Head Start Registration Form Questions

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OMB Control Number: 0970-0617
Expiration date: XX/XX/XXXX

Question Bank for Head Start Registration Forms
The Office of Head Start registers individuals to access Head Start related events and resources. This document contains a bank of questions from which questions for registration forms will be selected. A few notes on how this question bank is used:
    • Not all registration fields are selected for registration forms. 
    • Items with [bracketed red text] are updated to reflect the specific event or resource. 
    • Although the question bank provides flexibility in the development of registration forms, the number of registration fields selected will average 1 minute response burden and the majority will only contain name, e-mail, organization, and role.
    • The “Question Text” column indicates different ways to ask the same question. 
    • Fields if asked multiple times, e.g., registering multiple people in one form or registering for a waitlist, may be numbered or may include “waitlist” in the question text.
    • The following Paperwork Reduction Act (PRA) statement is displayed within the registration form display per requirements of the PRA. 
PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to [purpose statement]. Public reporting burden for this collection of information is estimated to average [x minutes] including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This 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 subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0617 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact [contact e-mail].

Question Sub-Category
Question Text Options
Response Type or Option Set
State
-- State
-- State/Territory
List of applicable states/territories fully spelled out 
City
-- City
Textbox
Zip Code
-- Zip Code
Textbox
Region
-- ACF Region ID
-- ACF Region
List of applicable regions: 
{01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 11, 12}
{West, Midwest, Southwest, Southeast, Northeast, AIAN}
Grant Recipient
-- Are you a [program] grant recipient?
Yes/No/Not sure
Grant Number
-- Grant Number/ID
-- What is your grant number? If you do not know it, you may leave this field blank
Textbox or List of pre-filled grant numbers/Not sure
Organization
-- Organization Name
-- Agency Name
-- Program Name
-- Organization/Agency Name
Textbox or List of pre-filled program names
Organization Type
-- Type of Agency
List of organization types: {Private/Public Non-Profit (Non-CAA) (e.g., church or non-profit hospital),
Community Action Agency (CAA),
School System,
Private/Public For-Profit (e.g. for-profit hospitals),
Government Agency (Non-CAA)
Tribal Government or Consortium (American Indian/Alaska Native)} and Textbox for other

OR

{Community Action Program or Community Action Agency (CAP/CAA), EHS-CC Partnership, For-Profit, Local Government, Non-Profit (non-CAP/CAA), Regional or Statewide, School System, Single Purpose, Tribal Government} and Textbox for other
Tribal Affiliation
-- Tribal Affiliation
Textbox
E-mail
-- E-mail
-- [Position] E-mail
-- Contact E-mail
-- Contact Person Email
-- Registrant Email
Textbox
Phone Number
-- Phone Number
-- Contact Phone Number
-- Please provide the best phone number to reach you at for [specify reason for needing phone number]
-- Phone number (cell or other number that we could use to contact you about or during the [training event])
-- Primary Phone Number
-- Secondary Phone Number
Textbox
Address
-- Mailing Address
Textbox
Event
-- Event Title
Textbox
Registration Type 
-- Registration type
-- Please select the option that best describes you.
-- Please select the description that best represents you
List of registration types: {Participant, Speaker, Both, Other [please specify], [Position]}

OR

{Central Office Staff, Regional Office Staff, Regional TA Staff, National Centers Staff, Grant Recipient Program Staff, Tribal Leader, Vendor, Other [please specify], [Position]}
Date
-- Registration date
Textbox
Name
-- First Name
-- Last Name
-- [Position] Name
-- Contact Name
-- Contact Person Name
-- Registrant Name
Textbox
Role/Position
-- Role/position/title
-- Registrant Title
-- Contact Title
-- Contact Person Title
-- Title
Textbox
List of roles or position types: {EHS/HS Program Directors, Fiscal Staff, Human Resource Staff, Disabilities Staff, Mental Health Staff, Health Staff, Nutrition Staff, Governance Staff, Parent Family Community Engagement Staff, ERSEA Saff, Center/Site managers/directors, Transportation Staff, Education Staff, Coaching Staff, Homebased managers/coordinators, Facilities staff, [Position]}

