East Central Illinois Community Action Agency
Head Start – Birth to Five Program
Forms and Informational Materials
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Activity Based Intervention
Special Needs/Mental Health Coordinator will receive copies at end of month. The originals will go
to the Computer Information Specialist at the end of each month to be filed in permanent file.
Agency File Requisition Form
Form to be submitted to the Computer Information Specialist when requesting access to child’s permanent
file.
A Parent’s Guide: The Educational Rights of Students with Disabilities (*Spanish)
This is an informational sheet given to parents when their child is referred.
Attendance - monthly
Form is used to enter attendance data in CHILD PLUS System.
Baseline Data Collection
The originals as soon as completed by Classroom Teams will go to the Special Needs/Mental Health
Coordinator.
Weekly Individualized Plan (B-3) Center Base
Form is used by center teachers to use for individualization of child. Form is submitted to the Supervisor
Birth to Three Services weekly for review. Special Needs/Mental Health Coordinator will receive a copy
for children with an IFSP.
Bus List
Submit at end of month to the Facilities/Transportation Coordinator. Form should be turned in no later
than three days after specified calendar due date.
Career Log
All trainings should be recorded on this form. The form should be turned in at the end of the program year
to assigned Supervisor. Make a copy for your own records. Supervisors will turn the forms in to Human
Resources.
Center-Based Evaluation Form
Designated staff will do monthly during program year and share with staff.
Center Visit Record
It is located and kept in the Blue Notebook in classrooms. (Not in FCD Classrooms)
Child Add/Drop Form
Family Advocates will submit to the Computer Information Specialist on an as needed basis. A copy is sent
to assigned supervisor.
Child and Family Referral
Form to be sent to the Special Needs/Mental Health Coordinator on an as needed basis.
Class Development Assessment
The original document is sent to the Special Needs/Mental Health Coordinator who input data in CHILD
PLUS System.
Child Health History
The form is filled out and completed with parent during orientation. Form is then submitted to the Health
Services Technician who will send a copy to the Computer Information Specialist. The form will then be
placed in the child’s permanent file. Maintain a copy for the working file.
Child Nutrition Assessment
The form is filled out and completed with parent during orientation. Form is then submitted to the
Computer Information Specialist. The form will then be placed in the child’s permanent file. Maintain a
copy for the working file.
Class Lists
Copy monthly and place in classroom blue binders
Classroom Safety Checklist
Form to be filled out by Classroom Teams and submitted monthly to the Facilities/Transportation
Coordinator.
Classroom Monthly Report
Form is due at the end of each month. Submit copies to the following:
Assigned Supervisor
Special Needs/Mental Health Coordinator
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Supervisor Health Services
Transition/Recruitment Coordinator
Form should be turned in no later than three days after specified calendar due date.
Community Partnership Agreement
To be filled out jointly with community partner and agency. Each will keep a copy for their records.
Agency copy will be placed in white notebook under Community Partnerships.
Computer Log
Form to be kept in Red Notebooks and will be available for review upon request.
Core Item Collection Plan
Form is filled out for each child (3-5) at beginning of program year. Form is placed in front pocket of each
child’s portfolio. Form to be available upon request for review.
Core Items
This is an information material to be kept in form box. Refer to as needed. (3-5 only)
Daily Child Transition Log
Bus drivers give to Family Advocates at the end of each week. The form is then filed in the Red
Notebook. At FCD, this document is kept in a separate blue notebook.
Developmental Milestones Collector Form
Form is used by B-3 center staff when child has a documented IFSP. The form is placed in the child’s
portfolio and reviewed by the Supervisor B-3 Services.
Diagnostic Referral and Reporting
The original will be sent to the Special Needs/Mental Health Coordinator who will send originals to the
Diagnostician. As soon as form is returned to the Special Needs/Mental Health Coordinator it will be
forwarded to the MIS Department to be filed in permanent file.
Discipline Policy (*Spanish)
Form is signed by parent during parent orientation. Family Advocates will then forward to the Computer
Information Specialist to be placed in child’s permanent file.
Documentation Request
Family Advocates will give to parents when requesting information for child’s file. White copy is kept in
child’s file and yellow copy is given to parents.
