ACF - 801 Child Care Quarterly Case Record Form
OMB #: 0970-0167 Expires: 02/28/2022
Head of Family Receiving Assistance
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1. Reporting Period |
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2. Unique State Identifier |
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3. Filler (Leave Blank) |
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4. Family FIPS Code |
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5. Single Parent |
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6. Reason for Receiving Subsidized Child Care |
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7. Total Monthly Child Care Co-payment by Family |
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8. Month/Year Child Care Assistance to the Family Started |
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9. Total Monthly Family Income for Determining Eligibility |
Family Income Sources
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10. Employment Including Self-Employment |
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11. Cash or Other Assistance Under Title IV of the Social Security Act (TANF) |
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12. State Program for Which State Spending Is Counted Towards TANF MOE |
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13. Housing Voucher or Cash Assistance |
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14. Supplemental Nutrition Assistance Program (SNAP, formerly Food Stamps) |
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15. Other Federal Cash Income Programs (such as SSI) |
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16. Family Size Used for Determining Eligibility |
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16a. Family Homeless Status |
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16b. Family ZIP Code |
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16c. Military Status |
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16d. Primary Language Spoken at Home |
Child Data Sources
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17. Filler (Leave Blank) |
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18. Hispanic or Latino |
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19. American Indian or Alaskan Native |
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20. Asian |
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21. Black or African American |
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22. Native Hawaiian or Other Pacific Islander |
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23. White |
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24. Gender |
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25. Month/Year of Birth |
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25a. Child Disability |
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26. Type of Child Care |
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27. Total Monthly Amount Paid to Provider |
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28. Total Hours of Care Provided in Month |
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29. Provider FEIN |
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30. Provider Unique State ID |
Provider Data Sources
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31. Provider FEIN (same as #29) |
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32. Provider State ID (same as #30) |
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33. QRIS Participation |
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34. QRIS Rating |
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35. Accreditation Status |
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36. Provider is Subject to Pre-K Standards |
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37. Other State-Defined Quality Measure |
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38. Provider is Subject to Head Start or Early Head Start Standards |
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39. Provider ZIP Code |
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40. Inspection Date |