TN Parent Occupational Survey

Tennessee Parent Occupational Survey

Under Title I, Part C of the Elementary and Secondary Education Act (ESEA) our school district provides supplemental services to the children of agricultural workers who have recently moved. This survey is to help the school identify if your child might qualify for these free supplemental services such as tutoring, school supplies, summer camps in select counties, and other free services. Please answer the following questions and return this form to your child's school. The information provided below will be kept confidential.

Today's Date

Date

Parent/Guardian First Last Name

Name

Student First NameStudent Last Name

School Name

Student Grade

1. Have you or an immediate family member performed any agriculture or fishing jobs temporarily or seasonally, in any part of the United States, in the past 3 years?

Select Yes or No*

Yes (Check all that apply below)No

If Yes - Check all that apply

Processing & Packaging: fruit, vegetables, chicken, pork, beef, eggs, etc.Agriculture/Field Work: planting, picking, sorting crops, soil preparation, irrigation, fumigationDairy/Cattle Raising: feeding, milking, rounding up.Nursery/Greenhouse: planting, potting, pruning, watering, harvesting.Forestry: soil preparation, planting, cutting trees; does not include landscaping.Other Any other agriculture or fishing work please list here

2. In the past 3 years, has your family moved to another state, city, school district, and/or county?

Select Yes or No

Yes - My family has moved in the past 3 years. Please indicate below.No

Years

Months

Weeks

If you answered "Yes" to question 1 above, please complete the information below. A staff from the Migrant Education Program will follow up with your family to verify if you qualify for free services.

Home Street Address

Apt #

City

Zip Code

Language

Telephone Number

Email Address*

example@example.com

Best Day of Week and Time to Call