Head Start core teacher child report

O MB # : 0970-0151

Expiration Date: X/XX/20XX

Head Start Family and Child Experiences Survey

Teacher’s Child Report Form 

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection will be entered after clearance. The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. This information collection is voluntary. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Mathematica Policy Research, 1100 1st Street, NE, 12th Floor, Washington, DC 20002, Attention: Jerry West.

I agree that I understand the purpose of this study including privacy assurances, and that my participation is completely voluntary. I may withdraw this consent at any time without penalty.

Signature Today’s date

Name (print)

ID Number:

Child Name:

A1. Are you currently the Head Start teacher for the child listed above? (Use an “X” to mark your response.)

1  Yes GO TO B1

0  No

A2. What is the main reason you are no longer this child’s teacher?

1  Child moved to another class

in the same center

2  Child moved to another center

3  Child left the Head Start program

A3. What is the name of the Head Start teacher whose class this child currently attends?

Name:

A4. Please record the last date this child was in your class.

| | | / | | | / | | | | |

Month Day Year

A5. Thank you for completing this form.

These questions are about things that different children do at different ages. These things may or may not be true for this child.

B1. Can this child recognize…

1  All of the letters of the alphabet,

2  Most of them,

3  Some of them, or

4  None of them?

B2. How high can this child count? Would you say…

1  Not at all,

2  Up to five,

3  Up to ten,

4  Up to twenty,

5  Up to fifty, or

6  Up to 100 or more?

B3. How often does this child like to write or pretend to write? Would you say…

1  Never,

2  Has done it once or twice,

3  Sometimes, or

4  Often?

B4. Can this child identify the colors red, yellow, blue, and green by name? Would you say…

1  All of them,

2  Some of them, or

3  None of them?

B4a. Can this child demonstrate a beginning understanding of the relationship between sounds and letters (e.g., the letter B makes a “buh” sound)? Would you say…

1  Not at all,

2  For one or two letters,

3  For a few (up to 5) letters, or

4  For several (6 or more) letters

B5. Please answer “Yes” or “No” to each question about this child’s abilities.

	MARK “YES” OR “NO” ON EACH LINE
	YES	NO
a. Does this child mostly write and draw rather than scribble?	1 	0 
b. Can this child write (his/her) first name even if some of the letters are backward?	1 	0 
c. Does this child trip, stumble, or fall easily?	1 	0 
d. When this child speaks, is (he/she) understandable to a stranger?	1 	0 
e. Does this child stutter or stammer?	1 	0 
f. Does this child ever look at a book with pictures and pretend to read?	1 	0 
g. Does this child recognize (his/her) own first name in writing or in print?	1 	0 
h. Does this child read any other words in writing or in print?	1 	0 
i. Can this child identify rhyming words?	1 	0 

Mathematica’s agreement with the publisher/developer of this set of items does not allow us to share the items publicly without prior written approval.

Please describe this child according to how true each of these statements has been during the past month, from “not true” to “somewhat or sometimes true” to “very true or often true.” For each item, mark only one code.

	MARK ONLY ONE
	NOT TRUE	SOMEWHAT OR SOMETIMES TRUE	VERY TRUE OR OFTEN TRUE
a. Acts too young for his or her age	1 	2 	3 
b. Can't concentrate, can't pay attention for long	1 	2 	3 
c. Mathematica’s agreement with the publisher/developer of this item does not allow us to share the items publicly without prior written approval.	1 	2 	3 
d. Mathematica’s agreement with the publisher/developer of this item does not allow us to share the items publicly without prior written approval.	1 	2 	3 
e. Hard to understand what he or she is saying	1 	2 	3 
f. Hits or fights with others	1 	2 	3 
g. Keeps to herself or himself; tends to withdraw	1 	2 	3 
h. Lacks confidence in learning new things or trying new activities	1 	2 	3 
i. Is nervous, high-strung, or tense	1 	2 	3 
j. Is very restless, fidgets all the time, can't sit still	1 	2 	3 
k. Often seems sleepy or tired in class	1 	2 	3 
l. Has temper tantrums or hot temper	1 	2 	3 
m. Often seems unhappy, sad, or depressed	1 	2 	3 
n. Worries about things for a long time	1 	2 	3 

H1. Please describe this child according to how he or she approaches tasks. How often in the past month did he or she act this way? For each item, mark only one code: “never,” “sometimes,” “often,” or “very often?”

	MARK ONLY ONE FOR EACH ITEM
	NEVER	SOMETIMES	OFTEN	VERY OFTEN
a. Keeps belongings organized	1 	2 	3 	4 
b. Pays attention well	1 	2 	3 	4 
c. Shows eagerness to learn new things	1 	2 	3 	4 
d. Easily adapts to changes in routine	1 	2 	3 	4 
e. Persists in completing tasks	1 	2 	3 	4 
f. Works independently	1 	2 	3 	4 

F1. Has any professional such as a doctor or other health or education professional mentioned this child having a developmental problem or delay, for example, any special need or disability, such as physical, emotional, language, hearing difficulty or other special need?

