HEAD START FORMS
Section One: Enrollment
• Inspection of Confidential Records
• Referral Record
• Change of Status
• Child Plus Application Form
• District Enrollment Forms
• Notification Letter (optional if prior to school starting)
• Parent Handbook/Student Handbook Code of Conduct
• Copy of Birth Certificate
• Copy of Social Security card
• Video Surveillance Policy (as needed)
• Legal Document Log
If you have reviewed all this student’s
Education Folder and
do not find the information you
are looking for, please ask a
staff member.
Head Start
INSPECTION OF CONFIDENTIAL RECORD
NAME
TITLE
DATE
PURPOSE
Head Start
REFERRAL HEALTH/EDUCATION
CHILD’S NAME ___________________
DATE
TYPE OF
REFERRAL
REFERRAL
CONTACT
FOLLOW UP
DATE
COMMENTS
INITIAL OF
REFERRING
STAFF
Head Start
CHANGE OF STATUS
Effective Date:
Name of Child:
Center:
Teacher:
Drop
Re-enrollment
Reason:
Child withdraws before 10:00 a.m. /use that days date as drop date;
Child withdraws after 10:00 a.m. /use the next days date as drop date
Transfer
Campus:
Teacher:
Reason:
Change of Address:
Change of Phone:
Change of Employment:
Name:
Mother
Father
Place of Employment:
Company:
Phone:
Person to Contact in case of Emergency:
Name:
Submitted by:
Mother or Dad’s Signature:
Relationship:
Phone:
Title:
Date:
Date:
4/06
Applicant Information
Complete for individuals who are applying to a program.
Child’s Information
Last
First
Middle
Birthday:
Preferred
SSN
Gender:
Male
Female
Place of Birth:
Adult Name
Child’s Relationship
Custody?
Primary Language At Home
Parental Status:
One
Yes No
_______________________
Two
Number in Family
Number of Children _______
Number in Household
By age: 0-3
Yes No
Releases Signed? Yes
No
By age: 4-5
Date Signed
TANF Status:
YES
NO
SSI:
YES
NO
WIC:
YES
NO
Address/Phone
Living Address
Mailing Address
Living Address Line 2
Mailing Address Line 2
City
Phone
Type
State
9 if
Primary
Zip
County
City
Phone Number
State
Phone Number
(
)
(
)
(
)
(
)
Zip
Phone Note
Health Coverage
Medicaid Eligibility Status: On Medicaid
Potentially Eligible
Medicaid Number
Not Eligible
Primary Health Coverage
Other Health Coverage
Insurance Number
Demographics
Race (check ALL that apply):
† Asian
† Black
† Hispanic
† White
† Native American
† Pacific Islander
† Other:
Language
9 if
Primary
Proficiency
Nationality
English
Ethnicity
Certification: I certify that this information is true. If any part is false, my participation in this agency’s programs may be terminated and I may be subject to
legal action. I also understand that the information in this application will be held in strict confidence within the agency and is accessible to me during normal
business hours.
Mom or Dad’s/Guardian Signature ________________________________________
Date ____________________________
Verifying Staff Member _________________________________________________
Date ____________________________
Copyright © 2004 Management Information Technology USA, Inc.
Page 1 of 2
4/06
Informacion de Aplicante - Applicant Information
Complete for individuals who are applying to a program.
Información sobre su niño - Child’s Information
Apellido - Last
Primer Nombre - First
Fecha de Cumpleaños - Birthday:
Segundo Nombre - Middle
Nombre preferido - Preferred
Número de Seguro Social - SSN
Sexo - Gender: M
F
Ciudad, estado de nacimiento - Place of Birth:
Nombre de Adulto –
Relación al Niño –
Adult Name
Child’s Relationship
¿Es guardián?
Custody?
¿Cuántos padres viven en casa?
Parental Status:
Uno - One
Si - Yes
No - No
Si - Yes
No - No
Date Signed
Releases Signed?
Yes
No
Idioma que se habla en casa
Primary Language At Home
Dos - Two
¿Cuántos en la familia? – Number
in family
¿Cuántos niños en casa? Number
of Children
¿Cuántos viven en casa? Number in
household
Por edad: 0-3 By age: 0-3
TANF Status:
YES
NO
SSI:
YES
NO
Por edad: 4-5 By age: 4-5
WIC:
YES
NO
Dirección de Casa/ Número de Teléfono - Address/Phone
Dirección de casa - Living Address
Dirección de correo - Mailing Address
Línea adicional para dirección de casa - Living Address Line 2
Línea adicional para dirección de correo - Mailing Address Line 2
Ciudad - City
Tipo de
teléfono
Phone
Type
Estado - State
9 if
Primary
Código
Postal – Zip
CondadoCounty
Ciudad - City
Estado State
Número de Teléfono
Numero de Teléfono
Phone Number
Phone Number
(
)
(
)
(
)
(
)
Código Postal – Zip
Phone Note
Información sobre seguro de salud - Health Coverage
Medicaid Eligibility Status: On Medicaid
Potentially Eligible
Not Eligible
Número de Medicaid - Medicaid Number
Nombre de su seguro de salud - Primary Health Coverage
Nombre de seguro de salud adicional - Other Health Coverage
Número de su seguro de salud - Insurance Number
Información Demográfica - Demographics
Raza (favor de indicar todos lo
que pertenecen)
Race (check ALL that apply):
† Asiático - Asian
† Negro - Black
† Hispano - Hispanic
† Anglo - White
† Indio - Native American
† Indio de las islas Pacificas Pacific Islander
† Otra raza - Other:
Idioma - Language
9si es su
idioma
primaria
Proficiency
Nacionalidad - Nationality
9 if
Primary
Ingles - English
Su etnicidad - Ethnicity
Certificación: Certifico que esta información es la verdad. Si alguna parte no es la verdad, mi participación en los programas de esta agencia pueden ser terminados y quizás
resultará en acción legal. También entiendo que esta información está dada en confianza estricta dentro de esta agencia y tengo acceso de esta información durante las horas
de negocio de esta agencia.
Padre/Guardian __________________________________________
Fecha ___________________
Verifying Staff Member ________________________________________________________
Date ________________________________
Copyright © 2004 Management Information Technology USA, Inc.
4/06
NOTIFICATION LETTER
Head Start
Date:
Center:
Address:
Telephone:
Dear Parent/Guardian,
Your HEAD START application for
has been screened and the results are indicated by the check mark below:
Your child has been approved for the Head Start program.
Your child has been approved, but because our classes are
presently filled, has been placed on our waiting list.
Your child is too young for Head Start, this year.
Your family income makes your child ineligible at this time.
Your child’s name will be considered for enrollment on this basis.
If your child is accepted for enrollment at a later time, you will be notified.
If your child has been approved, an enrollment time and place have been written in below.
ENROLLMENT DATE
TIME
LOCATION
Completion of enrollment will take between 1 and 1 ½ hours. Please bring your Medicaid card and a copy of
current physical and dental records, if you have one, and proof of any insurance you may have.
Sincerely,
Head Start Representative
4/06
CARTA DE NOTIFICACION
Escuela:
Dirección:
Número de Teléfono:
Head Start
Fecha:
Estimados Padres/Guardianes,
Su aplicación en el programa de HEAD START para
(Nombre del niño)
ha sido revisada y el resultado está marcado:
Su hijo ha sido aprobado para el programa de Head Start.
Su hijo ha sido aprobado pero porque nuestras clases ya tienen el límite de niños, hemos puesto
el nombre de su niño en una lista de espera.
Su hijo está muy joven para el programa de Head Start este año.
El salario de su familia hace que su niño sea inelegible horita. Su niño no será considerado por
esta razón. Si aceptamos a su hijo en el futuro, le notificaremos.
Si hemos aceptado a su niño, la fecha, el tiempo de matriculación y el lugar en donde recibirse está escrito abajo.
FECHA DE MATRICULACION
HORA
LUGAR/ESCUELA
Se tomará aproximadamente una hora en matricular a su hijo. Favor de traer su tarjeta de Medicad, si lo tiene, o
prueba de seguro.
Sinceramente,
Representante de Head Start
5/2007
OPTIONAL
ENROLLMENT FORMS
• Thank You Letter for Your Interest
• Video Surveillance Policy
Head Start
Dear Parent/Guardian:
Thank you for your interest in our Head Start Child Development Program.
To be considered for the program, we must have reasonable verification of 12 months income for your total family.
Examples of this verification could be:
•
•
•
A copy of your current income tax (please note this is a federally sponsored program) OR
W-2 forms for parents or guardians
Income earned in previous 12 months (notarized family statement of gross earnings, 12 months worth of
check stubs).
Eligibility might be able to be determined with lesser documentation, but that will slow the eligibility process.
Also, please understand that we will need to determine your family composition for eligibility, i.e. total in
household including children.
You will need to bring documentation of any additional non-taxable income you receive:
• Child Support
• Social Security Benefits
• Unemployment Compensation
• Dividends, Interest
• Welfare Payments
• Pensions, Annuities
• Workers’ Compensation
• Alimony
• Educational Loans/Grants
Other necessary documentation to bring is your child’s:
• Birth Certificate
• Social Security Card
• Shot Record
• Food Stamp Letter
• TANF Documentation
• Proof of medical and/or dental insurance
When you come in to bring the information requested, it will take 15 to 30 minutes to complete the eligibility form.
If you have any questions, please feel free to call our office at ______________________________.
Thank you for your cooperation.
5/2007
Head Start
Estimado Padre/Guardián,
Muchas gracias por su interés en el programa de Desarrollo de Niños de Head Start.
Para ser considerado en el programa, tenemos que recibir 12 meses de verificación de salario de su familia en total.
Ejemplos de verificación pueden ser:
•
•
•
Copia de su declaración de impuestos federales, O
Formas de W-2 de los padres/guardianes,
Los recibos (de 12 meses) de sueldo.
Podemos determinar elegibilidad con menos documentación, pero el proceso tomará más tiempo. También, favor
de entender que necesitaremos determinar su elegibilidad considerando todas personas en su familia, incluyendo los
niños.
Necesitará traer documentación de ingresos adicionales que recibe. Por ejemplo:
•
•
•
•
•
•
•
•
•
Sostén de niño (resultado de divorcio)
Beneficios de Seguro Social
Beneficios de desocupación
Dividendo, Interés (de dinero)
Pagos de ayuda del Estado (para su bienestar)
Pensión, anualidad
Compensación de trabajo
Asistencia (resultado de divorcio)
Préstamos educacionales/donaciones
Otros documentos de su hijo que son necesario traer:
•
•
•
•
•
•
Certificado de nacimiento
Tarjeta de seguro social
Forma/record de inmunizaciones
Carta del estado acerca de poder recibir estampillas para comida
TANF – un programa del gobierno de Texas para familias en necesidad de ayuda
Prueba de seguro médico o dental
Cuando usted venga a traer la información requerida, tomará 15 a 30 minutos para completar la forma de
elegibilidad. Si usted tiene cualquier pregunta, favor de llamar nuestra oficina.
Muchas gracias por su cooperación.
Head Start
Video Surveillance Policy
Dear Parents,
This is to notify you of our classroom video surveillance cameras. The purpose of the video cameras is for your
child’s safety as well as the Head Start center teachers, staff and parents. We take pride in providing the best
childcare and learning environment, our preventative measure is to video tape your children in their classrooms.
Head Start has posted video surveillance signs in the classrooms and around the Head
Start building to inform the general public of the Head Start video cameras. Extreme care is enforced in
safeguarding these surveillance tapes against unauthorized use.
After reading the above notice, I
the parent/legal guardian of
understand that my children will be under videotape surveillance while in the
Head Start classroom.
I understand that the surveillance cameras in the classrooms are there to protect the welfare of my children, and the
Head Start staff and teachers.
Parent/Guardian
Date
Site Manager
Date
4/04
Head Start
PÓLIZA DE VIGILANCIA DE VIDEO
Estimados Padres,
Esta carta es para notificarle de nuestras cámaras de video para vigilancia en los salones de clase. El propósito de
las cámaras de video es para la seguridad de su niño así como la seguridad de las maestras de Head Start, los
empleados de Head Start, y los padres de los niños. Tomamos mucho orgullo en proveer el mejor cuidado de su
niño y ambiente de aprender. Nuestro método preventivo es de tomar video durante el tiempo que los niños están
en sus clases.
Head Start ha puesto rótulos dentro de y alrededor de la escuela que anuncian al público de las cámaras de video
para vigilancia. Tomamos cuidado en la salvaguardia de estos videos contra abuso ilegal.
Después de leer esta carta, yo
el padre/guardián legal de
entiendo que mis niños estarán bajo vigilancia de cámaras de video durante su tiempo
en el programa de Head Start.
Entiendo que las cámaras de vigilancia en las clases están allí para proteger el bienestar de mis niños y los
empleados de Head Start.
Padre/Guardián
Fecha
Empleado de Head Start
Fecha
INCOME
DOCUMENTATION
•
•
•
•
Eligibility Worksheet
Individual Systematic Form
Committee Systematic Form Signature Page
Group Systematic Selection Form
ELIGIBILITY
Family Size
(total # in household)
Family’s Gross Annual Income
(parents only)
ITEM
$
$
A) Taxable income earned (computed in the following ways)
1) Income earned in previous calendar year (from Federal Income
Tax Form)
2) Income earned in previous 12 months (family statement of gross
earnings)
(B) Additional non-taxable income
1) Veteran’s benefits
2) Social Security benefits
3) Unemployment compensation
4) Dividends, interest
5) Welfare payments
6) Pensions, annuities
7) Workers’ Compensation
8) Alimony
9) Child Support
10) Educational loans/grants
$
$
$
$
$
$
$
$
$
$
$
$
C) Total of B
$
D) Total of A & B
$
E)
Deductions (medical & dental expenses and casualty or theft loss
in excess of 10% of gross family income)
F)
Total (adjusted gross family income = E minus D)
$
$
MAXIMUM ALLOWABLE INCOME FOR FAMILY SIZE
$
ABOVE INCOME
$
BELOW INCOME
$
I (we) agree to report any and all changes as they occur in my (our) family’s income during the period my (our) children are enrolled in the
program. I also understand that I am required to furnish written proof of all income information on this form. I hereby affirm that all the
information given above is accurate.
_______
Date
_______________________________________
Verifier’s Signature
____________________________________________
Mom or Dad/Guardian’s Signature
5/2007
Head Start
This information is to be used with professional staff only in keeping with FERPA and I.D.E.A. – B Confidentiality Requirements and Head Start performance Standards.
Revised 4/2007
Region 9
Head Start Individual Systematic Selection Form
File in confidential folder for income
File in ERSEA Binder
Head Start
10
2 pts.
each
15
15
10
20/10
Signature of Systematic Selection _________________________________________ Date________________
Committee Member ____________________________________________________ Date________________
This information is to be used with professional staff only in keeping with FERPA and I.D.E.A. – B confidentiality requirements and Head Start performance
Standards.
Revised 8/2007
Date of Application
20
Totals
5
Parent Employment or Training
Child has Obvious Medical Need
30
Family has 3 or more Children
Family is Homeless
100
Child is Non English Speaking
Family is on TANF
200
Early Head Start Transfer/ Even Start
Family Preservation/Open CPS Case
25
1305.7(a)
Stressors (See Application Checklist)
Non Parent Guardian
20/10/5
Child in Foster Care
Disabilities
15
Family Income Below Poverty Guideline on Public
Assistance
Single Parent Home
Male/Female
# in Family
Code #
Child Age as of Sept. 1
Birth Date
Over Income
Approved
Region 9
Head Start Committee Systematic Selection Form
Signature Page
ISD _______________________
Revised 8/2007
5
20
10
2 pts.
each
15
15
10
20/10
This information is to be used with professional staff only in keeping with FERPA and I.D.E.A. – B confidentiality requirements and Head Start
performance Standards.
