INSTRUCTIONS FOR THE INDIVIDUAL STUDENT RECORD FORM

(ISRF) (rev August 2016)

This form is used for collecting student information during the intake process. Each data field has a number that can be cross-referenced between these instructions and the Individual Student Record Form

1. CONTACT INFORMATION:

FIRST NAME: Required Field for ASISTS. Enter the student’s first name on the line provided.

M.I. (MIDDLE INITIAL): not required

LAST NAME: Required Field for ASISTS. Enter the student’s last name on the line provided.

DATE OF BIRTH: Required Field for ASISTS, NRS, and EPE. Enter

the month, day and year of the student's birth. If necessary, add leading zeros to ensure that the month and day each contain two digits; the year must always contain four digits. For example, September 4, 1972 is coded: 09/04/1972.

ORIGINAL PROGRAM START DATE: Required Field for ASISTS.

Enter the month, day and year that the student began working with the program. If necessary, add leading zeros to ensure that the month and day each contain two digits; the year must always contain four digits. For example, September 4, 2016 is coded: 09/04/2016.

ADDRESS: Enter the student's address, including apartment

number, city and state.

HOME PHONE/MOBILE PHONE: Enter the student's area code(s) and phone number(S) in the space provided.

EMAIL: Enter the student's preferred email address in the space provided.

EMERGENCY CONTACT: Enter the phone number for the student’s Emergency Contact person and indicate the name and relationship of that contact to the student.

2. US WORK ELIGIBILITY:

SOCIAL SECURITY NUMBER: Enter the student’s social security number in the space provided

OR

WORK VISA NUMBER: Enter the student’s work visa number in the space provided

OR

VERIFY QUESTION WAS ASKED: Place a check mark in the box to indicate that the student was asked for his/her Social Security Number or Work Visa Number and cannot or will not answer. Initial of Intake staff is also required.

3. GENDER: Required Field for NRS. Check ‘M’ if the student is male. Check ‘F’ if the student is female.

4. RACE/ETHNIC IDENTITY: Required Field for NRS.

Step 1: Check the appropriate box to indicate whether the student identifies as being of Hispanic origin or not.

Step 2: Check the check box for any/all Ethnic Identities the student identifies as:

NATIVE HAWAIIAN: A person who is a member of or descended from the original peoples of the Islands of Hawaii

NATIVE AMERICAN: A person who is a member of or

descended from the original peoples of North America. This category describes American

Indians ALASKAN NATIVE: A person who is a member of or

descended from the original peoples of North America. This category describes Eskimos and Aleuts

ASIAN: A person who is a member of or descended from

any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent. This category includes, for example, people from China, India, Japan and Korea

PACIFIC ISLANDER: A person who is a member of or

descended from any of the original peoples of the Pacific Islands. This category includes, for example, people from the Philippine Islands and Samoa.

AFRICAN AMERICAN: A person born in the United States

who is a member of or descended from any of the original peoples of the Black racial groups of Africa, except for individuals who identify themselves as Latino/a

AFRO-CARRIBEAN: A person born in the Caribbean Islands

who is a member of or descended from any of the original peoples of the Black racial groups of Africa, except for individuals who identify themselves as Latino/a

AFRICAN: A person born in Africa who is a member of or

descended from any of the original peoples of the Black racial groups of Africa, except for individuals who identify themselves as Latino/a

LATINO/A: A person who is a member of or descended

from any of the ethnic groups of Mexico, Puerto Rico, Cuba, Central or South America regardless of race

WHITE (not Latino/a): A person who is a member of or

descended from any of the ethnic groups of Europe, North Africa or the Middle East.

5. EMPLOYMENT STATUS: Required field for NRS and EPE. Check the appropriate space based on the student’s own description of his/her employment status:

EMPLOYED: Adults who did any work at all as paid employees; in

their own business or profession, or on their own farms; or adults who worked 15 or more hours per week as unpaid workers on a farm or in a business operated by a member of the family; and adults who were not working but who had jobs or businesses from which they were temporarily absent.

FT: Employed Full-time: A person working 20 or

more hours per week. PT: Employed Part-time: A person working less than

20 hours per week.

Additional Information: If possible include the name of the student’s employer and the approximate date the student began working there.

UNEMPLOYED & SEEKING EMPLOYMENT: Adults who were not

working but are looking for a job and are available for work. This includes persons who were waiting to be called back to a job from which they had been laid off and persons waiting to report to a new job.

Additional Information: If possible include the approximate date when the student was last employed.

