Competition Data Capture Sheet (N)

OMB Control No.: 0970-xxxx

Expiration Date: xx/xx/20xx

Appendix N: Competition Data Capture Sheet

Public reporting burden for this collection of information is estimated to average 9 minutes per response, including the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This information collection is voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Reports Clearance Officer (Attn: OMB/PRA 0970-XXXX), Administration for Children and Families, Department of Health and Human Services, 370 L'Enfant Promenade, S.W., Washington, D.C. 20447.

Competition Data Capture Sheet

Name of the Organization Applying: _______________________________________________________

Service Area of Head Start Application (e.g. Neighborhood, Town, County):_______________________

Date of Application: ______________________________________________________________ _____

Headquarters Location:__________________________________________________________________

Funding Opportunity Number:____________________________________________________________

Instructions: This coversheet should be completed and attached at the top of your Head Start application. All questions should be answered by all Head Start applicants except for those questions that are explicitly for former Head Start grantees.

The data collected in this coversheet is being used for a research study titled Evaluation of the Head Start Designation Renewal System, conducted by the Urban Institute and the Frank Porter Graham Child Development Institute at the University of North Carolina-Chapel Hill on behalf of the Office of Planning, Research and Evaluation in the U.S. Department of Health and Human Services. This form will not be used by the Office of Head Start to determine the results of your application.

Indicate Your Organization Type:

(Check the category that best matches

your organization.)

• Private Child Care Provider

• Small Business

• Other For Profit Corporation

• Public School or School District

• Native American Tribal Governments

• Public Housing Authorities

• Local Government Organization

• State Government Organization

• Private Institutions of Higher Education

• Faith-Based Organization

• Community Action Agency

• Other Non-Profit Organization

• Other, specify:___________________

Indicate Your Organization Auspice:

• For Profit

• Non-Profit

• Public

• Other, specify:____________________

How many years has your organization been in business?

• 0-1 Year

• 2-4 Years

• 5-10 Years

• 11+ Years

What ages do you currently serve? (Check all that apply)

• Do not currently serve children

• 0-3 Years Old

• 3-5 Years Old

• 6-10 Years Old

• 10+ Years Old

Please list the state and zip code(s) in which you serve your current clients (if more than 3, list the 3 closest zip codes to the county for which you are applying for a Head Start Grant)

• State 1: _________________

• Zip code(s) 1: _______________

• State 2: _________________

• Zip code(s) 2: _______________

• State 3: _________________

• Zip code(s) 3: _______________

How many states do you serve? ___

Is your organization partnering with any other organizations or entities on this grant application? Please indicate all organization types with which you are partnering, as well as whether it is a new or a continuing partnership. (Check all that apply)

• Private Child Care Provider  New  Continuing

• Health Care Providers  New  Continuing

• IDEA Part B 619, Part C Providers  New  Continuing

• Small Business  New  Continuing

• Other For Profit Corporation  New  Continuing

• Public School or School District  New  Continuing

• Native American Tribal Governments  New  Continuing

• Public Housing Authorities  New  Continuing

• Child Welfare, Protective Services,

Family Preservations Services and Agencies  New  Continuing

• Local Government Organization  New  Continuing

• Private Institutions of Higher Education  New  Continuing

• Other educational institutions (e.g. libraries)  New  Continuing

• Religious Organization  New  Continuing

• Community Action Agency  New  Continuing

• Other Non-Profit Organizations  New  Continuing

• Other, specify:___________________  New  Continuing

• Not Partnering

For this Head Start grant, will this organization provide services directly to children and families?

• Delegate None

• Delegate Some, if so please specify number of delegates _____

• Delegate All, if so please specify number of delegates _____

What level of match or cost-share is your organization proposing? 

• More than the required 20%

• Required 20%

• Less that required 20% (waiver submitted)

Please indicate the sources for the match/cost-share and whether the resources will be provided as cash or in-kind:

Source:______________   Cash                 In-kind 

Source:______________   Cash                 In-kind 

Source:______________   Cash                 In-kind 

Proposed Enrollment: For each applicable box please fill out the proposed enrollment.

	Head Start		Early Head Start		Total
	Part Day	Full Day	Part Day	Full Day	Part Day	Full Day
Center Based
Home Based
Combination
FCC
Total

Proposed Number of Teachers: For each applicable box please fill out the proposed number of teachers.

	Head Start		Early Head Start		Total
	Part Day	Full Day	Part Day	Full Day	Part Day	Full Day
Center Based
Home Based
Combination
FCC
Total

Portion of the Teaching staff with BA’s/AA’s in early childhood education or related field:_____________

Please indicate during what part of the year each type of service will be delivered.

Center – Based  Year Round  During the school year  Other

Home – Based  Year Round  During the school year  Other

Combination  Year Round  During the school year  Other

FCC  Year Round  During the school year  Other

Have you ever applied for or held a Head Start grant? (Check all that apply)

• Current Head Start Grantee (This Service Area)

• Current Head Start Grantee (Other Service Area)

• Former Head Start Grantee

• Applied for Head Start Previously, but Never Received Grant

• Previously/Current Head Start Delegate

• Never Applied for Head Start Grant before

If you are a Head Start grantee:

Which kind of Head Start Grant do you currently have? (Check all that apply)

• Head Start  Migrant/Seasonal Head Start

• Early Head Start  American Indian/Alaska Native Head Start

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