UMCHS FORMS

Below is a list of the forms and handouts that Umatilla-Morrow County Head Start, Inc. has on file.  The forms are produced in Adobe Acrobat, therefore, you must have the Adobe Acrobat Reader in order to view these files, which you may download for free at this location:

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ADMINISTRATION FORMS:

 

CONTENT AREA MONITORS:

Disabilities Observation Tool

Family Partnership - Health Monitors

FCC Center File Monitoring Tool

Full Day Center File Monitor

Health Practices Observation

Nutrition Site Monitor

Part Day Center File Monitor Tool

Pre-approval Visit and Initial Training

Site Monitoring Report - Nutrition

 

FISCAL:

Administrative Cost Report

ARRA Contract Award Form

ARRA Reporting

Check Request

Contract Award Form

Contract Award Letter

Davis Bacon Exempt

Direct Deposit Authorization

End of Year Check List

Gift Card Expense Form

Inventory Transfer Form

Journal Voucher

Local Travel Expense Statement

Payroll Withholding Authorization Form

Personnel Activity Report

Petty Cash Reimbursement Form

Phone Log

Supply Requisition Form

Time Sheet

Time Sheet for Substitutes

Travel Expense Report

UMCHS Benefit Change/Update Form

WH 347 Form

 

HUMAN RESOURCES:

Application for Employment

CDA - Professional Development Plan

Direct Deposit Authorization Form

Doctors Report - Work Release Form

Emergency Contacts Form

Exit Interview Questions

Grievance Form

Employee Morale, Health and Wellness Activity Plan

Leave of Absence

Employee Family Medical Leave Form

Family Member Medical Leave Form

Motor Vehicle Report Authorization

OSEA Change Form

Payroll Deductions Authorization Form

Plan of Assistance

Professional Development Plan

Request for Leave

SDC Record Form

Staff Coverage Documentation for Centers

TB Screen

Transfer & Promotion Form

Volunteer Application

    Training Forms:

     SDC Record Form

     Training Evaluation

     Training Guidelines

     Training Request Form

     Training Summary

 

MONITORS & MONTH END REPORTS

    Month End Reports

Associate Director Content Monthly Report

Board Monthly Report

Child Care Director Month End Report

Content Area Director Month End Report

Education & Disabilities Month End Report

Family Development Director Month End Report

Fiscal Director Month End Report

Health Month End Report - HS

Health Month End Report - EHS

Healthy Start Monthly Report

Mental Health Month End Report

Education/Disabilities Month End Report

Nutrition Month End Report

Operations Director East Month End Report

Operations Director West Month End Report

Policy Council Monthly Report

    Monitors

Administrative Monitor

Administrative Monitor NCESD

Family Development Monitor

Health Monitor Observation

Mental Health Monitor

Nutrition Monitoring Form

Content Area Monitors

Disabilities Observation Tool

Family Partnership Health Monitor

FCC Center File Monitoring Tool

Full Day Center File Monitoring Tool

Health Practices Monitor

Nutrition Site Monitor

Part Day Center File Monitoring Tool

Pre-Approval Visit and Initial Training

Site Monitoring Report - Nutrition

Facilities Monitors

Checklist for Quality Head Start Facilities

Facilities Monitors

Monthly Health and Safety Checklist

Record Keeping Monitors

Disabilities Tracking Sheet

Education & Disability Record Keeping Monitor

Enrollment Monitor

Family Partnership Record Keeping Monitor

File Review Checklist Form

Health Record Keeping Monitor

Mental Health Monitor

 

OPERATIONS:

Fax Form

Foundation Application

Work Requisition Form

    Child Abuse and Neglect Forms:

Removal of a Child from the Classroom

Suspected Child Abuse & Neglect Report Form

    Complaint Forms:

Complaint Form

Civil Rights Complaint Form

Civil Rights Complaint Form - Spanish

Comment and Complaint Form - Spanish

DHS Discrimination Complaint Form

    Grievance Forms:

Grievance Form

    Referral:

Internal Referral Form

   Safety

     Injury Report Form

     Injury Report Form (SPANISH)

     Injury Report Policy

     Safety Report Form

    Wellness

     Physical Activity Log

 

CCR&R FORMS

Child Care Summary of Services

Parent Provider Month End Report

Daily Activity Log

    Complaint Forms:

DHS DPU Issues Form

Phone Log for Suspended Providers

     Provider Suspension Letter

    Lending Library Forms:

Checkout Form

Checkout Form - Spanish

    Mentor Forms:

Mentee Goal Form

Mentor Application

Oregon Statewide Mentoring Program Contact Form

    NACCRRAware Forms:

