For Staff Use Only

Education Service Center, Region 20

Head Start Program

Selection Criteria of Eligibility

Child’s Name: Total Points

Parent/Guardian Name:

Description / Supporting Documents / Y / N / Points
Family Status – Choose One
Single Parent in the Home / Application / 30
Guardian / Application / 30
Former Foster Care Placement / Foster Care Placement Letter / 20
CPS Safety Placement (with biological parent) / CPS Safety Plan / 20
Two Parents in the Home / Application / 0
Child Status
Primary Language – Spanish / ISD Home Language Survey / 10
Primary Language – Other ______/ ISD Home Language Survey / 10
Previously Enrolled in EHS or HS / Application & Previous EHS/HS Agency Verification / 10
Early Childhood Intervention (ECI) / ECI Verification Documentation / 10
Primary Language – English / ISD Home Language Survey / 0
Resource Assistance
Housing / Current Resource Agency Letter / Card / 5
Food Stamps / Current Resource Agency Letter / Card / 5
WIC / Current Resource Agency Letter / Card / 5
Medicaid/CHIP / Current Resource Agency Letter / Card / 5
Other ______/ Current Resource Agency Letter / Card / 5
None / Application / 0
Individualization / Special Needs – Choose One
Individual Education Plan (IEP) from ISD / Current IEP from ISD / 50
Receiving Professional Services / Current Agency Verification Letter / 20
Family Suspects Special Need / Statement from Parent / 10
Professional Suspects Special Need / Letter from Professional / 10
None / Application / 0
------Interviewer Stop Here ------
Eligibility Status #1 – Choose One
Categorically Eligible – Foster Care Placement / Foster Care Placement Letter / 100
Categorically Eligible – Homeless / ISD & Head Start Documentation / 100
SSI – Supplemental Social Security Income / Current SSI Documentation / 30
TANF – Temporary Assistance to Needy Families / Current TANF Documentation` / 30
None / 0
OR Eligibility Status #2 – Choose One
Income Eligibility at or below 100% Poverty Level / Eligibility Determination Documentation / 30
Income Eligibility at or below 130% Poverty Level / Eligibility Determination Documentation / 20
Over Income (10% consideration) / Eligibility Determination Documentation / 0
Over Income (non-eligible) / Eligibility Determination Documentation / 0
None / 0

Head Start Staff Interviewer Signature Date

Signature of Head Start Staff Completing Selection Criteria Date