Forms Directory - KidsCentral

For Staff

Forms Directory

This directory is a collection of all forms currently used by Kids Central, Inc. to document services to children and families as well as management and operation of the Head Start and Early Head Start programs.

Administration Forms

The Administration Forms should be processed through the office of Executive Director, Darrell Edwards.

A-100 – Sign-In Sheet: Used to document attendance at meetings
A-101 – Telephone Log: Used to document calls made and received by agency sites
A-102 – Staff Agreement: Used to document agreement between KCI and staff regarding hours and payment
A-103 – Personal Time Off Request: Used to request personal time off
A-104 – Volunteer Time Sheet: Used to document hourly volunteer activity for in-kind
A-105 – Group Activity Time Sheet: Used to document volunteer in-kind for group activities
A-106 – Statement of In-Kind Contribution: Used to document in-kind donations
A-107 – Purchase Requisition: Used to request goods or services for program operation
A-108 – Travel Advance Request: Used to request advance for travel expenses
A-109 – Expense Reimbursement: Used to request reimbursement for out-of-pocket expenses
A-111 – Hourly Wage Timesheet: Used to document time worked for hourly wage employees
A-112 – Salary Exempt Timesheet: Used to document work time for salary exempt employees
A-113 – Payroll Deduction Authorization: Used to allow KCI staff to withdraw funds from payroll for authorized reasons
A-114 – Reimbursement for local travel: Used to document local travel and submit requisition for reimbursement
A-115 – Benefits Pay Agreement: Used to document agreement between employee and KCI to repay benefits paid by the agency during authorized leave
A-116 – Report of Tuberculosis Screening: Used to document results of Tuberculosis Screening as required by Virginia Licensing Standards
A-117 – Sworn Statement of Affirmation: Used to document disclosure of information required for pre-employment by Virginia Licensing Standards
A-118 – Staff Grievance Form: Used to document grievances relating to personnel matters
A-119 – Personnel Action Form: Used to document resignation or termination of employment
A-120 – Progressive Counseling Form: Used to address personnel matters intended to improve employee performance
A-121 – Family Medical Leave Request: Used to notify staff of status of request for FMLA leave
A-122 – Return to Work Certification: Used to obtain certification for a medical provider that employee may return to work
A-123 – Staff Orientation Period: Used to document 30-60-90 day evaluations during orientation period
A-124 – Classroom Checklist: Classroom, Facilities, Grounds, and Bus Checklist
A-125 – Disciplinary Action Form: Used to document employee actions requiring disciplinary action
A-126 – Employee Termination Checklist: Used to verify that property belonging to KCI is returned in the event of employee termination
A-127 – Exit Interview: Used to conduct exit interview with employees leaving employment at KCI
A-128 – Employee Accident Form: Used to report accidents on the job
A-129 – Employee Physical Form: Not for Bus Drivers
A-130 – 30 Day Evaluation: Used to document 30 day evaluations during orientation period
A-131 – 90 Day Evaluation: Used to document 90 day evaluations during orientation period
A-132 – 180 Day Evaluation: Used to document 180 day evaluations during orientation period
A-133 – Performance Evaluation & Professional Development Plan: Used to highlight HS regs and guidelines and to identify key performance indicators for professional growth and development.
A-134 – Personal Time Off Transfer Request: Used to donate PTO to another eligible employee in times of extreme illness.

Disabilities Forms

The Disabilities Forms should be processed through the office of Disabilities Coordinator, Terry Gentry.