Date of Application
Region 9
Head Start Group Systematic Selection Form
Signature Page
Totals
Parent Employment or Training
30
Family has 3 or more Children
Child has Obvious Medical Need
100
Child is Non English Speaking
Family is Homeless
200
Early Head Start Transfer/ Even Start
Family is on TANF
25
Stressors (See Application Checklist)
Family Preservation/Open CPS Case
20/10/5
Non Parent Guardian
15
Child in Foster Care
Disabilities
ISD _______________________
Family Income Below Poverty Guideline on Public
Assistance
Single Parent Home
Male/Female
# in Family
Code #
Child Age as of Sept. 1
Birth Date
Over Income
Approved
File in ERSEA Binder
Head Start
1305.7(a)
APPLICATION CHECKLIST
Head Start
Child’s Name:
APPLICATION CHECKLIST
POINT SYSTEM:
Stressors (2 points each)
___ Lack of transportation……………………..family does not have private vehicle
___ Child living with relatives Explain: ______________________________________
___ CPS Intervention…………………investigation
___ Family living with relatives
___ Education level below 12th grade
___ Teenage Parent ……………… (when Head Start child was born - between 13-19)
___ Migrant Family……….family has moved several times in the past 12 mos. seasonal/agricultural work
___ Parent Deployed
___ Parent Disability
___ Sibling Disability
___ Pregnancy
___ Recent Relocation………………………….within 6 months
___ Recent Unemployment………………….within 6 months
___ Working and in school……………………… (including GED classes, Vo Tech, College)
___ Other
Explain: ______________________________
Disability (5, 10 or 20 points)
____ Suspected
___ ECI (Early Childhood Intervention) or other program for children with disabilities
___ Qualified for special education services
Medical (10 points)
____ Child has obvious medical need
Transition/Transfers (15 points)
___ Even Start Project Together/Early Head Start
___ Transfer (from another Head Start Program)
Other
___ Homeless (20 points) please explain: _________________________________
___ Non-parent Guardian (100 points)
___ Family Preservation (30 points)
___ Parent Employment or Training (20 points) both or (10 parents) one
MUST HAVE:
Child’s:
___ Birth Certificate
___ Social Security Card
___ Medicaid/Insurance Card
___ Shot Record
Parent’s:
___ Proof of Income
___ Picture I.D.
PLEASE ASK ABOUT THE FOLLOWING:
(Check if attached, if not checked, explain status)
___Physical exam Status: ___________________________________
___ Dental exam Status: ___________________________________
Approved 3-1-07
Verified by:
Section Two: Health
• Consent for Health Services
• Emergency Consent and Medical Information Release Form
• Copy of Health Contact Follow-up Form (as needed)
• Documentation of Insurance (Medicaid/Chips, etc.)
• Child Health-Form 2A,6
• Head Start Health Services Release of Information
• Child Health Form 3 - Physical
• Hearing and Vision for 3 year old
• Copy of Immunization Record
• Lead Screening/TB screening
• Child Health Record Form 5 - Dental
• Child Plus Growth Charts
• Head Start Observation Notes
• In House Referral (as needed)
• Accident Report (as needed)
Head Start
Consent for Health Services
I,
hereby give my consent for the child listed below to receive the screening tests and
examinations checked below, and for transport of the child to and from the services as needed. I understand these
services are deemed necessary or advisable by the Head Start program and that I will be informed of any results that
are not normal.
I also understand that is my responsibility to provide Head Start with an up-to-date immunization record and a
record of medical and dental examinations performed in the past year. This consent is valid for one year after the
signed date. The purpose of this consent has been explained to me. I agree:
That in case of emergency or if a parent or guardian cannot be contacted, Head Start may provide first aide or
emergency medical care if needed.
Yes
No
Initial below:
Developmental Screening
Mental Health Screening
Crisis Counseling
Medical Examination
Dental Examination
Speech Screening
Height and Weight
Hearing Test
Vision Test
Immunizations (if necessary)
T.B. Test
Brush teeth daily with fluoride toothpaste
I understand that this involves a blood sample obtained by a
Lead Screening
“fingerstick” or venipuncture if necessary.
, I hereby authorize the release of Medicaid/THSTEPS eligibility
As a parent/guardian of
information and medical records to satisfy Head Start requirements.
CHILD’S NAME
DATE OF BIRTH
Signature of Mom or Dad/Guardian
Relationship to Child
Date
the purpose of this release and the nature of the
I have explained to
tests and examinations that the children enrolled in Head Start receive.
Signature of Head Start Staff
Date
PERMISO PARA RECIBIR
SERVICIOS DE SALUD
Head Start
Yo,
doy permiso que mi hijo obtenga los exámenes que he designado en la siguiente parte de esta
forma. Además, doy permiso que alguien del programa de Head Start lo transporte para recibir estos servicios.
Entiendo que mi hijo necesita estos exámenes y que me avisarán si un examen no resulte en manera normal.
También entiendo que es mi responsabilidad proveerle a Head Start con los record corrientes de inmunizaciones de
mi hijo y examen hechos por un médico o dentista dentro del año pasado. Esta forma está en efecto por un año
desde hoy. Me han explicado el propósito de esta forma. Estoy en acuerdo:
Que si hay alguna emergencia en donde no me pueden comunicar por teléfono, el personal de Head Start puede
proveer auxilio de emergencia si es necesario.
Si
No
Favor de marcar los servicios que necesita su hijo:
Examen de desarrollo
Examen de salud mental
Examen por un medico
Examen por consejero de crisis
Examen por un dentista
Examen para manera de habla
Examen para saber que tan alto está y cuanto pesa mi hijo
Examen auditiva
Examen de visión
Inmunizaciones (si es necesario)
Examen para tuberculosis
Examen para ver si se cepilla los dientes con pasta de diente que contiene fluoruro
Examen que indica si el niño se ha puesto en contacto con plomo. (En años pasados los cuartos en casas eran
pintados con pintura que tenía plomo. Este plomo es como veneno si uno se pone en contacto con el.) En
este examen se le tiene que obtener sangre por un dedo.
Como padre/guardián de
, yo doy permiso que el programa/personal de Head Start puedan
usar la información de Medicad/THSTEPS y los record médicos de mi hijo.
NOMBRE DE NIÑO
FECHA DE NACIMIENTO
Firma de padre/guardián
Parentesco al niño
Fecha
Le he explicado a
niños de Head Start.
el propósito de esta forma y los servicios de salud que reciben los
Firma de personal de Head Start
Fecha
Head Start
Emergency Consent and Medical Information Release Form
Name of Child:
Birth Date:
Address:
School:
Student Social Security :
Teacher:
Sex:
In the event that I cannot be reached to make arrangements for medical attention for my child, at the time of an accident or
illness while he or she is attending a Head Start program, I grant and authorize a representative of Head Start to grant
permission to the medical staff and the Emergency Department staff of the local hospital to perform any medical or surgical
treatment and to administer such anesthesia and/or drugs as may be deemed necessary in the diagnosis or treatment of said
patient. Furthermore, I hereby authorize release of all medical/dental pertinent information concerning my child to a
designated representative of Head Start.
We the parent(s)/guardian(s) of the above named child acknowledge it is our responsibility to keep the information in this
Emergency Consent form current and correct. We agree to notify Head Start of any changes to phone numbers or changes of
physician or changes in name of those who shall be contacted in the event of any emergency.
Medications Taken By Child: ____________________________________________________
Child’s Allergies: _______________________________________________________________
Chronic Diseases: ______________________________________________________________
Child’s Doctor: ________________________________________________________________
Child’s Dentist: ________________________________________________________________
___________________________
Signature of Mom or Dad
_________
Date
______________
Home Phone
___________
Work Phone
4/06
Head Start
Permiso Para Divulgar Información de Emergencia y Medico
Nombre del niño:
Fecha de nacimiento:
Su dirección:
Nombre de escuela:
Número de seguro social (del niño):
Nombre de su maestra:
Sexo:
Durante el tiempo que mi niño esté bajo el cuidado del programa de Head Start, doy permiso que los empleados de
Head Start arreglen que mi niño tenga tratamiento de emergencia si es que no se puedan ponerse en contacto
conmigo. Les doy permiso a los empleados de Head Start que autoricen al Departamento de Emergencia que le den
a mi hijo anestesia y/o drogas que sean necesarias para el bienestar de mi hijo. Además, doy permiso al personal de
Head Start que puedan divulgar información de mi hijo acerca de su salud física o dental a personal de Head Start.
Nosotros, los padres/guardianes de este niño reconocemos que es nuestra responsabilidad de asegurar que esta
forma tenga la más reciente información acerca de la salud de mi niño y los nombres y números de teléfono de
emergencia. Aseguramos decirles a los empleados de Head Start cuando haya cambio de médico y su número de
teléfono o los nombres y números de teléfono de la gente a quien se le puede llamar en caso de emergencia.
Nombres de las medicinas que toma mi hijo:
Alergias que tiene mi hijo:
Enfermedades crónicas:
El nombre de su doctor:
El nombre de su dentista:
Firma de mamá o papá/guardián
Fecha:
/
Número de teléfono de casa/trabajo
Head Start
Health Contact Follow-up Form
This is a summary for the child listed below. We hope that it will be of assistance to you.
Child’s name___________________________________________
Date Screening
completed
Results were normal
Yes/No
Date of Followup/Treatment
Results
Hearing
Vision
Dental
Additional Information:
Staff Signature/Date
File in Health Section
and
Give copy to Parent
4/06
Head Start
Forma de Continuación
De Información de Salud
Esta forma sirve como sumario de examines para el niño cuyo nombre sigue. Esperamos que le ayude.
Nombre del niño
Fecha que se
cumplió el
examen
Los resultados
son normales
Si/No
Fecha para
continuación de
tratamiento
Los resultados
Examen de oídos
Examen de
visión
Examen dental
Información adicional:
Firma de Personal/Fecha
File in Health Section
and
Give copy to Parent
TO BE COMPLETED BY HEAD START STAFF DURING PARENT/GUARDIAN INTERVIEW. HEAD START CENTER: _______________________________
CHILD HEALTH RECORD:
FORM 2A, HEALTH HISTORY
CHILD’S NAME: __________________________________________________________ SEX: ___________ BIRTHDATE: ____________________
PERSON INTERVIEWED: __________________________________________________ DATE: __________ RELATIONSHIP: __________________
NAME OF INTERVIEWER: _________________________________________________ TITLE: _______________________________________
PREGNANCY/BIRTH HISTORY
1. DID MOTHER HAVE ANY HEALTH PROBLEMS DURING THIS
PREGNANCY OR DURING DELIVERY?
2. DID MOTHER VISIT PHYSICIAN FEWER THAN TWO TIMES
DURING PREGNANCY?
3. WAS CHILD BORN OUTSIDE OF A HOSPITAL?
4. WAS CHILD BORN MORE THAN 3 WEEKS EARLY OR LATE?
5. WHAT WAS CHILD’S BIRTH WEIGHT?
6. WAS ANYTHING WRONG WITH CHILD AT BIRTH?
7. WAS ANYTHING WRONG WITH CHILD IN THE NURSERY?
8. DID CHILD OR MOTHER STAY IN HOSPITAL FOR
MEDICAL REASONS LONGER THAN USUAL?
YES
NO
_________________________lbs., ______________ oz.
9. IS MOTHER PREGNANT NOW?
HOSPITALIZATIONS AND ILLNESSES
10. HAS CHILD EVER BEEN HOSPITALIZED OR
OPERATED ON?
11. HAS CHILD EVER HAD A SERIOUS ACCIDENT (broken bones,
head injuries, falls, burns, poisoning)?
12. HAS CHILD EVER HAD A SERIOUS ILLNESS?
YES
NO
HEALTH PROBLEMS
13. DOES CHILD HAVE FREQUENT _____ SORE THROAT;
____ Cough; ____ URINARY INFECTIONS OR TROUBLE
URINATING; ____ STOMACH PAIN, VOMITING, DIARRHEA?
14. DOES CHILD HAVE DIFFICULTY SEEING
(Squint, cross eyes, look closely at books)?
YES
NO
DID A DOCTOR OR OTHER HEALTH PROFESSIONAL TELL YOU
THE CHILD HAS THIS PROBLEM?
26. ARE THERE ANY CONDITIONS WE HAVEN’T TALKED ABOUT
THAT COULD GET IN THE WAY OF THE CHILD’S EVERYDAY
ACTIVITIES?
DID A DOCTOR OR OTHER HEALTH PROFESSIONAL TELL YOU
THE CHILD HAS THIS PROBLEM?
* If starred (*) questions have “yes” answers, go to question 25.
EXPLAIN (Use additional sheets if needed)
(If “yes”) WAS LAST CHECKUP MORE THAN ONE
YEAR AGO? _________________________________
*
*
19. IS CHILD TAKING ANY OTHER MEDICINE NOW?
(Special consent form must be signed for Head Start to administer
any medication).
20. IS CHILD NOW BEING TREATED BY A PHYSICIAN OR A
DENTIST?
21. HAS CHILD HAD: ____ BOILS, _ __ CHICKENPOX,
___ ECZEMA, ___ GERMAN MEASLES, ___ MEASLES,
___ MUMPS, ___ SCARLET FEVER, ____
____WHOOPING COUGH?
22. HAS CHILD HAD: ____ HIVES, _____ POLIO?
23. HAS CHILD HAD: ___ ASTHMA, __ BLEEDING TENDENCIES
___ DIABETES, ____ EPILEPSY, ___ HEART/BLOOD VESSEL
DISEASE, ____ LIVER DISEASE, ____ RHEUMATIC FEVER,
____ SICKLE CELL DISEASE?
24. DOES CHILD HAVE ALLERGY PROBLEMS (Rash, itch
swelling, difficulty breathing, sneezing)?
a. WHEN EATING ANY FOODS? _________________________
b. WHEN TAKING ANY MEDICATION? ___________________
c. WHEN NEAR ANIMALS, FURS, INSECTS, DUST, ETC? ____
25. (If any “yes” answers to questions 14, 16, 18, 22, 23, or 24 ask:) DO ANY
OF THE CONDITIONS WE’VE TALKED ABOUT SO FAR GET IN
THE WAY OF THE CHILD’S EVERYDAY ACTIVITIES?
(If yes, ask about prenatal care, or schedule time to discuss
prenatal care arrangements.)
EXPLAIN “YES” ANSWERS
*
15. IS CHILD WEARING (Or supposed to wear) GLASSES?
16. DOES CHILD HAVE PROBLEMS WITH EARS/HEARING
(Pain in ear, frequent earaches, discharge, rubbing or favoring one
ear)?
17. HAVE YOU EVER NOTICED CHILD SCRATCHING HIS/HER
BEHIND (Rear end, anus, butt) WHILE ASLEEP?
18. HAS CHILD EVER HAD A CONVULSION OR SEIZURE?
IS CHILD TAKING MEDICINE FOR SEIZURES
EXPLAIN “YES” ANSWERS
If “yes”, ask WHEN DID IT LAST HAPPEN? ________
WHAT MEDICINE? ____________________________
WHAT MEDICINE? _____________________________
(If “yes”) WILL IT NEED TO BE GIVEN WHILE CHILD
IS AT HEAD START? _________ HOW OFTEN?
________
(PHYSICIAN’S NAME: __________________________)
*
If “yes”, transfer information to Forms 1 & 5.
*
*
If “yes”, TRANSFER INFORMATION TO Forms 1 & 5.
WHAT FOODS?
WHAT MEDICINE?
WHAT THINGS?
HOW DOES CHILD REACT?
DESCRIBE HOW:
WHEN?
DESCRIBE HOW:
WHEN?
4/06
CHILD HEALTH RECORD:
FORM 2A, HEALTH HISTORY (Continued)
PERSON INTERVIEWED: __________________________________________________ DATE: __________ RELATIONSHIP: __________________
NAME OF INTERVIEWER: _________________________________________________ TITLE: _______________________________________
PHYSICAL, PSYCHOLOGICAL, AND SOCIAL DEVELOPMENT
THESE QUESTIONS WILL HELP US UNDERSTAND YOUR CHILD BETTER AND KNOW WHAT IS USUAL FOR HIM/HER AND WHAT MIGHT
NOT BE USUAL THAT WE SHOULD BE CONCERNED ABOUT:
27. CAN YOU TELL ME ONE OR TWO THINGS YOUR CHILD IS INTERESTED IN OR DOES ESPECIALLY WELL?
28. DOES YOUR CHILD TAKE A NAP? ____ NO, ____ YES. IF “YES” DESCRIBE WHEN AND HOW LONG.
29. DOES YOUR CHILD SLEEP LESS THAN 8 HOURS A DAY OR HAVE TROUBLE SLEEPING (SUCH AS BEING FRETFUL, HAVING
NIGHTMARES, WANTING TO STAY UP LATE)? ____NO, ____YES. IF “YES” DESCRIBE ARRANGEMENTS (OWN ROOM, OWN BED, AND
SO FORTH). ________________________________________________________________________________________________________________
30. HOW DOES YOUR CHILD TELL YOU HE/SHE HAS TO GO TO THE TOILET? _______________________________________________________
31. DOES YOUR CHILD NEED HELP IN GOING TO THE TOILET DURING THE DAY OR NIGHT, OR DOES YOUR CHILD WET HIS/HER PANTS?
____NO, ____YES. IF “YES” DESCRIBE. _______________________________________________________________________________________
32. HOW DOES YOUR CHILD ACT WITH ADULTS THAT HE/SHE DOESN’T KNOW?
33. HOW DOES YOUR CHILD ACT WITH A FEW CHILDREN HIS/HER OWN AGE?
34. HOW DOES YOUR CHILD ACT WHEN PLAYING WITH A GROUP OF OTHER CHILDREN?
35. DOES YOUR CHILD WORRY A LOT, OR IS HE/SHE VERY AFRAID OF ANYTHING? ____NO, ____YES. IF “YES”, WHAT THINGS SEEM TO
CAUSE HIM OR HER TO WORRY OR TO BE AFRAID?
