Name

Program Name

Mailing Address

Phone Number

Email Address

1. Please indicate the total number of children you have enrolled by age group:

             Infant/Toddler     Preschool     Kindergarten    School Age

2. Please indicate the total number of preschool classrooms you have at your site:

3. Please indicate the total number of childcare staff you have, by certification/role:

    Director I/Director II 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20     Lead Teacher 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20     Teacher 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20    Aide/Paraprofessional 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20    Other 0 1 2 3 4 5 6 7 8 9 10

4. Is your program available for care full year?  Yes No

5. Are you approved to accept any of the following types of childcare financial assistance funding (check all that apply):

                   Community Partnership Subsidies   Income Eligible Vouchers    Income Eligible Contracted Slots     DSS/DTA Contracted Slots

6. Please indicate, the number of staff that have the following.  (Please only count each staff person once):   

   DEGREE/CERTIFICATION	Total Number of Staff
   High School Diploma/GED
   Center Based CDA
   Associates Degree
   Bachelors Degree
   Masters degree
   Other

7. Do you currently utilize any of the following assessment tools in your program?  NO High/Scope Child Observation Record (COR) The Work Sampling System (WSS) Ages and Stages Questionnaire (ASQ) Creative Curriculum Developmental Continuum for Ages 3-5 Other

           If you chose Other in # 6, please provide us with the name of the assessment tool you use:

8. Are you/have you been involved with the UPK Grant through EEC?  No Currently Receiving Funding In Process of Applying Received Funding in the Past                                                           

9. Would you or your staff be interested in accessing career counseling services?  Yes No

10. Any additional comments, suggestions, ideas?