1. program planning 2. 3. - lower columbia...
TRANSCRIPT
MSYS
(Revised 02/18)
Lower Columbia College Head Start/EHS/ECEAP
Management Systems
Table of Contents
1. Program Planning
a. Program Planning Policy and Procedure (See Program Governance)
b. Committees and Responsibilities Policy and Procedure (Revised 08/15)
c. Program Planning and Management, Chart of Activities (Revised 08/15)
2. Communications
a. Confidential Communication Policy & Procedure (Revised 08/15)
a1. Request for Information (Revised 08/10)
b. Acronyms, Terms and Definitions (Revised 07/12)
c. Communication Policy and Procedure (Revised 07/14)
d. Guidelines for Development and/or Revisions of Policies & Procedures/Forms (Revised 11/16)
e. Coordination of Services Policy & Procedure (Created 11/17)
3. Communications with Families
a. Overview of Communication Between Parents and Staff (Revised 04/12)
b. Notes Home (see Notes Home Form in FS/PI/ERSEA)
4. Communication with the Community
a. Community Connection Newsletter (see sample, published semi-annually)
b. 2008/09 Annual Report (see sample)
5. Communication with Governing Bodies and Policy Council
a. Director’s Update (see sample)
b. Communication between Governing Body & Policy Council (Revised 08/15)
6. Communication Among Staff
a. Overview of Communication Among Staff (Revised 10/17)
b. (Vacant)
c. Routing Memo – Leadership Team (Revised 10/16)
d. Routing Memo General (Revised 07/06)
e. Directors Update (see sample MSYS 5a)
f. Mobile Computing Device Procedure (Created 08/15)
g. Mobile Device Checkout Form (Created 08/15)
7. Record-Keeping
a. Record-keeping Policy & Procedure (Revised 03/16)
b. Site Files Policy and Procedure (Revised 08/15)
c. Individuals Having Access to Records Form (Revised 07/14)
d. Site File Check-In/Check Out (Created 07/14)
e. File Contents Administration (Revised 07/17)
e1. Admin Site File Contents – EHS (Revised 06/17)
e2. Admin Site File Contents – EHS – Prenatal (Revised 06/17)
e3. Overview of Required Services for Enrolled Expectant Mother–EHS (Revised 07/17)
f. File Contents Health /Nutrition (Revised 06/16)
f1. Health Nutrition Site File Contents – EHS (Revised 06/17)
f2. Health Nutrition Site File Contents – EHS – Prenatal (Revised 06/17)
g. File Contents Social Services/Mental Health (Revised 07/17)
g1. Social Service Mental Health Site File Contents – EHS (Revised 06/17)
g2. Social Service Mental Health Site File Contents – EHS – Prenatal (Revised 06/17)
MSYS
(Revised 02/18)
h. Education Site File Contents (Revised 07/17)
h1. Education Site File Contents – EHS (Revised 06/17)
i. Special Needs File Contents (Revised 07/17)
i1. Special Needs File Contents-EHS (Revised 06/17)
j. Change of Status Form (See ERSEA 1e)
k. File Sign-Out Form (Revised 06/10)
k1. EHS Prenatal File Sign Out Portrait (Created 07/10)
l. Nutrition Consultant Site File Review Procedure (Revised 08/15)
m. Education Home Visit Observation Form (Revised 06/11)
m1. EHS Home Visiting Observation Checklist (Created 09/10)
n. Social Service Home Visit Observation Checklist (Revised 03/16)
o. Health Consultant Site File Review Procedure (Revised 01/18)
o1. Referral to Children with Special Health Care Needs (Revised 08/14)
o2. Record of Nursing Assessment (Revised 07/10)
o3. EHS Record of Nursing Assessment for Expectant Mothers (Revised 08/16)
p. Request for Change of Classroom (Revised 07/17)
p1. Procedure for Request for Change of Classroom or Site (Revised 07/17)
q. Health Accommodation Plan Meeting (Revised 06/16)
8. Reporting System
a. Reporting System Policy & Procedure (Revised 06/13)
a1. ChildPlus Reports Distribution Schedule (Revised 08/15)
b. Family Advocate EOM Policy and Procedure (See FS/PI 6a)
c. Advocate End of the Month Report (See FS/PI 6b)
d. Teacher EOM Policy and Procedure (See EDUC 6a)
e. Teacher End of the Month Report (See EDUC 6b)
f. Area Manager Monthly Report (Revised 02/18)
f1. End of the Month Report – Assistant Director (Revised 10/16)
f2. EHS Supervisor Monthly Report (Revised 10/16)
f3. EHS Manager/Health Specialist End of the Month Report (Revised 08/15)
g. Monitoring Schedule (Revised 03/15)
g1. Ongoing Monitoring Policy & Procedure (Revised 08/15)
h. Vacant
i. Site File Review Policy and Procedure (Revised 08/15)
j. Site File Review Form (Revised 06/11)
j1. EHS Prenatal Client File Review (Revised 08/11)
k. Vacant
l. Vacant
m. Vacant
n. EHS Classroom Setup & Postings Checklist (Revised 08/15)
o. Classroom Observation Instrument (Revised 07/06)
p. Procedure for Completing Program Inventory (Revised 08/10)
q. Property Log and Inventory (Revised 08/10)
9. Self-Assessment
a. Self-Assessment Policy & Procedure (Revised 07/17)
b. Site File Review Worksheet (Revised 09/17)
b1. EHS Site File Review Worksheet (Revised 09/17)
b1a. EHS Site File Review Worksheet – Prenatal (Created 09/17)
b2. Site File Review Summary (Revised 09/17)
b2a. EHS Site File Review Summary – Prenatal (Revised 10/17)
b2b. EHS Site File Review Summary (Created 09/17)
MSYS 1b
1 (C: 10/02: R: 08/15)
Lower Columbia College Head Start / EHS / ECEAP
Committees and Responsibilities
Policy
Subcommittees will be developed as needed to work with the director, college administration,
Policy Council, and appropriate staff on developing and analyzing program plans, long-range
goals and short-term objectives for each program area.
Procedure
Subcommittees may include:
STAFF DEVELOPMENT
Review Staff Development Requests
Plan and monitor Training and Technical Assistance Plan
Organize Trainings
Review and analyze evaluations of trainings
Meets monthly
Membership: One member from each area Fiscal Specialist I, parent, and leadership.
Facilitator: Assistant Director
QUALITY IMPROVEMENT COMMITTEE
Planning program improvement
Analyzing program operations
Brainstorm and Problem Solve
Visionaries for program – holistic view
Looking at outcomes – integrated approach
Look at all program models
Meets monthly
Membership: Assistant Director, Administrative Services Manager, one member from each area,
office, nutrition, parent, and leadership.
Facilitator: Director
BUDGET COMMITTEE
Analyze the budget
Give input into the development
Recommendations
Monitor Inkind Report
Meets bi-monthly Nov., Jan., March and May
Membership: Director, Treasurer Policy Council, one other PC member, one direct service staff,
one Area Manager, Fiscal.
Facilitator: Fiscal Specialist
MSYS 1b
2 (C: 10/02: R: 08/15)
NUTRITION COMMITTEE
Menu Planning
Workplan Development
USDA Observations
Analyze continuous improvement – make recommendations
Multi-cultural aspect
Meets quarterly
Membership: Director; one member from each area, Area Manager, Cook, EHS Family
Educator and one parent from each area.
Facilitator: Food Service Supervisor
INTERVIEW COMMITTEE
Interviewing candidates
Reviewing applications/résumés
Making recommendations to the President of the College and to Policy Council
Meets as needed
Membership: Policy Council member, Director, Assistant Director, and Leadership Team
Representative.
Facilitator: Director
EDUCATION OUTCOMES COMMITTEE
Review and analyze outcomes in accordance to outcomes measures and Kindergarten
readiness.
Analyze and problem solve outcomes three times yearly with Teaching Strategies Gold.
Revise and design current/and future Policies and Procedures regarding Education and
individualization.
Meets monthly
Membership: Assistant Director, Mentor Specialist, Area Manager(s), one lead teacher from
each area, one assistant teacher, community member, parent.
Facilitator: Child Development Specialist
WELLNESS/SELF-CARE COMMITTEE
Look at ways to encourage wellness throughout the program; i.e. News Notes, etc.
Promote a wellness program.
Meets every other month November, February & April
Membership: One member from each area
Facilitator: Assistant Director
MSYS 1b
3 (C: 10/02: R: 08/15)
FAMILY SERVICES/PARENT ENGAGEMENT COMMITTEE
Review Policies/Procedures in regards to Family/Community Services/Parent
Engagement.
Field questions regarding ChildPlus and provide guidance for continued training.
Plan and support parent education activities such as: ELL, GED, POP, Family Nights
and Support Groups.
Look at ways to develop a Parent Engagement program.
Meets every other month October, December, February & April
Membership: Director, one family advocate from each area, Area Manager, EHS Supervisor,
interpreter, one lead teacher, parent.
Facilitator: Area Manager / Family Services Content Specialists
RECRUITMENT/SELECTION COMMITTEE
Coordinate and plan recruitment efforts for program
Distribute fliers, posters and information to agencies
Develop Recruitment Plan & Selection Criteria; submits to Policy Council for approval
Meets quarterly until January then monthly.
Membership: Community Partnership/Public Relations Specialist, ERSEA Program
Coordinator; Interpreter, Family Advocate; one member from each Area; Director; three parents.
Facilitator: Community Partnership/Public Relations Specialist
HEALTH SERVICES ADVISORY COMMITTEE
The Health Services Advisory Committee addresses program issues in the medical, dental,
mental health, nutrition, and human services fields.
Meets quarterly: November, March, May
Membership: Community Representatives, Director, Mental Health Consultant, Nutrition
Consultant, Health Consultant, Oral Health/ABCD Coordinator, Disabilities Specialist, Family
Services Specialist, Content Experts, and a parent from each program (HS/EHS/ECEAP).
Facilitator: Health Specialist
TRANSPORTATION COMMITTEE Workplan Development
Analysis and problem solve transportation issues
Mentor staff on transportation regulations
Meets quarterly: October, February, May
Membership: Transportation Liaisons (LCC West / East, Barnes, Broadway), Director, Program
Coordinator, and parent.
Facilitator: Transportation Manager
MSYS 1b
4 (C: 10/02: R: 08/15)
CHILDPLUS COMMITTEE Review, update, and plan implementation of ChildPlus.net information management
system.
Meets: November, February, March, April
Membership: Area Manager, EHS Staff, Health Specialist, Two Lead Teachers, Two Family
Advocates
Facilitator: Computing Support Specialist
Policy complies with Head Start Performance Standard 1304.50(d)(1)(iv).
Lower Columbia College Head Start / ECEAP MSYS 1c
PROGRAM PLANNING AND MANAGEMENT The program’s planning, assessment and coordination of: components, monitoring and evaluation processes.
MILESTONE CHART OF PROGRAM ACTIVITIES
D = Director AD = Assistant Director AM = Area Manager ASM = Administrative Services Mgr. HNS = Health/Nutrition Specialist DIS=Disabilities Spec.
LT = Leadership Team PC = Policy Council FA = Family Advocate SDC = Staff Development Committee CPRS = Community/Public Relations Specialist (C: 09/02; R: 08/15)
MAJOR TASK / ACTIVITY A
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Person(s)
Responsible Monitored
By
Date
Comp.
Develop Program Planning Calendar X D PC
Complete Annual Community Assessment X X X D/CPRS PC
Annual Review of Program Options X LT PC
Developing Program Long/Short Term Goals and
Objectives, Timetables and Budgets
X D/LT PC
Review Written Workplans Based on Content Area
Objectives
X X X LT/D PC
Monitoring Processes X X X X X X X X X X X X LT PC
Train Self-Assessment Team X X LT PC/Grantee
Complete Annual Self-Assessment X X PC/D PC/Grantee
Develop Grantee Improvement Plan X X PC/LT PC/Grantee
Staff Development Process X X X X X X X X X X SDC Chair D
Develop Calendar of Program Year X X ASM/LT D
Establish HSAC and Timeline for Meetings X HNS D
Review Internal Communications Systems X LT D
Elect and Train Policy Council Representatives X X D PC/Grantee
Elect Policy Council Officers X D/AD/CPRS PC/Grantee
Train Policy Council Officers X D PC/Grantee
Train College Governing Body/Cabinet X D D
Grant Application Process X X X X X X D/ASM/PC PC/Grantee
Update Tracking Forms to Most Recent PIR X X LT D
Orientation of New Staff X X X X X ASM D
Review EOM Program Monitoring Reports X X X X X X X X X X X X LT/PC/
Grantee
D/PC/
Grantee
Staff Training Plan X X X LT/SDC D
USDA Application/Renewal X X ASM/HNS D
United Way Grant X X X D/ASM PC
Interagency Agreements X X X DIS D
Leases X X X X LCC Bus. Off. D
Contracts X X D D
MSYS 2a1
Lower Columbia College Head Start / EHS / ECEAP
Request for Information
Child’s Name: ____________________________________
Enrollment Year: _________________________ Date of Request: __________________
Parent /Guardian Name: ____________________________ Teacher: ________________
Specify Information Requested: ___________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________
Signature of Person Requesting Information
_________________________ ____________________________________
Date Completed Signature of Person Providing Information (R: 08/10; C: 10/06)
MSYS 2a1
Lower Columbia College Head Start / EHS / ECEAP
Request for Information
Child’s Name: ____________________________________
Enrollment Year: _________________________ Date of Request: __________________
Parent /Guardian Name: ____________________________ Teacher: ________________
Specify Information Requested: ___________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________
Signature of Person Requesting Information
_________________________ ____________________________________
Date Completed Signature of Person Providing Information (R: 08/10; C: 10/06)
MSYS 2a
pg. 1 (C: 04/03; R: 08/15)
Lower Columbia College Head Start / EHS / ECEAP
Confidential Communication Policy
Policy
The confidentiality of communications in the Lower Columbia College Head Start / EHS /
ECEAP clearly indicates the moral obligation of staff, parents and volunteers to keep private any
information involving Head Start / EHS / ECEAP families. The relationship between staff,
parents and volunteers is based on trust and any information obtained by conversation or
observation at a Head Start / EHS / ECEAP Center, on home visits or on any program-related
activity is to be discussed only at appropriate family staffings. Only authorized staff may consult
family records and such information will be disclosed to other persons and agencies only if
consent forms have been signed by the parent.
It is not ethical for any staff or volunteer (parents, community volunteers, interns, Foster
Grandparents or work study) to disclose information, discuss or listen to conversations
concerning Head Start / EHS / ECEAP families.
All staff and volunteers will be trained on the Confidentiality Policy and sign a Confidentiality
Statement annually.
"No state officer or state employee may accept employment or engage in any business or
professional activity that the officer or employee might reasonably expect would require or
induce disclosure of unauthorized confidential information acquired by the official or employee
by reason of the official's or employee's official position. No state officer or state employee may
disclose confidential information gained by reason of the officer's or employee's official position
or otherwise use the information for his or her personal gain or benefit or the gain or benefit of
another. No state officer or state employee may disclose confidential information to any person
not entitled or authorized to receive the information. No state officer or state employee may
intentionally conceal a record if the officer or employee knew the record was required to be
released under chapter 42.17 RCW, was under a personal obligation to release the record, and
failed to do so. This subsection does not apply where the decision to withhold the record was
made in good faith." (Excerpt from RCW42.52.050.)
Procedure
Confidentiality of Child/Family/Staff files and information:
1. All information on children, families and employees obtained by staff, consultants, and
volunteers is confidential.
2. Head Start/EHS/ECEAP child/family file information will not be shared with outside
agencies without written parent/guardian consent, except for contracted consultants,
requests from Child Protective Services, or a subpoena or judicial order.
3. Parents are informed of the confidentiality policy at the Parent Orientation, home visits
and in the Parent Handbook.
4. Staff, consultants, and volunteers are informed of the confidentiality policy and sign a
confidentiality agreement each year.
5. Information collected by outside agencies or persons, and forwarded with parental
consent to our program, becomes part of the child/family file and thus the responsibility
of our program.
MSYS 2a
pg. 2 (C: 04/03; R: 08/15)
6. The child/family file will not be removed from the program’s center or site location
without the approval of the direct supervisor and/or Director/Assistant Director.
7. These protective measures for information include both written documents and verbal
discussions about children, families, and staff.
Access to Child/Family/Staff Files
1. Parents/Guardians requesting specific information from the child/family site file must fill
out the Lower Columbia College Head Start/EHS/ECEAP Request for Information Form
(MSYS 2a1). Staff will check the parents/guardian identification to ensure that they are
legally entitled to view the children’s records and/or information. A copy of this form is
to be given to the direct supervisor. The original form is to be placed behind the “File
Sign Out form” in the Child/Family Site file.
2. Access to the specific request of information or record will be within ten (10) working
days. A confidential envelope will be used by staff to place any specific information that
is copied as a result of the request. Staff member must sign the File Sign-Out form
(MSYS 7k) stating the purpose. Document all information in ChildPlus.
3. If the child’s file contains information about another child, the staff will allow the
parent/guardian to view only those materials or parts of the file that contains information
about their child.
4. A staff member must remain with the parent/guardian when the file is being reviewed and
will not allow the parent to take the file from the premises.
5. Head Start/EHS/ECEAP Direct Service Staff, Supervisory staff and authorized federal
and state auditors have access to information and files of enrolled children and families
when needed for performance of their duties. (See also MSYS 7c – Individuals Having
Access to Records)
6. Conversations about children, families, or staff must be avoided outside of the workplace.
7. Disclosure of information and files to individuals and agencies outside of our program,
including school districts, will not be made without the written consent of the parent or
guardian on a Parent/Guardian Permission to Reveal or Obtain Confidential Information
form (ERSEA 1d). Reporting cases of suspected child abuse and neglect or responding
to court subpoenas are exempted from this policy, as set forth in Washington State law.
8. Computer systems containing personal information about children, families and
employees are kept secure with a User Name/Password security system, assuring access
only to the appropriate staff.
Storage of Files:
1. When not in use, all children, family and employee files are stored in locked cabinets.
Children’s records are not to be left unattended on desks, tables, or places where others
have access to them.
2. At the end of the program year, the files for returning children will be returned to the
Head Start/EHS/ECEAP Administration Office where they are secured in a locked file
cabinet. Files of non-returning children will be archived for three years, plus the current
year in a locked secure location at the HS/EHS/ECEAP Administration Office. After
three years the child/family files are shredded.
MSYS 2b
(C: 08/97; R: 07/12) 1
LOWER COLUMBIA COLLEGE HEAD START/EHS/ECEAP
Acronyms, Terms, and Definitions
*ACF – Administration for Children and Family – The branch of the Department of Health &
Human Services that administers Head Start and other programs concerned with children and
families.
Audit – An assessment of the total Head Start program designed in conformance with the National Head
Start Performance Standards to validate or invalidate the local program self-evaluation.
*BIA – Bureau of Indian Affairs (Federal).
Board of Directors – The group of people that has the legal responsibility of setting the purpose and
policies of an organization. Refers to either grantee or delegate agencies.
By-Laws – The common rules agreed upon by an organization under which it operates.
CA – Community Assessment – A survey in which data is gathered on the specific needs of the low-
income families in the community and the resources available to meet them.
CAA – Community Action Agency – An organization, either public or private nonprofit, which is
funded to administer and coordinate on a community-wide bases, a variety of antipoverty
programs (formerly funded by OEO or CSA).
CAN – Child Abuse and Neglect
CAP – Community Action Program – An organization either public or private nonprofit, which
receives block-grants and other funds to develop and administer community action projects in a
specified area. Such agencies are broadly based, organized on a community wide basis and
coordinate a variety of antipoverty activities. The grantee for Head Start programs is often a
CAP. (Often used to mean the same as CAA at the local level).
CCHD – Cowlitz County Health Department
CCS – Crippled Children’s Service – State program. Payment for services. Income eligibility,
managed by Parent & Child Health Services/DSHS and local county health departments.
CD – Communication Disorder – State education’s eligibility category for children exhibiting specific
expressive, receptive and/or articulation delays or disorders.
CDA – Child Development Associate Program – An individualized, competency-based assessment and
credentialing program for early childhood staff. Credentials are granted to candidates who
demonstrate competencies in six competency goals and thirteen related functional areas.
Training is also provided to improve staff performance in these areas and to help staff attain the
CDA credential.
CDMRC – Child Development and Mental Retardation Center – A university-affiliated facility
specializing in interdisciplinary research and training in the field of developmental disabilities.
Housed on the University of Washington campus, Seattle.
MSYS 2b
(C: 08/97; R: 07/12) 2
CDRC – Children’s Development Rehabilitation Center – A Department of Oregon Health Sciences
University, Portland
CEC – Council for Exceptional Children – Special Educators’ professional organization. Local, state,
national.
CEF – Child Enrollment Form (ECEAP)
Center Committee – A committee composed of all parents who have children enrolled in a particular
Head Start center, which works with teachers and other staff to determine what kind of education
and learning experiences children will receive.
CFDS – Child and Family Development Specialist for Early Head Start
CHMC – Formerly known as Children’s Orthopedic Hospital, a tertiary care facility offering a wide
range of pediatric specialties and labor intensive services. Located in Seattle, CHMC is a Level
III Neuromuscular Center.
Cluster – Several Head Start programs grouped together geographically for the purpose of training.
COH – Children’s Orthopedic Hospital – Now known as Children’s Hospital and Medical Center.
Component Plan (Work Plan) – A written plan for each of the program components, which details the
goals, objectives, and strategies that the program will pursue to meet component objectives.
COLA – Cost of Living Adjustment
CMH – Comprehensive Mental Health – Referent for community-based mental health programs most
often funded (in part) by state, federal mental health dollars.
Community Representative – Any member of the Policy Council who is not a parent of a currently
enrolled child (e.g., past parents, agency representative, or persons interested in child welfare).
Component – A work used to refer to the various parts of the total Head Start program (education,
social service, mental health, nutrition, health, administration, special needs and parent
involvement).
CPS – Child Protective Services – State program within Children Youth and Family Services/DSHS.
Monitors complaints of child abuse and neglect, provides services to families to reduce child
abuse, monitor out-of-home placements to hasten child’s return to natural family.
CSBG – Community Services Block Grant – State funding for CAP’s.
CTED – Department of Community, Trade, and Economic Development – State agency responsible
for the development of community programs including energy assistance and weatherization
programs.
DA – Delegate Agency – An agency to which responsibility is delegated by the Grantee for the
operation of a total Head Start program or a significant portion.
MSYS 2b
(C: 08/97; R: 07/12) 3
DCCDC – Day Care and Child Development Council – A national private non-profit, membership-
supported agency which is dedicated to the establishment of a system of child care for all
families who need it.
DD – Developmentally Disabled – Category used generally across the Division of Developmentally
Disabled for children, youth and adults who meet Division eligibility criteria. Criteria vary by
age of the client.
DDD – Division of Developmental Disabilities/DSHS – Provides home aid services to eligible clients
including respite care. Provides funding for early intervention services at the local level.
Disabilities eligibility only. Regional offices across the state.
DDPC – Developmental Disabilities Planning Council – A Governor-appointed interagency council
with staff housed within the Dept of Community Development, which serves as a major planning
body for children, youth, and adults with developmental disabilities.
DEL – Department of Early Learning, Olympia, WA
Delegate Agency – see DA.
DHHS – Department of Health and Human Services – Federal agency responsible for all federal
programs dealing with health and welfare.
DHP – Developmentally Handicapped Preschool – State education eligibility category for
developmentally delayed preschool children in the public school system, birth to six years only.
Double Session – The scheduling of two classes of children (morning and afternoon) per day in the
same classroom.
DSHS – Department of Social and Health Services – Statewide agency with six regional divisions.
Provides wide range of direct and contracted health and social services to Washington’s most
vulnerable citizens. Service system divisions include: Children, Youth and Family Services;
Health and Rehabilitation Services; Economic and Medial Services; Aging and Adult Services;
and Productivity and Administration.
DST – Direct Service Team – Teacher, Family Advocate and Teacher Assistant
ECDAW – Early Childhood Development Association of Washington – Statewide, primary service
provider/advocate organization serving 0-3 special needs children.
ECEAP – Early Childhood Education and Assistance Program/Department of Early Learning
(DEL) – State Program based upon income eligibility. Available at selected sites across
Washington.
ECLKC – Early Childhood Learning & Knowledge Center
ED – Emotionally disturbed.
EHS – Early Head Start serves pregnant women and children birth to three years.
MSYS 2b
(C: 08/97; R: 07/12) 4
ELL – English Language Learners
ELMS – Early Learning Management System (ECEAP)
ERIC – Educational Resources Information Center – A national network for collecting and
disseminating the most significant and timely educational research.
ESDs – Educational Service Districts – Regional clusters of school districts makeup educational
services districts which offer a variety of support services to school districts including technical
assistance and discretionary funds to public school special education preschool programs.
FHC – Family Health Center
FSA – Family Strengths Assessment.
FY – Fiscal Year – The 12-month period of funding start to end.
GED – General Education Development – A test for people 19 years and over which certifies
educational competence in lieu of a high school diploma.
GIP – Grantee Improvement Plan – A planning document that specifies how programs will institute
needed improvements or achieve compliance with performance standards.
GQP – Group of Qualified Professionals – Meeting held to determine the eligibility status of a child
with suspected delays.
Grant – Money, which is provided to conduct a specific program, which is described in the grant
application.
Grantee – A public or private agency which receives funds directly from a federal governmental agency
to conduct a particular program itself or may give some of the money to a delegate agency to run
part of the program (receives funds directly from ACF to operate Head Start programs).
HHS – Health and Human Services – Federal agency responsible for all federal programs dealing with
health and human services. Washington is part of Region X with administering offices in Seattle.
This agency houses most of the federal human service programs that states administer (i.e. Office of
Head Start, Maternal and Child Health, etc.).
HI – Health Impaired – State education’s eligibility category for children who experience health
impairments which impact the opportunity for them to benefit from their academic programs.
