Western Idaho Community Action Partnership, Inc.

Staff Resources

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ERSEA
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Forms & Letterhead
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Head Start Policies
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IT/Technical Support
Operational Procedures
Policy Council
Printer and Fax Supplies
Reporting Sites
Service Plans
Transportation Calendar

 

FORMS & LETTERHEAD

R 16 - Online Attendance/Transition Report COPA Application
WICAP Letterhead - your e-mail logon & password are required to open this link WICAP Sales Tax Exemption Form Request NCR Forms
Ages & Stages Questionnaire

Ages & Stages Questionnaire

Social / Emotional

Ages & Stages Questionnaire

Scoring Sheet

Community Partnerships

(HS 1200 - HS 1299)

Education

(HS 100 - HS 199)

ERSEA

(HS 200 - HS 299)

Facilities

(HS 700 - HS 799)

Family Services

(HS 1000 - HS 1099)

Health

(HS 300 - HS 399)

HS Admin

(HS 500 - HS 599)

Mental Health & Disabilities

(HS 800 - HS 899)

Monitoring

(M 01 - M 99)

Nutrition

(HS 400 - HS 499)

Reports

(R 01 - R 99)

Training

(HS 900 - HS 999)

Transportation

(HS 01 - HS 99)

WICAP Admin

(W 1 - W  99) 		Brochure Request Form

Ages & Stages Questionnaire
ASQ 4 mo ASQ 14 mo ASQ 2 yr ASQ 5 yr
ASQ 6 mo ASQ 16 mo ASQ 27 mo ASQ 42 mo
ASQ 8 mo ASQ 18 mo ASQ 30 mo ASQ 4 yr
ASQ 10 mo ASQ 20 mo ASQ 33 mo ASQ 54 mo
ASQ 1 yr ASQ 22 mo ASQ 3 yr ASQ Scoring Sheet

Ages & Stages Questionnaire - Social/Emotional
ASQ:SE 6 mo ASQ:SE 18 mo ASQ:SE 30 mo ASQ:SE 4 yr
ASQ:SE 1 yr ASQ:SE 2 yr ASQ:SE 3 yr ASQ:SE 5 yr
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Community Partnership Forms
=NCR Form
Form Number Description
HS 1200 Intake Application P-5 Yrs
HS 1201 Community Partnerships P-5 Yrs
HS 1202 Home Base Transition Plan P-3 Yrs
HS 1202(a) Transition Into Combination Plan P-3 Yrs
HS 1203 Combination Transition Plan P-3 Yrs
HS 1203(a) Transition Into Center Based Plan P-3 Yrs
HS 1204 Transition In Plan P-5 Yrs
HS 1205 Head Start Passport: Transition Through and/or Out of Head Start P-5 Yrs
HS 1206 Shared Families Transition P-5 Yrs
HS 1207 Child/Family Individual Staffing Plan P-5 Yrs
HS 1208 RIF Book Order Form P-5 Yrs
HS 1209 RIF Single Site Distribution Report P-5 Yrs
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Education Forms
=NCR Form
Form Number Description
HS 100 Weekly Lesson Plan 3-5 Years
HS 100(a) Class Planner P-5 Years
HS 101 Weekly Combination Lesson Plan P-3 Years
HS 102 Monthly Classroom Calendar P-5 Years
HS 103 Individual Children’s Observations P-5 Years
HS 104 Classroom Outcomes Planning P-5 Years
HS 105 Class Summary Worksheet 3-5 Years
HS 106 Small Group 3-5 Yrs
HS 107 Socialization Form P- 5 Yrs
HS 108 Education Home Visit & Parent-Teacher Conference Form 3-5 Years
HS 110 Required Assessment Entries Form: 0-18 Months
HS 112 Required Assessment Entries 18-36 Months 
HS 113 Required Assessment Entries 3-5 Years Log
HS 114 Field Trip Request Form P-5 Years
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ERSEA Forms
=NCR Form
Form Number Description
Child Intake Form - Found on COPA 
Family Intake Form - Found on COPA
HS 200(a) Enrollment Screening Instrument P-5 Years
HS 200(b) Application Eligibility Verification P-5 Years
HS 201 Application Checklist P-5 Years
HS 201 (sp) Application Checklist P-5 Years Spanish
HS 202 Classroom Roster P-5 Years
HS 203 Enrolled 3 Year Old Returning List 3-5 Years

