East Central Illinois Community Action Agency

Head Start – Birth to Five Program

Forms and Informational Materials

  1. Activity Based Intervention

Special Needs/Mental Health Coordinator will receive copies at end of month. The originals will go to the Computer Information Specialist at the end of each month to be filed in permanent file.

  1. Agency File Requisition Form

Form to be submitted to the Computer Information Specialist when requesting access to child’s permanent file.

  1. A Parent’s Guide: The Educational Rights of Students with Disabilities (*Spanish)

This is an informational sheet given to parents when their child is referred.

  1. Attendance - monthly

Form is used to enter attendance data in CHILD PLUS System.

  1. Baseline Data Collection

The originals as soon as completed by Classroom Teams will go to the Special Needs/Mental Health Coordinator.

  1. Weekly Individualized Plan (B-3) Center Base

Form is used by centerteachers to use for individualization of child. Form is submitted to the Supervisor Birth to Three Servicesweekly for review. Special Needs/Mental Health Coordinator will receive a copy for children with an IFSP.

  1. Bus List

Submit at end of month to the Facilities/Transportation Coordinator. Form should be turned in no later than three days after specified calendar due date.

  1. Career Log

All trainings should be recorded on this form. The form should be turned in at the end of the program year to assigned Supervisor. Make a copy for your own records. Supervisors will turn the forms in to Human Resources.

  1. Center-Based Evaluation Form

Designated staff will do monthly during program year and share with staff.

  1. Center Visit Record

It is located and kept in the Blue Notebook in classrooms. (Not in FCD Classrooms)

  1. Child Add/Drop Form

Family Advocates will submit to the Computer Information Specialist on an as needed basis. A copy is sent to assigned supervisor.

  1. Child and Family Referral

Form to be sent to the Special Needs/Mental Health Coordinator on an as needed basis.

  1. Class Development Assessment

The original document is sent to theSpecial Needs/Mental Health Coordinator who input data in CHILD PLUS System.

  1. Child Health History

The form is filled out and completed with parent during orientation. Form is then submitted to the Health Services Technician who will send a copy to the Computer Information Specialist. The form will then be placed in the child’s permanent file. Maintain a copy for the working file.

  1. Child Nutrition Assessment

The form is filled out and completed with parent during orientation. Form is then submitted to the Computer Information Specialist. The form will then be placed in the child’s permanent file. Maintain a copy for the working file.

  1. Class Lists

Copy monthly and place in classroom blue binders

  1. Classroom Safety Checklist

Form to be filled out by Classroom Teams and submittedmonthly to the Facilities/Transportation Coordinator.

  1. Classroom Monthly Report

Form is due at the end of each month. Submit copies to the following:

Assigned Supervisor

Special Needs/Mental Health Coordinator

Supervisor Health Services

Transition/Recruitment Coordinator

Form should be turned in no later than three days after specified calendar due date.

  1. Community Partnership Agreement

To be filled out jointly with community partner and agency. Each will keep a copy for their records. Agency copy will be placed in white notebook under Community Partnerships.

  1. Computer Log

Form to be kept in Red Notebooks and will be available for review upon request.

  1. Core Item Collection Plan

Form is filled out for each child (3-5) at beginning of program year. Form is placed in front pocket of each child’s portfolio. Form to be available upon request for review.

  1. Core Items

This is an information material to be kept in form box. Refer to as needed. (3-5 only)

  1. Daily Child Transition Log

Bus drivers give to Family Advocates at the end of each week. The form is then filed in the Red Notebook. At FCD, this document is kept in a separate blue notebook.

  1. Developmental Milestones Collector Form

Form is used by B-3 center staff when child has a documented IFSP. The form is placed in the child’s portfolio and reviewed by the Supervisor B-3 Services.

  1. Diagnostic Referral and Reporting

The original will be sent to the Special Needs/Mental Health Coordinator who will send originals to the Diagnostician. As soon as form is returned to the Special Needs/Mental Health Coordinator it will be forwarded to the MIS Department to be filed in permanent file.