Drop Off Pick-Up Agreement
Form is signed by parents during parent orientation and then placed in child’s permanent folder. A copy of
the form is given to the parent.
Drop Off Pick Up Record
Form is maintained in Red Notebook. Used on an on-going basis.
Early Childhood Education Family Partnership Agreement
Family Advocate will forward to the Computer Information Specialist to be filed in permanent file.
Facsimile
Used by staff as needed when faxing.
Fall Parent/Teacher Conference
The form is updated for each conference and will be given to staff before parent/teacher conferences are
scheduled. Classroom team will complete with parent and forward to assigned Supervisor. Assigned
Supervisor will forward to the Computer Information Specialist to be filed in child’s permanent file. Refer
to calendar for time line. Fall Parent/Teacher Home Visit
Fall Parent/Teacher Home Visit
The form is updated for each home visit and will be given to staff before scheduled home visits.
Form is completed in home with parent then forwarded to assigned Supervisor. Assigned Supervisor will
forward to the Computer Information Specialist who will place form in child’s permanent file. Refer to
calendar for time line.
Family Action NoteFamily Action Notes are entered directly into the CHILD PLUS system. Printed copies will be submitted
to the assigned Supervisor. Supervisor will read and initial then submit both copies to the Associate
Director of Educational Services. The Associate Director will read and initial. A copy will be sent to the
Computer Information Specialist so it can be placed in the permanent file. Staff should make copies of
Family Action Note and forward them to all members of the Management Team that might need the
information.
Forms should be submitted to their designated supervisor on a monthly basis or immediately when there is
an emergency within the family. Always maintain “running Family Action Notes” for routine matters.
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35. Family Goal Development Plan
Form to be completed by Family Advocate and Classroom Team. Refer to calendar for start and due dates.
Originals will be sent to assigned Supervisor. Supervisor will review and give to the Computer Information
Specialist to be placed in child’s permanent file. Copies of plan should be kept in the working file.
36. Field Trip Permission (*Spanish)
Classroom Teams will send permission slips home two weeks prior to field trip for parents or guardians to
sign and return by field trip due date. Keep on file in child’s working folder.
37. Field Trip Request
Send to assigned Supervisor.. After Supervisory approval a copy will be forwarded to
Facilities/Transportation Coordinator who will contact transportation services. If requesting food,
Supervisor will forward a copy to the Supervisor Health Services. If requesting money, Supervisor will
forward a copy to the Associate Director of Educational Services. Staff will be notified if for some reason
the field trip is denied.
38. File Completion Checklist
Classroom Teams and Family Advocate staff uses this form to monitor the completion of a child’s file.
Form to be kept in file until file is completed.
39. File Review Form
Supervisors use this form to monitor files. Form will be placed in the child’s file. Supervisors will keep a
copy for their own records. A copy is sent to the Family Advocate so that corrections can be made to the
files.
40. Fire Drill Log
Posted on bulletin board in classroom and updated monthly. Exceptions would be the FCD and Roselawn
Centers where Site Supervisors will keep fire drill logs in a binder. Fire drill logs are turned in at the end of
the year to the assigned Supervisor. Forward to Facilities/Transportation Coordinator at the end of the
program year.
41. Food Services Requisition
In place of the Food Requisition, use Form #108 Purchase Order Requisition Form.
42. Food Temperature Worksheet
At FCD the Food Service Specialist will file Food Temperature charts daily. At other sites, these will be
done daily and filed in the Red Notebook. A copy of all food temperature charts will be sent to the
Supervisor Health Services at the end of each month for review.
43. Guidelines and Checklists
These are found on Work Sampling on-line and filled out quarterly. Refer to calendar for date of
completion.
Forms (*44-*52) are filed before the letter “H” for Health
44. *Allergies and Food Restrictions
This must be posted in each classroom. FCD classes must send this form to the Food Service Specialist.
Copies of this form must be sent to the Supervisor Health Services.
44b.. Medical Exception Statement For Food Service Substitution
Form completed, sent to the Health Services Supervisor and copy to the MIS department.
Form is completed to document child’s food allergy. Form is signed by child’s physician.
45. *Authorization to Administer Medication (*Spanish)
This form must be signed by the parent or guardian. The original is sent to the Computer Information
Specialist to be filed in child’s permanent folder. A copy is to be kept on site in the child’s working file and
a copy is sent to the Supervisor Health Services.
