1. Program Planning 2. - Lower Columbia College · MSYS (Revised 11/19) Lower Columbia College Head Start/EHS/ECEAP Management Systems Table of Contents 1. Program Planning a. Program

MSYS

(Revised 01/2020)

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 10/19)

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 (Revised 01/19)

e1. CAST Classroom or Individual Child Documentation (Created 01/19)

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. 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)

c. FAX Transmittal Cover Sheet (Created 03/19)

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. Administration Site File Contents (Revised 06/19)

e1. Admin Site File Contents – EHS (Revised 07/19)

e2. Admin Site File Contents – EHS – Prenatal (Revised 06/19)

e3. Overview of Required Services for Enrolled Expectant Mother–EHS (Revised 06/19)

f. Health /Nutrition Site File Contents (Revised 06/19)

f1. Health Nutrition Site File Contents – EHS (Revised 07/19)

f2. Health Nutrition Site File Contents – EHS – Prenatal (Revised 07/18)

g. Social Services/Mental Health Site File Contents (Revised 06/19)

MSYS

(Revised 01/2020)

g1. Social Service Mental Health Site File Contents – EHS (Revised 07/19)

g2. Social Service Mental Health Site File Contents – EHS – Prenatal (Revised 07/18)

h. Education Site File Contents (Revised 06/19)

h1. Education Site File Contents – EHS (Revised 07/19)

i. Special Needs Site File Contents (Revised 06/19)

i1. Special Needs Site File Contents – EHS (Revised 07/19)

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. Database Reports Distribution and Monitoring Schedule (Revised 08/18)

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 01/2020)

f1. End of the Month Report – Assistant Director (Revised 10/16)

f2. EHS Teen Area Manager Monthly Report (Revised 08/18)

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. Classroom Observation Checklist (Revised 10/19)

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 12/18)

b1. EHS Site File Review Worksheet (Revised 12/18)

b1a. EHS Site File Review Worksheet – Prenatal (Revised 12/18)

b2. Site File Review Summary (Revised 12/18)

MSYS

(Revised 01/2020)

b2a. EHS Site File Review Summary – Prenatal (Revised 12/18)

b2b. EHS Site File Review Summary (Revised 12/18)

MSYS 1b

1 (C: 10/02: R: 08/15, 10/19)

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:

Program Planning Committee

Analyze and plan for program improvement utilizing the following tools: o Strategic Plan goals, progress, and outcomes o T/TA Plan o Quality improvement measures (i.e. staff surveys, monitoring)

Recommend related trainings

Identify and implement Conscious Discipline Strategies

Meets monthly Membership: Assistant Director, Administrative Services Manager, one staff from each area, office, nutrition, parent, and leadership. Facilitator: Director

Budget/In-Kind Committee

Analyze the budget

Give input into the development and make recommendations

Monitor In-kind Report

Plan and implement program wide in-kind strategies and activities



Planning for and implementing strategies for achieving program goals (Strategic Plan)

Meets bi-monthly Nov., Jan., March and May Membership: Director, Treasurer Policy Council, one other PC member, one staff from each area, one Area Manager, Fiscal. Facilitator: Fiscal Analyst

Establishing

Program Goals Ongoing Oversight,

Correction,

& Assessment

Using Data for

Continuous

Improvement

Reporting

MSYS 1b

2 (C: 10/02: R: 08/15, 10/19)

Nutrition Committee

Culturally Relevant Menu Planning

Workplan Development

USDA Observations

Analyze continuous improvement – make recommendations



Planning for and implementing strategies for achieving program goals (Strategic Plan) Meets quarterly Membership: Director; one member from each area, Area Manager, Cook, EHS Area Manager, 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, and Leadership Team Representative. Facilitator: Assistant Director School Readiness Committee

Review and analyze child outcomes in accordance to outcomes measures and Kindergarten readiness

Analyze and problem solve outcomes three times yearly with Teaching Strategies Gold.

Create and update program School Readiness Goals.

Revise and design current/and future Policies and Procedures regarding Education and individualization



Planning for and implementing strategies for achieving program goals (Strategic Plan) Meets monthly November, December, January, March, April Membership: Assistant Director, Child/Family Liaison, Coach, Area Manager(s), one lead teacher from each area, one assistant teacher, community member, parent. Facilitator: School Readiness Specialist Red Devils Wellness Committee

Look at ways to encourage wellness throughout the program

Promote participating in the wellness program.

Recommend related trainings Meets every other month November, February & April Membership: Administrative Services Manager Facilitator: LCC HR Family Engagement Committee

Review Policies/Procedures for Family Parent Engagement

Analyze Family Assessment Data as it relates to program outcomes.

MSYS 1b

3 (C: 10/02: R: 08/15, 10/19)

Plan and support parent/family education activities

Field questions regarding case management and provide guidance for continued training



Planning for and implementing strategies for achieving program goals (Strategic Plan) Meets every other month October, December, February, March, April, May Membership: one family advocate from each area, Area Manager(s), interpreter, one lead teacher, parent. Facilitator: Family Services/Parent Engagement Specialist 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



Planning for and implementing strategies for achieving program goals (Strategic Plan) Meets quarterly until January then monthly Membership: Community Partnership/Public Relations Specialist, ERSEA Program Support Supervisor, Interpreter, Family Advocate, one member from each Area, Director, three parents, AmeriCorps. Facilitator: Community Partnership/Public Relations Specialist Health Services Advisory Committee

Address program issues in the medical, dental, mental health, nutrition, and human services fields




Meets quarterly: November, February, May Membership: Community Representatives, Director, Mental Health Specialists, Nutrition Consultant,

Health Consultant, , Disabilities Specialist, Family Services/Parent Engagement Specialist, and a parent from each program (HS/EHS/ECEAP). Facilitator: Health Specialist

Transportation Committee

Analyze and problem solve transportation issues

Mentor staff on transportation regulations




Meets quarterly: October, February, May

Membership: Area Managers/Transportation Liaisons, Director, Program Coordinator, and parent. Facilitator: Transportation Manager

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


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)


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)


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)


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 2e1 Lower Columbia College Head Start/EHS/ECEAP

CAST Classroom or Individual Child Documentation

Classroom/Individual Child

Needs:

Actions Who will do what? By When? How will you notify team?

(C: 01/19)

MSYS 2e1

Lower Columbia College Head Start/EHS/ECEAP CAST Classroom or Individual Child Documentation

Classroom/Individual Child

Needs:

Actions Who will do what? By When? How will you notify team?

(C: 01/19)

MSYS 2e

(C: 11/17; R: 01/19)

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 comprised 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 posted to google shared drive weekly. The Content Area Support Team (CAST) is comprised 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 posted to google shared drive 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; R: 01/19)

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. CAST Staff Form (MSYS 2e1) will be used to document the action steps identified at CAST and shared with the staff by the Area Manager. The process for CAST will be as follows:

1. The Area Manager or Content Specialist will email the Assistant Director with the name of the child to be added to the week’s CAST discussion list.

