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Needs Assessment

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Sample Forms, Materials, and Policies

Charlotte-Mecklenburg Schools: McKinney-Vento Intake Affidavit
This form is used by Charlotte Mecklenburg Schools to enroll students eligible for McKinney-Vento rights and services. The form details the nighttime living arrangement of the student, documents the student's educational background, requests information about current student needs, and provides a checklist for staff to ensure that all necessary steps have been taken to meet the student's needs and to perform administrative responsibilities related to enrollment.
Download the form.

Iowa Identification and Needs Assessment Form
This form may be used by schools to record pertinent information regarding children and youth identified as living in homeless situations. The form is useful in obtaining a cumulative count of the number of students identified, determining individual needs, maintaining student-level data, and generating summary reports of demographic data, characteristics, and needs of homeless children and youth.
Download the form.

Nash-Rocky Mount Public Schools: Student/Family Assessment Form
This form may be used to document not only basic information about a student (including type of nighttime residence and contact information), but may also be used to document the individual needs of a student and his/her family, including information about health and mental health status, academic concerns, history of abuse, and more. It also may be used to record services offered and referrals made.
Download the form.

Snohomish School District: McKinney-Vento Intake and Referral Form
This one-page form provided by the Snohomish School District (WA) can be used to document eligibility for McKinney-Vento services, services needed by the student, and actions taken by the local liaison to meet student needs. Other states and districts may with to use this form as a guide for developing their own intake forms.
Download the form.

Texas Shelter Care Provider Questionnaire
This questionnaire form the Texas Education Agency (TEA) asks community shelter service providers to respond to questions about educational barriers for children and youth experiencing homelessness. Questions are intended to identify areas where progress has been made and areas where progress still needs to be made.
Download the questionnaire.

Washington Office of the Superintendent of Public Instruction (OSPI): McKinney-Vento Program Intake Form
This one-page form provided by the Washington Office of Superintendent of Public Instruction can be used to document eligibility for McKinney-Vento services and services needed by the student. Other states and districts may with to use this form as a guide for developing their own intake forms.
Download the form.
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The National Center for Homeless Education (NCHE) is the U.S. Department of Education's technical assistance center for the federal Education for Homeless Children and Youth (EHCY) Program. NCHE is housed at the University of North Carolina at Greensboro.

This website was produced with funding from the U.S. Department of Education, on contract no. ED-01-CO-0092/0001. The content of this website does not necessarily reflect the views or policies of the U.S. Department of Education or the University of North Carolina at Greensboro; nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government.

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