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ACF-801 Child Care Quarterly Case Record Form

Published: September 17, 2012
Categories:
Child Care Development Fund (CCDF) Reporting
Topics:
ACF-801

OMB #0970-0167
Expires: 04-30-2015

Head of Family Receiving Assistance

QUESTION NUMBER QUESTION RESPONSE
1. Reporting Period YYYYMM

2

Unique State Identifier (required in absence of SSN#)  

3

Social Security Number (optional) XXX-XX-XXXX

4.

FIPS Codes

State:

County:

5.

Single Parent  

6.

Reason for Receiving Subsidized Child Care  

7.

Total Monthly Child Care Co-payment by Family $ _ ,  _  _  _
8. Month/Year Child Care Assistance to the Family Started YYYYMM

9.

Total Family Income $ _  _ , _  _  _

10.

Employment Including Self-Employment _

11.

Cash or Other Assistance Under Title IV of the Social Security  Act (TANF) _

12.

State Program for Which State Spending Is Counted Towards TANF MOE _

13.

Housing Voucher or Cash Assistance _

14.

Supplemental Nutrition Assistance Program (formerly Food Stamps) _

15.

Other Federal Cash Income Programs (such as SSI) _

16.

Family Size Used to Determine Eligibility _

Dependent Children Receiving Child Care Assistance (One record per child)

QUESTION NUMBER QUESTION RESPONSE

17.

Social Security Number (Optional) OR Unique State  Identifier (Required in absence of SSN#) _

18.

Hispanic or Latino Ethnicity _

19.

American Indian or Alaskan Native _

20.

 Asian _

21.

Black or African American _

22.

Native Hawaiian or Other Pacific Islander _

23.

White _

24.

Gender _

25.

Month/Year of Birth YYYYMM

Setting Information (One record for each setting for each child)

QUESTION NUMBER QUESTION RESPONSE

26.

Type of Child Care _ _

27.

Total Monthly Amount Paid to Provider _ _ _ _

28.

Total Hours of Care Provided in Month _ _ _

29.

Provider FEIN _ _-_ _ _ _ _ _ _

30.

Provider Unique State ID _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Provider Information (One record for each provider)

QUESTION NUMBER QUESTION RESPONSE

31.

Provider FEIN (same as item 29) _ _-_ _ _ _ _ _ _

32.

Provider Unique State ID (same as item 30) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

33.

QRIS Participation _

34.

QRIS Rating _ _ _

35.

Accreditation Status _

36.

Provider is Subject to State Pre-K Standards _

37.

 Other State-defined Quality Measure _