NOT AVAILABLE FOR EMPLOYMENT: Unemployed adults will not or cannot return to the workforce. (NOTE: Students with this Employment status may not be eligible for WIOA funding or other NYSED funding sources that follow WIOA regulations)

INMATE: Adults who are incarcerated at the time of entry.

Additional Information: If possible include the approximate anticipated release date. (NOTE: Students who are more than 5 years away from release may not be eligible for WIOA funding or other NYSED funding sources that follow WIOA regulations)

6. INCOME INFORMATION:

STUDENT’S INDIVIDUAL ANNUAL INCOME: Indicate the student’s Annual Individual Income at the time of entry. NOTE: The amount indicated should be for the student as an individual, not a combined household income.

PUBLIC ASSISTANCE: If the student is receiving financial assistance from federal, state, and/or local public programs, enter the student’s case number and indicate the types of Public Assistance that the student receives.

Additional Information: If the student receives TANF and is set to exhaust his/her TANF benefits within the next 2 years, please indicate this by checking the check box.

7. EDUCATIONAL BACKGROUND: Required for NRS

HIGHEST GRADE COMPLETED IN THE U.S.: Indicate the highest grade that a student completed in a U.S. school.

HIGHEST CREDENTIAL IN OTHER COUNTRIES: Check the highest credential (check only one) received by this student in a country other than the US or Puerto Rico. Please check the credential closest to one of the options listed on the ISRF (High School or Secondary School Diploma, Undergraduate or Bachelor's or Baccalaureate degree, Master's or Graduate Degree, PhD or Doctorate).

YEARS OF SCHOOLING IN OTHER COUNTRIES: If the student did not earn an educational credential but did attend school in a country other than the United States, indicate the number of years of schooling that the student completed. If the number is greater than 12, please enter the value 12+.

CERTIFICATE FROM DOL PROGRAM: Check “Yes” if the student has already attended and completed an approved DOL Certificate program

DOL TRAINING/CERTIFICATE ENROLLMENT: If the student is currently enrolled in an approved DOL Training/Certificate program, please check “Yes”, then answer the additional questions:

What program does the student attend and what certificate does he/she plan to achieve? (Include the CIP code for that program/certificate in the space provided)

If the student is participating in training which is not a DOL eligible Training/Certificate program, is the program leading to a recognized post-secondary credential?

NOTE: The list of approved programs is available from the local Workforce Development Board

8. NATIONALITY:

COUNTRY OF BIRTH: Enter the student’s country of birth. (The list of countries is available at end of this document)

DATE OF U.S. SETTLEMENT: Enter the date of the student's

arrival in the United States. If necessary, add leading zeros to ensure that the month and day each contain two digits; the year must always contain four digits. For example, February 26, 2016 is entered: 02/26/2016.

CITIZEN: A person born or naturalized in the United States and subject to the jurisdiction thereof is a citizen of the United States and of the State wherein he/she resides. 

REFUGEE: A refugee is an individual who has fled a foreign country or power in order to escape danger or persecution. Check the box if this item applies to this student.

IMMIGRANT: An immigrant is anyone who was born outside of the United States and its territories (including Puerto Rico and the U.S. territories of American Samoa, Guam and the Virgin Islands). This includes any refugee admitted (paroled) into this country or any alien except one who is exempt under the provisions of the Immigration and Nationality Act, as amended. Check the box if this item applies to this student.

STUDENT’S PRIMARY LANGUAGE: Indicate the primary language that the student speaks if that language is not English.

9. SCHOOL-AGED CHILDREN:

PARENT/GUARDIAN: Is the student the parent or guardian or primary caretaker of school-aged child or children? Check the Yes or No box as it applies to this student and continue with the next section of this item.

SINGLE PARENT: One who is unmarried, separated, divorced or

widowed and has a minor child or children for whom the parent has either custody or joint custody. Check the Yes or No box as it applies to this student and continue with the next section of this item.

Additional Information: If the answers to either of the above questions in #9 are yes:

Enter the number of children in each school level: preschool, elementary, junior high school and high school. Note that the preschool category includes all children from infancy through kindergarten.

If possible, indicate the name of the school in which the student’s children at each level are enrolled.

(Continue to next page)

10. POPULATION CATEGORIES:

Check all items that apply to this student based on the information the student chose to share during the intake process.