36. CHILDREN LEARN TO DO THINGS AT DIFFERENT AGES. WE NEED TO KNOW WHAT EACH CHILD ALREADY CAN DO OR IS
LEARNING TO DO EASILY AND WHERE THEY MIGHT BE SLOW OR NEED HELP SO WE CAN FIT OUR PROGRAM TO EACH CHILD. I’M
GOING TO LIST SOME THINGS CHILDREN LEARN TO DO AT DIFFERENT AGES AND ASK WHEN YOUR CHILD STARTED TO DO THEM,
AS BEST YOU CAN REMEMBER. (INTERVIEWER: Read question for each item listed below, and check off the parent’s answer in the appropriate
space).
EARLIER
WHEN
LATER
AGE
EXPECTED
(a) SIT UP WITHOUT HELP
a. WOULD YOU SAY YOUR
(b) CRAWL
CHILD BEGAN TO
(c) WALK
______EARLIER THAN YOU
(d) TALK
EXPECTED, ABOUT WHEN
(e) FEED AND DRESS SELF
YOU EXPECTED, OR LATER
(f) LEARN TO USE THE TOILET
THAN YOU EXPECTED?
(g) RESPOND TO DIRECTIONS
(h) PLAY WITH TOYS
b. WHEN DID HE/SHE BEGIN TO
(i) USE CRAYONS
_________?
(j) UNDERSTAND WHAT IS SAID TO
HIM/HER
37. DOES YOUR CHILD HAVE ANY DIFFICULTIES SAYING WHAT HE/SHE WANTS TO DO OR DO YOU HAVE ANY TROUBLE
UNDERSTANDING YOUR CHILD? ____NO, ____YES. IF “YES” PLEASE DESCRIBE.
38. CHILDREN SOMETIMES GET CRANKY OR CRY WHEN THEY’RE TIRED, HUNGRY, SICK, AND SO FORTH. DOES YOUR CHILD OFTEN
GET CRANKY OR CRY AT OTHER TIMES, WHEN YOU CAN’T FIGURE OUT WHY? ____NO, ____YES. IF “YES” CAN YOU TELL ME
ABOUT THAT?
________________________________________________________________________________________________________________________
WHEN THIS HAPPENS, WHAT DO YOU DO ABOUT IT TO HELP THE CHILD FEEL BETTER?
39. HAVE THERE BEEN ANY BIG CHANGES IN YOUR CHILD’S LKIFE IN THE LAST SIX MONTHS? ____NO, ____YES. IF “YES” PLEASE
DESCRIBE.
40. ARE YOU OR YOUR FAMILY HAVING ANY PROBLEMS NOW THAT MIGHT AFFECT YOUR CHILD? ____NO, ____YES. IF “YES” PLEASE
DESCRIBE.
41. IS THERE ANYTHING ELSE YOU WOULD LIKE US TO KNOW ABOUT YOUR CHILD? ____NO, ____YES. IF “YES” PLEASE DESCIBE.
4/06
CHILD HEALTH RECORD:
FORM 6, NUTRITION
CHILD’S NAME: ___________________________________________ SEX: ___________ BIRTHDATE:_____________________
DIETARY HABITS
1. WHAT FOODS DOES YOUR CHILD ESPECIALLY LIKE? _________________________________________________________
PART 1. TO BE COMPLETED BY HEAD START STAFF DURING PARENT/GUARDIAN INTERVIEW
2. ARE THERE ANY FOODS YOUR CHILD DISLIKES?
3. DOES YOUR CHILD TAKE VITAMINS
AND MINERAL SUPPLEMENTS?
(a) If “yes”, what kind are they?
_________________________________
(b) Do they contain iron?
(c) Do they contain fluoride?
(d) Were they prescribed?
4. IS THERE ANY FOOD YOUR CHILD
SHOULD NOT EAT FOR MEDICAL,
RELIGIOUS, OR PERSONAL REASONS?
Yes
*
*
*
*
5. IS YOUR CHILD ON A SPECIAL DIET?
*
6. HAS THERE BEEN A BIG CHANGE IN
YOUR CHILD’S APPETITE IN THE LAST
MONTH?
*
7. DOES YOUR CHILD TAKE A BOTTLE?
*
8. DOES YOUR CHILD EAT OR CHEW
THINGS THAT AREN’T FOOD?
*
9. DOES YOUR CHILD HAVE TROUBLE
CHEWING OR SWALLOWING?
*
10. DOES YOUR CHILD OFTEN HAVE:
(a) Diarrhea?
(b) Constipation?
*
11. DO YOU HAVE ANY CONCERNS
ABOUT WHAT YOUR CHILD EATS?
No
12. ABOUT HOW OFTEN
DOES YOUR CHILD EAT
A FOOD FROM EACH
OF THE FOLLOWING
GROUPS?
Approximate Number of Times a
Week (circle the number(s)
nearest to parent’s answer)
___________________
0* 1* 2*
3
4 5
6
7
7+
0* 1* 2*
3
4 5
6
7
7+
0* 1* 2*
3
4 5
6
7
7+
0* 1* 2*
3
4 5
6
7
7+
0* 1* 2*
3
4 5
6
7
7+
0* 1* 2*
3
4 5
6
7
7+
0* 1* 2*
3
4 5
6
7
7+ *
0* 1* 2*
3
4 5
6
7
7+ *
(a) Milk, cheese, yogurt.
(b) Meat, poultry, fish, eggs; or
dried beans/peas,
peanut butter.
(c) Rice, grits,
bread, cereal,
tortillas.
(d) Greens, carrots,
broccoli, winter
squash, pumpkin,
sweet potatoes.
(e) Oranges, grapefruit, tomatoes
(fruit/juice).
(f) Other fruits and
vegetables.
(g) Oil, butter,
margarine, lard.
(h) Cakes, cookies,
sodas, fruit
drinks, candy.
*Starred answers may require follow-up. Explain details or give additional comments here.
Head Start
HEAD START HEALTH SERVICES
RELEASE OF INFORMATION
HEAD START Performance Standard 1304.20 (a) (1) (ii) requires a professional determination as to whether the
child is up to date on a schedule of appropriate preventative and primary health care which includes medical, dental
and mental health.
Every child enrolled in the HEAD START program must have regularly scheduled physical examinations,
including dental and mental health screenings. Parents with private insurance, including Medicaid and
CHIPS, have the option of scheduling the exam directly and providing the documentation, or must
provide documentation of the last physical examination, and/or a release of information to be used to
acquire such information.
Note to staff: Please check areas of information that are being required from the parent.
□
□
□
I will make private arrangements for my child’s physical and/or dental examination
and forward documentation to HEAD START Personnel within 30 days.
My child has had a physical and/or dental examination within the past year, and I would
like the supporting documentation forwarded to HEAD START Personnel within 30 days.
My child has not had a physical and/or dental examination within the past year and I would
like him/her to participate in the HEAD START physical/dental examination.
As the mom or dad/legal guardian of
, I hereby authorize
Provider Name/Clinic
Address
to release the results of my child’s latest physical exam to Head Start Personnel. The purpose of this release is to
coordinate health services provided by Head Start. Please include any information related to future physical/dental
examinations and/or appointments.
I have been fully informed and understand the school’s request for my consent, as described above.
I understand that my consent is voluntary and may be revoked at any time. This release of information will
expire one year from the date below.
Signature of Mom or Dad/Guardian
Date
Signature of Head Start Personnel
Date
Head Start
SERVICIOS DE SALUD
DEL PROGRAMA DE
HEAD START
PERMISO PARA DIVULGAR INFORMACION
El programa de Head Start en sus leyes de Medidas de Desempeño 1.304.20 (a) (1) (ii), requiere que tengamos
determinación por parte de persona calificada, de que el niño esté al día en un plan de exámenes apropiados, que
incluyen exámenes médicos, dentales, y de salud mental.
Cada niño matriculado en el programa de Head Start tiene que tener exámenes físicos regularmente incluyendo
exámenes de dentista y exámenes sobre su bienestar mental. Familias que tengan seguro, incluyendo Medicaid y
CHIPS, puedan hacer sus citas con doctores directamente. Necesitan proveer documentación de estos exámenes o
dar permiso que los empleados de Head Start puedan obtener esta información de estos doctores.
Atención Personal de Head Start: Favor de marcar las áreas de información que se requieren del padre.
Haré arreglos para que mi niño tenga examen físico y/o dental y mandaré los resultados a Head Start dentro
de 30 días.
Mi niño ha tenido examen físico y/o dental durante este año y doy permiso que el personal de Head Start
pueda obtener esta información y doy permiso que se lo mande dentro de 30 días.
Mi niño no ha tenido examen físico y/o dental durante este año y quiero que participe en el examen
físico/dental de Head Start.
Como padre/guardián de
, yo autorizo a
Nombre de Clínica/Doctor
Dirección
que mande los resultados de este examen físico/dental al personal de Head Start. El propósito de compartir esta
información es para coordinar los servicios de salud de Head Start. Favor de incluir información que relate a
exámenes físicos/dentales en el futuro y/o citas del futuro.
El personal de Head Start me ha informado y entiendo el propósito de esta forma de permiso. Entiendo que mi permiso es
voluntario y que puedo revocar mi permiso a cualquier tiempo. Esta forma está en efecto por un año de la fecha que sigue.
Firma de Mamá o Papá/Guardián
Fecha
Firma de Personal de Head Start
Fecha
CHILD HEALTH RECORD: FORM 3, SCREENINGS, PHYSICAL EXAMINATION/ASSESSMENT
CHILD’S NAME: _______________________________________________________________ SEX: _____________________ BIRTHDATE: ____________________
HEAD START CENTER: ____________________________________________________________________________________PHONE: _________________________
ADDRESS: ________________________________________________________________________________________________________________________________
1. RELEVANT INFORMATION (from Health History, Parent/Teacher Observations):
SECTIONS BELOW TO BE COMPLETED BY PHYSICIAN
2. SCREENING TESTS. (*) REQUIRED by Head Start. Enter dates if done previously.
TEST
DATE
RESULTS
a. PRESENT AGE*
____Yrs. ____Mos.
j. VISION (Type of test): ___________________________________
* DATE: _______________________________________________
b. HEIGHT (no shoes, to nearest 1/8 in.)*
ACUITY, R/L: _________________________________________
c. WEIGHT (light clothing to nearest ¼ lb.)*
STRABISMUS: _________________________________________
d. BMI
COMMENTS: __________________________________________
k.
HEARING
(Type of test): _________________________________
e. BLOOD PRESSURE*
* DATE: ________________________________________________
f. TEMPERATURE
RESULTS, R/L: _________________________________________
COMMENTS: ___________________________________________
g. RESPIRATION
TEST
DATE
RESULTS
l. OTHER TESTS (if indicated)
(*) REQUIRED by Head Start. Enter dates if done previously.
h. HGB/HCT: _________________________________ DATE: ___________________
(1) TB
□ Normal
□ Abnormal
TX: _______________________________________
i. LEAD: ______________________________________ DATE: ___________________
(2) SICKLE CELL
□ Normal
□ Abnormal
(3) OVA & PARASITES
(4) URINALYSIS
TX: ________________________________________
(5) OTHER: ___________________
3. PHYSICAL EXAMINATION/ASSESSMENT.
NORMAL
ABNORMAL
NOT EVAL.
COMMENTS (Use Additional sheet if necessary)
a.
b.
c.
d.
e.
f.
GENERAL APPEARANCE
POSTURE, GAIT
SPEECH
HEAD
SKIN
EYES: (1) External Aspects
(2) Optic Fundiscopic
(3) Cover Test
g. EARS: (1) External Aspects
(2) Tympanic
h. NOSE, MOUTH, PHARYNX
i. TEETH
j. HEART
k. LUNGS
l. ABDOMEN (include hernia)
m. GENITALIA
n. BONES, JOINTS, MUSCLES
o. NEUROLOGICAL/SOCIAL
(1) Gross Motor _________________
(2) Fine Motor __________________
(3) Communication Skills _________
(4) Cognitive ___________________
(5) Self-Help Skills ______________
(6) Social Skills _________________
p.
q.
r.
4.
GLANDS (Lymphatic/Thyroid)
MUSCULAR COORDINATION
OTHER
FINDINGS, TREATMENTS, AND RECOMMENDATIONS
ABNORMAL FINDINGS/DIAGNOSIS
TREATMENT PLAN
RECOMMENDED FOLLOW-UP OR RESULTS
(Initial when complete)
DATE
a.
b.
c.
5. GENERAL STATEMENT ON CHILD’S PHYSICAL STATUS:
Physician’s Signature: ______________________________ Date _______________
Head Start
HEARING/VISION SCREENING FOR
THREE (3) YEAR OLD STUDENTS
NAME:
DATE OF TESTING:
DOB:
DISTRICT:
STAFF MEMBER CONDUCTING SCREENING:
PARENT/GUARDIAN PROVIDING INFORMATION:
VISION SCREENING
YES
1.
NO
2.
Formal vision testing by doctor/eye specialist?
Name of doctor:
Date:
Does the parent suspect any problems with vision?
3.
Does the child squint, close, or cover one eye?
4.
Does the child move his/her head forward or backward when looking at near/distant objects?
5.
Does the child tilt his/her head to one side?
6.
Do the child’s eyes turn inward/outward?
7.
Can the child track/follow moving objects around the room?
HEARING SCREENING
1.
Formal hearing testing by doctor/ENT?
Name of doctor:
Date:
2.
Tubes in ears? Date of surgery:
3.
Does the parent suspect a hearing loss?
Which ear?
Has the child had a history of frequent ear infections?
4.
5.
Does the child respond to a familiar voice when that person is out of the room or out of
sight?
6.
Does the child discriminate between different sounds (telephone, doorbell, loud/soft voices)?
COMMENTS
4/06
EXAMEN PARA NIÑOS DE 3 AÑOS
DE VISIÓN Y EXAMEN AUDITIVO
Nombre:
Fecha del examen:
Fecha de nacimiento:
Nombre del distrito escolar:
Head Start
Nombre de la persona encargada del examen:
Nombre del padre/guardián que nos da esta información:
CERNIMIENTO DE VISIÓN
SI
1.
2.
3.
4.
5.
6.
7.
NO
¿Ha tenido examen su niño, por un doctor/oculista?
El nombre del doctor:
Fecha del examen:
¿Piensa usted que su niño tenga problemas con su visión?
¿Mira con un ojo entornado, cierra un ojo para ver, o se cubre un ojo para ver?
¿Mueve su cabeza para delante o para atrás cuando está viendo objetos cerca de o lejos de
si?
¿Inclina o ladea su cabeza a un lado?
¿Se le parece que tiene los ojos bizcos?
¿Cuándo se le mueve un objeto enfrente de sus ojos y mueve el objeto a lado a lado,
mueve sus ojos su niño para seguir el objeto?
CERNIMIENTO DE OIDOS
1.
2.
3.
4.
5.
6.
¿Le han examinado un especialista de oídos?
El nombre del doctor:
Fecha de examen:
¿Le han puesto tubos en los oídos?
Fecha de cirugía:
¿Piensa usted que su niño no puede oír bien?
¿En cuál oído?
¿Ha tenido muchas infecciones en sus oídos?
¿Si alguien conocido no está en el cuarto y habla esa persona, puede su hijo reconocer su
voz?
¿Puede su hijo distinguir diferentes sonidos? (el sonido de teléfono, timbre de la puerta,
voces altas/bajas)
Otros comentos que nos quiera decir:
Head Start
NAME: ________________________________________________________ DOB: ________________________
PARENT QUESTIONNAIRE
Prescreening Questions for a Child who has never had a High Blood Lead
This questionnaire is about lead. Lead is a dangerous substance that sometimes gets into children’s bodies. It can make them
sick and affect their behavior and ability to learn. Answers to these questions will help the doctor see if your child may have
been exposed to lead. If your child has been exposed to lead, the doctor will need to do a blood test. The test may show that the
child has lead in his/her blood or it may show that your child is fine. Even if your child does have a high blood lead, the doctor
can tell you things that you can do to help your child be healthy. If any of these questions are confusing, ask the doctor or nurse
to help you with them.
