Civic Service Institute
PO BOX 5063, Flagstaff, AZ 86011
(928)523-3560 or Toll Free at (866)856-3017
RSVP Program Child Assignment & Assessment Plan
Mentoring/Teen Parenting – 2016-2017 School Year
RSVP Education Coach (Full Name):
Does the Volunteer:
Tutor
Name of School/Volunteer Site:
School Location (City):
Mentor
Both
Please see instructions on back for more details
Complete in the fall
Special
Need
Student Name
(First name & last initial)
Grade
Level
Start
Date
Choose ONE
To Track
(See Codes
Below)
Example: Sue K
K
9/1/16
J
Example: Amy J
3RD
9/1/16
C
Complete in the spring
Check
if
Parent
is in
Prison
Check
if
Parent
is a
Veteran
Check
if
Child
is in
Foster
Care
Student Outcomes
Academic
Engagement
Academic
Performance
Please Check Either:
Improved
Not Improved
Please Check Either:
Improved
Not Improved
End Date
5/20/17
X
X
5/20/17
1.
2.
3.
4.
5.
Special Need Codes
A – Abuse or neglect
B – Developmental Challenges
C – Emotional Challenges
D – Hearing Impaired
E – Homeless
F – Adjudicated Youth / Juvenile Offender
G – Language Barriers
Fall Signature:
Teacher:
H – Learning Disabilities
I – Physical Disabilities
J – Significantly Medically Impaired
K – Substance Abuse
L – Teen Parent
M – Terminally Ill
N – Visually Impaired
O – Other Special Needs
_____________
Date:
__________
______
How do you measure students’ outcomes?
Changes in grades
Pre/Post tests
Standardized test scores
Observation
Other: __________________________
If no outcome is reported for a youth please list reason:
_
___________________________________________
_________________________________________________
Spring Initials:
Teacher:
Date:
____
______
I have reviewed this Plan with my teacher and accept it for the 2016-17 school year:
RSVP Education Coach:
_____
RSVP Education Coach:
___
______
Updated 8/2016
Information and Instructions for Teachers
Purpose


The RSVP Program is required to measure and report on the activities of the volunteers and the impact those activities have on the children with whom
they work. This Child Assignment and Assessment Plan (CAAP) allow us to collect all the necessary data as required by our program’s funders. For the
volunteers who serve in your classroom/program, our program is measuring the impact of the volunteer on the students’ academic engagement and
academic performance.
o In 2015-2016, teachers reported that 94% of students improved with regard to Academic Engagement and 92% in Academic Performance.
All information provided on this form is confidential. RSVP never shares any specific information about a child and his or her special needs. Any data on
these forms is reported in aggregate numbers and not on an individual or school basis.
Instructions




This form can be typed and if you prefer to do so, please visit our website to download the form (http://nau.edu/sbs/csi/programs/rsvp/) or request an
electronic version from your Program Coordinator.
You will receive a blank CAAP at the beginning of the school year or when a new volunteer is placed in your classroom. When you receive the CAAP:
o 1) Identify the 4-6 children who will be assigned to the volunteer (we understand that all the volunteer will interact with all the students in the class
throughout the year but there must be specific students identified with whom they will work most closely)
o 2) Complete the first 7 columns of the table
 Each student’s first name and last initial
 Grade level
 Choose one (1) special need code from the box below.
 Check if student has a parent who is in prison or a veteran and if they are in foster care
 Sign and date in the Fall Signature line for teachers.
o 3) Share the information with your volunteer who will also sign and date and return to their Program Coordinator.
o 4) In the spring, RSVP will redistribute your CAAP to you through the volunteer. Enter the last day (approximately) the volunteer will be serving in
your classroom, the two columns relating to outcomes, as well as noting how you measured these changes. Initial and date on the Spring set of
lines.
o 5) If you cannot provide an outcome for one of the students assigned to a volunteer, please provide a reason, i.e. moved or changed classrooms.
Teachers or other qualified school/organization staff must determine each child’s Special Need Code. A student does not need to have an Individualized
Education Program (IEP) to qualify to be matched with a volunteer.
If you have any questions do not hesitate to call your local program coordinator or the Flagstaff office toll free at 1-866-856-3017. We are happy to help.
Thank you and have a great school year!
Updated 8/2016