Early Learning Quality and Inclusion Partnership (EQ+IP)
2015-16 ECE PROVIDER INFORMATION AND CONSENT FORM
PLEASE NOTE: IT IS VERY IMPORTANT THAT YOU ANSWER EVERY QUESTION BELOW
A. First Name
Middle (optional)
Last Name:
C. Email Address:
B. Phone Number:
D. Date of Birth (MM/DD/YYYY):
E. Home Address:
F. City, State:
H. Type of Provider: (check ONE box)
 Transitional Kindergarten Teacher
 Nanny
 Relative Caregiver
I. Employer & Site Where You
Work:
G. Zip Code:
 Center-Based Child Care/ECE
 Licensed Family Child Care
 Kindergarten Teacher
 Health Care Provider
 Not Currently Working  Other (specify): _______________
J. Position:
K. Workplace
 Lead Teacher  Teacher  Asst. Teacher ZIP:
Aide  Site Supervisor  Program Director
 Other (specify): _______________________
L. Gender:
 Female
 Male
M. Primary Ethnicity & Race
1. Ethnicity: Are you of Hispanic or Latino origin?
 Yes
 No
2. Race: (check ALL that apply)
 Alaskan Native/American Indian
 Asian
 Black/African-American
 Native Hawaiian/Other Pacific Islander
 White/Caucasian
N. Primary Language: (check ONE box)
 English
 Spanish
 Arabic
 Cantonese
 Mandarin
 Vietnamese
 Tagalog (Philipino)
 Korean
 Other Language (specify): _________________________________
Second Language: (if you are bilingual, please write in second language) ___________________________________
O. When did you begin working in the field of child care or early childhood education?: ______________
(please enter the year)
P. What is your current level of education?: (Select highest level completed)
 Some High School  High School Diploma/GED  Associate Degree (AA/AS)
 Bachelor’s Degree  Master’s Degree
 Doctorate/PhD/MD
Q. 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, leave blank)
R. Is this degree from a foreign
country?:  No
 Yes
S. Number of Early Childhood Education/Child Development units
completed: (enter “0” if none) ________________
T. Do you hold a California Child Development Permit?:  No
 Yes  If Yes, select permit level:
 Assistant  Associate  Teacher  Master Teacher  Site Supervisor  Program Director
Valid Date: ________________________
Expiration Date: ________________________
Please review your responses above to ensure you have answered every question.
Form continues on the next side.
Revised 7/17/15
CONSENT TO PARTICIPATE IN EVALUATION AND SHARE INFORMATION
I agree to allow the San Mateo County Office of Education (SMCOE) to share information about me with First
5 San Mateo County (F5SMC) and their evaluators. This information will help SMCOE and F5SMC to 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, contact information, date of birth, gender, ethnicity,
language, level of education, and my history in the field of early childhood education.
At some point during the year, 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 form. My answers might help to improve EQ+IP activities
for service providers in San Mateo County.
It is very important to SMCOE and F5SMC that my information is safe, so it will be protected as
required by law.
If I do not complete this form, it will not effect my employment.
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:
Early Learning Support Services, San Mateo County Office of Education, 101 Twin Dolphin Drive,
Redwood City, CA 94065.
For more information, please call: 650-802-5452.
 I consent to take part in this evaluation. My information will only be shared with authorized individuals
from SMCOE and F5SMC 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 SMCOE.
Please print your name, sign and date below.
________________________________________________________________________________
Name of Individual (printed name)
_________________________________________________________________________________
Signature
Date Signed
Revised 7/17/15