46. *Explanation of Medical Forms
Form to be used as a reference in using the health forms. Keep in file box for easy reference access.
47. *First Aid Inventory List
Classroom Teams should fill out on as needed basis and send to the Health Services Technician. It is
important that first aid kits are well stocked at all times. Refer to calendar for due date.
48. *Health Alert Record (May have been exposed)
To be sent out to parents when a child in the classroom may have one of the conditions listed. The
Supervisor Health Services should also be notified and sent a copy.
49. *Health Alert Record (Suspected)
To be sent only to the family of the child suspected of having one of the listed conditions. The Supervisor
Health Services should also be notified and sent a copy.
50. *Height, Weight and Circumference Form
Classroom Teams do three times during the year according to calendar schedule. Classrooms keep a copy
for their records. Originals are sent to the Health Services Technician, Facilities/Transportation
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Coordinator and Bus Driver. Head Circumferences are only done for the Birth to Three children and
babies.
50 (a) Vision/Hearing Screening and Rescreening Form (NEW FORM!)
Record hearing results. Send copy to Computer Information Specialist for filing.
50 (b) Vision Screening and Rescreening for B-3 (NEW FORM!)
Record vision results. Send copy to Computer Information Specialist for filing.
50 (c) Hearing Screening and Rescreening for B-3(NEW FORM!)
Record hearing results. Send copy to Computer Information Specialist for filing.
51. *Medication, Administration and Observation Log
Site Supervisors are responsible for the completion of this form. At the FCD Center, the Supervisor Health
Services will fill out this form as medication is given. Upon completion of the medication, Site Supervisors
will forward the original copy to the Supervisor Health Services for review. Send copy to Computer
Information Specialist so that forms are filed.
52. *Pregnancy History and Prenatal Risk Assessment Form. (B-3)
To be completed at time of enrollment. A copy is kept in the working file and the original is kept in the
permanent file. Form is given to the Computer Information Specialist for filing. A copy is sent to the
Supervisor Health Services. Staff will complete form after pregnancy and update information in the
permanent file.
53. Home Base Visit Schedule
Form is to be submitted to the designated Supervisor when ever changes occur in the weekly schedule.
54. Home Base Weekly Report (3-5)
Kept in Notebook and available for review upon request. Yellow copy is left weekly with parent. Copies
are to be turned in monthly to designated supervisor.
55. 55-1, 55-2, 55-3, 55-4, 55-5 Home Visit forms for children and pregnant women
Kept in notebook and available upon request. Yellow copy is left weekly with parent. Copies are to be
turned in monthly to designated Supervisor. A copy of children with an IFSP is sent to Special
Needs/Mental Health Coordinator.
56. Incident Report
Form is used to report any accident and/or occurrence that is not in the normal routine of the day.
All reports go to their assigned Supervisor. At FCD and Roselawn, the Site Supervisors will receive report
and forward to assigned Supervisor. Copies of incident reports pertaining to a child’s injury must be sent to
their assigned Supervisor and the Supervisor Health Services as soon as possible. Parents must be called
and must receive a copy of the report if injury pertains to their child. If the child needs medical or
emergency treatment, call Assigned Supervisor and the Supervisor Health Services and fax incident report
to both Supervisor and Supervisor Health Services within 24 hours.
57. IEP/IFSP (*IEP in Spanish)
Original will go to the Special Needs/Mental Health Coordinator. Special Needs/Mental Health
Coordinator will forward to the Computer Information Specialist to be filed in CHILD PLUS. The
Computer Information Specialist will file in the permanent file. Special Needs will give copies of the
IEP/IFSP to teaching team for working file. A copy of the IFSP will be given to the Supervisor B-3
Services.
58. Individualized Transition Plan
58a.Transition Recruitment Coordinator completes the form with family when the child begins the transition
process for B-3. The plan is then filed in child’s permanent file.
59. Individuals With Disabilities Act (*Spanish)
This is an informational sheet given to parents when their child is referred.
60. Infant/Toddler Daily Report – English and Spanish
Submit monthly to the Supervisor B-3 Services.
