Profit/Non-profit Sponsors and Child Care Centers

APPENDIX C4. INCOME ELIGIBLITY APPLICATION ABSTRACTION FORM

OMB Number: 0584-XXXX

Expiration Date: XX/XX/XXXX

ERRONEOUS PAYMENTS IN CHILD CARE CENTERS STUDY (EPICCS)

INCOME ELIGIBILITY APPLICATION ABSTRACTION FORM

Summary

Field Data Collectors will collect data on all enrolled children in sampled child care centers. While onsite, the income eligibility application data will be abstracted and entered on computerized data entry forms. Data from the master list of enrolled students will be abstracted separately to document the center’s official record of certification status. This will be compared to certification status recorded on the application.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-XXXX. The time required for the sponsoring organization director or the child care center director or manager to provide access to the center’s administrative records is estimated to average 15 minutes per response during each data collection round, including the time to review instructions, search existing data resources, gather and maintain the data needed, and complete and review the collection of information.

A. CENTER INFORMATION
CENTER NAME: CENTER TYPE: SCCC ICCC HEAD START	CENTER STUDY ID:
SPONSOR NAME (SKIP IF CENTER TYPE = ICCC)	SPONSOR STUDY ID:

B. APPLICATION INFORMATION

B1. ENROLLED CHILD’S NAME:
	FIRST		MIDDLE INITIAL		LAST
	__________________________		________		______________________________
B2. IS ENROLLED CHILD COVERED UNDER ANOTHER APPLCATION (e.g., Sibling’s Application)?		☐ YES (END)		☐ NO (GO TO B3)
		Sibling Name (s): ________________________		________________________		_______________________
B3. PARENT/GUARDIAN NAME:		________________________
B4. HOME ADDRESS:		__________________________City:_____________________State__________ZIP__________
B5. APPLICATION SUBMITTED BY HOUSEHOLD?		☐ YES (GO TO B7)		☐ NO (GO TO B6)
B6. IF NO APPLICATION SUBMITTED, SPECIFY THE REASON.		☐ Categorically eligible		☐ Directly Certified		☐ Household chose not to submit application
		☐ Center does not require household to submit application		☐ Other, specify: ______________________
ONCE B6 COMPLETED, END OF FORM)

B7. APPLICATION DATE: | | |/| | |/| | |

MONTH DAY YEAR  Not Recorded on Application

B8. APPLICATION FORMAT:	☐ Hardcopy	☐ Electronic		☐ Web-based	☐ Other-Specify:
C. CHILDREN ENROLLED AT THE CHILD CARE CENTER
Start with the enrolled child listed in question B1, and continue with additional children in the household.
CHILD NAME: (First, Middle Initial, Last)			SPECIAL STATUS?			DATE OF BIRTH (or age if not available)
			 Foster Child  Runaway  Homeless  Migrant  Institutionalized  Other  None			| | |/| | |/| | | MONTH DAY YEAR Age (at Last Birthday): _______ ☐ Not recorded on application

*Repeat rows for each additional child in household.

D. BENEFITS STATUS RECORDED ON APPLICATION (check if applicable)

 Participation in Supplemental Nutrition Assistance Program (SNAP)	TYPE OF DOCUMENTATION: ☐ Case Number ☐ Other, specify:______________________
 Participation in Temporary Assistance to Needy Families (TANF)	TYPE OF DOCUMENTATION: ☐ Case Number ☐ Other, specify:______________________
 Participation in Food Distribution Program on Indian Reservations (FDPIR)	TYPE OF DOCUMENTATION: ☐ Case Number ☐ Other, specify:______________________

E. HOUSEHOLD AND INCOME INFORMATION:

☐ CHECK IF BASIS OF ELIGIBILITY IS NOT INCOME, AND SKIP SECTION E.

List all household members recorded on the application, including all children covered by application. Record income data for all household members exactly as shown on the application.

Choose the “PER” period amount from the drop down menu. The coded options will include: H= Hourly; D=Daily; W=Weekly; BW=Bi-weekly (every two weeks); SM=Semi-Monthly (twice a month); M=Monthly; Y=Yearly; OTH=other (indicate period on form); or MS=Missing.

1		2	3	4		5		6		7
LIST HOUSEHOLD MEMBERS		Check if child under age 18	Check if Zero ($0) Income	EARNINGS FROM WORK		WELFARE, CHILD SUPPORT, OR ALIMONY (NO SNAP)		PENSIONS, RETIREMENT, OR SOCIAL SECURITY		ALL OTHER INCOME
FIRST NAME	LAST NAME			AMOUNT	PER	AMOUNT	PER	AMOUNT	PER	AMOUNT	PER
1.				$		$		$		$
2.				$		$		$		$
3.				$		$		$		$
4.				$		$		$		$
5.				$		$		$		$
6.				$		$		$		$
7.				$		$		$		$
8.				$		$		$		$
9.				$		$		$		$
10.				$		$		$		$

*If PER period selected is OTH = Other, the CAPI program will prompt the data collector to enter the other type of income period.

F. SPONSOR/CENTER ASSESSMENT AS REPORTED ON APPLICATION

1. ELIGIBILITY DETERMINATION DATE | | |/| | |/| | | MONTH DAY YEAR  Not recorded on application  Obtained from secondary Source  Center Report (Electronic or Printed)  Other: _________________________	4. REASON FOR DENIAL  Income  Incomplete Application  Application Withdrawn  Other: _________________  Not recorded on application  Obtained from secondary Source  Center Report (Electronic or Printed)  Other: _________________________
2. BASIS FOR ELIGIBILITY  Income  Categorical Eligibility:  SNAP  FDPIR  TANF ☐ Not Specified  Foster Child  Special Status  Runaway  Homeless  Migrant  Institutionalized ☐ Not Specified ☐ Alternative Method  Direct Certification  Other: _________________________  Not recorded on application  Obtained from secondary Source  Center Report (Electronic or Printed)  Other: _________________________	5. TOTAL HOUSEHOLD SIZE | | |  Not recorded on application  Obtained from secondary Source  Center Report (Electronic or Printed)  Other: _________________________
3. ELIGIBILITY DETERMINATION  Free (go to #5)  Reduced-Price (go to #5)  Denied /Paid (go to # 4)  Not recorded on application  Obtained from secondary Source  Center Report (Electronic or Printed)  Other: _________________________	6. TOTAL INCOME $ | | | ||,| | | |  Weekly  Biweekly  Semi-Monthly  Monthly  Annual  Other: _________________  Not recorded on application  Obtained from secondary Source  Center Report (Electronic or Printed)  Other: _________________________

G. FORM COMPLETENESS

	Yes	No
1. If basis for eligibility is TANF, SNAP, or FDPIR, was case number recorded?	1	0	N/A
2. If basis for eligibility is income, was income recorded for at least one household member?	1	0	N/A
3. Was the form signed by an adult household member?	1	0
4. Was SSN (or last four digits) of adult signer entered?	1	0	No SSN
5. Documentation or signature obtained for homeless, runaway, migrant, institutionalized status?	1	0	N/A
5. Is the Sponsor/Center section signed?	1	0

H. COMMENTS

Document any additional information and/or any special circumstances, procedures, and/or information regarding this application.

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I. DATA COLLECTOR INFORMATION

NAME

ID

DATE: | | | / | | | / | | | MONTH DAY YEAR

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