  1. Discipline Policy (*Spanish)

Form is signed by parent during parent orientation.Family Advocates will then forward to the Computer Information Specialist to be placed in child’s permanent file.

  1. Documentation Request

Family Advocates will give to parents when requesting information for child’s file. White copy is kept in child’s file and yellow copy is given to parents.

  1. Drop Off Pick-Up Agreement

Form is signed by parents during parent orientation and then placed in child’s permanent folder. A copy of the form is given to the parent.

  1. Drop Off Pick Up Record

Form is maintained in Red Notebook. Used on an on-going basis.

  1. Early Childhood Education Family Partnership Agreement

Family Advocate will forward to the Computer Information Specialist to be filed in permanent file.

  1. Facsimile

Used by staff as needed when faxing.

  1. Fall Parent/Teacher Conference

The form is updated for each conference and will be given to staff before parent/teacher conferences are scheduled.Classroom team will complete with parent and forward to assigned Supervisor. Assigned Supervisor will forward to the Computer Information Specialist to be filed in child’s permanent file. Refer to calendar for time line.Fall Parent/Teacher Home Visit

  1. Fall Parent/Teacher Home Visit

The form is updated for each home visit and will be given to staff before scheduled home visits.

Form is completed in home with parent then forwarded to assigned Supervisor. Assigned Supervisor will

forward to the Computer Information Specialist who will place form in child’s permanent file. Refer to calendar for time line.

34. Family Action Note-

Family Action Notes are entered directly into the CHILD PLUS system. Printed copies will be submitted to the assigned Supervisor. Supervisor will read and initial then submit both copies to the Associate Director of Educational Services. The Associate Director will read and initial. A copy will be sent to the Computer Information Specialist so it can be placed in the permanent file. Staff should make copies of Family Action Note and forward them to all members of the Management Team that might needthe information.

Forms should be submitted to their designated supervisor on a monthly basis or immediately when there is an emergency within the family. Always maintain “running Family Action Notes” for routine matters.

  1. Family Goal Development Plan

Form to be completed by Family Advocate and Classroom Team. Refer to calendar for start and due dates. Originals will be sent to assigned Supervisor. Supervisor will review and give to the Computer Information Specialist to be placed in child’s permanent file. Copies of plan should be kept in the working file.

  1. Field Trip Permission (*Spanish)

Classroom Teams will send permission slips home two weeks prior to field trip for parents or guardians to sign and return by field trip due date. Keep on file in child’s working folder.

  1. Field Trip Request

Send to assigned Supervisor.. After Supervisory approval a copy will be forwarded to Facilities/Transportation Coordinator who will contact transportation services. If requesting food, Supervisor will forward a copy to theSupervisor Health Services. If requesting money, Supervisor will forward a copy to the Associate Director of Educational Services. Staff will be notified if for some reason the field trip is denied.

  1. File Completion Checklist

Classroom Teams and Family Advocate staff uses this form to monitor the completion of a child’s file. Form to be kept in file until file is completed.

  1. File Review Form

Supervisors use this form to monitor files. Form will be placed in the child’s file. Supervisors will keep a copy for their own records. A copy is sent to the Family Advocate so that corrections can be made to the files.

  1. Fire Drill Log

Posted on bulletin board in classroom and updated monthly. Exceptions would be the FCD and RoselawnCenters where Site Supervisors will keep fire drill logs in a binder. Fire drill logs are turned in at the end of the year to the assigned Supervisor. Forward to Facilities/Transportation Coordinator at the end of the program year.

  1. Food Services Requisition

In place of the Food Requisition, use Form #108 Purchase Order Requisition Form.

  1. Food Temperature Worksheet

At FCD the Food Service Specialist will file Food Temperature charts daily. At other sites, these will be done daily and filed in the Red Notebook. A copy of all food temperature charts will be sent to the Supervisor Health Services at the end of each month for review.

  1. Guidelines and Checklists

These are found on Work Sampling on-line and filled out quarterly. Refer to calendar for date of completion.

Forms (*44-*52) are filed before the letter “H” for Health

  1. *Allergies and Food Restrictions

This must be posted in each classroom. FCD classes must send this form to the Food Service Specialist. Copies of this form must be sent to the Supervisor Health Services.

44b.. Medical Exception Statement For Food Service Substitution

Form completed, sent to the Health Services Supervisor and copy to the MIS department.

Form is completed to document child’s food allergy. Form is signed by child’s physician.

  1. *Authorization to Administer Medication (*Spanish)

This form must be signed by the parent or guardian. The original is sent to the Computer Information Specialist to be filed in child’s permanent folder. A copy is to be kept on site in the child’s working file and a copy is sent to theSupervisor Health Services.

  1. *Explanation of Medical Forms

Form to be used as a reference in using the health forms. Keep in file box for easy reference access.

  1. *First Aid Inventory List

Classroom Teams should fill out on as needed basis and send to theHealth Services Technician. It is important that first aid kits are well stocked at all times. Refer to calendar for due date.

  1. *Health Alert Record (May have been exposed)

To be sent out to parents when a child in the classroom may have one of the conditions listed. The Supervisor Health Services should also be notified and sent a copy.

  1. *Health Alert Record (Suspected)

To be sent only to the family of the child suspected of having one of the listed conditions. The Supervisor Health Services should also be notified and sent a copy.

  1. *Height, Weight and Circumference Form

Classroom Teams do three times during the year according to calendar schedule. Classrooms keep a copy for their records. Originals are sent to theHealth Services Technician, Facilities/Transportation Coordinator and Bus Driver. Head Circumferences are only done for the Birth to Three children and babies.

50 (a) Vision/Hearing Screening and Rescreening Form (NEW FORM!)

Record hearing results. Send copy to Computer Information Specialist for filing.

50 (b) Vision Screening and Rescreening for B-3 (NEW FORM!)

Record vision results. Send copy to Computer Information Specialist for filing.

50 (c) Hearing Screening and Rescreening for B-3(NEW FORM!)

Record hearing results. Send copy to Computer Information Specialist for filing.

  1. *Medication, Administration and Observation Log

Site Supervisors are responsible for the completion of this form. At the FCDCenter, the Supervisor Health Services will fill out this form as medication is given. Upon completion of the medication, Site Supervisors will forwardthe original copy to theSupervisor Health Services for review. Send copy to Computer Information Specialist so that forms are filed.

  1. *Pregnancy History and Prenatal Risk Assessment Form. (B-3)

To be completed at time of enrollment. A copy is kept in the working file and the original is kept in the permanent file. Form is given to the Computer Information Specialist for filing. A copy is sent to theSupervisor Health Services. Staff will complete form after pregnancy and update information in the permanent file.

  1. Home Base Visit Schedule

Form is to be submitted to the designated Supervisor when ever changes occur in the weekly schedule.

  1. Home Base Weekly Report (3-5)

Kept in Notebook and available for review upon request. Yellow copy is left weekly with parent. Copies are to be turned in monthly to designated supervisor.

  1. 55-1, 55-2, 55-3, 55-4, 55-5 Home Visit forms for children and pregnant women

Kept in notebook and available upon request. Yellow copy is left weekly with parent. Copies are to be turned in monthly to designated Supervisor. A copy of children with an IFSP is sent to Special Needs/Mental Health Coordinator.

  1. Incident Report

Form is used to report any accident and/or occurrence that is not in the normal routine of the day.

All reports go to their assigned Supervisor.At FCD and Roselawn, the Site Supervisors will receive report and forward to assigned Supervisor. Copies of incident reports pertaining to a child’s injury must be sent to their assigned Supervisor and the Supervisor Health Services as soon as possible.Parents must be called and must receive a copy of the report if injury pertains to their child. If the child needs medical or emergency treatment, call Assigned Supervisor and theSupervisor Health Servicesand fax incident report to both Supervisor and Supervisor Health Services within 24 hours.