D-323 – Consent to Exchange Information: Used to allow agencies to exchange certain information to help coordinate services
D-501 – Disabilities Observation Request: Used to request observations of children with suspected disabilities
D-505 – IEP/IfSP Activities Record: Refer to Disabilities Coordinator for use of this form
D-506 – Permission for referral to Special Education Services: Refer to Disabilities Coordinator for use of this form
D-507 – Out of system referral: Refer to Disabilities Coordinator for use of this form
D-508 – Referral to early intervention: Refer to Disabilities Coordinator for use of this form
D-509 – Sign-In/Out Sheet: IEP/IFSP Provider Sign-In/Out Sheet

Education Forms

E-400 – Home Visits and Parent Conference: Used to document Home Visits and Parent Conference
E-401 – Attendance Tracking: Used to track child’s attendance
E-402 – Monthly Attendance Monitoring: Used to track child’s monthly attendance
E-403 – Daily Lesson Plan EHS: Used to document daily lesson plan
E-404 – Daily Lesson Plan: Used to document daily lesson plan
E-405 – Safe Environments: Form used for safety checklist that must be completed each month and sent to education supervisor by the 5th day of the month.
E-406 – Antecedents Behaviors Consequences: Used to document specific behaviors in children
E-407 – Field Trip Permission: Used to document permission given by parents for children to participate in field trips
E-408 – Field Trip Request: Used to request permission for field trip
E-409 – Gone on a Field Trip: Used to post notification that a center/class has gone on a field trip
E-412 – Cooking Experience: Used to document cooking experience
E-413 – Good News Gazette: Used to inform parents of child activities and progress in Head Start
E-414 – Infant Daily Report: Used to document activities of infants in Early Head Start
E-415 – Lending Library: Used to document resources loaned from classrooms
E-416 – Smoke Detector Checklist: Used to document testing of smoke detector and other emergency equipment
E-417 – Emergency Drills: Used to document fire drills
E-419 – Classroon/Home Visit Observation: Used in monitoring system to document center based and home based observations
E-420 – Teacher Contact Note: Used by center staff to document routine family contacts
E-421 – Center Sign-In Sheet: Used as a sign-in sheet for classroom visitors
E-422 – Home Visit Report: Used to document home visits
E-423 – Home Base Socialization Plan: Used to document plan for home base socialization
E-424 – Home Base Visitation Schedule: Used to document weekly schedule for Home Base Visitation
E-425 – Home Base Field Trip Plan: Used to document plan for Home Base Field Trip Socialization
E-427a – EHS, Infants Transition Plan: Used to document planned transition activities for EHS, Infants
E-427b – EHS, Toddlers Transition Plan: Used to document planned transition activities for EHS, Toddlers
E-427c – HS, 3-4 year old Transition Plan: Used to document planned transition activities for HS, 3-4 year olds
E-427d – HS, 4-5 year old Transition Plan: Used to document planned transition activities for HS, 4-5 year olds
E-428 – Missing Information Form: Used to notify parents of information missing in child’s files
E-429 – Infant Feeding Form: Used to document feeding plans for infants enrolled in EHS
E-430 – Home Base Withdrawal Letter: used to notify parents of intent to withdraw them when unable to make required visits
E-431 – Central Store Order Form: Used to submit orders for supplies needed for classroom operation
E-432 – Classroom Closing Checklist: Used to document activities required to close classroom at the end of the school year
E-433 – Classroom Observation Checklist: Used to document finding during classroom observations
E-434 – EHS Home Base Forms Checklist: Used as a checklist for Early Home Base Head Start Files
E-435 – Early Head Start Forms Checklist: Used as a checklist for Early Head Start Files
E-436 – Home Base Head Start Forms Checklist: Used as a checklist for Home Base Head Start Files
E-437 – Head Start Forms Checklist: Used as a checklist for Head Start Files
E-438 – Home Base EHS – Pregnant Mothers: Used as a checklist for Early Head Start Home Base Pregnant Mother Files
E-439 – Service Tracking Form: Used to track services received by Head Start Families
E-440 – Home Base EHS Home Visit Tracking Form: Used to track home visits for Home Base Early Head Start
E-441 – Home Base Head Start Home Visit Tracking form: Used to track Home Visits for Home Base Head Start
E-443 – EHS Individualized Development Plan: Used to state and track an Individualized Development Plan for a child in the Early Head Start Program
E-444 – Parent and Home Visitor Agreement: Used to outline responsibilities of the Parent and the Home Visitor when home-based services are received.
E-445 – Enrollment Checklist: Used to help teachers make sure they have all the information needed to start a child in their class
E-446 – Home Base Directions to Home Visits: Used to directions to a child’s home from offices
E-448 – HighScope Enrollment Changes: Used to document enrollment changes from HighScope
E-453 – Staffing Report: Used to document staffing Report
E-454 – Staffing Referral: Used to follow up on staffing
E-455 – Family Experiences Classroom Checklist: Family Experiences Classroom Checklist
E-456 – Guidelines for Classroom Space: Guidelines and Strategies for arranging and equipping classroom space
E-457 – Daily Classroom Checklist: Used to document daily tasks for centers
E-458 – Playground Checklist: Used to check playground for safety issues
E-460 – At Home Activities: Used to document at home activities and in-kind contribution
E-463 – Lesson Plan Submission Form: Used by teachers to submit lesson plans
E-464 – Schedule Change Request: Fillable form to request a schedule change request
E-465 – Teaching Practice Needs Assessment: Used to assess teaching practices for PBC
E-466 – PBC Action Plan: Used to document PBC coaching goal
E-467 – PBC Coach Observation Form: Used to document coaching observation visits
E-468 – PBC Teaching Aspects: Used during PBC goal setting
E-469 – PBC Learning Domains: Used during PBC goal setting
E-470 – PBC Partnership Agreement: Used to document partnership agreement during PBC
E-477 – Service Tracking: Used to track service and referrals for pregnant women
E-480 – One Call Now Parent Sign-up Request: Used to sign up families for the One Call Now service
E-481 – Attendance Transition: Used to document the count of children during transition

