Migrant Education ProgramRe-Interview Form

Re-Interview No.: Student Name: Qualifying Arrival Date:

(Target QAD)District: DOB: Grade:

Address: Same as list Different from list (include new address below)

Home Attempt #1 Attempt #2 Attempt #3

Declined Interview Date: Date: Date:

Moved Away (see below) Time: Time: Time:

Indicate reason: New tenants in residence Neighbor indicated family moved Residence empty/abandoned

Interviewer: Date of Interview:

Same as original interview Different from originalPerson Interviewed:

(Check relationship to student) Father Mother Guardian Self Spouse Other:

1. How long have you or your family lived at this address?¿Por cuánto tiempo ha vivido usted o su familia en esta dirección?

(Less than 36 months?) Yes No

1a. Have you traveled recently to other cities or states searching for work?

¿Ha viajado recientemente a otras ciudades u otros estados buscando trabajo?

(Within the last 36 months?) Yes No

2. Where did you live before you moved here? ¿Dónde vivieron antes de mudarse para acá?(Fill this out completely to show the last 36 months)

When/Cuándo From-To/Desde-Hacia Why/Por Qué

Is the Target QAD of listed in #2? Yes No (If No, review COE to identify proper date.)

THE FOLLOWING QUESTIONS ARE REGARDING THIS Target QAD OF .

3. When you moved on (Target QAD), did the child listed above move with you? (If yes, skip question #4.)

Cuando se mudó en (Target QAD), ¿su niño nombrado más arriba se mudó con usted?(Si la respuesta es sí, omita la pregunta #4.)

Yes No

3a. List the full name(s) of all the children who made the move on (Target QAD).Escriba los nombres de todos los niños que hicieron la mudada en (Target QAD).

4. What date did the child(ren) move here?¿Cuál es la fecha en que los niños se mudaron para acá?

(Within last 12 months?) Yes No

Date:

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Migrant Education ProgramRe-Interview Form

Re-Interview No.: Student Name: Target QAD

5. How old are the children that are living with you?¿Cuáles son las edades de los niños que viven con usted?

(Under 22 years old?) Yes No

Ages:

6. (If applicable) Have any of your children graduated from high school or obtained a GED?

(Si aplica) Algunos de sus hijos, ¿se han graduado de la escuela superior o han obtenido un diploma de equivalencia (GED)?

Yes No

7. Why did you/your family move from to on ? (Target QAD)

¿Por qué se mudó usted/su familia de hacia en ? (Target QAD)

(Moved based on Economic Necessity?) Yes No

(Seek or obtain work?) Yes No

8. What type of work were you (or other family member) looking for when you moved on ? (Target QAD)

(If this move does not qualify, ask if there have been other moves that may qualify.)

¿Cuál fue el trabajo que usted u otro miembro de su familia estaba buscando cuando se mudaron en ? (Target QAD)(Si ésta mudada no califica, pregunte si ha habido otras mudadas que quizás califican.)

Agricultural OR Fishing

AND

Seasonal OR Temporary

9. Were you able to get a job in ?(State the qualifying work they mentioned before.)¿Pudo encontrar trabajo en ?(Indique el trabajo, la cual califica, que la persona mencionó anteriormente.)

Yes No(If no, why not?)

10. How soon did it take you to get a job?_________________________?Cuanto tiempo tardo para obtener el trabajo_________________________?

What is the name of the employer?(___________________________?

Yes No

Re-interviewer Comments:

To the best of my knowledge, the information documented on this form is correct.

De acuerdo a mi conocimiento y entendimiento, la información estipulada en éste documento es verdadera.

Signature of person interviewed: Date:

Signature of re-interviewer: Date:

FOR OFFICIAL USE ONLY Review Date:

Eligible as documented on COE

Eligible with corrections on COE required Not Eligible Need more information

to make determination

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