A. HOMELESS: Adults lacking a fixed, regular, and adequate nighttime residence or adults having a primary nighttime residence that is: (1) a supervised publicly or privately operated shelter designed to provide temporary living accommodations (including welfare hotels, congregate shelters, and transitional housing for the mentally ill); (2) an institution that provides a temporary residence for individuals intended to be institutionalized; or (3) a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings. The term "homeless adult" does not include any individual imprisoned or otherwise detained pursuant to an Act of the Congress or a State law.

B. IN CORRECTIONAL FACILITY: Adults who are inmates in any

prison, jail reformatory, work farm, detention center, halfway house, community-based rehabilitation center, or any other similar Federal, State, or local institution designed for the confinement or rehabilitation of criminal offenders.

C. OTHER INSTITUTIONALIZED: Adults who are patients or

residents of a medical or special institution. An example is a halfway house.

D. HIGH SCHOOL GRADUATE OR EQUIVALENT: Adults who have

received a regular high school diploma or an equivalency diploma (HSE), from the U.S. or one of the American territories.

E. DISPLACED HOMEMAKER: participant, at program entry, has

been providing unpaid services to family members in the home and who: (A)(i) has been dependent on the income of another family member but is no longer supported by that income; or (ii) is the dependent spouse of a member of the Armed Forces on active duty (as defined in sec. 101(d)(1) of title 10, United States Code) and whose family income is significantly reduced because of a deployment (as defined in section 991(b) of title 10, United States Code, or pursuant to paragraph (4) of such section), a call or order to active duty pursuant to a provision of law referred to in section 101(a)(13)(B) of title 10, United States Code, a permanent change of station,

or the service-connected (as defined in sec. 101(16) of title 38, United States Code) death or disability of the member; and (B) is unemployed or underemployed and is experiencing difficulty in obtaining or upgrading employment.

F. HEAD OF HOUSEHOLD: Adults who have the primary responsibility for the care of the family.

G. DISABLED: Participant has any type of physical or mental

disability that substantially impairs or restricts one or more major life activities including walking, seeing, hearing, speaking, working, learning. This definition includes adults who are alcohol or drug abusers, mentally retarded, hearing impaired, adults with exceptional learning disabilities and other health impairments. (Specification of disability is optional and may be described on reverse side of form.)

H. ENROLLED IN OTHER EDUCATION/TRAINING: Participant is

currently enrolled in a vocational, occupational training, or an academic program other than the adult literacy program reported on this form.

I. VETERAN: Participant has served on active duty in the Armed

Forces of the United States for at least 180 days and have been discharged under other than dishonorable circumstances.

J. DISLOCATED WORKER: Participants who have been:

Laid off or have received a layoff notice as a result of a plant/business closing or large lay off.

Laid off and are eligible for, or have exhausted Unemployment Insurance benefits. Limited to persons who were employed in occupations not in demand.

Long term unemployed (15 weeks or longer). Limited to persons who were employed in occupations not in demand.

(Continue to next page)

K. EMPLOYED AT 200% POVERTY LINE: Participant is employed and his/her family income does not exceed 200% of the federal poverty level.

Department of Health & Human Services (HHS)2016 Federal Poverty Level Chart

2016 POVERTY GUIDELINES FOR THE 48 CONTIGUOUS STATES AND THE DISTRICT OF COLUMBIAPERSONS IN FAMILY/HOUSEHOLD POVERTY GUIDELINEFor families/households with more than 8 persons, add $4,160 for each additional person.1 $11,8802 16,0203 20,1604 24,3005 28,4406 32,5807 36,7308 40,890

Please check the Department of Health & Human Services website for more/updated information: https://aspe.hhs.gov/poverty-guidelines

L. RURAL AREA RESIDENT: Participant’s living area population is less than 2500 and is not near a city with a population of greater than 50,000.

(Continue to next page)

M. LOW INCOME: Participant, at program entry, is a person who: (a) Receives, or in the 6 months prior to application to the

program has received, or is a member of a family that is receiving or in the past 6 months prior to application to the program has received: (i) Assistance through the supplemental nutrition assistance program (SNAP) under the Food and Nutrition Act of 2008 (7 USC 2011 et seq.);(ii) Assistance through the temporary assistance for needy families program under part A of Title IV of the Social Security Act (42 USC 601 et seq.);(iii) Assistance through the supplemental security income program under Title XVI of the Social Security Act (42 USC 1381); or(iv) State or local income-based public assistance.