Family & Community Partnership Forms

FCP-600 – Head Start Application: Used to apply for Head Start or Early Head Start
FCP-601 – Employment Verification Form: Verification Form for Full-Day, Full-Year Program Option
FCP-602 – Absentee Follow-Up: Used to document follow-p to three and four-day absentees
FCP-603 – Attendance Follow-Up: Used to follow up on center monthly attendance that falls below 85%
FCP-604 – Income Declaration Form: Used to declare income when applicants can’t provide documentation or when family claims 0 income
FCP-606 – Reporting Suspected Child Abuse: Used to document report of suspected child abuse
FCP-607 – KCI Re-Enrollment Application: Used to update the original Head Start Application
FCP-608 – Income from Public Assistance: Used to document income received from public assistance (TANF, SSI)
FCP-609 – Family Contact Note: Used to document contact with families
FCP-612 – Change of Status: Used to document changes in child’s development status
FCP-615 – Family Development Strengths: Used to assess family strengths and needs
FCP-616 – Application Request: Used to request an appointment to complete an application for services.
FCP-617 – Activity Services Form: Used to document services directed to family
FCP-618 – Family Goals & Services Plan Worksheet (fillable form): Used to plan goals and results for family services
FCP-619 – Pregnant Women Family Strengths Form: Used to assess family strengths and needs
FCP-620 -Schedule Change Request Form: Used to request a change in schedule

