Head Start Forms

For information on forms or categories listed please call (209) 238-1800.  Contact: Carolyn Armstrong, Office Supervisor carmstrong [ahtsym] stancoe [dhotsym] org

For questions regarding online form links, please Email pim [ahtsym] stancoe [dhotsym] org

*Head Start Order Form 2017

2017-2018 Master Forms:

Attendance

Form Hot Sheet Fillable Form
A-1 Child Action Follow Through Report (E) A-1 A-1

Disabilities

Form Hot Sheet
D-6 Child Success Team Request (E) D-6
D-6.1 Child Success Team Request (S) D-6.1
D-7 Notification of Child Success Team Meeting (E)  
D-7.1 Notification of Child Success Team Meeting (S)  
D-8 Results of Child Success Team Meeting (E) D-8
D-8.1_Results_of_Child Success Team Meeting_(S)  
D-10_Head_Start_Referral for Special Education Services (E) D-10
D-11 Special Education Meeting Record (E) D-11 

Education

Form Hot Sheet Fillable Form
E-2 Infant/Toddler Needs and Service Plan (page 1) (E) E-2   
E-2 Infant/Toddler Needs and Service Plan (page 2) (E) E-2.1   
E-2.1 Infant/Toddler Needs and Service Plan (page 1) (S)    
E-2.1 Infant/Toddler Needs and Service Plan (page 2) (S)    
E-4 Diaper Chart (E) E-4  E-4
E-4_1 Diaper Chart (S)   E-4_1
E-6a Infant Toddler Activity Plan (E-S) E-6a&b E-6a
E-6b Preschool Activity Plan (E-S) E-6a&b E-6b
E-6cFamily Child Care Home Activity Plan(E-S    
E-7 Parent Contact Record (E-S) E-7  E-7 
E-8 Incident Report (E-S) E-8  E-8
E-9 I Missed You For Our Home Visit Parent Conference (E-S) E-9  E-9 
E-11 Success Report (E) E-11  E-11
E-11.1 Success Report (S) E-11.1  E-11.1
E-18 Family Home Visit Plan (E) E-18   
E-18.1 Family Home Visit Plan (S) E-18.1  
E-21 Home Base Socialization Activity Plan E-21 E-21
E-21.1 Home Base Socialization Plan (S) E-21.1 E-21.1
E-22 Home Visit-Class Conference Release Form (E-S) E-22   
E-23 Parent Guidelines for Successful Home Visits (E) E-23  
E-23.1 Parent Guidelines for Successful Home Visits (S)    
E-24 School Readiness Goal Composite-Preschool (E) E-24  E-24
E-24_1 School Readiness Goal Composite-Preschool (S) E-24.1 E-24.1
E-29b Child School Readiness Plan (E-S)

E-29b(E)

E-29b(S)

E-29b
E-30 Classroom Level Planning Programs (E) E-30 E-30 
E-30.1 Classroom Level Planning Programs (S) E-30.1 E-30.1
E-31 Coaching Agreement (E) E-31   
E-31.1 Coaching Agreement (S) E-31.1  
E-32 Needs Assessment (E) E-32   
E-32_1 Needs Assessment (S) E-32.1  
E-33 Teaching Practice Action Plan (E) E-33   
E-33_1 Teaching Practice Action Plan (S) E-33.1   
E-34 Professional Growth Record (E) E-34   
E-34_1 Professional Growth Record (S)    
E-35 PBC Mentee Program Evaluation Form E-35   
E-35_1 PBC Mentee Program Evaluation Form (S) E-35.1  
E-36 PBC Mentor Program Evaluation - Director Form (E) E-36   
E-36_1 PBC Mentor Program Evaluation - Director Form (S) E-36.1  
E-37 Program Level School Readiness Planning Form (E) E-37 E-37
E-37_1 Program Level School Readiness Planning Form (S)   E-37.1
E-38 Child and Family Transition Plan (E) E-38 E-38
E-38_1 Child and Family Transition Plan (S)   E-38.1
E-39 DRDP 2015 Rating Record - Preschool (E) E-39.1   
E-39_1 DRDP 2015 Rating Record - Preschool (S) E-39.1   
E-40 DRDP 2015 Rating Record - Infant-Toddler (E) E-40  
E-40_1 DRDP 2015 Rating Record - Infant-Toddler (S) E-40.1  
E-41 Playgroup Learning Experiences Pla (E) E-41   
E-42 Admission Agreement - Contract for Services (E) E-42  
E-42_1 Admission Agreement - Contract for Services (S)    
E-43 Home-Based School Readiness Goals (E) E-43   