61. In-kind Donation Record
Form 61-1:
Classroom Team will oversee that this form is filled out as in-kind occurs daily and weekly. In-kind sheets
are found in the Blue Notebook and must be submitted at the end of the month to their assigned Family
Advocate. Family Advocates enter in-kind data in to the Child Plus System. Refer to calendar for date due.
Submit form no later than three business days at the end of each month.
61-2.Inkind-Statement of Contribution
Form is filled out when specific items of monetary value are donated. Donor is to sign form. Form is
turned in to assigned Supervisor at end of month. Check calendar for Inkind due dates.
61-3.Inkind-Special Events
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Form is used specifically for special events and must be submitted at the end of the month to their
assigned Supervisor. Refer to calendar for date due. Submit form no later than three business days at the
end of each month.
62-1. Eligibility Verification
A form filled out by the Computer Information Specialists.
62-2. Income statement
A form filled out by the Computer Information Specialists.
63. All Kids Application and Information Packet
Family Advocate Staff will need to access this packet from the Human Resources Assistant.
64. Lesson Plan (B-3)
For center base submit on a weekly basis and for socialization submit a copy twice monthly to the
Supervisor B-3 Services. Assigned Supervisors may also request copies.
65. Lesson Plan Critique (B-3)
Supervisor Birth to Three Services will use form to monitor lesson plan. Teachers will receive a copy of
the critique and the Supervisor Birth to Three Services will keep a copy on file.
66. Lesson Plan (3-5)
Post white copy and send a copy to assigned Supervisor according to calendar due date.
67. Lesson Plan Critique (3-5)
Supervisors send a copy to Classroom Teams and Supervisors file a copy with lesson plans.
68. Lesson Plan Explanation (3-5)
Form is used to inform staff on how to fill out lesson plan.
69. Lesson Plan Parent Input Sheet (3-5)
Current form is posted in classroom.
Submit a copy to assigned Supervisor at the end of each month. Refer to calendar on date due. At the end
of the month a completed copy is placed in the Blue Notebook.
70. Lesson Plan Parent Input Sheet (3-5) Instructions
Form is used to inform staff on how to fill out parent input. Keep in file form box for reference.
71. Lesson Plan September
Staff must use this lesson plan for the first month. Post on bulletin board for first month‘s use.
72. Maintenance and Janitorial Requests
To be submitted to Human Resources.
73. Meal Participation Record
All Classroom Teams will submit this form to the Interim Fiscal Officer. This is due at the end of each
month or at the end of the last day children are served meals for that month. Refer to calendar due date.
Form should be submitted no later than three business days after the end of each month. Question
about Block claiming must be answered and two staff must sign.
74. Mentoring Tool for Enhancing Literacy, Language and Math Skills
Classroom teams are to fill out monthly and hand in at the same time as lesson plans. Refer to calendar for
due date.
75. Mileage Report
Car pooling is an agency procedure to curtail costs.
Staff will fill out and turn in at the same time as the second time card is due for payroll. Mileage will be
turned in to the assigned Supervisor for review and approval.
76. Multi-Cultural Checklists
Classroom Teams complete in early fall, refer to calendar for due date. Form is submitted to assigned
Supervisor for review.
77. Newsletter
Classroom Teams will work together to develop a newsletter. This is due to your assigned Supervisor at the
same time as lesson plans. Refer to calendar for date due.
78. Newsletter (Example)
This is used as a reference material that shows how calendar should be filled out. Keep in file box for
reference.
79. Notice of Parents Rights and Due Process (*Spanish)
The original will be sent to the Special Needs/Mental Health Coordinator who will make a copy for the
working file. The Special Needs/Mental Health Coordinator will send the original to the Computer
Information Specialist to be placed in the permanent file and make a copy for the working file.
80. Nutrition Checklist
Form is filled out by the Nutrition Consultant or the Supervisor Health Services. The yellow copy is given
to the Site Supervisor. The white copy is kept by the Supervisor Health Services.
81. Outcome Reports
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Assigned Supervisor will review outcomes report with classroom teams three times during the year.
Classroom Teams will place the outcomes report in the Blue Notebook for easy access.