* 1) Do you live in or often visit a house that was probably built before 1978?
YES □
NO □
I DON’T KNOW □
* 2) Does your child live in or often visit a house that is being painted, remodeled, or
YES □
NO □
I DON’T KNOW □
having the paint scraped or sanded?
* 3) Does your child eat or chew on non-food things like paint chips or dirt?
YES □
NO □
I DON’T KNOW □
* 4) Have any other members of the family or your child’s playmates had high blood
YES □
NO □
I DON’T KNOW □
leads as far as you know?
* 5) Does anyone living in your house work at a place where any of these things happen or have a hobby that involves these things (circle
the ones that apply):
radiator repair
lead industry
welding
battery manufacture or repair
house construction or repair
smelting
chemical preparation
making pottery
going to a firing range
stained glass with lead solder
brass/copper foundry
valve and pipe fittings
bridge, tunnel and elevated
industrial machinery and
casting ammunition, fishing
refinishing furniture
highway construction
equipment
weights, or toy soldiers
burning lead-painted wood
automotive repair shop
Does anybody that your child spends a lost of time with (outside of your home) do any of
YES □
NO □
I DON’T KNOW □
these things or work at a place where these things are done?
6) Does anybody that your child spends a lot of time with (outside of your home) do any of these things or work at a place where these
things are done?
7) Do you give your child, or have you ever given your child, any of these products
from another country:
MEDICINES like greta or azareon for empacho, alarcon, alkohl,
bali goli, coral, ghasard, liga, pay-loo-ah or rueda?
NUTRITIONAL PILLS OTHER THAN VITAMINS?
YES □
NO □
I DON’T KNOW □
YES □
NO □
I DON’T KNOW □
COSMETICS like surma or kohl?
8) Does your home’s plumbing have lead pipes, lead solder or lead-containing holding
tanks:
9) Is imported or glazed pottery, or a Mexican bean pot, used to cook or store your food?
10) Does your child eat foods canned outside the U.S.?
YES □
NO □
I DON’T KNOW □
YES □
NO □
I DON’T KNOW □
YES □
YES □
NO □
NO □
I DON’T KNOW □
I DON’T KNOW □
(NOTE: Asterisks by questions indicate that answers to these questions are particularly important in determining if a child may have a
high blood lead.)
________________________________________________
Signature – Title of person completing checklist
__________________________________
Date
4/06
Head Start
NOMBRE: ______________________FECHA DE NACIMIENTO:_____________________
CHART #:
PREGUNTAS PARA PADRES
Preguntas sobre niños que nunca han tenido examen para saber si se ha puesto en contacto con plomo.
Esta forma cubre preguntas sobre plomo en la pintura de su casa o si alguien con quien vive trabaja en lugares
donde se puede poner en contacto con plomo. El plomo es muy venenoso y algunas veces se puede introducir en
los cuerpos de niños en varias formas. Se pueden enfermar y afectar su modo de ser y su habilidad para aprender.
Las respuestas suyas le ayudarán al médico en determinar si su niño se ha puesto en contacto con plomo. Si el
médico piensa que haya razón, le sacará sangre al niño para determinación positivo. Si resulta que tiene plomo en la
sangre, el doctor puede decirle que hacer para sanarlo. Si no entiende las preguntas que siguen, el médico o
enfermera le puede ayudar.
*1. ¿Viven ustedes en casa construida o visita casas construidas antes del año 1978?
*2. ¿Vive su niño o visita una casa que la están pintando, haciendo arreglos, o le están quitando la
pintura?
*3. ¿Sabe si su niño ha comido o masticado pedazos de pintura o tierra?
Si
Si
No
No
No se
No se
Si No
No se
*4. ¿Sabe si otros miembros de su familia o amigos de su niño han tenido exámenes positivos de
Si
No
No se
plomo?
*5. ¿Sabe si alguien que vive con ustedes trabaja en una de los siguientes lugares o tienen pasatiempo que envuelve algunas de
las actividades que siguen? Favor de marcar todas lo que aplican.
reparación de radiadores de carro
trabajan en industria de plomo soldadura participan en hacer o reparar baterías de carro
construcción o reparación de casas extracción de metal
preparación de químicos hacen vasijas de barro
disparan armas
hacen vidrios de color con soldadura de plomo
fundición de metales de bronce, cobre
instalador de cañerías/válvulas construcción de túneles, puentes, carreteras
maquinaria/equipo industrial
fundición de munición, sedales, soldados (juguetes) de hierro
retocar muebles
encender madera que tenga plomo
trabajar en reparación de automóviles
¿Tiene su niño amigos con quien se junta mucho (fuera de su casa), que estén envueltos en las
Si
No
No se
ocupaciones que están identificadas en la pregunta #5?
6. ¿Tiene su niño amigos con quien se junta mucho (fuera de su casa), que estén envueltos en las ocupaciones que siguen? Favor
de marcar todos lo que aplican.
extracción de metal
lugar donde se pone desperdicios arriesgados
la industria de plomo
industria de hacer o preparar baterías de carro
construcción de casas
carretera publica en donde hay mucho tráfico
lugar en donde se abandonan carros o los reparan
7. ¿Le da o le ha dado a su hijo algunas de las medicinas/productos que siguen que son de otro país?
Si
No
No se
- MEDICINA como greta o azarcon para empacho, Alarcón, alkohl, bali goli, coral,
ghasard, liga, pay-loo-ah o rueda
PASTILLA DE NUTRICION (QUE NO SON VITAMINAS)
Si
No
No se
COSMETICOS como surma o kohl
Si
No
No se
8. ¿Tiene su casa sistema de cañerías de plomo, soldadura de plomo o tanques de agua hecha de
Si
No
No se
plomo?
9. ¿Usa usted ollas hechas en México u otros países para cocinar o guardar comida?
Si
No
No se
10. ¿Come su niño comidas que fueron enlatadas en país fuera de los estados unidos?
Si
No
No se
(Nota: Las preguntas que tienen asterisco indican que las respuestas son particularmente importante en determinar si su hijo tenga nivel alto de plomo en
su sangre.)
Firma/titulo de la persona completando esta forma
Fecha
Head Start
NAME: _____________________________________________ DOB: ___________________________
This questionnaire is about tuberculosis: Tuberculosis can be transmitted to children by adults who live with or spend a great
deal of time with them. Tuberculosis is transmitted by a person with tuberculosis to another person through airborne droplets
that are coughed or sneezed into the air and breathed in by the child. This transmission of infection is more likely to occur
when the child and the infectious person spend a lot of time together in a closed environment, like a small room, a car, or
other similar situations.
Adults who have tuberculosis will often have the following symptoms: cough for more than two weeks duration, loss of
appetite, weight loss of ten or more pounds over a short period of time, fever, chills, and night sweats.
Children with tuberculosis frequently do not have symptoms.
A person can have a tuberculosis infection and not have active tuberculosis.
ƒ
ƒ
ƒ
ƒ
Not everyone who coughs has tuberculosis.
Tuberculosis is preventable and treatable.
Children can become very ill with tuberculosis.
We need your help to find out if your child has been exposed to tuberculosis.
YES NO
I DON’T KNOW
Has anyone in your family had tuberculosis?
Has your child or any of your other children or family members ever had a
positive TB skin test?
Has your child been around anyone with tuberculosis since his/her last skin
test?
Was your child born in a foreign country where there is a lot of TB, or has your
child visited relatives there?
Has your child been around any adult who coughs a lot (relative, baby sitter,
teacher, neighbor)?
Has your child had any health problems over the past year such as a cough of
two or more weeks duration?
Has your child had contact with anyone who is/has been a drug user?
HIV-infected?
In jail/prison?
Foreign born?
_____________________________________________________
Signature – Title of person completing checklist
____________________________________
Date
4/06
Head Start
NOMBRE:
FECHA DE NACIMIENTO:
Este cuestionario cubre la enfermedad de tuberculosis. Tuberculosis se puede transmitir por parte de adultos a niños con
quien viven o si pasan mucho tiempo con adultos con tuberculosis. Tuberculosis es transmitido de persona a persona por
gotitas transmitidas por el aire cuando uno toce o estornuda y son respiradas por el niño. Esta transmisión de infección ocurre
cuando el niño y la persona infectada pasan mucho tiempo junto en cuartos chicos, un carro, o situaciones similares.
Adultos que tienen tuberculosis pueden tener las síntomas que siguen: tos por más de dos semanas, no tienen apetito para
comer, han perdido diez libras o más de peso durante tiempo muy poco de duración, tienen fiebre, escalofrió, y sudan mucho
durante la noche.
Los niños que tienen tuberculosis frecuentemente no tienen síntomas.
Una persona puede tener infección de tuberculosis y no tener tuberculosis activo.
• Si una persona tiene tos, no quiere decir que tiene tuberculosis
• Tuberculosis puede ser prevenido y tratable
• Niños pueden enfermarse demasiado con tuberculosis
• Necesitamos su ayuda para determinar si su niño tenga riesgo de tener tuberculosis
SI
¿Tiene un miembro de su familia que haya tenido tuberculosis?
¿Desde la última vez que su niño tuvo examen para tuberculosis,
se ha puesto en contacto con alguna persona con tuberculosis?
¿Fue nacido su hijo en un país en donde se encuentran muchas
personas con tuberculosis, o ha visitado parientes en ese país?
¿Se ha puesto en contacto su hijo con algún adulto que toce
mucho (pariente, niñera, maestra, vecino)?
¿Ha tenido su hijo problemas de salud durante el año pasado,
especialmente una tos que le duró dos o más semanas?
¿Ha tenido contacto su hijo con personas que eran/usan drogas
(ilegales)?
¿Qué están infectados con SIDA?
¿Qué han estado en la cárcel o prisión?
¿Qué son nacidos en otros países?
Firma/titulo de la persona completando esta forma
Fecha
NO
NO SE
OPTIONAL HEALTH
FORMS
•
•
•
•
•
•
•
•
Parent Letter – If You Do Not Have Medical Insurance
Head Start Emergency Card
Health Contact Follow-up Form
Denial of Service
Hearing/Vision Screening
Documentation of Physical & Dental Exam Form
In-House Referral
Accident Report
Head Start
Parents of Head Start Students,
If you do not have medical insurance, a copy of the CHIPS/Medicaid application has been given to you at the
time of registration.
Please complete this form and attach information requested for your child to be covered by insurance.
Thank you.
MOM OR DAD/GUARDIAN SIGNATURE
STAFF SIGNATURE
DATE
4/06
Head Start
PADRES DE ESTUDIANTES DEL PROGRAMA DE HEAD START,
SI USTED NO TIENE SEGURO CONTRA ACCIDENTES, UNA COPIA DEL PROGRAMA CHIPS SE LO
FUE DADO AL TIEMPO DE MATRICULACION.
FAVOR DE COMPLETAR ESTA FORMA Y ANADIRLE LA INFORMACION PEDIDA PARA QUE
PODAMOS DARLE UNA POLIZA DE SEGUROS.
MUCHAS GRACIAS
FIRMA DE PADRE/GUARDIAN
FIRMA DE PERSONAL DE HEAD START
FECHA
HEAD START EMERGENCY CARD
Race:
Grade
EMERGENCY INFORMATION
CARD
Please Print Student’s Last Name
Date Entered
First Name
M
Head FStart
SS#
Middle Name
Birth Date
Home Address
Home Phone
What (if any) drug is your child allergic to?
What (if any) chronic diseases does your child have?
What medications will your child take at school?
What (if any) medication does your child take daily?
Mother: Name
Work
Work Phone
Father: Name
Work
Work Phone
List two neighbors or nearby relatives who will assume temporary care of your child if you cannot be reached.
1. Name
2. Name
Address
Phone
Address
Phone
Family Physician’s Name
Office Address
Office Phone
In the event of accident or serious illness, I request the school to contact me when time allows. If the school is
unable to reach me, I hereby authorize the school to contact the physician indicated above and follow his
instructions. If the physician is not available the school is authorized to make whatever arrangements seem
necessary. Permission for Emergency Treatment is good for one school year only.
Signature of Mom or Dad/Guardian
x ___________________________________
Yes __
No __
Date____________________
4/2006
HEAD START EMERGENCY CARD
TARJETA DE INFORMACION EN
CASO DE EMERGENCIA
Apellido
Primer Nombre
FECHA
Segundo Nombre
Head Start
Raza:
Sexo:
Número de Seguro
Social
Fecha de nacimiento
Dirección
Número de teléfono
¿Tiene su niño alergia a drogas? ¿Cuáles son?
¿Tiene su niño enfermedades crónicas? ¿Cuáles son?
¿Cuáles son las medicinas que su niño debe de tomar durante su día en la escuela?
¿Cuáles son las medicinas que su niño toma diariamente?
Nombre de Madre:
Su empleo:
Número de teléfono:
Número de teléfono:
Nombre de Padre:
Su empleo:
Favor de apuntar los nombres de dos vecinos con quien se pueda quedar su niño si no podemos encontrarlo:
1. Nombre Dirección
2. Nombre Dirección
Número de teléfono
Número de teléfono
Nombre del doctor de su familia:
Su dirección:
Número de teléfono
En el evento que ocurra un accidente o enfermedad grave, pido que la escuela me contacte si hay tiempo. Si la
escuela no me puede encontrar, yo autorizo a la escuela que se ponga en contacto con el doctor indicado y que
sigan sus instrucciones. Si el médico no está disponible, la escuela está autorizada para hacer cualquier arreglo
necesario. El Permiso Para Tratamiento de Emergencia está en efecto solamente por un año.
____________________________
Firma de Padre/Guardián
Si ____ No ___
___________________________
Fecha
Head Start
Health Contact Follow-up Form
This is a summary for the child listed below. We hope that it will be of assistance to you.
Child’s Name___________________________________________
Date Screening
Completed
Results were Normal
Yes/No
Date of
Follow Up/Treatment
Results
Hearing
Vision
Dental
Additional Information
Staff Signature/Date
File in Health Section
and
Give copy to Parent
4/06
Head Start
Forma de Continuación
De Información de Salud
Esta forma sirve como sumario de examines para el niño cuyo nombre sigue. Esperamos que le ayude.
Nombre del niño
Fecha que se
cumplió el
examen
Los resultados
son normales
Si/No
Fecha para
continuación de
tratamiento
Los resultados
Examen de oídos
Examen de
visión
Examen dental
Información adicional:
Firma de Personal/Fecha
File in Health Section
and
Give copy to Parent
Head Start
Denial of Service Form
I,_________________________________________ , the mom or dad/guardian
(PRINT your name)
of
, Head Start student attending
(PRINT name of Head Start student)
Center/School during the
school year.
I understand what the test, treatment or evaluation entails. I understand that this is part of the Head Start Program. I
decline the following services offered by Region 9.
The REASON for declining this service is stated below:
Mom or Dad/Guardian Signature
Date
HS Personnel Accepting this Form
6/2007
Head Start
Negación de Servicios
Yo,
el padre/guardián de
(Favor de imprimir su nombre)
(Favor de imprimir el nombre del niño)
estudiante en el programa de Head Start matriculado en la escuela
(Nombre de la escuela)
durante el año escolar
.
(Por ejemplo: 2005-2006)
Entiendo en qué consisten los exámenes, tratamientos o evaluaciones que le quieren hacer a mi niño y que son parte
del programa de Head Start. En firmar esta forma, quiero negar los servicios ofrecidos por Región 9.
La RAZON porque quiero negar estos servicios:
Firma de Padre/Guardián
Fecha
Firma del empleado del Programa de Head Start que acepta esta forma
Head Start
HEARING/VISION SCREENING FOR
THREE (3) YEAR OLD STUDENTS
NAME: ______________________
DATE OF TESTING: _________________________
DOB: ________________________
DISTRICT: __________________________________
STAFF MEMBER CONDUCTING SCREENING: __________________________________
PARENT/GUARDIAN PROVIDING INFORMATION: ______________________________
VISION SCREENING
YES
NO
1. ___
___
2.
3.
4.
5.
6.
7.
Formal vision testing by doctor/eye specialist?
Name of doctor: ________________ Date: ___________________
Does the parent suspect any problems with vision?
Does the child squint, close, or cover one eye?
Does the child move his/her head forward or backward when looking at near/distant objects?
