PK-12 MOCK FOLDER_Left

You can either obtain pre-pronged folders, add prongs to folders with a 2-hole
puncher, or staple your docs inside the folder. Do not use paper clips to secure your
docs inside the folder for submission.

Write your student’s name or
use a folder label.

THE FOLLOWING SHEETS
GO ON THE LEFT SIDE OF YOUR

FOLDER IN THAT ORDER.

ON THESE SHEETS, LOOK FOR THE BRIEF
HIGHLIGHTED GUIDANCE TO READ.

REVIEW THE STUDENT
FOLDER CHECKLIST FOR

FULL DETAILS.

REMEMBER… wherever you
write/type the Student ID, you must

add the prefix to the ID (the ID is
always 9 digits long for
CIS documentation).

LEFT SIDE OF FOLDER

Student Folder Checklist 2020-2021

Student Name: Josephina Schmo
Student ID: 903404272

Left Side of the Folder

1. Student Folder Checklist (This form)
2. Student Recommendation (Optional; Only if Received on Paper)
3. Parent Consent/Release of Information (Original Mandatory)
4. Family Profile
5. Report Cards from Each Grading Period in 2020-2021 (Original Mandatory)

(Most Recent On Top)

6. First Progress Report for 2020-2021 (Optional; Only if Assessed Before End of First

Grading Cycle)

7. STAAR Score Reports from Spring 2021 (Or Master List) *Cancelled due to COVID
8. STAAR Score Reports from Spring 2020(Or Master List)*Cancelled due to COVID
9. Assets Inventory Score Report and Responses (MANDATORY)

(Print Out Emailed Report if Administered Digitally)

Pre
Post
10. Student Registration And Assessment Information (Print Out From Bluebonnet)
11. Goal Agreement (ORIGINAL MANDATORY)
12. End of Year Outcome Form (Print Out From Bluebonnet)
13. School Faculty Survey (Print Out Emailed Report if Administered Digitally)

Pre - 1
Post – 1

Pre - 2
Post - 2
14. Termination Form (Optional; Only if the Student Leaves Before the end of the School

Year)

15. ISD Withdrawal Verification (Optional; Only if the Student Leaves Before the end of

the School Year)

Right Side of the Folder

1. Student Record Tracking Report (Print out Completed Record Tracking Report

from Bluebonnet at Outcomes Only)

2. CIS Local Service Log (Print out Completed CIS Local Service Logs from

Bluebonnet at Outcomes Only)

No other information, aside from what is listed above, may be included
in this folder, unless specifically authorized by the Director of Q&S.

LEFT SIDE OF FOLDER

Student Recommendation Form 2020-2021

Campus Name and Code: __M__o__c_k__A__c_a_d_e__m__y__9_2__0_-_0_1__6________________ Student ID: __9_0__3_4_0__4_2__7_2__________

Student First Name: ___J__o_s_e__p_h_i_n_a____________ Last Name: ___S__c_h__m_o_________________________ Grade: _2_n__d__

Please check (√) all areas of concern for this student and provide as much information as possible to assist in determining eligibility for CIS
services. If the student receives appropriate consent and is eligible for CIS services, CIS staff will develop a service plan and coordinate
appropriate services for the student. The student may be served at school or referred to an outside agency for services.

 Academics:

____________________________________________________________________________________________________________

 Attendance :

____________________________________________________________________________________________________________

 Behavior:

____________________________________________________________________________________________________________

 Social Service Needs:

____________________________________________________________________________________________________________

My relationship to this student is (select only one): 01-CIS Staff 03-Self Recommendation

07-Peer 09-Parent 12-School Counselor 14-Teacher

16-Assistant Principal 18-Principal 21-School Nurse  23-Juvenile Court

29-Texas Youth Hotline 31-Law Enforcement 32-Other: ____________________________________

Provide Contact Phone Number: ( )

Signature: ___________________________________ Printed Name:__T__e_j__S__i_n_g__h___________________________ Date:__9_-__1_8_-_2__0___

(Signature must be in ink)

Please return this form to the CIS office. Thank you.