Parent Intake Form

Parent Intake Form - Spanish

Provider Intake

Provider Intake - Spanish

    Parent

Parent Interview Checklist Form

Parent Interview Checklist Form - Spanish

Standard Parent Letter

Standard Parent Letter - Spanish

 

 

ELECTRONIC FORMS

Direct Deposit Authorization Form

Head Start Transition Survey

In-Kind

Payroll Deductions Authorization Form

Supply Requisition Form

Time Sheet for Substitutes

Timesheet (2 Page)

Time Sheet (3 Page)

Time Sheet (4 Page)

 

HEAD START & EARLY HEAD START FORMS

 

    CHILD CARE FORMS:

Acknowledgment of Receipt

Acknowledgment of Receipt Spanish

Attendance In/Out Log

Attendance In/Out Log - Spanish

Budget Income Control Sheet

Budget Income Control Sheet - Spanish

CCDF Application

Child Care Tracking Form

Child Care Payment Plan

Child Care Payment Plan - Spanish

Co-pay Reminder

Co-pay Reminder Spanish

DHS Contract Eligibility Checklist

DHS Contract Parents Permission to Access Records

DHS Enhanced Contract Families Worksheet

DHS Enhanced Contract Families Worksheet - Spanish

Migrant & Seasonal Child Care Application

Enrollment Child Care Billing Worksheet

Payment Record for Co-pays

Reduced Copay Request

Staff Payment Form

Staffing Attendance Record

Toileting Sleeping Feeding Chart

Toileting and Sleeping Chart

 

    DISABILITIES FORMS:

Consultant Visit Record

ESD Consultant Sign-In Sheet

Head Start Teacher Input Form

 

    EDUCATION FORMS:

    Assessment Forms:

Outcomes Worksheet - Infants

Outcomes Worksheet - Preschool

Outcomes Worksheet - Toddlers

    Attendance Forms:

Attendance Plan & Follow Up - English & Spanish

EHS Attendance Form

HS Attendance Form

    Checklists:

End of Year Checklist

Portfolio Collection Schedule - Head Start

Portfolio Collection Schedule - Early Head Start

    Comprehensive Staffing Forms

Comprehensive Staffing Report & Consent

    Cultural Survey:

Cultural Survey

    Curriculum and Classroom Daily Plans:

Changes to the Environment - EHS

Changes to the Environment - HS

Individualized Goal Tracking

Lesson Plan - EHS

Lesson Plan - HS

    Education Staff Qualifications:

Education Professional Development Plan

    Family Child Care

Family Child Care Monitor Form

Family Child Care Monthly Monitor Schedule

    Field Trip Forms

Field Trip Authorization Form

Field Trip Special Permission Form

    Home Visit Forms

Home Visit Form

    Month End Forms

Month End Tracking Form

Month End Tracking Form (Excel)

    Staff Observations

Child Observation Evaluation

Classroom Transitions

Coaching Visit Record

Creative Observation

Daily Plan Observation

Diapering Observation

Education-Disabilities Record Keeping Monitor

Formal Observation Form

Health Practices Observation

Home Visit Forms Evaluation

Infant-Toddler Environmental Observation

Language Observation

Observation Cycle

Observation  of Outdoor Activities

Questioning Techniques Observation

Responsive Observation

Running Observation

Safety Observation

Sub Evaluation

Teacher Assistant Observation

Video Response Observation

    Transition Plans

Early Head Start Transition Plan for Parents and Staff

Head Start Transition Survey

 

    FACE SHEETS & PROGRESS NOTES:

Child Care Face Sheet

Disabilities Face Sheet

Education Face Sheet - Head Start

Education Face Sheet - Early Head Start

Enrollment Face Sheet

Health Face Sheet

Mental Health Services Face Sheet

Program Face Sheet

Progress Notes

Social Services Face Sheet

 

    FAMILY & COMMUNITY DEVELOPMENT FORMS:

Document of Refusal

Emergency and Crisis Needs

Emergency and Crisis Needs Spanish

Family Advocate/Family Educator/Program Manager Month End Report

Family Partnership Goal and Score Sheet

Family Partnership Goal and Score Sheet - Spanish

Family Partnership Tracking Form

Multicultural Interview

Multicultural Survey

Multicultural Survey - Spanish

Parent Center Meeting Attendance

Parent Meeting Report

Shoe Souls Referral Form

Social Service Home Visit Contact Tracking Sheet

UMCHS Family Partnership Plan

UMCHS Family Partnership Plan - Spanish

    HEALTH FORMS:

Asthma Management Plan

Asthma Management Plan (Spanish)

