North Carolina Community College System Literacy Education

North Carolina Community College System

Literacy Education Information System (LEIS) – Page 1

LAST NAME ______________________________________ FIRST NAME ___________________________ MIDDLE/MAIDEN NAME _________________________

STUDENT SOCIAL SECURITY #_ STUDENT COLLEAGUE/LACES ID # ____________________________________

Records maintained by the Community Colleges System Office or any community college, which contain personally identifiable information from or about an applicant for admission to one or more constituent institutions or

to one or more community colleges shall be confidential and shall not be subject to public disclosure pursuant to G.S. 132-6(a).

INTAKE DATE (Program Entry date) PROGRAM YEAR PERIOD OF PARTICIPATION FOR PROGRAM YEAR:

(Initial date when student first attends the intake process or returns after exited for more than 90 days. Leave blank for continuing students.)

SEPARATION DATE FOR THIS PERIOD OF PARTICIPATION Course/section # (CC only if using as registration) ___________________________

IF REQUIRED BY YOUR COLLEGE/ORGANIZATION:

Form Completed by: Comments:

Student Signature: Date:

1. Mailing Address ____________________________________________

Address Line 2 ______________________________________________

City State (postal abbreviation)

Zip Code County

2. Home Telephone

Cell Telephone

Email Address

3. Birth Date 4. Gender M F (Month/Day/Year)

5. Ethnicity (Select one.)

1. Hispanic/Latino 2. Non- Hispanic/Non-LatinoRace (Select at least one.)

1. American Indian/Alaska Native 2. Asian 3. White

4. Black or African-American 5. Hawaiian/Pacific Islander

6. Schooling History

Last Secondary/Elementary School Attended

____________________________________________________________

Location ___________________________________________________

Date Last Attended Secondary/Elementary School

Mo. Year

7. Country of Last School Attended

_____ US Based Schooling ____Non-US Based Schooling

8. Highest Educational Level at Entry (check one) ___ No Schooling

___ No diploma (Enter 1 – 11 for last grade completed)

___ High school graduate/Grade 12 completed

___ High School Equivalency graduate

___ Certificate of attendance/completion as a result of completing a IEP

___ Adult High School graduate

___ Some Postsecondary education, no degree

___ Post high school vocational diploma

___ Associate degree

___ Bachelor degree

___ Master degree or higher

___ Unknown

9. Employment Status at Entry

___ FT - Employed full-time

___ PT - Employed part-time

___ Employed, but received notice of termination of employment or military

separation is pending

___ Unemployed (unemployed and currently seeking employment)

___ Not in the Labor Force (retired, not seeking employment, or incarcerated)

DMV Certification – Community College Only

10. NC Residents Under Age 18

Driver’s License Number State of Issue

Date of Issue

Provider Name:

Required use beginning:July 1, 2017

North Carolina Community College System

Literacy Education Information System (LEIS) – Page 2 OFFICE USE ONLY: (To be completed by faculty/staff)

__LAST NAME ______________________________________ FIRST NAME _ ________________________ MIDDLE/MAIDEN NAME

STUDENT COLLEAGUE/LACES ID #

INTAKE DATE (Program Entry date) PROGRAM YEAR PERIOD OF PARTICIPATION FOR PROGRAM YEAR:

IF REQUIRED BY YOUR COLLEGE/ORGANIZATION:

Form Completed by: Comments:

11. Special Programs Specification:

___ Basic Skills Plus student Student is co-enrolled as a Basic Skills Plus Students and meets guidelines for Basic Skills Plus

___ Community Correctional Program* A community-based rehabilitation facility or halfway house

___Correctional Facility* Prison, jail, or other institution for criminal offenders

___ Distance Learning student Greater than 51% contact hours for a student is in distance education

___ Family Literacy student Student participates in a program with a literacy component for parents and children or other intergenerational literacy components.

___ Integrated English Literacy and Civics

Education (IELCE) *Only applicable for providers receiving the IELCE grant. The student is a participant in the IELCE grant program offered by the institution.

___ Integrated Education and Training

(IET) student Student participates in a service that provides adult education and literacy activities concurrently and contextually with workforce preparation activities and

workforce training.

___ Other Institutionalized Program* Any other medical or special institution

___ Workplace Literacy student Student participates in a program designed to improve the productivity of the workforce through improvement of literacy skills needed in

the workplace.