2. The Assistant Director will invite the presenting staff member that will be presenting to the CAST team meeting.

3. At the CAST meeting, the child will be flagged in the childplus system as a member of the CAST staffing team. The presenting member will take action notes on the CAST plan form and documentation of decisions made for individual children will be done in case management by a CAST team member.

4. An email will be sent out to the DST following the CAST meeting, notifying them that the CAST meeting has occurred and that the follow up plan is noted in cp.net.

5. A copy of the CAST plan form will be given to the School Readiness Specialist, Area Manager, Coach and Teacher.

6. The School Readiness Specialist will share the CAST Plan Form (MSYS 2e1) in coaching coordination meetings for continuity in services.

7. The CAST team will review the child within 60 days, to ensure follow-up is occurring, to monitor success or to re-establish plans of action.

MSYS3a

(C: 06/03; R: 04/12)


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

Email to Text (HS/ECEAP)

Text (EHS)

Surveys

Parent Boards

Interpreters

Website

MSYS 5b

(C: 08/05; R: 08/15)


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)


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 5c


1600 MAPLE STREET - P.O. BOX 3010 LONGVIEW, WA 98632

360-442-2800 Phone

360- 442-2819 Fax

(C: 03/19)

FAX Transmittal Cover Sheet

Destination

Organization:

Contact Person:

FAX Number:

Phone Number:

Originator

Organization: Lower Columbia College Head Start/EHS/ECEAP

Contact Person:

Phone Number:

Description:

Number of Pages: (including cover sheet)

Date Sent:

Notes/Comments:

If there are problems with this transmission, please contact the originator.

Confidentiality: The information contained in this message and any attachments may be confidential and privileged. Unauthorized review, use or disclosure is strictly prohibited. If you are not the intended recipient or have received this communication in error, please notify the sender immediately and promptly delete the message. Thank you.

MSYS 6a

(C: 06/03; R: 10/17)


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

Email

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:





ROUTING MEMO

ROUTING MEMO

To:__________________________________

From:_________________ Date: __________

Comments:





ROUTING MEMO

To:__________________________________

From:_________________ Date: __________

Comments:





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)


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)


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


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)


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: 07/19) 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 ________ ________

________________ Withdrawal/Transfer Checklist

_________________ Parent Agreement Contract

________________ Birth Certificate (copy of State or Hospital) (optional)

Parent/Guardian Release of Information Forms: (date, initials, provider name)

________________ Medical

________________ Dental

________________ Mental Health

________________ DSHS

________________ Progress Center

________________ School District

________________ Specialist(s)

________________ W.I.C.

________________ Other

________________ Request for Information (MSYS 2a1) (copy of documentation/questionnaire to outside agency)

________________ Applicant Information/Family Member Information (original or computer generated application with parent signature)

________________ Intake/Enrollment Forms Checklist

________________ Medicaid/Insurance Card (optional)

MSYS 7e2


Lower Columbia College Early Head Start - Prenatal




________________ Prenatal Emergency Information Form (FS/PI 16a)


________________ Legal Documents ______ ______

________________ Parent Agreement Contract (FS/PI 17b)

Release of Information Forms (Optional): (date, initials, provider name)

________________ Medical

________________ Dental

________________ Mental Health

________________ DSHS

________________ School District

________________ W.I.C.

________________ Other ________________ ________________ _______________

________________ Request for Information (MSYS 2a1) (copy of documentation/questionnaires to an

outside agency)


________________ Intake/Enrollment Visit Form – Prenatal

________________ Medicaid/Insurance Card (optional)

MSYS 7e3

(C: 01/15; R: 06/19)

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 ___ LEHSP uses FS/PI 16c and completes their own intakes. If completed by a CFDS, it will count as a 1st visit.

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

MSYS 7e3

(C: 01/15; R: 06/19)

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.)

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


Lower Columbia College Head Start/ECEAP





________________ Withdrawal/Transfer Checklist

________________ Parent Agreement Contract (FS/PI 7a)

________________ Legal Documents

________________ Change of Classroom Request Form

________________ 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

________________ Request for Information (MSYS 2a1) (copy of documentation sent to outside agency)


________________ Intake Forms Checklist (ERSEA 4a)

________________ Medical Coupon/Insurance Card

MSYS 7f1

Items placed in chronological. (C: 06/10; R: 07/19) Print on Blue


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 History Form

________________ Health Specialist Records ________ ________ ________ ________

________________ Hearing/Vision 3-Prong Approach (see Ed section for screening summary)

________________ Height/Weight Chart / /

________________ 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)

________________ 18 Vision Developmental Milestones from Birth to Baby’s First Birthday

________________ PIR Enrollment Questionnaire

________________ PIR Spring Health Questionnaire

________________ WA State Immunization Form/Immunization Agreement

________________ Well Child Exam Document / /

________________ Other

Dental

________________ Dental Emails ___________

________________ 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: 07/18) Print on Blue

Lower Columbia College Early Head Start – Prenatal

Health/Dental/Nutrition File Contents


________________ Dental Exam Form ________________ ________________

________________ Health/Dental/Emails

________________ Nutrition Assessment Form

________________ Prenatal Dental History Questionnaire (HLTH 14c)

________________ Prenatal Health/Dental/Nutrition History Form (FS/PE 16a)

________________ EHS Record of Nursing Assessment for Expectant Mother (MSYS 7o3)

________________ Post-Partum Assessment/Newborn Home Visit Form (FS/PE 16f)

________________ Other

MSYS 7f

Documents to be placed in chronological order with most current on top. (C: 06/01; R: 06/19) Print on Blue


Health/Nutrition File Contents


Health/Medical

________________ Accident Form (HLTH 9c) ________________ ________________ ________________

________________ Health Follow-Up needed (1/2 sheet)

________________ Health History Form for Returning Children

________________ Health History Form

________________ End of Year Health Summary

________________ Hearing & Vision Screening Form

________________ Hearing & Vision Records

________________ Lead Screening

________________ Medical Action Plans

________________ Health Accommodation Meeting

________________ 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 (HLTH 10i)

________________ Specialist Records _______ _______ _______ _______ _______ _______

________________ Provider Immunization Records

________________ Immunization Agreement (HLTH 13c)

________________ WA State Immunization Form/Exemption Form (COE)

________________ Well Child Exam Document ________________

________________ Other

Dental

________________ Dental Emails/Memos

________________ Dental Exam Document

________________ Dental Request/Correspondence

________________ Dental Screening Form

________________ Dental Treatment Records

Nutrition

________________ Dietary Restrictions (CACFP Non-Disabling Medical Statement)

________________ 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: 07/19) Print on Green


Social Service/Mental Health File Contents


Social Service

________________ Attendance Success Plan

________________ Family Interest Survey

________________ Family Partnership Agreement; (Family Goal Setting Sheet)

Additional Goal Setting Forms / / /

________________ Family Picture

________________ Head Start/EHS Bridge to Family & Child Success

________________ Home Safety Checklist

________________ Home Visit Plan (Notes)

Aug. Sept.

Oct. Nov.

Dec. Jan.

