Instrument 2: 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 member 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 team member will ask EHS staff (typically the On-Site Coordinator) to identify any siblings among the selected children. We 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 or home visitor, record in the sampling website each child’s (or pregnant woman’s) name and dates of birth (or due date) in columns B-C. Please be sure to include all children in the selected classrooms and record whether each child is funded fully or partially by EHS (including EHS, EHS Expansion, and EHS-CC Partnership funds).For each selected home visitor, you should include only EHS-funded children (or pregnant women) in her caseload.

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 F-H for selected children only. In Column H, 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’s/Pregnant Woman’s Name First Name Last Name	Date of Birth/ Due Date Month/Day/Year		Check Box if Selected		Child’s Sex (M=Male F=Female)	Home Language E – English S- Spanish O - Other	Parent(s)/Guardian(s)
				Check Box if Child is Fully or Partially Funded by EHS		Siblings			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 XX/XX/XXXX.