Program Information Report 2011-20112

COPA Supplementary Close Out Data Entry Form

Section Q-

Delegate Agency: / Yes No / Program Type:
Name of Delegate Agency: / Head Start Early Head Start
Delegate Agency Address
Delegate Agency Zip Code
HS Director Name:
Contact Phone Number:
Email address:

Section A-

Center Based Program 5 days/week: / Funded Enrollment
Full day enrollment (6 or more hours per day)
Part Day Enrollment (less then 6 hours per day)
Center Based Program 4 days/week: / Funded Enrollment
Full day enrollment (6 or more hours per day)
Part Day Enrollment (less then 6 hours per day)
Funded Enrollment
Combination Program: program providing services both in a center and home
Home Based Program Option: program providing services in a child’s home
Family Child Care: program providing EHS or HS services in a family child care home
A17- What is the total actual enrollment of pregnant women (EHS ONLY)?
A18- Of the pregnant women enrolled, how many were under the age of 18 years old?
A21-Please provide any comments for enrollment by Ethnicity and Race as it pertains to your program(Please explain “other” or “unspecified”:
A23-Of the children and pregnant women who dropped out, what is the number replaced during the enrollment year?
A29-30 Comments pertaining to Child Care program:

Section B-

B1b- What is the number of staff who left your program and were replaced during the year. (Include those who left during the enrollment year and during any non-operating summer months)
Head Start Staff Contracted
B7-Disability Services Manager
On average, how many hours per week does the person with lead responsibility for coordinating disability services devote to the role?
B20- What is he number of teacher vacancies in your program that were unfilled for a period of 3 months or longer?
B21- What is the number of teachers hired during the year due to turnover (do not count teachers added due to expansion)?

Section C-

C1&2- Please specify the names and number of children with other health insurance not listed. Examples include Tri-Care Military Health/CHAMPUS, Migrant Health Services, etc:
C10d- Number of children who received medical treatment for the following conditions…
Overweight:
C17- If the total from C17 is less then 90% of the children diagnosed as needing treatment (C17b), please specify any additional reasons that have not yet been listed in COPA PIR report:
C17- If C17c is less that 90% of children diagnosed as needing treatment (C17b), please specify the primary reason below. Check one primary reason: (specify any additional reasons in the general "Comments" section)
Health insurance for children doesn't cover dental treatment / No dental care available in local area
Medicaid not accepted by dentist / Dentist does not treat 3-5 years old children
Parents did not keep appointment / Child dropped out before appointment date
Other (please specify)
C21- Average total hours per operating month mental health professional(s) spends on site:
C24- List the number of LEA’S (or Part C agencies for those programs serving infants and toddlers) in you Head Start or Early Head Start service area (EHS ONLY):
C25- The number of LEA’S (or Part C agencies for those programs serving infants and toddlers) that your program has a formal agreement with to coordinate services for children with disabilities(EHS ONLY):
C31-Transition Activities- Please provide the number of local school districts in your Head Start service area:
C31a-Of the number of local school districts, provide the number with whom you have a formal agreement to coordinate transition services for children and families:
C32-Of the number of children enrolled in Head Start at the end of the current enrollment year, the number that you project to be entering kindergarten in the following school year:
C34a -Of the number of children screened, what is the number identified as needing follow-up assessment or formal evaluation. e.g., to determine if a child has a disability?
C35-What curriculum model does your program use as its primary foundation?
For Center Based services?
For Home Based services?
C36-What instrument does your program use for developmental screening?
C37-What approach or tool does your program use for ongoing child assessment?
Is this tool locally designed? Yes No
C54 Enter the number of buses, if any, which were purchased by your program during the operating period: Include only buses purchased with ACF grant funds that will be used to support the operations of your Head Start or Early Head Start program.
August / March
September / April
November / May
December / June
January / July
February
C55- Did you lease any of the buses used by your program? / Yes No
If yes, how many?
C56-Did you contract with a transportation provider to transport some or all of your enrolled children? / Yes No
C57- Please confirm that an appropriate Federal Interest has been established by listing below every facility which has been purchased, constructed, or received major renovations using Head Start funds during the 2006-2007 operating period.
  • Report the addresses of program centers that were purchased, constructed, or received major
renovations using Head Start Funds during 2006-07 operation period.
  • Then, indicate in the corresponding check box whether the Federal Interest has been formally established.
  • Refer to 45 CFR Part 1309 of the Head Start Performance Standards for additional guidance on Federal Interest and facilities

A. Center 1
Address 1 / Address 2
City, State, Zip / Federal Interest has been established
B. Center 2
Address 1 / Address 2
City, State, Zip / Federal Interest has been established
C. Center 3
Address 1 / Address 2
City, State, Zip / Federal Interest has been established