HS 204

Google

 Annual Recruitment Plan P-5 Years
HS 205 Recruitment of Children with Diagnosed or Suspected Disabilities P-5 Years
Website Recruitment Flyers (English & Spanish Combined)
Website Public Service Announcements (PSA)
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Facilities Forms
=NCR Form
Form Number Description
HS 700 Custodial and Paper Supply Order Form P-5 Years
HS 701 Facilities Technician Staff Daily Duties P-5 Years
HS 702 Lawn Equipment Maintenance Checklist P-5 Years
HS 703 Disaster Action Drill Checklist P-5 Yrs
HS 704 Receipt of Agency Keys P-5 Yrs
HS 705 Checklist for Closing Sites P-5 Yrs
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Family Services Forms
=NCR Form
Form Number Description
HS 1000 Prenatal Home Visit Form P-3 Years
HS 1001 Combination Home Visit Form P-3 Years
HS 1002 Home Base Home Visit Form P-5 Years
HS 1003 Door Hanger “Sorry We Missed You”   P-5 Years  View Document
HS 1004 Center Base Home Visit/Parent Contact Guide P-5 Years 
HS 1005 Permission Slip P-5 Years
HS 1006 Circle of Support – Family Partnership Plan P-5 Years (Optional)
HS 1006(sp) Circle of Support – Family Partnership Plan P-5 Years - Spanish - GUIDE
HS 1007 Shared Families Documentation P-5 Years
HS 1008 Parent Volunteer Application and Family Activity Survey P-5 Years 
HS 1009 Child/Family Form Tracking System P-5 Years
HS 1009(a) Child/Family Form Tracking System - Family Services P-5 Years
HS 1009(b) Child/Family Form Tracking System - Children Services P-5 Years
HS 1009(c) Child/Family Form Tracking System - Health/Nutrition Services P-5 Years
HS 1010 Election Ballot P-5 Years
HS 1011 Parent Elections P-5 Years
HS 1013 Parent Meeting/
Family Activity Planning P- 5 Yrs
HS 1014 Request for Transportation (E & S) P-5 Years
HS 1015 Parent Meeting Agenda P-5 Years 
HS 1016 Parent Meeting Minutes P-5 Years
HS 1017 My Pregnancy Memory Book
HS 1017(Sp) My Pregnancy Memory Book - Spanish
COPA Family Home Visit Form
COPA Family Assessment
COPA Family Referrals & Services
COPA Family Partnership Plan
COPA Child Emergency Information
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Health Forms
=NCR Form
Form Number Description
COPA Emergency Record P-5 Years
HS 301 Authorization to Release/Share Information and/or Records P-5 Years
HS 302  Individual Child Health Plan P-5 Years
HS 302(a) Individual Child Dental Plan P-5 Years
HS 303 Administering Medication and Medical Procedures Consent Form P-5 Years
HS 303 (a) Medication Dispensing Sheet P-5 Years
HS 304 Dental Screening P-3 Years
HS 305 Daily Health Check P-5 Years
HS 306 Program Child Referral P-5 Years View Document
HS-306(a) Referral for Special Services P-5 Years View Document
HS 307 Child Health History P-5 Years 
HS 308 Insurance Documentation P-5 Years
HS 309 Individual Hearing Screener (Pilot) 3-5 Years
HS 310 Denial of Consent for Dental and/or Physical Exam P-5 Years
HS 311 Hearing Screening Tracking Class (Pilot) 3-5 Years
HS 312 Vision Screening Tracking 3-5 Years
HS 313 2-Week Mother’s Well Being Assessment P-5 Years
HS 314 Checklist for Center First Aid Kit P-5 Years
HS 314(a) Checklist for Backpack First Aid Kit P-5 Years
HS 314(b) Checklist for Bus/Vehicle First Aid Kit P-5 Years
HS 315 Heights and Weights Screening Form Class 3-5 Years
HS 316 Prenatal Assessment Form P-3 Years
HS 317 Initial Summary Form – Screening for Vision/Hearing Concerns P-3 Years
HS 317(a) Parent Interview – Vision and Hearing Concerns P-3 Years
HS 317(b) Medical/Family History Review – Vision and Hearing Concerns P-3 Years
HS 317(c) Observations That May Indicate Visual Impairment or Hearing Loss in Young Children P-3 Years
HS 318 Diapering Schedule P-5 Years
HS 319 Health Action Plan P-5 Years
