Teachers Data Collection Checklist

Appendix J. Data Collection Checklist for the "Student Health Survey"

Condition: 1

2

3

4

Data Collection Checklist

Form Approved
OMB No: 0920-XXXX
Expiration Date: XX/XX/XXXX

School:________________________________________________
Teacher/Class:_____________________

State: _________

Period/Grade:________________________________
Teacher Use

Student Name or ID

Grade

Gender
(M/F)

Date
Permission
Form
Distributed

Date
Reminder
Distributed

Data Collector Use
Returned
Returned
"Yes" (Parent
"No"
Gives
(Parent
Permission)
Refusal)

No Form
Returned

Absent/
ISS

Student
Refusal

Other**

Returned
Returned
"Yes" (Parent
"No"
Gives
(Parent
Permission)
Refusal)

No Form
Returned

Absent/
ISS

Student
Refusal

Other**

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

TOTAL
Totals

# of
eligible
students

# of
completed
surveys

Males
Females
** The following non-participation codes should be used to identify why students are not eligible to participate in the survey
(e.g.,other). Do not include these students in the enrollment totals or on the Make-Up List.
CCI - Cannot Complete Independently

E - Expelled

M - Moved Away

DC - Dropped Class

EA - Extended Absence

OSS - Out of School Suspension

DS - Dropped School

HB - Homebound

TAC - Took in Another Class

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information
unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden to: CDC Reports Clearance Officer, 1600 Clifton Road, Room MS E-11, Atlanta, GA 30333, ATTN:PRA (0920-XXXX).