Child roster form (from EHS staff)

ATTACHMENT 2

CHILD ROSTER FORM FROM EARLY HEAD START STAFF

NOTE: For each selected classroom or home visitor caseload, a Baby FACES study team Field Enrollment Specialist (FES) will request the names and dates of birth (or due dates for pregnant women) and enrollment of each child or family enrolled in the selected classroom or HV caseload from Early Head Start (EHS) staff (typically the On-Site Coordinator). The attached child roster form is an example of the information required for sampling children and families. EHS 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, EHS staff will not physically fill out the attached child roster form. Once children/families are selected, the FES will ask EHS staff (typically the On-Site Coordinator) to identify any siblings among the selected children. The FES will identify the sibling groups in the sampling program and the sampling program will then randomly drop all but one member of each sibling group, leaving one child per family.

INSTRUCTIONS: 1. For each selected classroom, record in the sampling website each child’s name and dates of birth (or due date) and enrollment in columns B-D. Please be sure to include only EHS funded children in the selected classrooms or home visitor caseloads.

2. Ask the OSC if any children in the selected classrooms/home visitor caseloads are siblings. If so, in Column E, record the number that corresponds to that child’s sibling. The Baby FACES definition of siblings is any set of children who live in the same household.

3. Once children are selected for each classroom or home visitor caseload, record the corresponding information in columns G-I for selected children only. In Column I, please record the name of at least one parent.

							SELECTED CHILDREN ONLY
	A (If HV)	B	C	D	E	F	G	H	I
	Type (C= Child P=Pregnant woman)	Child First Name Last Name	Date of Birth/ Due Date Month/Day/Year	Enrollment Date Month/Day/Year	Siblings	Check Box if Selected	Child’s Gender (M=Male F=Female)	Home Language E – English S- Spanish O - Other	Parent(s)/Guardian(s)
									First Name(s) Last Name(s)
1	C P						M F
2	C P						M F
3	C P						M F
4	C P						M F
5	C P						M F

This collection of information is voluntary and will be used to describe the characteristics of children and families served by Early Head Start, and the characteristics and features of programs and staff that serve them. Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. 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 number for this information collection is 0970-0354 and the expiration date is 9/30/2019.