Fiscal

Form Hot Sheet Fillable Form
F-1 Non- Federal Share Volunteer Service (E) F-1 F-1
F-1.1 Non- Federal Share Volunteer Services (S)   F-1.1
F-2 Donated Goods and Services Non-Federal Share (E) F-2  
F-2.1 Donated Goods and Services Non-Federal Share (S)    
F-4 Non Federal Share Summary(E) F-4   
F-5 Delegate Property Inventory (E) F-5   
F-6 Delegate Budget Revision Request (E) F-6   
F-7 Delegate Agency Claim (E) F-7   
F-8 Staff Information Form (E) F-8   
F-9 Staff Action/Follow Through Report (E) F-9   

 

Health & Safety

Form Hot Sheet Fillable Form
H-3a Health History/Nutrition Assessment (E) H-3a   
H-3.1a Historial de Salud/Evaluacion De Nutrition (S)    
H-3c Infant Health History Form (E) H-3c  
H-3.1c_Infant Health History (S) H-3.1c  
H-4a Immunization Referral (E-S) H-4a  
H-4b CA Immunization Registry Refusal/Info Request (E) H-4b c   
H-4.1b CA Immunization Registry Refusal/Info Request (SP)    
H-4c CA Immunization Registry Disclosure Statement (E-S)    
H-5a Dental Care Report (E) H-5a  
H-5b Dental Exam Result (E-S) H-5b   
H-6 Vision Screening Referral (E) H-6   
H-7a Hearing and Vision Screening Form (E-S) H-7a  
H-7c On Site Screen Results (E) H-7c   
H-7e Diagnostic Follow-up Form (hearing screening referral) H-7e & f  
H-8a Consent for Medication/Consentimiento para medicinas (S) H-8a & 8b  
H-8b Medication Chart (E-S)    
H-8c Individualized Health Care Plan (E) H-8c H-8c
H-8d Medication Box Labels (E) H-8d  
H-8e Temporary Individual Health Care - Emergency Plan H-8e  
H-8_1e Temporary Individual Health Care - Emergency Plan for Respiratory Distress (S)    
H-8f Temporary Individualized Health Care Plan for Anaphylaxis (E) H-8f  
H-8.1f Temporary Individualized Health Care Plan for Anaphylaxis (S)    
H-9 Appointment Reminder (E-S) H-9  
H-10 Physical Screening for Children (E) H-10  
H-11a EHS Child's Health Tracking Form (E) H-11a  
H-11b Newborn Health Visit (E) H-11b  
H-12 Notice of Needed Information/Exclusion (E) H-12   
H-12_1 Notice of Needed Information/Exclusion (S)    
H-12.1a Home Base Notice of Needed Info (S)    
H-12a Home Base Notice of Needed Info (E)    
H-13a Volunteer TB Record (E) H-13a  
H-13b TB Clearance Documentation (E) H-13b   
H-13c Medical Billing Form (E) H-13c   
H-13d Tuberculosis Risk_Assessment (E) H-13d   
H-13.1d Tuberculosis Risk Assessment (S)    
H-13eHead Start Tuberculosis Concern Referral (E) H-13e  
H-14a Snack Menu (E) H-14a  
H-14b Food Temperature Record (E) H-14b  
H-14c Medical Statement to Request Special Meal Request (E) H-14c   
H-14d Nutrition Concern (E) H-14e   
H-14e Food Preference Request H-14e   
H-16 Parent/Guardian Release of Lead Level Results (E) H-16  
H-17 Child Asthma Plan (E) H-17   
H-18 Requesting Information from Doctor Fax Cover Sheet (E) H-18   
H-20 Infant Meal Record (E) H-20  
H-21 Treatment Refusal (E) H-21   
H-21.1Treatment Refusal (S)    

 

Safety

Form Hot Sheet Fillable Form
H-15a Daily Indoor Safety Checklist (E) Interim 2-17 H-15a & b  
H-15_1a Daily Indoor Safety Checklist (S) Interim 2-17    
H-15b Daily Outdoor Safety Checklist (E) Interim 2-17    
H-15_1b Daily Outdoor Safety Checklist (S) Interim 2-17    
H-15c Child Active Supervision Plan (E) H-15c H-15c
H-15.1c Child Active Supervision Plan (S)   H-15.1c 
H-15d Child Active Supervision Plan for (FCCH) (E) H-15d  H-15d 
H-15.1d Child Active Supervision Plan for (FCCH) (S)   H-15.1d
H-19 Field Trip Checklist (E) H-19  
H-22 Unannounced Safety and Supervision Visit Report H-22 H-22 

