Instrument 3 Site Application Form 111221

^{OMB Control #: XXXX-XXXX}

Region V Head Start Outcomes Innovation Site Application Form

In partnership with NCHBHS, the Center for Childhood Resilience (CCR) at Lurie Children’s Hospital in Chicago is offering an innovative project to promote child well-being especially for children exposed to potentially traumatic events early in life. This Outcomes Innovation Project brings trauma informed care to early childhood classrooms through implementation of the Ready to Learn through Relationships (RLR) Framework and Toolkit. The RLR Framework provides foundational knowledge about trauma while the RLR Toolkit provides “plug-and-play” activities in four critical areas that promote wellbeing for all children:

• Creating a Safe Environment

• Building Relationships and

Connectedness

• Supporting and Teaching Emotion

Regulation

• Provider Self-Care

All activities are embedded within a culturally attuned, racial equity framework and promote understanding of the connection between the recommended activities and the needs of children who have been exposed to trauma. For more information about the program or this opportunity, please contact ……………………….

In order to participate in this study, your site must meet the following requirements:

• No changes in center and key support personnel stable in the last 2 years and no upcoming transitions anticipated, including:

  • Head Start grantee since at least 2020

  • Same Center director since at least 2020

  • Education Manager or Coordinator since at least 2020

• One or more interested coaches with an existing coaching relationship with teachers at the Center who have availability for the following:

  • Monthly: participate in two professional development activities (3 hours total)

  • Weekly: meet with assigned teacher(s) for coaching sessions and informal observations of classroom practices (average of 1- 1.5 hours per week per teacher)

• No active Head Start regulatory deficiencies

• Not actively training on another program designed to impact teacher practices

• At least three 3-5 year old classrooms at the Center

• Teacher turnover rate of 28% or less (average for the Region)

If you do not meet these requirements, there is no need to complete this application form. Please note that there are other considerations beyond these requirements that will determine whether your site is selected.

As part of your site’s application, please include submission of the following questionnaires completed by each potential participant including preschool leads and assistants, administrators, and coaches:

• Attitudes Related to Trauma Informed Care (ARTIC) measure

• Trauma-Informed System Change Instrument (TISCI)

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to identify teacher practices for supporting children’s social-emotional development and to identify training and implementation factors that may enhance these practices. Public reporting burden for this collection of information is estimated to average 1 hour per grantee, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. Additionally, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB number for this information collection is OMB Control #: XXXX-XXXX and it expires on [DATE]. If you have any comments on this collection of information, please contact [NAME AND CONTACT INFORMATION].

Name and role of individual completing this form:	Name __________________ Role ____________________
Best way to contact	Email ___________________ Phone __________________
Were other site or regional Head Start staff consulted in your decision to apply? If so, please describe:	No Yes [describe]
Name of your site:	[Text box]
Please tell us why you are interested in participating in the Innovations study?	[Text box]
What type of training (if any) has your staff participated in recently related to trauma and promoting children’s social-emotional development?	[Text box]
How do you believe a program like RLR might be helpful for your site?	[Text box]
Section A: Site Characteristics
State in which your site is located:	Illinois Indiana Michigan Wisconsin
What type of setting is your site located in?	Urban Suburban Rural
What is your agency type?	Community Action Agency (CAA) Government Agency (Non-CAA) Charter School Private/Public For-Profit (e.g., for profit hospitals) Private/Public Non-Profit (e.g., church or non-profit hospital) School System Tribal Government or Consortium (American Indian/Alaska Native)
Agency Description:	Delegate Agency Grantee that delegates all of its programs; it operates no programs directly and maintains no central office staff Grantee that directly operates program(s) and has no delegates Grantee that directly operates programs and delegates service delivery Grantee that maintains central office staff only and operates no program(s) directly
How many days per week are 3-5 year olds enrolled?	4 OR 5
Is this full-day or half-day programming?	Full-day Half-day
Is your site actively involved in another program designed to impact teacher practices?	No Yes [describe]
In what year did your site first become a Head Start grantee?	[Drop down years 2022-2012 or before]
In what year did your Center Director begin in their position?	[Drop down years 2022-2012 or before]
In what year did your current Education Manager or Coordinator begin in this position?	[Drop down years 2022-2012 or before]
Does your site anticipate any upcoming transitions in leadership at the Center?	No Yes
If yes to the previous question, please explain:	[Text box]
Section B: Characteristics of Teachers and Students
How many total classroom teachers were at your Center during the last enrollment year?	0 – 5+ [drop down menu]
How many left your Center during that year?	0 – 5+ [drop down menu]
Total number of 3-5 year old lead teachers	0 – 5+ [drop down menu]
Total number of 3-5 year old assistant teachers	0 – 5+ [drop down menu]
Total number of 3-5 year olds enrolled at the beginning of this academic year	0 – 5+ [drop down menu]
How many 3-5 year old classrooms does your site anticipate for the next academic year?	0 – 5+ [drop down menu]
Number of 3-5 year old children who have an Individualized Education Plan	0 – 5+ [drop down menu]
Approximate percentage of families enrolled who identify as Hispanic	0 – 100 percent [drop down range]
Approximate percentage of families enrolled who identify as African-American or Black	0 – 100 percent [drop down range]
Approximate percentage of families enrolled who identify as a race other than White?	0 – 100 percent [drop down range]
Approximate percentage of single-parent families	0 – 100 percent [drop down range]
Section C: Implementation Supports
Average total hours per operating month a mental health (MH) professional(s) spends on-site	Number of hours [drop down range]
Approximate percentage of children for whom the MH professional consulted with program staff about the child’s behavior / mental health (i.e., are on a behavior support plan)	0 – 100 percent [drop down range]
Approximate percentage of children referred out for additional mental health support	0-100 percent [drop down range]
What is the role of the individual(s) you believe would be an appropriate coach for the RLR program?	[Text box]
How long have they worked at your Center?	Number of years [drop down]
Why do you think they would be an appropriate coach for the RLR program?	[Text box]
How will you ensure the coach(es) has adequate time to participate in professional development activities and meet with teachers? (e.g., classroom ratio coverage)	[Text box]
Do you think your preschool teachers will be interested in participating in the RLR training and trying new strategies? Why or why not?	No [describe] Yes [describe]
How will you support teachers in completing evaluation activities like daily surveys? (e.g., access to devices to complete surveys, access to reliable internet)	[Text box]
How will you support teachers in meeting with their coaches and trying new strategies?	[Text box]