82. Parent Consent for Referral and Evaluation (*Spanish)
The original will be sent to the Special Needs/Mental Health Coordinator who will make a copy for the
working file. The Special Needs/Mental Health Coordinator will send the original to the Computer
Information Specialist to be placed in the permanent file and make a copy for the working file.
83. Parent Orientation Checklist
Updated yearly and placed in Parent Orientation folders.
84. Playground Safety Checklist
Classroom teams will fill out this form each day before taking children outside on the playground. At FCD
and Roselawn a different classroom team is assigned monthly to do the daily playground checklist.
Playground checklists will be turned in monthly to the Facilities/Transportation Coordinator.
85. Registration Packet
All staff will do registration. The packet should contain:
1. Intake Application
Yellow copy should go to the parent.
2. Documentation Request.
Yellow copy will go to parents and white will remain in the file.
3. Physical
This should be given to the parents and returned by the date on the documentation request
form.
4. Statement of Non-Verifiable Income
To be filled out only if there has been no income for the last thirty days from date of
application. Document money and vouchers family has received that is not income.
86. Request for Leave
Form must be turned in before time card is due. Refer to Procedures Manual and PTO Leave Policy for
Leave notification regarding PTO.
87. Request for Time Off Protocol
Form is signed by staff verifying they have read and agree to procedure. Human Resources put the original
in the staff file and staff receives a copy.
88. Request for “Thank You” Letter
Staff turns in request to assigned Supervisor and assigned Supervisor will forward to Human Resources for
processing.
89. Request for Transportation Change
Submit this form to the Facilities/Transportation Coordinator for processing.
90. Request for Verification of Birth – NO LONGER IN USE - DELETED
91. Release and Emergency Contact Form
Family Advocates and Classroom Teams will obtain this information during the Parent Orientation. Form
will be updated as necessary. Forms should be kept in the working file, forwarded to the Transportation
/Facilities Coordinator, First Student bus driver, and CIS for placement in permanent file.
92. Screening Advisement Form
Family Advocates and classroom teams will fill this form out when screenings are completed. The yellow
form will go to the parent. Family Advocate Staff will send the white copy to the Computer Information
Specialist for processing. A copy will be given to the Supervisor Health Services. A copy must be made for
the working file.
93. Special Needs Mental Health Observation List
Special Needs/Mental Health Coordinator uses form to observe a child who is to be referred or has an
IEP/IFSP. Observations are shared with Supervisors. The form is given to the Computer Information
Specialist to be placed in the child’s permanent file. The Special Needs/Mental Health Coordinator will
make copies of form and give to the teaching team and coordinators.
94. Socialization Plan (B-3)
The B-3 Home Base Teacher completes and submits to assigned Supervisor for review one week prior to
Socialization.
95. Spring Parent/Teacher Conference
The form is updated for each home visit and will be given to staff before scheduled home visits.
Form is completed in home with parent then forwarded to assigned Supervisor. Assigned Supervisor will
forward to the Computer Information Specialist who will place form in child’s permanent file. Refer to
calendar for time.
96. Standard of Business Conduct
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All staff and partnerships sign a copy. Human Resources place a signed form in the personnel file.
97. Summary Reports
Form is found on Work Sampling on-line and filled out quarterly according to date on calendar. A copy is
ran off and given to the parent. The cumulative third quarter report is sent to the Computer Information
Specialist to be filed in the child’s permanent file.
98. Supply Requisition Form
Classroom Teams are responsible in getting this form turned in to their assigned Supervisor by the assigned
scheduled date. Staff should make copies for their records.
99. Teacher’s Classroom Equipment Resource Inventory
Form is filled out three times yearly by Classroom Teams. Teams will fill out form in September, January
and May. Check calendars for due dates.
100. Team Meeting Report
Form is used weekly to record Team Meetings. Submit form or fax form as soon as possible to assigned
Supervisor after each weekly meeting.
101. Time and Attendance Report
Form is used for designated staff. Form is turned in to assigned Supervisor.
102. Tornado Drill Log
Site Supervisors use this form monthly starting in September to record tornado drills. Form is posted in
classroom except at FCD and Roselawn where the Site Supervisors maintain form in the office. Forwarded
to Facilities/Transportation Coordinator at the end of the program year.
103. Winter Parent/Teacher Home Visit
The form is updated for each home visit and will be given to staff before scheduled home visits.