CIS Use Only

Verbal recommendation taken from (NAME): _____________________________________________________________
Date________________ CIS Staff Initials________________

Follow-up Note: Date met with Student:_0_9_/_1_8_/_2_0_ Date consent given to student/parent: _0_9_/_1_8_/_2_0_

CIS services needed: yes / no Student interested in services: yes / no

CIS Staff Signature: _________________________________________ Staff Code:__1_0__4_4__5__________ Date: __9_-_1__8_-_2__0________________
Communities In Schools of Texas is a Stay In School program administered by the Texas Education Agency

LEFT SIDE OF FOLDER CIS PARENT CONSENT / RELEASE OF INFORMATION # CI20-2

School Year 2020-2021

Campus Name & Code: _M__o_c_k__A_c_a_d__e_m_y__9_2__0_-_0_1_6_ Student ID: _9_0_3__4_0_4_2__7_2_______________

Student Name: _J__o_s_e_p_h_i_n_a__S_c_h_m__o_____________ Grade: 2__n_d__________________________

Consent to Participate:
1.JIogsievpehpienramission for my child (name):_____J_o_s_e_p_h_in__a_S_c_h_m__o_________________ to participate in the Communities In Schools

(CIS) program for the 2020-2021 school year. Services my child may receive include but are not limited to supportive
guidance/counseling, educational support, tutoring, mentoring, enrichment activities, referrals to other agencies, and other:
__________________________________.
2. I give permission for my child to complete surveys and/or assessments administered by CIS to guide service planning and
determine progress.
3. I acknowledge that this consent is voluntary and may be revoked at any time by informing CIS staff, in writing, except that prior
consent will still apply to the extent that agencies have already acted in reliance of it.
4. I give permission for my child to participate in field trips and other activities sponsored by CIS. Private transportation may be
used in these and other activities.
5. I give permission for routine or emergency medical or dental treatment by any licensed medical doctor to be provided in the event
of illness or accident if I am unable to be reached.

Consent to Release of Information:
6. I give permission for CIS to provide and obtain the following information about my child (name):_J_o_s_e_p_h_i_n_a__S_ch_m__o_________

from the school, school district, the Texas Education Agency and/or the CIS National Office: demographics, grade reports,
attendance records, test scores, disciplinary information, class schedules, identification numbers, free/reduced lunch status,
health-related information, special education information, interventions and services provided, survey responses and other:
_______________.
7. I acknowledge that the information provided and obtained may be used to plan and adjust services that will help my child, for
tracking and reporting purposes, and to evaluate and determine the effectiveness of the CIS program.
8. I acknowledge that the records and information released under this consent will be kept confidential to the extent permitted by
law and used only for the purpose indicated.
9. I acknowledge that the release of records under this consent is subject to any limitations placed by federal and state law.
10.I acknowledge that this consent allows release of data for the school year listed above. Data from this year will be retained for
up to five years and may be shared during that time for evaluation purposes or to provide services that will help my child.
11.I acknowledge that the records released concerning the student may contain references to other persons (i.e., members of the
student’s family).
12.I understand that the data and information collected on my child including documentation of services provided to my child is
maintained in a secure computer database and a case file. I authorize CIS to maintain the information provided for the purposes
noted above in the CIS computer database and case file.
13.I acknowledge that I have the right to inspect or obtain a copy of any record released by this consent upon request in writing to
the releasing agency, subject to any applicable copying costs and legal limitations.

14. In addition, I give permission for CIS to provide and/or obtain the above information and other information noted below from the
following individuals or organizations:

_____________________________Individual/Organization _____________________________Individual/Organization

15. I acknowledge receipt of the CIS Participant Rights.

CIS may use my child’s image as explained herein. I understand that CIS may take and use photographs, digital or other recordings, or other images of my
child participating in the Program as part of its fundraising and marketing efforts. I consent to CIS’s use of my child’s image for these and similar purposes,
whether in printed materials, on the Internet, or in any other medium, without any time limitation. I understand that CIS is not obligated to compensate me

or my child for such use of my child’s image. X☐ YES ☐ NO

My signature below gives permission for my child to participate in the CIS program. My signature authorizes CIS to obtain
the above types of information related to my student and to provide the above types of information to the school, school
district, Texas Education Agency, CIS National Office and/or the released agents identified above.