Home Base – A Head Start program option that focuses on parents as educators and includes regular
home visits by an assigned home visitor who works with families and supports parents in
meeting the needs of their young children.
HSAC – Health Services Advisory Committee – Each Head Start program must have a HSAC made
up of health professionals and parents of Head Start children. The function of the committee is
to advise in the planning, operation, and evaluation of the health service program for Head Start
children.
MSYS 2b
(C: 08/97; R: 07/12) 5
Home Visitor – The primary contact with families in the home-based program option. The home visitor
works with parents to enhance their capabilities as educators of their children. He/she assists
parents in identifying their children’s strengths and needs, share information, discusses parent
concerns, and plans and carries out small and large group activities for children and parents.
IEP – Individual Education Plan – An individualized education plan for the provision of special
education services to Head Start/ECEAP children.
IEP Meeting – Meeting including the child’s parent, specialist, IEP Case manager, child’s teacher and
any visitor the parent wishes to invite for the purpose of developing the child’s individual
education program.
IFSP – Individualized Family Service Plan – Key component for P.L. (Public Law) 99-457’s Early
Intervention Services. Combines all the “IPs” various systems required into one document.
Children 0-3 years.
ILP – Individual Learning Plan – Each child has an individual learning plan developed to support
their growth and developmental needs while participating in Head Start. The plan is developed
by the child’s teacher and parent based on the assessment tool information and parent’s goals for
their child.
*Indian Program Division – An office in the National Head Start Bureau, which administers funds to
all Indian Tribal Head Start grantees in all Federal regions.
*In-Kind – The volunteer hours and donations needed in order to keep getting money from the federal
government to run Head Start.
In-Service Training – An on-going job related learning experience for Head Start/ECEAP employees,
which takes place during employment hours.
LEA – Local Education Agency
LD – Learning Disabilities – State education eligibility category for school-age children exhibiting
specific behaviors and levels of academic performance.
LDO – Locally Designed Option – A variation in the Head Start program design developed by the
local grantee to meet the unique needs of the area. Said variation must meet OCD’s criteria and
is consistent with good child development practices.
LICWAC – Local Indian Child Welfare Advisory Council – Reviews child welfare cases at the local
level, which have come to the attention of the state children’s services system.
MDT – Multi-disciplinary Team – A team used by the LEA (as per 94-142) for interdisciplinary
research, training, and treatment facilities, and Child Protective Services. This team may have
slightly different meanings for each of these systems. (Use term with care.)
MH – Multiple Handicapped – State education’s eligibility category for children with two or more
handicapping conditions (excluding learning disabilities).
MSYS 2b
(C: 08/97; R: 07/12) 6
*Migrant Programs Divisions – An office in the National Head Start Bureau, which administers funds
to all Migrant Head Start grantees in all Federal regions.
MR – Mentally Retarded – State education’s eligibility category for children exhibiting varying
degrees of cognitive delay.
NAEYC – National Association for the Education of Young Children – An organization, which
publishes materials and holds a yearly national conference for the development and education
needs of young children.
Needs Assessment – A community will conduct a survey in which data is gathered on the specific needs
of low-income families in the community and the resources available to meet them.
NFA – Notice of Financial Assistance – The document which specifies the terms and conditions of the
grantees grant award. It is prepared and sent by ACF. This document replaces the one
previously known as the Notice of Grant Award (NGA).
OHDS – Office of Human Development Services – The agency in the Dept. of Health and Human
Services responsible for the Administration for Children, Youth, and Families.
OHS – Office of Head Start – Responsible for ensuring grantees follow Federal regulations.
OHSMS – Office of Head Start Monitoring System. Protocol used to determine Head Start program’s
level of compliance with Federal Performance Standards.
OI – Orthopedically Impaired – State education’s eligibility category for children exhibiting
orthopedic handicaps which impact the opportunity for them to benefit from their academic
programs.
OHSU – Oregon Health Sciences University. Portland, OR
OSEP – Office of Special Education Programs – Federal education agency branch administering
education funds for special education and related programs. Is a part of the Office of Special
Education and Rehabilitation Services (SERS) within the Department of Education.
OSPI – Office of the Superintendent of Public Instruction – State agency providing funding,
technical assistance, and guidance to local education agencies. Often referred to as “the SEA
(State Education Agency)”. Provides program support to six educational service districts and
five local education agencies in basic education, vocational education, special education and
professional programs, as well as food services, transportation, and legal services. Elected
superintendent and 18 member elected state school board.
OT – Occupational Therapist
PA – Program Accounts
PA – Public Assistance or welfare (through DSHS)
PAF – Program Activity Form (ECEAP). Reporting form submitted monthly to ECEAP.
MSYS 2b
(C: 08/97; R: 07/12) 7
PAR – Program Activity Report
PCP – Primary Care Provider
Performance Standard Review – An assessment of the total Head Start program designed in
conformance with the National Head Start Performance Standards to validate or invalidate the
local program self evaluation.
Performance Standards – The overall goal of the Head Start program is to bring about a greater degree
of social competence in children of low-income families. There are many objectives of the basic
components. The program performance standards specify these objectives and constitute Head
Start Policy. Guidance for interpreting and implementing the Performance Standards is
provided. Performance Standards are mandatory, but the guidance is not.
PIF – Program Information Form (ECEAP)
PIR – Program Information Report – The form that provides quantitative information on key
characteristics of each Head Start program, and is completed yearly.
PL 94-142 – The Education of ALL Handicapped Children Act, which provides for a free, appropriate
public education for children with handicaps from age 3 through 21. It sets procedures for
serving the children and for involving the parents in planning their child’s special education
services. (Reauthorized under P.L. (Public Law) 98-199).
Policy Committee – Committee set up at the delegate agency when the program is delegated. At least
50% of the membership of the committee is composed of parents of children currently enrolled
in that program, plus representatives from the community.
Policy Council – A council set up at the grantee level. At least 50% of the members must be parents of
Head Start children currently enrolled in the grantee Head Start program. It may also include
representatives of the community. Where the grantee delegates the Head Start Program to
various agencies (delegate agencies). Each delegate agency has a Policy Committee and
representatives from each Policy Committee help to make up the Policy Council. The Policy
council establishes the goals of the Head Start program and ways to use all the community’s
resources in the Head Start program.
Poverty Index – A federal table of eligibility of families by size of income and numbers of dependents.
Issued Annually.
Pre-Services Training – An orientation and introduction of the general goals and objectives of Head
Start, as well as the more specific plans of a particular Head Start agency for the coming year.
Project Specialist – A member of the Office of Head Start at the Regional Office that provides help and
assistance to the local Head Start programs. Also responsible for monitoring the Head Start
programs to assure compliance with all applicable regulations. Questions about Head Start
policy which cannot be answered in the local program can be directed to this person.
PT – Physical Therapist
Region X – Head Start Region including Washington, Idaho, Alaska, and Oregon.
MSYS 2b
(C: 08/97; R: 07/12) 8
SBD – Seriously Behavior Disordered – State education’s eligibility category for children exhibiting
characteristics and academic delays associated with emotional disabilities.
SDC – Staff Development Committee – A committee at the grantee level composed of staff and/or
parents, responsible for training for all staff and parents in the agency.
Self-Assessment – The process whereby the staff, parents, and community of a local Head Start
program assess their total program’s compliance with the Performance Standards. The OSPRI or
SAVI instruments often used for this. (Also called – self-evaluation).
SIF – Subcontractor Information Form (ECEAP)
SLP – Speech and Language Pathologist – (Formerly called Speech Therapist)
TANF – Temporary Assistant Needy Families – A federal program giving financial assistance to
families with minor children (under 18) meeting one of the following criteria: 1) Absence, death
or incapacitation of wage earner; 2) Unemployment of primary wage earner.
TNA – Training Needs Assessment – A needs assessment survey tool utilized by component personnel
in each Head Start program to determine training needs. Data from this survey is also utilized to
plan cluster training sessions in each component area.
T/TA – Training and Technical Assistance – Training is provided to Head Start programs in the
following two ways: (1) Training - a group session at which time a trainer instructs the group in
order to make them more proficient; (2) Technical Assistance - on-site technical assistance or
professional advice to the Grantee/Delegate Agency.
Training Plan – A written plan developed by the local training committee of each grantee describing
the training provided by the agency for staff, parents, and volunteers.
*USDA – United States Department of Agriculture – Reimburses for cost of meals/snacks served at
Head Start at a fixed rate for breakfast, lunch, and snack. Requires certain amounts and food
patterns be followed for reimbursement.
VCA – Variation in Center Attendance – A Head Start program option in which some of the children
attend center activities less than five (5) days per week. For some families, this may mean a
combination of center based and home based approaches and others it may mean attending the
center activities from two (2) to four (4) days per week. Shortened hours in the classroom may
be supplemented by a parent education program.
VI – Vision Impaired – State education’s eligibility category for children exhibiting specific behaviors
and levels of academic performance.
WAEYC – Washington Association for Education of Young Children
WIC – Women, Infants, and Children nutrition program – Administered through the Bureau of
Parent and Child Health Services. Contracted services through local health departments and/or
other local vendors. Provides pregnant and lactating mothers, and newborns with nutrition
counseling and food vouchers for nutrients, which promote healthy prenatal, perinatal, and
postnatal development.
MSYS 2b
(C: 08/97; R: 07/12) 9
WSA HS/ECEAP – Washington State Association of Head Start / ECEA Programs – A group
composed of staff, parents, directors, and representatives from each grantee and delegate agency
in the state, meeting together 3-4 times a year to discuss matters of concern to Head Start /
ECEAP. Advises ACF Project Officers concerning Head Start parent needs, and to receive
training.
WorkFirst – A program administered by DSHS to TANF recipients in order to gain economic
independence by removing the barriers to work and reducing poverty while protecting children.
MSYS 2c
(C: 08/03; R: 07/14)
Lower Columbia College Head Start / EHS / ECEAP
Communication Policy and Procedure
Policy
The program will ensure that information is provided regularly to families, the grantee, members of
the policy group and staff.
Procedure
The communication system will include opportunities for the program to share and receive
information on program activities, goals and philosophy, as well as opportunities for parents to share
and receive feedback on their child. Communication may be carried out in a variety of ways, such
as:
Orientation activities;
Regular, informal telephone or face-to-face conversations, or notes in the parents’ preferred
language;
Newsletters;
Home Visits and Parent/Teacher Conferences; and
Email/Text.
In an effort to make communication more effective, the program communicates, whenever possible,
in the parent’s preferred language. Examples of ways to communicate with parents in their primary
or preferred language include:
Using Head Start / EHS / ECEAP bilingual staff;
Collaborating with local organizations, such as ethnic associations, for assistance in
communicating with parents;
Drawing upon parents and members of the local community to obtain bilingual staff and
interpretation services and to ensure sensitivity to family culture and heritage.
The program will use strategies to ensure that members of the governing body and policy group
understand information as specified in the Performance Standards. Strategies will include:
Providing new members of the governing body and policy group with an orientation packet
and appropriate training necessary to understand and participate in collective decision-
making;
Ensuring the policy group and governing body members have adequate preparation time to
review and “digest” material they receive from the program;
Facilitating discussions and an open exchange of ideas on program plans, policies,
procedures, program instructions or information memoranda released by the Office of Head
Start or Department of Early Learning and reports at the meetings of the policy group and
governing body.
The program will support the ongoing exchange of information among staff, will focus on quality of
services, and will represent the best interests of children and families. Effective formal and informal
communication methods include:
Establishing a supportive climate in which open and frequent staff communication is
encouraged and appreciated, so staff can feel free to share their ideas and concerns and
provide constructive feedback to their colleagues and supervisors;
Considering various ways that regularly scheduled staff meetings at all levels of the agency
can be used to facilitate staff input and discussions (See MSYS 1b & MSYS 6a);
Utilizing computer technology to support and enhance staff communication and to minimize
geographical constraints – through electronic mail and Internet access.
Policy complies with Head Start Performance Standard 1304.51(c)(1) & (2), 1304.51(d) and 1304.51(e)
MSYS 2d
(C: 09/03; R: 11/16)
Lower Columbia College Head Start/EHS/ECEAP
Guidelines for Development and/or Revision of Policies & Procedures/Forms
In order to be consistent in approval and formatting of policies and procedures and forms,
the following guidelines are to be followed:
Proposed recommendations/changes/additions will be discussed with the appropriate
Content Area Specialist.
Content Area Specialist or designee will request Word access to document(s) needing
revision from the Program Coordinator.
“Track changes” or “comments” in Microsoft Word will be used to document the
changes.
All proposed revisions/additions of policies, procedures and forms are to be presented to
the Leadership Team for input and approval.
Policy Council and Governing Board approval is required if changes are made to a
policy. Revisions to procedures and forms do not require Policy Council and Governing
Board approval.
If approved, all final revisions to documents are to be given to the Program Coordinator
to be uploaded to the Lower Columbia College/Head Start/EHS/ECEAP Staff Handbook
website. Include a timeline for completion to the Program Coordinator.
Distribution of Policies and Procedures/Forms to Staff
1. The Program Coordinator will put all new policies and procedures/forms on the LCC
Head Start/ EHS/ECEAP website;
2. Revised and or new policies/procedures/forms will be shared with all staff via e-mail
from the Program Coordinator once they have been uploaded to the LCC Head
Start/EHS/ECEAP website.
3. Leadership and managers will determine which information needs to be shared in more
detail at staff meetings and/or monthly area meetings.
MSYS 2e
(C: 11/17)
Lower Columbia College Head Start/EHS/ECEAP Coordination of Services Policy and Procedure
Policy Communication and coordination supports: high-quality early learning experiences; school readiness; family engagement; child well-being (mental health/health/nutrition); full and effective participation for children with disabilities and their families; full and effective participation for dual language learners and their families; enrollment/placement; transitions (in/out/within); effective health and safety practices; and fiscal needs. Intentional and frequent communication ensures services are appropriate and responsive to child/family needs. Procedure Leadership is made up of all Area Managers, Content Area Specialists, Director and Assistant Director with the purpose of information sharing and coordination among members. Relevant communication is then shared throughout the program to Policy Council, Board of Trustees, staff, parents, etc. in a coordinated manner. Leadership meets twice monthly and minutes are shared out to the whole Leadership team. The Content Area Support Team (CAST) is made up of the following participants: Director, Assistant Director, Computer Support Specialist, and Content Area Specialists (Administrative Services, Disabilities, Education, ERSEA, Family Services, Fiscal, Health, and Mental Health). Area Managers and other members of the Leadership team may attend as desired, but it is not required. Minutes are shared out to all Leadership team members weekly. CAST meets weekly with three primary purposes:
Coordination of Program Systems and Operations;
Policy and Procedure development and;
Coordination for individual child and family needs/transitions. Coordination of Program Systems and Operations CAST members work together to implement and revise program systems and operations. At each meeting, Content Specialists provide updates on events and processes currently underway in the program. Examples of these are: LEA Staffings, PLCs, Home Visits and Computer System Updates. Cast members discuss these operations in order to determine and provide planning, coordination and support. Policy and Procedure Development Content Area Specialists will work together in the development/revision of program policies and procedures to ensure a program-wide approach to implementation of Lower Columbia College policies and procedures, federal and state program performance standards, childcare licensing rules, Early Achievers requirements, CACFP regulations; and other funding mandates. Data sources to be used include but are not limited to: community assessment, strategic plan goals, school readiness goals, family assessment outcomes, training and technical assistance plan, self-assessment action plans, on-going monitoring and reporting systems, staff, parent(s)/guardian(s), and community input/feedback. Area Managers may also participate in the development and revision of policies and procedures as interest is identified or assigned via committee, strategic plan team, self-assessment team, etc. The Area Manager works alongside the Content Area Specialist in development and presentation of the policy and procedure at CAST and/or Leadership.
MSYS 2e
(C: 11/17)
New or revised policies are presented to Leadership, Policy Council for approval, then staff and parent(s)/guardian(s) (as applicable). New and revised procedures are presented at Leadership for further input and communicated to staff for implementation. All policies and procedure are maintained and accessible on the program website. Ongoing monitoring is then adjusted and/or begins to ensure continuous improvement and goal achievement. See MSYS 1c, 8a, 8g, and 8g1 for more information about the programs ongoing monitoring system. Coordination for Individual Child and Family Needs/Transitions Children are identified and presented at CAST by Area Mangers, Content Area Specialists, and sometimes staff. Child/Family needs are typically presented at CAST when there is a need for increased coordination and/or decision making, action steps, support services, placement, or plan for continuation of Early Head Start services past the third birthday. Needs may include but are not limited to: high-impacting behaviors, extraordinary safety threat, special health care needs, complex family dynamics, or barriers to accessing community resources, etc. All program services are maintained while a child’s needs are waiting to be presented at CAST (i.e. classroom/home-visiting attendance, screening/referral/evaluation, mental health processes, case management, etc.). Exception: limited use of suspension may be determined through an emergency CAST meeting due to an extraordinary safety threat and will only be temporary. Expulsion is prohibited. Regulations for Suspension and Expulsion located in the Head Start Program Performance Standards 1302.17 and ECEAP Performance Standards E-9 will be followed. CAST serves as an action step catalyst for individualization of services. It does not replace other program processes that include staff and parent(s)/guardians(s) such as LEA/Part C Staffing, Multi-Disciplinary Team Meetings, Child/Family Care Plans, Coaching Coordination, Teacher/Family Advocate staffing, etc. CAST is a support to the leaders who facilitate the mentioned program processes and in parallel supports the staff, family, and child. CAST members utilize tenets of reflective practice to explore with the presenting person/team. A -Mental Health Staffing Form (MH7a) will be used to document the action steps identified at CAST and shared with the staff by the Area Manager. The Child Development Specialist will share the Mental Health Staffing Form (MH7a) in coaching coordination meetings for continuity in services. Documentation of decision-making for individual children will be made in case management by a CAST team member.
MSYS3a
(C: 06/03; R: 04/12)
Lower Columbia College Head Start / EHS / ECEAP
Overview of Communication Between Parents and Staff
Communication is fostered in a variety of ways. Staff communicates with parents through:
Monthly individual class newsletters
Phone calls
Fliers for field trips
Fliers for special events
Volunteer activities
Parent meetings
Parent trainings
Notes Home
Daily contact at child pickup/drop off
Home Visits
Parent / Teacher Conferences
Informational Handouts / Fliers
Email to Text (HS/ECEAP)
Text (EHS)
Surveys
Parent Boards
Interpreters
Website
MSYS 5b
(C: 08/05; R: 08/15)
Lower Columbia College Head Start/EHS/ECEAP
Communication Between Governing Board & Policy Council
Policy
Regular communication and information is supported through open channels of communication
between the Policy Council and governing board to ensure that they receive accurate information
about program planning, policies and agency operations.
Procedure
A. Governing Body Communication
1. The Program Director meets bi-weekly with the Executive Director of the Head
Start/EHS/ECEAP Program / Vice President of Instruction of Lower Columbia College
to give an update of program operations.
2. The Vice President of Instruction meets weekly with the Lower Columbia College
Cabinet at which time information can be conveyed regarding the Head
Start/EHS/ECEAP program.
3. The Vice President of Instruction also meets monthly with the Lower Columbia College
Board of Trustees, which provides a conduit between Lower Columbia College and Head
Start/EHS/ECEAP.
4. The Program Director attends the Lower Columbia College Operational Council
meetings monthly to exchange information regarding Head Start/EHS/ECEAP with the
department chairs on campus. Monthly Operational Council minutes are shared with the
Board of Trustees.
5. The Program Director presents a report to the Board of Trustees twice yearly.
6. The Program Director meets quarterly or as needed with the College Cabinet.
B. Policy Council Communication
1. Policy Council is informed by mail and/or e-mail one week in advance of the regularly
scheduled meeting with a packet containing an agenda for the upcoming meeting,
minutes from the previous meeting, Policy Council Executive Committee minutes and
any information needed to prepare for discussion or vote on action items at the upcoming
meeting, along with any other information that needs to be approved
2. Handouts at the Policy Council meeting will include: monthly program reports regarding
activities, health and nutrition, disabilities, enrollment, budget, inkind, training materials,
information from Region X and HHS Informational Memorandums.
3. The Vice President of Instruction attends monthly Policy Council meetings.
4. Policy Council minutes, current budget, inkind reports, monthly Program Information
Report are sent to the Governing board and staff monthly to keep them abreast of the
status of the Head Start/EHS/ECEAP program.
Policy relates to Performance Standard 1304.51 (d); 1304.50(d)(1)(ii)
MSYS 5b
(C: 08/05; R: 08/15)
Lower Columbia College Head Start/EHS/ECEAP
Comunicación entre el Consejo Directivo y la Mesa Directiva
Política
La información y la comunicación regular es apoyada a través de canales abiertos de
comunicación entre la Mesa Directiva y el Consejo Directivo para asegurar que ellos reciban
información precisa sobre la planeación, políticas y operaciones de la Agencia.
Procedimientos
A. Comunicación del Consejo Directivo
1. El Director del Programa se reúne cada dos semana con el Director Ejecutivo del
Programa Head Start / EHS / ECEAP / Vicepresidente de Instrucción del Colegio Lower
Columbia para darle una actualización de las operaciones del Programa.
2. El Vicepresidente de Instrucción se reúne semanalmente con el Gabinete del Lower
Columbia para comunicar la información acerca del Programa Head Start/EHS/ECEAP.
3. El Vicepresidente de Instrucción también se reúne mensualmente con el Consejo
Administrativo del Colegio Lower Columbia, y funciona como conducto entre el Colegio
Lower Columbia y el Head Start/EHS/ECEAP.
4. El Director del Programa asiste a las reuniones mensuales del Consejo Operacional del
Colegio Lower Columbia para intercambiar información acerca del Head Start / EHS /
ECEAP con los Directores de Departamento en el Colegio. Las minutas mensuales del
Consejo Operacional son compartidas con el Consejo Administrativo.
5. El Director del Programa presenta un reporte al Consejo Administrativo.
6. El Director del Programa se reúne cada tres meses con el Gabinete del Colegio.
B. Comunicación de la Mesa Directiva
1. La Mesa Directiva regularmente es informada por correo o correo electrónico una semana
antes de la reunión programada a través de un paquete que contiene la agenda de la
próxima reunión, las minutas de la reunión anterior, las minutas del Consejo Ejecutivo de
la Mesa Directiva y cualquier otra información necesaria para prepararse para la
discusión o voto en los asuntos de acción en la próxima reunión junto con otra
información que necesite ser aprobada.
2. Los folletos en la reunión de la Mesa Directiva incluirán: reportes mensuales de las
actividades del programa, salud y nutrición, discapacidades, inscripción, presupuesto,
trabajo voluntario, materiales de capacitación e información de la Región X y
memorándums de información de HHS.
3. El Vicepresidente de Instrucción asiste a las reuniones mensuales de la Mesa Directiva.
4. Las minutas de la Mesa Directiva, actualización del presupuesto, reportes del trabajo
voluntario, reporte de información mensual del Programa son enviados mensualmente al
Consejo Administrativo y al personal para mantenerlos al tanto de la situación del
programa Head Start/EHS/ECEAP.
Politicas relativas a las Normas de Operacion 1304.51 (d); 1304.50(d)(1)(ii)
MSYS 6a
(C: 06/03; R: 10/17)
Lower Columbia College Head Start/EHS/ECEAP
Overview of Communication Among Staff
Staff has the following opportunities to network and receive program information:
Staff Surveys
Director’s Update
Family Advocate Meetings
Professional Learning Communities for Education Staff
Direct Service Team Staffing
Area Meetings
Food Service Meeting Reports
Leadership Meetings
Content Area Support Team (CAST) Meetings
Office Staff Meetings
Policy Council Minutes
Pre-Service/In-Service Trainings
Committee Reports
Memos
Website
Telephone Calls
Program Calendar
Flyers
Policy and Procedure Updates
The staff who creates the communication keeps it on file electronically for three years.
To:__________________________________
From:_________________ Date: __________
Comments:
Sue Karen Chelie Carmen
Mindy Carleen Cheri Rick
Cianna Paul Teresa Erin
Suzanne Laurie Julie Kim
ROUTING MEMO
To:__________________________________
From:_________________ Date: __________
Comments:
Sue Karen Chelie Carmen
Mindy Carleen Cheri Rick
Cianna Paul Teresa Erin
Suzanne Laurie Julie Kim
ROUTING MEMO
ROUTING MEMO
To:__________________________________
From:_________________ Date: __________
Comments:
Sue Karen Chelie Carmen
Mindy Carleen Cheri Rick
Cianna Paul Teresa Erin
Suzanne Laurie Julie Kim
ROUTING MEMO
To:__________________________________
From:_________________ Date: __________
Comments:
Sue Karen Chelie Carmen
Mindy Carleen Cheri Rick
Cianna Paul Teresa Erin
Suzanne Laurie Julie Kim
MSYS 6c MSYS 6c
MSYS 6c MSYS 6c
To:__________________________________
From:_________________ Date: __________
Comments:
ROUTING MEMO
To:__________________________________
From:_________________ Date: __________
Comments:
ROUTING MEMO
ROUTING MEMO
To:__________________________________
From:_________________ Date: __________
Comments:
ROUTING MEMO
To:__________________________________
From:_________________ Date: __________
Comments:
MSYS 6d MSYS 6d
MSYS 6dMSYS 6d
MSYS 6f
Distribution: Original-Personal File Copies – 1) Supervisor (C: 08/15)
Lower Columbia College Head Start/EHS/ECEAP Mobile Computing Device - Procedure
Mobile Device: Any device that can be easily transported and that has the capability to store process or transmit data, including but not limited to laptops, portable hard drives, USB flash drives, smartphones, tablets, handheld PCs. Statement: Every member of Lower Columbia College Head Start/EHS/ECEAP community who utilizes a laptop computer or Mobile Device (e.g. IT portable hard drives, IT USB flash drives cell phones, tablets, IT cameras) is responsible for the Lower Columbia College Head Start/EHS/ECEAP data stored, processed or transmitted via that computer or Mobile Device and for following the security requirements set forth in this procedure and in the Lower Columbia College Information Security Policy. Procedure: The purpose of this procedure is to comply with federal regulations governing privacy and security of information, and to protect non-public information in the event of physical theft of a laptop computer or Mobile Device or loss, electronic invasion, or unintentional exposure of non-public information. Guidelines for Mobile Computing Security: While it may seem like no data is safe in this technological age, users can greatly decrease the likelihood of a security breach on their devices by adhering to the following mobile computing security guidelines. External Identification: Label mobile devices with name and telephone contact information so lost devices can be returned, even after their battery has gone dead. Configuration: Lower Columbia College Information Technology department and/or Lower Columbia College Head Start/EHS/ECEAP Computing Support Specialist will ensure that mobile computing devices are configured with approved and properly updated software-based security mechanisms including anti-virus, anti-spyware, firewalls, and intrusion detection. Lower Columbia College Head Start/EHS/ECEAP users shall not bypass or disable these security mechanisms under any circumstances. Limiting Data Storage: One of the best ways to prevent the compromise or loss of sensitive data is not to store it on a mobile device. Such data can be downloaded and stored on Lower Columbia College proprietary server. Means of access must be thoroughly secured, or there is no advantage to be gained from keeping sensitive data off a mobile device. Passwords and Timeouts: Passwords and timeouts prevent—or at least delay—unauthorized users from gaining access to sensitive data not only on lost or stolen devices, but also on devices left unattended in homes and offices. Entering a password at the beginning of every session is required. Passwords will be set by Lower Columbia College Information Technology department and/or Lower Columbia College Head Start/EHS/ECEAP Computing Support Specialist and are NOT to be changed. A relatively brief timer to shut down and lock the mobile devices when left idle for even a few minutes will also be set. Trusted Sources: Mobile devices can add/download software from a variety of sources to prevent software contaminated by viruses or other malware, Lower Columbia College Head Start/EHS/ECEAP users are NOT to download or rely only on trusted sources, such as the Apple iTunes Store, Google Play, or the Amazon App Store for Android, without written permission from your Supervisor and/or Lower Columbia College Head Start/EHS/ECEAP Computing Support Specialist.
