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