Private Schools

Attachment G.1-CEO Student Sampling File Documentation Form

N SLP AND SBP ACCESS, PARTICIPATION, ELIGIBILITY,
AND CERTIFICATION STUDY (APEC-II)

CEO SCHOOLS

C onducted on behalf of the USDA

Phone: 1-8XX-XXX-XXX

Email: email@mathematica-mpr.com

SAMPLING DATA FILE

Background:

As part of the study we will need to collect lists of students in the following schools:

1. SCHOOL1

2. SCHOOL2

3. SCHOOL3

For schools operating in their first year of CEO or schools that are revising their claiming percentages in their second year, lists should reflect information as of April 1, 2012 and include all students enrolled in these schools at that time.

For schools operating beyond their first year of CEO and are not revising their claiming rates, lists should reflect information as of April 1, 2011 and include all students enrolled in these schools at that time.

For schools operating in their first year of CEO or operating beyond their first year of CEO and are not revising their claiming rates, the lists should include all enrolled students (at reference period), specifying the following for each enrolled student:

1. Students certified to receive free and reduced price meals by application

2. Students directly certified for free meals

3. Students certified to receive free and reduced price meals through special program participation, not by application:

   1. Migrant students (i.e. students enrolled in MEP)

   2. Runaway and/or homeless students (i.e. in assistance programs under Runaway and Homeless Youth Act)

4. Students with paid status (denied applicants and non-applicants)

For schools that are revising their claiming rates in their second year, the lists should include all enrolled students (as of April 1, 2012), specifying the following for each:

1. Students directly certified for free meals

2. Students certified to receive free and reduced price meals through special program participation, not by application:

1. Migrant students (i.e. students enrolled in MEP)

2. Runaway and/or homeless students (i.e. in assistance programs under Runaway and Homeless Youth Act)

3. All other students not directly certified or included in item 2 above

NSLP AND SBP ACCESS, PARTICIPATION, ELIGIBILITY,
AND CERTIFICATION STUDY (APEC-II)

CEO SCHOOLS

Conducted on behalf of the USDA

Phone: 1-8XX-XXX-XXX

Email: email@mathematica-mpr.com

Instructions:

Please provide the data listed below for each student. Acknowledging that this data may be stored in multiple databases and lists, you may provide lists of students separately for each of the criteria above or in the template provided. If you choose to provide separate lists, please be sure to provide descriptions of the values entered in the list. Please provide files in .xls, .csv, or .txt format, with your district name in the document title.

Please provide this file within 2 weeks of receiving this form.

Once completed, please upload the data file and this form to __________. This is a secure site that will help protect the privacy of the data. If you have any questions about completing this form, please contact your liaison at Mathematica, or a member of the study team at 1-8XX-XXX-XXXX or email@mathematica-mpr.com. DO NOT email the data file to this address.

SAMPLING DATA FILE: REQUESTED DATA ITEMS

(SCHOOLS IN THEIR FIRST YEAR OF CEO OR SCHOOLS OPERATING BEYOND THEIR FIRST YEAR AND NOT UPDATING THEIR CLAIMING RATES)

NOTE: This information will only be used for matching to other records. Students and parents will not be contacted by the study.

1. Student ID

2. Student First Name

3. Student Middle Name

4. Student Last Name

5. Gender

6. Race

7. Ethnicity

8. Date of Birth

9. Student's Street Address, Line 1

10. Student's Street Address, Line 2

11. Student's City of Residence

12. Student's State of Residence

13. Student's Zip Code (5 digits)

14. Parent/Guardian First Name

15. Parent/Guardian Last Name

16. Parent/Guardian Street Address, Line 1

17. Parent/Guardian Street Address, Line 2

18. Parent/Guardian State of Residence

19. Parent/Guardian Zip Code (5 digits)

20. Parent/Guardian Last 4 Digits of Social Security Number (when available from meals application)

21. Student's School (Name or NCESID)

22. Student Certification Status [Free, Reduced-Price, or Paid/Full-Price]

23. Special Circumstance [Runaway, Homeless, or Migrant]

If certified (free or reduced-price):

24. Certification Method [Direct or Application]

25. Date of Certification

If certified by application:

26. Was student categorically eligible for free meals? (based on receipt of other assistance)

27. IF YES: Category of eligibility [SNAP, FDPIR, TANF, OTHER]

If directly certified:

28. Directly Certified [SNAP, FDPIR, TANF, or OTHER]

If paid/full price:

29. Did student apply and had application denied?

In addition to student-level data, please provide:

• A count of total currently enrolled students as of <CURRENT MONTH, YEAR>

SAMPLING DATA FILE: REQUESTED DATA ITEMS

(SCHOOLS BEYOND THEIR FIRST YEAR OF CEO AND UPDATING THEIR CLAIMING RATES)

NOTE: This information will only be used for matching to other records. Students and parents will not be contacted by the study.

1. Student ID

2. Student First Name

3. Student Middle Name

4. Student Last Name

5. Gender

6. Race

7. Ethnicity

8. Date of Birth

9. Student's Street Address, Line 1

10. Student's Street Address, Line 2

11. Student's City of Residence

12. Student's State of Residence

13. Student's Zip Code (5 digits)

14. Parent/Guardian First Name

15. Parent/Guardian Last Name

16. Parent/Guardian Street Address, Line 1

17. Parent/Guardian Street Address, Line 2

18. Parent/Guardian State of Residence

19. Parent/Guardian Zip Code (5 digits)

20. Parent/Guardian Last 4 Digits of Social Security Number (when available from meals application)

21. Student's School (Name or NCESID)

22. Directly certified [SNAP, FDPIR, TANF, OTHER]

23. Certified by special circumstances [Runaway, Homeless, or Migrant]

In addition to student-level data, please provide:

• A count of total currently enrolled students as of <CURRENT MONTH, YEAR>

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this collection is 0584-0530. The time required to complete this information collection is estimated to average 2 hours per response, including the time to review instructions, searching existing data resources, gather the data needed, and complete and review the information collected.

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