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:

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

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

Driver Information

Emergency Contacts Form

Exit Interview Questions

Grievance Form

Growth and Improvement 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

Staff Development Record Form

Staff Coverage Documentation for Centers

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

Child Care Record Keeping Monitor

Disabilities Tracking Sheet

Education & Disability Record Keeping Monitor

Enrollment Monitor

Family Partnership Record Keeping Monitor

File Review Checklist Form

Health Record Keeping Monitor

Outcomes Tracking Worksheet

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

Substitute Time Sheet

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

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 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

Staff Payment Form

Staffing Attendance Record

Toileting Sleeping Feeding Chart

    DISABILITIES FORMS:

Consultant Visit Record

ESD Consultant Sign-In Sheet

Head Start Teacher Input Form

    EDUCATION FORMS:

    Field Trip Forms

    Month End Forms

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

Neighborhood Revitalization Program 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

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

Fluoride Varnish Info Sheet

Fluoride Varnish Info Sheet (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)

Care Plan

Child and Adult Care Food Program Child Enrollment Form

Child and Adult Care Food Program Child Enrollment Form - Spanish

Infant Feeding Benefit Notification

Infant Feeding Benefit Notification (Spanish)

Head Start Nutrition Assessment Record

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 - Professional Experience

Documentation & Implementation of Learning - Self Study

Family Progress Review

Family Rights and Confidentiality Policy

Family Rights and Confidentiality Policy - Spanish

Form Case Plan

FSW Development Plan

FSW Supervision

FSW Supervision Binder Organization

General FSW Supervision

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 Goal Plan

Kempe Family Stress Inventory

Kempe Family Stress Inventory - Lined

Medicaid Time Tracker

Prenatal Tracking

Program Goal Plan

Referral Tracking

Referral Update Tracking

Release of Information

Release of Information - Spanish

Score that NBQ Quiz

Screening Process Questionnaire

Service Level Assignment

Special Service Level Assignment

Supervision Log

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

Add/Drop Form

Application

Application - Spanish

Authorization for Release of Information

Authorization for Release of Information - Spanish

Child and Adult Care Food Program Child Enrollment Form

Child and Adult Care Food Program Child Enrollment Form - Spanish

Confidential Income Statement

Confidential Income Statement - Spanish

Emergency Notification Bus Policy Form

Emergency Notification Bus Policy Form - 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

Letter of Agreement

Letter of Agreement - Spanish

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

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

Self Transport Form

Stop Times

Transportation Orientation Checklist

Transportation Orientation Checklist - Spanish

Vehicle Accident Procedures

Vehicle Emergency Procedures

Bus Inspection A4

USDA FORMS

    General Forms:

Infant Food Chart

Infant Menu Planning Sheets

Meal Reimbursement Report

Menu Planning Sheets

Menu Reimbursement Report

Recipe Crediting Worksheet

Shopping List Form

Toddler Food Chart

    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

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

   Monthly Report Forms:

Clinic Stats

Milton-Freewater Clinic

Pendleton Clinic

Umatilla Clinic

WIC Month End