(b) Is in a family with total family income that does not exceed the higher of the poverty line or 70% of the lower living standard income level;

(c) Is a youth who receives, or is eligible to receive a free or reduced price lunch under the Richard B. Russell National School Lunch Act (42 USC 1751 et seq.);

(d) Is a foster child on behalf of whom State or local government payments are made;

(e) Is a participant with a disability whose own income is the poverty line but who is a member of a family whose income does not meet this requirement;

(f) Is a homeless participant or a homeless child or youth or runaway youth; or

(g) Is a youth living in a high-poverty area.

N. MIGRANT/SEASONAL WORKER: Participant, at program entry, is a seasonal farmworker and whose agricultural labor requires travel to a job site such that the farmworker is unable to return to a permanent place of residence within the same day.

O. FAMILY LITERACY: Participant is involved in a Family Literacy

program, specifically designed to include interactive literacy activities between parents and their children.

P. PAROLE: The conditional release of a person convicted of a crime prior to the expiration of that person's term of imprisonment, subject to both the supervision of the correctional authorities during the remainder of the term and a resumption of the imprisonment upon violation of the conditions imposed.

Q. LEARNING DISABLED: Participant has physical, mental, or

learning disability restricting life activity. R. RUNAWAY YOUTH: Participant is under 18 years of age and

absents himself or herself from home or place of legal residence without the permission of his or her family.

U. IN COMMUNITY CORRECTIONAL FACILITY: Participant is part of a voluntary recovery or correctional program i.e. a community based support group for substance abuse.

V. OTHER

W. NON NATIVE ENGLISH SPEAKER. Adults for whom English is not their first language.

X. EX-OFFENDER: Participant, at program entry, is a person who either (a) has been subject to any stage of the criminal justice process for committing a status offense or delinquent act, or (b) requires assistance in overcoming barriers to employment resulting from a record of arrest or conviction.

Y. YOUTH IN FOSTER CARE: participant, at program entry, is a person who is currently in foster care or has aged out of the foster care system.

Z. CULTURAL BARRIERS TO LEARNING: participant, at program entry, perceives him or herself as possessing attitudes, beliefs, customs or practices that influence a way of thinking, acting or working that may serve as a hindrance to employment.

11. REFERRAL SOURCE: If the student was referred from another

service provider, please indicate "Yes”, then note the name of that provider. NOTE: this is especially important if the referring agency was a WIOA partner.

(Continue to next page)

12. INITIAL ASSESSMENT INFORMATION:

The Individual Student Record Form (ISRF) has space for two pretest results. The required tests are the BEST Plus 2.0 (BESTP) for ESOL students, or the TABE Reading (TR) and the TABE Math (TM) Test for ABE/HSE students. For each test, document the following:

TEST DATE: (Required) Enter the date of the Assessment. If

necessary, add leading zeros to ensure that the month and day each contain two digits; the year must always contain four digits. For example, February 26, 2016 is coded: 02/26/2016.

TEST NAME: (Required) Enter the name of the test. There is space for two-letter codes, as follows

CODE TEST NAME TR Tests of Adult Basic Education (TABE)

Reading TM Tests of Adult Basic Education (TABE)

Math BESTP2

Basic English Skills Test (Plus) 2.0

LEVEL: (Required for TABE) Enter the letter or number assigned

by the test publisher which identifies the level used

FORM: (Required) Enter the letter or number assigned by the publisher that identifies the form used

SUBSCORE (when applicable): Enter raw scores (i.e. the number

correct) for each subtest with pretest data. If only one subtest was given, leave the other subscores blank. The subscores must be entered in the format indicated below.

For TABE Reading, report the “reading” subscore (only one) in the first subscore column.

For TABE Math, report the “computation” subscore in the

first subscore column and “applied” subscore in the second column.

For ESOL enter no information in the subscore columns.

Report only the BEST Plus 2.0 test score in the “Total” column

GRADE EQUIVALENT (GE): (Optional) Where the grade equivalent

is available, enter the grade equivalent. For the TABE, grade equivalents are calculated by ASISTS and are based on the other scores.

NRS LEVEL: (Optional) Where the NRS Level is available, enter the Level. For all tests, NRS Levels are calculated by ASISTS.

TEST ADMIN: (Required) Record the name of the person administering the pre-test, this person should have attended training for the type of test being administered.

13. INITIAL ENROLLMENT INFORMATION:

Please list the class codes for all of the instructional offerings in which the student is enrolling and the date of enrollment.