I release Communities In Schools and its employees, volunteers, or agents from liability for accidents, injuries, or illnesses that may occur

to my child during his/her participation in the program. My child and I understand that we are voluntarily participating in the Communities

In Schools program.

Name (Please print): __J_o_r_g_i_n_a_S_c_h_m__o_______________________________________________________________________

Relationship to Student: X☐ Mother ☐ Father ☐ Legal Guardian ☐ Independent

Address: _1_1_7_1_9_E_v_e_s_b_o_r_o_u_g_h__D_r_i_ve__________________ City: _H_o__u_s_to_n_______________, TX Zip: _7_7_0_9_9___________

Phone: __8_3_2_-_4_5_5_-0_9_1_0____________________________ Phone Type: ☐X Cell ☐ Home ☐ Work

Jorgina SchmoE-Mail: ______________________________________________________________________

Signature: ____________________________________________ (Signature must be in ink) Date: __0_9_-_1_8_-2_0______________

CIS Staff Signature: _______________________________ Staff Code: __1_0__4_4__5___________________Date Received: __9_-_1_8__-_2_0______________

© 2019 Texas Education Agency Updated: JULY 2020 Page 1 of 1

LEFT SIDE OF FOLDER

2020-09-18T08:47:15+00:00 UTC

Mock Academy (920-016)

[email protected]

Josephina
Schmo
(832) 455-0910

1 – January 12 2012

404272

N/A
11719 Evesborough Drive
77009

[email protected]

Jorgina
Schmo

(832) 455-0910

Jorgina Schmo

LEFT SIDE OF FOLDER

From: Tej Singh <[email protected]>
Sent: Tuesday, September 15, 2020 8:36 AM
To: Schmo, Jorgina <[email protected]>
Subject: CIS Parent Consent

Good morning, Ms. Schmo. I enjoyed talking with you about the opportunity for your daughter, Josephina, to
participate in CIS at Mock Academy. If you have any other questions about CIS services, you may call me back.

In order for me to continue visiting with Josephina, please read the attached CIS Consent/Release of Information
Form. Then reply to this message by copying and pasting the following statement in your email with your
daughter’s name and date of birth along with your name as your e-signature. Thank you!

On behalf of [Student Full Name and Date of Birth] I have read the CIS Consent/Release of Information
and agree to the consent and release of information in its entirety. Please accept this statement and my e-
signature as agreement for CIS Services.

Thank you,
Mr. Singh

From: Schmo, Jorgina <[email protected]>
Sent: Friday, September 18, 2020 8:47 AM
To: Tej Singh
Subject: RE: CIS Parent Consent

CAUTION: This email originated from outside of the organization. Do not click links or open
attachments unless you recognize the sender and know the content is safe.

Hello Mr. Singh,

Here you go

On behalf of Josephina Schmo 1/29/12 I have read the CIS Consent/Release of Information and agree to the
consent and release of information in its entirety. Please accept this statement and my e-signature as
agreement for CIS Services.

Jorgina Schmo

832--455--09-10-----------------------------
CIS staff cell phone Parent cell phone

Hello Ms. Schmo. This is Mr. On behalf of Josephina
Singh. Nice talking to you Schmo 1/29/12 I have read
today. Please reply to this the CIS Consent/Release of
text by copying and pasting Information and agree to
the following message… the consent and release of
On behalf of [Student Full information in its entirety.
Name and Date of Birth] I Please accept this statement
have read the CIS and my e-signature as
Consent/Release of agreement for CIS Services.
Information and agree to

