HEAD START FORMS

2008-2009 Folder Checklist Section One: Enrollment x Inspection of Confidential Records x Referral Record x Change of Status x Child Plus Application form x District enrollment forms x Notification letter (optional if prior to school starting) x Parent Handbook/Student Handbook Code of Conduct x Copy of birth certificate x Copy of Social Security card x Video Surveillance Policy(as needed x Legal Document log

Section Two: Health x Consent for Health Services x Emergency Consent and Medical Information Release form x Copy of Health Contact Follow-up form (as needed) x Documentation of Insurance/Medicaid/Chips (as needed) x Child Health-Form 2A,6 x Head Start Health Services Release of Information x Child Health Form 3 - Physical x Hearing and vision for 3 year old Copy of immunization record x Lead Screening/TB screening x Child Health Record Form 5 - Dental x Child Plus Growth Charts x Head Start Observation Notes x In House Referral (as needed) x Accident Report (as needed)

Section Three: Social Services x Progress Notes Social Services x Center-based Family partnership Agreement x Head Start Family Partnership Agreement/Needs Assessment (home visit) x Thank you letter to family (optional) x Parent Interest Questionnaire x In House Referral (as needed) x Release of Information (optional)

Section Four: Parent Involvement x Parent notes x Parent Staff Contact sheets x Attendance/Tardies policy signed x Parent letter for their child’s absences (as needed) x Transportation enrollment (as needed)

Section Five: Education x Region 9 Outcomes Assessment checklist (after all 3 are completed by teacher) or Child Plus 5110 x Dial 3 x DECA (if applicable x Home visit form x In House Conference form x Home Language survey x Migrant Survey form x District Field Trip Permission form x In House Referral (as needed)

Section Six: Mental Health/Disabilities x Mental Health Observation x Consent for Psychological/Counseling services x BIPs (Behavior Intervention Plans x Psychological and Social Development forms x IFP/IEP x In House Referral (as needed) x Referral for Counseling (as needed)

Section One: Enrollment x Inspection of Confidential Records x Referral Record x Change of Status x Child Plus Application Form x District Enrollment Forms x Notification Letter (optional if prior to school starting) x Parent Handbook/Student Handbook Code of Conduct x Copy of Birth Certificate x Copy of Social Security card x Video Surveillance Policy (as needed) x 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.

INSPECTION OF CONFIDENTIAL RECORD NAME

TITLE

DATE

PURPOSE

REFERRAL HEALTH/EDUCATION CHILD’S NAME ___________________ DATE

TYPE OF REFERRAL

REFERRAL CONTACT

FOLLOW UP DATE

COMMENTS

INITIAL OF REFERRING STAFF

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: 

Person to Contact in case of Emergency:

Name:

Submitted by:

Mother or Dad’s Signature: 4/06

Phone:

Relationship:

Phone:

Title:

Date:

Date:

NOTIFICATION LETTER 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. 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

5/2008

CARTA DE NOTIFICACION Escuela: Dirección: Número de Teléfono:

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. 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

5/2008

OPTIONAL ENROLLMENT FORMS x Thank You Letter for Your Interest x Video Surveillance Policy

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: x x x

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: x Child Support x Social Security Benefits x Unemployment Compensation x Dividends, Interest x Welfare Payments x Pensions, Annuities x Workers’ Compensation x Alimony x Educational Loans/Grants Other necessary documentation to bring is your child’s: x Birth Certificate x Social Security Card x Shot Record x Food Stamp Letter x TANF Documentation x 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

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: x x x

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: x x x x x x x x x

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: x x x x x x

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.

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.

4/04

Parent/Guardian

Date

Site Manager

Date

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 x x x x

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

5/2007

_______________________________________ Verifier’s Signature

____________________________________________ Mom or Dad/Guardian’s Signature

APPLICATION CHECKLIST

Child 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/Previously diagnosed/Diagnosed ___ 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 (300/500 points) Please explain:_________________________________ ___ Non-parent Caregiver (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: ___________________________________

2/08

Section Two: Health x Consent for Health Services x Emergency Consent and Medical Information Release Form x Copy of Health Contact Follow-up Form (as needed) x Documentation of Insurance (Medicaid/Chips, etc.) x Child Health-Form 2A,6 x Head Start Health Services Release of Information x Child Health Form 3 - Physical x Hearing and Vision for 3 year old x Copy of Immunization Record x Lead Screening/TB screening x Child Health Record Form 5 - Dental x Child Plus Growth Charts x Head Start Observation Notes x In House Referral (as needed) x Accident Report (as needed)

