Proposed Plan to Replicate Parent-Child Home Program (Pchp)

PROPOSED LOCAL PARTNER AGENCY IMPLEMENTATION PLAN

SPONSORING AGENCY (school district, social service agency, library, etc)

Name: ______

Street Address ______

Town, State: ______County: ______

Country: ______Zip: ______

Phone: (______)______Fax: (______)______

Sponsoring Agency Director: ______Title: ______

Direct Supervisor of the PCHP Site Coordinator: ______

Title: ______Phone: (___) ______

Fax: ______E-Mail: ______

PARTNER OR SUBCONTRACTING AGENCY (if any)

Name: ______

Street Address ______

Town, State: ______County: ______

Country: ______Zip: ______

Phone: (______)______Fax: (______)______

Contact at Partner/Subcontractor: ______Title: ______

What is the Sponsoring Agency’s relationship with this partner/subcontractor? ______

______

PARENT-CHILD HOME PROGRAM REPLICATION

What will you call your PCHP replication site as: (Must include PCHP in Site Name)

______

Site Contact and Staff Information:

Address: ______Zip ______

Fax: ______E-Mail: ______

Coordinator: ______

Educational Background:

 Bachelors Degree Doctorate Degree

 Masters Degree Other: ______

Professional Background:

 Child Care Director

 Preschool Director

 Early Childhood Teacher

 Teacher (K-12)

 Family Child Care

 Social Worker

 Parent

 Other: ______

Title (if other than Parent-Child Home Program Coordinator): ______

Other Responsibilities in Sponsoring Agency: No ______Yes______

If yes, what else do you do? ______

How many hours a week are allocated to The Parent-Child Home Program: ______

Co-Coordinator: ______Phone (___) ______

Educational Background:

 Bachelors Degree  Doctorate Degree

 Masters Degree  Other: ______

Professional Background:

 Child Care Provider

 Preschool Director

 Early Childhood Teacher

 Teacher (K-12)

 Family Child Care

 Social Worker

 Parent

 Other: ______

Title (if other than Parent-Child Home Program Coordinator): ______

Other Responsibilities in Sponsoring Agency: No ______Yes ______

If yes, what else do you do? ______

How many hours a week are allocated to The Parent-Child Program: ______

Home Visitor Title (if other than Home Visitor): ______

# Paid HVs _____ # Unpaid HVs ______# Student HVs ______# AmeriCorps HV’s ______

How do you plan to recruit community based Home Visitor’s: ______

______

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PROGRAM MATERIALS:

Where will the site able to securely store materials: ______

Have you identified a potential vendor(s), if so please indicate: ______

______

Do you have any concerns about purchasing appropriate materials for the families you will be working with, if so, what are they? ______

______

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PROGRAM STRUCTURE/SCHEDULE

Please indicate which of the following program annual constructs will be implemented:

 Academic Calendar  Rolling Admissions

Number of families for first program cycle:Program I ______

Anticipated start date (approx. month & year): ______

How many weeks of home visits will you be offering (all families must receive a minimum of 23 weeks of visits per program cycle): ______

Proposed number of families in second program cycle: Program I ______Program II ______

Anticipated start date (approx. month & year): ______

How many weeks of home visits will you be offering: ______

Proposed number of families in third program cycle: Program I ______Program II ______

Anticipated start date (approx. month & year): ______

How many weeks of home visits will you be offering: ______

Proposed number of families in fourth program cycle: Program I ______Program II ______

Anticipated start date (approx. month & year): ______

How many weeks of home visits will you be offering: ______

DEMOGRAPHICS

What population(s) will the replication site target? (check all that apply):

 Single parents

 Immigrant/ELL Parents

 Teen parents

 Parents with limited education

 Families on TANF

 Reduced/free lunch eligible

 Homeless families

 Grandparents raising grandchildren

 Families w/ siblings receiving remedial services

 Families in child welfare system

 Foster parents

 Other (specify) ______

Age of children when entering program:Program I ______Program II ______

Ethnic groups to be served:

 Spanish/Hispanic/Latino of any race  Asian, non-Hispanic

 Cuban  Central American Japanese  Southeast Asia

 Puerto Rican  South American Chinese Vietnamese

 Mexican  Other S/H/L Korean Asian Indian

 Spanish ______ Filipino Malaysian

 Thai Other Asian

 White, non-Hispanic  Native Hawaiian or Other Pacific Islander

(Includes European, Middle Eastern,  Native Hawaiian  Guamanian

And North African origins)  Samoan  Other Pacific Islander

 American Indian or Alaskan Native Bi-Racial or Multi-Racial

 American Indian  Alaskan NativePlease specify: ______

 Black/African American, non-Hispanic

 African American Haitian

 Kenyan Other African

 Nigerian ______

Languages of families to be served:

 English Vietnamese Cambodian Haitian-Creole

 Spanish Laotian Tagalog Portuguese

 Arabic Chinese Polish Indian Dialect

 French  Mandarin Russian  Hindi

 Italian  Cantonese Farsi  Punjabi

 Taiwanese  Gujurati

 Other  Other

 African Dialect Other ______

 Amharic

 Twi

 Hausa

 Other

Briefly describe community (size, environs, jobs, housing, poverty, etc.):

______

What resources does the community have for your Program “graduates?” Head Start? Public school pre-k? Child Care Centers? Other?

______

Funding sourceS:

What funding sources are supporting your PCHP site?:

 Title 1 Corporate Donations

 Local School District Funds Individual Donations

 County Funds Service Organizations (e.g. Junior League, Kiwanis, Rotary)

 City Funds Federal Grants: ______

 State Education Funds State Grants: ______

 United Way Foundation Grants: ______

 Head Start Other: ______

 Early Head Start

Does your funding source require you to administer and implement a particular assessment?

______

Do your funding sources have any other requirements that could impact implementation of the Program?: ______

______

What challenges do you anticipate in implementing The Parent-Child Home Program? How do you propose to address with them?