Family Profile 2020-2021 LEFT SIDE OF FOLDER

Student Information Campus Name Mock Academy
Campus Code 920-016

Student Name (first) Josephina (last) Schmo

Grade Level: 2nd

Student Information Gender 1 Male 7 Female Ethnicity (required) Race (select all that apply)
1 American Indian/Native Alaskan
Date of Birth 01 / 29 / 2012 1 Hispanic/Latino 2 Asian
OR
(Check ONE) 1 English 3 Spanish 2 NOT Hispanic/Latino 3 Black/African American
5 Native Hawaiian/Other Pacific Islander
HomeLanguage
6 White
5 Vietnamese 9 Other: ___________

The Student Lives WITH: (Check ALL that apply) The Student Lives WHERE: (Check ONLY ONE)

1 Mother 3 Father 1 Immediate Family Home 10 Emergency Shelter
7 Grandmother 12 Other Relative 3 Other Relative's Home 13 Other Perm. Shelter
9 Grandfather 16 Legal Guardian 5 Motel 15 Detention Facility
14 Foster Parent 31 Independent 7 Halfway House 17 Foster Home
18 Step Parent 33 Non-Relative 9 Residential Placement 21 Non-Relative's Home
23 Homeless

Family Information _____ Yes ______ No Number of people living in the household __6___
Female Head of Household (Unmarried woman who

pays more than 50% of costs for mom and her
dependents)

Public Assistance Special Characteristics 11 Gifted & Talented
(Check ALL that apply to student and family) (Check ALL that apply) 12 Special Education
16 JJAEP
99 None 2 Parent(s) Incarcerated*** 23 ESL/LEP**
4 Migrant Family 28 Natural Disaster Victim
4 Public Housing 24 WIA Participant 6 Military Family
6 SSI 25 CHIP 8 Homeless** 30 None
8 Food Stamps 9 Foster Care** 51 Unschooled, Asylee or Refugee

11 Medicaid 10 Physical Disability
13 WIC 50 Immigrant
Student's Country of Origin:

CIS Staff Use Only - The asterisks (**) indicate that the selection
must also be selected on the Eligibilty Criteria Checklist.

903404272 2020-2021 LEFT SIDE OF FOLDER
10/04/2020
Josephina Schmo 2
77099 01/29/2012

LEFT SIDE OF FOLDER

903404272 2020-2021 2
09/20/2020
Josephina Schmo 01/29/2012

77099

LEFT SIDE OF FOLDER 903404272
Josephina Schmo
04/20/2021
Mock Academy
15 60
10/23/2020 4 12
6 12
15 60 00
4 12
84
5 10
11

83

LEFT SIDE OF FOLDER 903404272
10/23/2020
Josephina Schmo
Mock Academy



LEFT SIDE OF FOLDER 903404272
04/20/2021
Josephina Schmo
Mock Academy



LEFT SIDE OF FOLDER

From: Q & S <[email protected]>
To: Tej Singh
Sent: Monday, September 23, 2020 3:30 PM
Subject: Assets Inventory Score Report – Josephina Schmo

CAUTION: This email originated from outside of the organization.
Do not click links or open attachments unless you recognize the
sender and know the content is safe.

Josephina Schmo

Mock Academy

Taken: 09/23/2020

Score: 83%

Self-Mastery, Agency, and Self-Worth

Does the student believe in their own self-worth and ability to control
themselves and the things that happen to them?

I like myself.
Usually

I am a good problem solver.
Usually

I am a good learner.
Usually

I can keep going even when work is hard.
Usually

I know how to make good choices.
Usually

I know how to manage my feelings.
Usually

I know how to take care of myself.
Usually

I know what I want to be when I grow up.
Usually

I can do my work at school.
Usually

I get to help out with chores at home.
Usually

Relationship Connection & Support

Does the student experience close connections through which they discover who
they are and learn how to engage with the world around them? Is the student
supported by people who love, care for, appreciate, and accept them?