Consent for Health Services hereby give my consent for the child listed below to receive the screening tests and I, 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 Lead Screening I understand that this involves a blood sample obtained by a “fingerstick” or venipuncture if necessary. As a parent/guardian of , I hereby authorize the release of Medicaid/THSTEPS eligibility 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

I have explained to the purpose of this release and the nature of the tests and examinations that the children enrolled in Head Start receive. Signature of Head Start Staff

Date

PERMISO PARA RECIBIR SERVICIOS DE SALUD 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

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

4/06

_________ Date

______________ Home Phone

___________ Work Phone

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

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

TO BE COMPLETED BY HEAD START STAFF DURING PARENT/GUARDIAN INTERVIEW. HEAD START CENTER: _______________________________

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

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 2B, 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 LIFE 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 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

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 _______________

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.

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:

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:

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 4/06

__________________________________ Date

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

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 4/06

____________________________________

Date

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. x Si una persona tiene tos, no quiere decir que tiene tuberculosis x Tuberculosis puede ser prevenido y tratable x Niños pueden enfermarse demasiado con tuberculosis x 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 x x x x x x x x

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

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

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

Race: Grade EMERGENCY INFORMATION CARD Please Print Student’s Last Name

Date Entered First Name

M

F

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____________________ HEAD START EMERGENCY CARD

4/2006

HEAD START EMERGENCY CARD

TARJETA DE INFORMACION EN CASO DE EMERGENCIA Apellido Primer Nombre

FECHA Segundo Nombre

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

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

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

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

HS Personnel Accepting this Form

6/2007

Date

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

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)?

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:

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 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

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

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 x Progress Notes Social Services x Center-Based Family Partnership Agreement x Head Start Family Partnership Agreement/Needs Assessment (home visit) x Thank You Letter to Family (optional) x Parent Interest Questionnaire x In House Referral (as needed) x Release of Information (optional)

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 Between

HEAD START and (NAME) PARENT/LEGAL GUARDIAN of (CHILD) HEAD START will provide: x

Full-day child development/education services to Child on non-holiday weekdays during the ninemonth school year;

x

Health and dental screening for Child and assistance with treatment as necessary and appropriate;

x

Mental health screening for Child and assist with treatment services as necessary and appropriate;

x

Nutritious meals and snacks to Child and nutrition assessment and counseling as needed;

x

Parent education and involvement opportunities on a regular and ongoing basis;

x

Transition services as Child progresses to public school or other child development programs;

x

Comprehensive family support services to the Child’s entire family, including the identification of goals, objectives, and action steps necessary to accomplish them;

x

An opportunity for Child to brush teeth twice daily.

HEAD START may: x

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;

x

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;

x

Utilize photographs of Child for training, advertising or publicity purposes published in media whatsoever including electronic publication;

x

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) 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 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 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. _______________________________________

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 PACTO DE CONSORCIO DE FAMILIA Nombre del Niño Padre/Guardián Dirección HABILIDADES DE LA FAMILIA

1.___________________________ 2.___________________________ 3.___________________________ 4.___________________________

Fecha de Nacimiento Número de Teléfono Escuela

/

/

NECESIDADES DE LA FAMILIA

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

CHILD’S NAME: DATE OF BIRTH: Adult Education

FAMILY NEEDS ASSESSMENT Basic Life Skills

Child Care

Child/Family Health Development

Clothing

Communication/ Literacy Skills

Social Support

Continuing Ed.

Time Management

Before/After

Dental Care

Seasonal

ESL

Friends

Educational Planning

Homemaking/ HH/Skills

Referral

Health Insurance

Verbal Communication

Relatives

High School/GED

Other:

Funds for CC

Immunizations

Literacy

Other:

24 hr. CC

Medical Home

Other:

Vocational Training Other:

Prescriptions Treatment for acute Health problems SSI Medicaid

Family Relationships

Income Support

Employment

Early Intervention Strategies

Nutrition

Community Involvement

Transportation

Domestic Abuse

TANF

Job Hunting

Disabilities

Church/Religion

Bus

Marital/Partner

Child Support

Training

Speech

Food Needs Other:

Crime Prevention

Private Vehicle

Divorce

Food Stamps

Other:

Use Community Services

Other:

Legal Aide

Alimony

Physical Therapy Support Groups

Housing Assistance

Home Health care

Utilities

Other:

No needs at this time _______________________________ Date

Staff Signature ______________________ Date_______________________________

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: x x x

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: x Child Support x Social Security Benefits x Unemployment Compensation x Dividends, Interest x Welfare Payments x Pensions, Annuities x Workers’ Compensation x Alimony x Educational Loans/Grants Other necessary documentation to bring is your child’s: x Birth Certificate x Social Security Card x Shot Record x Food Stamp Letter x TANF Documentation x 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

Survey Binder or Parent Parent Meeting

Head Start Interest Questionnaire 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 Social Services Learning About Local Agencies That Help Your Family

Please Check Education and Child Development 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 Cuestionario de Interés

Survey Binder or Parent Meeting

Nombre de Padre: Nombre de Sitio de Head Start Fecha: Como padre, estoy interesado en los temas que siguen para discutir en las conferencias de Padres de Head Start.

Favor de indicar todas las categorías que apliquen. Salud Físico, Salud Dental, Nutrición  Síndrome de dientes  Cuando dejar que su niño quede en casa cuando está enfermo  Piojos  Inmunizaciones y record de inyecciones  Enfermedades de niñez  Leer etiquetas de comida

Salud Mental e Incapacidades  Deficiencia del lenguaje o en oír  La importancia de Admisión, Reviso y Despido (ARD)  Medicina de niños y efectos secundarios  Manteniendo buena salud mental  Problemas de habilidades conductuales  Otras sugestiones

 Prudentemente gastar su dinero en la comida de cada día  Otras sugestiones

Servicios Sociales  Información de agencias locales que pueden ayudarle a usted y su familia  Empleo  Volver a la escuela  Buscando almacenaje y arrendar  Conocimiento de drogas y alcohol  Otras sugestiones

Educación y Desarrollo de Su Nino  Grados de desarrollo de niño  Preparando su niño para entrar a la escuela preescolar y el kindergarten  El programa de alfabetismo  Actividades educativas que usted puede hacer en casa  Otras sugestiones

OPTIONAL SOCIAL SERVICES FORMS x In House Referral x Permission for Release & Exchange of Information

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 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 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 x Parent Notes x Parent Staff Contact Sheets x Attendance/Tardiness Policy (located in Parent Handbook) x Parent Letter for their Child’s Absences (as needed) x Transportation Enrollment (if applicable)

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

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

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

7/2008

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 unenroll your child from our program.

Sincerely,

Head Start Representative

Print Name

Telephone

Program Director

4/2006

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

dStartHeadStart HeadStart

Nombre del Director del Programa de 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 from my child’s physician, aid for my child hospital emergency room staff 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.

________________________________ Date

_____________________________________ Signature of Head Start Authorized Staff

_________________________________ Date dStartHeadStart HeadStart

_____________________________________ Signature of Parent/Legal Guardian



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 x Parent Interest Questionnaire x Parent Opinion Survey x Parent/Staff Contact Form x Need for Transportation Application x Transportation Enrollment

Name of Parent:

dStartHeadStart HeadStart

Parent Interest Questionnaire 

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 Social Services Learning About Local Agencies That Help Your Family

Please Check Education and Child Development 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 Cuestionario de Interés

Survey Binder or Parent Meeting

Nombre de Padre: Nombre de Sitio de Head Start Fecha: Como padre, estoy interesado en los temas que siguen para discutir en las conferencias de Padres de Head Start.

Favor de indicar todas las categorías que apliquen. Salud Físico, Salud Dental, Nutrición  Síndrome de dientes  Cuando dejar que su niño quede en casa cuando está enfermo  Piojos  Inmunizaciones y record de inyecciones  Enfermedades de niñez  Leer etiquetas de comida

Salud Mental e Incapacidades  Deficiencia del lenguaje o en oír  La importancia de Admisión, Reviso y Despido (ARD)  Medicina de niños y efectos secundarios  Manteniendo buena salud mental  Problemas de habilidades conductuales  Otras sugestiones

 Prudentemente gastar su dinero en la comida de cada día  Otras sugestiones

Servicios Sociales  Información de agencias locales que pueden ayudarle a usted y su familia  Empleo  Volver a la escuela  Buscando almacenaje y arrendar  Conocimiento de drogas y alcohol  Otras sugestiones

Educación y Desarrollo de Su Nino  Grados de desarrollo de niño  Preparando su niño para entrar a la escuela preescolar y el kindergarten  El programa de alfabetismo  Actividades educativas que usted puede hacer en casa  Otras sugestiones

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 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 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. Yes No 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 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 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 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 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 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 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 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?