Does the child tilt his/her head to one side?
Do the child’s eyes turn inward/outward?
Can the child track/follow moving objects around the room?
HEARING SCREENING
1.
2.
3.
4.
5.
6.
COMMENTS
Formal hearing testing by doctor/ENT?
Name of doctor:
Date: __________
Tubes in ears? Date of surgery: _______________________
Does the parent suspect a hearing loss?
Which ear? ____________
Has the child had a history of frequent ear infections?
Does the child respond to a familiar voice when that person is out of the room or out of sight?
Does the child discriminate between different sounds (telephone, doorbell, loud/soft voices)?
Head Start
EXAMEN PARA NIÑOS DE 3 AÑOS
DE VISIÓN Y EXAMEN AUDITIVO
Nombre: ______________________ Fecha del examen: __________________________________
Fecha de nacimiento: ____________ Nombre del distrito escolar: ___________________________
Nombre de la persona encargada del examen: ___________________________________________
Nombre del padre/guardián que nos da esta información: __________________________________
CERNIMIENTO DE VISIÓN
SI
1.
2.
3.
4.
5.
6.
7.
NO
¿Ha tenido examen su niño, por un doctor/oculista?
El nombre del doctor: ____________ Fecha del examen:_________________
¿Piensa usted que su niño tenga problemas con su visión?
¿Mira con un ojo entornado, cierra un ojo para ver, o se cubre un ojo para ver?
¿Mueve su cabeza para delante o para atrás cuando está viendo objetos cerca de o lejos de
si?
¿Inclina o ladea su cabeza a un lado?
¿Se le parece que tiene los ojos bizcos?
¿Cuándo se le mueve un objeto enfrente de sus ojos y mueve el objeto a lado a lado,
mueve sus ojos su niño para seguir el objeto?
CERNIMIENTO DE OIDOS
1.
2.
3.
4.
5.
6.
¿Le han examinado un especialista de oídos?
El nombre del doctor: ___________ Fecha de examen: _______________
¿Le han puesto tubos en los oídos?
Fecha de cirugía: ________________
¿Piensa usted que su niño no puede oír bien?
¿En cuál oído?________________________
¿Ha tenido muchas infecciones en sus oídos?
¿Si alguien conocido no está en el cuarto y habla esa persona, puede su hijo reconocer su
voz?
¿Puede su hijo distinguir diferentes sonidos? (el sonido de teléfono, timbre de la puerta,
voces altas/bajas)
Otros comentos que nos quiera decir:
Head Start
Documentation of Physicals/Dental Appointments for
Region 9 Head Start Children
Initiated Appointment By:
*
Physical
Dental
Complete
(yes/no)
Date
Parent
District Assists
District Assists
Scheduled for Student
Parent
*Attach Consent Forms
Denial of Services ______________________________
Date
Attach copy of form.
Encourage parents to obtain physicals/dental appointments for second year of Head
Start.
6/07
HEAD START
IN-HOUSE REFERRAL
Head Start
Please Circle:
HEALTH
SPEECH
TRANSPORTATION
MENTAL HEALTH/
SOCIAL SERVICE
BEHAVIOR
Student
DOB
Teacher
DOE
School
Referral Source
DATE
Reason for Referral
(Please describe in detail, including action taken, and relevant parent contact history):
Documentation is attached
DISPOSITION
Documentation:
Date Received:
Date Completed:
Specialist:
4/06
Head Start
Accident Report
Date
Name
/
/
Social Security No
Last
Home Address
First
Middle
Phone
Job Title
City
Employee No.
State
Age
Department
Location of accident
Zip
Sex □ Male □ Female
Shift
Date of accident
/
/
Date Reported
/
Time Reported
/
/
am
Time of accident
/
/
am
/
pm
pm
Description of accident (attach diagram if possible)
□
□
INDOORS
Quality of lighting
□ Poor □ Good □ Excellent
Type of floor
□ Concrete
□ Carpet □ Tile (if applicable)
□Wood
□ other
Condition of floor
OUTDOORS
Weather Conditions
□ Snow □ Sleet
□ other
□ Dry
□ Wet
Condition of surface
□ New Carpet
□ Freshly Waxed
Other conditions
List tools, chemicals or machinery involved in this accident
Witnesses:
Name
Address
City St. Zip
Phone
1
□ Clear □ Rain
2
3
Accident Report (continued)
Describe injuries and part of the body affected
Did a fatality occur? □ Yes
□ No
Medical Attention Given:
□ First Aid given by
Name
Address
Phone
City
(
)
AM
PM
Time
Name
Address
Phone
□ Taken to hospital
Zip
-
Date
□ Examined by doctor
State
City
(
)
State
Zip
-
Name
Address
Phone
City
(
)
State
Zip
-
Date
Time
□ Released
AM
PM
□ Admitted
Length of Stay
Family notified by: Name
Future action to be taken, describe
□ Insurance contacted
Prepared by
Date
/
/
Supervisor on duty
Date
/
/
Approved by
Date / /
□ Cause determined and corrected
□ Reported to personnel department
□ Damaged equipment replaced or repair
3/06
Head Start
Reporte de Accidente
Fecha:
Nombre:
/
/
Número de seguro social:
Apellido
Primer nombre
Segundo nombre
Dirección:
Ciudad:
Estado
Número de teléfono
Su empleado
Su edad
Su número de identificación de trabajo (si lo tiene)
El departamento en que trabaja
¿Donde ocurrió el accidente?
La fecha que lo reportó
/ /
Código postal:
Su sexo
Las horas que trabaja
La fecha del accidente
La hora que ocurrió el accidente
¿Por la mañana? Si
No
/
/
La hora que reportó el accidente
¿Por la tarde?
Si
No
Favor de explicar cómo pasó el accidente.
Si el accidente ocurrió adentro, favor de marcar las condiciones.
Calidad de luz:
Mala
Buena
Excelente
Favor de marcar el tipo de piso:
Concreto
Alfombra
Teja
Madera
Otra clase de piso:
Favor de marcar la condición del piso:
Seco
Mojado
Alfombra nueva
Con cera
Si el accidente ocurrió afuera, favor de marcar las condiciones.
¿Cómo estaba el tiempo?
Estaba claro el día
Estaba nevando/había nevado
Había granizo
Otras condiciones
Estaba lloviendo
Si el accidente ocurrió en parte por el uso de herramientas o sustancia química, favor de apuntarlos aquí.
Testigo(s) del accidente:
Nombre
Dirección
Ciudad, Estado, Código
Postal
Número de teléfono
Testigo #1
Testigo #2
Testigo #3
Reporte de Accidente (continuar)
Favor de decirnos cuales fueron las heridas y cuales partes de su cuerpo fueron afectadas:
¿Se murió alguien?
Si
No
Asistencia médica que se fue dada:
Asistencia de primer auxilio (First Aid) fue dado por:
Nombre
Dirección, ciudad, estado, código postal
Número de teléfono
Fecha
Hora
Por la mañana
la tarde
Examinado por doctor:
Nombre
Dirección, ciudad, estado, código postal
Número de teléfono
Fecha
Hora
Por la mañana
la tarde
Si fue llevado a un hospital:
Nombre
Dirección, ciudad, estado, código postal
Número de teléfono
Fecha
Hora
Por la mañana
la tarde
Fue admitido al hospital: si
no
¿Cuánto tiempo tuvo que quedarse en el hospital?
La familia fue notificada por: Nombre
Favor de decirnos que acción necesita tomar en el futuro (cuál es el resultado del accidente):
Forma preparada por:
Fecha
Contacto con la compañía de
seguros
Supervisor:
Fecha
La causa fue determinada y
fue corregida
Forma aprobada por:
Fecha
Fue reportado al departamento
de personal
Si se dañó equipo, fue
reparado o fue reemplazado
Section Three: Social Services
• Progress Notes Social Services
• Center-Based Family Partnership Agreement
• Head Start Family Partnership
Agreement/Needs Assessment (home visit)
• Thank You Letter to Family (optional)
• Parent Interest Questionnaire
• In House Referral (as needed)
• Release of Information (optional)
Head Start
STUDENT NAME: ____________________________________LOCATION: ____________________
DATE OF BIRTH: ____________________
HEAD START FAMILY/CHILD
PROGRESS NOTE (SOCIAL SERVICES)
DATE DOCUMENTATION
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
__________________________________________________________________________________
.* Release notes to be filed behind this form
4/06
CENTER-BASED
FAMILY PARTNERSHIP AGREEMENT
Head Start
Between
HEAD START and
(NAME)
PARENT/LEGAL GUARDIAN of
(CHILD)
HEAD START will provide:
•
Full-day child development/education services to Child on non-holiday weekdays during the ninemonth school year;
•
Health and dental screening for Child and assistance with treatment as necessary and appropriate;
•
Mental health screening for Child and assist with treatment services as necessary and appropriate;
•
Nutritious meals and snacks to Child and nutrition assessment and counseling as needed;
•
Parent education and involvement opportunities on a regular and ongoing basis;
•
Transition services as Child progresses to public school or other child development programs;
•
Comprehensive family support services to the Child’s entire family, including the identification of
goals, objectives, and action steps necessary to accomplish them;
•
An opportunity for Child to brush teeth twice daily.
HEAD START may:
•
Provide transportation for Child for field trips or medical and dental emergencies. I understand that
additional field trip permission forms will need to be returned so that my child may participate;
•
Disclose Child’s health, family, educational and other records to the HEAD START program, it’s
agents and employees, and/or to providers of human services for the provision of services;
•
Utilize photographs of Child for training, advertising or publicity purposes published in media
whatsoever including electronic publication;
•
Disclose records related to Child and family for the purpose of review and inspection by auditors,
monitors, or other representatives of organizations that provide funding for the goods and services
received by Child or myself in connection with the HEAD START program.
Page 1 of 2
CENTER-BASED FAMILY PARTNERSHIP AGREEMENT
(Continued)
Head Start
NOTICE: BY COMPLETING THIS FORM, YOU ARE ENROLLING YOUR CHILD IN A CHILD
DEVELOPMENT PROGRAM. IN ORDER TO MAINTAIN ENROLLMENT, YOU MUST ABIDE BY
THE REGULATIONS ESTABLISHED BY HEAD START.
The parent/guardian consents and agrees to the following
(Please initial each statement for which you are providing consent.):
The Parent is expected to:
_______ Update emergency and contact information on the HEAD START emergency card whenever necessary;
_______ Provide the Child’s health history, including medical conditions and other information as requested;
_______ Participate in developing Child’s educational goals and family goals;
_______ Participate in home visits during the school year by the classroom teacher and social service staff;
_______ Ensure Child’s regular attendance and contact the center when absences are necessary;
_______ Abide by HEAD START tardies and late pick-up policies.
_______ Follow through with plans of action formed in conjunction with HEAD START staff;
_______ Cooperate and work in partnership with all HEAD START components that may interface with Child
or Child’s family;
_______ Participate in center parent meetings, volunteering, and family activities.
The Parent/Guardian understands that HEAD START services may be suspended, terminated, or
transferred should any of the following conditions exist:
™ Child presents a health or safety risk to himself/herself or others;
™ Parents/Guardian’s words or actions (or the words or actions of the child’s other family
members or representatives) are perceived to represent a physical threat to staff, other
parents, children or volunteers;
™ Misrepresentation related to the information concerning household or family structure,
employment or family income, or a major change in that information that is not promptly
reported to HEAD START.
Staff Signature
Date
Signature of Mother or Dad
Date
Page 2 of 2
ACUERDO DE FAMILIA
Head Start
ENTRE
El Programa de Head Start y
(Nombre de padre/guardián)
Padre/Guardián legal de
(Nombre del niño)
HEAD START proveerá:
●
Día entero de servicios de desarrollo/educación al Niño durante los días lunes a viernes
durante los nueve meses escolares (con excepción de los días de fiesta);
●
Exámenes de salud y dentales para el Niño y ayuda con los tratamientos si son necesarios y
apropiados;
●
Examen de salud mental para el Niño y ayuda con los tratamientos si son necesarios y
apropiados;
●
Comida y bocaditos saludables (nutritivos) al Niño y evaluación/consejo para reconocer si
el niño está de buena salud (nutritivamente);
●
Educación para padres y oportunidades de asistir actividades regularmente;
●
Servicios de transición para el Niño cuando pasa a la escuela pública u otros programas de
desarrollo de niño;
●
Sosten de servicios para toda la familia, incluyendo la identificación de metas, objetivos, y
planes para cumplirlos;
●
Oportunidad para el Niño de cepillarse sus dientes diariamente en el programa de Head
Start con fluoruro de 4% para prevención de decaimiento de dientes.
HEAD START puede:
●
Proveer transportación para el Niño cuando lleven a los niños a día de campo o cuando sea
apropiado por razón de emergencia física o dental. Entiendo que habrá formas de
permiso para el día de campo. Necesitaré firmar esa forma para que mi niño pueda
participar;
●
Revelar información sobre el Niño en relación de su salud, información de familia,
información educativa y otros documentos al programa de HEAD START. Se le puede dar
esta información a sus agentes y empleados y/o las agencias de servicios humanos para
proveer servicios;
●
Utilizar fotografías del Niño para usar en casos de entrenamiento, anuncios o avisos
publicados en cualquier publicación incluyendo publicación electrónica;
●
Revelar los documentos del Niño y familia para el propósito de repaso e inspección por
medio de auditores, instructores, y otros representantes de organizaciones que proveen
fondos para los servicios que recibe el Niño y/o en conjunto con el programa de HEAD
START.
ACUERDO DE FAMILIA
Head Start
ENTRE (continuar)
Advertencia: En completar esta forma, está usted matriculando a su hijo en un programa de desarrollo de niños.
Para que siga su niño en este programa, usted necesita apoyar las reglas/leyes establecidos por el programa de
Head Start.
El padre/guardián da su permiso y está en acuerdo de lo siguiente. (Favor de poner su inicial al lado de las declaraciones que
usted está de acuerdo):
Se le espera al Padre que:
Mantenga la elegibilidad del Niño en el programa de HEAD START. En hacer esto, el padre
tendrá que asegurar que todos los adultos en casa tengan empleo de tiempo completo, estén en la
escuela, o estén entrenándose para trabajo;
Nos avise cuando hay cambio de la información de personas a quien le podemos llamar en caso de
emergencia;
Provea información del Niño acerca de su historia de salud, incluyendo condiciones medicas y más
información que le pidamos;
Participe en el desarrollo de las lecciones de clase y que el Niño regrese sus tareas escolares hechos
en casa;
Participe en las visitas de hogar durante el año escolar por parte de la maestra del Niño y
empleados de los servicios sociales del programa;
Asegure que su Niño venga a su clase regularmente y que nos avise cuando el Niño esté enfermo;
Siga con los planes de acción formuladas en conjunto con los empleados de HEAD START;
Apoye la póliza del programa de HEAD START de recoger su Niño a tiempo cada día. Se entiende
que la póliza dice que el niño puede ser suspendido del programa o ser inelegible para servicios del
programa si usted recoge tarde al niño más de tres veces durante el año escolar;
Coopere y trabaje en conjunto con todos los programas de HEAD START que le sirven a su niño
o su familia;
Participe 75% del tiempo en juntas de padres;
Participe en servir como voluntario.
El Padre/Guardián entiende que los servicios de HEAD START pueden ser suspendidos, terminados, o
transferidos si alguna de las condiciones siguientes existen:
™ Si el niño tiene arriesgo de salud o que sea arriesgo a si mismo u otros;
™ Si las palabras o acciones (o palabras o acciones de la familia/representantes del niño) se perciben
representar amenazo físico para los empleados de HEAD START, otros padres, niños, o
voluntarios;
™ Noticia falsa de información de casa o la estructura de la familia, su trabajo o ingresos de la
familia, o si ocurre cambio mayor en esa información que no se reporta pronto al programa de
HEAD START.
La firma del Padre/Guardián Legal que sigue, entiende que él/ella puede matricular un niño si es el
padre de este niño o que tiene custodia legal o sea guardián legal. En firmar, el Padre/Guardián Legal se
representa como persona calificada de matricular al niño.
Firma de Maestro
Fecha
Firma de Padre/Guardián
Fecha
HEAD START
FAMILY PARTNERSHIP AGREEMENT
Child’s Name
Parent/Guardian
Address
FAMILY STRENGTHS
1. _______________________________________
2. _______________________________________
3. _______________________________________
4. _______________________________________
Head Start
Date of Birth
Phone
Location
FAMILY NEEDS
1. _______________________________
2. _______________________________
3. _______________________________
4. _______________________________
NOTES
GOALS
Short Term:
Time Table:
Strategies:
Long Term:
Time Table:
Strategies:
I am not interested in setting any goals at this time, but I may contact you at a later time.