Mental Health

Form Hot Sheet Fillable Form
MH-4 Parent Consent Individual Social Emotional Observation (E-S) MH-4   
MH-5 Request For An Individual Child Observation (E) MH-5  
MH-7 FCCH Social Emotional Health (0-5 Year Olds) (E) MH-7 MH-7
MH-7_1 FCCH Social Emotional Health (0-5 Year Olds) (S)   MH-7.1
MH-7 IT Infant Toddler Classroom Observation (E)   MH-7
MH-7 P Preschool Classroom Observation (E)   MH-7
MH-9 Head Start & Leaps and Bounds Collaboration (E) MH-9   
MH-9.1 Colaboracion de  Head Start y Leaps and Bounds (S)    
MH-10 Patient Health Questionnaire.(E) MH-10  
MH-10.1 Patient Health Questionnaire.(S)    

Other

Form Hot Sheet
O-3 In Service or General Staff Meeting Record (E) O-3
O-5 File Sticker (E) O-5
O-10 Transfer of Childs Records (E) O-10
O-17 Training Evaluation Sheet (E) O-17
O-18 Enrollment/Attendance Work Plan (E) O-18
O-19a Case Conferencing Worksheet O-19a & 19b
O-19b FCCH Case Conferencing Worksheet  
O-20 Head Start Eligibility Criteria (E) O-20
O-21 Head Start Field Trip Request (E) O-21
O-23 Site Visit Report (E) O-23
O-24 Migrant Preliminary Eligibility Worksheet (E) O-24
O-24.1 Migrant Preliminary Eligibility Worksheet (S)  
O-26 Case Conferencing Follow-Up O-26
O-27 Fax Referral Form (E) O-27
O-27.1 Fax Referral Form (S)  
O-28 Recruitment Work Plan (E).pdf  

Parent Involvement 

Form Hot Sheet Fillable Form
P-2 Center Parent Committee/Meeting Calendar MHS (E-S) P-2  
P-2 Center Parent Committee/Meeting Calendar RHS (E-S    
P-3 Center Meeting Planning Sheet (E) P-3  
P-4 Parent Meeting Agenda (E) P-4  
P-4.1 Parent Meeting Agenda (S)    
P-5 Parent Meeting Minutes (E) P-5 P-5
P-5.1 Parent Meeting Minutes (S)   P-5.1
P-6 Center Committee/PC Sign In Sheet (E-S) P-6  
P-7 Center Committee Data (E) P-7  
P-8 Regional Delegate Policy Committee Data (E) P-8  
P-8a CCMHS Policy Committee Data P-8a  
P-9 Parent Volunteer Calendar (E) P-9  
P-10 Parent Survey (E) P-10  
P-10_1 Parent Meeting Survey (S) P-10.1  
P-11 Delegate Policy Committee Meeting Agenda (E) P-11  
P-11.1 Delegate Policy Committee Meeting Agenda (S)    
P-12 Delegate Policy Committee Meeting Minutes (E) P-12  
P-12.1 Delegate Policy Committee Meeting Minutes (S)    
P-13 Parent Meeting Evaluation (E-S) P-13  
P-14 Policy Council Reimbursement Claim (E-S) P-14  
P-15 Policy Committee Center Report (E) P-15  
P-16 Policy Council-Committee Approval Form (E-S) P-16 P-16
P-17 Policy Council-Committee Interview Minutes (E-S) P-17 P-17
P-18 Parent Meeting Survey Compilation (E) P-18  
P-18_1 Parent Meeting Survey Compilation (S) P-18.1  
P-19 Policy Council Ratification of Assignment of Staff (E-S) P-19 P-19
P-20 CCMHS Policy Council Rep Confirmation    
P-21 RHS-EHS Policy Council Rep Confirmation    

Pregnant Women

Form Hot Sheet
PW-1 Pregnant Women Emergency Form (E) PW-1
PW-1.1 Pregnant Women Emergency Form (S) PW-1.1
PW-2 Pregnant Minor Emergency Form (E) PW-2
PW-2.1 Pregnant Minor Emergency Form (S)  
PW-3 Teen Father/Minor Emergency Form (E) PW-3
PW-3.1 Teen Father/Minor Emergency Form (S)  
PW-5 Early Head Start Prenatal Health History (E) PW-5
PW-5.1 Early Head Start Prenatal Health History (S)  
PW-7 Pregnant Women Parent Interest Survey (E) PW-7
PW-7.1 Pregnant Women Parent Interest Survey (S)  
PW-9 Curriculum Services Tracking Sheet (E) PW-9
PW-11 Pregnant Women Case Conference Tracking Sheet (E) PW-11
PW-13 Contact Record (E) PW-13

