NEW JERSEY DEPARTMENT OF EDUCATION
FORM
NEW JERSEY DEPARTMENT OF EDUCATION
Division of Programs and Operations
Office of Title I
Immigrant Student Count Summary Verification Form (Form A)
Winter 2011-12
*Please note: this form must be submitted to the NJDOE.
School District:_______________________________________ District Code:_______________________
County: _____________________________________________ County Code:_______________________
Contact Person: ______________________________________ Phone No.:_________________________
E-mail:______________________________________________
Federal regulations define immigrant students as those who:
• are age 3 to 21;
• were not born in any State, and
• have not been attending one or more schools in any one or more States for more than three full academic years.
Students from Puerto Rico and the U.S. Virgin Islands are NOT considered immigrants.
Immigrant Student Count
A) Number of eligible public school immigrant students (Pre-K – 12) _______________________
B) Number of eligible immigrant students enrolled in nonprofit, nonpublic schools within the district
(Please list each school separately). This form may be duplicated if there are more than five nonpublic schools.
County Code School Code Name of School Number of
Immigrant Students
__________ ________ _______________________ _________________________
__________ ________ _______________________ _________________________
__________ ________ _______________________ _________________________
__________ ________ _______________________ _________________________
__________ ________ _______________________ ________________________
Total number of immigrant students
(Totals of section A and B) ________________________
Statement of Assurance
The certifying official for the district (chief school administrator) verifies that immigrant students have been identified
using the following criteria:
• are age 3 to 21;
• were not born in any State, and
• have not been attending one or more schools in any one or more States for more than three full academic
years.
Students from Puerto Rico and the U.S. Virgin Islands are NOT considered immigrants.
I hereby certify that the above information is true and accurate and supporting district documentation/records regarding
Immigrant students are maintained in (indicate where records are kept)_________________________________________.
___________________________________________________ Date ______________________
Chief School Administrator Signature
FORM B
NEW JERSEY DEPARTMENT OF EDUCATION
Division of Programs and Operations
Office of Title I
Immigrant Student Count
Winter 2011-12
Nonpublic School Data Collection Form
The Nonpublic School Verification Form may be duplicated and must be completed by each nonpublic/nonprofit school
within the jurisdiction of the district. This information will be forwarded to the district and recorded in the Immigrant Student
Count Summary Verification (Form A) which will be submitted to the New Jersey Department of Education.
Please Note: This form should be retained on file at the district. Do not forward the Nonpublic School Data Collection Form to the New Jersey Department of Education.
For each language, please provide the number of eligible immigrant students enrolled in nonprofit, nonpublic schools within the district. Please include the native language for each immigrant student, and indicate the number of immigrant students reported in column 1 who have been identified as limited English proficient (LEP).
County Code and Name of School Language Number Of LEP Immigrant
Immigrant Students Students
School Code
__________ ________________ __________________ _____________ _____
________________ _____________ ______
________________ _____________ ______
________________ _____________ ______
________________ _____________ ______
_________________ _____________ ______
________________ _____________ ______
________________ _____________ ______
________________ _____________ ______
________________ _____________ ______
Statement of Assurance
I hereby certify that the above information is true and accurate and represents the total number of immigrant students in _______________________ nonpublic/nonprofit school.
________________________________________________________ Date ___________________
Certifying Official for Nonpublic/Nonprofit School Signature
................
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