Classroom sampling form from Head Start staff

ATTACHMENT 1

CLASSROOM SAMPLING FORM FROM HEAD START STAFF

NOTE: Upon arrival at a selected center, a FACES study team Field Enrollment Specialist (FES), will request a list of all Head Start-funded classrooms from Head Start staff (typically the On-Site Coordinator). The attached classroom sampling form is an example of the information required for classroom sampling. Head Start staff may provide this information in various formats such as print outs from an administrative record system or photocopies of hard copy list or records. Therefore, Head Start staff will not physically fill out the attached classroom sampling form. The FES will enter the information into a tablet computer. For each classroom, the FES will enter the teacher’s first and last names, the session type (morning, afternoon, full day, or home visitor), and the number of Head Start children enrolled into a web-based sampling program via the tablet computer. The sampling program will select about two classrooms for participation in the study.

FACES 2014-2018

CLASSROOM SAMPLING FORM

Program: [HS Program]	OSC: [OSC Name]
Center: [Center1 Name]	OSC Phone: [Phone #]
[Center2 Name]	F.E.S.
[Center3 Name]	(Please Print Your Name)
Center Phone: [Phone #]

INSTRUCTIONS: Please enter into the sampling website the information below for each classroom in this center (or center group) that contains Head Start funded children.

A	B	C
Lead Teacher	Classroom Type
First Name Last Name	(Select Only One) AM, PM, Full Day, Home Visitor	Number of Head Start Children Enrolled
1.	1.	1.
2.	2.	2.
3.	3.	3.
4.	4.	4.
5.	5.	5.
6.	6.	6.
7.	7.	7.
8.	8.	8.
9.	9.	9.
10.	10.	10.
11.	11.	11.
12.	12.	12.
13.	13.	13.
14.	14.	14.

P

Paperwork Reduction Act Statement: The referenced collection of information 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. The OMB control number for this collection is 0970-0151 and it expires XX/XX/XXXX.

Paperwork Reduction Act Statement: The referenced collection of information 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. The OMB control number for this collection is 0970-0151 and it expires XX/XX/XXXX.

Paperwork Reduction Act Statement: The referenced collection of information 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. The OMB control number for this collection is 0970-0151 and it expires XX/XX/XXXX.

aperwork Reduction Act Statement: The referenced collection of information 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. The OMB control number for this collection is 0970-0151 and it expires XX/XX/XXXX. The time required to complete this collection of information is estimated to average 10 minutes, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the collection of information. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Mathematica Policy Research, 1100 1st Street, NE, 12th Floor, Washington, DC 20002, Attention: Jerry West.