Years in Current Role
-- Number of years in current role
-- Number of years as [position]
Textbox
Attendance tracking
-- Number viewing in group
-- Number of participants
-- Number of program participants
-- Will you attend [activity]?
-- Please choose the session topics you are most interested in
Textbox or List pre-filled with session topics/activities for event or yes/no
Group Attendance
-- Attending as a group?
-- We will participate as a group
List of Yes/No or Yes/No/NA
Program Option/Type
-- Program Option
-- Program Type
List of applicable program options: {Center-based Head Start Preschool, Center-based Early Head Start, Home-based, Family Child Care, and EHS-CC Partnership} 

Or

{Head Start, Early Head Start, American Indian and Alaska Native (AIAN) Head Start}
TTA Center
Please specify your Training and Technical Assistance (TTA) Office
Drop down – list of TTA for agency
Attendance Type
-- How will you attend the event?
In-Person/Virtually/ Combination of Both
Hotel
-- Will you be staying at [the hotel/hotel name]?
Yes/No
Accommodations
-- Please describe any accommodations that will facilitate your full participation in this event
-- ADA Accommodations:
-- Pursuant to the Americans with Disabilities Act, do you require specific aids or services? 
Textbox or List of accommodations: {Audio, Visual, Lactation room, interpretation services, Other [please specify], N/A}
Dietary Restrictions
--Do you have any dietary restrictions?
Textbox
Language/Translation
-- In which language would you like to register? 
-- Preferred language
-- Do you require any translation services?
Textbox or List of languages: {English, Spanish, Other [please specify]} or Yes/No



Event promotion
-- How did you hear about this [activity/event/training]?
List of options: {Headstart.gov website, Email, Social media, Word-of-mouth, Other [please specify]}
Topic(s) of Interest 
-- Select the topic area(s) of interest:
-- Select the national center content area(s) of interest:
-- Select the topic areas for [purpose]:
-- Select the national center content area(s) for [purpose]:
-- Please select the topics below that you have questions about and would like to discuss with your colleagues. You may select more than one topic.
-- Please choose the session topics you are most interested in.



List pre-filled with some or all of the topics below:
*Note: topic groupings by National Center are optional; all categories may be combined for a single question.  
*Note: the option set for this question can either be at the National Center-level (i.e., DTL, HSHS, PFCE, PMFO) or at the individual category level (e.g., Coaching, Nutrition, Communication)

    • Early Childhood Development, Teaching, and Learning (DTL) topic areas: Child Assessment, Development, Screening; CLASS: Classroom Organization; CLASS: Emotional Support; CLASS: Instructional Support; Coaching; Culture & Language; Curriculum (Instructional or Parenting); Home Visiting; Learning Environments; Teaching / Caregiving Practices; Transition Practices
    • Health, Behavioral Health, and Safety (HBHS) topic areas: Behavioral / Mental Health / Trauma; Disabilities Services; Emergency Preparedness, Response, and Recovery (EPRR); Environmental Health and Safety; Nutrition; Oral Health; Physical Health and Screenings; Pregnancy Services / Expectant Families; Safety Practices
    • Parent, Family, and Community Engagement (PFCE) topic areas: Family Support Services; Fatherhood/Male Caregiving; Parent and Family Engagement; Partnerships and Community Engagement
    • Program Management and Fiscal Operations (PMFO) topic areas: Communication; Community and Self-Assessment; Data and Evaluation; ERSEA; Facilities; Fiscal / Budget; Five-Year Grant; Human Resources; Leadership / Governance; Ongoing Monitoring and Continuous Improvement; Program Planning and Services; Quality Improvement Plan / QIP; Recordkeeping and Reporting; Technology and Information Systems; Transportation