MSYS 6f
Distribution: Original-Personal File Copies – 1) Supervisor (C: 08/15)
Updates: Hackers and defensive software are engaged in running battles for superiority, so any delay in updating operating systems and/or security systems leaves mobile devices particularly vulnerable. Systems are set to check automatically for updates. Along with the automatic updates, Lower Columbia College Head Start/EHS/ECEAP devices have forced updates between June and August each year. Lower Columbia College Head Start\EHS\ECEAP users can schedule manual updates with the Lower Columbia College Head Start/EHS/ECEAP Computing Support Specialist on a case by case basis. Secure Device: Mobile devices belonging to Lower Columbia College Head Start/EHS/ECEAP are not to be used for personal use. Mobile devices can only be removed from Lower Columbia College Head Start/EHS/ECEAP premises if authorized by Supervisor and check out form has been completed. Do NOT pass mobile devices between users. Users are responsible for mobile devices that have been assigned to them. If mobile device is no longer needed, return to Lower Columbia College Head Start/EHS/ECEAP Supervisor and/or Lower Columbia College Head Start/EHS/ECEAP Computing Support Specialist for re-assignment. Devices must be stored and locked up when not in use. Lost Device: Users in the possession of Lower Columbia College Head Start/EHS/ECEAP owned mobile devices during transport or use in public places, meeting rooms and other unprotected areas must not leave these devices unattended at any time, and must take all reasonable and appropriate precautions to protect and control these devices from unauthorized physical access, tampering, loss or theft.
Immediately notify Lower Columbia College Head Start/EHS/ECEAP Direct Supervisor and/or Lower Columbia College Head Start/EHS/ECEAP Computing Support Specialist if a mobile device is lost, stolen, or misplaced, and/or the user has determined unauthorized access has occurred. Personal Device: Lower Columbia College Head Start/EHS/ECEAP is not responsible for physical theft, loss, electronic invasion, or unintentional exposure of non-public information on personally owned devices.
I have read and understand this procedure. Print Name Signature Date
MSYS 6g
Distribution: Original-Computing Support Specialist Copies – 1) Supervisor & 2) Employee (C: 08/15)
Lower Columbia College Head Start/EHS/ECEAP Mobile Device Checkout Form
This agreement ensures that Lower Columbia College Head Start/EHS/ECEAP mobile devices checked out by you will be used and maintained according to procedure. By filling out this form, you accept responsibility to demonstrate proper use of specified equipment and abide by the Mobile Computing Device – Procedure. All specified equipment is the property of Lower Columbia College Head Start/EHS/ECEAP and is configured with standard software needed for use. You must not install software of any kind, other than software provided by the Lower Columbia College IT department and/or Lower Columbia College Head Start/EHS/ECEAP Computing Support Specialist. The Lower Columbia College Head Start/EHS/ECEAP Computing Support Specialist is available to provide assistance when needed. Protect the device from damage and temperature extremes. Equipment should not be left inside automobiles, for any period of time. Leaving a laptop or other electronic device in an automobile overnight then using it the following morning can cause damage due to moisture and condensation. You can also damage a device by leaving it in a hot vehicle on a warm sunny day. Use care not to drop your device, place pressure on the interior/exterior of the LCD panel, or eat/drink around the device.
Manufacturer Model # Asset Tag # Serial # Device Type: E.g. Laptop IT portable hard drive IT USB flash drive cell phone tablet handheld PC IT Camera projector
Included Accessories: E.g. carrying case keyboard mouse power cord docking station charger
Full Name Site LOC ID Phone # Supervisor Name Date checked out Date returned Employee Signature Supervisor Approval Signature
MSYS 7a
Policy complies with Head Start Performance Standard 1304.51(g). (C: 08/03; R: 03/16)
Lower Columbia College Head Start/EHS/ECEAP
Record-Keeping Policy and Procedure
Policy
The program will establish and maintain efficient and effective record-keeping systems to provide
accurate and timely information regarding children, families, and staff and will ensure appropriate
confidentiality of the information.
Procedure
Building and Updating When building and updating record-keeping systems, the program will consider:
What information is to be collected;
Who needs to receive the information;
How the information should be stored;
Policy/Procedures & Use of Standard Forms
Current program policies, procedures and standard forms are maintained on the Head Start/ EHS/
ECEAP website.
Program Policies/ Procedures and Forms are also maintained on the computer system of the
Administration Services Manager and Program Coordinator.
Program Policies/ Procedures and Form contents are updated as needed.
The website provides access for and all Program Policies/ Procedures & Forms by staff.
Computer Technology
The program uses several computer database programs that allow staff to share information; quickly
aggregate financial or program data; generate and produce standard forms; and update, store and
retrieve program records quickly and easily.
The program uses the ChildPlus computer program as the main database system for staff personnel
and health/ nutrition information in addition to student enrollment, disability, family services,
education and attendance information.
The program also uses the ELMS (early Learning Management System) for ECEAP documentation
regarding enrollment, Family Services, teacher contact time, center staffing, health/ nutrition, waitlist,
disabilities and screening information.
Confidentiality of Information The program’s policy on confidentiality of information incorporates:
Controlling access to files;
Family permission / consent forms;
Familiarizing relevant staff with all laws governing confidentiality policies;
Recording and Storage of Useful Information
All program staff members are responsible for maintaining and securing confidential records in
appropriate and locked cabinet drawers and shelves or secured and locked storage areas.
Records are stored and maintained according to applicable federal, state and other applicable
governing regulations.
Staff members are encouraged to avoid unnecessary paperwork and files associated with information
duplication.
MSYS 7a
Policy complies with Head Start Performance Standard 1304.51(g). (C: 08/03; R: 03/16)
Transfer of Records
When children and families transition from Head Start/EHS/ECEAP, copies of records will be sent
with written parental consent. A Release of Information form, completed, signed and dated by the
student’s parent/guardian, will be used for this purpose.
Exchange of Information
A Release of Information (ROI) form, completed, signed and dated by the student’s parent/guardian
is required for the exchange of student information to another agency.
White out is not to be used on ROI’s under any circumstance. If a change needs to be made, a single
line will be drawn through it with the original signature’s initials. (Applies to parent portion and
office for data basing.)
If there are any crossed off items and there is information written over the crossed off information:
Redo the ROI. If the parent has initialed written in information, than the ROI is okay.
Include a note to office staff for reasons why there are duplicate or revised ROI’s being submitted to
the office. In turn, office staff will include a note explaining why a ROI was returned so the staff
know what action to take.
MSYS 7b
1 (C: 08/01; R: 08/15)
Lower Columbia College Head Start/EHS/ECEAP
Site File Policy and Procedure
Policy
Site files will be maintained to provide information needed to individualize programs for
children and families, monitor the quality of program services, and to ensure the delivery of
quality services. To ensure confidentiality, safeguards will be implemented and maintained.
Procedure
A Site File will be generated within 24 hours after the Enrollment Intake is completed by the
Program Coordinator or ERSEA Program Support Supervisor. The Program Coordinator or
ERSEA Program Support Supervisor will notify the DST/EHS staff and Area Manager/EHS
Supervisor by e-mail that the site file is ready for pick-up. The Teacher/Family Advocate, EHS
staff and/or Area Manager/EHS Supervisor is to pick up the Site File from the Program
Coordinator or ERSEA Program Support Supervisor within 1-day after notification. Ongoing 1st
Home (Welcome) Visit/Parent Orientation for Head Start/ECEAP is to be completed by the
Family Advocate or Teacher/Family Advocate within three (3) days of receiving the site file.
EHS first home visit is to begin within (7) days of receiving the file. All communication
attempts and/or barriers are to be documented and discussed with your direct supervisor. This
does not exclude a child from attending class before the visit/orientation takes place, if the
following are completed and in the site file when staff receive it. The file must be reviewed prior
to the child starting class to ensure knowledge of medical and/or other special accommodations.
Child Site Files will initially include at least the following:
Applicant Information
Current Family Information
Release of Information Form(s)
WA State Certificate of Immunization Form
WA State Certificate of Exemption Form (if needed)
Immunization Agreement (if needed)
Plan in place for child with a potentially life threatening medical condition
Health History
Parent Agreement Contract
PIR Enrollment Questionnaire
Teachers, Family Advocates, and Child/Family Development Specialists (CFDS) are responsible
for maintaining and securing in a locked file drawer all children’s site files. All files are to be
reviewed before the 1st Home Visit and the first date of school attendance.
Prenatal Site Files will initially include at least the following:
Overview of Required Services for Enrolled Expectant Mother
Applicant Information
Current Family Information
Prenatal Emergency Information Form
WIC Release
Prenatal Health/Dental/Nutrition History
Prenatal Dental Questionnaire
Parent Agreement Contract
MSYS 7b
2 (C: 08/01; R: 08/15)
EHS is responsible for maintaining and securing in a locked file drawer all Enrolled Expectant
Mom site files. All files are to be reviewed before the first 1st Home Visit.
Site File Sign-Out
Place enrolled child’s name (or enrolled expectant mom’s name) on File Sign-out
inside site file front cover.
Each person who reviews the site file must sign the File Sign-Out form (in ink).
Teacher, Family Advocate, Teacher/Family Advocate and CFDS do not have to sign
the File Sign-Out form unless an item is being removed from the site file.
Only those persons listed on the Individuals Having Access to Records Form may
review site files without prior approval of the Area Manager/EHS Supervisor.
Site file sections are arranged in the following order:
Administration
Education
Special Needs
Social Services/Mental Health
Health/Nutrition
Appropriate File Content Forms are at the front of each section of the site file. Forms are to be
placed in the appropriate section of the site file. In the case of multiples of any form, the most
recent date goes on top. Staff is to initial and date the appropriate File Content Form when
documentation is added. Area Managers/EHS Supervisor and Content Specialists will utilize the
File Content Form when reviewing the child's site file for documentation, monitoring and
technical assistance purposes.
Delivery of Forms
In conjunction with their Area Manager/EHS Supervisor, each site/center is to develop a plan
outlining their mail delivery and pick up at the LCC Center. The designated person(s) is to pick
up/drop off site mail daily.
Change of Status Form If a change in child/family status occurs, the DST/EHS staff is responsible for:
Changing/revising information on appropriate forms and reports, i.e., Family
Information Form (ChildPlus Reports: Emergency Notebook, Bus), and class lists;
Documenting change in Case Management
Completing a Change of Status Form;
Name Change – completed as indicated
Student Emergency Contact Change – complete as indicated including
circling of ADD or DELETE
(For those who have multiple changes, write complete additional emergency contact
information on the back of the Change of Status form. Copy both the front and back of
the form to send to the Program Coordinator with the date sent in the lower right hand
corner. Be sure to indicate that information continues on the back of the form).
Parent/Guardian signature and/or signature of staff member verifying the changes
is required for all of the above items.
Withdraw/Transfer – Transfer Date, Withdrawal Date and information are
routed to the Program Coordinator and/or ERSEA Program Support
Supervisor within 1-day of change.
MSYS 7b
3 (C: 08/01; R: 08/15)
Change of Insurance or Medicaid Information or providers – complete as
indicated
Other – include any additional information not previously included, i.e.,
restraining orders, custody papers, changes in spouse, births, blended families,
foster child, etc.
Routing/Data Entry/Retention of Records
A copy of the Change of Status form is routed to and received by the Program Coordinator for
data entry within 72 hours of change. The original signed Change of Status Form is retained
in the child's site file in the Administration Section.
After data entry, the copy of the Change of Status form will be dated and initialed in the lower
right corner and returned to the DST/EHS staff along with 1 copy of the Family Information
Form for the Child's Site File. Verify/Check information on the Family Information Forms
against the current Change of Status before placement. The copy of the Change of Status Form
is to be shredded.
The original signed Family Information Form completed at intake is to be permanently retained
in the child's site file. Upon receipt of Family Information Form updates, all previous copies
(with the exception of the original of the Family Information Form in the Child's Site File) are to
be shredded.
Change of Status for Bus Drivers The DST is to copy the Change of Status form for the bus driver indicating any changes to
phone, address or emergency contact.
Enrolled Family Health Database Information Head Start/EHS/ECEAP staff are to view health information on the ChildPlus database monthly
or more often.
Return of Site Files
As a child transfers or withdraws from the program, the Family Advocate or CFDS will do the
following:
E-mail the Program Coordinator and/or ERSEA Program Support Supervisor and Area
Manager/EHS Supervisor.
Complete a Head Start/ECEAP Child/Family File Transfer/Withdrawal Checklist form
(FS/PI 7k) or EHS Child/Family File Transfer/Withdrawal Checklist form (FS/PI 7k1)
and Change of Status Form. Place on top of the file when it is returned to the office.
Complete case management and make sure everything is in order in the site file (i.e. all
forms/notes are to be in the proper sections). Teaching Strategies Gold needs copied and
placed in file.
Deliver the Site File including the Working File into the office within 5 working days of
withdrawal to the Program Coordinator and/or ERSEA Program Support Supervisor. The
Area Manager will be notified when the file is received.
Deliver the Site File including the Working File into the office within 3 working days of
transfer to the appropriate Program Coordinator. The Area Manager will be notified
when the file is received.
For pick-up and/or return of file a Site File Check-In/Check-Out Form (MSYS 7d) is to
be filled out at the main office.
MSYS 7b
4 (C: 08/01; R: 08/15)
Processing of Original Health Documentation
All health documentation (physical exam forms and dental exam forms, etc.), received by the
Direct Service Team and/or EHS staff, are to be copied and the copies routed to the
Disabilities/Health Coordinator for data entry.
The pink copy of a completed Medication Authorization form is to be routed to the
Disabilities/Health Coordinator.
Health documentation received by the Disabilities/Health Coordinator is entered into the
database. After data entry, the documentation will be dated and initialed in the lower right
corner and returned to the DST/CFDS. The documentation is to be retained in the
Health/Nutrition section of the site file noted on the File Content Form with date and initials.
Working File
A separate “Red Case Management File and Yellow Working File” will be placed in each
individual child’s site file (or expectant mother’s site file) to be used as a working file. Items,
information, and forms needed or collected for a home visit, conference, or discussion with the
child’s parent/guardian (or enrolled expectant mother) may be placed in the “Yellow Working
File”. The “Yellow Working File” is removed from the site file and taken to the home visit,
conference, etc. The Red Case Management File will be a holding file for staffing discussion
items and/or items to be entered into case management.
Placement of Documents As Teachers, Family Advocates and CFDS receive and/or complete documents, they are to be
placed in the Red Working File. All documents are to be placed from the Red Working File into
the appropriate sections of the child’s site file (or enrolled expectant mother’s site file) at or
before the monthly Family Staffing Meeting.
Site File Maintenance Teachers are responsible for maintenance of the Education and Special Needs sections of the site
files. Family Advocates are responsible for the Administration, Health/Nutrition and Social
Services/Mental Health sections of the site files. Child/Family Development Specialists are
responsible for the maintenance of all sections of their site files.
Policy complies with Performance Standard 1304.5(g) and 1304.52(h)(1)(ii).
MSYS 7c
(C: 10/00; R: 07/14)
Lower Columbia College Head Start/EHS/ECEAP
Individuals Having Access to Records
School Year _______________________ Site __________________________
Following is a current list of names and positions of those officials (including teachers) in the
county who, because of their legitimate educational interest, may have access to personally
identifiable information without consent from the parent or legal guardian. As required by the
Buckley Amendment (45 CFR Part 99.5), the records policy specifies the criteria for determining
which parties are “officials” and what the program considers to be “a legitimate educational
interest.”
NOTE: The requirement to maintain a record of parties requesting or gaining access to
student’s records does not apply to the following persons:
NAME POSITION NAME POSITION
Child Protective Services Child Protective Services
School District
Specialist(s)
Health Consultant
Nutrition Consultant
Mental Health
Consultant
Self Assessment Team (Head Start/EHS/ECEAP Staff
Only)
Federal and/or State
Audit Team
Subpoena or Judicial
Order
Progress Center
MSYA 7d
(C: 07/14)
Lower Columbia College Head Start/EHS/ECEAP Site File Check-In/Check-Out Form
Child’s Name
Date
Returning File
Picking Up File
Office Staff Signature
DST Staff Signature
MSYS 7e1
Place in order as listed above. (C: 08/10; R: 06/17) Print on White
Lower Columbia College Early Head Start
Administration File Contents
Staff Initial & Date
________________ Contact Information Form ______ ______ ______ ______ ______ (original and most current in file; all other shredded)
________________ Change of Status Form(s) ______ ______ ______ ______ ______
________________ Legal Documents (Custody Papers/Adoption/Restraining Order)
________________ Withdrawal/Transfer Checklist
_________________ Parent Agreement Contract
_________________ Change of Classroom Request
________________ Birth Certificate (copy of State or Hospital) (optional)
Parent/Guardian Release of Information Forms: (date, initials, provider name)
________________ Dental
________________ Medical
________________ Mental Health
________________ DSHS
________________ Progress Center
________________ School District
________________ Specialist(s)
________________ W.I.C.
________________ Other
________________ Applicant Information/Family Member Information (original or computer generated application with parent signature)
________________ Intake/Enrollment Forms Checklist
________________ Medicaid/Insurance Card (optional)
MSYS 7e2
Place in order as listed above. (C: 07/10; R: 06/17) Print on White
Lower Columbia College Early Head Start - Prenatal
Administration File Contents
Staff Initial & Date
________________ Contact Information Form ______ ______ ______ ______ ______ (original and most current in file; all other shredded)
________________ Prenatal Emergency Information Form (FS/PI 16a)
________________ Change of Status Form(s) ______ ______ ______ ______ ______
________________ Legal Documents (Custody Papers/Adoption/Restraining Order)
________________ Parent Agreement Contract (FS/PI 17b)
________________ Request for Change of Classroom (MSYS 7p)
Release of Information Forms (Optional): (date, initials, provider name)
________________ Dental _________________________________________
________________ Medical _________________________________________
________________ Mental Health _________________________________________
________________ DSHS _________________________________________
________________ School District _________________________________________
________________ W.I.C. _________________________________________
________________ Other ________________ ________________ _______________
________________ Applicant Information/Family Member Information (original or computer generated application with parent signature)
________________ Intake/Enrollment Visit Form – Prenatal
________________ Medicaid/Insurance Card (optional)
MSYS 7e3
(C: 01/15; R: 07/17)
LOWER COLUMBIA COLLEGE EARLY HEAD START Overview of Required Services for Enrolled Expectant Mother
EDINBURGH DEPRESSION SCALE SCREENINGS: The EHS Health Consultant and EHS Child & Family Development Specialist (CFDS) will facilitate the completion of the Edinburgh Postnatal Depression Scale (EPDS) with the mother. In most instances, this will take place during a Home Visit but may take place at an alternate setting if deemed more appropriate. The CFDS is responsible for contacting the EHS Health Consultant to arrange for these screenings. When Completed:
At any point in time when the mother is expressing or exhibiting any signs or symptoms of depression; ___ Between 32 to 36 weeks gestation; - REQUIRED ___ Between 4 to 6 weeks postpartum; - REQUIRED
Additional screening can be done at anytime; ___ The EHS Health Consultant with the CFDS will visit the mother and newborn and do an informal screening for depression (The appointment for this home visit must be scheduled within 2 weeks of the mother having given birth). –REQUIRED
REQUIRED PRENATAL TOPICS:
___ Fetal Development (including the risks of alcohol, drugs and smoking) ___ Labor and Delivery ___ Post-Partum Recovery (including maternal depression) ___ Parental Depression ___ Benefits of Breast Feeding ___ Dental Care ___ Prenatal Health Care ___ Importance of Nutrition ___ Family Planning ___ Infant Care ___ Safe Sleep Practices ___ Substance Abuse Prevention (risks of alcohol, drugs and smoking) ___ Mental Health (including Edinburgh Screenings 1x during 3rd Trimester & 1x at 4 to 6
weeks postpartum) ___ Address needs for support for emotional well-being, nurturing and responsive caregiving and father engagement during pregnancy and early childhood
INTAKE APPOINTMENT (PROGRAM COORDINATOR)
Introduce self and the Early Head Start mission and purpose
Review the original application for accuracy/any questions you may have
Fill out Release of Information Form for WIC (If not on WIC, refer to WIC.)
Fill out a Release of Information for Family Health Center/First Steps
Review/Complete Parent Agreement with parent(s)
Complete Prenatal Intake/Enrollment Appointment form
Complete the Prenatal Health History form for expectant mother
Complete Prenatal Dental History form
Complete Prenatal Emergency Contact form
Contact EHS Staff when file is ready for pick-up (cc: EHS Supervisor and Health Specialist) (Copy the appropriate EHS Area Manager on email exchanges.)
MSYS 7e3
(C: 01/15; R: 07/17)
FIRST HOME VISIT (CFDS)
Complete Prenatal Home Visit Form/pull together all resources (including handouts on some or all Required Prenatal Topics) for the visit
Introduce self and the Early Head Start mission and purpose
Review Parent Agreement Contract with parent(s)
Review Prenatal Health History form
Review Prenatal Dental History form
Complete Family Interest Survey and start monthly topics interest requirement
Set up the monthly home visit schedule
Review sections of the Parent Handbook (i.e. Child Abuse and Neglect Policy)
Give out Community Resource Directory
Discuss Inkind/Home Learning
Take a picture of the family
Give book to parent
SECOND HOME VISIT (CFDS)
Prior to second Home Visit inform both Health and Mental Health Consultants of
expectant family
Complete Home Visit form/pull together all resources (including handouts on remaining Required Prenatal Topics) for the visit
Provide information on Mental Health, RN, and dental services offered by the program
Provide information on PAL groups, Center Committee Meetings and Policy Council
Review Child Abuse and Neglect Policy
Introduce and begin Partners for Healthy Baby (PHB) or Parents As Teachers Curriculum
Discuss mandatory topics to be covered (See List Above & Home Visit Plan Form)
Follow up on referrals given/services received (community, medical, dental and mental
health)
Complete Family Goal Setting
Leave rhyme/song for notebook - review with parent
MONTHLY HOME VISIT REQUIRED Continue monthly visits (or more frequent based on client needs) with expectant family using curriculum.
MSYS 7e
Place in order as listed above. (C: 06/01; R: 07/17) Print on White
Lower Columbia College Head Start/ECEAP
Administration File Contents
Staff Initial & Date
________________ Contact Information Form ______ ______ ______ ______ ______ (original and most current in file; all other shredded)
________________ Change of Status Form(s) ______ ______ ______ ______ ______
________________ Withdrawal/Transfer Checklist
________________ Parent Agreement Contract
________________ Restraining Order/Legal Documents
________________ Change of Classroom Request form
________________ Legal Documents
________________ Birth Certificate (copy of State or Hospital)
Parent/Guardian Release of Information Forms:
(date, initials, provider name)
Medical
Dental
School District
Specialist(s)
Mental Health
W.I.C.
