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:

FISCAL:

Administrative Cost Report

Check Request

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

HUMAN RESOURCES:

Application for Employment

Doctors Report - Work Release Form

Driver Information

Emergency Contacts Form

Grievance Form

Growth and Improvement Form

Employee Morale, Health and Wellness Activity Plan

Leave of Absence

Motor Vehicle Report Authorization

Plan of Assistance

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 NEWLY REVISED

     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

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

Education & Disabilities Monitor

Family Partnership Health Monitor

FCC Center File Monitoring Tool

Full Day Center File Monitoring Tool

Part Day Center File Monitoring Tool

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:

Comment and Complaint Form - Spanish

Complaint Form

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

    Wellness

     Physical Activity Log

CCR&R FORMS

Child Care Summary of Services

Parent Provider Month End Report

Phone 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

In-Kind

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 Log

Attendance 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 2007-2008

DHS Enhanced Contract Families Worksheet

DHS Enhanced Contract Families Worksheet - Spanish

Enrollment Child Care Billing Worksheet

Payment Record for Co-pays

Staff Payment Form 2007-2008

Toileting Sleeping Feeding Chart

    DISABILITIES FORMS:

Consultant Visit Record

ESD Consultant Sign-In Sheet

Head Start Teacher Input Form

Pre-Referral Checklist

    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 Program Monitoring

Education-Disabilities Record Keeping Monitor

Health Practices Observation

Home Visit Forms Evaluation

Home Visit Observation Instrument

Home Visit Topics

Infant-Toddler Environmental Observation

Language Observation

Observation Cycle

Observation of the Environment

Questioning Techniques Observation

Responsive Observation

Running Observation

Safety Observation

Sub Evaluation

Teacher Assistant Observation

Video Response Observation

    Staff Observations

Early Head Start Transition Plan for Parents and Staff

    FACE SHEETS & PROGRESS NOTES:

Child Care Face Sheet

Child Care Face Sheet (2)

Disabilities Face Sheet

Education Face Sheet

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 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

    HEALTH FORMS:

Asthma Management Plan

Asthma Management Plan (Spanish)

Bleach Bottle Labels

Blood Clean up/First Aid Packs

Cleaning Log

Dental Exam Record

Dental Screening Record (EHS)

Developmental History

Emergency Preparedness Plan

First Aid Kit Supplies

Health Appraisal Form (English & Spanish)

Health & Dental Vouchers

Health History Record

Health Referral

Hearing & Vision Screening Announcement Letter to Parents

Hearing Screening Record

Immunization Review Form

Immunization Review Form - Spanish

Incident Report Record

Incident Report Record (Spanish)

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

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:

Individualized Prosocial Guidance Plan

Mental Health Classroom Observation Form

Mental Health Monitor

Parental Permission

Parental Permission Spanish

Restraint Incident Report Form

    NUTRITION FORMS:

0-3 Month Feeding Log

4-7 Month Feeding Log

8-11 Month Feeding Log (SAMPLE ONLY)

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

INKIND FORMS

Inkind:

Bus Volunteer Sheet

Family Activity Form

Home Visit Sheet

In-Kind

Parent Mileage - Time In-Kind Sheet

Policy Council Attendees

Volunteer Sheet

RECRUITMENT, SELECTION & ENROLLMENT FORMS

2006-07 Selection Sheet

2007-2008 Confidential Income Statement

2007-2008 Confidential Income Statement - Spanish

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

Emergency Notification Bus Policy Form

Emergency Notification Bus Policy Form - Spanish

Head Start/Early Head Start Application

Head Start/Early Head Start Application - Spanish

Head Start Referral Memorandum

Head Start/Early Head Start Recruitment Notes - Family Profile

Head Start/Early Head Start Selection Sheet

Letter of Agreement

Letter of Agreement - Spanish

Letter to Parent/Guardian

Letter to Parent/Guardian - Spanish

Parent Consent Form

Parent Consent Form Spanish

PIR Information Update

Recruitment Form

Status Change Form

TRANSPORTATION FORMS

Bus Volunteer Sheet

Emergency Exit Drill Checklist

Emergency Notification Bus Policy Form

Emergency Notification Bus Policy Form - Spanish

Evaluation Form

Inspection Checklist

Mileage Sheet

Monthly Mileage Report

Part 8 Evaluations

Stop Times

Vehicle Accident Procedures

Vehicle Emergency Procedures

Bus Inspection A4

USDA FORMS

    General Forms:

Infant Menu Planning Sheets

Meal Reimbursement Report

Menu Planning Sheets

Menu Reimbursement Report

Nutrition Site Monitoring Report

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

WIC FORMS

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:

Client Contact Call Schedule Form

Client Contact Log

Peer Counseling Weekly Activity Report

UMCHS Co-Enrollment

UMCHS Co-Enrollment - 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

Last Updated: 01/08/08