Bleach Bottle Labels

Bleach Bottle Labels 500-800ppm

Blood Clean up/First Aid Packs

Certification of Immunization Status

Children On Emergency Protocols

Cleaning Log

Dental Exam Record

Dental Screening Record (EHS)

DHS Release of Information

DHS Release of Information (Spanish)

Developmental History

Emergency Preparedness Plan

First Aid Kit Supplies

Fluoride Varnish Consent Form (English & Spanish)

Fluoride Varnish Info Sheet (English & Spanish)

Fluoride Varnish Privacy Notice

Fluoride Varnish Privacy Notice - Spanish

Health Appraisal Form (English & Spanish)

Health & Dental Vouchers

Health History Record

Health Referral

Health Tracking

Hearing & Vision Screening Announcement Letter to Parents

Hearing Screening Record

Immunization Review Form

Immunization Review Form - Spanish

Incident Report Record

Incident Report Record (Spanish)

Lead Blood Test Form

Lead Screening Form

Medication Administration Record

Medication Administration Record (Spanish)

Medication Log

Monthly Health & Safety Checklist

Prenatal Dental Exam Record

Prenatal Health Appraisal Form (English & Spanish)

Prenatal Health History (English & Spanish)

Seizure Protocol

Seizure Protocol (Spanish)

Severe Allergy and Food Substitution Protocol

Vision Screening Record - Casey Eye Institute

Vision/Hearing Follow-Up

    Sick Child - Parent Letters

Chicken Pox

Chicken Pox - Spanish

Conjunctivitis

Conjunctivitis - Spanish

Fifth Disease

Fifth Disease - Spanish

Giardia

Giardia - Spanish

Hand, Foot & Mouth Disease

Hand, Foot & Mouth Disease - Spanish

Head Lice

Head Lice - Spanish

Herpes Simplex

Herpes Simplex - Spanish

Impetigo

Impetigo - Spanish

Measles

Measles - Spanish

Meningitis

Meningitis - Spanish

Ringworm

Ringworm - Spanish

Rubella

Rubella - Spanish

Salmonella

Salmonella - Spanish

Scabies

Scabies - Spanish

Scarlet Fever

Scarlet Fever - Spanish

Shigella

Shigella - Spanish

Strep Throat

Strep Throat - Spanish

Tuberculosis

Tuberculosis - Spanish

    MENTAL HEALTH FORMS:

Edinburgh Depression Scale

Individualized Prosocial Guidance Plan

Mental Health Classroom Observation Form

Mental Health Monitor

Parental Permission

Parental Permission Spanish

Pre-Referral Checklist

Restraint Incident Report Form

    NUTRITION FORMS:

0-3 Month Feeding Log

4-7 Month Feeding Log

8-11 Month Feeding Log (SAMPLE ONLY)

CACFP Child Enrollment Form

CACFP Child Enrollment Form - Spanish

CACFP Infant Feeding Benefit Notification

CACFP Infant Feeding Benefit Notification - Spanish

Care Plan

Head Start Nutrition Assessment Record

Medical Statement - Participants With Disabilities

Medical Statement - Participants With Disabilities - Spanish

Medical Statement - Participants Without Disabilities

Medical Statement - Participants Without Disabilities - Spanish

Pregnant Woman Nutrition Assessment Record

 

HEALTHY START/HEALTHY FAMILIES

Oregon Healthy Start Forms Manual

Consent Form - Talking Points

Consent to Contact

Consent to Contact - Spanish

Consent to Participate

Consent to Participate - Spanish

Data Tracking

Documentation & Implementation of Learning

Family Assessment Interview Questions

Family Assessment Interview Scores

Family Concerns and Referrals (Intake)

Family Goal Plan Worksheet

Family Goal Plan Worksheet - Spanish

Family Values: What is Important to You?

Family Values: What is Important to You? - Spanish

Family Values Cards

Family Progress Review

Family Rights and Confidentiality Policy

Family Rights and Confidentiality Policy - Spanish

FSW Development Plan

FSW Supervision Binder Organization

General Weekly Supervision

Home Visit Record Option 1

Home Visit Record Option 2

Home Visit Record - Lined Option 1

Home Visit Record - Lined Option 2

Home Visitor Plan - Initial Approach

Home Visitor Supervision Binder Organization

Medicaid Time Tracker

New Baby Questionnaire

New Baby Questionnaire (Spanish)

Prenatal Tracking

Program Goal Plan

Release of Information

Release of Information - Spanish

Score that NBQ Quiz

Screening Process Questionnaire

Service Level Assignment

Special Service Level Assignment

Supervision Log

Wishes for my Child - Version 1

Wishes for my Child - Version 1 - Spanish

Wishes for my Child - Version 2

Wishes for my Child - Version 2 - Spanish

 