Other
________________ Applicant Information/Family Member Information (original or computer generated application with parent signature)
________________ Intake Forms Checklist
________________ Medical Coupon/Insurance Card
MSYS 7f1
Items placed in chronological. (C: 06/10; R: 06/17) Print on Blue
Lower Columbia College Early Head Start
Health/Dental/Nutrition File Contents
Staff Initial & Date Health/Medical
________________ Accident Form / / / /
________________ At-Home Meds Form – Side Effects
________________ Denial of Consent (Physical, Dental, Lead Screening)
________________ Diaper/Pull-Up Offer Form
________________ Food Allergy Statement from Health Care Provider
________________ Formula Offer Form
________________ Health Emails/Health Memos ________________ ________________
________________ Health History Form
________________ Health Specialist Records ________ ________ ________ ________
________________ Hearing/Vision 3-Prong Approach (see Ed section for screening summary)
________________ Height/Weight Chart
________________ Immunization Agreement
________________ Lead Screening Documentation
________________ Medical Documentation Request/Correspondence /
/ / / /
________________ Medication Authorization
________________ Medication Information on completed medications (Original Authorization, Checklist and Administration Forms)
________________ Nursing Assessment Form ______________________________________
________________ OAE Hearing & Spot Vision (see Ed section for screening summary)
________________ PIR Enrollment Questionnaire
________________ PIR Spring Health Questionnaire
________________ WA State Immunization Form
________________ Well Child Exam Document / /
________________ Other
Dental
________________ Caries Risk Assessment
________________ Dental Emails/Memos___________
________________ Dental Exam ______________/___________________/______________
________________ Dental Request /Correspondence_________________________________
________________ Dental Screening Form
________________ Other
Nutrition
________________ Nutrition Assessment Form______________
________________ Nutrition Handout Distribution Form____________________________
________________ Nutrition Request/Correspondence_____________/_________________
________________ W.I.C. ____________/_______________/______________/___________
________________ Other
MSYS 7f2
Items placed in chronological. (C: 07/10; R: 06/17) Print on Blue
Lower Columbia College Early Head Start – Prenatal
Health/Dental/Nutrition File Contents
Staff Initial & Date
________________ Dental Exam Form ________________ ________________
________________ Dental Screening Form ________________ ________________
________________ Health/Dental/Emails
________________ Nursing Assessment Form / /
________________ Nutrition Assessment Form
________________ Prenatal Dental History Questionnaire (HLTH 14c)
________________ Prenatal Health/Dental/Nutrition History Form (FS/PI 16a)
________________ PIR Enrollment Questionnaire (FS/PI 7f)
________________ PIR Health Questionnaire (end of year) (HLTH 10i)
________________ Post-Natal Nursing Assessment
________________ W.I.C.
________________ Other
MSYS 7f
Documents to be placed in chronological order with most current on top. (C: 06/01; R: 06/16) Print on Blue
Lower Columbia College Head Start/ECEAP
Health/Nutrition File Contents
Staff Initial & Date
Health/Medical
________________ Accident Form ________________ ________________ ________________
________________ Denial of Consent (Physical, Dental, Lead Screening)
________________ Health History Form
________________ Health Summary (Spring)
________________ Hearing & Vision Screening Form
________________ Immunization Agreement
________________ Lead Screening
________________ Medical Action Plans
________________ Medical Documentation Request/Correspondence
________________ Medical Emails/Memos
________________ Medication Authorization
________________ Medication Information on Completed Medications (original Authorization, Checklist and Administration Forms)
________________ Medication Side Effect Sheet
________________ Nursing Assessment Form
________________ PIR Enrollment Questionnaire
________________ PIR Spring Health Questionnaire
________________ Provider Immunization Records
________________ Specialist Records _______ _______ _______ _______ _______ _______
________________ WA State Immunization Form/Exemption Form
________________ Well Child Exam Document ________________
________________ Other
Dental
________________ Dental Emails/Memos
________________ Dental Exam Document
________________ Dental Request/Correspondence
________________ Dental Screening Form
________________ Other
Nutrition
________________ Dietary Restrictions
________________ Growth Chart _______ _______ _______ _______
________________ Nutrition Assessment Form
________________ Nutrition Request/Correspondence
________________ Nutrition Referral Review
________________ Nutrition Emails/Memos
________________ Nutrition Handout Distribution Form
________________ W.I.C. (HGB/HCT)
________________ Other
MSYS 7g1
Items to be placed in chronological order. (C: 06/10; R: 06/17) Print on Green
Lower Columbia College Early Head Start
Social Service/Mental Health File Contents
Staff Initial & Date
Social Service
________________ Family Interest Survey
________________ Family Partnership Agreement; (Family Goal Setting Sheet)
Additional Goal Setting Forms / / /
________________ Home Safety Checklist (Updates)
________________ Home Visit Plan (Notes)
July Aug.
Sept. Oct.
Nov. Dec.
Jan. Feb.
March April
May June
________________ Parent/Guardian Orientation Checklist
________________ Permission to Transport
________________ Shared Family/Forms/Emails
________________ Start-Up for Enrolled Families
________________ Other
Mental Health
________________ EHS Mental Health Observation (MH 9b)
________________ External Mental Health Provider Report
________________ Family/Child Support Plan (MH 6a)
________________ Family/Child Support Plan Update (MH 6b)
________________ Mental Health Documentation Request/Correspondence _______
_______ ________
________________ Mental Health Staffing Form (MH 7a)
________________ Mental Health/Behavioral Request for Observation/Assessment (MH 5a)
________________ Mental Health Checklist (MH 2a)
________________ Parent/Guardian Permission for MH Observation/Assessment (MH 3a)
________________ Parent Interview for MH/Behavioral Observation/Assessment (MH 4a)
________________ Parent/Mental Health/Behavioral Consult (MH 5c)
________________ Request for MH/Social Emotional Observation (MH 5a)
________________ Safety Intervention Report (EDUC 5b)
________________ Sensory Symptoms Checklist School Version
________________ Sensory Symptoms Checklist
________________ Social and Emotional Observation and Assessment Report (MH 5b)
________________ Parent Mental Health/Behavioral Consult (MH 5c)
________________ Sensory Profiles
________________ Other (memos, emails, etc.)
MSYS 7g2
Items to be placed in chronological order. (C: 07/10; R: 06/17) Print on Green
Lower Columbia College Early Head Start - Prenatal
Social Service/Mental Health File Contents
Staff Initial & Date
Social Service
________________ Attendance Letter
________________ Attendance Plan
________________ Family Interest Survey
________________ Family Goal Setting
Additional Goal Setting Forms
________________ Home Safety Checklist (Updates) / /
________________ Home Visit Plan Forms / / /
/ / / /
________________ Newborn Announcement
________________ Newborn Checklist
_____________ Post-Partum Assessment / 2-week Newborn Home Visit Form
________________ Overview of Required Services for Expectant Mother
________________ Permission to Transport
________________ Start-Up for Enrolled Families
________________ Supplemental Prenatal Client Questions
Mental Health
________________ Family/Child Support Plan (MH 6a)
________________ Family/Child Support Plan Update (MH 6b)
________________ Edinburgh Prenatal Depression Scale
Pre 32-36 Weeks Gestation
Post 4-6 week Post-Partum
Additional
________________ Mental Health Staffing Form (MH 7a)
________________ Parent Consult (MH 5c)
________________ Other (memos, emails, etc.)
MSYS 7g
Place in order as listed above. (C: 06/01; R: 07/17) Print on Green
Lower Columbia College Head Start/ECEAP
Social Service/Mental Health File Contents
Staff Initial & Date
Social Service
________________ Attendance Plan
________________ Child and Family Profile
________________ ECEAP Family Assessment
________________ Family Interest Survey
________________ Family Partnership Agreement; (Family Goal Setting Sheet)
Additional Goal Sheets ________________ ________________
________________ HS Family Outcomes Assessment
________________ FDM (ECEAP) Empowerment Plan _______ _______
________________ Home Safety Checklist
________________ Home Visit Plan Forms _______ _______ _______ _______ _______
________________ Notes Home _______ _______ _______ _______ _______
________________ Notes from Parent/Guardian _______ _______ _______ _______
________________ Parent Orientation Checklist
________________ Permission to Transport Form _______ _______ _______ _______
________________ Transportation Request _______ _______ _______ _______
________________ Other (memos, emails, etc.)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Cardstock - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Mental Health
________________ Intervention Strategies (MH 1a1)
________________ Mental Health Checklist (MH 2a)
________________ Parent/Guardian Permission for MH Social/Emotional Observation/Assessment (MH 3a)
________________ Parent/Guardian Interview for MH Social/Emotional Observation/Assessment (MH 4a)
________________ Request for MH/Social Emotional Observation/Assessment (MH 5a)
________________ MH Social/Emotional Observation/Assessment Report (MH 5b) _____ _____
________________ Parent/Guardian Consult (MH 5c)
________________ Family/Child Support Plan (MH 6a)
________________ Family/Child Support Plan Update (MH 6b) ____ ____ ____ ____ ____
________________ Mental Health Staffing Form (MH 7a) _____ _____
________________ Safety Intervention Report (EDUC 5b) ____ ____ ____ ____ ____ ____
________________ Sensory Symptoms Checklist School Version (original)
________________ Sensory Symptoms Checklist (original)
________________ Mental Health Documentation Request/Correspondence _____ _____
________________ External Mental Health Provider Report
________________ Other: Vanderbilt Assessment completed for PCP. Other information
completed for Mental Health
________________ Protein Snack Permission
MSYS 7h1
Items to be placed in chronological order. (C: 06/10; R: 06/17) Print on Yellow
Lower Columbia College Early Head Start
Education File Contents
Staff Initial & Date
________________ Ages and Stages Screening Tool ________ ________ ________
________________ Ages and Stages Social Emotional ________ ________
________________ Attendance Letter
________________ Attendance Participation Plan
________________ Home Language Survey
________________ Individual Child Education Plan(s) ________ _________ _________
________________ Pre-Conference Survey (EDUC 2b)
________________ Screening Summary Forms
________________ PAL Socialization Sign-In and Observation Form
________________ Transition Conference Form & Updates (DISA 3b3)
________________ Transition Survey (DISA 3b4)
________________ Transition Plan/Exit Record
________________ Other
Teen Program Only
________________ Absence Notes from Parents
________________ Attendance Calendars (please circle)
July, Aug, Sept, Oct, Nov, Dec, Jan, Feb, March, April, May, June
________________ Notes Home
________________ Parent/Teacher Conference Form and TSG Family Conference Form (Fall)
________________ Parent/Teacher Conference Form and TSG Family Conf. Form (Spring)
MSYS 7h
Documents to be placed in chronological order with most current on top. (C: 06/01; R: 07/17) Print on Yellow
Lower Columbia College Head Start/ECEAP
Education File Contents
Staff Initial & Date
________________ Absence Notes from Parents
________________ ASQ-3 Developmental Screening _________ __________
________________ ASQ SE-2 _________ __________
Classroom Sign-In Sheets (please circle)
Sept. Oct. Nov. Dec. Jan. Feb. Mar. Apr. May June
________________ Developmental Screening Summary
________________ Education Home Visit Plan Forms (EDUC 2a1)
________________ Field Trip Permission Slips
________________ Home Language Survey
________________ Notes Home
________________ Other Screening Tool: ____________________
________________ Parent/Teacher Conference Form (EDUC 2a1)
________________ Pre-Conference Survey
________________ Teaching Strategies Gold (Individual Child) (Final Checkpoint)
________________ School Readiness Summary
MSYS 7i1
(C: 06/10; R: 06/17) Print on Cherry
Lower Columbia College Early Head Start
Special Needs File Contents
Staff Initial & Date
________________ Confirmation of IFSP
________________ Discontinuation of Services
________________ EHS Early Intervention Referral Form (DISA 3a) _________ _________
________________ IFSP __________
________________ IFSP Goal Areas
________________ IFSP Transition Summary (@ 6 months)
________________ Notice/Consent for Initial Evaluation
________________ Notice/Consent for Reassessment/Re-Evaluation
________________ Parental Consent to Evaluate
________________ Prior Written Notice/Reinstatement of Services
________________ Request for Records __________ __________ __________
________________ Other (health reports that relate to disability, Progress Center, Special
Education Memos, Refusal of Services form, etc.)
MSYS 7i
Documents to be placed in chronological order with most current on top. (C: 06/01; R: 07/17) Print on Cherry
Lower Columbia College Head Start/ECEAP
Special Needs File Contents
Staff Initial & Date
________________ Consent for Initial Evaluation/Evaluation/Re-evaluation Consent ______
_______ _______
________________ Disabilities Staffing Form __________ __________
________________ Evaluation Summary DOE/DNQ
Embedded Schedule
______________ ______________ ______________ ______________
______________ ______________ ______________ ______________
________________ IEP __________
IEP At A Glance ______________ ______________ ______________
________________ Invitation to Attend Meeting
________________ Request for IEP/IFSP
Special Education Service Log(s) (Original) (please circle)
Sept. Oct. Nov. Dec. Jan. Feb. Mar. Apr. May June
________________ Teacher Assessment Summary
Team Meeting Notes
__________ __________ __________ __________ __________
__________ __________ __________ __________ __________
________________ Other (health reports that relate to disability, Progress Center (IFSP), Special
Education Memos, Refusal of Services form, etc.)
__________ __________ __________
MSYS 7k1
Lower Columbia College Early Head Start - Prenatal
File Sign-Out
Expectant Mother’s Name: ______________________________
(C: 07/10)
Person
Viewing File
Date & Time
Removed
Purpose Date & Time
Returned Initials
MSYS 7k
Lower Columbia College Head Start/EHS/ECEAP
File Sign-Out
Child’s Name: ______________________________
(C: 08/00; R: 06/10)
Person
Viewing File
Date & Time
Removed
Purpose Date & Time
Returned Initials
MSYS 7l
(C: 11/03; R: 08/15)
Lower Columbia College Head Start/EHS/ECEAP
Nutrition Consultant Site File Review Procedure
Procedure
Upon Leadership Team member referral or Direct Service Team member/EHS staff request, the
appropriate Nutrition Consultant will observe child and/or review Child Site files to support DST
members / EHS staff in the delivery of timely services to program children and their families.
Scheduling
The Nutrition Consultant will contact the appropriate Family Advocate, Teacher or EHS staff
member to schedule an observation and/or Site File reviews and Debriefing meetings.
The Site File Review Form The Site File Review form has a section for the Nutrition Consultant to write down: items which
have not been addressed or are in process of being completed; questions regarding items, record
keeping and tracking; possible ideas for a plan of action and timeline; strengths and what is being
done well.
Debriefing Meeting & Action Plan
1. Following the observation and/or review of Site files, a scheduled debriefing meeting will be
held with the Nutrition Consultant, the Family Advocate and/or Lead Teacher or Child/Family
Development Specialists (CFDS). When available, the Supervisor and/or Health Specialist will
also attend.
2. The Consultant will facilitate the meeting by asking questions and sharing gathered
information and sharing recommendations.
3. The purpose of the debriefing meeting is to create a written and workable Action Plan.
Possible technical and mentoring support for the Direct Service Team / EHS staff member will
also be discussed.
4. The Nutrition Consultant will email her observation notes, site file review notes and
recommendations in a standard written format to the Lead Teacher, Family Advocate, Area
Manager and Health Specialist.
5. Area Managers will place a copy of Nutritionist notes and recommendations into their
monitoring notebook.
6. The Nutrition Consultant will also send her notes and recommendations to the Disabilities /
Health Assistant to enter onto the ChildPlus Health database and then forward to the Family
Advocate and/or CFDS to place in the child’s site file.
Procedure complies with Head Start Performance Standard 1304.51(i)(2)
MSYS 7m1
(C: 09/10)
Lower Columbia College Early Head Start
EHS Home Visiting Observation Checklist
EHS Staff: ___________________________ Home Visit Date:___________________
Time Scheduled/Arrived:________/________
Child’s Name: _________________________ Parent’s Name:_____________________
Did the EHS staff complete the following prior to the Home Visit?
o Reviewed previous home visit record, child development, and FPA goals.
o Identified and reviewed the plan (s) for the visit.
o Filled out the information on the Home Visit Form.
o Selected activity and collected necessary materials for the visit.
During the Home Visit, did the EHS staff do or cover the following?
Relationship /rapport building:
o Family was greeted in warm, positive manner.
o Engaged the family in conversation about what is going on in their life.
o Family given opportunity to discuss or ask questions.
o Review of last week’s session and in-kind/education activities done.
Parent/child interaction:
o Parent/child interaction activity conducted. Explained the rationale to the family.
o Made modifications on activity as needed.
o Parent child relationship observed and supported.
o Balanced needs of the family with plans for the visit.
Child development:
o Child development skills observed, assessed, and screened.
o Child development goals articulated.
o Child development curriculum carried out.
o Child development needs discussed and addressed:
___Nutrition ___Physical health ___Dental Health
___Motor Skills ___ Cognitive skills ___Mental Health
___Language/Literacy ___Social Skills ___Disabilities
Family Services:
o Family Partnership agreement reviewed and revised.
o Parents’ personal growth needs addressed and referrals made:
___Education ___Employment ___Physical Health
___Self-esteem ___Parenting skills ___Mental Health
Review and plan for next visit:
o Plans discussed for next visit.
o Discussed upcoming EHS activities ie.PAL time, parent meetings, Policy Council
meeting, etc.
o Session closed with review, goal setting, and positive affirmation of parent’s efforts
MSYS 7m1
(C: 09/10)
EHS Staff skill observed during the visit:
o Offered suggestions and gave concrete examples.
o Verbally reflected parents’ and child’s feelings.
o Asked open –ended questions and encouraged conversation
o Attuned to emotional level of family; listened carefully to what parent said.
o Affirmed and showed support for parent’s efforts.
Notable examples made during the observation:
Follow-up:
MSYS 7m
(C: 07/05; R: 06/11)
Lower Columbia College Head Start/ECEAP
Education Home Visit Observation Form
Date ____________ Time Begun ___________ Time Ended ____________ Total ________
Area Manager ____________________________ Home Visitor ___________________________
Child’s Name ____________________________ Parent’s Name __________________________
1. Who was present for the Home Visit?
( ) Mother ( ) Father ( ) Enrolled Child ( ) Sibling
( ) Other ______________________________________________
2. Did the Home Visitor seat themself so that the parent and child were able to interact?
3. What is the Home Visitor’s plan and was the purpose of the visit clearly stated?
4. How did the Home Visitor review the last visit’s activities with the parent (i.e. referrals, FPA,
education goals, health, etc.)?
5. Were materials and information prepared? ( ) Yes ( ) No
6. Were parent ideas included in the Home Visit?
7. Did the activities correspond with individual goals chosen by the parent / staff?
8. Did the Home Visitor serve as a facilitator and encourage the parent to lead the activity?
9. How were those present involved (parent, child, siblings)?
10. Were materials and/or routines in the home utilized?
11. Were developmental reasons for activities provided?
MSYS 7m
(C: 07/05; R: 06/11)
12. How did the Home Visitor provide reinforcement, i.e., active listening, encouragement, praise?
13. Were referrals made? If so, to whom?
14. Was a plan of action developed for future activities/visits?
15. Were parent educational opportunities addressed?
16. Were upcoming events discussed? ( ) Yes ( ) No
Classroom
Parent Involvement
Health
17. Which areas were covered?
( ) Mental Health ( ) Nutrition ( ) Special Needs ( ) Other
( ) Education ( ) Health/Safety ( ) Dental
( ) Parent Involvement ( ) Social Services ( ) Home Learning
Which upcoming events/or educational opportunities were discussed:
Additional comments:
18. Did the Home Visitor summarize the visit and review follow-up to be completed by the visitor and
the parent? (Including referrals made). ( ) Yes ( ) No
MSYS 7n
(C: 07/05; R: 03/16)
Lower Columbia College HS/ECEAP Social Service Home Visit Observation Checklist
Staff: Observer: Home Visit Date:
Time Scheduled/Arrived: Time Ended: Total:
Child’s Name:
Parent’s Name:
Who was present at Home Visit? Did the Staff complete the following prior to the Home Visit?
o Reviewed previous home visit record(s), health records, child development and FPA goals.
During the Home Visit, did the Staff do or cover the following?
Relationship/rapport building:
o Family was greeted in warm, positive manner. o Identified the purpose and plan (s) for the visit with the family. o Engaged the family in conversation about what is going on their life. o Family given opportunity to discuss or ask questions.
Family Services:
o Family Partnership agreement reviewed and revised. o Parent’s personal growth needs addressed and referrals made:
____Employment ____Social Services
____ Parent Involvement ____Safety
____ Parenting Skills ____Physical Health
____ Mental Health ____Dental
____Self-Esteem ____Other
Education:
_____School Readiness _____Adult Education ____ Attendance _____In-Kind _____Special Needs
Review and plan for next visit:
o Plans discussed for next steps o Discussed upcoming activities, parent meetings, Policy Council meeting, etc. o Session closed with review of the visit, goals setting and positive affirmation of parent’s efforts
Staff skill observed during the visit:
o Attuned to the emotional level of family; listened carefully to what parent said. o Verbally reflected parent’s and child’s feelings o Affirmed and showed support for parent’s efforts o Asked open-ended questions and encouraged conversation o Offered suggestions and gave concrete examples.
MSYS 7o1
CHSCN Referral (C: 07/09; R: 08/14)
REFERRAL TO CHILDREN WITH SPECIAL HEALTH CARE NEEDS PROGRAM Fax – 360-425-7531
Client Information: DOB: M F
Home Address:
Home Telephone: Parent Cell:
Parent/Guardian: E-mail:
Primary Language:
Referring Agency or School:
Address:
Primary Contact Person:
Telephone: Email:
Physician Name:
Check the address of client’s physician listed below:
□ Child & Adolescent Clinic
971 11th Avenue Longview, WA 98632 Phone: 360-577-1771 Fax: 360-423-9537
□ PeaceHealth Medical Group
□Family Medicine □Lake Front □Ocean Beach
1615 Delaware Street Longview, WA. 98632 Phone: 360-636-4885 (medical records) Fax: 360-501-7517 (medical records)
□ Kaiser Permanente
1230 7th Avenue Longview, WA. 98632 Phone: 360-636-2400 Fax: 360-636-6242
□ Cowlitz Family Health Center
1057 12th Avenue Longview, WA. 98632 Phone: 360-636-3892 Fax: 360-414-1342
□ Castle Rock Pediatrics &
Family Wellness Center 139 1st Avenue SW Castle Rock, WA 98611 Phone: 360-274-2353 Fax: 360-274-2354
Description of problem or incident resulting in referral:
MSYS 7o2
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Date:
Complete:____ OR Ongoing:____
Sent for Records:__________ (Date)
Met with DST/EHS: ____________ (Date)
Loc ID#:
Record of Nursing Assessment
Name (Last, First, M.I.): M F DOB:
Primary care provider: Date of last well child examination:
Parent/Guardian name: Due now for well child examination
HEALTH HISTORY Current medical diagnosis or concerns: (teacher observation, parent report and/or physician diagnosis)
Laboratory tests, measurements, out of range (HGb, BMI, etc)
Up-to-date Exemption signed
Child’s immunizations are up-to-date per current ACIP Guidelines (cdc.gov/vaccines)
OVERDUE IMMUNIZATIONS
DTaP Hepatitis B
Polio MMR
Hib Pneumococcal
Influenza Chickenpox
Hepatitis A Other:
Surgeries, hospitalizations, other major illness or injury None
Year Reason Hospital
Is child currently being treated by a specialist? Yes No
Where? Diagnosis:
List any medication drugs and over-the-counter drugs, such as vitamins and inhalers the child takes None
Drug Dosage Frequency Taken
Does the child have allergies to any medications? (If yes, please list below) None
Drug Reaction
Lower Columbia College
Head Start / EHS / ECEAP
MSYS 7o2
\\Adminsrv\headstart$\Hdst\Forms\Karla ONLY FORMS\MSYS\MSYS 7o2 Record of Nursing Assessment.docx Page 2 Last updated: July 21, 2010 Original Form: Data Entry / Child Site File
NURSING ASSESSMENT AND PLAN
ASSESSMENT:
PLAN:
RECHECK/REVISIT CHILD’S FILE No YES, WHEN:
FAMILY HEALTH HISTORY
Family Member Age Significant Health Problems
________________________________________________ ______________ Signature of Staff Completing Form Date Notes:
MSYS 7o3
(C: 08/16)
Date:
Complete: ____ OR Ongoing: ____
Sent for Records:__________ (Date)
Met with EHS/CFDS: ____________ (Date)
Loc ID#:
Record of Nursing Assessment for Expectant Mother
Name (Last, First, M.I.): DOB:
Primary Care Provider: Date of last OB examination:
OB Provider: Due now for OB examination
HEALTH HISTORY Current medical diagnosis or concerns: (self-report and/or physician diagnosis)
Laboratory tests, measurements, out of range (HGb, BMI, etc.)
Flu Vaccine Date:
Surgeries, hospitalizations, other major illness or injury None
Year Reason Hospital
Is expectant mother currently being treated by a specialist? Yes No
Where? Diagnosis:
List any medication drugs and over-the-counter drugs, such as vitamins and inhalers the expectant mother takes None
Drug Dosage Frequency Taken
Does the expectant mother have allergies to any medications? (If yes, please list below) None
Drug Reaction
Lower Columbia College Early Head Start
MSYS 7o3
(C: 08/16)
NURSING ASSESSMENT AND PLAN
ASSESSMENT:
PLAN:
RECHECK/REVISIT EXPECTANT MOTHER’S SITE FILE No YES, WHEN:
FAMILY HEALTH HISTORY
Family Member Age Significant Health Problems
________________________________________________ ______________ Signature of Nurse Completing Form Date Notes:
MSYS 7o
(C: 08/05; R: 01/18)
Lower Columbia College Head Start/EHS/ECEAP
Health Consultant Site File Review Procedure
Procedure
Upon Health Coordinator notification, Leadership Team member referral or by Direct Service
Team/EHS staff member request, the Health Consultant will review participant site files
(including Family Services Database health events) to support DST members/EHS staff in the
delivery of timely services to program children and their families.
Scheduling
The Health Consultant will contact the appropriate Family Advocate, Child/Family Development
Specialist or Teacher to schedule Site File reviews and meetings with Direct Service Teams.
Nursing Assessment Form/DST Meeting/Action Plans
1. During the review of the child’s Site file, the Health Consultant will initiate a Nursing
Assessment form specific to that referral. If team meeting is not planned or deemed
necessary by the Health Consultant, the form will be considered complete and given to
the Health Coordinator for entry into the database.
2. Following the review of child’s Site file, a scheduled meeting with the Health Consultant
and Direct Service Team/EHS staff member may be held depending on outstanding care
needs. When available the supervisor and/or Health Specialist may also attend.
3. The purpose of the meeting is to ensure identified heath concerns are addressed, training
needs identified, and planning occurs in a coordinated and timely manner. The Health
Consultant will complete the nursing assessment to reflect decisions and
recommendations made by the team.
4. The Health Consultant will facilitate the meeting by asking questions and sharing
gathered information such as the outstanding items found, feedback regarding record
keeping/tracking, strengths and what is being done well.