Mother or Dad’s Signature
Date
Agency Representative
Date
4/2005
Head Start
HEAD START
PACTO DE CONSORCIO DE FAMILIA
Nombre del Niño
Padre/Guardián
Dirección
Fecha de Nacimiento
Número de Teléfono
Escuela
/
/
HABILIDADES DE LA FAMILIA
NECESIDADES DE LA FAMILIA
1.___________________________
2.___________________________
3.___________________________
4.___________________________
1.___________________________
2.___________________________
3.___________________________
4.___________________________
APUNTES
METAS
Duración corta:
Horario:
Estrategias:
Duración larga:
Horario:
Estrategias:
□ No tengo interés en establecer metas en este momento, pero quizás quisiera ponerme en contacto con el
programa de Head Start más tarde.
Firma de Padre/Guardián
Fecha
Representante de Head Start
Fecha
Head Start
Dear Parent/Guardian:
Thank you for your interest in our Head Start Child Development Program.
To be considered for the program, we must have reasonable verification of 12 months income for your total
family. Examples of this verification could be:
•
•
•
A copy of your current income tax (please note this is a federally sponsored program) or
W-2 forms for parents or guardians
Income earned in previous 12 months (Notarized family statement of gross earnings, 12 months worth of
check stubs).
Eligibility might be able to be determined with lesser documentation, but that will slow the eligibility process.
Also, please understand that we will need to determine your family composition for eligibility, i.e. total in
household including children.
You will need to bring documentation of any additional non-taxable income you receive:
• Child Support
• Social Security Benefits
• Unemployment Compensation
• Dividends, Interest
• Welfare Payments
• Pensions, Annuities
• Workers’ Compensation
• Alimony
• Educational Loans/Grants
Other necessary documentation to bring is your child’s:
• Birth Certificate
• Social Security Card
• Shot Record
• Food Stamp Letter
• TANF Documentation
• Proof of medical and/or dental insurance
When you come in to bring the information requested, it will take 15 to 30 minutes to complete the eligibility
form.
If you have any questions, please feel free to call our office at ______________________________.
Thank you for your cooperation.
5/2007
Head Start
Head Start
Interest Questionnaire
Survey Binder or Parent
Parent Meeting
Name of Parent:
Center Name:
Date:
As a parent, I am interested in the following topics to be discussed at our Head Start Parent Meetings.
Please Check
Please Check
Health, Dental, & Nutrition
Mental Health and Disabilities
Bottle Tooth Syndrome
Speech and/or Hearing Impairments
When to Keep Your Child Home from School
The Importance of (ARDS) Admission,
Review and Dismissal
Head Lice
Children’s Medication and Side Effects
Immunization and Shot Record
Maintain Good Mental Health
Childhood Diseases
Behavioral Problems
Reading Food Labels
Stretching Your Food Dollar
Other Suggestions
______________________________
Other Suggestions
Please Check
Please Check
Social Services
Education and Child Development
Learning About Local Agencies That
Help Your Family
Stages of Child Development
Preparing Your Child for Preschool/Kindergarten
Employment
Literacy Program
Returning to School
Educational Activities You Can Do At Home
Affordable Housing and Renting
Other Suggestions
Drug and Alcohol Awareness
Other Suggestions
OPTIONAL SOCIAL
SERVICES FORMS
• In House Referral
• Permission for Release &
Exchange of Information
Head Start
HEAD START
IN-HOUSE REFERRAL
Please Circle:
HEALTH
SPEECH
TRANSPORTATION
Student
Teacher
School
Referral Source
MENTAL HEALTH
SOCIAL SERVICE
BEHAVIOR
DOB
DOE
DATE
Reason for Referral
(Please describe in detail, including action taken, and relevant parent contact history):
Documentation is attached
DISPOSITION
Documentation:
Date Received:
Date Completed:
Specialist:
4/2006
Head Start
HEAD START
PERMISSION FOR RELEASE AND EXCHANGE OF
INFORMATION
CHILD’S NAME
DATE OF BIRTH
MOM OR DAD/GUARDIAN NAME
I authorize Head Start to release/receive the following confidential information regarding the
above named child to/from:
The purpose of this release is to:
Records/Information to be released/received includes:
I have been fully informed and understand the school’s request for my consent, as described above.
I understand that my consent is voluntary and may be revoked at any time.
This release of information will expire one year from the date below.
Signature of Mom or Dad/Guardian
Date
Signature of Staff Member
Date
4/2006
Head Start
HEAD START
PERMISO DE PUBLICAR Y CAMBIAR INFORMACION
NOMBRE DEL NINO
FECHA DE NACIMIENTO
NOMBRE DE PADRE/GUARDIAN
Yo autorizo al programa de Head Start que puede publicar/recibir información confidencial acerca del niño
nombrado aquí. Esta información será recibida de o dado a:
El propósito en publicar esta información es para:
El record/La Información para publicar/recibir incluye
Me han informado y entiendo la petición por parte de la escuela, para recibir mi permiso. Entiendo que mi
permiso es voluntario y se puede renunciar a cualquier tiempo. Este permiso se venza dentro de un año de la
fecha que sigue.
Firma de Padre/Guardián
Fecha
Firma de Empleado de Head Start
Fecha
Section Four: Parent Involvement
• Parent Notes
• Parent Staff Contact Sheets
• Attendance/Tardiness Policy (located in Parent
Handbook)
• Parent Letter for their Child’s Absences (as needed)
• Transportation Enrollment (if applicable)
Head Start
Date:
Time:
Parent/Staff Contact Form
Name of Staff Worker:
Signature
Name of Family:
Whom did you talk with?
What other family members were present?
Check the following that applies:
□ Telephone Call
□ Home Visit
□ Note to Parent
□ Conference
□ Health Related
(Please Highlight)
State briefly the nature of the conversation. List problems or things that you feel should be given
attention.
Mom or Dad/Guardian Signature (if required):
4/2006
Head Start
To the Parents of
:
Our records show that your child, to date, has been
absent
___________times
and
tardy (coming in/afternoon pick-up)
times.
The school district requires a 90% attendance record for each enrolled student. This means that your child is
allowed 18 excused absences within any given school year.
Please make certain your child is in school every school day she/he is not ill! Not only will she/he be missed,
she/he will be missing out on important and FUN instruction!
Please monitor your child’s attendance carefully. Don’t put your child in danger of being dropped from HEAD
START because of low attendance. There are children on a waiting list that would be glad to attend our
program.
Thank you for attending to this matter,
HEAD START STAFF
4/2006
Head Start
Date
/
/
Child’s Name
Dear Parent,
Our records show that your child has been absent since
If your child is ill, please notify us immediately so that his/her slot will be held.
.
It is mandatory for our program to maintain a daily average attendance of 90% of children enrolled. When your
child is absent, it not only lowers the percentage required, but it reflects on the progress your child would make
with regular attendance.
You have until
to notify us, however, if we do not hear from you, we will
have no other choice but to drop your child from our program.
Sincerely,
Head Start Representative
Print Name
Telephone
Program Director
4/2006
Head Start
Fecha
/
/
Nombre del niño
Estimado Padre/Guardián,
Nuestros record/datos indican que su niño ha estado ausente de la escuela desde
/
/
.
Si su niño está enfermo, favor de notificarnos inmediatamente para que pueda continuar su matriculación en
nuestro programa.
Es un mandato de nuestro programa mantener record de asistencia diaria de 90% (de los niños matriculados).
Cuando su niño falta, el porcentaje requerido baja y es un reflejo del progreso de lo que su niño puede hacer
cuando viene a la escuela regularmente.
Tiene hasta
para notificarnos. Si no recibimos notificación, tendremos que quitar su
hijo de nuestra lista de niños matriculados.
Sinceramente,
Nombre de Representante de Head Start
Imprima el nombre (del representante)
Número de teléfono
Nombre del Director del Programa de Head Start
Head Start
TRANSPORTATION ENROLLMENT
Child
Date of Birth
Name
Address
Phone
Mother
Work
Phone
Father
Work
Phone
Address of deliver, if other than above
Persons, other than parent/guardian to notify in case of emergency:
Name
Address
Relationship
Phone
1.
2.
3.
I authorize my child to be released to the following people: (must be 18 years or older)
1.
2.
3.
AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT:
If required, I hereby authorize the Head Start Teacher and/or Staff to get medical aid for my
child
from my child’s physician, hospital emergency room staff
emergency medical technicians, or the center nurse, if they are unable to contact me or other
. I understand
legal guardian. My hospital of choice is
that, if required, the nearest hospital available to provide the needed emergency service will be
used.
_____________________________________
Signature of Parent/Legal Guardian
________________________________
Date
_____________________________________
Signature of Head Start Authorized Staff
_________________________________
Date
Head Start
REGISTRO DE TRANSPORTACION
Escuela
Fecha de Nacimiento
/
/
Nombre
Dirección
Teléfono
Madre
Su empleo
Teléfono
Padre
Su empleo
Teléfono
Dirección en donde podamos dejar a su niño si no lo dejamos en su propia casa.
Personas, además de los padres/guardianes, para notificar en caso de emergencia:
Nombre
Dirección
Parentesco
Número de teléfono
1.
2.
3.
Autorizo que las siguientes personas pueden recoger a mi hijo: (tienen que tener 18 años de edad o más)
1.
2.
3.
Doctor
Dirección
Teléfono
Dentista
Dirección
Teléfono
Atención especial/datos médicos
Alergias
Nombres de medicinas que toma mi hijo
Número de Medicad o Numero/Nombre de su seguro de salud
OPTIONAL PARENT
INVOLVEMENT FORMS
• Parent Interest Questionnaire
• Parent Opinion Survey
• Parent/Staff Contact Form
• Need for Transportation Application
• Transportation Enrollment
Parent Interest Questionnaire
Head Start
Name of Parent:
Center Name:
Date:
As a parent, I am interested in the following topics to be discussed at our Head Start Parent Meetings.
Please Check
Please Check
Health, Dental, & Nutrition
Mental Health and Disabilities
Bottle Tooth Syndrome
Speech and/or Hearing Impairments
When to Keep Your Child Home from School
The Importance of (ARDS) Admission,
Review and Dismissal
Head Lice
Children’s Medication and Side Effects
Immunization and Shot Record
Maintain Good Mental Health
Childhood Diseases
Behavioral Problems
Reading Food Labels
Other Suggestions
Stretching Your Food Dollar
Other Suggestions
Please Check
Please Check
Social Services
Education and Child Development
Learning About Local Agencies That
Help Your Family
Stages of Child Development
Preparing Your Child for Preschool/Kindergarten
Employment
Literacy Program
Returning to School
Educational Activities You Can Do At Home
Affordable Housing and Renting
Other Suggestions
Drug and Alcohol Awareness
Other Suggestions
Head Start
HEAD START PARENT OPINION SURVEY
Dear Parents:
Our commitment is to make Head Start more effective in meeting the needs of children and families. Head Start
parents and staff work closely together to achieve this goal. Parent opinions and suggestions regarding the
various parts of the total program are needed to fully realize this goal.
The enclosed questionnaire is being sent to all Head Start parents. We would appreciate your responses to the
questions. You will find that most of the questions can be answered either by circling a number or making a
check mark.
Your responses help to direct our efforts to improve the program and provide quality services. Your input helps
to ensure that the children receive the best “head start” possible.
After you have completed the questionnaire, please return it to your child’s teacher by the end of the week.
Thank you for participating in this survey.
Very Sincerely,
Head Start Staff
HEAD START PARENT OPINION SURVEY
Head Start
Please circle the number that closely describes your opinion. The number 1 means you least agree and the
number 5 means you most agree.
I have been satisfied with this year’s Head Start Program.
1
2
3
4
5
I have been kept informed about classroom activities and what goes on in school.
1
2
3
4
5
During this past year, I felt welcomed to contact my child’s teacher or teacher’s assistant.
1
2
3
4
5
During this past year, I felt comfortable in contacting the Head Start office about a question or concern.
1
2
3
4
5
I was given the opportunity to participate in planning my child’s educational goals with the teacher.
1
2
3
4
5
I have received help in getting ideas on how to teach my child at home.
1
2
3
4
5
For the following items, please check all that apply and then give written responses for those that need
comments or suggestions.
Ways that were used to inform you about how your child is getting along in school and about school activities
in general.
Home visits
Notes sent home
Phone calls
Volunteering in the classroom
My child tells me
Other parents
Classroom newsletter
Other
Head Start
HEAD START PARENT OPINION SURVEY
8. Ways you think are best for informing parents about their child’s progress and school activities.
Home visits
Notes sent home
Phone calls
Volunteering in the classroom
Have my child tell me
Other parents
Classroom newsletters
Other
9. I attended 1 or more of the monthly parent meetings.
Yes
No
If no, please tell us the reason you were unable to attend.
10. I have volunteered in the classroom this year.
Yes
No
If no, please tell us the reason you were unable to attend.
11. I have attended 1 or more field trips this year.
No
Yes
If no, please tell us the reason you were unable to attend.
12. Please list any activities for parents other than those covered above, which you think should be added to the
Head Start program.
Head Start
HEAD START PARENT OPINION SURVEY
13. Listed below are some services that are available to Head Start families. Please check each service that you
or your child used this year and then check if that service was satisfactory or unsatisfactory.
Services Used
Satisfactory
Unsatisfactory
School Bus
Health Services
Dental Services
Social Services
Clothing
Further Education (GED)
Housing
Personal Counseling
Employment services
Holiday assistance
Did you have any particular problems with any of the services that you used? Yes
If yes, please describe:
No
Please list other services you feel are needed:
14. Thinking of the Head Start program as a whole, which parts of it did you like best this year?
15. What problems did you have with Head Start this year?
Head Start
HEAD START PARENT OPINION SURVEY
16. What changes do you think should be made in the Head Start program next year?
17. What training programs for Head Start parents would you recommend to be added to those now being
provided?
18. What additions or deletions to the curriculum would you like to see for next year?
19. Please describe what you know about the Policy Council.
20. Please list any comments and/or concerns you have about the food your child is being served.
21. If you had the opportunity to talk about Head Start to next year’s new parents, what would you tell them?
Head Start
HEAD START
ESTUDIO DE OPINION DE PADRES
Estimados Padres:
Nuestro cometido es hacer que el programa de Head Start sea más efectivo en el éxito de las necesidades de los
niños y las familias. Los padres y los empleados de Head Start trabajan juntos para obtener esta meta.
Opiniones y sugestiones de los padres con respeto a los varios partes del programa son necesarias para realizar
esta meta.
Mandamos este cuestionario incluido en esta carta, a todos los padres en el programa de Head Start. Le
apreciamos sus respuestas. Casi todas las preguntas se les pueden rodear el número o marcar con (√).
Sus respuestas nos ayudan dirigir nuestros esfuerzos para mejorar el programa y proveer servicios de calidad.
Sus ministros nos ayudan asegurar que los niños reciban programas de la mejor calidad.
Después de completar el cuestionario, favor de regresarlo a la maestra de su hijo para el fin de la semana.
Muchas gracias por participar en este estudio.
Muy sinceramente,
Los Empleados de Head Start
Head Start
HEAD START
ESTUDIO DE OPINION DE PADRES
Favor de rodear el número que más bien expresa su opinión. El número 1 es lo que menos representa su opinión
y el numero 5 quiere decir que representa la respuesta que usted más le gusta.
1. He estado satisfecho con el programa de Head Start este año.
1
2
3
4
5
2. Me han informado de las actividades de las clases y lo que pasa en la escuela.
1
2
3
4
5
3. Durante este año pasado, me sentí bien recibido en ponerme en contacto con la maestra de mi hijo o su
asistente.
1
2
3
4
5
4. Durante este año pasado, me sentí confortable en ponerme en contacto con la oficina de Head Start cuando
tenía una pregunta.
1
2
3
4
5
5. Me dieron la oportunidad de participar en planear las metas educativas de mi hijo con su maestra.
1
2
3
4
5
6. He recibido ideas en cómo enseñar mi niño en casa.
1
2
3
4
5
7. Para lo que sigue, favor de marcar todos los que aplican y escriba sus comentarios.
Visitas de casa
Cartitas (notas)
Llamadas por telefónicas
Servir como voluntario en la clase
Mi niño me dice
Otros padres
El periódico de la clase
HEAD START
ESTUDIO DE OPINION DE PADRES
Head Start
8. Favor de marcar los métodos que usted piensa son superiores en como informarle del progreso de su niño y
las actividades de la escuela.