INKIND FORMS

Inkind:

Bus Volunteer Sheet

Family Activity Form

Home Visit Sheet

In-Kind

In-Kind Voucher for Space

Parent Mileage - Time In-Kind Sheet

Policy Council Attendees

Volunteer Sheet

 

RECRUITMENT, SELECTION & ENROLLMENT FORMS

Application

Application - Spanish

Authorization for Release of Information

Authorization for Release of Information - Spanish

CACFP Child Enrollment Form

CACFP Child Enrollment Form - Spanish

CACFP Infant Feeding Benefit Notification

CACFP Infant Feeding Benefit Notification - Spanish

Confidential Income Statement

Confidential Income Statement - Spanish

Emergency Notification Bus Policy Form

Emergency Notification Bus Policy Form - Spanish

Full Day Program Copay Procedure

Full Day Program Copay Procedure - Spanish

Head Start Referral Memorandum

Head Start/Early Head Start Recruitment Notes - Family Profile

Head Start/Early Head Start Selection Sheet

Income Eligibility Data Collection Form

Income Guidelines

Income Verification Worksheet

Intent to Re-Enroll

Migrant & Seasonal Application 8-08S

Parent Consent Form

Parent Consent Form Spanish

Parent Letter/Confidential Income Statement

Parent Letter/Confidential Income Statement - Spanish

PIR Information Update

Recruitment Form

Selection Sheet

Status Change Form

UMCHS Parent Compact

UMCHS Parent Compact - Spanish

 

TRANSPORTATION FORMS

Bus Driver Check Ride

Bus Volunteer Sheet

Emergency Exit Drill Checklist

Emergency Notification Bus Policy Form

Emergency Notification Bus Policy Form - Spanish

Evaluation Form

Inspection Checklist

Mileage Sheet

Monitor Check Ride

Monthly Mileage Report

Part 8 Evaluations

Stop Times

Transportation Orientation Checklist

Transportation Orientation Checklist - Spanish

Vehicle Accident Procedures

Vehicle Emergency Procedures

 

Bus Inspection Forms

Bus Inspection Appendix

Bus Inspection A4

Bus Inspection B4

Bus Inspection C4

Bus Inspection D4

Bus Inspection Forward

Bus Inspection Index

Form 581-2255-M

 

Oregon Department of Education Forms

Annual Vehicle Certification Report

Annual Vehicle Inspection

New School Bus Checklist

Request for Approval of Emergency Driver

Requirements - Permit Original Renewal

School Bus Driver Attendance Record

School Bus License Approval

Type 10 Approval Form

Vehicle Accident Report

 

Reports

Mileage Sheet

Monthly Mileage Report

Vehicle Maintenance Sheet

 

USDA FORMS

    General Forms:

CACFP Child Enrollment Form
CACFP Child Enrollment Form - Spanish
Compost Care Plan

Feedback on Monthly Paperwork Form

Food Service Staff Orientation Checklist

Garden Care Plan

Infant Menu Planning Sheets

Meal Reimbursement Report

Menu Planning Sheets

New Staff Orientation

Recipe Crediting Worksheet

Shopping List Form

    Attendance and Meal Counts:

Attendance and Meal Counts

   Monitoring Forms:

5 Day Verification

Addendum to Monitor for Staff Training

Feedback of Monthly Paperwork

Food Service Staff Orientation Checklist

Site Monitoring Report - Nutrition

 

WIC FORMS

Authorization for Release of Information

Breast Pump Distribution Log

     Breast Pump Distribution Agreement

Diet Assessment - Child 1-2

Diet Assessment - Child 2-5

Diet Assessment - Woman

Evaluación de Dieta - Mujer

Evaluación de Dieta - Niño 1 -2

Evaluación de Dieta - Niño 2-5

Nutrition Assessment Record

Prescription (RX) Form

Referral Form - Health Department HCHC

Referral Form - Health Department HCHC - Spanish

   Breastfeeding Peer Counselor Program Forms:

Activity Report Template

Breastfeeding Peer Counselor Consent Form

Breastfeeding Peer Counselor Consent Form - Spanish

   Head Start/Early Head Start Nutrition Assessment Forms:

Nutrition Growth Assessment Tracking Sheet

Nutrition Assessment Monthly Report

Nutrition Assessment Record

   Monitoring:

High Risk Client File Monitor

   Monthly Report Forms:

WIC Month End

 

 

PDM Workplan

Forms

Work Plan

Performance Standards

Head Start

Early Head Start

WIC

CCR&R

Car Seat Program

Literacy

WebAccess Email

Discussion Forum

Center Directory

Staff Directory

Contact Us

UMCHS Employment

 

 

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