o Oral Computer-Adaptive
o Oral Print-Based
NOTE: Enter the lowest assessment area OR the assessment area in which the student is focusing.
Area (Check ONE)
Date
Entry
o Reading
o Math
o Language
o Listening Speaking
Student Achievements –
Interim
Exit
Form
Results
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
Completion of this section of the “paper Student Profile” is optional. This information MUST be updated in AEMIS by the
10th of the following month, per the program assurances/grant award, AND documented in the individual student folders.
EDUCATIONAL
o Increased level gain(s), completed a module, or mastered a CSO(s)
while utilizing a Learning Management System in any assessment
area: Select all that apply
o Plato
o USA Learns
o Skillstutor
o Rosetta Stone
o WIN
o Computer Essentials
o TASC Academy
o Other
o Completed entire vocational / assessment battery / test
o
o
o
o
o
o
Level
(i.e. LPN, TABE, CASAS, ACT)
Completed High School Equivalency Readiness Assessment
Passed High School Equivalency Readiness Assessment
Completed High School Equivalency Orientation
Completed a Career Exploration Activity
Completed a College Preparation Activity
Obtained “Computer Based Testing (CBT)” Skills
FURTHER ED/TRAINING
o Met requirements for entrance into technical training
o Met score requirements on entrance exam for college
(i.e. ACT, SAT, Compass, Accuplacer)
o Enrolled in private WV college / university, specify _________
o Enrolled in out-of-state post-secondary / job training
o Enrolled in private / local training outside of WV’s K-12 system
(i.e. Truck Driving, Cosmetology, Real Estate, Mining, CNA)
o Enrolled in on-line post-secondary / Career Tech Ed (CTE)
(i.e. University of Phoenix Online, DeVry University Online)
o Enrolled in local CTE program (WVEIS)
FAMILY-Increased Involvement in Children’s Education
o Helped children more frequently with school
o Increased contact with children’s teacher
o Increased involvement in children’s school activities
WORK-BASED PROJECT
o Completed all project objectives
INSTITUTUIONAL EDUCATION ONLY
o Cognitive Skills
o CTE
o AE / High School Equivalency
o College 101
EMPLOYMENT-RELATED
The following employment achievements are for ALL WVAdultEd
o
o
o
o
o
Obtained a better job or job promotion
Obtained / retained subsidized job
Earned a Computer Essentials Achievement Certificate
Completed a worksite learning experience
Passed an employment or state licensing exam
The following employment achievements reserved for
SPOKES & Hit the Ground Running enrollees
o Earned a Ready to Work Certificate
o Completed an approved job readiness program
The following employment achievements are reserved for SPOKES enrollees
o Earned a National Career Readiness Certificate (Select all that apply)
o
o
o
o
o Platinum
Earned
Earned
Earned
Earned
o Gold
o Silver
o Bronze
a Customer Service Certificate
a Customer Service Certificate II
an Achievement Certificate
a Microsoft Office Certification (Select all that apply)
o Excel Specialist
o Outlook Specialist
o Excel Expert
o Word Specialist
o Access Specialist
o Word Expert
o PowerPoint Specialist
o MOS Master
o Earned an Intuit QuickBooks Certification
o Earned an Adobe Certified Associate Certification
o Dreamweaver
o InDesign
o Flash
o Premier Pro
(Select all that apply)
o Illustrator
o Photoshop
o Earned IC3 Certification (must achieve all 3 IC3 Credentials)
o Earned IC3 Achievement Credentials: Select all that apply
o Computing Fundamentals
o Living On-line
PERSONAL
o Obtained computer skills
o Other, select ONE o Educational
o Family
o Key Applications
o Personal Goal
o Further Ed/Training
o Employment Related
o Community
FAMILY-Increased Involvement in Children’s Lit. Activities
o Read to children more frequently
o Visited library more frequently
o Purchased books and magazines for children
COMMUNITY
o Increased involvement in community activities
o Voted or registered to vote for the first time
o Became a U.S. Citizen
o Volunteered for Community Service
05/28/2015... LM