 

Registration

Form Hot Sheet Fillable Form
R-1 Child Family Services Head Start Application (E) R-1  
R-1.1 Child Family Services Head Start Application (S) R-1.1  
R-3 Emergency Card (E-S) R-3  
R-4 Notification of Parent's Rights (E) (Fresno) R-4  
R-4_1 Notification of Parent's Rights (S) (Fresno)    
R-4 Notification of Parent's Rights (E) (Oakland)    
R-4_1 Notification of Parent's Rights (S) (Oakland)    
R-4 Notification of Parent's Rights (E) (Sacramento)    
R-4_1 Notification of Parent's Rights (S) (Sacramento)    
R-4 Notification of Parent's Rights (E) (San Jose)    
R-4_1 Notification of Parent's Rights (S) (San Jose)    
R-5 Personal Rights (E) (FRESNO) R-5  
R-5_1 Personal Rights (S) (FRESNO)    
R-5 Personal Rights (E) OAKLAND    
R-5_1 Personal Rights (S) OAKLAND    
R-5 Personal Rights (E) SACRAMENTO    
R-5_1 Personal Rights (S) SACRAMENTO    
R-5 Personal Rights (E) SAN JOSE    
R-5_1 Personal Rights (S) SAN JOSE    
R-6 File Access Log (E) R-6  
R-7 Consent Form (E) R-7  
R-7.1 Consent Form (S)    
R-8 Family Contact Log (E) R-8  
R-9 Parent Release SCOE (E-S) R-9  
R-10 Caregiver's Authorization Affidavit (E) R-10  
R-10.1 Caregiver's Authorization Affidavit (S)    
R-12 Migrant Certification of Income Verification (E) R-12 R-12
R-12.1 Migrant Certification of Income Verification (S)    
R-13 Head Start Infant-Toddler Program Extension (E-S) R-13  
R-14 Head Start Toddler Option Program Parent Authorization (E) R-14  
R-14 Head Start Toddler Option Program Parent Authorization (S)    
R-15 Income Calculation Worksheet & Family Size Worksheet-RHS & EHS (E) R-15 R-15
R-20 Self-Identification of Current Residency Form (E) R-20  
R-20.1 Self-Identification of Current Residency Form (S) R-20.1  
R-21 Declaration of Intent to Work in Agriculture (E-S) R-21  
R-22 Tracking Sheet for Declaration of Intent to Work in Ag (E) R-22  
R-22 Tracking Sheet for Declaration of Intent to Work in Ag (S)    
R-23 Self-Certification of Income (E) R-23  
R-23.1 Self-Certification of Income (S)    
R-24 Employment Verification Form (E) R-24  
R-25  Request to Actively Seek Employment (E-S) R-25  
R-26 Statement of Incapacity (E) R-26  
R-27 Self-Employment Verification (E) R-27  
R-28a Training Verification Electronic Printout (E) R-28a  
R-28b Training Verification No Electronic Printout (E) R-28b  
R-30 Self-Declaration of Migratory Move (E) R-30  
R-30.1 Self-Declaration of Migratory Move (S)    
R-31 EHS Application Approval Checklist (E) R-31  
R-32 MSHS Application Approval Checklist (E) R-32  
R-33 Consent for Release of Information (E) R-33  
R-33.1 Consent for Release of Information (S) R-33.1  
R-34 Parent Guardian Consent-Release of Information RHS EHS (E) R-34  
R-34.1 Parent Guardian Consent-Release of Information RHS EHS (S)    
R-35 Child Information Sheet R-35  
R-35_1 Child Information Sheet (S)    

Social Services

Form Hot Sheet Fillable Form
S-1 Family Summary and Partnership Agreement (E) S-1 S-1
S-1.1 Family Summary and Partnership Agreement (S) S-1.1 S-1.1
S-3 Social Service Referral (E-S) S-3  
S-4 Orientation Volunteer Checklist (E) Interim 2-17 S-4  
S-4_1 Orientation Volunteer Checklist (S)    
S-7 Community Agency Contact Record (E) S-7