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Appendix F: Record Review Data Collection Form
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Program ID: ______ Center ID: ______Date: __ __ / __ __ / __ __
Program Name _________________________ Center Name _________________________
Group: ______ (3=enrolled, 2=enrolled and attended,
but left; 1=enrolled but never attended)
Instruction: Use the "0" code when information is missing or
when the answer to the question is not available from the information
in the child's file. A "no" code ("1") is used to
indicate an actual "no" answer in the file, and not to indicate
where specific information is not available in the file.
Child Information |
Child Birthdate: __ __ / __ __ (Month/year; fill in 00/00 if not available)
Child gender ______ (1=female; 2=male; 0=not available)
Child ethnicity ______ (0=not available; 1=Asian/Pacific
Islander; 2=Black/African American, non-Hispanic; 3=White, non-Hispanic;
4=Hispanic; 5=Native American/Alaskan Native; 6=Other)
Is there a record of the child having a: (2=yes;
1=no; 0=not available)
Health Exam ______ Dental Exam ______ Disability ______
(Do not use immunization record as indication
of a health exam) (May be by parent report)
Has the child/family been assigned an enrollment priority score? ______
(2=yes; 1=no; 0=not available)
Which of the following risk factors does this child or family have?
(2=yes; 1=no; 0=not available)
| ________ | Single parent | ________ | Four year old | |
| ________ | Age of parent/caregiver | ________ | Three year old | |
| ________ | (Teen parent at birth / >55 years) | ________ | Child disability | |
| ________ | ________ | Parent disability | ||
| ________ | Foster child / Foster care | ________ | Child health problem | |
| ________ | Non-related primary caregiver | ________ | Parent health problem | |
| ________ | Sibling previously enrolled | ________ | Low developmental screening (Only if actual test score is noted, not based on parent report) | |
| ________ | Non-English speaking family | ________ | Homeless family | |
| ________ | Parent in training/education program | ________ | Poor housing conditions | |
| ________ | Parent(s) did not graduate high school | ________ | Child abuse/neglect | |
| ________ | Unemployed parents (both) | ________ | Domestic violence | |
| ________ | Low-income family with no health insurance or public assistance* (need hit on all three parts) | ________ | Referral from child welfare or family services agency | |
| ________ | ________ | Family substance abuse | ||
| ________ | Family receives TANF | ________ | Incarcerated parent | |
| ________ | Family income is lower than 50% of the poverty level* | ________ | Recent death in family, divorce or separation / family in crisis | |
*Needs to be specifically noted this way in the file; otherwise code as '0' |
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Family Information |
Date of recruitment or application: __ __ / __ __ / __ __ (fill
in 00/00/00 if not available)
Number of individuals living with the Head Start child: ___ ___ (Not
including child; 00=not available)
If this number is available, how does the Head Start record indicate the source? ______
(1= number in the family; 2=number in the household; 0=source not noted)
Number of children living with the Head Start child: ___ ___ (Not
including child; 99=not available)
(Note change for 'not available' code)
Is the mother present in the household? ____ (2=yes;
1=no; 0=not available)
If 'yes': Mother birthdate: __ __ / __ __ (Month/year;
fill in 00/00 if not available)
OR
Mother age (if listed) __ __ (00=not available)
Mother employed ____ (2=yes; 1=no; 0=not available)
Is the father present in the household? ____ (2=yes;
1=no; 0=not available)
If 'yes': Father birthdate: __ __ / __ __ (Month/year;
fill in 00/00 if not available)
OR
Father age (if listed) __ __ (00=not available)
Father employed ____ (2=yes; 1=no; 0=not available)
Note: Above information may be used for child's caregiver, note
relationship below).
Is anyone, different from a parent, listed as a primary caregiver for
the child? ____ (2=yes; 1=no; 0=not available)
If yes, what is the relationship of this person with the child? _____
| 00=not available | 07=Great grandmother | 13=Foster parent(female) |
| 08=Great grandfather | 14=Foster parent (male) | |
| 03=Stepmother | 09=Sister/Stepsister | 15=Other non-relative (female) |
| 04=Stepfather | 10=Brother/Stepbrother | 16=Other non-relative (male) |
| 05=Grandmother | 11=Other relative or in-law (female) | 17=Parent's partner (female) |
| 06=Grandfather | 12=Other relative or in-law (male) | 18=Parent's partner (male) |
Is there any indication that English is not the primary
language spoken in the home? ______
(2=yes
English is the primary language; 1=no, English is not the primary language;
0=no information is recorded)
If English is not the primary language in the home, what language is recorded? ______
(0=not available; 1=French; 2=Spanish; .3=Cambodian (Khmer); 4=Chinese; 5=Haitian; 6=Hmong; 7=Japanese;
8=Korean; 9=Vietnamese; 10=Arabic; 11=other)
Recorded family income: $_______________ (000 if
not available; also write "No Income" if that is the case)
If this number is recorded, how does the Head Start record indicate the source: ______
(1=Reported monthly income; 2=Report annual income; 3=Previous Year Tax Return; 0=source not noted)
Does the family receive the following: (2=yes;
1=no; 0=not available)
Medicaid ______ Food Stamps ______ WIC ______ SSI ______
TANF/PA ______ Child support ______ Unemployment ______
Worker's Comp/Disability ______
Record Summary Information |
Is the program's form/file complete? ______ (2=yes; 1=no)
Is the form kept on the computer? ______ (2=yes;
1=no)
Where is the form maintained? ______ (1=the program;
2=the center; 3=both)
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