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 Need for Transportation Application Application Date Child’s Name

Head Start School

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

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

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 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

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 x x x x x x x x x

Creative Curriculum Assessment Dial 3 DECA Home Visit Form In House Conference Form Home Language Survey Migrant Survey Form District Field Trip Permission Form In House Referral (as needed)

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

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 8/2005

Fecha

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

Permiso Para Participar en esta Excursión

Escuela:

Fecha:

Queridos Padres: La clase de Head Start irá en un excurso a El día y fecha que iremos es Nos iremos

. .

a.m. (por la mañana), regresaremos

p.m. (por la tarde).

Favor de escribir el nombre de su niño y indique si puede participar en la excursión. 

Sí, mi niño puede participar.



No, mi niño no puede participar.

Nombre del niño: Firma de padre:

7/2008

OPTIONAL EDUCATION FORMS x x x x x x x

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

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

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

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 4/06

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

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

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

Never

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: 4/06

Section Six: Mental Health/Disabilities x Consent for Mental Health/Behavior Services x Mental Health Observations x Behavior Guidance Plan (as needed) x Psychological and Social Development Forms x IEP/IFSP x In House Referral (as needed) x Referral for Counseling (as needed)

STUDENT:

CONSENT for HEAD START MENTAL HEALTH/BEHAVIORAL SERVICES 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 Staff Signature 3/2006

Date Date

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 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

DOCUMENTATION

4/2006

Attention Consistent Intermittent Non-Attentive

OPTIONAL SPECIAL NEEDS FORMS x In-House Referral x Referral for Counseling

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: 4/06

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 x Head Start Visitor’s Log x Records Management Report x Head Start Parent Training Tracking Sheet

Head Start Visitor’s Log ______________________________ Site

Date Time In

3/2006

Name

Reason

Time Out

Initials

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

Topic (Component)

Health, Dental, & Nutrition

Mental Health

Child Abuse

Education Child Growth & Development

Social Services

Transition I

Pedestrian Safety/Transportation

Contact Phone Number

No. of Hours

Head Start Parent Training Tracking Sheet

Name of Speaker/Organization (City, State, Zip)

End of year total # of:

d St ar tH ea

Date of Topic

Center______________________

Place in front of Parent Meeting notebooks.

No. of Parents

Head Start



No. of Staff

No. of Comm.

COMMUNITY PARTNERSHIP x Community Partnership Agreement

Place in Community Binder

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 x Code of Conduct x Proxy x Verification of Attendance x Center/Site Report x Personnel Report x Personnel Recommendation to Board x Site/Safety Inspection x Steps to Developing a Personal Professional Development Plan

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 codes of ethical conduct: x 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; x I will follow the program confidentiality policies concerning information about children, families, staff, and/or internal operating procedures; x I will adhere to the program’s policies and procedures for filing a community complaint; x 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; x 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

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: x

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;

x

Seguiré las pólizas de confianza del programa tocante la información de niños, familias, personal, y/o las operaciones internas;

x

Apoyaré las pólizas de programas y procedimientos para registrar queja de comunidad;

x

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;

x

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 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 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.

VERIFICATION OF ATTENDANCE

DATE: ___________________________

LOCATION:______________________________________________________

PURPOSE:_______________________________________________________

NAME:__________________________________________________________

Attended the meeting and is entitled to mileage from your site.

COORDINATOR:________________________________________________ Jill Landrum

Region 9 Education Service Center Head Start Site Report

_____________________ Name of Site

# of students

# on last report

_____________________ Month/Year

# on waiting list

Field trips, special visitors, community involvement activities:

Parent meetings: (Topic/Speaker)

Please e-mail to Jill Landrum: [email protected] one week prior to scheduled Policy Council Meeting.

Steps to Developing a Personal Professional Development Plan You wouldn’t dream of walking into a classroom without any idea of what you wanted to accomplish. Why would you treat your own learning differently? A plan with explicit goals provides structure for your learning. Use the following steps and the planning template to develop your personal professional development plan. Step 1: Review the components of a good professional development plan. 3It addresses individual needs to improve practice, but it balances those needs with the needs of the students, campus, district and Head Start. 3It focuses on improving student learning as the overall goal of professional development, and it connects the educator’s individual goals to demonstrated student needs. 3It reflects campus, district, state or Head Start educational initiatives.

3It includes reflection as a part of the individual’s learning and growth. 3It includes documentation of the outcomes of the professional development activities. Step 2: Ask yourself these questions to clarify your goals and begin planning: 3What do I want all my students to know or do as a result of my teaching? 3How will I judge the quality of my students’ work? 3How does my practice impact student achievement? 3Based on what data, what do I know about my students’ needs? 3 How do my campus’ goals and improvement plan impact my goals? 3How can I improve or strengthen my practice?

