3 Crime Prevention Through Environmental Design (cpted) St

APPENDIX N

Active and Passive CPTED Student Survey Data Collection Checklists

Active Data Collection Checklist

Form Approved

OMB No. 0920-XXXX

Exp. Date:

Public Reporting burden of this collection of information is estimated at 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-24, Atlanta, GA 30333; Attn: PRA (0920-XXXX).

CRIME PREVENTION THROUGH ENVIRONMENTAL DESIGN (CPTED) STUDENT SURVEY

DATA COLLECTION CHECKLIST

School Name: ____________________________________________ Date of Survey Administration: _____________________

Teacher: __________________________________ Grade(s): _____ Class: ______________________ Period: ______ A

	Total Number of Students Enrolled in Class Minus Ineligible* Students	Number of Eligible Students that were Unavailable for this Administration (Code as A – Absent; ISS - In School Suspension; SR – Student Refusal; or NFR – No Form Returned)				Number of Parent Refusals (PR)	Number of Completed Surveys
		A	ISS	SR	NFR
Females
Males
Total

* The following non-participation codes should be used to identify why students are not eligible to participate in the survey. Do not include these students in the enrollment totals or on the Make-Up List.

CCI – Cannot Complete Independently DS – Dropped School EA – Extended Absence MA – Moved Away TAC – Took in Another Class

DC – Dropped Class E – Expelled H – Homebound OSS – Out of School Suspension

Please Print

Student Name or Identifier

Gender

(M/F)

Grade

Date Reminder Sent

Check if Permission

Form was Returned

“No”

Check if Permission

Form was Returned “Yes”

If Student Did NOT Participate

Record Eligibility Code

If Eligibility Code is:

A, ISS, SR

or NFR

• Student IS Eligible for Make-Up

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(OVER →)

Please Print Student Name or Identifier	Gender (M/F)	Grade	Date Reminder Sent	Check if Permission Form was Returned “No”	Check if Permission Form was Returned “Yes”	If Student Did NOT Participate Record Eligibility Code	If Eligibility Code is: A, ISS, SR or NFR Student IS Eligible for Make-Up
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Passive Data Collection Checklist

Form Approved

OMB No. 0920-XXXX

Exp. Date:

Public Reporting burden of this collection of information is estimated at 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-24, Atlanta, GA 30333; Attn: PRA (0920-XXXX).

CRIME PREVENTION THROUGH ENVIRONMENTAL DESIGN (CPTED) STUDENT SURVEY

DATA COLLECTION CHECKLIST

School Name: ____________________________________________ Date of Survey Administration: _____________________

Teacher: __________________________________ Grade(s): _____ Class: ______________________ Period: ______ P

	Total Number of Students Enrolled in Class Minus Ineligible* Students	Number of Eligible Students that were Unavailable for this Administration (Code as A – Absent; ISS - In School Suspension; or SR – Student Refusal)			Number of Parent Refusals (PR)	Number of Completed Surveys
		A	ISS	SR
Females
Males
Total

* The following non-participation codes should be used to identify why students are not eligible to participate in the survey. Do not include these students in the enrollment totals or on the Make-Up List.

CCI – Cannot Complete Independently DS – Dropped School EA – Extended Absence MA – Moved Away TAC – Took in Another Class

DC – Dropped Class E – Expelled H – Homebound OSS – Out of School Suspension

Please Print

Student Name or Identifier

Gender

(M/F)

Grade

Check if Permission

Form was Returned “No”

If Student Did NOT Participate

Record Eligibility Code

If Eligibility Code is:

A, ISS, or SR

• Student IS Eligible for Make-Up

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

(OVER →)

Please Print Student Name or Identifier	Gender (M/F)	Grade	Check if Permission Form was Returned “No”	If Student Did NOT Participate Record Eligibility Code	If Eligibility Code is: A, ISS, or SR Student IS Eligible for Make-Up
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