HS 320 Infant Health Assessment - 2 Week Visit P-3 Years
HS 321 Individual Vision Screening 3-5 Years
HS 322 Certificate of Exemption, School Immunization Requirement P-5 Years
HS 323 Health Status Determination P-5 Years
HS 324 Oral Health Status Determination P-5 Years 
HS 325 Health and Nutrition Summary P-5 Years
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Head Start Administration Forms
=NCR Form
Form Number Description
HS 500 Petty Cash Ledger P-5 Yrs
HS 501 Office Supply Order Form P-5 Years
HS 502 Parent Survey P-5 Years
HS 502(Sp) Parent Evaluation of WICAP Head Start P-5 Years - Spanish
HS 503 Staff Program Survey P-5 Years
HS 504 Community Survey P-5 Years
HS 505 Employee of the Month Application P-5 Years
HS 506 Reimbursement Request for Child Care Expenses Incurred By Parents/Guardians Off Site P-5 Years
HS 507 Policy Council Profile P-5 Years
HS 508 Team Meeting Agenda P-5 Years
HS 509 Management Team Meeting Agenda P-5 Years
HS 511 Individualized Goal and Volunteer Record P-5 Years  Flow Chart
HS 512 Request for Dollars P-5 Years
HS 513 Consultant Questionnaire P-5 Years
HS 514 Staff Schedule P-5 Years
HS 515 Sign In/Sign Out Record P-5 Years
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Mental Health/Disabilities Forms 
=NCR Form
Form Number Description
HS 800 Special Services P-5 Years View Document
HS 801 Developmental and Mental Health Screener P-6 Months
HS 802 Developmental and Mental Health Screening Results P-5 Years (Bilingual) View Document
HS 802(a) Guidance for Explaining Screening Results P-5 Years
HS 803 Articulation Screener 3-5 Years
HS 804 Comprehensive Social/Emotional Screening Form 3-5 Years
HS 806 Temperament Screener P-5 Years
HS 807 Special Services Contact Record P-5 Years
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Monitoring
=NCR Form
Form Number Description
M 01 Monitoring Documentation P-5 Years
M 02 Pre-Approval Visit Form
M 04 Transportation Bus Driver Monitoring Record P-5 Years
M 05 Teacher-Monitor Monitoring Record P-5 Years
M 06 Custodial Monitoring Record P-5 Years
M 08 Home Visit Monitoring Observation Form P-5 Yrs
M 10 Parent Meeting/Activity Monitoring/Observation Form P-5 Yrs
M 11 Safe Environment Inspection P-5 Years
M 13 Referral Monitoring Form P-5 Years
M 14 Sponsoring Organization Review Form P-5 Yrs
M 15 Checklist for EHS Classrooms P-3 Yrs
M 16 Checklist for Preschool Classrooms 3-5 Years
M 17 Guiding Behaviors Checklist for EHS and Preschool Classrooms P-5 Years
M 18 Guiding Behaviors, Part 2-EHS & Preschool P-5 Yrs
M 19 Safe Environment Inspection, Annual P-5 Years
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Nutrition Forms
=NCR Form
Form Number Description
HS 400 Temperature Inspection Record P-5 Years
HS 401 Menu Substitution P-5 Years
HS 401(a) Cook's/Center's Choice/Emergency Menu P-5 Years
HS 403 Blended Rate Meal Count Sheet P-5 Years
HS 404 CACFP Production Record P-5 Years
HS 409 Nutrition Experience P-5 Years
HS 410 Food Inventory P-5 Years
HS 412 Special Diet Statement for Infants
HS 413 Medical Statement for Food Substitutions P-5 Years
HS 414 Nutrition Assessment Prenatal P-3 Years
HS 415 Nutrition Assessment:  Postpartum P-3 Years
HS 416 Parent's Observation of Eating Habits P-18 Months
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Reports
=NCR Form
Form Number Description
R 02 Children Services Field Advisor Monthly Report P-5 Years
R 03 Family Service Field Advisor Month End Report P-5 Yrs
R 04 Policy Council Report From Parent Committee P-5 Years
R 05 Parent Committee Report from Policy Council P-5 Years
R 06 Teacher's Monthly Report P-5 Years
R 07 PIR/Family Advocate Tracking P-5 Years
R 08 Family Advocate Monthly Report 3-5 Years
R 09 Home Base/Combination Monthly Report P-5 Years

