TPS Truancy Mediator Checklist TPS Truancy Mediator Checklist Question Title * 1. What is the Child's Name? First Name: Last Name: OK Question Title * 2. What school does the student attend? Arlington Beverly Birmingham Burroughs Byrnedale Chase DeVeaux East Broadway Edgewater Elmhurst Escuela SMART Garfield Glendale Feilbach Glenwood Harvard Hawkins Keyser Larchmont Leverette Longfellow Marshall Martin Luther King Jr. McKinley McTigue Navarre Oakdale Old Orchard Ottawa River Pickett Raymer Reynolds Riverside Robinson Rosa Parks Sherman Spring Walbridge Whittier OK Question Title * 3. What is the mediation date? MM/DD/YYYY Date OK Question Title * 4. What is this mediator's name? Barbara Furr Brent Schlegel Christine Johnston Ernie Ducey Joyce Henderson Rebecca Ligibel Tara McCutcheon Tiffany Cavanaugh Val Cavitt Wazeda Wilson OK Question Title * 5. What type of mediation is this? Absence Intervention Plan Truancy Prevention (if you don't know, choose this please). OK Question Title * 6. In 15 minute increments, how long was the mediation? Please round up and approximate. 0 15 30 45 60 OK Question Title * 7. What is the age of the child? Unknown 5 6 7 8 9 10 11 12 13 14 15 16 OK Question Title * 8. What grade is the child in? K 1 2 3 4 5 6 7 8 Unknown OK Question Title * 9. What is the sex of the child? Male Female Unknown/Not Provided OK Question Title * 10. What is the child's race/ethnicity? Black White American Indian or Alaskan Native Hawaiian Pacific Islander Latino or Hispanic Multiracial Other Unknown OK Question Title * 11. How many parents or legal custodians live in the home with the student? Unknown 0 1 2 3 4 or more OK Question Title * 12. How many children reside in the student's home? Unknown 0 1 2 3 4 5 6 7 8 9 10 or more OK Question Title * 13. What is the student's 5-digit home zip code? (If not provided, enter X) OK Question Title * 14. What was the result of the mediation? Agreement reached. Mediation occurred however no agreement reached. No mediation occurred because a parent or custodian did not show. Mediator screen out. School matter Other (please specify) OK Question Title * 15. What is the reason for the child's absence or tardiness? Unknown Illness of child or family member Lacking basic needs such as clothes, food, utilities, etc. Personal Issues such as mental health and or substance abuse issues Employment or scheduling issues Transportation issues such as car troubles, bus route problems, etc. Parent or custodian was unaware that child was absent or tardy Child safety (bullying) Family Violence Death of family or close friend Childcare (for children in the house) Housing issues Parent or custodian incarceration Behavior Vacation Technology Problems (Internet, Computer, etc) Other (please specify) OK Question Title * 16. What is the total number of UNEXCUSED HOURS the child missed this year? (from current attendance printout) Not Applicable or Unknown Number of hours absent: OK Question Title * 17. What is the number of DAYS the child was TARDY this year? (from current attendance printout) Not Applicable or Unknown Number of DAYS tardy: OK Question Title * 18. Did parent/guardian understand the problem or situation better after the mediation? Yes No Unsure Unknown--mediation not held OK Question Title * 19. How did parent/guardian feel about the mediation outcome or agreement? Satisfied Not satisfied Unsure Unknown--mediation not held OK DONE