I have someone to talk to who listens to me.
Usually

I have friends.
Usually

I know how to get help with a problem.
Usually

My family cares about me.
Usually

I help others at school.
Usually

I have an adult who wants me to do my best.
Sometimes

My teacher helps me in class.
Sometimes

My teacher thinks I am a good learner.
Sometimes

Resources

Does the student have opportunities and resources both in and outside of
school to learn and develop new skills and interests?

I have books to read at home.
Sometimes

I am a member of a club, sports team, church group or other group.
Rarely

I take classes in music, arts, sports or have a hobby.
Rarely

Safety

Does the student feel safe at home, at school and in the neighborhood?

I feel safe at school.
Rarely

I feel safe online or on my phone.
Rarely

I feel safe at home.
Rarely

I sleep well at night.
Never

LEFT SIDE OF FOLDER

From: Q & S <[email protected]>
To: Tej Singh
Sent: Tuesday, April 20, 2021 2:30 PM
Subject: Assets Inventory Score Report – Josephina Schmo

CAUTION: This email originated from outside of the organization.
Do not click links or open attachments unless you recognize the
sender and know the content is safe.

Josephina Schmo

Mock Academy

Taken: 04/20/2021

Score: 84%

Self-Mastery, Agency, and Self-Worth

Does the student believe in their own self-worth and ability to control
themselves and the things that happen to them?

I like myself.
Usually

I am a good problem solver.
Usually

I am a good learner.
Usually

I can keep going even when work is hard.
Usually

I know how to make good choices.
Usually

I know how to manage my feelings.
Usually

I know how to take care of myself.
Usually

I know what I want to be when I grow up.
Usually

I can do my work at school.
Usually

I get to help out with chores at home.
Usually

Relationship Connection & Support

Does the student experience close connections through which they discover who
they are and learn how to engage with the world around them? Is the student
supported by people who love, care for, appreciate, and accept them?

I have someone to talk to who listens to me.
Usually

I have friends.
Usually

I know how to get help with a problem.
Usually

My family cares about me.
Usually

I help others at school.
Usually

I have an adult who wants me to do my best.
Sometimes

My teacher helps me in class.
Sometimes

My teacher thinks I am a good learner.
Sometimes

Resources

Does the student have opportunities and resources both in and outside of
school to learn and develop new skills and interests?

I have books to read at home.
Sometimes

I am a member of a club, sports team, church group or other group.
Rarely

I take classes in music, arts, sports or have a hobby.
Rarely

Safety

Does the student feel safe at home, at school and in the neighborhood?

I feel safe at school.
Rarely

I feel safe online or on my phone.
Rarely

I feel safe at home.
Rarely

I sleep well at night.
Rarely

JOSEPHINA SCHMO LEFT SIDE OF FOLDER

903404272 Mock Academy
2nd Grade 920-016

2020 - 2021

Student Information Recommendation

TUID 8479764252 Recommendation 9/18/2020
Date of Birth 1/29/2012 Date
Tej Singh
Gender Female Case Assigned To Tej Singh
Ethnicity Hispanic
Recommendation CISH Staff
Race White Source
Primary Spanish Behavior
Language Relationship Social
Special ESL/LEP Services
Characteristics Reason

Eligibility

Criteria A student
who is
affected by a
natural
disaster /

Free Lunch

LEP

Not
Advanced

Family Profile Assessment & Service Plan

Lives Where Immediate Family Assessment 10/22/2020
Home Date NA
Number in 6
Household Educational
Lives With Father Goal
Mother
Barriers To Success Plan

Female Head No Academics Grades 500
of Household

Public Medicaid Self Esteem 100
Assistance WIC 100
Behavior
Social Skills

Social Services Basic Needs 200

Consent & Contact

Consent 9/18/2020
Date

Photo Yes
Consent
Parent Name Jorgina Schmo
Address 11719 Evesborough

Drive
Houston, TX 77099
Contact 8324550910
Number

LEFT SIDE OF FOLDER

Name: Josephina Schmo
Student ID Number: 903404272

CIS Staff Signature:
Date: 10/27/20

My goal

NAME Jo Schmo I am not so good at
1. school
I am good at
1. making friends

2. helping my family 2. sports

3. drawing 3. being angry

4. video games

5. jump rope

I want to get better at

sports and not being angry

I will reach my goal by doing

learn to calm down and practice soccer

I will get help from

my teachers and my friends

DEPARTMENT OF PROGRAM OPERATIONS GOAL-SETTING | 1

School Code and 920-016 Mock Academy Grade Level: LEFT SIDE OF FOLDER
Name: Assessment Date:
JOSEPHINA SCHMO 2nd Grade
Student ID and (903404272)
Name: 10/22/2020