3How can I work with others to address my goals? 3How will I know I have accomplished my goals? 3How can I embed the professional development strategies I choose into my classroom day? Step 3: Decide on the activities or strategies you will include in your plan to accomplish your goals. As you select activities, bear in mind that your plan should not be built around attending one-hour inservices with little or no follow-up. According to research, your professional development should be: focused on student learning, job-embedded, continuous

and on-going, and include evaluation. A few of the may activities or strategies that you might consider are:

3Get involved in a book study. 3Conduct action research. 3Do professional reading. 3Get involved with a professional organization. 3Learn to use technology. 3Attend conferences and/or workshops that will address the areas you have identified. Step 4: Evaluate your plan Even if you do not have to submit your plan to a committee or administrator, ask yourself the following questions: 3Do the goals and the plan reflect your needs as well as your students’, the campus, your district and Head Start? 3Does your plan reflect new learning and growth, not just time and effort? 3Have you used data to determine your goals? 3Does your plan reflect how student achievement will be enhanced? 3Does your plan include reflection on the outcomes and appropriate adjustment?

3Have you included methods of self assessment? 3Have you identified evidence that you will gather? Step 5: Reflect early and often Don’t wait until you’re finished with activities included in your plan to reflect on how you are doing. Consider keeping a log or journal, finding another teacher to act as a reflective partner, or participating in an online discussion group. Step 6: Create a portfolio of your accomplishments. Whether a portfolio is required by your school or not, you will personally benefit from collecting evidence of the activities that you’ve undertaken. Your portfolio should be organized, clearly connected to your plan, include your best materials, and include a reflective piece that articulates your learning. Your portfolio could include the following: 3A reflective journal, log or diary 3Samples of students’ work

3Data and data analysis 3Samples of lesson plans or other work you have created. 3Certificates of attendance. 3Articles you have published. 3Power Point presentations you have made. 3Videotapes 3Photographs Step 7: Keep an updated copy of your professional development plan accessible for ESC 9 Head Start/district staff to review when visiting in your classroom. At the end of the year, this plan should go into your professional folder at the district office. This planning tool is based on By Your Own Design, By the Eisenhower National Clearinghouse for Mathematics and Science Education and the National Staff Development Council.

Region 9 Education Service Center Head Start Professional Development Plan

School year

Name_____________________________________________Campus___________________________________ Goal:_______________________________________________________________________________________ _____________________________________________________________________________________________ Steps/Strategies: 1.___________________________________________________________________________________________ _____________________________________________________________________________________________ 2. ___________________________________________________________________________________________ _____________________________________________________________________________________________ 3.____________________________________________________________________________________________ _____________________________________________________________________________________________ 4.____________________________________________________________________________________________ _____________________________________________________________________________________________ Time Frame for each Step 1.___________________________________________________________________________________________ 2.___________________________________________________________________________________________ 3.___________________________________________________________________________________________ 4.___________________________________________________________________________________________ Evaluation for each Step 1.___________________________________________________________________________________________ 2.___________________________________________________________________________________________ 3.____________________________________________________________________________________________ 4.____________________________________________________________________________________________

DISTRICT-BASED HEAD START PERSONNEL APPROVAL PROCESS (SEE “Head Start Personnel Report” FORM) 1. Local school district Superintendent or Superintendent Designee (not an employee of Head Start) provides a signed “Head Start Personnel Report” regarding the hiring status of each Head Start employee. 2. The Policy Council/Parent Committee representative reviews the “Head Start Personnel Report” and signs denoting approval. If there are concerns, prior to signing, the representative voices these concerns to the campus principal who will meet with the local school district Superintendent or Superintendent Designee. Once resolution is reached, the “Head Start Personnel Report” is signed by the Policy Council/Parent Committee representative. 3. The “Head Start Personnel Report” is submitted by the Superintendent or Superintendent Designee’s to the Region 9 ESC Head Start Coordinator. 4. The Region 9 Head Start Coordinator solicits the approval of the “Head Start Personnel Report” by the Policy Council based on the data contained in the signed report. 5. The Policy Council Liaison, the Region 9 Head Start Coordinator and the Region 9 Executive Director discuss the “Head Start Personnel Report” for each local school district with the Region 9 Board of Directors. 6. The Region 9 Board of Directors makes their decision based on the inputs of all parties and approves the “Head Start Personnel Report” contingent upon subsequent approval by the local school district boards. 7. The local school district board approve the “Head Start Personnel Report” at the March (teachers) and April (support personnel) board meetings, or in the months traditionally designated by each local school district. 8. The superintendent sends the documentation of the final approval of the “Head Start Personnel Report” to the Region 9 Head Start Coordinator following the local school districts board’s approval.

