Form Ade 41 123 – Fill Out and Use This PDF

Official Notice of Pupil Withdrawal

Arizona Public Schools

Student Information

1. Student’s Legal Last Name

2. Student’s Legal First Name

3. Middle Name

4. Sr/Jr/2nd/3rd

5. SAIS Student ID

6. School Student ID

7. Grade Level

8. Gender

9. Date of Birth

(mm/dd/ccyy)

Male

Female

/

/

10a. Primary Withdrawal Type

10b. Additional Withdrawal Reason

11. Last day of

attendance (mm/dd/ccyy)

Select the following that best describes why the

(Optional) Select one of the following only if

student is withdrawing from school:

applicable:

W1

Transfer to another school

WR1

School identified for Federal School

W2

Illness

Improvement1

W3

Expelled or long term suspension

WR2

School identified as persistently

W4

Absence or status unknown

dangerous1

W5

Dropout

WR3

Individual Transfer Option (victim of a

W6

Age

violent crime or criminal act)1

W7

Graduated

WR4 Pregnancy / Biological Parent of a Child2

W8

Deceased

/

/

W9

Transfer to be home taught

1 In accordance with No Child Left Behind

W10

Transfer to detention

W11

GED

2 In accordance with ARS §15-1042.H.

W12

Continuing studies at vocational or

technical school

Note for WR1 and WR2

W13

Completed course requirements but did

If a school does not have this designation, or if a student

not pass AIMS

transfers to another school with the same designation, then

this withdrawal reason is invalid

Other ________________________________

________________________________________

12. Parent/Guardian Signature

13. Date (mm/dd/ccyy)

/

/

Information is certified correct according to School records

14. School

15. District /Charter# (CTD)

16. School # (S)

17. Withdrawal Code (based on 10a.)

W ___

18. School Official Signature

19. Date (mm/dd/ccyy)

/

/

Note: If parent or guardian is unable to sign this form, the school district should indicate the reason the signature was not obtainable.

Form #: ADE-41-123, rev 5/2004; in compliance with ARS 15-827.

Official Notice of Pupil Withdrawal FORM INSTRUCTIONS

REVISED JANUARY 2004

ARIZONA PUBLIC SCHOOLS

The information provided below is intended to provide general guidelines for the information to be collected in each box on the Pupil Withdrawal Form.

Required versus Optional: If information for a particular box exists, then it is required to be entered on the form – even if the field is marked optional. Optional fields should only be left blank if the information does not exist or is not reasonably available. The fields marked as Required are necessary for a successful enrollment in the SAIS system.

Box #	Required	Description
1	Yes	Last name of the student as it appears on the document used for registration
2	Yes	First name of the student as it appears on the document used for registration
3	No	Middle name of the student as it appears on the document used for registration
4	No	Name extension (e.g., Jr. Sr., III) as it appears on document used for registration
5	Yes	SAIS Student ID is a number issued by the Arizona Department of Education after the enrollment
		record for this student is submitted to the department
6	Yes	School Student ID is a number issued by the district/charter
7	Yes	Grade Level is standard PS, KG, 1-12, UE (Ungraded Elementary), US (Ungraded Secondary)
8	Yes	Gender of the student
9	Yes	Date of the student’s birth as it appears on the document used for registration
10a	Yes	Type of withdrawal, as identified by the parent/guardian or school official
10b	No	Supplemental withdrawal reason as identified by the student, parent, or guardian (NOT by a school
		official).

•For WR1 and WR2 - If a school does not have this designation, or if a student transfers to another school with the same designation, then this withdrawal reason is invalid

•Schools are not required to find out whether or not students are leaving school because of pregnancy. If the school does receive that information, however, it should be reported. As stated in A.R.S. §15-1042(H): "[T]he student level data shall include reasons for the withdrawal if reasons are provided by the withdrawing pupil or the pupil's parent or guardian."

11	Yes	Last day of attendance (This is the date used for withdrawal date)
12	Yes	Signature of the parent or guardian of the student (or signature of the student if the student is
		emancipated)
13	Yes	Date the form was signed by the person named in box 12
14	Yes	School withdrawing the student
15	Yes	District/Charter # (CTD) County Type District (Must be a 6 digit number)
16	Yes	School # (S) (Must be a 3 digit number)
17	Yes	Withdrawal Code, based on information in 10a – See attached withdrawal code definitions
18	Yes	School Official Signature certifying the information is correct
19	Yes	Date the form was signed by the person named in box 18

WITHDRAWAL CODES

Withdrawal Codes: Transfers

W1 TRANSFER: Withdrawn to continue studies in another school.

