Intake Assessment Form

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Lanier Technical College
FY2016 Intake Assessment Form
Completion of this form is required for all adult learners in all programs. Required data is in bold with an asterisk (*).
Please print legibly. All signatures should be in ink.
Date
Subject
Form
Level
SS
GE
EFL
*Entry Educational Functioning Level:
Class site:
Other:
Pretest ____TABE ____CLAS E
____ BEST Literacy
Hard copies of all assessment records must be maintained in the student permanent record.
STUDENT DATA
Today’s Date: ________________________
Social Security Number: ________ - ______ - ________ *Date of Birth: _______/_______/_______ Age: __________
Month / day / year
*Name: _________________________________________________________________________________________
Last
First
Middle/Former Name
Suffix
*Hispanic/
No, not Hispanic/Latino
*Gender:
Male
Latino:
Yes, Hispanic/Latino
Female
*Race:
American Indian or Alaska Native
FOR PROGRAM USE ONLY:
Asian
(Select one or more)
Institution 1:___________________________
Black or African-American
Institution 2:___________________________
Native Hawaiian or Other Pacific Islander
White
*Highest Degree or Level of School Completed:
th
th
No Schooling
5
grade
10
grade
Some College, no degree
Doctorate or Professional
Associate’s degree
st
th
th
1
grade
6
grade
11
grade
degree
Bachelor’s degree
nd
th
th
2
grade
7
grade
12
grade (no diploma)
Unknown
Master’s degree
rd
th
3
grade
8
grade
High School Diploma
Specialist’s degree
th
th
4
grade
9
grade
GED
*Where was this Degree or Level of School Completed?
U.S. Based Schooling
Non-U.S. Based Schooling
How did you hear about the program?
Print Media
Friend
TV
Radio
Referral
Internet
Family
Previous Enrollment
Previous Enrollment in another program: If so, which one? ___________________________
Special Enrollment (if applicable):
Technical College Cert./Dip./Deg. program
Compass/Asset Review
WIA/Economic Development/WorkKeys
Georgia High School Graduation Test
Other ___________________________________
I-BEST Accel. Op. (IBESTA)
I-BEST ACE (IBESTM)
I-BEST TAACCT (IBESTT) Banner ID _________________
STUDENT CONTACT INFORMATION
Address: _________________________________________________________________________________________
Street Address/ Apartment Number / PO Box
*City
*State
*Zip
*County of residence: _________________________ Email Address: _______________________________________
Phone 1: (______)_________________ Phone 2: (______)_________________ Phone 3: (______)________________
EMERGENCY CONTACT INFORMATION
Name: ___________________________________________________________________________________________
Last
First
Middle/Former Name
Phone 1: (______)_________________ Phone 2: (______)_________________ Relationship: ___________________
Technical College System of Georgia, Office of Adult Education, Intake Assessment Form, Effective: July 1, 2014
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