(2) Child roster form from Head Start staff (AI/AN FACES)

ATTACHMENT 2

CHILD ROSTER FORM FROM HEAD START STAFF

NOTE: For each selected classroom, a FACES study team Field Enrollment Specialist (FES) will request the names and dates of birth of each child enrolled in the selected classroom from Head Start staff (typically the On-Site Coordinator). The attached child roster form is an example of the information required for sampling children. Head Start staff may provide this information in various formats such as print outs from an administrative record system or photocopies of hard copy lists or records. Therefore, Head Start staff will not physically fill out the attached child roster form. The FES will use a tablet computer to enter this information into a web-based sampling program. The program will select up to 14 children per classroom for participation in the study.  For these selected children only, the FES will then enter each child’s gender, home language, and parents’ names into the sampling program. Finally, the FES will ask Head Start staff (typically the On-Site Coordinator) to identify any siblings among the 28 selected children. The FES will identify the sibling groups in the sampling program and the sampling program will then drop all but one member of each sibling group, leaving one child per family.

American Indian and Alaska Native FACES

CHILD ROSTER FORM

[PROGRAM]

[CENTER]

[CLASSROOM]

INSTRUCTIONS: 1. For each selected classroom, record in the sampling website each child’s name and date of birth in columns A and B. Please be sure to include all children in the selected classrooms.

2. Ask the On-Site Coordinator (OSC) for the date (month and year) each child first enrolled in preschool Head Start. Record this date in column C.

3. Ask the OSC if any students in the selected classrooms are siblings. If so, in Column D, record the number that corresponds to that child’s sibling. The FACES definition of siblings is any set of children who live in the same household and are cared for by the same primary caregiver(s).

4. Once children are selected for each classroom, record the corresponding information in columns F-H for selected children only. In Column H, please record the name of at least one parent.

						SELECTED CHILDREN ONLY
A		B	C	D	E	F	G	H
Child							Home Language E – English S- Spanish O - Other	Parent(s)/Guardian(s)
First Name Last Name		Date of Birth Month/Day/Year	Date Child First Enrolled in Preschool Head Start Month/Year	Siblings	Check Box if Selected	Gender (M=Male F=Female)		First Name(s) Last Name(s)
1.		1.	1.	1.	1. 	1. M F	1.	1.
2.		2.	2.	2.	2. 	2. M F	2.	2.
3.		3.	3.	3.	3. 	3. M F	3.	3.
4.		4.	4.	4.	4. 	4. M F	4.	4.
5.		5.	5.	5.	5. 	5. M F	5.	5.
6.		6.	6.	6.	6. 	6. M F	6.	6.
7.		7.	7.	7.	7. 	7. M F	7.	7.
8.		8.	8.	8.	8. 	8. M F	8.	8.
9.		9.	9.	9.	9. 	9. M F	9.	9.
10.		10.	10.	10.	10. 	10. M F	10.	10.
11.		11.	11.	11.	11. 	11. M F	11.	11.
12.		12.	12.	12.	12. 	12. M F	12.	12.
13.		13.	13.	13.	13. 	13. M F	13.	13.
14.		14.	14.	14.	14. 	14. M F	14.	14.
15.		15.	15.	15.	15. 	15. M F	15.	15.
16.		16.	16.	16.	16. 	16. M F	16.	16.
17.		17.	17.	17.	17. 	17. M F	17.	17.
18.		18.	18.	18.	18. 	18. M F	18.	18.
19.		19.	19.	19.	19. 	19. M F	19.	19.
20.		20.	20.	20.	20. 	20. M F	20.	20.
21.		21.	21.	21.	21. 	21. M F	21.	21.
22.		22.	22.	22.	22. 	22. M F	22.	22.
23.		23.	23.	23.	23. 	23. M F	23.	23.
24.		24.	24.	24.	24. 	24. M F	24.	24.
25.		25.	25.	25.	25. 	25. M F	25.	25.
26.		26.	26.	26.	26. 	26. M F	26.	26.
	Paperwork Reduction Act Statement: The referenced collection of information 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. The OMB control number for this collection is 0970-0151 and it expires XX/XX/XXXX. The time required to complete this collection of information is estimated to average 20 minutes, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the collection of information. 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.