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Literacy Education Information System (LEIS) DATA

NAME ___________________________________________________ (Last) (First) (MI/M) 3. STUDENT DATA (Check All Applicable) Date _ _ / _ _ / _ _ 1. T Community Correctional Program 2. T Compensatory Education Participant 3. T Dislocated Worker 4. T Family Literacy Participant 5. T Homeless Person 6. T Immigrant 7. T Low Income 8. T Migrant Worker 9. T Nonreader 10. T Other Institutionalized Person 11. T Person Receiving Public Assistance 12. T Work-First Participant 13. T Workplace Literacy Participant 14. T Other: Specify 7. STUDENT GOALS/INTENTS Date _ _ / _ _ / _ _ (Check All Applicable) 1. T Higher Level of Independent Living 2. T Increase Daily Living Skills 3. T Learn Basic Functional Skills 4. T Learn to Read (Nonreader) 5. T Improve Reading Skills/Comprehension 6. T Improve Communication Skills (Oral &/or Written) 7. T Improve Math Skills 8. T Complete Current Level 9. T Adult High School Diploma 10. T General Educational Development (GED) 11. T Enter This Community College 12. T Enter Other Postsecondary Education/Training Program 13. T Get Off Public Assistance 14. T Get a Job 15. T Retain a Job 16. T Get a Better Job or Promotion 17. T Achieve Work-based Project Learning Goal

STUDENT SOCIAL SECURITY # _ _ _ - _ _ - _ _

DATE _______________________________

7. STUDENT GOALS/INTENTS (Continued) 18. T U.S. Citizenship 19. T Greater Involvement in Childrens Education 20. T Increase Involvement in Childrens Literacy Activities 21. T Improve Basic Skills for Personal Satisfaction and Increased SelfConfidence 22. T Student Defined Goal _______________ 13. SERVICES NEEDED (Check All Applicable) 1. T Auxiliary Aids 2. T Class for Shut-In 3. T Counseling 4. T Day Care 5. T Financial Assistance 6. T Interpreter 7. T Job Placement 8. T Job Training 9. T Notetaker 10. T Reader 11. T Transportation 12. T Tutoring 13. T Other: Specify 17. AHS UNITS TRANSFERRED IN 18. AHS UNITS NEEDED 19. ROUND-TRIP MILEAGE 20. RECRUITER 22. REFERRED BY (Check All Applicable) COMMUNITY COLLEGE 1. T Adult Education Staff 2. T Community College Recruiter 3. T GED Testing Center 4. T Human Resources Development 5. T Job Training Partnership Act

22. REFERRED BY (Continued) COMMUNITY 6. T Church 7. T Community Organization 8. T Library 9. T Literacy Council 10. T Voluntary Organization GOVERNMENT AGENCIES/PROGRAMS 11. T Antipoverty Program 12. T Correctional Institution 13. T Department of Motor Vehicles 14. T Department of Social Services 15. T Employment Security Commission 16. T Health Agency 17. T Institution for Handicapped 18. T Military/V.A. 19. T Public School 20. T Vocational Rehabilitation MEDIA 21. T Newspaper 22. T Poster, Flier, Letter 23. T Radio 24. T Television PRIVATE SECTOR 25. T Business & Industry 26. T Hospital/Doctor/Clinic 27. T Labor Union 28. T Vocational School OTHER 29. T Friend or Relative 30. T Other Student in Program 31. T Previous Enrollment 32. T Other: Specify ____________________________

Interview Conducted by Comments

Interviewers SS/I.D. # (Revised 5/09/05)