Early Childhood Quality Improvement Project (EQuIP)
2014-15 ECE PROVIDER INFORMATION AND CONSENT FORM
**PLEASE NOTE: IT IS VERY IMPORTANT THAT YOU ANSWER EVERY QUESTION BELOW.
PLEASE REVIEW THE QUESTIONS CAREFULLY AND ENSURE THAT YOU ANSWER ALL QUESTIONS**
Today’s Date: _________________
Agency (Employer): ___________________________________________________
Site Name: ___________________________
A. First Name
Classroom Name:_____________________________________________
Middle (optional)
Last Name
B. Date of Birth:
/
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D. Residential Street Address:
E. City, State:
G. Email Address:
H. Phone Number:
I. Primary Race/Ethnicity: (check ONE box)
 Alaska Native or American Indian
 Asian
 Pacific Islander
J. Primary Language: (check ONE box)
 English
 Spanish
 Korean
C. Gender:
 Male
 Female
F. Zip Code:
 Black/African-American
 Hispanic/Latino
 White
 Multi-Racial
 Other (specify): _____________
 Cantonese
 Mandarin
 English-Spanish Bilingual
 Vietnamese
 Tagalog (Pilipino)
Other Bilingual (specify): ______________________
 Other Language (specify)_______________________
K. Type of employment: (check ONE box) (If you are not currently working, check “Not currently working” and skip to Question #O)
 Center-Based Child Care/Preschool
 Licensed Family Child Care
 Family Support Professional
 Health Care Provider
 Not currently working
 Other: __________________
Workplace Name: ______________________________________________________________
Zip Code: ____________
If you are working in the field of Early Childhood Education, please answer questions L and M:
L. What is your current position?
 Assistant Teacher  Teacher  Lead Teacher
 Supervisor
 Program Director/Administrator  Other:__________________
M. How long have you been working in the field of Early Childhood Education (enter number of years)? ________ Years
******ANSWER ALL QUESTIONS BELOW (N - R )******
N. What is your current level of education? (Select highest level completed):
 Some High School  High School Diploma/GED  Some College  Associate Degree (AA/AS)
 Master’s Degree
 Doctorate/PhD/MD
 Bachelor’s Degree
O. Field of study for highest degree completed (e.g., Mathematics, Early Childhood Education, History, Human Development, Child
Development, Elementary Education, Sociology, etc): __________________________________________________________
(if your highest degree is High School, you may leave Field of Study blank)
P. Is the degree selected above from a foreign country?
 No  Yes
Q. Number of Early Childhood Education/Child Development units completed (enter “0” if none): _______________
R. If your highest level of education is High School or "Some College", enter the number of college General Education (GE) units
completed here (enter “0” if none): _________
S. Do you hold a California Child Development Permit?  No
 Yes  If Yes, select your permit level:
 Assistant  Associate  Teacher  Master Teacher  Site Supervisor  Program Director
Expiration Date_______________
Please review your responses above to ensure you have answered every question. Please go to the next page
to complete the form.
CONSENT TO PARTICIPATE IN THE FIRST 5 SAN MATEO COUNTY EVALUATION
I agree to allow the Early Childhood Quality Improvement Project (EQuIP)/San Mateo County Office of Education
(SMCOE) to share information about me with First 5 San Mateo County (F5SMC) and their evaluators (including SRI
International). This information will help F5SMC learn about the service providers with whom they work. I understand
that:
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This form asks for my name, date of birth, zip code, ethnicity, language, level of education, and my history in the
field of early childhood education.
At some point during the program, I may be asked to complete a survey that asks me to rate my level of
knowledge and skill as a service provider.
I can skip any question I do not want to answer.
Only a few people will be able to see my answers. Those people are not allowed to share my private information
with anyone.
Reports will not include my private information.
There are no known risks to completing this survey. My answers might help to improve EQuIP and F5SMC
activities for service providers in San Mateo County.
It is very important to EQuIP and F5SMC that my information is safe, so it will be protected as required by law.
If I do not complete this survey, I will still receive services from this program.
My consent to share my answers will end 10 years from today. I can always change my mind and have my
information erased. To do this I send a request to:
EQuIP, San Mateo County Office of Education, 101 Twin Dolphin Drive, Redwood City, CA 94065. For more
information, please call: 650-802-5345.
 I consent to take part in this evaluation. My information will only be shared with authorized individuals from
EQuIP, First 5 San Mateo and their evaluators. Reports will never include my private information.
Please print your name and sign and date below.
________________________________________________________________________________
Name of Individual (printed name)
_________________________________________________________________________________
Signature
Date Signed
 I do not consent to participate in this evaluation. The only people who will see my information are representatives
of EQuIP/San Mateo County Office of Education.
Please print your name, sign and date below.
________________________________________________________________________________
Name of Individual (printed name)
_________________________________________________________________________________
Signature
Date Signed
Revised 9/10/2014