TUID: 8479764252 Update Date: N/A

Assigned To: 10445 Tej Singh

Termination Date: 5/9/2021 Reason: 999999-E-Ennddoof fSScchhooool lYYeeaar r OR
OTHER______________________________

Improvement in assessed areas:
1 = improved; 2 = no change; 3 = got worse
*** = Added on Update Date

Academics Grades Improved
1
01 Grades

Behavior Student Health & Wellness Improved
1
16 Self Esteem 1
17 Social Skills

Social Services Improved
2
21 Basic Needs

Promoted to next 103-Promoted
grade level?

Other Information Should student continue CIS services next year? Yes
Needed

Student participated in school or CIS afterschool activities? Yes

CIS Staff Signature ________________________________________ Date: ___6_-_3_-_2_1_______ [mm/dd/yyyy]

LEFT SIDE OF FOLDER

School Faculty Survey
2020-2021

Student Name: _J__o_s_e_p_h_i_n_a_S__c_h_m_o____________ Student ID: _9_0_3__4_0_4_2__7_2________________

School Name: __M__o_c_k__A_c_a_d_e__m_y________________________________________________________

Please rate this student’s demonstrated behavior in the following areas by circling the ranking that most
accurately reflects what you have observed with the student.

Evaluator’s Name: __J_a__n__e__C_h__e_n__________________________ Date: _1_0_-_1_-_2_0_____________
Evaluator’s Title: __E_n__g__li_s_h___T_e__a_c_h__e_r__________________________________________________

Thank you for completing the CIS School Faculty Survey. Your time and opinions are valued and appreciated.
This survey will help us determine the student's need for CIS services, plan possible interventions, and measure
progress. You may be contacted at the end of the year to complete a follow up survey on the student's progress in
the surveyed areas.

LEFT SIDE OF FOLDER

School Faculty Survey
2020-2021

Student Name: _J__o_s_e_p_h_i_n_a_S__c_h_m_o____________ Student ID: _9_0_3__4_0_4_2__7_2________________

School Name: __M__o_c_k__A_c_a_d_e__m_y________________________________________________________

Please rate this student’s demonstrated behavior in the following areas by circling the ranking that most
accurately reflects what you have observed with the student.

Evaluator’s Name: __J_a__n__e__C_h__e_n__________________________ Date: _5_-_1_5_-_2_1_____________
Evaluator’s Title: __E_n__g__li_s_h___T_e__a_c_h__e_r__________________________________________________

Thank you for completing the CIS School Faculty Survey. Your time and opinions are valued and appreciated.
This survey will help us determine the student's need for CIS services, plan possible interventions, and measure
progress. You may be contacted at the end of the year to complete a follow up survey on the student's progress in
the surveyed areas.

LEFT SIDE OF FOLDER

School Faculty Survey
2020-2021

Student Name: _J__o_s_e_p_h_i_n_a_S__c_h_m_o____________ Student ID: _9_0_3__4_0_4_2__7_2________________

School Name: __M__o_c_k__A_c_a_d_e__m_y________________________________________________________

Please rate this student’s demonstrated behavior in the following areas by circling the ranking that most
accurately reflects what you have observed with the student.