Visitas de casa
Cartitas (notas)
Llamadas telefónicas
Servir como voluntario en la clase
Mi niño me dice
Otros padres
El periódico de la clase
Otros
9. Atendí uno o más de las juntas mensuales de padres.
Si
No
Si contesta que no, favor de decirnos la razón por qué no pudo asistir.
10. He sido voluntario en la clase este año.
Si
No
Si contesta que no, favor de decirnos la razón por qué no ofreció su tiempo.
11. He ido uno o más de los viajes de campo este año.
Si
No
Si contesta que no, favor de decirnos la razón por qué no pudo ir.
12. Favor de hacer lista de actividades para padres (que no hemos mencionado) que usted piensa que
necesitamos añadir al programa de Head Start.
HEAD START
ESTUDIO DE OPINION DE PADRES
Head Start
13. En la lista que sigue hay servicios que son disponibles a las familias de Head Start. Favor de marcar cada
servicio que usted o su hijo usó este año y díganos si fue satisfactorio u no.
El servicio
El autobús
¿Usó este servicio?
¿Fue satisfecho?
¿No fue satisfecho?
Servicios de salud
Servicios dentales
Servicios sociales
Ropa
Más educación (GED)
Encontrar casa
Consejero personal
Servicios de empleo
Asistencia durante los
días de fiesta
¿Tuvo problemas particulares con alguno de los servicios que usó?
Si contesta que sí, favor de decirnos lo que pasó.
Si
No
Favor de decirnos si hay otros servicios que usted sienta que son necesarios:
14. Tomando en acuerdo todos los programas de Head Start, ¿Cuáles partes le gustó mejor?
15. ¿Cuáles problemas tuvo con el programa de Head Start este año?
HEAD START
ESTUDIO DE OPINION DE PADRES
Head Start
16. ¿Cuáles cambios piensa usted que se puedan hacer en el programa de Head Start en el próximo año?
17. ¿Qué clase de entrenamiento para padres de Head Start recomendaría usted que sean añadidos a los
programas que tenemos hoy?
18. ¿Qué podemos añadir o borrar del plan de estudios en el próximo año?
19. Favor de decirnos lo que sabe usted sobre el Concilio de Póliza.
20. Favor de comentar y/o decirnos si tiene preocupación de la comida que servimos a su niño.
21. Si usted tuviera la oportunidad de hablar con los padres de niños que vienen al programa de Head Start el
año entrante, ¿Qué les diría?
Head Start
Date:
Time:
Parent/Staff Contact Form
Name of Staff Worker:
Signature
Name of Family:
Whom did you talk with?
What other family members were present?
Check the following that applies:
□ Telephone Call
□ Home Visit
□ Note to Parent
□ Conference
□ Health Related
(Please Highlight)
State briefly the nature of the conversation. List problems or things that you feel should be given
attention.
Mom or Dad/Guardian Signature (if required):
Head Start
HEAD START
Need for Transportation
Application
Application Date
Head Start School
Child’s Name
Parent’s/Guardian’s Name
Home Address (or address for Pick-Up/Drop Off)
Phone numbers where parents/guardians may be reached during the day, in case we have questions concerning
your application:
Please describe your need for transportation (or why does your child need a ride to and/or from Head Start).
Please check appropriate line
Request is for: Morning Only
Application Status:
Afternoon only
Date:
Both Morning & Afternoon
Head Start
REGISTRO DE TRANSPORTACION
Escuela
Fecha de Nacimiento
/
/
Nombre
Dirección
Teléfono
Madre
Su empleo
Teléfono
Padre
Su empleo
Teléfono
Dirección en donde podamos dejar a su niño si no lo dejamos en su propia casa.
Personas, además de los padres/guardianes, para notificar en caso de emergencia:
Nombre
Dirección
Parentesco
Número de teléfono
1.
2.
3.
Autorizo que las siguientes personas pueden recoger a mi hijo: (tienen que tener 18 años de edad o más)
1.
2.
3.
Doctor
Dirección
Teléfono
Dentista
Dirección
Teléfono
Atención especial/datos médicos
Alergias
Nombres de medicinas que toma mi hijo
Número de Medicad o Número /Nombre de su seguro de salud
Head Start
TRANSPORTATION ENROLLMENT
Child
Date of Birth
Name
Address
Phone
Mother
Work
Phone
Father
Work
Phone
Address of deliver, if other than above
Persons, other than parent/guardian to notify in case of emergency:
Name
Address
Relationship
Phone
1.
2.
3.
I authorize my child to be released to the following people: (must be 18 years or older)
1.
2.
3.
AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT:
If required, I hereby authorize the Head Start Teacher and/or Staff to get medical aid for my
from my child’s physician, hospital emergency room staff
child
emergency medical technicians, or the center nurse, if they are unable to contact me or other
legal guardian. My hospital of choice is
. I understand
that, if required, the nearest hospital available to provide the needed emergency service will be
used.
_____________________________________
Signature of Parent/Legal Guardian
________________________________
Date
_____________________________________
Signature of Head Start Authorized Staff
_________________________________
Date
REGISTRO DE TRANSPORTACION
Head Start
Escuela
Fecha de Nacimiento
/
/
Nombre
Dirección
Teléfono
Madre
Su empleo
Teléfono
Padre
Su empleo
Teléfono
Dirección en donde podamos dejar a su niño si no lo dejamos en su propia casa.
Personas, además de los padres/guardianes, para notificar en caso de emergencia:
Nombre
Dirección
Parentesco
Número de teléfono
1.
2.
3.
Autorizo que las siguientes personas pueden recoger a mi hijo: (tienen que tener 18 años de edad o más)
1.
2.
3.
Doctor
Dirección
Teléfono
Dentista
Dirección
Teléfono
Atención especial/datos médicos
Alergias
Nombres de medicinas que toma mi hijo
Número de Medicad o Numero/Nombre de su seguro de salud
Section Five: Education
• Region 9 Outcomes Assessment Checklist (after all 3
are completed by teacher) or ChildPlus 5110
• Dial 3
• DECA (if applicable)
• Home Visit Form
• Home Language Survey
• Migrant Survey Form
• District Field Trip Permission Form
• In House Referral (as needed)
Head
Home Visit
Child’s Name
Date
Visit 1st
2nd
Parent’s or Guardian’s Name
Address
Phone
Name of Persons Making Visit
Agenda
Subjects Discussed
Based on visit, what will be the plan of action in the classroom with this child?
Parent’s Comments
Actions Taken by Staff (to be completed if the child or family needs special services)
Mom or Dad’s Signature
Date
Staff Signature _________________________________________
Date __________________
3/06
Head Start
Visita de Casa
Nombre del Niño
Primera visita
Fecha
Segunda visita
Nombre de Padre/Guardián
Dirección
Hora que llegamos
Número de teléfono
Hora que nos regresamos
Nombres de las personas que hicieron la visita
Orden del día
Asuntos discutidos
¿Cual será el plan de acción en la clase, basado en el resulto de esta visita?
Comentarios por los padres
Acciones que pueden tomar la maestra o su ayudante (esta parte se cumple si el niño o la familia necesitan
servicios especiales)
Firma del Padre/Guardián
Fecha
8/2005
Field Trip Permission Slip
Campus: _________________________________
Date: ___________________
Dear Parents:
The Head Start class will be going on a field trip to _________________________________
This will take place on___________________________.
We will be leaving at _____a.m. and returning at _____ p.m.
Please provide the child’s name, check yes or no if your child can attend, and sign below.
Yes, my child can attend.
No, my child cannot attend.
Child’s Name: __________________________________________
Parent Signature: ________________________________________
8/2007
OPTIONAL EDUCATION
FORMS
•
•
•
•
•
•
•
Letter to Parents – 1st Home Visit
Letter to Parents – Absent or Tardy
Referral for Counseling
In House Referral Form
Accident Report
Pre-Kindergarten Selection Form
Late Pick Up Notice
Head Start
Parents:
It is time for our first home visit to discuss your child’s progress and answer any questions you may have.
Please let me know if the below time is convenient for you.
Our visits are usually conducted
. We are unable to make morning visits
as we are busy in the classroom. Please call the center if you have any questions.
We are looking forward to working with you and your child.
Thank you for your cooperation.
Day:
Date:
Time:
Parent:
Director:
8/2007
Head Start
Estimados Padres:
Es tiempo de su primera visita en su hogar para discutir el progreso de su hijo y para contestar cualquier
pregunta que usted tenga. Favor de regresar esta carta con el día, fecha, y tiempo que es conveniente para usted.
Ordinariamente nuestras visitas son hechas dentro de la 1:00 p.m. y las 3:00 p.m. No podemos hacer visitas por
la mañana porque estamos muy ocupados en las clases. Favor de llamarnos si usted tiene preguntas.
Nos da gusto de poder trabajar con usted y su hijo. Queremos darles las gracias por su cooperación.
Día:
Fecha:
/
/
Hora:
Firma de Padre/Guardián
Fecha
Firma del Director
Fecha
Head Start
To the Parents of
:
Our records show that your child, to date, has been
___ times
absent
and
tardy (coming in/afternoon pick-up)
times.
The school district requires a 90% attendance record for each enrolled student. This means that your child is
allowed 18 excused absences within any given school year.
Please make certain your child is in school every school day she/he is not ill! Not only will she/he be missed,
she/he will be missing out on important and FUN instruction!
Please monitor your child’s attendance carefully. Don’t put your child in danger of being dropped from HEAD
START because of low attendance. There are children on a waiting list that would be glad to attend our
program.
Thank you for attending to this matter,
HEAD START STAFF
4/06
Head Start
Para los Padres de
:
Nuestros documentos indican que su niño, hasta hoy día, ha sido
ausente
veces
y
ha llegado tarde (llegando después de 8:30 a.m.)
veces.
El distrito escolar
requiere asistencia de 90% para cada estudiante matriculado.
Esto quiere decir que su niño se le permite 18 ausencias con disculpa dentro del año escolar. Más de dos
ausencias por mes sin disculpa producen este número.
¡Favor de asegurar que su niño este en la escuela cada día si no esta enfermo!! ¡Nos hace mucha falta y él
pierde instrucción importante!
Favor de dar atención a la asistencia de su niño a la escuela si no está enfermo. No ponga su niño en peligro de
no poder quedarse en el programa de HEAD START por caso de no asistir regularmente. Hay una lista de
niños esperando para matricularse en nuestro programa a quien le gustaría tomar el lugar de su niño.
Muchas gracias por su atención a este asunto,
HEAD START
Coordinador del Programa/Principal
Head Start
Referral for Counseling
Student
Age
Teacher
Date
What is the student’s academic level?
Low
Grade
Middle
High
Is the child in any special programs?
With whom does the child live?
Are the parents or guardian aware of a problem?
Place a check in the appropriate column:
Always
Sometimes
Never
Completes work
Talks out without permission
Stays on task
Lies
Cheats
Steals
Participates in group activities
Aggressive with peers
Respects authority
Daydreams
Follows directions
Immature
Shy or withdrawn
Gets along with peers
Cries
Whines
Please explain intervention strategies you have tried. (List on back)
3/06
HEAD START
IN-HOUSE REFERRAL
Head Start
Please Circle:
HEALTH
SPEECH
TRANSPORTATION
Student
Teacher
School
Referral Source
MENTAL HEALTH/
SOCIAL SERVICE
BEHAVIOR
DOB
DOE
DATE
Reason for Referral
(Please describe in detail, including action taken, and relevant parent contact history):
Documentation is attached
DISPOSITION
Documentation:
Date Received:
Date Completed:
Specialist:
4/06
Section Six: Mental Health/Disabilities
• Consent for Mental Health/Behavior Services
• Mental Health Observations
• Behavior Guidance Plan (as needed)
• Psychological and Social Development Forms
• IEP/IFSP
• In House Referral (as needed)
• Referral for Counseling (as needed)
Head Start
CONSENT for HEAD START
MENTAL HEALTH/BEHAVIORAL SERVICES
STUDENT:
CENTER:
DATE OF BIRTH:
AGE:
TELEPHONE:
PARENT(S) NAME:
PARENT(S) ADDRESS:
TELEPHONE:
TEACHER:
The undersigned, as the parent, guardian, or person standing in parental relationship with the above named
student requests and consent to psychological/counseling for such student. I understand
these services may include any of the following, as deemed appropriate by licensed mental health professionals,
whether employed or retained on a contract basis by Head Start:
(a) observations within the school setting, (b) interviews with the parent (s) or other person (s) with whom the
student resides, (c) consultation with teachers and others involved in the education of the student, (d) clinical
interview (s) with the student, (e) review of all educationally relevant records, (f) psychological evaluation
which may include behavior rating scales, self-report inventories, and/or projective techniques, and/or (g) direct
and indirect classroom interventions which may include a behavior management plan.
Please respond with a (÷) indicating “yes” or “no” beside the statements below. This consent is valid for one
academic year unless revoked in writing by the undersigned and such revocation is delivered to the Director of
Legal Services for Head Start.
Yes
No
I have been fully informed and understand the process for obtaining
psychological services and the reasons they are being recommended
for the student.
Yes
No
I grant Head Start permission to provide the psychological services
described above.
Yes
No
I understand that consent for these psychological services is voluntary
and may be revoked in writing at any time as described above.
It is my understanding that any information obtained or records developed in connection with these services will
not be disclosed except as allowed by the Family Education Records Privacy Act (FERPA).
Signature of Mom or Dad/Legal Guardian
Date
Staff Signature
Date
3/2006
Head Start
PERMISO PARA SERVICIO
SALUD MENTAL/SERVICIOS DE CONDUCTA
NOMRE DE ESTUDIANTE:
NOMBRE DE ESCUELA:
FECHA DE NACIMIENTO:
NUMERO DE TELEFONO ESCUELA:
EDAD:
NOMBRE DE PADRE:
SU DIRECCION:
NUMERO DE TELEFONO:
MAESTRA:
La persona que firma esta forma, como padre, guardián, o persona actuando como padre del niño nombrado,
requiere y da permiso para que el niño reciba servicios de una persona con calificaciones para observar la salud
mental y/o la conducta de mi niño. Entiendo que estos servicios pueden incluir algunas de las evaluaciones que
siguen. Estos servicios han sido juzgado apropiados por una persona calificada en la salud mental, tanto si son
empleados del distrito escolar ______________________o son contratados con el distrito:
(a) observaciones dentro/durante de la escuela, (b) entrevistas con los padres o otras personas con quien vive el
estudiante, (c) consultación con las maestras y otras personas involucradas en la educación del estudiante, (d)
entrevista clínica con el estudiante, (e) revista de todos los documentos educativos pertinentes, (f) evaluación
psicólogo que puede incluir escala de apreciar su comportamiento, inventarios de si mismo, y/o planeamiento
técnica, y/o (g) intervenciones directas o indirectas que puedan incluir un plan de administración de su
comporte.
Favor de responder usted con (√) marcando el “si” o “no” al lado de las declaraciones que siguen. Este permiso
es valido por un año académico. Se puede renunciar este permiso por la persona indicada en esta forma si trae
carta de renuncio al Departamento de Servicios Legales del
___________________________________________________
(Distrito Escolar).
Si
No
Si
No
Si
No
He sido informado y entiendo el proceso de obtener servicios psicólogos y las razones
por qué se le están recomendando al estudiante.
Doy permiso a
(distrito escolar) que provee los servicios
psicólogos escritos en esta forma.
Entiendo que permiso para estos servicios psicólogos son voluntarias y puedo renunciar
mi permiso (haciéndolo en forma escrita) a cualquier tiempo que quiera.
Es mi entendimiento que la información obtenida o documentos desarrollados en conexión con estos servicios
no serán hechos públicos con el excepto del acto, Family Records Privacy Act (FERPA).