Health Forms

H-300 – Authorization to give medication: Form authorizing Kids Central Inc. to administer medications according to agency policy
H-301 – Daily Medication Log: Used to record medications administered by Kids Central Inc. staff
H-302 – Special Care Plan for Children with Asthma: Used to document child’s medical history relating to asthma and instruction for using specific asthma medications
H-303 – Child Incident Report: Used to document child incidents/accidents
H-304 – Child Incident Report Log: Used to document child incidents/accidents occurring in a specific center/location
H-305 – Sun Block Authorization: Used to authorize the application of sun block
H-306 – Daily Health Observation: Used to record daily observation of child health conditions
H-306a – Child Health Summary: Used to document details about daily health observations.
H-307 – Well Baby Check-Up: Used to document well baby check-up by physicians
H-308 – Medical/Dental Referral: Used to document referrals made for medical and dental follow up
H-309 – Newborn Welcome Visit: Used to document Newborn Visits
H-311 – Consents and Permissions: Used to document consent for health screenings, releases, and emergency medical information
H-312 – Seizure Care Plan: Used to document a seizure care plan for a child
H-314 – Health Services Screening Results: Used to document health screening
H-315 – Vision Observation: Form used to screen children 0-11 months.
H-317 – Dental Reminder Notice: Used to inform parents of dental services provided to children
H-319 – Lead Screening Questionaire: Used to assess potential at-risk conditions for lead
H-323 – Consent to Exchange Information: Used to exchange information with other agencies
H-324 – Oral Health: Used to document oral health care and treatment
H-325 – Allergy Action Plan: Used to document plan of action in the event of an allergic reaction
H-326 – Medical/Dental Payment Requisition: Used to request payment for non-insured medical or dental sercices
H-328 – Child Nutrition Assessment: Used to record child’s dietary habits
H-329 – Immunization Letter: Used to notify parents/guardians that children past due immunizations
H-331 – Health History: Used to document child’s health history
H-332 – Exposure Notice: Used to notify parents/guardians that children may have been exposed to a communicable disease
H-335 – Prenatal Birth History: Used to document prenatal history (EHS Only)
H-336 – Pregnancy Outcome Tracking: Used to document results/outcome of pregnancy (EHS Only)
H-337 – Pregnancy History and Tracking: Used to document pregnancy history (EHS Only)
H-338 – Dietary Action Plan: Used to document child’s dietary action plan
H-339 – Health and Vision Screening Report: Used to notify parents of results of full screenings for hearing and vision.
H-340 – Notice of Health and Vision Screening: Used to notify parents of results of initial screenings for hearing and vision.

Nutrition Forms

N-202 – Field Trip Lunch: Form submitted to choose a menu for a field trip lunch
N-203 – Socialization Meals Count Report: Form submitted with meals and attendance report
N-204 – Production Worksheet: Form used to document meals production
N-205 – Supply requisition Form: Requisition for food and non-food supplies
N-206 – Central Store Food Division Order Form: Requisition for food
N-207 – End of the Month Inventory Form: Form used to inventory food located in the center at the end of each month.
N-208 – USDA Child Enrollment Form: Used to document USDA requirements
N-209 – Fire Suppression and Hood Cleaning Checklist: Form should be posted in the kitchen and used to track cleanings.

Transportation Forms

The Transportation Forms should be processed through the office of Executive Director, Darrell Edwards.

T-700 – Vehicle Condition Report: Used to document result of daily pre-trip inspection on buses
T-701 – Vehicle Mileage Log: Used to record mileage on agency vehicles.
T-702 – School Bus Schedule: Used to document distance and time relating to bus routes
T-703 – Driver’s Log: Used to document pre-trip inspections on agency vehicles
T-704 – Monthly Gas Log: Used to document consumption of gas/diesel fuel
T-705 – Work Order/Maintenance Request: Used to request repairs and maintenance
T-706 – Inventory Master Form: Used to inventory centers or location
T-707 – Inventory Instructions: Used to provide instructions on inventory
T-708 – Surplus Deletion Form: Used to inventory surplus items
T-709 – Inventory Addition Form: Used to add items to inventory
T-710 – Lesson Plans on the Bus: Used to document lessons on the bus
T-711 – Bus Monitor Orientation: Used to document Bus Monitor training
T-712 – Transporting Children: Used to document pick-up and delivery of children on the bus

Staff Resources

General documents, health policies, KCI policy and procedures and Written Plans are on the staff documents page. Forms can be found in the forms directory.

Program Calendars

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Part Year

Staff Email Accounts