Feb. March

April May

June July

________________ Parent/Guardian Orientation Checklist

________________ Permission to Transport

________________ Shared Family/Forms/Emails

________________ Start-Up for Families

________________ Other

Mental Health

________________ Classroom/Home 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)

________________ Mental Health/Social/Emotional Request for Observation/Assessment

(MH 5a)

________________ Parent/Guardian Consult (MH 5c)

________________ Family/Child Support Plan (Observation Summary ___ Family Team

Update ___ Coordination Summary ___ ) (MH 6a)

________________ Family/Child Support Plan Update (Observation summary ___ Family

Team Update ___ Coordination summary ___ ) (MH 6a)

________________ Mental Health Staffing Form (MH 7a)

________________ Safety Intervention Report (EDUC 5b)

________________ Sensory Symptoms Checklist (original of what was completed)

________________ Mental Health Documentation Request/Correspondence

________________ Other: (memos, e-mails, assessments, etc.)

MSYS 7g2

Items to be placed in chronological order. (C: 07/10; R: 07/18) Print on Green




Social Service


________________ Head Start/EHS Bridge to Family & Child Success

________________ Family Interest Survey

________________ Family Goal Setting

Additional Goal Setting Forms / /

________________ Family Picture

________________ Home Safety Checklist

________________ 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 New or 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)


________________ Other (memos, emails, etc.)

MSYS 7g

Place in order as listed above. (C: 06/01; R: 06/19) Print on Green




Social Service

________________ Family Picture (FS/PI 7b)

________________ Family Interest Survey (FS/PI 7m)

________________ Family Partnership Agreement/Family Goal Setting (FS/PI 10b-Head Start, FS/PI 10c-ECEAP)

Additional Goal Sheets ________________ ________________

________________ Bridge to Family & Child Success _______ _______ (FS/PI 7b1-Head Start, FS/PI 7b2-ECEAP)

________________ Home Safety Checklist (FS/PI 7p)

________________ Family Contact Forms (FS/PI 7a3) ______ ______ ______ ______ _____


________________ Transportation Request (TRAN 5d) _______ _______

________________ Parent Orientation Checklist (FS/PI 13b)

________________ Permission to Transport Form (TRAN 5c)

________________ Shared Family/Forms/Emails

________________ Communication (notes, letters, emails, etc.) _______ _______ _______

_______ _______ _______ _______ _______ _______

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Cardstock - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Mental Health

________________ Classroom/Home/Pals 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)

________________ MH/Social/Emotional Request for Observation/Assessment (MH 5a)


________________ Family/Child Support Plan (Observation Summary_____ Family Team Update____

Coordination Summary Update______ Classroom/Strategy Matrix_____ ) (MH 6a)

________________ Family/Child Support Plan Update (Observation summary/Family Team

Update/Coordination Summary Update/Classroom/Strategy Matrix_____) (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 _____ _____

________________ Other: Vanderbilt Assessment completed for PCP. Other information

completed for Mental Health

________________ Protein Snack Permission

________________ BHT Social/Emotional Family/Child Support Plan (EDUC 5a1)

MSYS 7h1

Items to be placed in chronological order. (C: 06/10; R: 07/19) Print on Yellow


Education File Contents


________________ ASQ-3 ________ ________ ________

________________ ASQ SE-2 ________ ________ ________

________________ Home Language Survey

________________ School Readiness Individualized Learning Plan(s) (EDUC 1g1)

________ _________ _________ _________

________________ Screening Summary Form (HLTH 12h)

________________ Transition Conference Form & Updates (DISA 3b3)

________________ Transition Survey (DISA 3b4)

________________ Other

LEHSP Program Only

________________ Absence Notes from Parents

________________ Attendance Calendars (please circle)

Aug, Sept, Oct, Nov, Dec, Jan, Feb, March, April, May, June, July

________________ Notes Home

________________ Family Contact Form and TSG Family Conference Form (FS/PI 7a3)

(please circle) Fall Spring

MSYS 7h

Documents to be placed in chronological order with most current on top. (C: 06/01; R: 06/19) Print on Yellow


Education File Contents


________________ ASQ-3 _________ __________

________________ ASQ SE-2 _________ __________

Classroom Sign-In Sheets (please circle)

Sept. Oct. Nov. Dec. Jan. Feb. Mar. Apr. May June

________________ Developmental Screening Summary (EDUC 4a)

________________ Field Trip Permission Forms (EDUC 9g)

________________ Home Language Survey

________________ Kindergarten Transition Cover Sheet

________________ Notes Home

________________ Other Screening Tool: ____________________ (Dial-4)

________________ Parent/Teacher Conference Fall Winter Spring (circle) (Family Contact Form FS/PI 7a3)

________________ Pre-Conference/Home Visit Survey (EDUC 2b) Fall Winter Spring (circle)

________________ School Readiness Individualized Learning Plan (EDUC 1a)

_________________ (HS Only) School Readiness Visit 1st 2nd (circle)

(Family Contact Form FS/PI 7a3)

________________ Teaching Strategies Gold (Report Card) (Final Checkpoint)

MSYS 7i1

(C: 06/10; R: 07/19) Print on Cherry


Special Needs File Contents


________________ 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 with IFSP Documentation

________________ 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: 06/19) Print on Cherry


Special Needs File Contents


________________ Consent for Initial Evaluation/Evaluation/Re-evaluation Consent ______

_______ _______

________________ Disabilities Staffing Form (DISA 2b) __________ __________

________________ Evaluation Summary DOE/DNQ

________________ IEP __________

IEP At A Glance ______________ ______________ ______________

________________ IEP Records Request

Special Education Service Log(s) (DISA 2j) (Original) (please circle)

Sept. Oct. Nov. Dec. Jan. Feb. Mar. Apr. May June

________________ Teacher Assessment Summary Form (DISA 2d)

Other Records Needed (i.e. outside services):

__________ __________ __________ __________ __________

__________ __________ __________ __________ __________

________________ Other (health reports that relate to disability, Progress Center (IFSP), Special

Education Memos, Refusal of Services form, etc.)

__________ __________ __________

MSYS 7k1


File Sign-Out

Expectant Mother’s Name: ______________________________

(C: 07/10)

Person

Viewing File

Date & Time

Removed

Purpose Date & Time

Returned Initials

MSYS 7k


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)


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)


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)


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 7n

(C: 07/05; R: 03/16)

Notable examples made during the observation: Follow-up:

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

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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


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)


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)


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)


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)


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: 05/18) 1


Database Reports Distribution and Monitoring Schedule

I. Monthly Student Medical Concerns/Allergies List HS, EHS, E

ChildPlus.net Report 3010 (Separate reports for each program)

Staff Responsible: Health Coordinator & Health Specialist

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) HS, EHS, E

Original to Family Advocate and CFDS

One copy to appropriate Area Manager

One copy to Health Specialist (Whole Program); one to Program Coordinator at LCC West Reception

desk, one to Kitchen Manager at LCC East Reception desk and one to Program Coordinator at Memorial

Park Center

Bus Copies

(Run the reports by center; combine LCC East and West.) 1 copy to each Area Manager for the LCC East and West buildings; 1 copy to Broadway Area Manager; 1

copy to Barnes Area Manager; 1 copy to Memorial Park Area Manager

Report Cover Sheets

Attach completed Report Cover sheet to each report prior to distribution and three-hole punch.