Head Start Personnel Report

Name of Site:______________________________________ Staff Position

Name

Recommended Action to be Taken: Employ: Rehire; Retirement; Reassignment; Resignation

We the undersigned wish to submit the above personnel actions to be taken by the Region 9 Head Start Policy Council and Region 9 ESC Board of Directors. ____________________________________________________________ Superintendent or Superintendent Designee signature

Date of Recommendation

______________________________________________________________ PolicyCouncilRepresentativesignatureDateofRecommendation  _____________________________________________________________________________________ PolicyCouncilOfficerSignatureDateofContingencyApproval   ______________________________________________________________________________________ Region9ESCBoardSignatureDateofContingencyApproval  ______________________________________________________________________________________ SuperintendentorSchoolBoardOfficersignatureDateofFinalLocalSchoolBoardApproval   4/08               

Reporte de Personal de Head Start

Nombre de Sitio de Head Start: Puesto de Personal

Nombre

Recomendación: Emplear Emplear por segunda ves Retirar Transferir Resignar

Nosotros, los infrascritos, deseamos proponer la/las acción(es) aquí nombrado al Consejo de Oficiales de Head Start de Region 9 y el Consejo de Administraciones de Region 9.

Firma de Superintendente o su representante

Fecha de recomendación

Firma de Representante del Consejo de Oficiales de Head Start

Fecha de recomendación

Firma de Funcionario del Consejo de Oficiales de Head Start

Fecha de contingencia

Firma de Superintendente o representante de la Junta de Educación

Fecha de aprobación final de la Junta de Escuela

7/08

Region 9 ESC Head Start Personnel Recommendation to Board

Name: _________________________________________________ Interviewed by: ________________________________________ Recommended assignment___________________________________________________ Present position____________________________________________________________ Education High School____________________________________________________ Bachelor’s degree_______________________________________________ Master’s degree_________________________________________________ Other universities attended________________________________________ ______________________________________________________________

Teaching Fields (if applicable

______________________________________________

Otherqualifications_________________________________________________________ Previous teaching experience (if applicable) ____________________________________

Total years of teaching experience (if applicable) ________________________________ Strengths________________________________________________________________

Other relevant experience___________________________________________________

Other comments/information

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)

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 childresistance 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

Inspección de desguardo de sitio La inspección debe de tomar lugar al mínimo, anualmente (CFR 1304.53(a)(10) Nombre de Sitio: Fecha de inspección: Nombre y titulo de la persona que hace la inspección:

Direcciones: La inspección necesita ocurrir en el sitio. Para contestar cada pregunta, el inspector tiene que haber visto el incidente. Cada pregunta necesita respuesta de “Si”, “No” o “n/a” (no ser aplicable). Cada respuesta de “No” tiene que proveer información específica con explicación. 1. Hay un sistema de calentador que es sano y salvo que está aislado para proteger los niños y personal para que no se quemen; 2. Hay sistema de enfriar que es sano y salvo para proteger los niños y personal; 3. No hay muebles, decoraciones, o materiales que emiten vapores de gas toxico cuando están encendidos; 4. Peligrosos encendidos materiales y venenos potenciales están en gabinetes con llave o almacenamiento separado de medicinas o comida y son disponible nada mas a personas autorizadas; 5. Todas medicinas, incluyendo medicinas para personal y voluntarios, tienen etiquetas, están en gabinetes de llave, están refrigerados si es necesario, y sin ser disponibles para niños; 6. Todos los cuartos tienen bastante luz o iluminación; 7. Los cuartos tienen luces de emergencia en caso de falta de energía; 8. Extintores matafuegos son disponibles; 9. Hay descubridores de humo que están instalados y son probados regularmente; 10. Los descubridores de humo son probados regularmente (documentación sigue);