Form is completed in home with parent then forwarded to assigned Supervisor. Assigned Supervisor will
forward to the Computer Information Specialist who will place form in child’s permanent file. Refer to
calendar for time..
104. Work Sampling System – Introduction for Families (Spanish)
Form in English and Spanish is found on the Work Sampling-on-line Site. Staff may copy off information
as needed.
105. Cleaning Schedule
Complete as indicated on the form. Post in classroom as form is being completed. After completion, place
Form in red notebook to be reviewed upon request.
106. Written Consent to Release Information
All original consents will be sent to the Computer Information Specialist to be filed in Child’s permanent
file.Those consents needed for kindergarten should be sent to the Transition Recruitment Coordinator.
All information needed for kindergarten will be attached to the written consent. Transition Recruitment
Coordinator will distribute to school districts.
Referrals: A copy of the Consent for referral should be sent to the Special Needs/Mental Health
Coordinator. Special Needs/Mental Health Coordinator will send copy and referral information to referred
agency.
107. Purchase Order Requisition Form
To be completed and turned in to Supervisor two weeks before requesting food/supplies. Requisition must
be completed and prices obtained for form to be processed. Supervisor will review and then give to
Associate Director of Educational Services for processing. Staff submitting form will be notified if request
is not approved.
108. Bus Evacuation Drill
Laidlaw conducts bus evacuations three times during the year. The Laidlaw Transportation Representative
will submit a copy of the completed form to the Facilities Transportation Coordinator. The form will then
be filed in the Transportation Notebook.
109. Family Development Monthly Report
Form is due at the end of each month. Submit copies to the following:
Assigned Supervisor
Special Needs/Mental Health Coordinator
Supervisor Health Services
Parent Involvement Coordinator
Form should be turned in no later than three days after specified calendar due date.
Copy placed in PIR binder for Head Start Director.
110. Custody Receipt
Form is filled out by staff requesting equipment and submitted to assigned Supervisor for approval.
111. Parent Stipend Form
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A form filled out by parents attending Policy Council or a special event. Form is given to the Associate
Director of Educational Services and then processed by Fiscal office.
112. DHS Verification Form
Form that is used by Family Advocate and sent to Public Aid for verification of income received. When
form is received back from public aid, it is placed in application folder.
112-1. Income Statement
Form that is used by Family Development and sent to Employer of applicant for verification of income
received. When form is received back from employer it is placed in application folder.
113. Classroom Information Monitoring Schedule
The form lists items posted in classroom. Supervisor will review classrooms twice yearly to monitor.
114. Home Base Evaluation Form
Form is completed by assigned Supervisor when observing home visits. Visits will be monitored at least
twice yearly and more if needed..
115. Bathroom/Classroom Cleaning Schedule
Complete as indicated on the form. Post in classroom until form is completed. After completion, place
form in red notebook to be reviewed upon request.
116. Tracking Monthly Paper Work
Supervisors use this form to track when staff submits monthly paper work. Staff will be notified when
paperwork is overdue.
117. PIR Control Form – DELETED with the implementation of Child Plus
Family Advocate and Home Base Teachers use this form to track child and family outcomes. A copy if
forwarded to the Associate Director of Educational Services on a monthly basis. Information is updated on
form as needed.
118. Parent Survey
Included in Parent Orientation folder
119. Parent Evaluation Tally
Used to Tally Parent Survey
120. Well Baby Check up form – For Birth to Three Services
To be completed by physicians. Copy is placed in child’s file.
121. Mental Health Observation Checklist
Completed by Mental Health Consultants
122. Staff Weekly Planning Calendar
Used by classroom teams to plan team planning time. Copy submitted to supervisor
123. Letter for Child’s Physical
DCFS requirement for families to sign when the child’s physical is over 6 months old
124. Child Housing Form
Completed by all families to be in compliance with the McKinney/Vento Act
125. Refusal of Health Services
Used when parents refuse to allow their child to receive a health screening.
Travel Authorization
Completed by Supervisors or Associate Directors when travel for training has been approved.
Check Request
Completed by Coordinators, Supervisors or Associate Directors when an expenditure that requires a check
has been approved.
Technology Request Form – not on form file
NCR form must be used and sent to Supervisor.
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