R 10

Transportation Field Advisor Monthly Report P-5 Yrs
R 11 Bus Driver's Monthly Report P-5 Yrs
R 12 60 Day Inspection Report P-5 Years
R 13 Bus Driver's Report on School Bus Passing Violation P-5 Yrs
R 14 Vehicle Accident Report P-5 Yrs
R 15 Cooks Nutrition Monthly Report P-5 Years
R 16 Attendance/Transition Report P-5 Years
R 17 Volunteer/Children’s Injury/Accident Report P-5 Years
R 18 Sick Child Report P-5 Years
R 19 Facilities Field Advisor Month End Report P-5 Years
R 20 Suspected Child Abuse/Neglect Report P-5 Years View Document
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Training Forms
=NCR Form
Form Number Description
HS 901 Training Procedure Flow Chart P-5 Years
HS 903 Application for Training P-5 Years
HS 904 Approval/Disapproval of Training Application P-5 Years
HS 905 Professional Development, Credentials/Degrees P-5 Years
HS 906 Credentials and Degree Completion Plan P-5 Years
HS 909 Bus Driver Training P-5 Years
HS 910 Teacher Monitor Training P-5 Years
HS 911 Training Attendance Log P-5 Years
HS 912 Training Evaluation P-5 Years
HS 912(sp) Training Evaluation P-5 Years - Spanish
HS 912(a) Individual Presentation Workshop Evaluation P-5 Years
HS 913 Site Parent Training Plan P-5 Years
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Transportation Forms
=NCR Form
Form Number Description
HS 01 Daily Pre and Post Trip Maintenance Checklist P-5 Years
HS 02 Bus Attendance P-5 Years
HS 03 Bus Driver Roster List P-5 Years
HS 04 Weekly Bus Activity Record 3-5 Yrs
HS 06 Vehicle Log P-5 Years
HS 07 Bus Check-Out List P-5 Years
HS 08 School Bus Withdrawal From/Return to Service P-5 Years
HS 10 Daily Monitoring of the Bus P-5 Years
HS 11 Self Transport 3-5 Years
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WICAP Administration Forms
=NCR Form
Form Number Description
W 01 Time & Activity Record -  HMS, YC, HS
W 01(a) Time & Activity Record - Indirect, CSBG, HSG, TEFAP, EA
W 02 Travel Expense Statement - Mileage (auto-calculating spreadsheet, can be printed for Hand Completion)
W 03 Long Distance Telephone Record
W 04 IRS form W 4
W 06 Direct Deposit Request
W 09 Office Supply Order Form
W 10 Inventory Check Out
W 11 Donated Inventory Items
W 13 Inventory Transfer/Disposal Form
W 15 Statement of Contribution
W 16 Hold Harmless Agreement
W 17 Volunteer Record
W 18 In-Kind Contribution Report
W 23(a) Change of Address
W 24 Checklist for Termination of Employee
W 25 Insurance Election/Waiver 
W 26 Vehicle Insurance Form (Used in Admin Office Only)
W 27 Request for Travel
W 28 Travel Back Voucher
W 30 Petty Cash Voucher
W 31 Incoming Mail Log 
W 32 Vehicle Usage Sheet
W 35 Cellular Phone Policy/Procedure
W 36 Cellular Phone Agreement
W 38 Application for Volunteers
W 39 Respectful Workplace & Confidentiality Policy - Interns/Volunteers
W 40 Performance Correction Notice
W 63 Fax Cover Sheet
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