12. Student Data Specification:

____ Aged out of Foster Care At program entry, youth, up to age 24, who have ever been in, or have aged out of the foster care system

____ Displaced Homemaker Provided unpaid services to family in the home, has been dependent on the income of another family member but is no longer supported

by that income, and is unemployed or underemployed and experiencing difficulty obtaining or upgrading employment.

____ English Language Learner(ELL),

Low Levels of Literacy, Cultural Barriers

At program entry, program participant who is an ELL (initial placement in any ESL Level), individual who has a low level of literacy (initial

placement in ABE Level 1 or 2), or who face substantial cultural barriers

____ Exhausting Temporary Assistance for

Needy Families (TANF) Within 2 Years At program entry, program participant who will exhaust Temporary Assistance for Needy Families (TANF)(Part A Title IV of the Social Security Act)

within 2 years

____ Ex-offender The 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.

____ Homeless Program student At program entry: (a) Lacks a fixed, regular, and adequate nighttime residence; or (b) Has a primary nighttime residence that is a publicly supervised

____ Long-term Unemployment The participant, at program entry, has been unemployed for 27 or more consecutive weeks

____ Low income The 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 financial public assistance.

____ Migrant and Seasonal Farmworker Has been primarily employed in agriculture or fish farming labor characterized by unemployment or underemployment; and (ii) faces barriers to economic

self-sufficiency or is a seasonal farmworker and whose job requires travel such that the student cannot return to a permanent residence the same day.

Individual with disability

__Learning Disability __Intellectual Disability

__ Other Disability

The participant indicates that he/she has any "disability”, a physical or mental impairment, that substantially limits one or more of the

person's major life activities.

____ Single Parent Learner has sole custodial support of one or more dependent children. Include Single Pregnant Women.

Provider Name:


North Carolina Community College System Literacy Education Information System (LEIS) – Page 3 OFFICE USE ONLY: (To be completed by faculty/staff)

LAST NAME ______________________________________ FIRST NAME ___________________________ MIDDLE/MAIDEN NAME __________________

STUDENT COLLEAGUE/LACES ID #

SIGN IF REQUIRED BY YOUR COLLEGE/ORGANIZATION:

Form Completed by:

Comments:

Adult High School Only (update #16 - #18 each program year)13. HS credits required to graduate14. # AHS credits transferred in15. # AHS credits earned this program year (July 1 – June 30)

16. Date first AHS course was attempted this program year

17. Date first AHS course was completed this program year

18. Date AHS diploma was earned

High School Equivalency

19. Date HSE earned

20. HSE earned through GED/TASC/HiSET/Multiple Pathway

21. HSE ID

22. Placement and Progress Test Scores – NRS-Approved Tests Only

Date Test Component Level/ Score EFL Form

NRS Approved Tests Through February 2019 (updated 7/1/2016)

Reference the Assessment Manual for Valid Score Ranges and re-test

guidelines

1. BEST Literacy (Forms B, C, D) (BESTLITR)

2. BEST Plus 2 (Forms D, E, F and computer adaptive) (BESTPLUS2)

3. CASAS Life Skills Math (31A, 32A, 33B, 34B, 35C, 36C, 37D, 38D) (CASASMATH)

4. CASAS L&W Reading (27, 28, 81A, 82A, 81AX, 82AX, 83B, 84B, 86C, 185C, 186C, 187D,

188D, 310AA, 311AA) (CASASREAD)

5. CASAS Reading for Citizenship (951A, 952A, 951AX, 952AX) (CASESLCTIRD)

6. CASAS Life & Work Listening (981L, 982L, 983L, 984L, 985L, 986L) (CASESLLWLST)

7. CASAS ESL Reading (27, 28, 81A, 82A, 81AX, 82AX, 83B, 84B, 86C, 185C, 186C, 187D,

188D) (CASESLREAD)

8. TABE CLAS-E Listening (Forms 1A, 2A, 3A, 4A, 1B, 2B, 3B, 4B) (TABECLEL)

9. TABE CLAS-E Reading (Forms 1A, 2A, 3A, 4A, 1B, 2B, 3B, 4B) (TABECLER)

10. TABE CLAS-E Speaking (Forms 1A, 2A, 3A, 4A, 1B, 2B, 3B, 4B) (TABECLES)

11. TABE CLAS-E Total Listening and Speaking (Forms 1A, 2A, 3A, 4A, 1B, 2B, 3B, 4B)

(TABECLETLS)

12. TABE CLAS-E Total Reading and Writing (Forms 1A, 2A, 3A, 4A, 1B, 2B, 3B, 4B)

(TABECLETRW)