5. Information, in the assessment and plan sections, of the Nursing Assessment form is to be
entered onto the Program Health Database. The Health Coordinator will enter the
information onto the database. The form will then be forwarded to the Family
Advocate/Child/Family Development Specialist for placement in the Child’s Site File.
MSYS 7p1
(C: 08/08; R: 07/17)
Lower Columbia College Head Start/EHS/ECEAP
Procedures for Request for Change of Classroom or Site
1. If a parent requests a change to a different classroom in the same building, fill out
the Request for Change of Classroom Form (MSYS 7p);
2. If a parent requests a transfer to a different site, fill out the Request for Change of
Classroom (MSYS 7p) AND the Change of Status Form (ERSEA 1e) with all
pertinent information (i.e. change of address/phone; withdraw/transfer
information, etc.);
3. Completed Request for Change of Classroom forms for ECEAP and Head Start
are to be turned into the appropriate Area Manager who will forward to
appropriate Program Coordinator for ECEAP and/or Head Start or EHS;
4. Parents are to be advised that we will “try” to meet their request, but there are
many factors to be considered;
5. All changes will be considered by the Content Area Specialist Team (CAST) and
forwarded to the appropriate Intake Team Program Coordinators. Staff are not to
make internal changes without going through this process;
6. If the request is in the same site location, the Program Coordinator will send back
the Request for Change of Classroom Form (ERSEA 1e) to the staff who
requested the change so they may contact the family of the decision;
7. If the request is approved and the child/family will be going to a different
classroom within the same building or to another center the current staff are to
contact the new coming staff to do a short staffing on the child/family prior to
the first day of change;
8. If the request is not approved due to availability of space and the family would
like to withdraw and/or put themselves on a waitlist, the staff is to follow the Site
File Policy and Procedure (MSYS 7a) and Child/Family File Transfer Checklist
(FS/PI 7k).
MSYS 7p
(C: 11/07; R: 07/17)
Lower Columbia College Head Start/EHS/ECEAP
Request for Change of Classroom
Child’s Name: Parent’s Name:
Current Teacher/Loc ID: Requested Teacher/Loc ID:
Reason for request:
Please provide the following information about the child:
Special child and/or parent concerns: Please explain
IEP: List Agency IFSP: List Agency
Birthdate:
Language: English _____ Spanish _____ Other _____
Gender : Male _____ Female _____
Toileting: Diapers _____ Pull-ups _____ Underwear _____
Behavior Concern Yes _____ No _____
Transportation: Bus Rider Yes _____ No _____
Drive-in Yes _____ No _____
Other Please list
Please obtain signatures and route Head Start requests to the Head Start Program Coordinator and
ECEAP requests to the ECEAP Program Coordinator in the Head Start / ECEAP Administration Bldg.
Teacher Signature Date
Family Advocate/CFDS Signature Date
Area Manager Signature Date
Comments:
CAST Signature Date
Approved _____ Disapproved _____
Program Coordinator Signature Date
MSYS 7q
Distribution: White: Site File Copy: Emergency Notebook Copy: Health Specialist Copy: Primary Health
Care Provider (C: 03/13; R: 06/16)
LOWER COLUMBIA COLLEGE HEAD START/EHS/ECEAP
Health Accommodation Plan Meeting
Child’s Name: Birthdate: Date:
Parent/Guardian Name: LOC ID:
Teacher / EHS Staff: Family Advocate:
Area Manager / EHS Supervisor: __________________________________________________
Purpose or Concern:
Recommended Plan of Action/Who's Responsible/Timeline:
Members Present:
MSYS 8a1
(C: 10/06; R: 08/15) 1
LOWER COLUMBIA COLLEGE HEAD START/EHS/ECEAP
ChildPlus.net Reports Distribution Schedule
I. Monthly Student Medical Concerns/Allergies List (Separate reports for each program) H, EH, E
ChildPlus.net Report 3010
Fields: By Classroom/Detail/All Data Options/All Events/Event Types: Acute Illness, Allergy, Asthma,
Chronic Illness, Dietary Restrictions, Health History, Illness and Medication
Report Distribution Time Frame: Monthly
Report Distribution (1 Original & 10 copies) H, EH, E
Original to Family Advocate and/or each Teen and Combo CFDS
One copy to EHS Family Educator
One copy to appropriate Supervisor
One copy to Health Specialist; one to Program Assistant at LCC West Reception desk, one to Program
Coordinator at LCC East Reception desk
Bus Copies
3 copies to LCC West Area Manager for the LCC East and West buildings; 2 copies to Broadway Area
Manager; 1 copy to Barnes Area Manager; (Run the reports by center; combine LCC East and West.)
Report Cover Sheets
Attach completed Report Cover sheet to each report prior to distribution.
Placement: Emergency Response Procedures Notebook
=====================================================================
II. Weekly Emergency Contacts Report Program Coordinator
ChildPlus.net Report 1520
*Program Coordinator Responsibility
Report Distribution Time Frame: Beginning of each week.
Report Distribution:
Original to Teachers and each Teen EHS CFDS
One copy to PAL T/A
One copy of each of their site emergency contacts report to: Bus Drivers, Area Managers, EHS
Supervisor
Placement: Emergency Response Procedures Notebook; Bus Notebook
=====================================================================
III. First of the Month Student Roster Program Coordinator & Program Support Supervisor
ChildPlus.net Report 2110
*Program Coordinator and Program Support Supervisor Responsibility
Report Distribution Time Frame: Beginning of each month.
Report Distribution:
Original to Teachers and each Teen EHS CFDS
One copy of their classroom rosters to: Family Advocates or HS/ECEAP CFDS
One copy to PAL T/A
One copy of their site rosters to: Area Managers and EHS Supervisor
One copy of all rosters to: Program Coordinator, Mental Health Consultant
Placement: Emergency Response Procedures Notebook (Except Family Adv. & MH Consultant Copies)
MSYS 8a1
(C: 10/06; R: 08/15) 2
IV. First of the Month Student Roster Program Coordinator & Program Support Supervisor ChildPlus.net Report 2125
*Program Coordinator and Program Support Supervisor Responsibility
Print: A-Z by site.
Report Distribution Time Frame: Beginning of each month.
Report Distribution:
One copy to: Director, Assistant Director, Health Specialist, Area Managers, EHS Supervisor, Mental
Health Consultant.
Placement: None
=====================================================================
V. Monthly Student Dietary Restrictions Report Dis./Health Coordinator H, EH, E
ChildPlus.net Report 3010
Fields: By Class / Detail / All Data Options / All Events / Event Type: Dietary Restrictions
(EHS – Bottle Feeding/Nutrition, Dietary Restrictions)
Report Distribution Time Frame: Monthly
Report Distribution (1 Original & 3 copies) Original to Direct Service Team and each Teen CFDS
One copy to PAL T/A
Copy to appropriate Food Service Worker (LCC West, Broadway, Barnes, Castle Rock, Highlands and
Teen)
Copies to: Health Specialist and Food Service Supervisor
Placement: Post in Kitchen/Classroom (Except Health Specialist)
=====================================================================
VI. Monthly Child Health Reports Dis./Health Coordinator EH
ChildPlus.net Report 3010
Fields: By Class / Individual / All Data Options / All Events / All Types
Report Distribution Time Frame: Monthly
Report Distribution:
Original to CFDS (Home Base & Teen) and upon request to Family Advocate or HS/ECEAP CFDS.
Placement: Child Site Files
VII. Monthly Child Health Reports Dis./Health Coordinator EH
ChildPlus.net Report 3420
Fields: By Class / Detail
Report Distribution Time Frame: Monthly
Report Distribution:
Original to CFDS (Home Base & Teen) and upon request to Family Advocate or HS/ECEAP CFDS.
Placement: Child Site Files
MSYS 8a1
(C: 10/06; R: 08/15) 3
VIII. Consultant Child Health Reports Dis./Health Coordinator H, EH, E
A. Health Consultant
In September and thereafter following data entry of child with severe medical concerns referred to
appropriate Health Consultant, print ChildPlus.net Report 3010
Fields: By Class / Individual / All Data Options / All Events / All Types
B. Head Start/ECEAP Nutrition Consultant – Nutrition Assessments
Beginning end of Oct, and monthly thereafter; identify students needing Nutrition Assessments by
comparing ChildPlus Report 3010 with 2110 Master List of Participants.
Fields: By Class / Individual / All Data Options / All Events / All Types
To determine children in need of nutrition assessment:
Run Report 3065 with Event Types: Nutrition Assessment
Nutrition Consultant – Growth Assessment
Head Start & ECEAP Child Health Reports to Nutrition Consultant following data entry of each
classroom’s height/weight measurements from screenings and monthly thereafter. Monthly reports of
NEW STUDENTS ONLY. (i.e. If the previous month’s report was ran on Nov. 4th and the next
month’s report is to be ran on Dec. 2nd; then special condition reports are to be printed for new students
with enrollment dates of Nov. 4th through Dec. 2nd).
C. EHS Nutrition Consultant – Nutrition Assessments
At end of each month, identify children and expectant mothers needing Nutrition Assessments by
comparing ChildPlus Report 3010 with 2110 Master List of Participants. Print growth charts and attach
to report. Expectant moms include WIC release.
Fields: By Class / Individual / All Data Options / All Events / All Types
To determine children/expectant mothers in need of nutrition assessment:
Run report 3065 with Event Types: Nutrition Assessment
=====================================================================
IX. End of Month Health Specialist Reports Dis./Health Coordinator 1. ChildPlus.net Immunization Report 3330 (3 Separate Reports by Site: 1. Program Term H Head Start
current yr.; 2. Program Term E ECEAP current yr.; 3. Program Term EH Early Head Start current yr.)
2. ChildPlus.net Report 2110 (Insurance) (3 Separate Reports: 1. Program Term H Head Start current
year; 2. Program Term E ECEAP current year; 3. Program Term EH Early Head Start current year).
Fields: Reporting Group: None / Data Options: Show Medicaid Information and Show Insurance
Information (End Date – last date of report month)
3. ChildPlus.net Report 3065 – Run separate reports on each event type (Run separate: Head Start, EHS,
ECEAP reports by class); 1. *Dental Exam *Begin date – 6 months prior to current program year
start date (ECEAP: Dental Exam & Dental Screening) – unclick ‘A’ Absent and ‘M’ missed, 2.
*Physical Exam *Begin date – one year prior to current program year start date. End date –
last date of report month, unclick ‘A’ Absent and ‘M’ missed, (EHS will include appropriate Well
Baby Checks.) 3. Nutrition Assessment Reports – Begin date June 1 prior to current program
year start date, end date last date of report month. Status Types: uncheck All types; check: F, L,
P, Q, R, 4. Lead Screening – No begin date.
Field: Appropriate Event Type (i.e. Dental Exam or Dental Exam & Dental Screening or Physical Exam
or Nutrition Assessment or Lead Screening) for each report.
4. ChildPlus.net Report 3015 (Incomplete) – Run separate reports on each event type (Run separate
reports: Head Start , EHS, ECEAP reports by class); 1. Dental Exam (ECEAP: Dental Exam &
Dental Screening), 2. Physical Exam *Run 3015 Reports December through May Only
MSYS 8a1
(C: 10/06; R: 08/15) 4
Fields: Appropriate Event Type (i.e. Dental Exam or Dental Exam & Dental Screening or Physical
exam) for each event.
Report Distribution: Original to EHS Manager/Health Specialist (End of Month report then compiled and sent to
Administrative Services Manager and Director.)
=====================================================================
X. Monthly Mental Health Report Disabilities/Health Coordinator H, EH, E
ChildPlus.net Report 3010 (3 Separate Reports: 1. Program Term H head Start current year; 2. Program
Term E ECEAP current; 3. Program Term EH Early Head Start current year.)
Fields: Mental Health
Report Distribution: Original to Mental Health Specialist
=====================================================================
XI. Disabilities/Health Coordinator Monthly Report Dis./Health Coordinator H, EH, E To track Health History: ChildPlus.net Report 3015
Fields: By Class/Detail
Report: Health History (7 Days) / Completion Status: Incomplete/Order by Event Date
Report Distribution: Disabilities/Health Coordinator
=====================================================================
XII. Required Activities Status Report 45-day Incomplete for Developmental Dis./Health Coord.
ChildPlus.net Report 3015
Fields: Developmental Screen (To Determine Children Who Need Dial 3 or ASQ Screening)
Report Distribution (1 Original & 2 Copies): Original to DST and/or CFDS
Copy to Disabilities Specialist, Director, EHS Supervisor, appropriate Area Manager as needed
=====================================================================
XIII. Monthly–Reports to Cross-Check for Prior Sp. Ed. Records Dis./Health Coordinator ChildPlus.net Report 3010 – check students enrolled since last report date to see if any have “sent for
records” for prior special education.
Developmental Activity – if records not received – re-send;
Report Distribution:
Original to Disabilities/Health Coordinator
=====================================================================
XIV. Monthly Disabilities Reports Disabilities/Health Coordinator ChildPlus.net Report 3010
Current IEP/Referral status----Excel spreadsheet
ChildPlus.net Report 3520 – Disability Conditions
ChildPlus.net Report 3510 – Disability Concerns
Reports Distribution: Disabilities Specialist, Director, Assistant Director
MSYS 8a1
(C: 10/06; R: 08/15) 5
XV. Quarterly Disabilities Reports Disabilities/Health Coordinator ChildPlus 3550 – HSTARS Cluster Quarterly
Report Distribution Time Frame (1 Original): November, March & May (HSAC Report)
Report Distribution: Copies to Disabilities Specialist, Director
=====================================================================
XVI: Yearly PIR Reports ChildPlus.net Reports
====================================================================
XVII. Family Services Monitoring Reports of Social Area Manager H, E
Social Service Home Visits
1. Report 4110 for Social Service Home Visit and Family Partnership Agreement Event Types only.
Show-caseworker and Family Service Action Notes; Status-Enrolled; Grouping-Classroom; Order By-
Participant; Report Type-Detail; Sort Actions by-Newest to Oldest; Initial Service Date Filter, Begin
Date-to match the Family Advocate annual start date in August, End Date-to match the date the report is
run.
Report Distribution (none, view-only end of October, January, May): =====================================================================
XVIII. Family Services Monitoring Reports of Social Family Advocates H, E
Service Referrals
Report 4120 is a cumulative report to be viewed by each of the Family Advocates every month in order to
complete their End of Month Report. Status-Enrolled/ Terminated/ Term Wait; Grouping-Classroom;
Report Type-Detail; Order By-Family; Referral Agencies/Families-All. The Report Grand Total on the
last page is the number to be written on the Family Advocate End of Month Report. Family Advocates
with 2 classrooms can use the Advanced Setup link in blue to run this report for both classrooms at once.
Report Distribution: None, View Only Monthly
=====================================================================
XIX. Family Services Monitoring Reports of Area Manager H, E
Education Home Visits and Parent/Teacher Conferences
Report 4110 for Parent Teacher Conference and Education Home Visit Event Types only. Show-
caseworker and Family Service Action Notes; Status-Enrolled; Grouping-Classroom; Order By-
Participant; Report Type-Detail; Sort Actions by-Newest to Oldest; Initial Service Date Filter, Begin
Date-October 1, End Date-to match the date the report is run.
Report Distribution Time Frame (none, view-only end of October, January, May):
MSYS 8a
(C: 08/03; R: 06/13)
Lower Columbia College Head Start / EHS / ECEAP
Reporting System Policy and Procedure
Policy
The program will establish and maintain efficient and effective reporting systems that generate
periodic reports of financial status and program operations in order to control program quality,
maintain program accountability, and advise the governing body, policy group, and staff of
program progress; and generate official reports for Federal, State, and local authorities, as
required by applicable law.
Procedure
The following strategies will be considered when designing and implementing effective and
efficient reporting systems:
Identification of critical reports. Staff is to consult with each of their funding sources and
with State and local licensing agencies for complete lists of reports that agencies may be
required to produce in areas such as personnel qualifications, facilities and property, and
health, safety, and sanitation. Management staff are to consult with governing bodies and
Policy Council to determine the discretionary reports that will allow those groups and
staff to most effectively plan and manage the program and its finances.
Report content and structure. The program will produce reports that are clear, accurate,
and readable. The reports will help staff, the governing body, and Policy Council with
varying levels of experience and education to make informed decisions concerning the
program.
Frequency of reports. A time schedule will be developed for the release of reports that
allows staff, the governing body, and Policy Council to schedule meetings when up-to-
date information is available.
Examples of official reports may include:
Reports required by the Office of Head Start, HHS or other offices, including the
Program Information Report (PIR), financial audit reports, and reports of financial status
and expenditures (SF-425s) and Inkind.
Monthly reports for the ELMS (Early Learning Management System) for DEL
(Department of Early Learning) status on ECEAP services.
Forms providing information on payroll taxes, such as Social Security (FICA) taxes,
withholding of income taxes, Federal unemployment (FUTA) and State unemployment taxes.
Reports of meals served, menus, and training provided for the USDA meal program.
Program enrollment reports, including attendance reports for children whose care is
partially subsidized by another public agency.
Program End of Month Reports, which include content areas of Family Service,
Education, Health, Nutrition, ERSEA, Disabilities, Attendance and Meal Counts, etc.
Training and Technical Assistance Plan.
Program Monthly Community Partnership and Public Relations Report.
Other reports may include community assessment, strategic plan, financial objectives and
an educational outcomes/annual report.
Other reports as required by Federal, State, or local law. Policy Complies with Head Start Performance Standard 1304.51(h)(1) and 1304.51(h)(2).
MSYS 8f1
(C: 08/07: R: 10/16)
Lower Columbia College Head Start/EHS/ECEAP Assistant Director End of the Month Report for 3 -5 Program/EHS
Month: August Information used:
Area Manager/EHS Supervisor End of the month report
Teacher/Family Advocate End of the month report Education Head Start
LOC ID Funded Conference HV #1 Conference HV #2
Barnes
Broadway
Castle Rock
Catlin
LCC West/East
Memorial Park
Wallace
Totals
ECEAP
LOC ID Funded
Fall Conference
HV #1 Winter Conf. (FD)
Spring Conf.
Barnes
Broadway
Castle Rock
LCC East
Memorial Park
Totals
Early Head Start Education & Social Services
Model Funded PT Fall Conference FPA PT Spring Conference
Home Base 52
Teen 8
Totals 60
MSYS 8f1
(C: 08/07: R: 10/16)
Social Services
Child/Family Development Specialist & Family Advocate
LOC ID Funded WV HV #2 HV #3 FPA Conf. 1 Conf. 2
1000D 17
2000G 10
3000A 17
7000A 17
8000D 17
CFDS Totals 78
1000A/B 36
5000E/F 38
6000A/B 38
8000A/B 38
8000C 17
HS Totals 245
3000B 17
5000L 17
FD Totals 24
1000E 19
2000A 17
2000B 17
2000C/D 34
2000E 17
2000F 17
5000G/H 34
8000E 17
8000F 17
ECEAP Totals 223
EHS Attendance Percentages
Staff/Loc ID # enrolled # HV to complete # HV completed Attendance %
HB 1 10
HB 2 11
HB 3 11
HB 4 10
HB 5 10
Teen Infant 4
Teen Toddler 4
Totals 60
MSYS 8f1
(C: 08/07: R: 10/16)
Parent Family Community Engagement
Program Parent Engagement Activities/Attendance:
Date Site Activity Name/Description Number of Participants
Recruitment Activities:
Date Site Activity Name/Description Number of Participants
Community Involvement/Presentations in Community:
Date Site Activity Name/Description Number of Participants
Trainings Given/Meetings Facilitated:
Date Site Activity Name/Description Number of Participants
Family Outcomes:
Date (report ran) Site Outcomes (PIR/ELMS)
Support Given:
Date Activity Description (i.e. HV coaching, case management, training plan flup...) Who?
Community Referrals
Aug Sept Oct Nov Dec Jan Feb Mar April May June July
3-5
EHS
Monitoring to Date
Assistant Director Monitoring
Career Developments Complete: Evaluations Complete: Classroom Ideas/Training Requests:
Area Manager
Classroom Observations
DST Checklists ECERS
File Reviews
(4110) Case Management Observations
Home Visit/ Conference Observation
Other
Barnes/Wallace
Broadway/Catlin
LCC/CR
Memorial Park
EHS
MSYS 8f2
(C: 09/10; R: 10/16)
Lower Columbia College Early Head Start EHS Supervisor Monthly Report
Month: Year:
Staff Loc ID
Current
Enrollment
#
With- drawn
# Pregnant
Moms
FPA
Comp
FPA
Declined
Total
Cumulative Referrals
Total
Services Received
# Child Abuse/ Neglect Reports
# Families @
PAL
PT
Conference
Fire Drill
Comp
Earthquake
Drill
Lockdown
Fall
Spri
ng
Fall
Spri
ng
HB 1
HB 2
HB 3
HB 4
HB 5
Teen Infant
Teen Toddler
Totals
Comments: Attendance Percentages
Staff Loc ID # enrolled # HV to
complete # completed attendance % Make-Up Visit Offered/Plans for Improvement
HB 1
HB 2
HB 3
HB 4
HB 5
Teen Infant
Teen Toddler
Totals
MSYS 8f2
(C: 09/10; R: 10/16)
Report for Prenatal Families
Staff Loc ID Date & Initials
Mental Health Interventions
and Follow-Up
Substance Abuse Prevention and Treatment
Prenatal Education and Fetal Development
Information on the Benefits of Breastfeeding
Is this Pregnancy Considered High Risk?
HB 1
HB 2
HB 3
HB 4
HB 5
Teen Infant
Teen Toddler
Newborn Statistics
LOC ID of Family that Delivered
Date & Initials
Newborn Checklist Completed Yes/No
New Baby Announcement Completed
Yes/No
Edinburgh New Born Screening Completed
Yes/No: Date
Score of Edinburgh/Action Taken
Nurse Consultant Hours:
PAL Observations:
Supervisor Monitoring
Staff Loc ID
Files Reviewed
(4110) Case Management Observations
(4140 & 4110) HV Observations
Complete
Career Development Plan Fall Spring
Parent/Teacher Conference
Fall Spring
DST Checklist
Oct. Jan.
ITERS
HB 1
HB 2
HB 3
HB 4
HB 5
Teen Infant
Teen Toddler
Totals
MSYS 8f2
(C: 09/10; R: 10/16)
Community Involvement: List community meetings, boards, committees attended where you represented Head Start/EHS/ECEAP. Things that went well this month: My ideas, goals and plans for next month: I have attended and/or would like:
MSYS 8f3
Page | 1 (C: 08/11: R: 08/15)
Lower Columbia Head Start/EHS/ECEAP
Health Specialist
End of the Month Report
Month:
PARTICIPANTS WITH HEALTH INSURANCE Prior Month Percentiles
Head Start: _________________ Students _____ Increase of _____
Prior Year: _________________ Students
EHS: _________________ Participants _____ Increase of _____
Prior Year: _________________ Participants
ECEAP: _________________ Students _____ Increase of _____
Prior Year: _________________ Students
PHYSICAL EXAMINATION
Barnes HS _________________ Students _____ Increase of _____
Castle Rock HS _________________ Students _____ Increase of _____
Catlin _________________ Students _____ Increase of _____
LCC West _________________ Students _____ Increase of _____
St. Helens _________________ Students _____ Increase of _____
Wallace _________________ Students _____ Increase of _____
Head Start Total: _________________ Students _____ Increase of _____
Prior Year: _________________ Students
Barnes ECEAP _________________ Students _____ Increase of _____
Broadway ECEAP _________________ Students _____ Increase of _____
Castle Rock Full Day _________________ Students _____ Increase of _____
LCC East _________________ Students _____ Increase of _____
LCC East Full Day _________________ Students _____ Increase of _____
ECEAP Total: _________________ Students _____ Increase of _____
Prior Year: _________________ Students
EHS Total: _________________ Children _____ Increase of _____
Prior Year: _________________ Children
DENTAL EXAMINATIONS
Barnes _________________ Students _____ Increase of _____
Castle Rock _________________ Students _____ Increase of _____
Catlin _________________ Students _____ Increase of _____
LCC West _________________ Students _____ Increase of _____
St. Helens _________________ Students _____ Increase of _____
Wallace _________________ Students _____ Increase of _____
Head Start Total: _________________ Students _____ Increase of _____
Prior Year: _________________ Students
MSYS 8f3
Page | 2 (C: 08/11: R: 08/15)
Head Start Students Needing Dental TX:
The number who have begun or completed their Dental TX:
EHS Total: _____________ Children 1 year of age or older _____ Increase of _____
Prior Year: _____________ Children 1 year of age or older
EHS Children Needing Dental TX:
The number who have begun or completed their Dental TX:
Barnes ECEAP _________________ Students _____ Increase of _____
Broadway ECEAP _________________ Students _____ Increase of _____
Castle Rock Full Day _________________ Students _____ Increase of _____
LCC East _________________ Students _____ Increase of _____
LCC East Full Day _________________ Students _____ Increase of _____
ECEAP Total:
Dental Exams/Screenings: ______________ Students _____ Increase of _____
Prior Year: _________________ Students
ECEAP Students Needing Dental TX:
The number who have begun or completed their Dental TX:
IMMUNIZATIONS
Up-To-Date Out of Compliance Conditional Exempt
Head Start
EHS
ECEAP
NUTRITION ASSESSMENTS
Head Start: _____________Students
ECEAP: _____________Students
EHS: _____________Participants
LEAD SCREENINGS
Head Start: ______________Students
ECEAP: ______________Students
EHS: ______________Children 1 year of age or older
EHS Leadership Team Meetings Attended by Health Specialist:
MSYS 8f
1 (C: 08/00; R: 2/18)
LOWER COLUMBIA COLLEGE HEAD START/ECEAP Area Manager Monthly Report
CENTER(S) MONTH YEAR
AREA MANAGER Attachments: Classroom Tracking Totals Report; by center; last page only (cp.net E2501S) Supervision/Monitoring completed (to date):
Classroom LOC ID
File Review (# to date)
ECERS (date complete)
DST Checklist (date)
Oct. Jan.