W9 TRANSFER: Home Taught. Student withdrawn from public school system to be home taught.

W10 TRANSFER: Detention. Withdrawn because student was transferred to a state detention or correctional facility.

The W1 code is used when a student transfers to another school or educational program--public or private--which meets Arizona requirements for obtaining a high school diploma. This code also applies to students who have been accepted into an early admission college program so long as that student is attending college full-time and is working toward an Arizona high school diploma.

The W9 code is used for students who, after filing an affidavit with the County School Superintendent, transfers out of the public school system to be taught at home. Verbal notification from a responsible adult is sufficient to apply the W9 code.

The W10 code is used when a student has been transferred to a state of Arizona detention facility. Students receive educational services while at a state of Arizona detention facility. Verbal notification from a responsible adult is sufficient to apply the W10 code.

EXAMPLE

Jeremy was sent to Adobe Mountain during the middle of his junior year at Coronado High School. While incarcerated at Adobe Mountain, he participated in an education program in anticipation of graduating from high school in his senior year. Coronado High School coded Jeremy as W10 (Transfer: Detention).

Withdrawal Codes: Dropouts

W2 ILLNESS. Withdrawn due to chronic illness (withdrawal may not be required; refer to district’s chronic illness policy).

W3 EXPELLED. Withdrawn due to expulsion or long term suspension.

W4 ABSENCE/STATUS UNKNOWN. Withdrawn for 10 consecutive days of unexcused absence, status or location is unknown to the school or school district.

W5 DROPOUT. School received verification that student has withdrawn from school; student does not intend to complete requirements for a high school diploma.

W6 AGE. student not of school age (under 6 or over 21 years of age).

W11 GED. Student withdrew from school expressly for the purpose of obtaining a GED. Students of high school age must withdraw to take the GED test. Verbal notification at the time of withdraw is sufficient to apply the W11 code.

W12 VOCATIONAL SCHOOL. Student withdrew to continue studies at a technical or vocational school; this includes ALL schools or education programs that DO NOT meet Arizona requirements for obtaining a high school diploma. Verbal notification from a responsible adult is sufficient to apply the W12 code.

The withdrawal code W4 (Absence) must be used when the student has ten consecutive days of unexcused absence or when the student’s status or location is unknown. The effective date of withdrawal is the last day of actual attendance.

EXAMPLE

Kathy was attending tenth grade at Sahuaro High School in the Tucson Unified School District. She was absent for more than two weeks, and her whereabouts were unknown. The school attempted to locate her but was unable to find sufficient information that Kathy was enrolled elsewhere. She was coded as a W4 (Withdrawn, Absence/Status Unknown).

Withdrawal code W5 should be used for students who have intentionally dropped out of school, except for the following reasons: (1) chronic illness, (2) to receive a GED certificate, or (3) transfer to a juvenile correctional facility. Any student who was withdrawn under the codes W2, W3, W4, W5, W11, and W12 and did not return to school before the end of the school year will be counted as dropouts in the annual Dropout Rate Study. In order to present additional information about the status of students coded with dropout- related codes, however, these withdrawal categories will be disaggregated.

EXAMPLES

Sarah withdrew from Greenway High School to take the GED test. She was withdrawn from school using the W11 code.

Michelle left Cactus Shadows High School and enrolled in a Nurse Assistant course at a local nursing home. Since the vocational school does not meet the Arizona requirements for graduation, Michelle will be withdrawn using the W12 code (Transfer: Vocational School).

Withdrawal Codes: Mid-Year Graduate/Completer

W7 GRADUATE. Student has completed course of study requirements for high school and received a passing score on the AIMS test (applies to mid-year graduates). Graduates are issued a high school diploma by the school district.+

W8 DECEASED.