Placement: Emergency Response Procedures Notebook – Section 9

=====================================================================

II. Weekly Emergency Contacts Report HS, EHS, E

ChildPlus.net Report 1520

Staff Responsible: Program Coordinator

Fields: By Site/Status = Enrolled/Grouping = Classroom/Type = Detail/Show Secondary Adult, Release

to Contacts, Emergency Contacts, Doctors and Dentists

Report Distribution Time Frame: Every Friday for the following week.

Report Distribution:

Original to Teachers and each Teen CFDS

One copy of each of their site emergency contacts report to: Bus Drivers and Area Managers

Placement: Emergency Response Procedures Notebook; Bus Notebook

=====================================================================

III. First of the Month Student Roster HS, EHS, E


Staff Responsible: Program Coordinator & Program Support Supervisor

Report Distribution Time Frame: Beginning of each month.


MSYS 8a1

(C: 10/06; R: 05/18) 2

Original to Teachers and each Teen CFDS

One copy of their classroom rosters to: Family Advocates or HS/ECEAP CFDS

One copy of their site rosters to: Area Managers

One copy of all rosters to: Program Coordinator

One copy of Memorial Park only roster to Program Coordinator

One copy of Head Start only to Mental Health Specialist

Placement: Emergency Response Procedures Notebook (Except Family Adv. & MH Consultant Copies)

=====================================================================

IV. First of the Month Student Roster HS, EHS, E


Staff Responsible: Program Coordinator & Program Support Supervisor

Fields: Status = Enrolled / Grouping = Site

Report Distribution Time Frame: Beginning of each month.


One copy to: Director, Assistant Director, Health Specialist, Area Managers, Mental Health Specialist

Placement: None

=====================================================================

V. Monthly Student Dietary Restrictions Report HS, EHS, E



Fields: By Classroom / Detail / All Data Options / All Events / Event Type: Head Start/ECEAP -Dietary

Restrictions; EHS – Bottle Feeding, Dietary Restrictions & Nutrition.


Report Distribution (1 Original & 4 copies) HS, EHS, E Original to Direct Service Team and each Teen CFDS

One copy to appropriate Area Manager for their Centers

Copy to appropriate Food Service Worker (LCC West, Broadway, Barnes, Castle Rock, Memorial Park

and Teen)

Copies to: Health Specialist (Whole Program) and Kitchen Manager (Whole Program)

Report Cover Sheets

Attach completed Report Cover sheet to each report prior to distribution

Placement: Post in Kitchen/Classroom (Except Area Managers & Health Specialist)

=====================================================================

VI. Health Consultant(s) Child Health Reports HS, EHS, E



Fields: By Classroom / Individual / All Data Options / All Events / All Types

Report Distribution Time Frame: Ongoing

MSYS 8a1

(C: 10/06; R: 05/18) 3

Report Distribution (1 Original)

In September and thereafter following data entry of child with severe medical concerns refer to

appropriate Health Consultant, print ChildPlus.net Report 3010 and Distribute to appropriate Health

Consultant.

=====================================================================

VII. Head Start/ECEAP Nutrition Consultant – Nutrition Assessments HS, E



Fields: By Classroom / Individual / All Data Options / All Events / All Types

Report Distribution Time Frame: Beginning at the end of October for each school year, print and

distribute Head Start/ECEAP Child Health Reports for Nutrition Assessments following data entry

of each classroom’s Health Histories/Nutrition Intake forms and height/weight measurements from

screenings and monthly thereafter; Identify remaining or new students needing Nutrition Assessments,

each month, by comparing ChildPlus Report 3010 with 2110 Master List of Participants. Can also run

Report 3065 with Event Type: Nutrition Assessment to determine children in need of a Nutrition

Assessment.


Original to Head Start/ECEAP Nutrition Consultant

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).

=====================================================================

VIII. EHS Nutrition Consultant – Nutrition Assessments EHS



Fields: By Class / Individual / All Data Options / All Events / All Types


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 for infants

and toddlers and attach to each child’s 3010 report. Expectant moms, print copy of WIC release and

attach to each Expectant mom’s 3010 report. Can also run Report 3065 with Event Type: Nutrition

Assessment to determine children in need of a Nutrition Assessment.


Original to EHS Nutrition Consultant

=====================================================================

IX. End of Month Health Specialist Reports 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).

Staff Responsible: Health Specialist

MSYS 8a1

(C: 10/06; R: 05/18) 4

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.

Fields: 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 for Each Program After Their 90-Day

Deadline Has Passed (EHS – Start With October EOM; Head Start& ECEAP – Start with

December EOM);

Fields: Appropriate Event Type (i.e. Dental Exam or Dental Exam & Dental Screening or Physical

exam) for each event.


Report Distribution: Original to Health Specialist (End of Month report then compiled and sent to Administrative Services

Manager and Director.)

=====================================================================

X. 45-day Developmental Requirements HS, EHS, E


Staff Responsible: Disability Specialist

Fields: Developmental Screen (To Determine Children Who Need ASQ Screening) Select Program

Term, site and classroom; Responsible Staff: do not filter by this; Status-Enrolled; Grouping-site;

Oder Participants by-Last Name; Order Requirements by-Due in Date; Report Type-Detail.

Select Requirements to Report, Select-Include required events that are...

Report Distribution Time Frame: September, October, as needed

Report Distribution (1 Original & 2 Copies): Original to DST

Copy to Education Specialist, Director, Assistant Director, appropriate Area Manager as needed

=====================================================================

XI. Monthly Management Report for Disability Sp. Ed. Records HS, EHS, E



Fields: Select Program Term, site and classroom; Responsible Staff: do not filter by this; Status-

Enrolled; Grouping-classroom; Report Type-Summary. Select Concern Options; Select-

IEP/IFSP Options; Select Additional Options

MSYS 8a1

(C: 10/06; R: 05/18) 5



Director, Assistant Director

=====================================================================

XII. Monthly Disabilities Reports HS, EHS, E



Fields: Select Program Term, site and classroom; Responsible Staff: do not filter by this; Status-

Enrolled; Grouping-classroom; Report Type-Detail. Select Concern Options; Select-IEP/IFSP

Options; Select Additional Options


Reports Distribution: Director, Assistant Director, DST

=====================================================================

XIII: Yearly PIR Reports HS, EHS, E

ChildPlus.net Reports

====================================================================

XIV. Family Services Social Service Home Visits HS, E

ChildPlus.Net Report E2501

Staff Responsible: FA/Teacher/CFDS/Area Manager/ FSPES

Fields: For Family Visit, School Readiness Visit, Parent/Teacher Conference and Family

Partnership Agreement dates. Select site and select classroom; Responsible Staff: do not filter

by this; Status-Enrolled; Report Type-Detail.


