Page 1 SC9000 Annual Survey of Children in Local Residential Facilities for Neglected/Delinquent October 2021 Caseload Information Number 1. Enter the number of children, ages 5 to 17 inclusive, who resided in the facility for at least one day during the month of October 2021. Exclude foster home children under the conservatorship of the Texas Department of Family and Protective Services. 2. How were the children accounted for (i.e. monthly roster, sign in sheet)? (Max of 500 Characters) 3. If number has increased/decreased from prior year submission by 25 children or more, please explain why. (Max of 1000 Characters) Supporting Documentation Request Houston ISD is required to collect the information of each student to determine the use of Title I, Part D funds (ESSA § 1424). This information is not shared with outside agencies. Please fill out requested information on the form titled SC9000 Annual Survey Supporting Documentation of Children in Local Residential Facilities for Neglected/Delinquent. This information will need to be filled out for the children that have resided in the facility for at least one day during the month of October 2021.The number of children listed on the supporting documentation must match the number of children entered for the October 2021 caseload information. Facility Name Facility Mailing Address Independent School District Boundary Where the Facility is Located Houston Independent School District Type of Facility Legal or Administrative Basis (Licensed By) If selected other, please specify:
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Page 1
SC9000 Annual Survey of Children in Local Residential Facilities for
Neglected/Delinquent
October 2021 Caseload Information Number 1. Enter the number of children, ages 5 to 17 inclusive, who resided in the facility for at
least one day during the month of October 2021. Exclude foster home children under the conservatorship of the Texas Department of Family and Protective Services.
2. How were the children accounted for (i.e. monthly roster, sign in sheet)? (Max of 500 Characters)
3. If number has increased/decreased from prior year submission by 25 children or more, please explainwhy. (Max of 1000 Characters)
Supporting Documentation Request Houston ISD is required to collect the information of each student to determine the use of Title I, Part D funds (ESSA § 1424). This information is not shared with outside agencies.
Please fill out requested information on the form titled SC9000 Annual Survey Supporting Documentation of Children in Local Residential Facilities for Neglected/Delinquent. This information will need to be filled out for the children that have resided in the facility for at least one day during the month of October 2021.The number of children listed on the supporting documentation must match the number of children entered for the October 2021 caseload information.
Facility Name
Facility Mailing Address
Independent School District Boundary Where the Facility is Located Houston Independent School District Type of Facility
Legal or Administrative Basis (Licensed By)
If selected other, please specify:
Page 2
SC9000 Annual Survey of Children in Local Residential Facilities for
Neglected/Delinquent
Facility Primary Contact First Name Last Name Title
Telephone Email
Sign Date
Page 1
SC9000 Annual Survey Supporting Documentation of Children in Local Residential Facilities
for Neglected/Delinquent
Count of Children Listed
Child Name Age of Child
Date Child was Admitted to
Facility
Child Still Resides in Facility – Yes or No
Date Child Vacated the Facility (if no
longer in facility)
Status of Child – Neglected (N) or Delinquent (D)
1
2
3
4
5
6
7
8
Name of Facility:
INSTRUCTIONS - Please fill out the requested information below. The number of children listed on this form MUST match the number of children indicated to reside in the facility for at least one day during the month of October 2021 on the form titled SC9000 Annual Survey of Children in Local Residential Facilities for Neglected/Delinquent.
NOTE – All children listed MUST have resided in the facility for at least ONE day during the month of October 2021.
Additional blank pages have been provided, if needed.
Page 2
SC9000 Annual Survey Supporting Documentation of Children in Local Residential Facilities
for Neglected/Delinquent
Count of Children Listed
Child Name Age of Child
Date Child was Admitted to
Facility
Child Still Resides in Facility – Yes or No
Date Child Vacated the Facility (if no
longer in facility)
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Status of Child – Neglected (N) or Delinquent (D)
Page 3
SC9000 Annual Survey Supporting Documentation of Children in Local Residential Facilities
for Neglected/Delinquent
Count of Children Listed
Child Name Age of Child
Date Child was Admitted to
Facility
Child Still Resides in Facility – Yes or No
Date Child Vacated the Facility (if no
longer in facility)
23
24
25
26
27
28
29
30
31
32
33
34
35
36
Status of Child – Neglected (N) or Delinquent (D)
Page 4
SC9000 Annual Survey Supporting Documentation of Children in Local Residential Facilities
for Neglected/Delinquent
Count of Children Listed
Child Name Age of Child
Date Child was Admitted to
Facility
Child Still Resides in Facility – Yes or No
Date Child Vacated the Facility (if no
longer in facility)
37
38
39
40
41
42
43
44
45
46
47
48
49
50
Status of Child – Neglected (N) or Delinquent (D)
Page 5
SC9000 Annual Survey Supporting Documentation of Children in Local Residential Facilities
for Neglected/Delinquent
Count of Children Listed
Child Name Age of Child
Date Child was Admitted to
Facility
Child Still Resides in Facility – Yes or No
Date Child Vacated the Facility (if no
longer in facility)
51
52
53
54
55
56
57
58
59
60
61
62
63
64
Status of Child – Neglected (N) or Delinquent (D)
Page 6
SC9000 Annual Survey Supporting Documentation of Children in Local Residential Facilities
for Neglected/Delinquent
Count of Children Listed
Child Name Age of Child
Date Child was Admitted to
Facility
Child Still Resides in Facility – Yes or No
Date Child Vacated the Facility (if no
longer in facility)
65
66
67
68
69
70
71
72
73
74
75
76
77
78
Status of Child – Neglected (N) or Delinquent (D)
Page 7
SC9000 Annual Survey Supporting Documentation of Children in Local Residential Facilities
for Neglected/Delinquent
Count of Children Listed
Child Name Age of Child
Date Child was Admitted to
Facility
Child Still Resides in Facility – Yes or No
Date Child Vacated the Facility (if no
longer in facility)
79
80
81
82
83
84
85
86
87
88
89
90
91
92
Status of Child – Neglected (N) or Delinquent (D)
Page 8
SC9000 Annual Survey Supporting Documentation of Children in Local Residential Facilities
for Neglected/Delinquent
Count of Children Listed
Child Name Age of Child
Date Child was Admitted to
Facility
Child Still Resides in Facility – Yes or No
Date Child Vacated the Facility (if no
longer in facility)
93
94
95
96
97
98
99
100
Status of Child – Neglected (N) or Delinquent (D)
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