Evaluator’s Name: __J_o__r_d__a_n___B__a_k__h_s_h__i__________________ Date: _1_0_-_1_-_2_0_____________
Evaluator’s Title: __S_o_c__i_a_l__S_t_u__d_i_e_s__T__e_a__c_h__e_r__________________________________________

Thank you for completing the CIS School Faculty Survey. Your time and opinions are valued and appreciated.
This survey will help us determine the student's need for CIS services, plan possible interventions, and measure
progress. You may be contacted at the end of the year to complete a follow up survey on the student's progress in
the surveyed areas.

LEFT SIDE OF FOLDER

School Faculty Survey
2020-2021

Student Name: _J__o_s_e_p_h_i_n_a_S__c_h_m_o____________ Student ID: _9_0_3__4_0_4_2__7_2________________

School Name: __M__o_c_k__A_c_a_d_e__m_y________________________________________________________

Please rate this student’s demonstrated behavior in the following areas by circling the ranking that most
accurately reflects what you have observed with the student.

Evaluator’s Name: __J_o__rd__a_n__B_a__k_h_s_h_i______________________ Date: _5_-_1_5_-_2_1_____________
Evaluator’s Title: __S_o_c_i_a_l_S_t_u_d__ie_s__T_e_a__c_h_e_r_______________________________________________

Thank you for completing the CIS School Faculty Survey. Your time and opinions are valued and appreciated.
This survey will help us determine the student's need for CIS services, plan possible interventions, and measure
progress. You may be contacted at the end of the year to complete a follow up survey on the student's progress in
the surveyed areas.

LEFT SIDE OF FOLDER

From: Q & S <[email protected]>
Sent: Tuesday, October 1, 2020 3:40 PM
To: Tej Singh
Subject: Faculty Survey Score Report – Josephina Schmo

[EXTERNAL] This Message Came From an External Source

Josephina Schmo

Mock Academy
Faculty Respondent: Jane
Chen, teacher
Taken: 10/01/2020

Score: 15 out of 20

I have observed this student demonstrating appropriate social
interactions.
Sometimes
I have observed this student making positive choices.
Sometimes
I have observed this student demonstrating a healthy self-concept.
Sometimes
I have observed this student taking responsibility for their school
success.
Sometimes
I have observed this student demonstrating the ability to cope with
challenges.
Sometimes
Additional Comments

LEFT SIDE OF FOLDER

From: Q & S <[email protected]>
Sent: Friday, May 15, 2021 1:40 PM
To: Tej Singh
Subject: Faculty Survey Score Report – Josephina Schmo

[EXTERNAL] This Message Came From an External Source

Josephina Schmo

Mock Academy
Faculty Respondent: Jane
Chen, teacher
Taken: 5/15/2021

Score: 18 out of 20

I have observed this student demonstrating appropriate social
interactions.
Usually
I have observed this student making positive choices.
Usually
I have observed this student demonstrating a healthy self-concept.
Usually
I have observed this student taking responsibility for their school
success.
Sometimes
I have observed this student demonstrating the ability to cope with
challenges.
Sometimes
Additional Comments

LEFT SIDE OF FOLDER

From: Q & S <[email protected]>
Sent: Tuesday, October 1, 2020 3:45 PM
To: Tej Singh
Subject: Faculty Survey Score Report – Josephina Schmo

[EXTERNAL] This Message Came From an External Source

Josephina Schmo

Mock Academy
Faculty Respondent: Jordan
Bakhshi, teacher
Taken: 10/01/2020

Score: 20 out of 20

I have observed this student demonstrating appropriate social
interactions.
Usually
I have observed this student making positive choices.
Usually
I have observed this student demonstrating a healthy self-concept.
Usually
I have observed this student taking responsibility for their school
success.
Usually
I have observed this student demonstrating the ability to cope with
challenges.
Usually
Additional Comments

LEFT SIDE OF FOLDER

From: Q & S <[email protected]>
Sent: Friday, May 15, 2021 1:45 PM
To: Tej Singh
Subject: Faculty Survey Score Report – Josephina Schmo

