Head Start staff (FSS) roster form

ATTACHMENT 13

HEAD START STAFF (FAMILY SERVICES STAFF) ROSTER FORM

NOTE: A FACES study team liaison will request a list of all Family Services staff (FSS). The attached FSS Roster form is an example of the information required for sampling (number and names of FSS, their title, and the centers they serve). Head Start staff may either physically fill out the attached roster or provide the information in various formats, such as print outs from an administrative record system or photocopies of hard copy list or records. The liaison will enter the roster information for each program into a data entry program.

FACES 2014-2018

Family Services Staff Roster FORM

Program: [HS Program]	OSC: [OSC Name]
Center Phone: [Phone #]	OSC Phone: [Phone #]
	Liaison: [Liaison Name] Liaison Phone: [Liaison Phone #] Liaison Email: [Liaison Email Address]

INSTRUCTIONS:

We would like to know how many family services staff this Head Start program employs, along with their names, titles, and centers served.

Family services staff may include family service workers, family services managers, family services coordinators, and family services assistants. Please include staff that work part-time as well as full-time.

A	B	C
Staff Member Name	Staff Member Title (e.g. Family Services Manager)	Centers Served by Staff Member
1.
2.
3.
4.
5.
A	B	C
Staff Member Name	Staff Member Title (e.g. Family Services Manager)	Centers Served by Staff Member
6.
7.
8.
9.
10.
11.
12.

*Note, please continue on the back of this form and add additional pages as needed.

Total number of Family Services Staff employed by this program: