Attachment 33. AIAN FACES 2019 fall 2021 special teacher sampling form from Head Start staff_clean

Attachment 33

AIAN FACES 2019 Fall 2021 Special Teacher Sampling Form
from Head Center Start Staff

This page has been left blank for double-sided copying.

NOTE: For each center, an AIAN FACES 2019 study liaison will request a list of all teachers providing instruction to Head Start-funded children from a designated Head Start staff member (typically the on-site coordinator, known as the OSC). The attached teacher sampling form is an example of the information required for teacher sampling. The liaison will request this information via a secure file sharing website. The liaison will enter the information into the online sampling program. For each teacher or home visitor, the liaison will obtain the first and last name, their email address, the mode(s) of instruction of the children they teach (in-person, virtual/remote, hybrid, home visit, or other), and the number of children they teach. The study liaison will enter this information into a web-based sampling program that will include fields that match those on the attached form. The sampling program will randomly select about two teachers per selected center for participation in the study. 

This page has been left blank for double-sided copying.

AIAN FACES 2019

FALL 2021 SPECIAL TEACHER SAMPLING FORM FROM HEAD START STAFF

Program: [HS Program]	OSC: [OSC Name]
Center: [Center Name]	OSC Phone: [Phone #]
	Liaison
Center Phone: [Phone #]	(Please Print Your Name)

INSTRUCTIONS: Please provide the information below for each teacher or home visitor providing instruction in this center for one or more Head Start funded children. Indicate the mode(s) of instruction for each teacher. For mode of instruction, please choose as follows:

• In-person refers to instruction taking place face-to-face with children and providers.

• Virtual or remote instruction can be received:

  1. in real time via a web-based video platform (such as Zoom),

  2. by completing assignments on the child/family’s own time on platforms such as Class Dojo or Ready Rosie, or

  3. on paper with instructional materials sent home.

• Hybrid refers to a situation in which a child receives a combination of in-person and virtual or remote instruction.

A	B	C	D
Lead Teacher or Home visitor (Lead teachers are the head or primary teachers for a group of children.)	Lead Teacher or Home Visitor Email Address	Mode(s) of Instruction (Select all that apply)	Number of Children Taught by Lead Teacher or Home Visitor
First Name Last Name		In-person only, Virtual/Remote only, Hybrid only, Home Visit, Other
1.	1.	1. __________________	1. __________________
2.	2.	2.	2.
3.	3.	3.	3.
4.	4.	4.	4.
5.	5.	5.	5.
6.	6.	6.	6.
7.	7.	7.	7.
8.	8.	8.	8.
9.	9.	9.	9.
10.	10.	10.	10.
11.	11. __________________	11.	11.
12.	12.	12.	12.
13.	13.	13.	13.
14.	14.	14.	14.

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to provide descriptive information about Head Start programs and the families they serve. Public reporting burden for this collection of information is estimated to average 10 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 and expiration date for this collection are OMB #: 0970-0151, Exp: XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Lizabeth Malone, Mathematica, 1100 1st Street, NE, 12th Floor, Washington, DC 20002.