14. NOTES: Self Explanatory

15. OTHER STUDENT GOALS:

10. Obtain Citizenship Skills

11. Reduce Public Assistance

12. Get Involved in Community Activities 13. Get Involved in Children’s Education 14. Get Involved in Children’s Literacy Activities

15. Vote or Register to Vote

FORM COMPLETED BY (Signature and Date): The staff person who filled out the form is to sign the form at the bottom, and indicate the date it was completed.

Country Codes for “Country of Birth”

Country Code Country Name Country

Code Country NameAA Aruba CV Cape VerdeAB Albania CY CyprusAC Africa CZ Czech RepublicAD Andorra DJ DjiboutiAE Amerasian DN DenmarkAF Afghanistan DO DominicaAG Angola EA EstoniaAI Anguilla EC EcuadorAL Algeria EG EgyptAM Armenia EN England

AN Antigua & Barbuda EQ Equatorial GuineaAR Argentina ER EritriaAS American Samoa ES El SalvadorAT Austria ET EthiopiaAU Australia FG French GuianaAZ Azerbaijan FI FinlandBA Barbados FJ FijiBD Bermuda FR FranceBE Belize/British

Honduras GA GuamBF Burkina Faso GB GambiaBG Belgium GD GuadeloupeBI Benin GE GreeceBL Bulgaria GG GeorgiaBM Bahamas GH GhanaBN Bangladesh GI GuineaBO Bolivia GL GreenlandBR Brazil GM GermanyBS Belarus GN Guinea-BissauBT Bhutan GO GabonBU Burma - see Myanmar GR GrenadaBV Bosnia and

Herzegovina GU GuatemalaBW Botswana GY GuyanaBX Brunei Darussalam HA HaitiBY Burundi HK Hong KongBZ Bahrain HL NetherlandsCA Cambodia HO HondurasCC Comoros HU HungaryCD Chad IA IraqCE Central African

Republic IB Northern IrelandCG Congo IC Ivory CoastCH China ID IndonesiaCI Chile IE IrelandCL Cayman Islands IL IcelandCM Cameroon IN IndiaCN Canada IR IranCO Colombia IS IsraelCR Costa Rica IT ItalyCS Canary Islands JA JamaicaCT Croatia JO JordanCU Cuba JP Japan

CUR Curacao KI KiribatiCountry Code Country Name Country

Code Country NameKN Kenya PG PortugalKO Korea, South PH PhilippinesKT Korea, North PL PalestineKU Kuwait PN PanamaKV Kosovo PO PolandKY Kyrgyzstan PR Puerto RicoKZ Kazakhstan PX Papua New Guinea

LA Laos PY ParaguayLB Liberia QA QatarLE Lebanon RI Reunion IslandLI Lithuania RO RomaniaLN Liechtenstein RU RussiaLS Lesotho RW RwandaLU Luxembourg SA Saudi ArabiaLV Latvia SAM SamrLY Libya SB SeychellesMA Malaysia SC St. ChristopherMB Montenegro SD ScotlandMC Macao SE SenegalMD Maldives SER SerbiaME Mexico SF South AfricaMF Mauritania SG Solomon IslandsMG Madagascar SH Sao Tome and

PrincipeMH Marshall Islands SI SingaporeMI Mali SJ St. JohnMJ Mongolia SK St. Kitts and NevisML Malagasy SL St. LuciaMM Myanmar SM St. MaartenMN Macedonia SN SurinameMO Morocco SO SomaliaMQ Mozambique SP SpainMR Martinique SQ Sierra LeoneMS Montserrat SR Sri LankaMT Malta SS SloveniaMU Mauritius ST St. ThomasMV Moldova aka

Moldavia SU Sudan

MW Malawi SV St. Vincent & Grenadines

MX Micronesia SW SwedenMY Malaya SX St. CroixMZ Monaco SY SyriaNA Netherlands Antilles SZ SwitzerlandNB Namibia TA TaiwanNE New Guinea TAN TanzaniaNG Nigeria TG TongaNI Nicaragua TH ThailandNO Norway TI TibetNP Nepal TK TurkmenistanNR Niger TN TunisiaNU Nauru TO TogoNZ New Zealand TR Trinidad and TobagoOM Oman TU TurkeyPA Pakistan TV TuvaluPE Peru TZ Tajikistan

Country Code Country Name

U UnknownUA United Arab Emirates

UG UgandaUK UkraineUR UruguayUS United StatesUZ UzbekistanVA VanuatuVB British West IndiesVE VenezuelaVI VietnamVL U.S. Virgin IslandsVR Slovak RepublicWS Samoa WesternYE YemenYU YugoslaviaZI ZaireZM ZambiaZW Zimbabwe