Report Distribution: Attach to end of the month report

=====================================================================

XV. Family Services Social Service Referrals HS, EHS, E

ChildPlus.Net Report 4120

Staff Responsible: Family Advocate/CFDS/ FSPES

Fields: Report 4120 is a cumulative report to be viewed by each of the Family Advocates and

EHS CFDS every month in order to complete their End of Month Report. Status-Enrolled/

Dropped/ Drop Wait; Grouping-Classroom; Report Type-Detail; Order By-Family; Check insert

page break after each group. In the custom filter tab, choose the Custom Filter name: Family

Information... Action Referrals... [Family Service Actions. Action Type Code EQUALS

'Referral' AND Family Service Actions. Start Date GREATER THAN OR EQUAL TO

'7/1/2017']. Click on Preview to view the report. 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

MSYS 8a1

(C: 10/06; R: 05/18) 6

2 classrooms can use the Advanced Setup link in blue to run this report for both classrooms at

once.


Report Distribution: View Only =====================================================================

XVI. Family Services EHS HB Home Visits and PAL EHS


Staff Responsible: EHS CFDS/Area Manager/ FSPES

Fields: Report 4140 is to be viewed by CFDS every month in order to complete their End of the

Month report. Status – Enrolled; Grouping-Classroom; Report Type-Detail; Show Action for

these event types-EHS Home Visit, Prenatal Home Visit and EHS Play and Learn; Include

family service actions in which agency worker is - you; choose ‘action date ‘is between and enter

dates of the previous month; choose ‘only show the actions’ that meet the criteria.


Report Distribution: View Only

=====================================================================

XVII. Monthly Attendance Analyzing HS, EHS, E


Staff Responsible: Family Advocates/CFDS

Fields: Report 2305 is to be viewed by each Family Advocate and CFDS on a monthly basis in

order to complete their End of the Month report. Status – Enrolled; Grouping-Classroom; Report

Type-Detail; Run report for 1 month; choose month and year you need to review; Click preview

to view and print the report.



=====================================================================

XVIII. Classroom Tracking HS, E

ChildPlus.Net Report E2501

Staff Responsible: FA/Teacher/CFDS/Area Manager/FSPES

Fields: Report E-2501 Classroom Tracking: Status-Enrolled; Grouping-Classroom; Report

Type-Detail; Click preview to view and print the report.



MSYS 8a1

(C: 10/06; R: 05/18) 7

=====================================================================

XIX. Family Assessment and Goals Count E

ELMS Report

Staff Responsible: FA/CFDS/Area Manager/FSPES

Fields: Family Assessment and Goals Count Report is to be viewed by each Family Advocate,

CFDS, their Area Manager and the Family Services Parent Engagement Specialist for regular

family goal status monitoring. Select school year; select display data by; select data to be run as

of current date or as of cumulative date (last year); Contractor is Lower Columbia College; Press

blue button on lower right ‘run report’.



=====================================================================

XX Family Goals by Child E

ELMS Report

Staff Responsible: Area Manager/FSPES

Fields: Family Goals by Child report is to be viewed by Area Managers and the Family Services

Parent Engagement Specialist for regular family goal monitoring. Select school year; select

display data by; select data to be run as of current date or as of cumulative date (last year); Press

blue button on lower right ‘run report’.

Report Distribution Time Frame: 3 times per year, (December March May)


=====================================================================

XXI. Family Support Monitoring by Child E ELMS Report


Fields: Family Support Monitoring by Child report is to be viewed by each Family Advocate,

CFDS, Area Managers and the Family Services Parent Engagement Specialist for regular family

goal monitoring on a monthly basis. Select display data by; Click on current date. Press blue

button on lower right ‘run report’.



=====================================================================

XXII. Family Support Visits and Parent-Teacher Conferences Minutes E

MSYS 8a1

(C: 10/06; R: 05/18) 8

ELMS Report


Fields: Family Support Visits and Parent-Teacher Conferences Minutes report is to be viewed

by each Family Advocate, CFDS, Teacher, Area Managers, Child Development Specialist and

the Family Services Parent Engagement Specialist for regular family contact monitoring on a

monthly basis. Select school year; Select display data by; Contractor is: Lower Columbia

College. Press blue button on lower right ‘run report’.



MSYS 8a

(C: 08/03; R: 06/13)


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:


Community Involvement/Presentations in Community:


Trainings Given/Meetings Facilitated:


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

1 (C: 08/00; R: 08/18)

LOWER COLUMBIA COLLEGE Early Head Start Teen Area Manager Monthly Report

CENTER(S) MONTH YEAR

AREA MANAGER Attachments: Teen Classroom Tracking Totals Report; last page only

Supervision/Monitoring completed (to date):

Classroom LOC ID

File Review (# to date)

ERS (date

complete)

DST Checklist (date)

Sept. Jan.

Lesson Plan Checklist

(date)

Classroom Observation

Checklist (date to CDS)

TSG Analysis (date to

CDS)

TSG Documentation

Report (date)

Totals

Classroom

LOC ID Case Management Observation

(Enter Follow-Up Dates)

(45-Day/HV’s) (90-Day/ FPA) (PTC) (HV/Tx Flup) (HV) (PTC/Tx Flup) Sept. Oct. Nov. Jan. Mar. June

PIR – Pregnancy and Family Services Information Tabs (Review Date)

LOC ID

Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July

Number of Pregnant Moms:________ Parent Meeting Sign-Ins/Agendas/Minutes/Flyers (FS/PI 14 d/j/l/m) placed in your Center Notebook: (a copy of sign-in sheets from center/classroom meetings/events (FS/PI 14d) is sent to the Family Services/Parent Engagement Specialist) Yes _____ No _____ PACT /Parent Meeting Sign-Ins (date sent to FSPE Specialist/Fiscal Specialist):______ Classroom Attendance Percentage: Infant______ Toddler _____ Consultant Contacts (list how many per type):_______________________________________________ ____________________________________________________________________________________

MSYS 8f2

2 (C: 08/00; R: 08/18)

Conferences (observations completed to date): Home Visits (observations completed to date):

Professional Development Plans (to date): Performance Evaluations -include probationary (to date):

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): _________________________________________________________________ I have attended and/or would like: For you: ______________________________________________________________________ For Your Staff: __________________________________________________________________

Monthly Report Due to Assistant Director by the 10th of the month.

Fall Spring

Summer School Year

Fall Winter Spring

Number completed this month:

Total number completed to date:

Classroom LOC ID Fire Drills

(Monthly date) Earthquake Drills

(Monthly date)

Lockdown Drills Fall Spring

(date) (date)

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 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 _____


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 _____


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 _____


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 _____


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:


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 _____


ECEAP Students Needing 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: 01/2020)

LOWER COLUMBIA COLLEGE HEAD START/ECEAP Area Manager Monthly Report

AREA MANAGER CENTER(S) MONTH YEAR

Attachments:

Classroom Tracking Totals Report; by center; last page only (cp.net E2501S)

Success Stories

Forward:

Original Special Education Services Logs (DISA 2j) to Disabilities Specialist

Original Area Meeting Sign-In (HR 8j) and Agenda to Administrative Services Manager

Reviewed and signed School Readiness at Home/Inkind (FISC 1e) to Fiscal Specialist

Time and Effort to Fiscal Specialist

Supervision/Monitoring completed (to date):

Classroom LOC ID

File Review

(# to date)

ECERS (date)

DST Checklist (date)

Sept. Jan.