Curriculum Fidelity (date)
Classroom
Case Management Observation Follow-Up Dates
Nov. Dec. Feb. March May
Conferences (to date): Fall Winter (Full Day only) Spring Home Visits Observed (to date):
Ed SS CFDS
Professional Development Plans: Performance Evaluations (include probationary):
Number completed this month: ______ Total number completed to date: ______
Fall Winter Spring
MSYS 8f
2 (C: 08/00; R: 2/18)
Safety:
Total number of referrals made to date (cp.net report 4120):
# of Child Abuse/Neglect reports made this month: # of Safety Intervention reports made this month: Community Involvement: List community meetings, boards, committees attended where you represented Head Start/ECEAP. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Things that went well for me this month: For You: ______________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
For Your site(s): ________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ My ideas, goals and plans for next month: For You: ______________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
For Your site(s): ________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Classroom LOC ID
Fire Drills (Monthly)
Earthquake Drills
(Monthly)
Lockdown Drills
Fall Spring
Classroom LOC ID
Fire Drills (Monthly)
Earthquake Drills
(Monthly)
Lockdown Drills
Fall Spring
Monthly Emergency Light 30 second test (Date)
Annual August Emergency Light 90 minute Test (date)
Aug Dec Apr
Sept Jan May
Oct Feb June
Nov Mar July n/a
MSYS 8f
3 (C: 08/00; R: 2/18)
I have attended and/or would like: For you: ______________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
For Your Staff: _________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Monthly Report Due to Assistant Director by the 10th of the month.
MSYS 8g1
(C: 01/04; R: 08/15)
LOWER COLUMBIA COLLEGE HEAD START/EHS/ECEAP
Ongoing Monitoring Policy & Procedure
Policy
Through the use of standard procedures, LCC Head Start/EHS/ECEAP will conduct ongoing and
regular monitoring of program operations to ensure that timely and necessary steps are being
taken to meet Head Start Performance Standards, other applicable federal and state regulations
and local goals and objectives. LCC Head Start/EHS/ECEAP recognizes and embraces ongoing
monitoring as an important component of continuous improvement and program excellence.
Procedure
Computer Database System Computer databases are used to systematically collect and record information. Periodic
reporting of this information to appropriate supervisors, managers, policy groups and leadership
occurs on a scheduled basis and upon request. Program monitoring systems include the use of
the following database systems:
ChildPlus.net
The program uses the ChildPlus.net system for the centralized recording and
maintenance of child/family information.
Disabilities, health, nutrition and enrollment information on each family are
monitored through ChildPlus.
The program's main office uses the ChildPlus.net systems for the centralized
recording and maintenance of employee health, training and personnel
information.
Employee health information is monitored through ChildPlus.
Teaching Strategies GOLD
Individual classroom reports will be distributed to Lead Teachers/Home Visitors
who will review them and complete the TSG Analyzing Form and meet with the
Child Development Specialist/Assistant Director or Mentor Specialist to discuss
next steps.
ELMS (Early Learning Management Systems)
The program uses the ELMS system for recording health/ nutrition, development
screenings, waitlist, enrollment, staff, etc. for ECEAP Program.
Monitoring Schedule The established LCC Head Start/EHS/ECEAP Monitoring Schedule (MSYS 8g) is followed and
implemented by the Leadership Team and staff. This schedule lists the checklists, monitoring
forms, observation instruments, monthly reports, milestones, action plans and supervision and
monitoring schedule which are utilized to monitor classroom environments, classroom records,
employee health requirements, and student site files which contain child and family information.
The schedule includes the following information for each monitoring task:
Monitoring Tool
The tool title indicates the records to be reviewed and/or the observations to be
made.
Timeline
Reviewer
Person responsible for completing the tool and communicating results to
appropriate Leadership and staff.
MSYS 8g1
(C: 01/04; R: 08/15)
Follow-up Manager
Person(s) responsible for ensuring follow-up and/or written action plans are
completed for identified issues.
The identified manager maintains the original (or a copy) of the completed tool
and documentation of follow-up steps and/or completion of action items.
Consultant Site File Reviews
Consultants will implement their Site file Review procedure. This procedure outlines the
process for consultants:
To be notified of the need to review a student's site file.
To schedule site file reviews with appropriate DST/EHS staff members.
To review the site file and complete the appropriate form.
To schedule and facilitate debriefing meetings.
To facilitate the writing of action plans.
To provide written comments to be entered into the ChildPlus database.
Transportation Monitoring
Transportation monitoring is also performed on a scheduled basis and the following
procedure/tools are utilized:
Transportation Procedure Annual Training
Annual Road Observations
Annual Bus Driver Performance Checklist
"Seven Step" Pre-Trip Procedure
Driver's Daily Vehicle Inspection Report/Zonar
Emergency Exit Drill
The program's Transportation Manager coordinates these monitoring efforts and is also
responsible for ensuring timely follow-up for identified issues.
Self-Assessment
The Self-Assessment procedure (MSYS 9a) outlines the following steps for the multi-
faceted monitoring process:
Method of Measuring
Specified Time Schedule
Preparations
Conducting the Self-Assessment & Making Review Decisions
Self-Assessment Report
Improvement Plan Development
Ongoing Evaluations
Results of the Self-Assessment are analyzed, an improvement plan is written and the
results are considered within the program planning process.
Policy complies with Head Start Performance Standard 1304.51.
MSYS 8g
1 (C: 11/00; R: 03/15)
Lower Columbia College Head Start/EHS/ECEAP
Monitoring Schedule
Tool: Site File Review Form (MSYS 8j)
Timeline: To be completed during reviews of Site files.
Reviewer: Area Manager, EHS Supervisor, Health Specialist
Follow-up Manager: Area Manager/EHS Supervisor
Tool: Direct Service Team Monthly Health & Safety Checklist (FACI 1c)
Timeline: To be completed each month.
Reviewer: Direct Service Team Members
Follow-up Manager: Area Manager
Tool: EHS Monthly Health / Safety Checklist (FACI1c1)
Timeline: To be completed each month.
Reviewer: Child & Family Development Specialist, Family Educator
Follow-up: EHS Supervisor
Tool: Annual Health & Safety Checklist (FACI 1b)
Timeline: To be completed annually during the month of June/July.
Reviewer & Follow-up Manager: Transportation Manager, Area Manager
Tool: ECERS (Early Childhool Environment Rating Scale)
Timeline: Completed annually in the fall.
Reviewer: Child Development Specialist/Mentor Specialist
Follow-up Manager: Area Manager
Tool: CACFP Meal Monitoring Form
Timeline: To be completed, at each center, in October, January/February, March,
April/May.
Reviewer: Food Service Supervisor
Follow-up Manager: Area Manager & EHS Supervisor
Tool: Home Visit Observation Form (MSYS 7m, MSYS 7n)
Timeline: To be completed annually at Home Visit for Family Advocate, Teacher and
Teacher/Family Advocate.
Reviewer: Area Manager
Follow-up Manager: Area Manager
Tool: EHS Home Visit Observation Form (MSYS 7m1)
Timeline: To be completed annually at Home Visit for EHS staff.
Reviewer: EHS Supervisor
Follow-up Manager: EHS Supervisor
Tool: ECEAP Physical Environment Checklist
Timeline: To be completed annually during the ECEAP Program Self-Assessment.
Reviewer: Self Assessment Team Members
Follow-up Managers: Area Manager & Health Specialist
MSYS 8g
2 (C: 11/00; R: 03/15)
Tool: Lesson Plans
Timeline: To be completed weekly.
Reviewer: Area Manager/Assistant Director/EHS Supervisor/ Child Development
Specialist/Mentor Specialist
Follow-up Manager: Area Manager/Assistant Director/EHS Supervisor
Tool: Teacher End of Month Report (EDUC 6a)
Timeline: Due 5th
of each month.
Reviewer: Teacher
Follow-up Manager: Area Manager
Tool: EHS CFDS EOM Report (FS/PI 17c)
Timeline: Due 5th
of each month
Reviewer: EHS Staff
Follow-up Manager: EHS Supervisor
Tool: Family Advocate End of Month Report (FS/PI 6b)
Timeline: Due 5th
of each month.
Reviewer: Family Advocate
Follow-up Manager: Area Manager
Tool: Teacher/Family Advocate End of Month Report (EDUC 6c)
Timeline: Due 5th
of each month.
Reviewer: Teacher/Family Advocate
Follow-up Manager: Area Manager
Tool: Family Services History Reports (ChildPlus.net Report 4110)
Timeline: To be reviewed one month prior to and directly after Parent/Teacher
Conference, Social Service Home Visits, Family Partnership Agreement,
and Education Home Visit due dates.
Reviewer: Area Manager
Follow-up Manager: Area Manager
Tool: Area Manager / EHS Supervisor End of Month Report (MSYS 8f)
Timeline: Due 10th
of each month.
Reviewer: Area Manager/ EHS Supervisor
Follow-up Manager: Assistant Director
Tool: ELMS ECEAP Report
Timeline: Due 10th
of each month.
Reviewer: Area Manager
Follow-up Manager: Area Manager
Tool: Disabilities End of Month Report
Timeline: Due 15th
of each month.
Reviewer: Disabilities Specialist
Follow-up Manager: Director
MSYS 8g
3 (C: 11/00; R: 03/15)
Tool: Mental Health End of Month Report
Timeline: Due 15th
of each month.
Reviewer: Mental Health Consultants
Follow-up Manager: Director
Tool: Assistant Director End of Month Report (MSYS 8f1)
Timeline: Due 15th
of each month
Reviewer: Assistant Director
Follow-up Manager: Director
Tool: EHS Supervisor EOM Report (MSYS 8f2)
Timeline: Due 10th
of each month
Reviewer: EHS Supervisor
Follow-up Manager: Assistant Director
Tool: Health/Nutrition End of Month Report (MSYS 8f3)
Timeline: Due 15th
of each month.
Reviewer: Health Specialist
Follow-up Manager: Director
Tool: Program Information Report
Timeline: Due 20th
of each month
Reviewer: Director
Follow-up Manager: Director, Policy Council, Governing Board
Tool: Enrollment Report
Timeline: To be completed monthly.
Reviewer: ERSEA Program Support Supervisor, Program Coordinator
Follow-up Manager: Director, ERSEA Program Support Supervisor
Tool: Monthly Attendance Percentages
Timeline: 5th
of each month.
Reviewer: Program Coordinator
Follow-up Manager: Director, Assistant Director, Area Managers, EHS Supervisor
Tool: Classroom Attendance Plan
Timeline: As needed
Reviewer: Direct Service Team
Follow-up Manager: Area Manager/ EHS Supervisor
Tool: Employee Health Data Base
Timeline: To be completed quarterly
Reviewer: Administrative Services Manager
Follow-up Manager: All Supervisors
Tool: Classroom Assessment Scoring System (CLASS) (Preschool & Toddler)
Timeline: Fall / Spring
Reviewer: Assistant Director, Area Managers, Child Development Specialist, Mentor
Specialist
MSYS 8g
4 (C: 11/00; R: 03/15)
Follow-up Manager: Area Managers, Assistant Director, Child Development Specialist,
Mentor Specialist
Tool: EHS Classroom Set-up and Postings Checklist (MSYS 8n)
Timeline: To be completed prior to first day of class and follow-up
October/November
Reviewer: EHS Staff/EHS Supervisor
Follow-up Manager: EHS Supervisor
Tool: Direct Service Team/Center Preparation/Checklist 3 – 5 (MSYS 8k)
Timeline: To be completed prior to first class day and follow-up Nov./Feb./April
Reviewer: Direct Service Team, Area Manager
Follow-up Manager: Area Manager
Tool: Site File Review Checklist (MSYS 9b)
Timeline: To be completed during Self Assessments.
Reviewer: Self Assessment Team
Follow-up Manager: Area Manager, Assistant Director, Director
Tool: Mental Health Classroom Observation
Timeline: To be completed once yearly and ongoing as needed – Fall
Reviewer: Mental Health Consultant
Follow-up Manager: Director, Assistant Director, Area Managers, EHS Supervisor, Mental
Health Consultant
Tool: Classroom Family Tracking Form (FS/PI 3f)
Timeline: To be updated monthly and as needed.
Reviewer: Direct Service Team
Follow-up Manager: Area Manager
Tool: EHS Classroom Family Tracking Form (FS/PI 17d)
Timeline: To be updated monthly and as needed
Reviewer: EHS Staff
Follow-up Manager: EHS Supervisor
Tool: EHS Prenatal Tracking Form (EOM) (FS/PI 16g)
Timeline: To be updated monthly and as needed
Reviewer: EHS Staff
Follow-up Manager: EHS Supervisor
Tool: EHS Health / Nutrition Tracking Form (EOM) (FS/PI 17e)
Timeline: To be updated monthly and as needed
Reviewer: EHS Staff
Follow-up Manager: EHS Supervisor
Tool: Infant/Toddler Environment Rating Scales (ITERS)
Timeline: October/November & March/April
Reviewer: Assistant Director
Follow-up Manager: EHS Supervisor
MSYS 8g
5 (C: 11/00; R: 03/15)
Tool: Teaching Strategies GOLD (3 – 5)
Timeline: Observations weekly/quarterly checkpoints.
Reviewer: Teachers, Teacher Assistants, Child Development Specialist, Mentor
Specialist
Follow-up Manager: Area Managers, Assistant Director, Child Development Specialist,
Mentor Specialist
Tool: Teaching Strategies GOLD (EHS)
Timeline: Observation weekly / quarterly checkpoints
Reviewer: EHS Staff/Assistant Director/EHS Supervisor
Follow-up Manager: EHS Supervisor, Assistant Director
Tool: Milestones
Timeline: Ongoing
Reviewer: Leadership Team
Follow-up Manager: Director
Tool: Quarterly Outcomes Report
Timeline: January, April, June
Reviewer: Policy Council, Governing Board, Director, Child Development Specialist,
Area Managers
Follow-up Manager: Child Development Specialist
Tool: School Readiness Plan (EDUC 9o, 9p, 9q)
Timeline: Fall & Winter
Reviewer: Education Committee, Child Development Specialist, Assistant Director
Follow-up Manager: Area Managers, EHS Supervisor
MSYS 8i
1 (C: 04/03; R: 08/15)
Lower Columbia College Head Start/EHS/ECEAP
Site File/ChildPlus Review Policy & Procedure
Policy
Area Managers, EHS Supervisor and Health Specialist are to review Student Site files to monitor
and support Direct Service Team members / EHS staff in the delivery of timely services to
program children, expectant mothers and their families.
Procedure
File/ChildPlus Review
1. Area Manager: Each Area Manager will randomly select and review one (1) Student
Site files monthly from each classroom. Each Area Manager will also monitor ChildPlus
on an ongoing basis.
2. Health Specialist: The Health Specialist will monitor ChildPlus, on an ongoing basis, to
assist DST members/EHS staff in meeting the outstanding health care needs of enrolled
children and expectant mothers.
3. Disabilities Specialist: The Disabilities Health Assistant and/or Disabilities Specialist
will check Special Needs section of the Student Site files of children who are on an
IEP/IFSP or who have been referred to the LEA to ensure all IEP/IFSP Disabilities
components are in place in January and ongoing.
4. Program Self-Assessments: During program self-assessments, typically conducted in
Winter (Head Start) and in Spring (ECEAP) team members will use and complete
assessment tools that cover all component areas.
5. EHS Supervisor: The EHS Supervisor will randomly select and review one (1) student
site files monthly from each Early Head Start caseload. The EHS Supervisor will also
monitor ChildPlus on an ongoing basis.
Forms
1. File Sign-Out Form: All authorized individuals reviewing site files are to sign the File
Sign-Out form and state the date, purpose, date and time returned and are to initial the
form.
2. Site File Review Form: The Site File Review form has a section for the Reviewer to
write down: items which have not been addressed or are in process of being completed;
questions regarding items, record keeping and tracking; possible ideas for a plan of action
and timeline; strengths and what is being done well.
MSYS 8i
2 (C: 04/03; R: 08/15)
Debriefing Meeting & Action Plan
1. Following the review of Site files, a scheduled debriefing meeting will be held with the
Reviewer and the Family Advocate, Lead Teacher, and/or Child/Family Development
Specialist (CFDS). If someone other than Area Managers/EHS Supervisor conducted the
review, then the Area Manager/EHS Supervisor will also attend those debriefings, if
possible.
2. The Reviewer will facilitate the meeting by asking questions and sharing gathered
information such as the outstanding items found, feedback regarding record
keeping/tracking, strengths and what is being done well. In regards to tracking, the team
must answer whether or not the child and family’s story of identifying needs and
receiving services can be readily followed in the student’s Site file.
3. The purpose of the debriefing meeting is for the Reviewer and staff to create a written
and workable Action Plan for outstanding items as determined by the team. Possible
technical and mentoring support will also be discussed. The Site File Review form has a
section for the team to write down the agreed upon Action Plan. All Action Plans are to
include: timelines; who is responsible and as appropriate planned referrals/crisis
intervention. The due date for turning in the completed Site File Review form will also
be written on the form.
4. At the end of the debriefing meeting, the Reviewer and the Teacher, Family Advocate or
CFDS will sign the Site File Review form with Action Plan. A copy is made for the Area
Manager/EHS Supervisor to use in their future monitoring. If the review of Site files was
conducted by the Health Specialist, the Action Plan notes this Reviewer as a “person
responsible” and a photocopy will be made for his or her use.
5. The Family Advocate, Teacher or CFDS will initial and date each action item as it is
completed. The Family Advocate/CFDS will then turn-in the completed form on the
stated due date with their End of the Month report.
6. Area Managers/EHS Supervisor will place their copies of the Site File Review form into
their monitoring notebook. When an original and completed form is turned-in, by a
Family Advocate/CFDS, it will be attached to the Area Manager/EHS Supervisor’s copy
in the notebook. Area Managers/EHS Supervisor will report trends/issues at the monthly
content expert meeting and/or Leadership meeting.
Policy and procedure comply with Head Start Performance Standard 1304.51(i)(2)
MSYS 8j1
(C: 06/10; R: 08/11)
Lower Columbia College Early Head Start
Prenatal Client File Review Form
Client Name: Due Date:
Date of Entry into program: Delivery Date:
Component Area Completed Issues Identified
Prenatal Health History
Medical or OB provider:
Regular Visits documented
Dental Provider: Visit
documented
Dental Screening
WIC
*Release on File
Nutrition Assessment
Childbirth Class
Maternal Mental Health
Screening
Major Focus Area
Notes Reflect Assessed
Risks from Health
HX & HV
Service Needs Identified
Based on Risk, as
Identified in HV Notes
Education Plan
Completed, as
reflected in HV notes
Health
Fetal Development*,
Prenatal exams,
Risks*, labor &
delivery*,
Postpartum recover*
Dental
Nutrition
WIC, Breastfeeding*
Substance Abuse
Mental Health
Maternal
depression*
* Discussion topics required by EHS standard
MSYS 8j
Distribution: Original: DST Copy: Supervisor 1 (C: 08/02; R: 06/11)
Lower Columbia College Head Start/EHS/ECEAP
Site File Review Form
Child's Name: DST/EHS Staff:
Reviewer: Date:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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______________________________________________________________________________
______________________________________________________________________________
MSYS 8j
Distribution: Original: DST Copy: Supervisor 2 (C: 08/02; R: 06/11)
Reviewer / DST / EHS Staff Meeting Date: __________________________________________
Action Plan / Timeline: __________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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______________________________________________________________________________
Completed form due to your direct Supervisor by:
Reviewer Signature: Staff Signature:
MSYS 8L
(C: 10/00; R: 08/10) 1
Lower Columbia College Head Start/EHS/ECEAP
Checklist for 3 – 5 Component Areas (Health/Nutrition/Safety)
Name:
Site: Date:
Communicable disease boards are clearly identifiable in English & Spanish to those who
enter the site. The information on them must be the most current (for a whole month) and
cannot have any names listed on it (this can be a dry erase board or a chalkboard).
________________________________________________________________________
________________________________________________________________________
Site has a well-defined parent area that has: the most current information available on
Healthy Kids Now, Washington State Basic Health Plan, current program/community
events, Food Assistance List, WIC, Mental Health Services, etc.
________________________________________________________________________
________________________________________________________________________
The most current classroom procedures or posters must be posted: Student Dietary
Concerns List, Emergency Medical/Dental Procedures, Classroom Fire Drill/Evacuation
Plan, Exit signs by each Exit Door, Emergency Phone Numbers for Police, etc., Phone
Location Sign, Germ Buster Poster (Handwashing Poster), Dental Health Poster(s),
Toothbrushing Procedure, Bathroom Procedure, First Aid Kit Location Sign, Emergency
Light Source Sign, Smoke Free Environment Policy/Procedure, Justice for All Poster,
USDA Meal Portions Poster, First Aid Poster (When a child is choking). Direct Service
Team Health/Sanitation form (at Broadway, Wallace and Castle Rock) (Flood, Bomb
Threat, Volcanic Eruption and C, A & N at Broadway) must be posted.
________________________________________________________________________
________________________________________________________________________
Storage of any cleaning supplies must either be in a cabinet well out of the reach of
children or locked and separate from food, food service equipment and medications.
________________________________________________________________________
________________________________________________________________________
Material Safety Data Sheets (MSDS) (informational sheets explaining potential hazards
of the products) are located in the M.S.D.S. binder in the building.
________________________________________________________________________
________________________________________________________________________
Emergency Response Procedures notebook contains the current Student Medical
Concerns/Allergies/Medication list, Medication Authorization forms and Medication
Administration forms for all student medications present in the classroom. (*Monitor
medication storage area to assure both of these forms are present for each medication in
storage. Also monitor medication storage area to assure, when a medication has been
MSYS 8L
(C: 10/00; R: 08/10) 2
completed or discontinued, the Medication Authorization form and Medication
Administration form are immediately forwarded to the Health/Nutrition Specialist.)
________________________________________________________________________
________________________________________________________________________
Medications are kept in a labeled and locked cabinet where children are unable to see and
reach them.
________________________________________________________________________
________________________________________________________________________
The Emergency Response Procedures Notebook contains both a completed and current
School Building Data Sheet, a Disaster Preparedness outline and Emergency Evacuation
Information form for Parent/Guardians.
________________________________________________________________________
________________________________________________________________________
Staff does the following daily: Mix and fill all clean spray bottles with a bleach/water
solution to be used to sanitize hard surfaces; Date each bottle; At the end of each day
empty all spray bottles.
________________________________________________________________________
________________________________________________________________________
Tables used for food services will be washed and disinfected before and after each meal
or snack.
________________________________________________________________________
________________________________________________________________________
Kitchen or food service area is not accessible to children, unless there is constant
supervision by an adult.
________________________________________________________________________
________________________________________________________________________
The following items need to be posted in the appropriate areas of each building:
Annual Child Care License by the Department of Health. (Building or Classroom)
________________________________________________________________________
________________________________________________________________________
Health Department Food Program Permit. (Building or Classroom)
________________________________________________________________________
________________________________________________________________________
Annual Fire Marshall's report. (Building or Classroom)
________________________________________________________________________
________________________________________________________________________
MSYS 8L
(C: 10/00; R: 08/10) 3
Food Handler Cards for each employee. (Classroom)
_______________________________________________________________________
________________________________________________________________________
Up-to-date First Aid and Pediatric CPR cards. (Classroom)
________________________________________________________________________
________________________________________________________________________
Resource files are maintained by the Family Advocates, which includes resources on:
mental health, medical/dental topics, nutrition, etc.
________________________________________________________________________
________________________________________________________________________
Staff monitors all children in the classroom.
________________________________________________________________________
________________________________________________________________________
Staff monitors all children on the playground.
________________________________________________________________________
________________________________________________________________________
Staff maintain proximity and/or monitor children who are likely to need assistance or
extra support.
________________________________________________________________________
________________________________________________________________________
Fire Extinguishers are present and current.
_______________________________________________________________________
________________________________________________________________________
Strengths:
Recommendations/Timelines:
MSYS 8n
1 (C: 09/10; 08/15)
Lower Columbia College Early Head Start
Early Head Start Classroom Set-Up and Posting Checklist
Classroom/Center Classroom Staff Year
#1 #2 (Date completed-due by September 30) (Date completed-January 31)
PRIOR TO THE FIRST DAY OF CLASS
Environment
Indoor Environment-available daily, sized for the appropriate age of the group:
Books and stories-i.e. books displayed in see through pockets, in a book stand, or in a low shelf. The
area has soft places to sit, i.e. pillows, covered mattresses, etc. At least 12 books (no less than 2 per
child) available and accessible – wide selection is accessible – staff read daily.
Quiet area-i.e. carpet or carpet squares on which to sit, soft chairs, pillows, stuffed animals, etc, (may
be part of another area i.e. books)
Sand and water/sensory-i.e. low sensory table, small tubs on tables or floors, props including basters,
plastic containers, plastic animals, funnels, scoops, etc.
Imitating and pretending-i.e. simple dress up clothes (hats, bags, etc.), small table and chairs, cooking
utensils, dolls, prop boxes. Props represent what children experience in real life. Props represent
diversity.
Art- on washable surface, near sink. May have a low table, small easel, shelves with various papers,
crayons, play dough, etc. A variety of materials are introduced. Access to materials is based on ability.
Playing with toys-may be on a carpeted area rug, or low table. Materials in tubs or baskets labeled with
pictures or pictures/words. Pop beads, puzzles, sorting games, small blocks, cardboard or foam blocks,
animals, cars, boats, trains, and other block accessories are some examples. Block area may be
separate for older children with more choices for building. At least two sets of different types are
accessible.
Music and Movement-tape/CD/record player, tapes/records/CD, instruments, things that make sounds,
space to move and dance, ribbons/streamers/fabric for dancing. A variety of instruments and music are
used.
Gross motor- furniture for climbing, sliding, and stepping up and down, open space for active play,
riding toys, tumble mats, tunnels, large cardboard boxes, are some examples both indoors and outdoors.
Diapering/toileting- changing table (with steps for toddlers); steps up to sink to wash hands, soap and a
paper towels where children can reach them, garbage cans children can reach.
Eating- low tables and chairs on washable floors, child size utensils and dishes, small pitchers and
serving utensils. Opportunities for children to taste and prepare food.
