NEEDS ASSESSMENT
MACHINE SCOREABLE SURVEY SHEETS

ORDER FORM

  1. Enter the number of schools doing each survey below.
  2. Enter the total number of machine scoreable answer sheets (forms) below. For example, if 220 staff in 4 schools were doing survey A, put "4" in column No. 1 and 220 in column No. 2.

 

Survey
#		 1
Number
of Schools		 2
Number
of Forms
A ________ ________
1 ________ ________
2 see right ________
3 see right ________
4 ________ ________
5 ________ ________
6 ________ ________
7 ________ ________
8 ________ ________
9 ________ ________
10 ________ ________
11 ________ ________
12 ________ ________
13 ________ ________
14 ________ ________
15 ________ ________
16 ________ ________
Total ________  



Parent (#2)
No. Schools		 Student (#3)
No. Schools
________ ________ $200 up to 100 copies/school
________ ________ $400 up to 500 copies/school
________ ________ $600 up to 1,000 copies/school



$________ Amount for parent (#2) and/or student (#3) surveys requested.
$________ $200 X number of schools in column 1
$________ Total

Fill out and return with your check or Purchase Order to:

Systemic Assessment, Inc.
24 James Street
Shoreham, NY 11786
Phone: 516-821-0588 Fax: 516-821-6691
Email: drkelly@drtomkelly.com