Form 1 Monthly Enrollment

OMB Control No: 0970-0427 Expiration date: X/XX/XXXX

Monthly Enrollment

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average 0.05 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. 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.

Monthly Enrollment Instrument

Grant Number: System Generated

Center Name: System Generated

Address Line: System Generated

City: System Generated

State: System Generated

[HS/EHS] Program number: System Generated

Total [HS/EHS] Slots from Centers Tab: System Generated

Total Funded Enrollment: System Generated

Operated this month:	[Yes/No]
Last day of services provided:	[Date Field]
Funded Enrollment:	System Generated
Actual Enrollment (incl. enrolled, reserved, and vacant (less than 30 days) slots):	[Numerical Entry Field]
Grantee Comments:	[Text Box]
Initially Reported:	System Generated
Last Modified:	System Generated
Regional Office Comments: Regional Office Edited:	Not Completed by Respondent
HSES Help Desk Comments:	[Text Box]
Questions for Enrollment Reporting Due to COVID-19
Impacted by Natural Disaster:	[Yes/No]
[HS/EHS] Status of in Person Services:	[Open for in person program services/Closed for in-person services due to COVID-19/Closed for in-person services due to natural disaster/ Closed for in person program services because it is not in season]
[HS/EHS] Program Option	[Center-based/Home-based or services to pregnant women/Family child care/Locally designed option/More than one program option]
# of [HS/EHS] Children in Person Only	[Numerical Entry Field]
# of [HS/EHS] Children Virtual/Remote Only	[Numerical Entry Field]
# of [HS/EHS] Children in both in Person and Virtual/Remote	[Numerical Entry Field]
Notes Regarding Center/Program:	[Text Box]