Quiet areas should be away from noisier areas. Wet/messy areas should be near sinks and separated
from "dry" activities.
Diapering/Toileting areas are separate from eating, cooking and children's activity areas.
Each cubby is labeled with the child's name and photo.
The environment is organized and free of clutter. Materials in cabinets and shelves are easily
accessible, organized and labeled. Displays at children’s eye level.
Environment is print rich as appropriate for the developmental level of the children. For further
guidance, see The Creative Curriculum for Infants, Toddlers & Twos.
MSYS 8n
2 (C: 09/10; 08/15)
Fine motor materials at different levels of difficulty are accessible.
Nature/Science materials are available and well organized. Outdoor experiences with nature are done
at least two times a week.
Communicable Disease board is posted and clearly identifiable in English and Spanish.
Materials are labeled with pictures and or/pictures and words, as appropriate for the developmental
level of the children.
The environment is attractive, colorful and welcoming without being overly stimulating. The amount of
commercial poster/decorations is minimal. Children's work dominates the items displayed. Items
displayed are at children's level.
Label shelves and other classroom equipment. Do not put tape directly onto carpets.
Outdoor Environment The outdoor environment should be sized for the appropriate age group: Examples of appropriate elements- not all
may be available every day:
Places for children to run, climb, jump, push, pull, haul, and dump.
Variety of surfaces-soft, hard, bumpy, smooth, etc.
Variety of textures- hard, soft, shiny, bumpy, smooth.
Objects that draw children to notice the elements and use their senses- plants of various textures,
smells, tastes, colors: windsocks, flags, banners, mobiles: mirrors, wind chimes, bells, gazing balls
decorative garden elements, etc.
Sensory table with props for digging and pouring (cover when not in use)
Riding toys, carts, push and pull toys, wagon.
Small slides, rocking toys or rocking boats, low steps
Range of equipment which are rotated and may include but not be limited to:
o Balls of various sizes and textures
o Wagons, buckets and baskets that children can fill, haul and dump
o Hollow blocks, plastic crates and other items for creating structures
o Low easel or fence easel with chalk, crayons, paint, etc.
o Brushes and buckets with water for painting
o Water play containers and materials- on a table or tubs at children’s level
o Musical instruments
o Mats for tumbling
o Cars and trucks
o Tunnels
o Cardboard boxes
o Playhouse
o Ribbons, scarves, fabric for dancing/moving
o Plastic animals
o Opportunity for planting/growing
Health/Safety
Each child has a nametag to wear the first weeks of school.
Electrical outlets covered.
Fire extinguisher is easily accessible and current.
A fully stocked First Aid kit is available. A sign indicating the location of the first aid kit is posted.
Classroom Staff have plans for keeping the kit stocked.
All medication is in a locked cabinet, or refrigerator lock box, and all appropriate forms have been
completed (Medication policy and procedure HLTH 5a)
All plants (non-poisonous only) are labeled.
MSYS 8n
3 (C: 09/10; 08/15)
Food Service items and dishes are stored separately from cleaning and art supplies in a closed
cabinet or in a covered container. Cleaning supplies may not be stored above food service items.
(All area labeled for easy accessibility).
Diapering/toileting areas are separate from eating/cooking areas with procedures posted.
Covered garbage can is available for food waste.
Covered garbage can is available for soiled diapers.
Attendance, In-kind forms, monthly meal counts, and child sign in/out forms are available on
clipboards or other easily accessible system.
Food allergies, First Aid/CPR and Food Handler’s cards posted.
Emergency Notebook is easily accessible and in a locked and marked location and up to date.
Toothbrushes are labeled with each child’s name and tooth brushing has begun as a regular routine
(See Tooth Brushing Procedure).
Are smoke detectors installed and tested regularly?
Are windows and glass doors constructed, adapted, or adjusted to prevent injury to children? Look
for a seal on the safety glass.
Does the program insure that indoor and outdoor premises are cleaned daily and kept free of
undesirable and hazardous materials and conditions?
Are indoor and outdoor spaces at center-based programs in use by mobile infants and toddlers
separated from general walkways and from areas in use by preschoolers? If not, describe the space
observed.
Postings Checklist
Each classroom and or site will post the following in accordance with Head Start Program Performance Standards
1304.22(a)(1)(2)(3); 1304.53(10)(vii), and other applicable policies and procedures.
Classroom Postings
Emergency medical/dental procedures are posted with center name, address, and phone numbers filled out
near the telephone.
Exit doors clearly marked with exit signs.
Emergency Evacuation Routes map, which indicated written instructions, at each classroom exit door
(create specific to each classroom/site)
Annual Fire Marshall report
Annual Child Care license by the Dept. of Health (Even Start)
Location of telephone is clearly marked
Location of First Aid kit is clearly marked
Location of flashlight is clearly marked
Hand washing signs at each sink must include instructions and pictures for proper procedure using soap,
water, and paper towel.
List of allergies near eating area/menu
Menu with substitutions recorded
Food Portions Poster (post in plain view, near menu)
Fire and Earthquake Drill Record Form
Daily cleaning log for indoor/outdoor environment
Diaper/Pull-ups Changing procedure
Toileting procedure
MSYS 8n
4 (C: 09/10; 08/15)
“And Justice For All” USDA poster in plain sight for parents
Curriculum/lesson Plan-weekly
Daily Schedule for adults with time/activities
Child oriented pictorial schedule at child height, oriented from left to right.
Photos of each child visible somewhere in the classroom
Tooth Brush Procedure
Parent Involvement
Program Calendar/Handbook
Volunteer In-kind
Center committee Meeting Minutes
Policy Council Agenda/Minutes (last meeting)
Menu
Healthy Kids Now
Washington State Basic Health Plan
WCCC Information
Food Assistance List
Mental Health Services
WIC
Current Program Community Events
#1- Staff Signatures/Date
#2- Staff Signatures/Date
#1- EHS Supervisor/Date
#2-EHS Supervisor/Date
MSYS 8o
1 (R:07/06; C:08/04)
CLASSROOM OBSERVATION INSTRUMENT
Site:
Teacher:
Date: Start Time: End Time:
Date: Start Time: End Time:
Date: Start Time: End Time:
Number of Children:
Number of Staff:
Number of Parents/Volunteers:
MSYS 8o
2 (R:07/06; C:08/04)
1. Teacher Interaction and Strategies
adults using a variety of intentional strategies that vary in complexity;
supervision of all indoor and outdoor activities; and
positive child guidance and appropriate limits;
adults maintain a predictable and consistent schedule.
Observe: What are the children doing? What are the teachers and adults doing? What is the environment like?
Examples you might look for include;
Child-initiated and adult-directed activities;
Individual and small group experiences;
Children exploring and making choices;
Timely, predictable, and unhurried routines and
transition;
Providing advance notices of transitions and
explain what happens next;
Talking to babies, singing and playing with them
during diaper changes, mealtimes, and other
routines.
Adjusting the schedule when appropriate to
respond to children and circumstances;
Providing time to expend energy and time to
relax;
Indoor Daily Time Schedule (picture schedule) is
posted that reflects a balance of individual, small
and large group and child initiated/adult initiated
activities; and
Staff maintains proximity and/or monitor children
who are likely to need assistance or extra support.
Yes No Comments
MSYS 8o
3 (R:07/06; C:08/04)
2. Facilitating Children's Language and Literacy Development
Language use and interaction among and between children and adults;
Adults fostering children's communication, including home language;
Experiences that develop auditory and visual discrimination;
Experiences that support creative expression; and
Experiences that develop school-readiness skills in literacy.
Observe: What are the children doing? What are the teachers and adults doing? What is the environment like?
Examples you might look for include;
Alphabet posters, puzzles, and books;
Examples of functional print and other materials
in appropriate places: mailboxes, sign-in charts,
maps, helper charts, and schedules;
Opportunities for children to write and dictate
stories and messages;
Art, music, rhyming songs, and movement;
Learning activities such as games, puzzles, and
books that promote knowledge of letters
(alphabet) and sounds;
Adults reading and discussing stories one-on-one
and in small groups;
Children choosing books to look at alone, to
share with a friend, or to take home;
Adults and children asking questions and
engaged in meaningful conversations; and
Experiences, materials, conversation and
activities that support the language used at home
and English as a second language.
Yes No Comments
MSYS 8o
4 (R:07/06; C:08/04)
3. Facilitating Children's Math and Science Development
Experiences that develop skills in mathematics and science;
Experiences that develop auditory and visual discrimination; and
Opportunities for children to discover how numerical concepts relate to other concepts.
Observe: What are the children doing? What are the teachers and adults doing? What is the environment like?
Examples you might look for include;
puzzles, games, unit blocks, and manipulatives
that range in complexity;
materials and experiences that develop counting,
sequencing, and one-to-one correspondence;
materials and experiences that encourage
understanding of cause and effect and spatial
relationships;
opportunities for children to discover how
mathematical concepts relate to other concepts,
for example measuring or weighing;
opportunities for children to count, classify,
sequence, sort, and match;
children experiment, describe, and make
predictions;
children using recipes for making snacks;
children caring for plants and animals, and
learning about science in their surroundings; and
adults asking questions in ways that extend
children's thinking.
Yes No Comments
MSYS 8o
5 (R:07/06; C:08/04)
4. Facilitating Children's Social and Emotional Development
Experiences that foster independence and trust;
Age-appropriate expectations of children;
Adults interacting in supportive ways;
Experiences that help children develop social skills, competence, respect for others, and positive attitudes towards learning; and
Tailor positive guidance strategies to fit the child and the situation.
Observe: What are the children doing? What are the teachers and adults doing? What is the environment like?
Examples you might look for include;
Self-portraits and family pictures;
Books, stories, puppets, and other dramatic play
experiences;
Interactive games and activities;
Familiar routines and transitions;
Clear, consistent age-appropriate rules developed
with child input;
Children accessing materials independently;
Adults timely response to children's cries and
other cues;
Adults encouraging and modeling problem
solving, behaviors, and language;
Singing or talking during routines and transitions;
Involve children in carrying out routines and
transitions;
Help children and families cope with separation
at arrival and reunions at the end of the day;
Rules are posted in the classroom and playground
with pictures or photographs to illustrate;
Protected place for each child's belongings, such
as a cubby with the child's picture and name; and
Children's completed work is displayed and
protected.
Yes No Comments
MSYS 8o
6 (R:07/06; C:08/04)
5. Facilitating Children's Physical Development
Experiences that develop sensory and motor skills;
Experiences that develop fine and gross motor skills;
Children using and coordinating small muscles, including eyes, hands, and eye-hand coordination; and
Sufficient safe indoor and outdoor space with age-appropriate equipment and materials.
Observe: What are the children doing? What are the teachers and adults doing? What is the environment like?
Examples you might look for include;
Tools such as blocks, beads, scissors, stapler, and
writing or drawing tools, pencils and brushes, and
appropriate;
Opportunities and sufficient space for children to
crawl, sit, walk, run, jump, and climb;
Age-and ability-appropriate equipment and
materials;
Children using motor skills in daily routines such
as pouring juice or milk, serving themselves,
buttoning and zipping; and
Children manipulative materials such as sand,
water, and clay.
Yes No Comments
MSYS 8o
7 (R:07/06; C:08/04)
6. Prevention and Early Intervention-Integrating Health, Nutrition, Mental Health, Safety, and Wellness
Health, nutrition, and mental health integrated into routines and children's learning experiences.
Observe: What are the children doing? What are the teachers and adults doing? What is the environment like?
Examples you might look for include;
toothbrushing and handwashing;
children using tissues and throwing them in the
wastebasket after use;
sufficient time for meals;
adults, toddlers, and pre-school children sharing
family-style meals and pleasant conversations;
infants held while being fed;
children involved in food experiences;
topical books, songs, games, and fingerplays;
children role playing;
adults and children talking about visits to the
dentist and doctor;
experiences representative of children's cultures;
children instructed in pedestrian safety. Added to
PRISM instrument to reflect Performance
Standards on Transportation.; and
follow an individual approach for carrying out
personal routines.
Yes No Comments
MSYS 8o
8 (R:07/06; C:08/04)
7. Individualizing and Disabilities Services
respect for the culture, language, ethnicity, family, and ability of each child;
facilities that ensure children's safety, comfort, and participation;
environment and curriculum that reflect the IFSP of IEP;
adults observing and assessing children's behavior and progress; and
system is being following for individualizing.
Observe: What are the children doing? What are the teachers and adults doing? What is the environment like?
Examples you might look for include;
books, music, posters, and games in different
languages and representing different cultures;
dolls, posters, pictures and books that represent
children with disabilities;
special furniture, equipment, and materials, if
needed, to accommodate a child with disabilities;
experiences required in the IFSP or IEP;
adults working with individual children with
small groups of children;
Post-its, notebooks, folders, cameras, or other
tools used to record observations;
Individual Child Education Plans are in place for
each child and strengths/interests are used in
developing activities;
Individual Child Profiles are up to date with
observation notes evident; and
prior week's lesson plan is posted in a visible
location and prior plan available in a binder.
Yes No Comments
MSYS 8o
9 (R:07/06; C:08/04)
8. Parent Involvement/Family Services
▪ Site has a workspace for parents?
Comments:
▪ Classroom session has representation on Policy Council (one representative / Alternate per teacher) and takes an active role in
monthly Parent Meetings (check agenda development, minutes, etc.) and provides a Policy Council report each month (see Center
Notebooks and interview staff).
Comments:
▪ Parents are encouraged to participate in giving input into activities for children or adults depending upon interest; evident in
lesson planning, home visit forms, parent meeting minutes and inkind forms.
Comments:
▪ Classroom or site has the most current information posted, i.e. current program community events, Policy Council events, Parent
Committee meeting minutes, lesson plans, daily schedule, and parent education meeting.
Comments:
▪ Attendance / meal count forms are being filled out correctly. Review for children that are absent and review the documentation
for absences on the Case Management form. Also check for analyzing of classroom attendance that is below 85% and for
attendance plans for children.
Comments:
▪ Center Notebook is maintained? (see content sheet in Center Notebook)
Comments:
MSYS 8o
10 (R:07/06; C:08/04)
▪ Resource files are being maintained by the Family Advocates, which include resources on parenting, child development and
personal growth.
Comments:
▪ Emergency Notebook is current and complete?
Comments:
MSYS 8p
(R: 08/10; C:05/03)
LOWER COLUMBIA COLLEGE HEAD START/EHS/ECEAP
Procedure for Completing Program Inventory
1. Complete the top line with the Center name and room number. Then check the appropriate
program for your room: Head Start, ECEAP, EHS.
2. List all items in your classroom including manipulatives, blocks, housekeeping, library,
furniture, computers, desks, chairs, etc. DO NOT list consumable supplies like paper, glue,
crayons, paint, etc. Group similar items together using the name of the item, or a brief
description.
3. Larger items may have a model or serial number. If so, record those in column 2.
4. Under column 3, list the Washington State tag number. This will appear on larger items such
as desks, computers, appliances, etc.
5. In column 4, record the date the items was purchased and from which company, if you have
this information. Any new items that are received during the year must have this information
recorded.
6. Record the purchase price in column 5, for ECEAP items.
7. Record the condition of the item in column 6, i.e. new, good, fair, poor.
8. Under column 7, record how an item is disposed of and when, i.e. surplused (for larger
items), thrown away, or transferred to another classroom.
9. Column 8 needs to be initialed by the person completing the inventory and the date of when
it was done. If one person completed it and on the same date, you may initial and date at the
top of the column of each page and draw an arrow down.
10. Columns 9 and 10 are to be used in subsequent years to complete the inventory. New items
will need to be added each year with all appropriate columns completed. If items are
received mid year, it may be easier to complete the inventory log at the time the item was
acquired rather than waiting till the end of the year. If the condition of an item changes from
one year to the next, then note that in column 6 and date.
11. Attach all pages of your inventory together and return to your Area Manager.
MSYS 8q
(C:05/98;R:08/10)
LOWER COLUMBIA COLLEGE HEAD START/EHS/ECEAP
Property Log and Inventory
Center: _______________________________________ Room Number: _____________________ Head Start: __________ ECEAP: __________ EHS: __________
Item/Description (Group similar items together)
Model/Serial
Number
WA State
Tag Number
Date/Place of
Acquisition
Purchase
Price
(ECEAP)
Condition
How & When
Disposed
By _____
Date _____
By _____
Date _____
By _____
Date _____
MSYS 9a
Policy complies with Head Start Performance Standard 1304.51(i)(1) (C: 08/03; R: 07/17)
Lower Columbia College Head Start/EHS/ECEAP
Self-Assessment Policy and Procedure
Policy
Once each program year, with the consultation and participation of the policy group and, as
appropriate, other community members, the program will conduct a self-assessment of their
effectiveness and progress in meeting program goals and objectives and in implementing
Federal/State regulations.
Procedure
Method of Measuring The self-assessment will be used as a method of measuring program accomplishments, strengths,
and weaknesses. This process is utilized for the continuous improvement of program plans and
service delivery methods; and for the enhancement of program quality and timely responses to
issues that arise in the community, the program, and among enrolled families.
Specified Time Schedule
Each year, our program’s structured self-assessment process will be scheduled as part of the
continuous cycle of program planning and in a way that responds flexibly to the program’s need
for review and evaluation.
Preparations
The program Leadership Team will take the following steps prior to the conducting the self-
assessment:
Develop a Self-Assessment calendar;
Select a Self-Assessment team, depending upon the specific focus of the self-assessment, by
providing opportunities for staff, policy council members, parents, representatives from
community organizations, governing body members, and staff from other Head Start/ EHS/
ECEAP agencies to participate;
Select Monitoring Tools and update, as needed, the contents of the Team Member self-
assessment materials.
Self-Assessment tools will be outlined.
Performance Standards are available online for team members to access as needed.
Other relevant Federal, Tribal, State and local regulations will also be available.
Provide the following self-assessment process training sessions:
Staff Training at Area Meetings
Policy Council Training
Self-Assessment Team Member Training provided by Team Leader
All training sessions will include information regarding:
Purposes of the Self-Assessment;
The Method of Accomplishing the Self-Assessment;
The Program’s Policy on Confidentiality;
Develop a Self-Assessment schedule and outline which includes:
Areas to be monitored
Data Sources
Training Logistics
Interview Logistics
Individual Self-Assessment Teams
Important Dates
MSYS 9a
Policy complies with Head Start Performance Standard 1304.51(i)(1) (C: 08/03; R: 07/17)
Conducting the Self-Assessment & Making Review Decisions
Utilizing the above methods, the program will be assessed by collecting information about
program practices, and comparing the information with the goals and objectives established
in program plans and with the Head Start / EHS / ECEA Program Performance Standards and
other relevant Federal, Tribal, State and local regulations.
The following will be used in developing Individual Self-Assessment Team compliance
recommendations, and in the final determination process of Core Question compliance status
at the Review Decision meeting:
Team agrees on what they saw, heard and read.
The group discusses performance standard compliance.
Specific performance standards with areas of noncompliance are determined.
The area of noncompliance is determined as due to a management system and/or as a
result of inadequate or inconsistent implementation.
The group discusses protocol compliance and determines no areas of noncompliance or
areas of noncompliance with regard to the body of standards summarized in each
protocol section.
Final Determination of Compliance
Final decisions are made by the team leaders following the Review Decision meeting.
Self-Assessment Report
The Self-Assessment report will be written by appropriate Leadership Team members. This
analyze report will include:
Identified regulatory citation numbers;
Specific descriptions of what was seen, heard or read or other discovered, including
quantification (frequency or extent) and qualification (severity or significance).
Outlines of the difference between what the regulation requires and what was found;
Statements regarding the impact of the situation on services to children and families.
Improvement Plan Development
Action plans addressing changes necessary to correct areas of weakness will be written by
appropriate Leadership Team members. This combined improvement plan and working
document will include:
Regulatory Citation Numbers;
Specific Action Steps;
Who Is Responsible;
Timelines
Self-Assessment Report and Action Plan Approval and Implementation
The assessment summary and improvement plan will be presented to Policy Council for
approval.
The assessment report and improvement plan will be presented to the College Administration
for approval.
The improvement plan will be monitored by the Director and progress reported to Policy
Council and College Administration.
Ongoing Evaluations
The impact of proposed changes will be evaluated during the subsequent self-assessment, to
ensure that the results of the changes are beneficial to the program and to the children and
families served.
MSYS 9b1a
As applicable, place date of document and/or following in boxes: X = Requirement met O = Requirement not met (C: 09/17)
SP = Place by child's name to indicate child with Spanish as primary language. M = Place by child's name to indicate child with medical condition(s).
D = Place by child's name to indicate child with disabilities. - 1 -
Lower Columbia College Early Head Start - Prenatal
Site File Review Worksheet
Child's Name & Loc ID:
Total Enrollment Date:
Date of Birth:
Inside Front Cover Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
File Sign Out
Administration Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP Individual Site File Content
Sheet – date/initialed
Prenatal Emergency
Information Form (FS/PI 16a)
Contact Information Form (current and original)
Change of Status Form(s)
Legal Documents
Parent Agreement Contract
Change of Classroom Request
Parent/Guardian Release
Forms (ROI’s) (Med/Dental/PC/
School Districts/ PCAP/WIC/Specialists
Application Info/Family
Member Info (original or computer
generated application with parent
signature)
Intake/Enrollment Forms
Checklist (check name)
Medicaid/Insurance Card (optional)
Education – N/A Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP Individual Site File Content
Sheet – date/initialed
N/A
MSYS 9b1a
As applicable, place date of document and/or following in boxes: X = Requirement met O = Requirement not met (C: 09/17)
SP = Place by child's name to indicate child with Spanish as primary language. M = Place by child's name to indicate child with medical condition(s).
D = Place by child's name to indicate child with disabilities. - 2 -
Child's Name & Loc ID:
Total Enrollment Date:
Date of Birth:
Special Needs – N/A Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
Individual Site File Content
Sheet – date/initialed
Social Service Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP Individual Site File Content
Sheet – date/initialed
Attendance Letter
Attendance Plan
Family Interest Survey
Family Partnership Agreement
Home Safety Checklist
(Updates)
Home Visit Plan Forms
Newborn Announcement
Newborn Checklist
Post-Partum Assessment/2-wk
Newborn Home Visit Form
Overview of Required
Services for Expectant Mother
Parent/Guardian Orientation
Checklist
Permission to Transport
Start-Up for Enrolled Families
Supplemental Prenatal Client
Questions
Other (Notes Home/Emails)
MSYS 9b1a
As applicable, place date of document and/or following in boxes: X = Requirement met O = Requirement not met (C: 09/17)
SP = Place by child's name to indicate child with Spanish as primary language. M = Place by child's name to indicate child with medical condition(s).
D = Place by child's name to indicate child with disabilities. - 3 -
Child's Name & Loc ID:
Total Enrollment Date:
Date of Birth:
Mental Health Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
Family/Child Support Plan
Family/Child Support Plan
Update
Edinburgh Prenatal
Depression Scale
Pre32-36 Weeks
Post 4-6 Weeks
Additional
MH Staffing Form
Parent Consult
Other (memos, emails, etc.)
Health/Nutrition Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
Individual Site File Content
Sheet – date/initialed
Accident Form
At-Home Meds Form – Side
Effects
Denial of Consent (Physical,
Dental, Lead Screening)
Diaper/Pull-Up Offer Form
Food Allergy Statement from
Health Care Provider
Formula Offer Form
Health Emails/Health Memos
Health History Form
MSYS 9b1a
As applicable, place date of document and/or following in boxes: X = Requirement met O = Requirement not met (C: 09/17)
SP = Place by child's name to indicate child with Spanish as primary language. M = Place by child's name to indicate child with medical condition(s).
D = Place by child's name to indicate child with disabilities. - 4 -
Child's Name & Loc ID:
Total Enrollment Date:
Date of Birth:
Health/Nutrition Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
Health Specialist Records
Hearing/Vision 3-Prong
Approach: Check Date
Height/Weight Chart
Immunization Agreement
Lead Screening
Documentation
Medical Documentation
Request/Correspondence
Medication Authorization
Medication Info. on completed
medications (Original Authorization,
Checklist and Administration Forms)
Nursing Assessment Form
OAE Hearing & Spot Vision (See Ed section for screening summary)
PIR Enrollment Questionnaire
PIR Spring Health
Questionnaire
WA State Immunization Form
Well Child Exam Forms
Other
Dental Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
Carries Risk Assessment
Dental Emails/Memos
MSYS 9b1a
As applicable, place date of document and/or following in boxes: X = Requirement met O = Requirement not met (C: 09/17)
SP = Place by child's name to indicate child with Spanish as primary language. M = Place by child's name to indicate child with medical condition(s).
D = Place by child's name to indicate child with disabilities. - 5 -
Child's Name & Loc ID:
Total Enrollment Date:
Date of Birth:
Dental Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
Dental Exams
Dental
Request/Correspondence
Dental Screening Form
Other
Nutrition
Nutrition Assessment Form
Nutrition Handout Distribution
Form
Nutrition/Request/
Correspondence
WIC
Other
MSYS 9b1
As applicable, place date of document and/or following in boxes: X = Requirement met O = Requirement not met (C: 11/15; R: 09/17) SP = Place by child's name to indicate child with Spanish as primary language. M = Place by child's name to indicate child with medical condition(s).
D = Place by child's name to indicate child with disabilities. - 1 -
Lower Columbia College Early Head Start
Site File Review Worksheet
Child's Name & Loc ID:
Total Enrollment Date:
Date of Birth:
Inside Front Cover Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
File Sign Out
Administration Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP Individual Site File Content
Sheet – date/initialed
Contact Information Form (current and original)
Change of Status Form(s)
Legal Documents
Withdrawal/Transfer List
Parent Agreement Contract
Change of Classroom Request
Birth Certificate (copy of State or
Hospital)
Parent/Guardian Release
Forms (ROI’s) (Med/Dental/PC/
School Districts/PCAP/WIC/Specialists
Application Info/Family
Member Info (original or computer
generated application with parent signature)
Intake/Enrollment Forms
Checklist (check name)
Medicaid/Insurance Card (optional)
MSYS 9b1
As applicable, place date of document and/or following in boxes: X = Requirement met O = Requirement not met (C: 11/15; R: 09/17) SP = Place by child's name to indicate child with Spanish as primary language. M = Place by child's name to indicate child with medical condition(s).