13. TABE CLAS-E Writing (Forms 1A, 2A, 3A, 4A, 1B, 2B, 3B, 4B) (TABECLEW)

14. TABE Battery Language (Forms 9 and 10 Levels E, M, D, A) (TABBATLANG)

15. TABE Battery Reading (Forms 9 and 10 Levels L, E, M, D, A) (TABBATREAD)

16. TABE Battery Total Math (Forms 9 and 10 Levels L, E, M, D, A) (TABBATTOMA)

17. TABE Survey Language (Forms 9 and 10 Levels E, M, D, A) (TABSURLANG)

18. TABE Survey Reading (Forms 9 and 10 Levels E, M, D, A) (TABSURREAD)

19. TABE Survey Total Math (Forms 9 and 10 Levels E, M, D, A) (TABSURTOMA)

20. WONDERLIC GAIN Quantitative (Forms A and B) (WONDQUAN)

21. WONDERLIC GAIN Verbal (Forms A and B) (WONDVERB)

Exit Criteria from Advanced ESL (updated 7/1/2017) CASAS Reading> 236; CASAS Life and Work Listening > 228 (Entry into ASE)

TABE CLAS-E Reading >588; Writing >612, Total Reading and Writing >600, Listening >607,

Speaking >594, Total Listening and Speaking > 600 (TABE CLAS-E is exit criteria; must retest

to determine ABE or ASE placement)

BEST Plus2 > 565(BEST Plus2 is exit criteria; must retest to determine ABE or ASE

placement) BEST Literacy – no exit criteria

Future Service (Student must sign below confirming intent to return at scheduled date of service.)

Date of Future Service

Student Signature

Provider Name:


http://www.nccommunitycolleges.edu/sites/default/files/basic-page-file-uploads/ccr/nc_ccr_assessment_policy_july_2016-june_2017_approved_final.pdf#overlay-context=college-and-career-readiness

North Carolina Community College System Literacy Education Information System (LEIS) – Page 4

NRS Approved Test Scale Score Ranges by Educational Functioning Level (See NRS approved list for exact forms and levels) Educational Functioning Level TABE Battery and TABE Survey CASAS GAIN

Beginning ABE Literacy

(ABE Level 1)

Reading: 367 and below

Total Math: 313 and below

Language: 389 and below

Reading: 200 and below

Math: 200 and below

English: 200-406

Math: 200-314

Beginning Basic Education

(ABE Level 2)

Reading: 368–460

Total Math: 314–441

Language: 390–490

Reading: 201–210

Math: 201–210

English: 407-525

Math: 315-522

Low Intermediate Basic Education

(ABE Level 3)

Reading: 461–517


Language: 491–523

Reading: 211–220

Math: 211–220

English: 526-661

Math: 523-669

High Intermediate Basic Education

(ABE Level 4)

Reading: 518–566


Language: 524–559

Reading: 221–235

Math: 221–235

English: 662-746

Math: 670-775

Low Adult Secondary Education

(ABE Level 5)

Reading: 567–595


Language: 560–585

Reading: 236–245

Math: 236–245

English: 747-870

Math: 776-854

High Adult Secondary Education

(ABE Level 6)

Reading: 596 and above

Total Math: 595 and above

Language: 586 and above

Reading: 246 and above

Math: 246 and above

English: 871-1000

Math: 855-1000

Educational Functioning Level TABE CLAS-E CASAS BEST Plus 2 Best Literacy

Beginning ESL Literacy

(ESL Level 1)

Total Reading and Writing: 225-394Total Listening and Speaking: 230-407

Reading:180 and below

L&W Listening: 162-180

88 - 361 (SPL 0-1) 0-20

Low Beginning ESL

(ESL Level 2)

Total Reading and Writing: 395-441

Total Listening and Speaking: 408-449

Reading: 181-190


362-427 (SPL 2) 21-52

High Beginning ESL

(ESL Level 3)



Reading: 191-200


428-452 (SPL 3) 53-63

Low Intermediate ESL

(ESL Level 4)



Reading: 201-210


453-484 (SPL 4) 64-67

High Intermediate ESL

(ESL Level 5)

Total Reading and Writing: 515-556Total Listening and Speaking: 526-558

Reading: 211-220


485-524 (SPL 5) 68-75

Advanced ESL

(ESL Level 6)

Total Reading and Writing: 557-600 Total Listening and Speaking: 559-600

Reading: 221-235


525-564 (SPL 6) 76-78

Documents

North Carolina Community College System Literacy Education