Lesson Plan Checklist

(date)

Classroom Observation

Checklist (date)

TSG Analysis (date to SRS)

TSG Documentation

Report (date)

Classroom LOC ID

Case Management Observation (Enter Follow-Up Dates)

(90-Day/HV’s Nov.

(90-Day/PTC/FPA) Dec.

(HV’s) Feb.

(PTC/HV/Tx Flup March

May

Conferences (observations completed to date): Home Visits (observations completed to date):

Professional Development Plans (to date): Performance Evaluations -include probationary (to date):

Staff Qualifications Spreadsheet is up-to-date: yes no

Original Updated PDP sent to Administrative Services Manager: yes no

Fall Winter Spring

S School Readiness Family Visit CFDS

Fall Winter Spring

Number completed this month:

Total number completed to date:

MSYS 8f

2 (C: 08/00; R: 01/2020)

Cp.net report 3110 review:

Date Emergency Tests completed and documented on DCYF Emergency Drill Record for the center: # of referrals made to date (cp.net report 4120/ELMS):

# of Child Abuse/Neglect reports made this month:

# of Safety Intervention reports made this month:

# of Individual Care Plans:

Community Involvement: List community meetings, boards, committees attended where you represented Head Start/ECEAP. ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

Things that went well this month: For You: _____________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ For Your Site(s): _______________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

My ideas, goals and plans for next month: For You: _____________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ For Your Site(s): _______________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

I have attended and/or would like: For you: _____________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ For Your Staff: ________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

Monthly Report Due to Assistant Director by the 10th of the month.

Classroom

LOC ID

# of Medications

in Classroom

Documented Health

Accommodation Meeting for all ?

(yes or no)

Classroom

LOC ID

# of

Medications in Classroom

Documented Health

Accommodation Meeting for all ?

(yes or no)

MSYS 8g1

(C: 01/04; R: 08/15)


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)


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


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


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


Tool: EHS CFDS EOM Report (FS/PI 17c)

Timeline: Due 5th

of each month

Reviewer: EHS Staff


Tool: Family Advocate End of Month Report (FS/PI 6b)

Timeline: Due 5th

of each month.

Reviewer: Family Advocate


Tool: Teacher/Family Advocate End of Month Report (EDUC 6c)

Timeline: Due 5th

of each month.

Reviewer: Teacher/Family Advocate


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.



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.



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


Tool: Assistant Director End of Month Report (MSYS 8f1)

Timeline: Due 15th

of each month

Reviewer: Assistant 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


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


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


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


Tool: EHS Classroom Family Tracking Form (FS/PI 17d)

Timeline: To be updated monthly and as needed

Reviewer: EHS Staff


Tool: EHS Prenatal Tracking Form (EOM) (FS/PI 16g)


Reviewer: EHS Staff


Tool: EHS Health / Nutrition Tracking Form (EOM) (FS/PI 17e)


Reviewer: EHS Staff


Tool: Infant/Toddler Environment Rating Scales (ITERS)

Timeline: October/November & March/April

Reviewer: Assistant Director


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


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 8h

Completed by Area Manager-Original in Monitoring Notebook; Uploaded into Google drive (C: 07/18; R: 10/19)

Lower Columbia College Head Start/EHS/ECEAP Classroom Observation Checklist

Purpose: To be completed two times a month for each classroom during a typical classroom walk-through (5-15 minutes of observation).

Date: Time/Classroom Activity: LOC ID: Names of Teaching Staff: Area Manager Name:

Implementation of Curriculum

5 – Met 3 – Partially Met 1 – Needs Support 0 – Not Observed

Comments

Did you see the teacher implementing the Study?

Did the teacher use the intentional teaching cards, mighty minutes, or book discussion card?

Are the interest areas defined, attractive and have enough material?

Do you see visual supports posted or being used in the classroom?

Is the environment healthy, safe and clean?

Do you see active supervision?

Is the classroom organized to support learning and encourage children to work independently?

Is the Daily Schedule posted?

Are the children engaged and interested in large and/or small groups?

Is the lesson plan posted?

Are the transitions smooth and was learning embedded into them?

Did the teaching staff interact with children in positive ways and established a positive climate?

Did teaching staff effectively guide children?

Did the teacher effectively promote English language acquisition with dual learners?

Are TS Gold observations being completed during class time?

Are parent volunteers involved in classroom activities?

Are outdoor activities/games planned and implemented?

Are staff actively participating in children’s active games?

(Source: Creative Curriculum Fidelity Tool)

Follow-up /action items/outcome:

MSYS 8i

1 (C: 04/03; R: 08/15)


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)


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)


Site File Review Form

Child's Name: DST/EHS Staff:

Reviewer: Date:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

MSYS 8j

Distribution: Original: DST Copy: Supervisor 2 (C: 08/02; R: 06/11)

Reviewer / DST / EHS Staff Meeting Date: __________________________________________

Action Plan / Timeline: __________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Completed form due to your direct Supervisor by:

Reviewer Signature: Staff Signature:

MSYS 8L

(C: 10/00; R: 08/10) 1


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)


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:



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.



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.



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.



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.



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.



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.



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)


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)


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)


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 R: 12/18)

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 -


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 (original & current)

Prenatal Emergency

Information Form (FS/PI 16a)

Change of Status Form(s)

Legal Documents


Request for Change of

Classroom

Parent/Guardian Release

Forms (ROI’s) (Med/Dental/PC/

School Districts/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


N/A

MSYS 9b1a




Special Needs – N/A Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP

Individual Site File Content


Social Service Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP Individual Site File Content


Attendance Success Plan

HS/EHS Bridge to Family &

Child Success

Family Interest Survey

Family Goal Setting/Family

Partnership Agreement

Family Picture

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

Permission to Transport

Start-Up for Enrolled Families

Supplemental Prenatal Client

Questions

Other (Notes Home/Emails)

Mental Health Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP

Family/Child Support Plan

(MH 6a)

MSYS 9b1a






Update (MH 6b)

Edinburgh Prenatal

Depression Scale

Pre32-36 Weeks

Post 4-6 Weeks

Additional

MH Staffing Form MH7a

Parent Consult MH 5c

Other (memos, emails, etc.)

Health/Nutrition Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP



Dental Exam Form

Health/Dental/Emails

Nutrition Assessment Form

Prenatal Dental History

Questionnaire HLTH 14c

Prenatal Health/Dental/

Nutrition History Form

(FS/PE 16A)

EHS Record of Nursing

Assessment for Expectant

Mother (MSYS 7o3)

Post-Partum

Assessment/Newborn Home

Visit Form (FS/PE 16f)

MSYS 9b1

As applicable, place date of document and/or following in boxes: X = Requirement met O = Requirement not met (C: 11/15; R: 12/18) 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).