W13 COMPLETED (AIMS). Student has completed course of study requirements for high school or Individual Education Plan but DID NOT receive a passing score on the AIMS test (applies to mid-year completers). Completers have concluded their high school education and are not expected to re-enroll.+∗

EXAMPLE

Before the end of her senior year, Mary completed her high school course of study requirements but DID NOT receive a passing score on the AIMS test. Mary is not expected to return to school. Mary is NOT a graduate; she is coded a W13 (Withdrawn, Completed: AIMS).+

DOCUMENTATION OF WITHDRAWAL

An Official Notice of Pupil Withdrawal form must be completed for each student who withdraws during the school year. Documentation helps to ensure uniform and comparable data across schools. In general, documentation of transfer to another school

(W1) consists of:

1.request from another school for transcript or student records; or

2.information from a responsible adult that the student is enrolled elsewhere.

+All changes related to the AIMS test will be collected beginning with the Graduating Cohort Class of 2002.

∗Currently, there is NOT an official policy on completers or attendees. The definitions in this document will be revised to reflect State Board of Education policies, once established.

Request for Transcript

♦A request from another school for transcript or other official school records will suffice to verify that a student has transferred to another school. The student’s record should indicate the date the transcript request was received, along with the name and address of the school to which the student has transferred. Arizona law requires Arizona schools to request school records quickly and exercise diligence in obtaining those records. “Within five school days after enrolling a transfer pupil from a private school or another school district, a school shall request directly from the pupil’s previous school a certified copy of his record. The requesting school shall exercise due diligence in obtaining the copy of the record requested” (ARS §15-828 F). After transmittal of the records, it is not necessary to verify actual enrollment in the new school or to follow up with the student any further.

Notification of current enrollment by a responsible adult

♦In the absence of a transcript request, notification by a responsible adult is acceptable evidence of transfer if it confirms actual enrollment in another school and not just the intent to enroll. “Responsible adult” is not limited to immediate family; the definition includes a school official, faculty member, or other adult with responsibility for the student (e.g., truant officer, medical doctor, corrections official, etc.). Schools should attempt to get written notification if possible. Verbal notification should be documented in the student record in the same manner as a request for transcript.

EXAMPLE

After Reuben had missed several days of school, the school counselor called Reuben’s home. Rueben’s mother said that he had moved to California to live with his sister and was enrolled as an eighth grader in Sacramento Elementary School. Rueben was withdrawn as a transfer student (W1).

Notification by the County School Superintendent

♦A.R.S. §15-802(B)(3) allows a student to be taught at home after certain requirements are met. The parent must file an affidavit with the County School Superintendent that the child is attending a regularly organized private or home school and the student is required to take achievement tests. However, to document a withdrawal to be home taught (W9), a record of verification from the County School Superintendent that the parent has filed the affidavit is NOT required. Verbal notification from a responsible adult is sufficient to apply the W9 code.

Changes in Withdrawal Codes

The withdrawal codes should be changed retroactively during the school year if additional information becomes available before the Year-End Enrollment Report is filed. Since withdrawal codes W2, W3, W4, W5, W11, and W12 are used to calculate dropout rates, it is to a school’s advantage to re-code those students whenever possible. However, the date of withdrawal must not be changed. The withdrawal codes NOT used in the dropout rate calculation are:

(a)Transfer, (W1)

(b)Age (W6)

(c)Graduate (W7)

(d)Death (W8)

(e)Transfer: Home Taught (W9)

(f)Transfer: Detention (W10), student is receiving educational services

(g)Completer (W13)

EXAMPLE

Luis was absent for two weeks, and his whereabouts were unknown. He was withdrawn as a W4. A week later, the school received a request from Maui High School in Hawaii for his school records. Luis’s withdrawal was reclassified from a W4 (Absence/Status Unknown) to a W1 (Transfer).

Supplemental Withdrawal Reasons

Supplemental Withdrawal Reasons are only compatible with certain specific Withdrawal Codes.

			WR1: school		WR2: school		WR3: school		WR4:
			choice: school		choice: school
							choice:		pregnancy /
	Withdrawal Code		identified for		identified as
							individual		biological parent
			Federal School		persistently
							transfer option		of a child
			Improvement		dangerous
W1	Transfer: other school		yes		yes		yes		yes
W2	Illness								yes
W3	Expelled or long term
	suspension
W4	Absence or status unknown								yes
W5	Dropout								yes
W6	Age
W7	Graduated
W8	Deceased
W9	Transfer: home taught								yes
W10	Transfer: detention
W11	GED
W12	Vocational school
W13	Completed (AIMS)