The following questions are applicable to specific tools or events and are not used broadly as items listed in the table above. 
Tool or Event
Question Text
Response Type or Options
Division/Office (used for ACF-wide events)
-- Division/Office
Textbox
ACF Program Office (used for ACF-wide events)
-- Please select the program office(s) you support
List of ACF program offices
Practice-based Coaching Tool 
-- Have you attended any PBC training? 
List of Yes/No
Practice-based Coaching Tool
-- Which option are you coaching? (check all that apply)
List of options: {Early Head Start, Head Start, Early Head Start-Child Care Partnership, Center-based, Home-based}
Practice-based Coaching Tool
-- Do you have a dual/multi-role (Coach and...)?
-- Please list dual/multi-role if applicable (Coach and...)? 
-- How many months as a coach?
List of Yes/No

Textbox

List of options: {0-6 months, 12-24 months, 24+ months, 6-12 months}
Practice-based Coaching Tool 
-- Assigned TTA Early Childhood Specialist: 
List of TTA Specialists or Textbox
Sponsored Travel
-- Name as it appears on your government issued ID
Textbox
Sponsored Travel
-- Is your primary work location more than 50 miles from [meeting venue]?
List of Yes/No
Sponsored Travel

-- Please note that travel arrangements paid on your behalf will be non-refundable and non-transferable. Check the box to confirm that you understand the airline tickets you will be reserving are non-refundable and non-transferable.
Checkbox to indicate agreement
Sponsored Travel
-- For planning purposes, the standard travel dates are to arrive in [meeting city] on [day, date, year] and depart [meeting city] the afternoon/evening on [day, date, year]. Please let us know if you have any schedule conflicts or other circumstances that need to be considered when coordinating your travel itinerary. Please note this is a request and must be approved by OHS. 
Checkbox to indicate agreement
Flexibility
-- If needed, I/we can switch to [alternative date(s)/session(s)]
-- I/we are available for [alternative date(s)/session(s)]
-- I/we prefer this/these times: [alternative date(s)/session(s)]
Checkbox to indicate agreement
Payment
-- Expected Payment Type
List of payment types: {Check, Credit Card, Purchase Order (for orders at $400 or more)}
Teacher observations
-- Will you observe teachers once certified?
List of Yes/No
Teacher observations
-- Will you collect data for Grant Recipient/Staff use from the observations?
List of Yes/No
Teacher observations
-- How do you plan to observe classrooms? (check all that apply)
List of observation types: {Live, Recorded, Virtual}
Trainings/ Certification
-- Have you attended Pre-K Observation Training before? 
-- If yes, please provide years
-- If yes, were you certified?
List of Yes/No

Textbox
List of Yes/No/N/A
Trainings/ Certification
-- Have you taken the QCIT Certification in the Past? 
-- If yes, please provide years
-- If yes, were you certified?
List of Yes/No

Textbox
List of Yes/No/N/A
Trainings/ Certification

-- Will you utilize QCIT to collect data?

List of Yes/No

Virtual attendance
-- Are you familiar with Zoom?
List of Yes/No
List of selections: {I have significant experience with Zoom., I'm a Zoom expert!, I've used Zoom minimally.}
Oral Testimony 
-- Do you intend to provide oral testimony at the event? (Note: In order to provide testimony, you must be a Tribal Leader or an Authorized Designee that has submitted a signed letter to {email address/contact information} before {date} to speak on behalf of the Tribe.) 
Yes/No 
Written Testimony 
-- Do you intend to provide written testimony for the Consultation Report? (Note: Tribes wishing to submit written testimony for the Consultation Report may submit it to ACF prior to the consultation session or within 30 days after the session. When possible, please submit written testimony at least 3 days in advance of the consultation. Written testimony may be submitted to {email address/contact information}.) 
Yes/No