Inspección de desguardo de sitio (continuado) 11. Salidas están facilmente visibles; 12. Las rutas de evacuacion están marcadas claramente y están anunciadas para que el camino para salir afuera con seguridad es inconfundible; 13. Los establecimientos interiores son limpiados diariamente sin materiales y condiciones peligrosos e indeseable; 14. Los establecimientos exteriores son limpiados diariamente sin materiales y condiciones peligrosos e ideseable; 15. La pintura usada en el interior y exterior en donde se cuidan los niños, no continene plomo peligroso; 16. La selección de patio de recreo, el modo de arreglo, y mantenimiento del equipo reduce al minimo la posibilidad de daño a los niños; 17. Enchufes eléctricos que son disponibles a niños, tendrán modos seguros para prevenir choque eléctrio; 18. Ventanas y puertas de vidrio estan constuidas, acomodadas, o ajustadas para prevenir daño para los niños; 19. Agua que ha sido aprobada por autoridad local o del estado, será la única agua usada; 20. Cuartos de baño y lava manos son adecuados, limpios, en reparación buena, y facil para usar por los niños; 21. El cuarto de baño y los sitios en donde se cambian pañales, tendrán que ser separadas de los sitios para preparar comida, comer la comida, y sitios en donde juegan los niños; 22. Hay equipo para entrenar los niños en el uso del cuarto de baño; 23. Aguas de albañal y liquidos inutiles son colocados por sistemas de albañal de la ciudad; 24. Basura y desecho estan puestas en una manera segura y sanitario; 25. Provisiones adecuadas son hechas para niños con disabilidades para asegurar su proteccion, su bienestar, y participacion.

Usado por permiso de TTAS/Western Kentucky University Chris Watkins, Consultant 7/2008

Steps to Developing a Personal Professional Development Plan You wouldn’t dream of walking into a classroom without any idea of what you wanted to accomplish. Why would you treat your own learning differently? A plan with explicit goals provides structure for your learning. Use the following steps and the planning template to develop your personal professional development plan. Step 1: Review the components of a good professional development plan. 3It addresses individual needs to improve practice, but it balances those needs with the needs of the students, campus, district and Head Start. 3It focuses on improving student learning as the overall goal of professional development, and it connects the educator’s individual goals to demonstrated student needs. 3It reflects campus, district, state or Head Start educational initiatives. 3It includes reflection as a part of the individual’s learning and growth. 3It includes documentation of the outcomes of the professional development activities.

Step 2: Ask yourself these questions to clarify your goals and begin planning: 3What do I want all my students to know or do as a result of my teaching? 3How will I judge the quality of my students’ work? 3How does my practice impact student achievement? 3Based on what data, what do I know about my students’ needs? 3 How do my campus’ goals and improvement plan impact my goals? 3How can I improve or strengthen my practice? 3How can I work with others to address my goals? 3How will I know I have accomplished my goals? 3How can I embed the professional development

strategies I choose into my classroom day? Step 3: Decide on the activities or strategies you will include in your plan to accomplish your goals. As you select activities, bear in mind that your plan should not be built around attending one-hour inservices with little or no follow-up. According to research, your professional development should be: focused on student learning, job-embedded, continuous and on-going, and include evaluation. A few of the may activities or strategies that you might consider are: 3Get involved in a book study. 3Conduct action research. 3Do professional reading. 3Get involved with a professional organization. 3Learn to use technology

3Attend conferences and/or workshops that will address the areas you have identified. Step 4: Evaluate your plan Even if you do not have to submit your plan to a committee or administrator, ask yourself the following questions: 3Do the goals and the plan reflect your needs as well as your students’, the campus , your district and Head Start? 3Does your plan reflect new learning and growth, not just time and effort? 3Have you used data to determine your goals? 3Does your plan reflect how student achievement will be enhanced? 3Does your plan include reflection on the outcomes and appropriate adjustment? 3Have you included methods of self assessment? 3Have you identified evidence that you will gather?

Step 5: Reflect early and often Don’t wait until you’re finished with activities included in your plan to reflect on how you are doing. Consider keeping a log or journal, finding another teacher to act as a reflective partner, or participating in an online discussion group. Step 6: Create a portfolio of your accomplishments. Whether a portfolio is required by your school or not, you will personally benefit from collecting evidence of the activities that you’ve undertaken. Your portfolio should be organized, clearly connected to your plan, include your best materials, and include a reflective piece that articulates your learning. Your portfolio could include the following: 3A reflective journal, log or diary 3Samples of students’ work 3Data and data analysis 3Samples of lesson plans or other work you have created.

3Certificates of attendance. 3Articles you have published. 3Power Point presentations you have made. 3Videotapes 3Photographs Step 7: Keep an updated copy of your professional development plan accessible for ESC 9 Head Start/district staff to review when visiting in your classroom. At the end of the year, this plan should go into your professional folder at the district office.