D = Place by child's name to indicate child with disabilities. - 2 -
Child's Name & Loc ID:
Total Enrollment Date:
Date of Birth:
Education Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
Individual Site File Content
Sheet – date/initialed
Ages and Stages Screening
Tool (date completed)
Ages and Stages Social
Emotional (date completed)
Attendance Letter
Attendance Participation Plan
Home Language Survey
Individual Child Education
Plan(s)
Pre-conference Survey
(EDUC 2b)
Screening Summary Forms
Socialization Sign-In Form and
Observation Form
Transition Conference Form &
Updates (DISA 3b3)
Transition Survey (DISA 3b4)
Transition Plan/Exit Record
Absence Notes from Parents
Attendance Calendars
Notes Home
Parent/Teacher Conference
Form and TSG Family
Conference Form (FALL)
MSYS 9b1
As applicable, place date of document and/or following in boxes: X = Requirement met O = Requirement not met (C: 11/15; R: 09/17) SP = Place by child's name to indicate child with Spanish as primary language. M = Place by child's name to indicate child with medical condition(s).
D = Place by child's name to indicate child with disabilities. - 3 -
Child's Name & Loc ID:
Total Enrollment Date:
Date of Birth:
Education Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP Parent/Teacher Conference
Form and TSG Family
Conference Form (SPRING)
Other
Special Needs Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
Individual Site File Content
Sheet – date/initialed
Confirmation of IFSP
Documentation of Services
EHS Early Intervention
Referral Form (DISA 3a)
IFSP
IFSP Goal Areas
IFSP Transition Summary
(@ 6 months)
Consent for Initial Evaluation
Consent for Re-Evaluation
Parental Consent to Evaluate
Prior Written
Notice/Reinstatement of
Services
Request for Records
Other (health reports that relate to
disability, Progress Center, Special
Education Memos, Refusal of Services
form, etc.)
MSYS 9b1
As applicable, place date of document and/or following in boxes: X = Requirement met O = Requirement not met (C: 11/15; R: 09/17) SP = Place by child's name to indicate child with Spanish as primary language. M = Place by child's name to indicate child with medical condition(s).
D = Place by child's name to indicate child with disabilities. - 4 -
Child's Name & Loc ID:
Total Enrollment Date:
Date of Birth:
Social Service Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP Individual Site File Content
Sheet – date/initialed
Family Interest Survey
Family Partnership Agreement
Home Safety Checklist
(Updates)
Home Visit Plan Forms
Parent/Guardian Orientation
Checklist
Permission to Transport
Shared Family/Forms/Emails
Start-Up for Enrolled Families
Other (Notes Home/Emails)
Mental Health Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
EHS Mental Health
Observation (MH9b)
External Mental Health
Provider Report
Family/Child Support Plan
Family/Child Support Plan
Update
MH Documentation
Request/Correspondence
MH Staffing Form
MH/Behavior Request for
Observation/Assessment
MSYS 9b1
As applicable, place date of document and/or following in boxes: X = Requirement met O = Requirement not met (C: 11/15; R: 09/17) SP = Place by child's name to indicate child with Spanish as primary language. M = Place by child's name to indicate child with medical condition(s).
D = Place by child's name to indicate child with disabilities. - 5 -
Child's Name & Loc ID:
Total Enrollment Date:
Date of Birth:
Mental Health Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
MH Checklist
Parent/Guardian Permission
for MH Observation/
Assessment
Parent/Guardian Permission
for MH/Behavioral
Observation/Assessment
Parent/Mental
Health/Behavioral Consult
Request for MH/Social
Emotional Observation
Safety Interventional Report
Sensory Symptoms Checklist
School Version
Sensory Symptoms checklist
Social and Emotional Obs. and
Assessment Report
Parent Mental Health
Behavioral Consult
Sensory Profiles
Other (memos, emails, etc.)
Health/Nutrition Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
Individual Site File Content
Sheet – date/initialed
Accident Form
At-Home Meds Form – Side
Effects
Denial of Consent (Physical,
Dental, Lead Screening)
MSYS 9b1
As applicable, place date of document and/or following in boxes: X = Requirement met O = Requirement not met (C: 11/15; R: 09/17) SP = Place by child's name to indicate child with Spanish as primary language. M = Place by child's name to indicate child with medical condition(s).
D = Place by child's name to indicate child with disabilities. - 6 -
Child's Name & Loc ID:
Total Enrollment Date:
Date of Birth:
Health/Nutrition Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
Diaper/Pull-Up Offer Form
Food Allergy Statement from
Health Care Provider
Formula Offer Form
Health Emails/Health Memos
Health History Form
Health Specialist Records
Hearing/Vision 3-Prong
Approach: Check Date
Height/Weight Chart
Immunization Agreement
Lead Screening
Documentation
Medical Documentation
Request/Correspondence
Medication Authorization
Medication Info. on completed
medications (Original Authorization,
Checklist and Administration Forms)
Nursing Assessment Form
OAE Hearing & Spot Vision (See Ed section for screening summary)
PIR Enrollment Questionnaire
PIR Spring Health
Questionnaire
MSYS 9b1
As applicable, place date of document and/or following in boxes: X = Requirement met O = Requirement not met (C: 11/15; R: 09/17) SP = Place by child's name to indicate child with Spanish as primary language. M = Place by child's name to indicate child with medical condition(s).
D = Place by child's name to indicate child with disabilities. - 7 -
Child's Name & Loc ID:
Total Enrollment Date:
Date of Birth:
Health/Nutrition Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
WA State Immunization Form
Well Child Exam Forms
Other
Dental
Carries Risk Assessment
Dental Emails/Memos
Dental Exams
Dental
Request/Correspondence
Dental Screening Form
Other
Nutrition
Nutrition Assessment Form
Nutrition Handout Distribution
Form
Nutrition/Request/
Correspondence
WIC
Other
MSYS 9b2a
(C: 09/17; R: 10/17)
- 1 -
Lower Columbia College Early Head Start
Site File Review Summary - Prenatal
Center Names:
Total Number of Files Reviewed:
Inside Front Cover Comments/Follow Up:
File Sign Out
Administration Comments/Follow Up:
Individual Site File Content
Sheet – date/initialed
Prenatal Emergency
Information Form
Contact Information Form
Change of Status Form(s)
Restraining Order/Legal
Documents
Parent Agreement Contract
Change of Classroom Request
Parent/Guardian Release
Forms (Medical/Dental/PC/School
Districts/PCAP/WIC/Specialists)
Application Info/Family
Member Info (original or computer
generated application with parent
signature)
Intake/Enrollment Forms
Checklist (check name)
Medical Coupon/Insurance
Card
Education – N/A Comments/Follow Up:
Individual Site File Content
Sheet – date/initialed
N/A
MSYS 9b2a
(C: 09/17; R: 10/17)
- 2 -
Center Names:
Total Number of Files Reviewed:
Special Needs – N/A Comments/Follow Up:
Individual Site File Content
Sheet – date/initialed
Social Service Comments/Follow Up:
Individual Site File Content
Sheet – date/initialed
Attendance Letter
Attendance Plan
Child and Family Profile
Family Interest Survey
Family Partnership Agreement
HS Family Outcomes
Assessment
Home Safety Checklist
Home Visit Plan Forms
Newborn Announcement
Newborn Checklist
Post-Partum Checklist/2-week
Newborn Home Visit form
Overview of Required Services
for Expectant Mother
Parent Orientation Checklist
Permission to Transport Form
Shared Family/Forms/Emails
Start-up for Enrolled Families
MSYS 9b2a
(C: 09/17; R: 10/17)
- 3 -
Center Names:
Total Number of Files Reviewed:
Social Service – (cont.) Comments/Follow Up:
Supplemental Prenatal Client
Questions
Other (notes home/emails)
Mental Health Comments/Follow Up:
Family/Child Support Plan
Family/Child Support Plan
Update
Edinburgh Prenatal Depression
Scale
Pre 32-36 weeks
Post 4-6 weeks
Additional
MH Staffing Form
Parent Consult
Other (memos, emails)
Health/Nutrition Comments/Follow Up:
Individual Site File Content
Sheet – date/initialed
Dental Exam Form
Dental Screening Form
Health/Dental/Emails
Nursing Assessment Form
Nutrition Assessment Form
Prenatal Dental History
Questionnaire (HLTH 14c)
Prenatal Hlth./Dental/Nutrition
History Form (FS/PI 16a)
MSYS 9b2a
(C: 09/17; R: 10/17)
- 4 -
Center Names:
Total Number of Files Reviewed:
Health/Nutrition – (cont.) Comments/Follow Up:
PIR Enrollment Questionnaire (FS/PI 7f)
PIR Health Questionnaire (end
of year) (HLTH 10i)
Post-Natal Nursing
Assessment
WIC
Other
MSYS 9b2b
(C: 09/17)
- 1 -
Lower Columbia College Early Head Start
EHS Site File Review Summary
Center Names:
Total Number of Files Reviewed:
Inside Front Cover Comments/Follow Up:
File Sign Out
Administration Comments/Follow Up:
Individual Site File Content
Sheet – date/initialed
Contact Information Form
Change of Status Form(s)
Withdrawal/Transfer Checklist
Parent Agreement Contract
Restraining Order/Legal
Documents
Change of Classroom Request
Birth Certificate
Parent/Guardian Release
Forms (Medical/Dental/PC/School
Districts/PCAP/WIC/Specialists)
Application Info/Family
Member Info (original or computer
generated application with parent
signature)
Intake/Enrollment Forms
Checklist (check name)
Medical Coupon/Insurance
Card
Education Comments/Follow Up:
Individual Site File Content
Sheet – date/initialed
MSYS 9b2b
(C: 09/17)
- 2 -
Center Names:
Total Number of Files Reviewed:
Education (cont.) Comments/Follow Up:
ASQ-3 Development
Screening
ASQ SE-2
Attendance Letter
Attendance Participation Plan
Home Language Survey
Individual Child Education
Plan(s)
Pre-Conference Survey
(EDUC 2b)
Screening Summary Forms
Socialization Sign-In Form and
Observation Forms
Other Screening Tools
Transition Conference Form
and Updates (DISA 3b3)
Transition Survey (DISA 3b4)
Transition Plan/Exit Record
Absence Notes from Parents
Notes Home
Parent/Teacher Conference
Form and TSG Family
Conference Form (FALL)
Parent/Teacher Conference
Form and TSG Family
Conference Form (SPRING)
Other
MSYS 9b2b
(C: 09/17)
- 3 -
Center Names:
Total Number of Files Reviewed:
Special Needs Comments/Follow Up:
Individual Site File Content
Sheet – date/initialed
Confirmation of IFSP
Documentation of Services
EHS Early Intervention
Referral Form (DISA 3a)
IFSP
IFSP Goal Areas
IFSP Transition Summary (@ 6 months)
Consent for Initial Evaluation
Consent for Re-Evaluation
Parental Consent to Evaluate
Prior Written
Notice/Reinstatement of
Services
Request for Records
Other (health reports that relate to
disability, Progress Center (IFSP), special education memos, refusal of services form,
etc.)
Social Service Comments/Follow Up:
Individual Site File Content
Sheet – date/initialed
Attendance Plan
Child and Family Profile
Family Interest Survey
MSYS 9b2b
(C: 09/17)
- 4 -
Center Names:
Total Number of Files Reviewed:
Social Service (cont.) Comments/Follow Up:
Family Partnership Agreement
HS Family Outcomes
Assessment
Home Safety Checklist
Home Visit Plan Forms
Parent Orientation Checklist
Permission to Transport Form
Shared Family/Forms/Emails
Start-up for Enrolled Families
Transportation Request
Mental Health Comments/Follow Up:
Intervention Strategies
EHS Mental Health
Observation (MH 9b)
External MH
Family/Child Support Plan
Family/Child Support Plan
Update
MH Documentation
Request/Correspondence
MH Staffing Form
MH Behavior Request for
Observation/Assessment
Mental Health Checklist
MSYS 9b2b
(C: 09/17)
- 5 -
Center Names:
Total Number of Files Reviewed:
Mental Health (cont.) Comments/Follow Up:
Parent/Guardian Permission
for MH
Observation/Assessment
Parent/Guardian Permission
for MH/Behavioral
Observation/Assessment
Parent/Mental
Health/Behavioral Consult
Request for MH/Social/
Emotional Observation
Safety Intervention Report
Sensory Symptoms Checklist
School Version
Sensory Symptoms Checklist
Social and Emotional
Observation and Assessment
Report
Parent Mental Health
Behavioral Consult
Other (Vanderbilt Assessment
completed for PCP, other information
completed for MH)
Protein Snack Permission
Health/Nutrition Comments/Follow Up:
Individual Site File Content
Sheet – date/initialed
Accident Form
At Home Meds Form – side
effects
Denial of Consent
Diaper/Pull-Up Offer Form
MSYS 9b2b
(C: 09/17)
- 6 -
Center Names:
Total Number of Files Reviewed:
Health/Nutrition (cont.) Comments/Follow Up:
Food Allergy Statement from
Health Care Provider
Formula Offer Form
Health Email/Memos
Health History Form
Health Specialist Records
Hearing and Vision 3 Prong
Approach – Check Date:
Height/Weight Chart
Immunization Agreement
Lead Screening
Documentation
Medical Documentation
Request/Correspondence
Medication Authorization
Medication Info on Completed
Medications (original Authorization,
Checklist and Administrations forms)
Nursing Assessment Form
OAE Hearing and Spot Vision (see Ed section for screening summary)
PIR Enrollment Questionnaire
PIR Spring Health
Questionnaire
WA State Immunization
Form/Exemption Form
Well Child Exam Forms
MSYS 9b2b
(C: 09/17)
- 7 -
Center Names:
Total Number of Files Reviewed:
Health/Nutrition (cont.) Comments/Follow Up:
Other
Caries Risk Assessment
Dental Emails/Memos
Dental Exams
Dental
Request/Correspondence
Dental Screening Form
Other
Nutrition Assessment Form
Nutrition Handout Distribution
Form
Nutrition
Request/Correspondence
WIC (HCB/HCT)
Other
MSYS 9b2
(C: 08/17)
- 1 -
Lower Columbia College Head Start/ECEAP
Site File Review Summary
Center Names:
Total Number of Files Reviewed:
Inside Front Cover Comments/Follow Up:
File Sign Out
Administration Comments/Follow Up:
Individual Site File Content
Sheet – date/initialed
Contact Information Form
Change of Status Form(s)
Withdrawal/Transfer Checklist
Parent Agreement Contract
Restraining Order/Legal
Documents
Change of Classroom Request
Birth Certificate
Parent/Guardian Release
Forms (Med/Dent/PC/School
Districts/PCAP/WIC/Specialists)
Application Info/Family
Member Info (original or computer
generated application with parent
signature)
Intake/Enrollment Forms
Checklist (check name)
Medical Coupon/Insurance
Card
Education Comments/Follow Up:
Individual Site File Content
Sheet – date/initialed
MSYS 9b2
(C: 08/17)
- 2 -
Center Names:
Total Number of Files Reviewed:
Education (cont.) Comments/Follow Up:
Absence Notes from Parents
ASQ-3 Development
Screening
ASQ SE-2
Classroom Sign-In Sheets
Developmental Screening
Summary
Education Home Visit Plan
Forms
Field Trip Permission Slips
Home Language Survey
Notes Home
Other Screening Tools
Parent/Teacher Conference
Form
Pre-Conference Survey
TSG (Individual Child) (Final)
Checkpoint
School Readiness Survey
Special Needs Comments/Follow Up:
Individual Site File Content
Sheet – date/initialed
Consent for Initial
Evaluation/Evaluation/Re-
evaluation Consent
Disabilities Staffing Form
MSYS 9b2
(C: 08/17)
- 3 -
Center Names:
Total Number of Files Reviewed:
Special Needs (cont.) Comments/Follow Up:
Evaluation Summary
DOE/DNQ
Embedded Schedule
IEP
IEP at a Glance
Invitation to Attend Meeting
Request for IEP/IFSP
Special Education Service
Log(s)
Teacher Assessment Summary
Team Meeting Notes
Other (health reports that relate to
disability, Progress Center, Special
Education Memos, Refusal of Services form, etc.
Social Service Comments/Follow Up:
Individual Site File Content
Sheet – date/initialed
Attendance Plan
Child and Family Profile
ECEAP Family Assessment
Family Interest Survey
Family Partnership Agreement
HS Family Outcomes
Assessment
MSYS 9b2
(C: 08/17)
- 4 -
Center Names:
Total Number of Files Reviewed:
Social Service (cont.) Comments/Follow Up:
FDM (ECEAP) Empowerment
Matrix
Home Safety Checklist
Home Visit Plan Forms
Notes Home
Notes from Parent/Guardian
Parent Orientation Checklist
Permission to Transport Form
Transportation Request
Mental Health Comments/Follow Up:
Intervention Strategies
Mental Health Checklist
Parent/Guardian Permission
for MH Social/Emotional
Observation/Assessment
Parent/Guardian Interview for
MH Social/Emotional
Observation/Assessment
Parent/Guardian Interview for
MH Social/Emotional
Observation/Assessment
Request for MH Social/
Emotional Observation/
Assessment Report
Parent/Guardian Consult
MSYS 9b2
(C: 08/17)
- 5 -
Center Names:
Total Number of Files Reviewed:
Mental Health (cont.) Comments/Follow Up:
Family/Child Support Plan
Family/Child Support Plan
Update
MH Staffing Form
Safety Intervention Report
Sensory Symptoms Checklist
School Version
Sensory Symptoms Checklist
MH Documentation
Request/Correspondence
External MH Provider Report
Other: Vanderbilt Assessment
completed for PCP, other
information completed for MH
Protein Snack Permission
Individual Child Observation
Report
Parent MH/Behavioral Consult
Positive Behavior Support Plan
Mental Health Staffing Form
for MDT
Physical Intervention Report
Sensory Profile Protocol
Sensory Profile Report
MH Documentation
Request/Correspondence
MSYS 9b2
(C: 08/17)
- 6 -
Center Names:
Total Number of Files Reviewed:
Mental Health (cont.) Comments/Follow Up:
External Mental Health
Provider Report
Health/Nutrition Comments/Follow Up:
Individual Site File Content
Sheet – date/initialed
Accident Form
Denial of Consent
Health History Form
Health Summary (Spring)
Hearing & Vision Screening
Form
Immunization Agreement
Lead Screening
Documentation
Medical Documentation
Request
Medical Action Plan
Medical Documentation
Request/Correspondence
Medication Authorization
Medication Info on Completed
Medications (original Authorization,
Checklist and Administration forms)
Medication Side Effect Sheet
Nursing Assessment Form
PIR Enrollment Questionnaire
MSYS 9b2
(C: 08/17)
- 7 -
Center Names:
Total Number of Files Reviewed:
Health/Nutrition (cont.) Comments/Follow Up:
PIR Spring Health
Questionnaire
Provider Immunization
Records
Specialist Records
WA State Immunization
Form/Exemption Form
Well Child Exam Document
Dental Emails/Memos
Dental Exams
Dental
Request/Correspondence
Dental Screening Form
Dental Treatment Document
Dietary Restriction
Growth Chart
Nutrition Assessment Form
Nutrition Referral Review
Nutrition Emails/Memos
Distribution of Nutrition
Handouts
WIC (HCB/HCT
Other
MSYS 9b
As applicable, place date of document and/or following in boxes: X = Requirement met O = Requirement not met (C: 12/04; R: 09/17)
SP = Place by child's name to indicate child with Spanish as primary language. M = Place by child's name to indicate child with medical condition(s).
D = Place by child's name to indicate child with disabilities. - 1 -
Lower Columbia College Head Start/ECEAP
Site File Review Worksheet
Child's Name & Loc ID:
Total Enrollment Date:
Inside Front Cover Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
File Sign Out
Administration Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
Individual Site File Content
Sheet – date/initialed
Contact Information Form (current and original)
Change of Status Form(s)
Withdrawal/Transfer Checklist
Parent Agreement Contract
Restraining Order/Legal
Documents
Change of Classroom Request
Birth Certificate
Parent/Guardian Release
Forms (ROI’s) (Med/Dental/PC/
School Districts/PCAP/WIC/Specialists)
Application Info/Family
Member Info (original or computer
generated app. with parent signature)
Intake/Enrollment Forms
Checklist (check name)
Medicaid/Insurance Card (optional)
Education Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
Individual Site File Content
Sheet – date/initialed
Absence Notes from Parents
MSYS 9b
As applicable, place date of document and/or following in boxes: X = Requirement met O = Requirement not met (C: 12/04; R: 09/17)
SP = Place by child's name to indicate child with Spanish as primary language. M = Place by child's name to indicate child with medical condition(s).
D = Place by child's name to indicate child with disabilities. - 2 -
Child's Name & Loc ID:
Total Enrollment Date:
Education Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
Attendance Plan
ASQ-3 Developmental
Screening
ASQ SE-2
Classroom Sign-In Sheets
Developmental Screening
Summary
Education Home Visit Plan
Forms
Field Trip Permission Slips
Home Language Survey
Notes Home
Other Screening Tools
Parent/Teacher Conference
Form
Pre-Conference Survey
TSG (Individual Child) (Final Checkpoint)
School Readiness Survey
Special Needs Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
Individual Site File Content
Sheet – date/initialed
Consent for Initial Evaluation/
Evaluation/Re-evaluation
Consent
MSYS 9b
As applicable, place date of document and/or following in boxes: X = Requirement met O = Requirement not met (C: 12/04; R: 09/17)
SP = Place by child's name to indicate child with Spanish as primary language. M = Place by child's name to indicate child with medical condition(s).
D = Place by child's name to indicate child with disabilities. - 3 -
Child's Name & Loc ID:
Total Enrollment Date:
Special Needs Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
Disabilities Staffing Form
Evaluation Summary
DOE/DNQ
Embedded Schedule
IEP
IEP at a Glance
Invitation to Attend Meeting
Request for IEP/IFSP
Special Education Service
Logs
Teacher Assessment Summary
Team Meeting Notes
Other (health reports that relate to
disability, Progress Center, special
education memos, refusal of services form, etc.
Social Service Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
Individual Site File Content
Sheet – date/initialed
Attendance Plan
Child and Family Profile
ECEAP Family Assessment
Family Interest Survey
Family Partnership Agreement
MSYS 9b
As applicable, place date of document and/or following in boxes: X = Requirement met O = Requirement not met (C: 12/04; R: 09/17)
SP = Place by child's name to indicate child with Spanish as primary language. M = Place by child's name to indicate child with medical condition(s).
D = Place by child's name to indicate child with disabilities. - 4 -
Child's Name & Loc ID:
Total Enrollment Date:
Social Service Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
HS Family Outcomes
Assessment
FDM (ECEAP)
Empowerment Matrix
Home Safety Checklist
Home Visit Plan Forms
Notes Home
Newborn Checklist
Notes from Parent/Guardian
Parent Orientation Checklist
Permission to Transport Form
Transportation Request
Other (Notes Home/Emails)
Mental Health Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
Intervention Strategies
Mental Health Checklist
Parent/Guardian Permission
for MH Social/Emotional
Observation/Assessment
Parent/Guardian Interview for
MH Social/Emotional
Observation/Assessment
Request for MH
Social/Emotional
Observation/Assessment
MSYS 9b
As applicable, place date of document and/or following in boxes: X = Requirement met O = Requirement not met (C: 12/04; R: 09/17)
SP = Place by child's name to indicate child with Spanish as primary language. M = Place by child's name to indicate child with medical condition(s).
D = Place by child's name to indicate child with disabilities. - 5 -
Child's Name & Loc ID:
Total Enrollment Date:
Mental Health Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
MH Social/Emotional
Observation/Assessment
Report
Parent/Guardian Consult
Family/Child Support Plan
Family/Child Support Plan
Update
Mental Health Staffing Form
Safety Intervention Report
Sensory Symptoms Checklist
School Version
Sensory Symptoms Checklist
Mental Health Documentation
Request/Correspondence
External Mental Health
Provider Report
Protein Snack Permission
Health/Nutrition Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
Individual Site File Content
Sheet – date/initialed
Accident Form
Denial of Consent (physical, dental,
lead screening)
Health History Form
Hearing & Vision Screening
Form
Immunization Agreement
MSYS 9b
As applicable, place date of document and/or following in boxes: X = Requirement met O = Requirement not met (C: 12/04; R: 09/17)
SP = Place by child's name to indicate child with Spanish as primary language. M = Place by child's name to indicate child with medical condition(s).
D = Place by child's name to indicate child with disabilities. - 6 -
Child's Name & Loc ID:
Total Enrollment Date:
Health/Nutrition Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
Lead Screening
Medical Action Plan
Medical Documentation
Request/Correspondence
Medication Authorization
Medication Info on Completed
Medications (original Authorization,
Checklist and Administration forms)
Medication Side Effect Sheet
Nursing Assessment Form
PIR Enrollment Questionnaire
PIR Spring Health
Questionnaire
Provider Immunization
Records
Specialist Records
WA State Immunization
Form/Exemption Form
Well Child Exam Document
Other
Dental Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
Dental Emails/Memos
Dental Exams
Dental
Request/Correspondence
MSYS 9b
As applicable, place date of document and/or following in boxes: X = Requirement met O = Requirement not met (C: 12/04; R: 09/17)
SP = Place by child's name to indicate child with Spanish as primary language. M = Place by child's name to indicate child with medical condition(s).
D = Place by child's name to indicate child with disabilities. - 7 -
Child's Name & Loc ID:
Total Enrollment Date:
Dental Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
Dental Screening Form
Dental Treatment Document
Other
Nutrition Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP
Dietary Restrictions
Growth Chart
Nutrition Assessment Form
Nutrition
Request/Correspondence
Nutrition Referral Review
Nutrition Emails/Memos
Distribution of Nutrition
Handouts
WIC (HCB/HCT)
Other