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 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.

INSTRUCTIONS: 1. For each selected classroom or home visitor, record in the sampling website each child’s name and date of birth in columns A-B. Please be sure to include only those children funded fully or partially by EHS in the selected classrooms and each child’s EHS funding level (full or partial)(including EHS, EHS Expansion, and EHS-CC Partnership funds). For each selected home visitor, you should include only EHS-funded children in her caseload.

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

	A	B	C	D	E	F	G
	Child’s Name First Name Last Name	Date of Birth 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)
			Indicate child’s EHS funding F- full P-Partial				First Name(s) Last Name(s)
1					M F
2					M F
3					M F
4					M F
5					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 10/31/21.