This planning tool is based on By Your Own Design, By the Eisenhower National Clearinghouse for Mathematics and Science Education and the National Staff Development Council.

Region 9 Education Service Center Head Start Professional Development Plan

School year Name_____________________________________________ Campus___________________________________ Goal:________________________________________________________________________________________ _____________________________________________________________________________________________ Steps/Strategies: 1.___________________________________________________________________________________________ _____________________________________________________________________________________________ 2. ___________________________________________________________________________________________ _____________________________________________________________________________________________ 3.____________________________________________________________________________________________ _____________________________________________________________________________________________ 4.____________________________________________________________________________________________ _____________________________________________________________________________________________ Time Frame for each Step 1.___________________________________________________________________________________________ 2.___________________________________________________________________________________________ 3.___________________________________________________________________________________________ 4.___________________________________________________________________________________________ Evaluation for each Step 1.___________________________________________________________________________________________ 2.___________________________________________________________________________________________ 3.____________________________________________________________________________________________ 4.____________________________________________________________________________________________

Section – Staff/Volunteer x x x x x x x x

Principal Observation Form Volunteer Code of Conduct Tuberculosis Health Screening Form Criminal History Authorization Personal Reference Professional Development Plan Staff Standards of Conduct Disability Enrollment Policy

Volunteer Code of Conduct For Region 9 ESC 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 volunteer of the Region 9 ESC Head Start, I agree to adhere to the following code of ethical conduct: x

I will respect and promote the unique identify of each child, family, and staff Member and refrain from stereotyping on the basis of gender, race, ethnicity, Culture, religion, or disability;

x

I will follow the program confidentiality policies concerning information About children, families, staff, and/or internal operating procedures;

x

I will adhere to the program’s policies and procedures for filing a Community complaint;

x

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;

x

I will share my skills, talents, and expertise to promote and improve the Quality of the program.

Signature:

___________________________

Date: _________________________________

12/1/06

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: x 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; x I will follow the program confidentiality policies concerning information about children, families, staff, and/or internal operating procedures; x I will adhere to the program’s policies and procedures for filing a community complaint; x 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; x 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

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

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

Region 9 Education Service Center Head Start Personal Reference is an applicant for a position as a teacher in the evaluation of School District. We would very much appreciate your assistance in the evaluation of this person. Please use the following scale to rate this applicant’s demonstrated competence: 1 Clearly Outstanding

2

Exceeding Expectation

3 Satisfactory

4 Below Expectation

I. INTERPERSONAL RELATIONSHIPS Please circle the appropriate number on the scale for each item A. Communicates personal enthusiasm B. Demonstrates warmth and friendliness C. Demonstrates patience, empathy, and understanding D. Promotes effective community public relations E. Exhibits judgment and tact

Expresses ideas clearly Exhibits sense of humor Exhibits health necessary to meet responsibilities Exhibits sound character traits Exhibits acceptable appearance Demonstrates cooperative attitude Exhibits dependability

1 1 1 1 1

2 2 2 2 2

3 3 3 3 3

4 4 4 4 4

5 5 5 5 5

Specific Comments 1 1 1 1 1 1 1

2 2 2 2 2 2 2

3 3 3 3 3 3 3

Additional Remarks

What opportunity have you had to form your judgment of this applicant?

Name

Official Position

Date

Signature

Phone # (Optional) (see reverse side)

12/1/06

Unsatisfactory

Specific Comments

II. PERSONAL CHARACTERISTICS Please circle the appropriate number on the scale for each item A. B. C. D. E. F. G.

5

4 4 4 4 4 4 4

5 5 5 5 5 5 5

III. TO BE COMPLETED BY APPLICANT This Character Reference form will be sent to long-time associates, bank executive, other acquaintances, etc. Please print or type the name and address of reference: Name

Address

City

State

Zip

We would appreciate your cooperation in reading and signing the statement below. The statement must be signed and returned with your application before it will be place in our active files. “In order that the officials of the School District may be fully informed as to my personal character and qualifications for employment, I refer to each of my former employers and to any other person who may have information concerning me. As this information is to be furnished at my express request and for my benefit, I do hereby release the above-named reference from any and all liability for damage of whatsoever nature on account of furnishing such information. I hereby authorize the party receiving this form to give full and complete information requested by the School District. I further agree that the information requested will become a part of my personnel file, if I am employed by the district. I agree that the information requested will not be disclosed to me, but will be treated as confidential by the District. I waive any right to see this information.”

Date

12/1/06

Applicant’s Legal Signature