JLG-E 2_Evaluation Eligibility Determination Form

Code: JLG-E 2


To be completed by parent/guardian/unaccompanied youth

STUDENT NAME:______________________________________________________________________________________________

SCHOOL:_____________________________________________________________________ DATE:_________________________

A fixed residence is one that is stationary, permanent, and not subject to change:

1. Is this a temporary living arrangement?  Yes  No

2. How long do you expect to be at this address? _______________________________________________________________

3. If “double up”, did you and your friends/relatives decide to move in together and share a home and expenses for the long term?  Yes  No

A regular residence is one that is used on a regular (i.e. nightly) basis:

1. Do you stay at the same place every night?  Yes  No

2. Do you move around a lot?  Yes  No

An adequate residence is one that is sufficient for meeting both the physical and psychological needs typically met in home environment:

1. Are you safe where you are staying?  Yes  No

2. Do you have adequate space for your belongings?  Yes  No

3. Do you share a room/bed with your children?  Yes  No

4. Are your children safe in you are not at home?  Yes  No

5. Do you have running water?  Yes  No

6. Do you have electricity?  Yes  No

7. Is there adequate food in the home?  Yes  No

Other considerations: Temporary housing due to loss of housing, economic hardship or similar reason:

1. Where did you live previously?____________________________________________________________________________

2. What happened to cause you to move?_____________________________________________________________________



McKinney-Vento Evaluation/Eligibility Determination Form

To be completed by district liaison

Did the family/student lose their previous housing due to:

1. An eviction or inability to pay rent or other bills?  Yes  No

2. Destruction of or damage to the previous home?  Yes  No

3. Conflict, child abuse or neglect?  Yes  No

4. Unhealthy conditions such as inadequate physical environment or infestations?  Yes  No

5. Drug or alcohol abuse in the home or domestic violence?  Yes  No

6. Absence of a parent/guardian due to abandonment, incarceration or other reason?  Yes  No

_____ Approved:

 Complete a Needs Assessment for Services Form

 Schedule/Participate in “Best Interest” placement meeting for the student

 Complete a McKinney-Vento Eligibility Notification letter

_____ Denied:

 Requested additional information for confirmation

 Complete a McKinney-Vento Eligibility Notification letter

District Liaison Signature:_____________________________________________Date:____________________

Adopted: 01/21/20