Firma de Padre/Guardián Legal
Fecha
Head Start
HEAD START
MENTAL HEALTH OBSERVATION/PROGRESS NOTE
STUDENT NAME:
Time Spent in
Child Direct Services
________________
LOCATION:
DATE:
Time Spent in
Parent Direct Services
Time Spent in
Parent Training
OBSERVATIONS
Crying/Whining
None
A little
A lot
Verbal Response to
Questions
Willing
Reluctant
No Response
Persistence
Stays with Task
Attempts Task
Refuses Task
Impulsivity
Impulsivity:
Non-Impulsivity
Activity Level
Sits Quietly
Some Wiggling
Excessive Wiggling
Understanding of
Participation
Directions
Willing
Easily Understands
W/ Encouragement
Needs Repetition
Unwilling
Unwilling/Unable to
Inappropriate
Follow Directions
Attention
Consistent
Intermittent
Non-Attentive
DOCUMENTATION
4/2006
OPTIONAL
SPECIAL NEEDS
FORMS
• In-House Referral
• Referral for Counseling
HEAD START
IN-HOUSE REFERRAL
Head Start
Please Circle:
HEALTH
SPEECH
TRANSPORTATION
Student
Teacher
School
Referral Source
MENTAL HEALTH/
SOCIAL SERVICE
BEHAVIOR
DOB
DOE
DATE
Reason for Referral
(Please describe in detail, including action taken, and relevant parent contact history):
Documentation is attached
DISPOSITION
Documentation:
Date Received:
Date Completed:
Specialist:
4/06
Head Start
Referral for Counseling
Student
Age
Teacher
Date
What is the student’s academic level?
Low
Grade
Middle
High
Is the child in any special programs?
With whom does the child live?
Are the parents or guardian aware of a problem?
Place a check in the appropriate column:
Always
Sometimes
Never
Completes work
Talks out without permission
Stays on task
Lies
Cheats
Steals
Participates in group activities
Aggressive with peers
Respects authority
Daydreams
Follows directions
Immature
Shy or withdrawn
Gets along with peers
Cries
Whines
Please explain intervention strategies you have tried. (List on back)
Please explain any information you think would be helpful in working with this child. (List on back)
3/2006
REQUIRED
DOCUMENTATION
• Head Start Visitor’s Log
• Records Management Report
• Head Start Parent Training Tracking Sheet
Head Start
Head Start Visitor’s Log
______________________________
Site
Date Time
In
Name
Reason
Time
Out
Initials
3/2006
___________________
Head Start
Records Management Report
_____________________________
SITE
The following student records were destroyed on_________________________ by ______________________
The destruction of these records is allowed by 45 CFR 74.53 or 45 CFR 92.42(Grantee financial records,
supporting documents, statistical records, and all other records pertaining to the grant award must be
maintained for a period of at least three years from the date of submission of the annual financial report).
Keep this document in a secured location.
03/2006
Date of
Topic
Pedestrian
Safety/Transportation
Transition I
Social Services
Education
Child Growth
& Development
Child Abuse
Mental Health
Health,
Dental, & Nutrition
Topic
(Component)
Center______________________
Place in front of Parent Meeting notebooks.
Contact
Phone
Number
No.
of
Hours
Head Start Parent Training
Tracking Sheet
Name of Speaker/Organization
(City, State, Zip)
End of year total # of:
No.
of
Parents
No. of
Comm.
Head Start
No. of
Staff
COMMUNITY
PARTNERSHIP
• Community Partnership Agreement
Place in Community Binder
Head Start
HEAD START PROGRAM
Community Partnership Agreement
__________________
Year
We believe a child benefits most from a comprehensive, interdisciplinary program designed to
meet the needs of the whole child. If the program is to have a lasting impact upon the child’s total
development and the well-being of the family, the community must be involved.
This agreement defines the partnership between
and the HEAD START Program to assist in providing support services in the form of: (Check all that apply)
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Training
In-Kind (Donations of money or volunteer services)
Materials/Equipment
Facilities
Public Relations (Radio, TV, & newspaper advertisement)
Transportation
Entertainment (Restaurant, event passes, music services, speakers, etc)
Treatment/Health Fairs/Supplies
Food/Clothing/Household Necessities for families in need
Discount services and/or merchandise
Public assistance (Emergency, crisis, utilities, etc)
Other:
Explanation of Services: __________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Agency Representative
Head Start Representative
Date Signed
Date Signed
Renewal Date: __________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
POLICY COUNCIL
DOCUMENTS
• Code of Conduct
• Proxy
• Verification of Attendance
• Center/Site Report
• Personnel Report
• Personnel Recommendation to Board
• Site/Safety Inspection
Code of Conduct for
Region 9 ESC
Head Start
Policy Council
Head Start
1304.52(h) (1) – Standards of Conduct. Grantee and delegate agencies must ensure that all
staff, consultants, and volunteers abide by the program’s standards of conduct.
As a member of the Early Head Start/Head Start Policy Council/Committee, I agree to adhere
the following codes of ethical conduct:
• I will respect and promote the unique identity of each child, family, and staff member and
refrain from stereotyping on the basis of gender, race, ethnicity, culture, religion, or
disability;
• I will follow the program confidentiality policies concerning information about children,
families, staff, and/or internal operating procedures;
• I will adhere to the program’s policies and procedures for filing a community complaint;
• I will refrain from accepting or soliciting personal favors, gratuities, or anything of
significant value from contractors or potential contractors and employees or potential
employees of the program;
• I will share my skills, talents, and expertise to promote and improve the quality of the
program as defined in 1304.50 – Appendix A: Program Governance and Management
Responsibilities of the Head Start Program Performance Standards.
Signature: _____________________________________
Date: _________________________________________
4/2006
Head Start
Código de Conducto Para
Region 9 ESC
Concilio de Póliza de
Head Start
1304.52(h)(1) – Las Reglas de Conducto. Agencias que sirven como cesionarios y delegados tienen que
asegurar que todo personal, consultantes, y voluntarios apoyan las reglas de conducto.
Como miembro de Early Head Start/El Concilio de Póliza de Head Start/Comité, estoy de acuerdo de apoyar el
conducto moral de las reglas de conducto que siguen:
•
Respetare y promoveré la identificación de cada niño, familia, y miembro de personal sin respecto a su
sexo, raza, étnico, cultura, religión, y/o incapacidad;
•
Seguiré las pólizas de confianza del programa tocante la información de niños, familias, personal, y/o las
operaciones internas;
•
Apoyaré las pólizas de programas y procedimientos para registrar queja de comunidad;
•
No aceptaré o solicitaré favores personales, propina, o cosa de valor significante por parte de un
contratante o contratante potencial y empleado o empleado potencial del programa;
•
Compartiré mis habilidades, talentos, y dictamen pericial para promover y mejorar la calidad del
programa como es definida en 1304.50 – Apéndice A: Programa de Gobernación y
Responsabilidades Administrativas de las Reglas de Desempeño de Head Start.
Firma: __________________________________________________
Fecha: __________________________________________________
Head Start
Head Start
Form of Appointment of Proxy
I,
(Full name)
of,
(Address)
of
(School District)
being a member of the Region 9 Head Start Policy Council
herby appoint
(Full name of proxy)
as my proxy to vote for me on my behalf at the regular scheduled policy council meeting.
To be held on the
day of
20
Signature of member appointing proxy
Date
*Proxy cannot be a school representative, must be a parent or community member.
5/2007
Head Start
Head Start
Forma de Cargo de Apoderado
Yo,
(Nombre completo)
de,
(Dirección)
de
(Distrito Escolar)
siendo miembro del concilio de Póliza del Programa de Head Start de Region 9
por este acto, nombro a
(*Nombre completo de la persona de cargo)
como persona que hace decisión por mi parte, en votar en el concilio de pólizas durante las juntas.
La junta será el día
de
del año 20
.
(Mes)
Firma del miembro
Fecha
*La persona de cargo no puede ser representante de la escuela; necesita ser un padre o miembro de la
comunidad.
Head Start
VERIFICATION OF ATTENDANCE
DATE: ___________________________
LOCATION: _____________________________________________________________
PURPOSE: ________________________________________________________________
NAME: ___________________________________________________________________
Attended the meeting and is entitled to mileage from your site.
COORDINATOR: __________________________________________________________
Nancy Ritchey
Head Start
Region 9 Education Service Center
Head Start Site Report
_____________________
Name of Site
# of students______________
_____________________
Month/Year
# on waiting list_______________
Field trips, special visitors, community involvement activities:
Parent meetings: (Topic/Speaker)
Please e-mail to Nancy Ritchey nancy.ritchey@esc9.net one week prior to scheduled Policy Council Meeting.
Head Start
Head Start Personnel Report
Name of Site__________________________________
Staff Position
Date of Review_____________________
Action Taken:
(recommend for hiring, retirement,
reassignment, or approval of
resignation)
Name
We the undersigned wish to submit the above personnel actions to be approved by the Policy Council.
Additional information will also be submitted with this recommendation, such as a resume or application.
(Head Start Staff Note: Please remove any personal identification from any documents submitted such as
social security, address and phone numbers, so that confidentiality can be maintained).
____________________________________
Parent/Policy Council Representative
_______________________
Date
______________________________________________________
___________________________________
Head Start Staff
Date
8/2007
Head Start
Reporte de Personal de Head Start
Nombre del Sitio
Titulo de Posición
Fecha de la revista
Nombre
Acción: (recomendación para contratar
o emplear esta persona, retirar a esta
persona, reasignación, aprobación de
resignación)
Nosotros, con nuestra firma, deseamos que el Comité de Póliza aprobé nuestras
recomendaciones de esta(s) persona(s). Información adicional será proveída con esta
recomendación, como un resumen o aplicación.
(Nota para personal de Head Start: Favor de quitar identificación personal de
documentos como el número de seguro social, su dirección y número de teléfono, para
mantener confianza.)
Firma de Padre/Representante del Comité de Póliza
Fecha
Region 9 ESC Head Start
Personnel Recommendation to Board
Head Start
Name: _________________________________________________
Interviewed by: ________________________________________
Recommended assignment___________________________________________________
Present position____________________________________________________________
Education
High School____________________________________________________
Bachelor’s degree_______________________________________________
Master’s degree_________________________________________________
Other universities attended________________________________________
_______________________________________________________________
Teaching Fields (if applicable) ______________________________________________________________
Other qualifications_______________________________________________________________________
Previous teaching experience (if applicable) ____________________________________________________
Total years of teaching experience (if applicable) ________________________________________________
Strengths________________________________________________________________________________
Other relevant experience___________________________________________________________________
Other comments/information
Head Start
Site/Center Safety Inspection
To be conducted annually at a minimum (CFR 1304.53(a) (10)
Name of Site/Center
Date of Inspection
Name and Position of Individual Performing Inspection
Directions: Inspection must be done on site. Inspector must have observed the item in order to
answer the question. Every item must have a “Yes”, or “No” or “n/a” (not applicable) answer.
All “No” answers must provide specific information and explanation on this form.
1. There is a safe and effective heating system that is insulated to protect children
and staff from potential burns;
2. There is a safe and effective cooling system that is insulated to protect children and staff
from potential burns;
3. No highly flammable furnishings, decorations, or materials that emit highly toxic fumes
when burned or used;
4. Flammable and other dangerous materials and potential poisons are stored in locked
cabinets or storage facilities separate from stored medications and food and are accessible
only to authorized persons;
5. All medications, including those required for staff and volunteers, are labeled, stored under
lock and key, refrigerated if necessary, and kept out of the reach of children;
6. Rooms are well lit;
7. Rooms are provided with emergency lighting in the case of power failure;
8. Approved, working fire extinguishers are readily available;
9. An appropriate number of smoke detectors are installed and tested regularly;
10. Smoke detectors are tested regularly (documentation:
);
Site/Center Safety Inspection (continued)
Head Start
11. Exits are clearly visible;
12. Evacuation routes are clearly marked and posted so that the path to safety outside
is unmistakable;
13. Indoor premises are cleaned daily and kept free of undesirable and hazardous
materials and conditions;
14. Outdoor premises are cleaned daily and kept free of undesirable and hazardous
materials and conditions;
15. Paint coatings on both interior and exterior premises used for the care of children
do not contain hazardous quantities of lead;
16. The selection, layout, and maintenance of playground equipment and surfaces minimize
the possibility of injury to children;
17. Electrical outlets accessible to children prevent shock through the use of child-resistance
covers, the installation of child-protection outlets, or the use of safety plugs;
18. Windows and glass doors are constructed, adapted, or adjusted to prevent injury to children;
19. Only sources of water approved by the local or State health authority are used;
20. Toilets and hand washing facilities are adequate, clean, in good repair, and easily
reached by children;
21. Toileting and diapering areas must be separated from areas used for cooking, eating, or
children’s activities;
22. Toileting training equipment is provided for children being toilet trained;
23. All sewage and liquid waste is disposed of through a locally approved sewer system;
24. Garbage and trash are stored in a safe and sanitary manner;
25. Adequate provisions are made for children with disabilities to ensure their safety,
comfort, and participation.
“Used by permission of TTAS/Western Kentucky University”
Chris Watkins, Consultant
9/2006
Section – Staff/Volunteer
•
•
•
•
•
Principal Observation Form
Volunteer Code of Conduct
Tuberculosis Health Screening Form
Criminal History Authorization
Personal Reference
Head Start
Code of Conduct for
Region 9 ESC
Head Start
Policy Council
1304.52(h)(1) – Standards of Conduct. Grantee and delegate agencies must ensure that all
staff, consultants, and volunteers abide by the program’s standards of conduct.
As a member of the Early Head Start/Head Start Policy Council/Committee, I agree to adhere
the following code of ethical conduct:
• I will respect and promote the unique identity of each child, family, and staff member and
refrain from stereotyping on the basis of gender, race, ethnicity, culture, religion, or
disability;
• I will follow the program confidentiality policies concerning information about children,
families, staff, and/or internal operating procedures;
• I will adhere to the program’s policies and procedures for filing a community complaint;
• I will refrain from accepting or soliciting personal favors, gratuities, or anything of
significant value from contractors or potential contractors and employees or potential
employees of the program;
• I will share my skills, talents, and expertise to promote and improve the quality of the
program as defined in 1304.50 – Appendix A: Program Governance and Management
Responsibilities of the Head Start Program Performance Standards.
Signature: _____________________________________________________________
Date: _________________________________________________________________
4/06
Head Start
Region 9 Head Start
Tuberculosis Health Screening Form
Name:
School:
Date:
Our records indicate that you are due an annual tuberculosis screening. Since we do not routinely recommend
annual tuberculosis tests, this brief questionnaire is very important.
Please answer all of the questions. When you are finished, return this questionnaire to the employee health
representative for your personnel file. This form is required to be completed annually.
*Please indicate if you have had any of the following problems for 3 to 4 weeks or longer.
Circle one
1.
Productive cough (3 weeks +)
yes
no
2. Persistent weight loss without dieting
yes
no
3.
yes
no
4. Night sweats
yes
no
5.
yes
no
6. Swollen glands, usually in the neck
yes
no
7. Recurrent kidney or bladder infections
yes
no
8.
Coughing up blood
yes
no
9. Shortness of breath
yes
no
10. Chest pain
yes
no
Persistent low grade fever
Loss of appetite
Explain if you answered yes to any of the above
__________________
________________________
Signature
Date
Verified by
Date
Approved October 26, 2006
Revisions approved March 1, 2007
Head Start
CRIMINAL HISTORY AUTHORIZATION
AND DECLARATION FORM FOR HEAD START EMPLOYEES
1301.31 of the Head Start Standards requires that current and prospective employees of Head Start programs sign a declaration which
will list the following:
(1)
All pending and prior criminal arrests and charges related to child sexual abuse and their disposition
(2)
Convictions related to other forms of child abuse and/or neglect and
(3)
All convictions of violent felonies
(4)
Any offense, other than any offense related to child abuse and/or child sexual abuse or violent felonies committed
(5)
Any conviction for which the record has been expunged under federal or state law and
(6)
Any conviction set aside under the federal youth correction act or similar state authority.
PLEASE PROVIDE YOUR SIGNATURE ON THE APPROPRIATE CATEGORY
I have not been arrested, charged and/or convicted on one or more of the three types of offenses listed above.
Signature
OR
Date
I have been arrested, charged, and/or convicted on one or more of the three types of offenses listed above.
Location (City and State)
Signature
Offense
Year
Date
I hereby authorize Region 9 Education Service Center (Region 9 Education Service Center) and its agents(s) to obtain a consumer report on me
excluding credit information but including public record information. Region 9 Education Service Center is authorized to use any source including,
but not limited to, consumer reporting agencies, private investigators, law enforcement agencies, DCS Information Services, Texas and the Texas
Department of Public Safety. Furthermore, I authorize these agencies to release any information on me to Region 9 Education Service Center or its
agent(s). I also hereby acknowledge that I have received notice that a report may be obtained for employment purposes if applicable/. I understand
that the information I am providing about age, sex, and ethnicity will not be used to determine my eligibility for employment or volunteer services,
but will be used solely for the purpose of obtaining consumer information, excluding credit information, but including criminal history information. I
further understand that information from my consumer report will not be used in violation of any applicable federal or state equal opportunity laws.
Signature of Applicant
Date