MARK ONLY ONE

1  Yes

GO TO F3

0  No

d  Don’t know

F2. How did the doctor or other health or education professional describe this child’s needs or disability?

MARK ALL THAT APPLY

1  VISION IMPAIRMENT

2  BLINDNESS

3  HEARING IMPAIRMENT/HARD OF HEARING

4  DEAFNESS

5  MOTOR IMPAIRMENT

6  SPEECH IMPAIRMENT/DIFFICULTY

COMMUNICATING

7  MENTAL RETARDATION

8  DEVELOPMENT DELAY

9  AUTISM OR Pervasive Developmental

Disorder (PDD)

10  BEHAVIOR PROBLEMS/HYPERACTIVITY/

ATTENTION DEFICIT (ADD or ADHD)

11  OPPOSITIONAL DEFIANT DISORDER

12  OTHER (Specify)

d  Don’t Know

GO TO F5

F3. Since this child has enrolled in Head Start, has anyone reported concerns about (his/her) health or development?

Note: This item does not refer to normal health concerns (e.g., “she has a lot of colds”); it refers to the conditions listed in F4 below. The concerns may be identified by yourself, another staff member, a parent or anyone else.

1  Yes

0  No

d  Don’t know

F4. To your knowledge, what areas of this child’s health and development appear to be of concern?

MARK ALL THAT APPLY

1  VISION IMPAIRMENT

2  BLINDNESS

3  HEARING IMPAIRMENT/HARD OF HEARING

4  DEAFNESS

5  MOTOR IMPAIRMENT

6  SPEECH IMPAIRMENT/DIFFICULTY

COMMUNICATING

7  MENTAL RETARDATION

8  DEVELOPMENT DELAY

9  AUTISM OR Pervasive Developmental

Disorder (PDD)

10  BEHAVIOR PROBLEMS/HYPERACTIVITY/

ATTENTION DEFICIT (ADD or ADHD)

11  OPPOSITIONAL DEFIANT DISORDER

12  OTHER (Specify)

d  Don’t Know

F5. What has been done so far to address the child’s condition or the concerns about the child’s health and development?

The definition of IFSP/IEP is as follows: “a written plan that describes goals for this child and the services [he/she] should receive.”

MARK ALL THAT APPLY

1  Discussions/plans are in progress

2  A specialist has been contacted

3  The child has been observed or evaluated

4  A meeting with the parents and the special

needs team has been made

5  An individualized education plan (IEP) or

an Individual Family Service Plan (IFSP)

has been developed

6  Modifications or accommodations to the

classroom or class activities have been made

d  Don’t Know

If F5 = 5 (An IEP or IFSP has been developed), go to F5a. Otherwise, go to F6.

F5a. Did you participate in the child’s IEP or IFSP meeting?

1  Yes

0  No

d  Don’t know

F5b. Which of the following services has the child received?

MARK ALL THAT APPLY

1  Speech or language therapy

2  Social work services

3  Psychological services

4  Special education teacher services

5  Other services

d  Don’t Know

If F5B = 1, 2, 3, 4, OR 5, go to F5C. Otherwise, go to F6.

F5c. How were these services delivered?

MARK ALL THAT APPLY

1  Consultation in the classroom

Note: Consultation includes recommending modifications, accommodations, or other methods to support the child’s learning and development

2  Direct teaching or services by a specialist in

the classroom

3  Direct teaching or services by a specialist in

another classroom or setting

d  Don’t Know

F6 IS NOT ASKED IN FALL 2014

F6. About how often has this child missed a Head Start class during the past year?

1  Never

2  1-5 days

3  6-10 days

4  11-20 days

5  More than 20 days

G1 AND G2 ASKED ONLY OF PAPER RESPONDENTS

G1. Why did you choose to complete the paper questionnaire rather than complete the questionnaire on the Web?

MARK ALL THAT APPLY

1  Did not have access to a computer

2  Computers were in use by others at the times

I wanted to do the questionnaire

3 Started survey, but experienced technical

problems such as…

3a  Screen frozen

3b  took too long to load the first page

3c  Took too long to load subsequent pages

4 Tried to log into Web address, but an error

message appeared…

4a  “Invalid password”

4b  “This page has expired”

4c  “This website is busy, please try

again later”

5  Computer screen too small to read questions,

such as required too much scrolling—up or

down, side to side

6  Unable to read the questions on the screen

because of the color scheme on the computer

7  Chose to complete the paper questionnaire

because it was readily available

G2. What kind of help could we have given you to make it easier to complete this form on the web?

Thank you for your participation in FACES!

Prepared by Mathematica Policy Research