OMB Control No.: 0970-xxxx
Expiration Date: xx/xx/20xx
Public reporting burden for this collection of information is estimated to average 9 minutes per response, including the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This information collection is voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Reports Clearance Officer (Attn: OMB/PRA 0970-XXXX), Administration for Children and Families, Department of Health and Human Services, 370 L'Enfant Promenade, S.W., Washington, D.C. 20447.
Name of the Organization Applying: _______________________________________________________
Service Area of Head Start Application (e.g. Neighborhood, Town, County):_______________________
Date of Application: ______________________________________________________________ _____
Headquarters Location:__________________________________________________________________
Funding Opportunity Number:____________________________________________________________
Instructions: This coversheet should be completed and attached at the top of your Head Start application. All questions should be answered by all Head Start applicants except for those questions that are explicitly for former Head Start grantees.
The data collected in this coversheet is being used for a research study titled Evaluation of the Head Start Designation Renewal System, conducted by the Urban Institute and the Frank Porter Graham Child Development Institute at the University of North Carolina-Chapel Hill on behalf of the Office of Planning, Research and Evaluation in the U.S. Department of Health and Human Services. This form will not be used by the Office of Head Start to determine the results of your application.
Indicate Your Organization Type:
(Check the category that best matches
your organization.)
Private Child Care Provider
Small Business
Other For Profit Corporation
Public School or School District
Native American Tribal Governments
Public Housing Authorities
Local Government Organization
State Government Organization
Private Institutions of Higher Education
Faith-Based Organization
Community Action Agency
Other Non-Profit Organization
Other, specify:___________________
Indicate Your Organization Auspice:
For Profit
Non-Profit
Public
Other, specify:____________________
How many years has your organization been in business?
0-1 Year
2-4 Years
5-10 Years
11+ Years
What ages do you currently serve? (Check all that apply)
Do not currently serve children
0-3 Years Old
3-5 Years Old
6-10 Years Old
10+ Years Old
Please list the state and zip code(s) in which you serve your current clients (if more than 3, list the 3 closest zip codes to the county for which you are applying for a Head Start Grant)
State 1: _________________
Zip code(s) 1: _______________
State 2: _________________
Zip code(s) 2: _______________
State 3: _________________
Zip code(s) 3: _______________
How many states do you serve? ___
Is your organization partnering with any other organizations or entities on this grant application? Please indicate all organization types with which you are partnering, as well as whether it is a new or a continuing partnership. (Check all that apply)
Private Child Care Provider New Continuing
Health Care Providers New Continuing
IDEA Part B 619, Part C Providers New Continuing
Small Business New Continuing
Other For Profit Corporation New Continuing
Public School or School District New Continuing
Native American Tribal Governments New Continuing
Public Housing Authorities New Continuing
Child Welfare, Protective Services,
Family Preservations Services and Agencies New Continuing
Local Government Organization New Continuing
Private Institutions of Higher Education New Continuing
Other educational institutions (e.g. libraries) New Continuing
Religious Organization New Continuing
Community Action Agency New Continuing
Other Non-Profit Organizations New Continuing
Other, specify:___________________ New Continuing
Not Partnering
For this Head Start grant, will this organization provide services directly to children and families?
Delegate None
Delegate Some, if so please specify number of delegates _____
Delegate All, if so please specify number of delegates _____
What level of match or cost-share is your organization proposing?
More than the required 20%
Required 20%
Less that required 20% (waiver submitted)
Please indicate the sources for the match/cost-share and whether the resources will be provided as cash or in-kind:
Source:______________ Cash In-kind
Source:______________ Cash In-kind
Source:______________ Cash In-kind
Proposed Enrollment: For each applicable box please fill out the proposed enrollment.
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Head Start |
Early Head Start |
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Part Day |
Full Day |
Part Day |
Full Day |
Part Day |
Full Day |
Center Based |
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Home Based |
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Combination |
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FCC |
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Total |
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Proposed Number of Teachers: For each applicable box please fill out the proposed number of teachers.
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Head Start |
Early Head Start |
Total |
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Part Day |
Full Day |
Part Day |
Full Day |
Part Day |
Full Day |
Center Based |
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Home Based |
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Combination |
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FCC |
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Total |
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Portion of the Teaching staff with BA’s/AA’s in early childhood education or related field:_____________
Please indicate during what part of the year each type of service will be delivered.
Center – Based Year Round During the school year Other
Home – Based Year Round During the school year Other
Combination Year Round During the school year Other
FCC Year Round During the school year Other
Have you ever applied for or held a Head Start grant? (Check all that apply)
Current Head Start Grantee (This Service Area)
Current Head Start Grantee (Other Service Area)
Former Head Start Grantee
Applied for Head Start Previously, but Never Received Grant
Previously/Current Head Start Delegate
Never Applied for Head Start Grant before
If you are a Head Start grantee:
Which kind of Head Start Grant do you currently have? (Check all that apply)
Head Start Migrant/Seasonal Head Start
Early Head Start American Indian/Alaska Native Head Start
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Derrick-Mills, Teresa |
File Modified | 0000-00-00 |
File Created | 2021-01-28 |