Date of Birth:


File Sign Out

Administration Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP Individual Site File Content


Contact Information Form (current and original)


Legal Documents

Withdrawal/Transfer List


Birth Certificate (copy of State or

Hospital)


Forms (ROI’s) (Med/Dental/MH/PC/




generated application with parent signature)




Education Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP



ASQ -3

MSYS 9b1



Education (cont.) Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP

ASQ SE-2

School Readiness

Individualized Learning

Plan(s)

Pre-Conference Survey

(EDUC 2b)

PAL Socialization Sign-In and

Observation Form

Transition Conference Form &

Updates

Transition Survey

Transition Plan/Exit Record

TEEN ONLY:

Absence Notes from Parents

Attendance Calendars

Notes Home

Parent/Teacher Conference

Form and TSG Family

Conference Form Fall


Form and TSG Family

Conference Form Spring

Special Needs Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP



Confirmation of IFSP

Discontinuation of Services

EHS Early Intervention

Referral Form (DISA 3a)

IFSP

MSYS 9b1



Special Needs (cont.) Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP

IFSP Goal Areas

IFSP Transition Summary

(@ 6 months)

Notice/Consent for Initial

Evaluation

Notice/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.)

Social Service Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP Individual Site File Content




Family Partnership

Agreement/Family Goal

Setting

Family Picture


Child Success



Parent/Guardian Orientation

Checklist


MSYS 9b1



Social Service (cont.) Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP

Shared Family/Forms/Emails




Classroom/Home Intervention

Strategies

Mental Health Checklist

Parent/Guardian Permission

for MH Social/Emotional

Observation/Assessment

Parent/Guardian Interview for

MH Social/Emotional


MH/Social/Emotional Request

for Observation/Assessment

(MH 5a)

Parent/Guardian Consult

Family/Child Support Plan (observation summary/family team

update/coordination summary)(MH 6a)


update (observation summary/family

team update/coordination summary)

MH Team Staffing Form

(MH 7a)

Safety Interventional Report

Sensory Symptoms Checklist

MH Documentation Request

External MH Provider Report


MSYS 9b1






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 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)

MSYS 9b1



Health/Nutrition (cont.) Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP


PIR Spring Health

Questionnaire

WA State Immunization Form

Well Child Exam Forms

Other

Dental

Carries Risk Assessment

Dental Emails

Dental Exams

Dental


Dental Screening Form

Other

Nutrition


Nutrition Handout Distribution

Form

Nutrition/Request/

Correspondence

WIC

Other

MSYS 9b2a

(C: 09/17; R: 12/18)

- 1 -


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:



Contact Information Form (original & current)

Prenatal Emergency

Information Form (FS/PI 16a)


Legal Documents


Request for Change of

Classroom


Forms (ROI’s) (Med/Dental/PC/





signature)




Education – N/A Comments/Follow Up:



N/A

MSYS 9b2a

(C: 09/17; R: 12/18)

- 2 -

Center Names:


Special Needs – N/A Comments/Follow Up:



Social Service Comments/Follow Up:





Child Success


Family Goal Setting/Family

Partnership Agreement

Family Picture


(Updates)


Newborn Announcement

Newborn Checklist

Post-Partum Assessment/2-wk

Newborn Home Visit Form

Overview of Required Services

for Expectant Mother



Supplemental Prenatal Client

Questions


MSYS 9b2a

(C: 09/17; R: 12/18)

- 3 -

Center Names:


Mental Health Comments/Follow Up:


(MH 6a)


Update (MH 6b)

Edinburgh Prenatal Depression

Scale

Pre32-36 Weeks

Post 4-6 Weeks

Additional

MH Staffing Form MH7a

Parent Consult MH 5c


Health/Nutrition Comments/Follow Up:



Dental Exam Form

Health/Dental/Emails


Prenatal Dental History

Questionnaire HLTH 14c

Prenatal Health/Dental/

Nutrition History Form

(FS/PE 16A)

EHS Record of Nursing

Assessment for Expectant

Mother (MSYS 7o3)

Post-Partum

Assessment/Newborn Home

Visit Form (FS/PE 16f)

MSYS 9b2b

(C: 09/17; R: 12/18)

- 1 -


EHS Site File Review Summary

Center Names:



File Sign Out






Legal Documents

Withdrawal/Transfer List


Birth Certificate (copy of State or

Hospital)


Forms (ROI’s) (Med/Dental/MH/PC/





signature)




Education Comments/Follow Up:



ASQ -3

MSYS 9b2b

(C: 09/17; R: 12/18)

- 2 -

Center Names:


Education (cont.) Comments/Follow Up:

ASQ SE-2

School Readiness

Individualized Learning

Plan(s)


(EDUC 2b)

PAL Socialization Sign-In and

Observation Form

Transition Conference Form &

Updates

Transition Survey

Transition Plan/Exit Record

TEEN ONLY:

Absence Notes from Parents

Attendance Calendars

Notes Home


Form and TSG Family

Conference Form (FALL)


Form and TSG Family

Conference Form (SPRING)

Special Needs Comments/Follow Up:



Confirmation of IFSP

Discontinuation of Services

EHS Early Intervention

Referral Form (DISA 3a)

MSYS 9b2b

(C: 09/17; R: 12/18)

- 3 -

Number of Files Reviewed:

Special Needs (cont.) Comments/Follow Up:

IFSP

IFSP Goal Areas

IFSP Transition Summary

(@ 6 months)

Notice/Consent for Initial

Evaluation

Notice/Consent for Re-

Evaluation

Parental Consent to Evaluate

Prior Written Notice/

Reinstatement of Services

Request for Records


disability, Progress Center, Special Education Memos, Refusal of Services

form, etc.)






Family Partnership

Agreement/Family Goal

Setting

Family Picture


Child Success



MSYS 9b2b

(C: 09/17; R: 12/18)

- 4 -

Center Names:


Social Service (cont.) Comments/Follow Up:

Parent/Guardian Orientation

Checklist






Classroom/Home Intervention

Strategies






MH Social/Emotional




(MH 5a)


Family/Child Support Plan (observation summary/family team

update/coordination summary)(MH 6a)


update (observation summary/family

team update/coordination summary)

MH Team Staffing Form

(MH 7a)

Safety Interventional Report


MSYS 9b2b

(C: 09/17; R: 12/18)

- 5 -

Center Names:


Mental Health (cont.) Comments/Follow Up:

External MH Provider Report


MH Documentation Request




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 History Form

Health Specialist Records

Hearing/Vision 3-Prong

Approach: Check Date

Height/Weight Chart


Lead Screening

Documentation



MSYS 9b2b

(C: 09/17; R: 12/18)

- 6 -

Center Names:


Health/Nutrition (cont.) Comments/Follow Up:


Medication Info. on completed

medications (Original Authorization,

Checklist and Administration Forms)


OAE Hearing & Spot Vision (See Ed section for screening summary)


PIR Spring Health

Questionnaire

WA State Immunization Form

Well Child Exam Forms

Other

Dental Comments/Follow Up:

Carries Risk Assessment

Dental Emails

Dental Exams

Dental



Other

Nutrition Comments/Follow Up:


Nutrition Handout Distribution

Form

MSYS 9b2b

(C: 09/17; R: 12/18)

- 7 -

Center Names:


Nutrition (cont.) Comments/Follow Up:

Nutrition/Request/

Correspondence

WIC

Other

MSYS 9b2

(C: 08/17: R: 12/18)

- 1 -


Site File Review Summary

Center Names:



File Sign Out






Withdrawal/Transfer Checklist


Legal Documents

Change of Classroom Request

Birth Certificate


Forms (ROI’s) (Med/Dental/School

Districts/Specialists/MH/WIC)



generated app. with parent signature)

Application/Intake/Enrollment

Forms Checklist (check name)


Education Comments/Follow Up:



MSYS 9b2

(C: 08/17: R: 12/18)

- 2 -

Center Names:


Education (cont.) Comments/Follow Up:

ASQ-3 Developmental

Screening

ASQ SE-2

Classroom Sign-In Sheets

Developmental Screening

Summary

Field Trip Permission Slips

Home Language Survey

Kindergarten Transition

Summary

Notes Home

Other Screening Tools



School Readiness

Individualized Learning Plan

HS Only School Readiness

Visit (Family Contact Form)

Teaching Strategies Gold (Report Card) (Final Checkpoint)

Special Needs Comments/Follow Up:



Consent for Initial

Evaluation/Evaluation/Re-

evaluation Consent

Disabilities Staffing Form

MSYS 9b2

(C: 08/17: R: 12/18)

- 3 -

Center Names:


Special Needs (cont.) Comments/Follow Up:

Evaluation Summary

DOE/DNQ

Embedded Schedule

IEP

IEP at a Glance

Invitation to Attend Meeting

Request for IEP

Special Education Service

Log(s)

Teacher Assessment Summary

Team Meeting Notes


disability, Progress Center, Special

Education Memos, Refusal of Services form, etc.





Bridge to Family & Child

Success

Communication


Family Partnership Agreement

Family Goal Setting

Family Picture

MSYS 9b2

(C: 08/17: R: 12/18)

- 4 -

Center Names:


Social Service (cont.) Comments/Follow Up:


Family Contact Forms

Parent Orientation Checklist

Permission to Transport Form


Transportation Request


Classroom/Home/Pals

Intervention Strategies

(MH 1a1)


(MH2a)




(MH3a)


MH Social/Emotional


(MH4a)



(MH 5a)


(MH 5c)

Family/Child Support Plan (observation summary/family team update

coordination summary update) (MH 6a)


Classroom Strategies

MSYS 9b2

(C: 08/17: R: 12/18)

- 5 -

Center Names:


Mental Health (cont.) Comments/Follow Up:


Update

Mental Health Staffing Form

Safety Intervention Report


School Version


MH Documentation


External Mental Health

Provider Report

Other: Vanderbilt Assessment

completed for PCP/other info

completed for MH providers

Protein Snack Permission

Referral to Explorers Form




Accident Form

Health Follow Up Needed

Health History Form for

Returners

Health History Form

Health Summary (Spring)

Hearing & Vision Screening

Form

MSYS 9b2

(C: 08/17: R: 12/18)

- 6 -

Center Names:


Health/Nutrition (cont.) Comments/Follow Up:

Hearing & Vision Referral

Records


Lead Screening

Medical Action Plan




Medication Info on Completed

Medications (original Authorization,

Checklist and Administration forms)

Medication Side Effect Sheet



PIR Spring Health

Questionnaire

Provider Immunization

Records

Specialist Records

WA State Immunization

Form/Exemption Form

Well Child Exam Document

Other

Dental Comments/Follow Up:

Dental Emails/Memos

MSYS 9b2

(C: 08/17: R: 12/18)

- 7 -

Center Names:


Dental (cont.) Comments/Follow Up:

Dental Exams

Dental



Dental Treatment Document

Other

Nutrition Comments/Follow Up:

Dietary Restrictions

Growth Chart


Nutrition


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: 12/18)








File Sign Out

Administration Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP





Withdrawal/Transfer Checklist


Legal Documents

Change of Classroom Request

Birth Certificate


Forms (ROI’s) (Med/Dental/School

Districts/Specialists/MH/WIC)



generated app. with parent signature)

Application/Intake/Enrollment

Forms Checklist (check name)


Education Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP Individual Site File Content


ASQ-3 Developmental

Screening

MSYS 9b




Education (cont.) Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP

ASQ SE-2

Classroom Sign-In Sheets

Developmental Screening

Summary

Field Trip Permission Slips

Home Language Survey

Kindergarten Transition

Summary

Notes Home

Other Screening Tools



School Readiness

Individualized Learning Plan

HS Only School Readiness

Visit (Family Contact Form)

Teaching Strategies Gold (Report Card) (Final Checkpoint)

Special Needs Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP



Consent for Initial Evaluation/

Evaluation/Re-Evaluation

Consent

Disabilities Staffing Form

Evaluation Summary

DOE/DNQ

Embedded Schedule

MSYS 9b




Special Needs (cont.) Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP

IEP

IEP at a Glance

Invitation to Attend Meeting

Request for IEP

Special Education Service

Logs

Teacher Assessment Summary

Team Meeting Notes


disability, Progress Center, special

education memos, refusal of services form,

etc.)

Social Service Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP




Bridge to Family & Child

Success

Communication


Family Partnership Agreement

Family Goal Setting

Family Picture


Family Contact Forms

Parent Orientation Checklist

MSYS 9b




Social Service (cont.) Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP

Permission to Transport Form


Transportation Request


Classroom/Home/Pals

Intervention Strategies

(MH 1a1)


(MH2a)




(MH3a)


MH Social/Emotional


(MH4a)



(MH 5a)


(MH 5c)

Family/Child Support Plan (observation summary/family team update

coordination summary update) (MH 6a)


Classroom Strategies


Update

Mental Health Staffing Form

Safety Intervention Report


School Version

MSYS 9b




Mental Health (cont.) Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP


Mental Health Documentation


External Mental Health

Provider Report

Other: Vanderbilt Assessment

completed for PCP/other info

completed for MH providers

Protein Snack Permission

Referral to Explorers Form




Accident Form

Health Follow Up Needed

Health History Form for

Returners

Health History Form

Health Summary (Spring)

Hearing & Vision Screening

Form

Hearing & Vision Referral

Records


Lead Screening

Medical Action Plan



MSYS 9b




Health/Nutrition (cont.) Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP


Medication Info on Completed

Medications (original Authorization,

Checklist and Administration forms)

Medication Side Effect Sheet



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



Dental Treatment Document

Other

MSYS 9b




Nutrition Comments/FLUP Comments/FLUP Comments/FLUP Comments/FLUP

Dietary Restrictions

Growth Chart


Nutrition


Nutrition Referral Review

Nutrition Emails/Memos

Distribution of Nutrition

Handouts

WIC (HCB/HCT)

Other