Building Bright Futures Early Childhood Services Child Screenings and Assessments
Parent Consent Form
Dear Parent/Guardian,
To ensure we meet the needs of children enrolled in this childcare facility, a partnership between
this child care center, Building Bright Futures Early Childhood Services (ECS)/Building Bright
Futures, and The University of Nebraska Medical Center/Munroe-Meyer Institute has been
formed. The Evaluation team and classroom teachers will complete regular assessments and
screenings of children’s development and learning across the year. These assessments/
screenings focus on your child’s growth and progress in the areas of social-emotional behavior,
health, language, vocabulary, early literacy and early concept development. Your child’s
participation in these assessments/screenings will help us learn how our program can better
meet the needs of your child and other children.
We will also continue to access your child’s public school records while they are a student in the
public school within Douglas or Sarpy Counties including: graduation rate, statewide and District
assessment data, to evaluate long-term impact of participation in Building Bright Futures Early
Childhood Services.
Your child will be evaluated by his or her classroom teaching staff, and/or evaluation staff, nurse,
during the regular school day. Your child’s name, demographic information and assessment
scores will be entered into and stored in a secure electronic database. Using a code for your
child’s name, this database will be stored at the University of Nebraska Medical Center/MunroeMeyer Institute and shared with ECS and Building Bright Futures.
A summary of the findings will be shared with ECS, Building Bright Futures. Your child’s name
and individual scores will not be shared with people outside of your childcare facility and
ECS specialists and supervisors.
Information about your family and your child’s scores on the assessments is completely
confidential. These scores will be used in the following ways: 1) by your child’s classroom
teaching staff to meet your child’s learning needs, 2) by program administrators and ECS
Specialists to identify ways to improve ECS to better meet the needs of all children and families,
3) by evaluation staff to report the progress of all children as a group and 4) by ECS to address
the needs of students and childcare facilities.
You and your child are not required to participate in these assessments. If you decide not
to participate, it will not affect you or your child’s standing in your childcare program in any way.
You can choose to withdraw your child from the evaluation at anytime. If you have any
questions, please do not hesitate to contact the director at your childcare; the Evaluation
Director, Jill Kumke, at 559-5795; ECS Director of Education, Penny Gildea, at 559-1079.
Sincerely,
1 Parent Consent Form
Building Bright Futures Early Childhood Services Child Screenings and Assessments
Parent Consent Form
Fawn Taylor, M.P.A.
Executive Director of ECS
Building Bright Futures
Jill Kumke, M.S. CCC-SLP
Evaluation Project Director
UNMC/MMI
This page provides a description of each of the assessments and screenings we will be using in
your childcare program.
The Devereux Early Childhood Assessment for Infants and Toddlers and preschoolers (DECA-I;
DECA-T; DECA): This assessment, done for every child enrolled, is a form completed by the classroom
teachers (based on their observations) and child’s parent. The form asks questions about your child’s
social-emotional development, including how your child reacts to others, handles their feelings, and
enjoys classroom activities. It is filled out two times per program year.
Preschool Language Scale-IV Edition: This assessment measures receptive (understanding) and
expressive (use of) language. It involves your child participating in playful activities with a member of the
evaluation staff. This assessment takes approximately 20 minutes and is completed as children enter and
every six months. This assessment is for children age 4 months through kindergarten entry. This
assessment will be completed in English and Spanish for bi-lingual children.
Peabody Picture Vocabulary Test – IV: This assessment measures a child understanding of words. It
involves children listening to a vocabulary word spoken to them and then pointing to the picture of that
word. This assessment is completed two times per program year and takes about 15 minutes to
complete. This assessment is completed on children 2 ½ through kindergarten entry.
Vision screening – a registered nurse will come to the program annually and complete a vision
screening on your child. The results of the screening will be shared with the center and you (the
guardian/parent) on the day of the screening.
Hearing screening – a registered nurse will come to the program annually and complete hearing
screenings on your child. The results of the screening will be shared with the center and you
(parent/guardian) on the day of the screening.
Dental Health- a fluoride treatment will be provided for your child annually. A specially certified dental
professional will come to the program up to four times a year to apply a fluoride varnish to your child’s
teeth.
The following two assessments are administered to Kindergarten-bound children only.
Phonological Awareness Literacy Screening- Preschool: This assessment is given to kindergartenbound children only. It looks at children’s beginning awareness of alphabet letters, beginning letter
sounds, rhymes, and writing skills. This assessment is done two times per program year and takes about
20 minutes to complete.
Bracken School Readiness Assessment: This assessment will be given to kindergarten-bound
children only. It evaluates your child’s development of basic school-related concepts including; knowledge
of colors, letters, numbers, sizes, directions, textures and social and emotional awareness. This
assessment is done once per program year in the spring and takes about 20 minutes to complete.
In order to evaluate the long-term effectiveness of participation, Building Bright Futures will continue to
access your child’s public schools specified records from public schools within Douglas and Sarpy
Counties. You can choose not to have your child tracked when they enter into public schools. Records
that will be accessed will include test results, attendance, and participation in special programs.
2 Parent Consent Form
Building Bright Futures Early Childhood Services Child Screenings and Assessments
Parent Consent Form
Photograph/Video Release
In order for the BBF specialists to work with the teachers and childcare facilities to improve overall quality,
we request permission to video tape and photograph your children. These videos and pictures will be
used as instructional tools for teachers, directors and board members. Pictures of you and your family
may be used in the evaluation publication. No photographs or videos will be released publicly without
prior permission of the parent or guardian.
I have read or have had explained to me the evaluation process used by Building Bright
Futures Early Childhood Services. Please check the first two items if you are willing to
allow your child to fully participate in the evaluation process.
YES (Mark these two)
[ ] I give permission for my child to participate in these routine assessments and
screenings.
[ ] I give permission for my child to be videotaped/photographed for instructional
purposes.
NO (Mark these two)
[ ] I do not give permission for my child to participate in these routine assessments and
screenings.
[ ] I do not give permission for my child to be videotaped/photographed for instructional
purposes.
Child’s First Middle and Last Name (PRINT)
Child Care Center (PRINT)
______________________________________
Signature of Parent/Guardian
_______________________________________
Signature of Childcare Staff Member or Director
(Please, return this page to your child’s childcare)
___________________________________________
Name of Childcare
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_____________
Date of Birth (DOB)
_____________
Classroom # (if applicable)
_______
Date
_____________
Date
Building Bright Futures Early Childhood Services Child Screenings and Assessments
Parent Consent Form
___________________________________________
Name of Parent (please print)
___________________________________________________
Child’s Name
___________________________________
_
Parent’s Address
_______, ________
City
State
(_ _ _) _ _ _ - _ _ _ _
Phone Number
Child’s Gender:
Male
Female
Child’s Race:
White, non-Hispanic
Black/African American
Hispanic or Latino
American Indian/Alaska Native
Asian American
Native Hawaiian or Pacific Islander
Multiple ethnicities
Other, please specify:__________________
What language is spoken most frequently in the child’s home?
English
Spanish
Arabic
Nuer
Russian
Vietnamese
Other, please specify: ___________
(Please return this page to your child’s childcare)
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_ _/ _ _/ _ _ _ _
Child DOB
____
Zip