[EXTERNAL] This Message Came From an External Source

Josephina Schmo

Mock Academy
Faculty Respondent: Jordan
Bakhshi, teacher
Taken: 5/15/2021

Score: 20 out of 20

I have observed this student demonstrating appropriate social
interactions.
Usually
I have observed this student making positive choices.
Usually
I have observed this student demonstrating a healthy self-concept.
Usually
I have observed this student taking responsibility for their school
success.
Usually
I have observed this student demonstrating the ability to cope with
challenges.
Usually
Additional Comments

LEFT SIDE OF FOLDER

Caseload Student Termination 2020-2021

School Name and Code Mock Academy 920-016

Staff Code 10445

Assessment Date 10 / 22 / 2020

Student Name (first) Josephina (last) Schmo

9 0 3Student ID 40 42 72

● Submit termination paperwork by the 9th of the month after the school withdrawal date.

● ASAP - Collect 2 School Faculty Surveys. Place in student folder.
● If student withdraws from school within 30 days of assessment, the Q&S Director/Specialist will remove the student and you will need to replace
the student.

Select the Leaver Reason below that matches the Leaver Reason on the student's Official School Paperwork.

(The codes below are created for CIS internal use and may not match the Leaver Codes from the school paperwork, so match the REASON)

Approved Reasons Dropout Reasons

83 - Administrative Withdrawal 84 - Academic Performance

24 - College, Pursue Degree 10 - Alcohol or other drug abuse program

31 - Completed GED 22 - Alternative Program, working toward diploma or cert.

72 - Court-ordered to GED program, has not earned GED 79 - Expelled, Can Return, Has Not

03 - Deceased 19 - Failed to meet graduation requirements

82 - Enrolled in school outside Texas 15 - Homeless or non-permanent resident

X 80 - Enrolled in school within Texas (verified) 07 - Illness

81 - Enrolled in Texas private school 04 - Joined the Military

78 - Expelled, cannot return 09 - Marriage

01 - Graduated 06 - Missing Youth/Runaway

62 - Graduated as a Military Child 98 - Other

63 - Graduated outside of Texas, Returned, and Left Again 08 - Pregnancy

60 - Homeschooling 02 - Pursue Job/Job Training

61 - Incarcerated in state jail or fed. penitentiary as an adult 20 - Student did not complete GED certification (other than court-
ordered GED Program)

64 - Received GED outside Texas, Returned, and Left Again 96 - Unverified - Enrolled in school within Texas

66 - Removed by Children's Protective Services 12 - Withdrawn/Delinquent Acts

16 - Returned to home country 14 - Withdrawn/Over age

Withdrawal Date : 5 9 2021

LEFT SIDE OF FOLDER

From: Tej Singh <[email protected]>
Sent: Tuesday, May 19, 2020 8:36 AM
To: Citizen, Patrice A <[email protected]>
Subject: Enrollment Status

Good morning, Ms. Citizen. Please advise if the below students are still enrolled at Mock
Academy. If they are not, can I have the withdrawal date and the reason for withdrawal plus
leaver code/status?

Durio, Andria (903555999)
Schmo, Josephina (903404272)
Durio, Zori (903555998)
O'Neal, Kendra (903333232)
Smith, Kya (903222343)

Thank you,
Tej

From: Citizen, Patrice A <[email protected]>
Sent: Tuesday, May 19, 2020 8:47 AM
To: Tej Singh
Subject: RE: Enrollment Status

CAUTION: This email originated from outside of the organization. Do not click links or
open attachments unless you recognize the sender and know the content is safe.

Great Morning Tej,

Below is the following students that are no longer enrolled at Mock Academy. All of
them have enrolled at another school in our district. Leaver code is 80.

Durio, Andria (903555999) ....Welch ES withdrew on 12-09-20
Schmo, Josephina (903404272) ....Welch ES withdrew on 5-09-21
Durio, Zori (903555998) ....Welch ES withdrew on 12-09-20
O'Neal, Kendra (903333232) ....Dawson ES withdrew on 01-22-21
Smith, Kya (903222343) ......Antoine ES withdrew on 12-03-20

If you have any questions please contact me at 832-999-9999.

Citizen