Civic Service Institute
PO BOX 5063, Flagstaff, AZ 86011
(928)523-3560 or Toll Free at (866)856-3017
Foster Grandparent Program Child Assignment & Assessment Plan
Mentoring & Teen Parenting – 2015-2016 School Year
Foster Grandparent (Full Name):
Does the Volunteer:
Name of Volunteer Station/Site:
Station Location (City):
Tutor
Mentor
Both
Please see instructions on back for more details
Complete in the fall
Special
Need
Student Name
(First name & last initial)
Grade
Level
Start Date
Choose
ONE To
Track
(See Codes
Below)
Example: Sue K
10TH
9/1/14
L
Example: Amy J
12TH
9/1/14
F
Complete in the spring
Check
if
Parent
is in
Prison
Check
if
Parent
is a
Veteran
Check
if
Child
is in
Foster
Care
Student Outcomes
End
Date
Academic Engagement
Please Check Either:
Improved
Not Improved
Academic
Performance
Please Check Either:
Improved
Not Improved
5/20/15
X
X
12/7/14
1.
2.
3.
4.
5.
Special Need Codes
A – Abuse or neglect
B – Developmental Challenges
C – Emotional Challenges
D – Hearing Impaired
E – Homeless
F – Adjudicated Youth / Juvenile Offender
G – Language Barriers
H – Learning Disabilities
I – Physical Disabilities
J – Significantly Medically Impaired
K – Substance Abuse
L – Teen Parent
M – Terminally Ill
N – Visually Impaired
O – Other Special Needs _____________
Fall Signature:
Teacher:
How do you measure students’ outcomes?
Date:
Changes in grades
Pre/Post tests
Standardized test scores
Observation
Other: __________________________
Spring Initials:
______________
__________
Date:
__________
I have reviewed this Plan with my teacher and accept this assignment plan for the 2015-16 school year:
Foster Grandparent:
D:\612937700.doc
_____
______________
Updated 8/2015
__________
Information and Instructions for Teachers
Purpose


The Foster Grandparent Program (FGP) is required to measure and report on the activities of the volunteers and the impact those activities have on the
youth with whom they work. This Child Assignment and Assessment Plan (CAAP) allow us to collect all the necessary data as required by our program’s
funders. For the volunteers who serve in your classroom, our program is measuring the impact of the Foster Grandparent volunteer on the students’
academic engagement and academic performance.
o In 2014-2015, teachers reported that 96% of students improved with regard to Academic Engagement and 97% in Academic Performance.
All information provided on this form is confidential. FGP never shares any specific information about a child/youth and his or her special needs. Any data
on these forms is reported in aggregate numbers and not on an individual or school basis.
Instructions




This form can be typed and if you prefer to do so, please visit our website to download the form (http://nau.edu/sbs/csi/programs/foster-grandparent/) or
request an electronic version from your Program Coordinator.
You will receive a blank CAAP at the beginning of the school year or when a new volunteer is placed in your classroom/program. When you receive the
CAAP:
o 1) Identify the 4-6 youth who will be assigned to the Foster Grandparent (we understand that all the volunteer may interact with more youth in the
class/program throughout the year but there must be specific youth identified with whom they will work most closely)
o 2) Complete the first 7 columns of the table
 Each youth’s first name and last initial
 Grade level
 Check if youth has a parent who is in prison or a veteran and if they are in foster care
 Choose one (1) special need code from the box below.
 Check if child has a parent who is in prison or a veteran and if they are in foster care
 Sign and date in the Fall Signature line for teachers.
o 3) Share the information with your volunteer who will also sign and date and return to their Program Coordinator.
o 4) In the spring, FGP will redistribute your CAAP to you through the volunteer. Enter the last day (approximately) the volunteer will be serving in
your classroom, the two columns relating to outcomes, as well as noting how you measured these changes. Initial and date on the Spring set of
lines.
Teachers or other qualified school/organization staff must determine each youth’s Special Need Code. A student does not need to have an Individualized
Education Program (IEP) to qualify to be matched with a Foster Grandparent.
If you have any questions do not hesitate to call your local program coordinator or the Flagstaff office toll free at 1-866-856-3017. We are happy to help.
Thank you and have a great school year!
D:\612937700.doc
Updated 8/2015