MIS1502
REV 06/14
SCHOOL DATA ENTRY
USE ONLY:
Date: ______________
Initials::____________
Title X – Students in Transition
2014 – 2015 Student Residency Questionnaire
Date _______________________________
Okaloosa County School District wants to make sure that your child receives the best possible education. The information from this
form will help to determine eligibility for benefits under the federal McKinney-Vento Act, a law that provides assistance to students
temporarily displaced from their home for certain reasons. PLEASE PRINT VERY CLEARLY, COMPLETE ONE FORM PER FAMILY and
return the form to your student’s school or teacher.
1.

What is the current student residence?
Living in a residence owned or rented by a parent or legal guardian.
□ Yes □ No
Placed in licensed foster care with DCF.
□ Yes □ No
STOP If the answer to either of the above was “Yes”, STOP and sign below (under Number 6). If the answer to both of the
above was “No”, please continue to Section 2 and complete form. Submit form to student’s school or teacher.
2. Check the one response that best describes the current nighttime residence of the children listed in #5. (Hs)
 In an emergency / transitional shelter (A)
 Temporarily sharing the housing of other persons due to loss of housing, economic hardship, or similar reasons (B)
 Living in a vehicle of any kind, travel trailer park or campground, abandoned building or other substandard housing (D)
 Living in a hotel / motel due to loss of housing, economic hardship, or similar reason (E)
 Awaiting their first placement in foster care (F)
3. Check the one response that best describes the reason for the temporary arrangement selected in the above #2. (Hc)
 Major Manmade Disaster (D) (e.g., environmental disasters, explosions, industrial accidents, chemical leaks, etc.)
 Earthquake (E)  Flood (F)  Hurricane (H)  Tropical Storm (S)  Tornado (T)  Wild fire (W)
 Other Natural Disaster (N)  Mortgage Foreclosure (M)  Unknown (U)
 Other (O) (e.g., lack of affordable housing, long-term poverty unemployment or underemployment, lack of affordable health
care, mental illness, domestic violence, forced eviction, etc.)
4. Unaccompanied Youth (Uy)
 Yes  No
Are the student(s) alone without an adult or with an adult that is not a
parent or legal guardian?
5. Complete the table for all school and pre-school age siblings living in the situation described above.
First Name
MI
Last Name
Birth Date
/
/
/
/
Grade
Current School or Last School Attended
/
/
/
/
6. The undersigned certifies that the information provided is accurate. Submit the signed form to student’s school or teacher.
________________________________________________________
_________________________________________________________
Name of the Person Completing This Form (Print)
Signature of the Person Completing This Form (Signature)
Mailing Address: _____________________________________________________________________________________________________
Street
City
State
Zip
Telephone: _______________________________ Cell phone: ____________________________ Work phone: _________________________
Directions for school staff: For students with positive responses to questions above with respect to Hs, Uy, and Hc sections, complete data entry in S316 with
the indicators selected by the parent/guardian. Complete school data entry box to indicate data entry has been completed and send a copy of the form to:
Title X Liaison, 202 A Hwy 85 N, Niceville, FL 32578 or fax to (850)833-6318.