north carolina community college system literacy education
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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:
Required use beginning:July 1, 2017
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:
Required use beginning:July 1, 2017
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
Total Math: 442–505
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
Total Math: 506–565
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
Total Math: 566–594
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
L&W Listening: 181-189
362-427 (SPL 2) 21-52
High Beginning ESL
(ESL Level 3)
Total Reading and Writing: 442-482
Total Listening and Speaking: 450-485
Reading: 191-200
L&W Listening: 190-199
428-452 (SPL 3) 53-63
Low Intermediate ESL
(ESL Level 4)
Total Reading and Writing: 483-514
Total Listening and Speaking: 486-525
Reading: 201-210
L&W Listening: 200-209
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
L&W Listening: 210-218
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
L&W Listening: 219-227
525-564 (SPL 6) 76-78