  1. IEP/IFSP (*IEP in Spanish)

Original will go to the Special Needs/Mental Health Coordinator. Special Needs/Mental Health Coordinator will forward to the Computer Information Specialist to be filed in CHILD PLUS.The Computer Information Specialist will file in the permanent file. Special Needs will give copies of the IEP/IFSP to teaching team for working file. A copy of the IFSP will be given to the Supervisor B-3 Services.

  1. Individualized Transition Plan

58a.Transition Recruitment Coordinator completes the form with family when the child begins the transition

process for B-3. The plan is then filed in child’s permanent file.

  1. Individuals With Disabilities Act (*Spanish)

This is an informational sheet given to parents when their child is referred.

  1. Infant/Toddler Daily Report – English and Spanish

Submit monthly to the Supervisor B-3 Services.

  1. In-kind Donation Record

Form 61-1:

Classroom Team will oversee that this form is filled out as in-kind occurs daily and weekly. In-kind sheets are found in the Blue Notebook and must be submitted at the end of the month to their assigned Family Advocate. Family Advocates enter in-kind data in to the Child Plus System.Refer to calendar for date due. Submit form no later than three business days at the end of each month.

61-2.Inkind-Statement of Contribution

Form is filled out when specific items of monetary value are donated. Donor is to sign form. Form is turned in to assigned Supervisor at end of month. Check calendar for Inkind due dates.

61-3.Inkind-Special Events

Form is used specifically for special eventsand must be submitted at the end of the month to their assigned Supervisor. Refer to calendar for date due. Submit form no later than three business days at the end of each month.

62-1.Eligibility Verification

A form filled out by the Computer Information Specialists.

62-2. Income statement

A form filled out by the Computer Information Specialists.

  1. All Kids Application and Information Packet

Family Advocate Staff will need to access this packet from the Human Resources Assistant.

  1. Lesson Plan (B-3)

For center base submit on a weekly basis and for socialization submit a copy twice monthly to the Supervisor B-3 Services. Assigned Supervisors may also request copies.

  1. Lesson Plan Critique (B-3)

Supervisor Birth to Three Services will use form to monitor lesson plan. Teachers will receive a copy of the critique and the Supervisor Birth to Three Services will keep a copy on file.

  1. Lesson Plan (3-5)

Post white copy and send a copy to assigned Supervisor according to calendar due date.

  1. Lesson Plan Critique (3-5)

Supervisors send a copy to Classroom Teams and Supervisors filea copy with lesson plans.

  1. Lesson Plan Explanation (3-5)

Form is used to inform staff on how to fill out lesson plan.

  1. Lesson Plan Parent Input Sheet (3-5)

Current form is posted in classroom.

Submit a copy to assigned Supervisor at the end of each month. Refer to calendar on date due. At the end of the month a completed copy is placed in the Blue Notebook.

  1. Lesson Plan Parent Input Sheet (3-5) Instructions

Form is used to inform staff on how to fill out parent input. Keep in file form box for reference.

  1. Lesson Plan September

Staff must use this lesson plan for the first month. Post on bulletin board for first month‘s use.

  1. Maintenance and Janitorial Requests

To be submitted to Human Resources.

73. Meal Participation Record

All Classroom Teams will submit this form to the Interim Fiscal Officer. This is due at the end of each month or at the end of the last day children are served meals for that month. Refer to calendar due date.Form should be submitted no later than three business days after the end of each month. Question about Block claiming must be answered and two staff must sign.

  1. Mentoring Tool for Enhancing Literacy, Language and Math Skills

Classroom teams are to fill out monthly and hand in at the same time as lesson plans. Refer to calendar for due date.

  1. Mileage Report

Car pooling is an agency procedure to curtail costs.

Staff will fill out and turn in at the same time as the second time card is due for payroll. Mileage will be turned in to the assigned Supervisor for review and approval.

  1. Multi-Cultural Checklists

Classroom Teams complete in early fall, refer to calendar for due date. Form is submitted to assigned Supervisor for review.