2011HS Wrk Prgm Interactive

Report as inappropriate Your report has been received

Shared by: TY0vGRq

Tags

Stats

views:: 0
posted:: 6/28/2012
language:
pages:: 33

Public Domain

Document Sample

CHICAGO DEPARTMENT OF FAMILY & SUPPORT SERVICES
HEAD START / EARLY HEAD START / COLLABORATION
FY ’11 WORK PROGRAM & RELATED SUBMISSION INSTRUCTIONS

Enclosed are the Department of Family & Support Services (FSS) forms necessary to complete a FSS Head Sta
and/or Early Head Start Work Program for FY = Review all Work Program forms and complete the request
11.
information as specified in the >
Work Program & Related Content=section below, noting changes from last fisc
year. Your agency should complete the budgetary documents and all other forms as instructed. Be certain
retain a reference copy of every submittal for your files.

A complete, typed, collated and unstapled Work Program (Forms 1-5) along with your agency’s respecti
budgetary documents on 82 " by 11" white paper inclusive of required signatures, as well as, all other item
identified on the submission package general checklist such as an agency organization chart, lease/rent
agreement (if applicable), and the agreement signature items comprise the sub-grant agreement documen
needed for your agency’s individual Head Start or Early Head Start contract. This original document and o
copy are to be submitted for each Head Start and/or Early Head Start contract for which your agency h
received a funding allocation summary. You will note that the Work Program for FY ’11 is interactive a
should be typed using your agency’s computer. Due to the nature of Forms 2, 3 and 4, which require signatur
or other special notations, a portion of these forms will require manual completion.

s
Your agency= work program(s), budgetary documents, signature item affidavit(s), etc. will be reviewed by vario
FSS staff who may contact your agency regarding the resubmission of materials which do not meet minimu
requirements. Agencies are to submit all completed documents on the Pre-Roundtable and Roundtab
dates to be provided. Do not submit items corrected with strikeovers or > .
white out= All original wo
program, budgetary documents and signature items forms for approval signature, should be signed wi
blue ink.

Work Program & Related Content:
1. The Program Information Summary, Form 1 (pages 1-6), requires the legally incorporated name of t
Agency, as well as, completion of all items. Some items will require additional documents. For multip
as well as single site agencies, summarize all the program activity information for the entirety of ea
separate Head Start and/or Early Head Start sub-grant agreement. If any item is not applicable, ma
with “N/A”.
2. The Project Recruitment Area, Form 2, must indicate the boundaries via the Map of Alderman
Wards and by specific street names/ numbers of the area from which enrollees are recruited under t
respective contract for Head Start, Early Head Start and/or Provider Homes site(s).
3. The Parent Policy Committee Approval, Parent Policy Committee Membership Roster, Pare
Involvement Activity Budget and Head Start / Early Head Start Training Plans; Forms 3-5, requ
the legally incorporated name of the Agency in addition to all the requested information.
4. The most recent Organization Chart that includes your agency’s Head Start / Early Head Start staffi
for the period 12/01/10 thru 11/30/11.
5. A Copy of your agency’s Lease/Rental Agreement(s) during the period 12/01/10 thru 11/30/11,
applicable.

NOTE: All Agencies funded for Head Start / Early Head Start Full Day Family Child Care Home program
must establish separate service agreements with their Licensed Family Child Care Home Providers.
Start
ested
fiscal
n to

ctive
ems
ental
ents
one
has
and
ures

rious
mum
able
work
with

f the
iple,
each
mark

anic
r the

rent
quire

ffing

11, if

ams,
.
HEAD START WORK PROGRAM
PO# / Form 1
INFORMATION SUMMARY

1. IDENTIFICATION
a. AGENCY NAME:
b. AGENCY TYPE: [In each row indicate only one selection with "x".]
HEAD START or EARLY HEAD START
DELEGATE AGENCY or PARTNER AGENCY [Both hereafter referred to as "Agency"]
PUBLIC [i.e. Governmental] or PRIVATE [Includes Not-for-Profit Corporations]
SCHOOL or COLLEGE / UNIV or CHURCH or OTHER [Specify]

c. MAIN OFFICE ADDRESS: ZIP CODE:

d. EXECUTIVE DIRECTOR: PHONE:
FAX: EMAIL:

e. PROGRAM DIRECTOR: PHONE:
FAX: EMAIL:

f. FISCAL OFFICER: PHONE:
FAX: EMAIL:

g. HEAD START POLICY COMMITTEE CHAIRPERSON:
PHONE: EMAIL:

2. ALLOCATION [This information should match the FY '11 Allocation sheet]
a. TOTAL NUMBER OF HEAD START + EARLY HEAD START + COLLABORATION SLOTS 0
1) CHILDREN 0 TO 3 YEARS OF AGE
2) CHILDREN 3 TO 5 YEARS OF AGE
3) CHILD 5 YEARS OF AGE & ABOVE

b. TOTAL NUMBER OF FUNDED CHILD CARE / SPECIALIZED CARE SLOTS

c. TOTAL NUMBER OF FUNDED SLOTS [2a + 2b] 0

Children Services Division Use Only:

Approval Signature for Entire Work Program: Date:

1
HEAD START WORK PROGRAM
PO# / Form 1

Site Name
INFORMATION SUMMARY

3ii. SERVICE FACILITIES & OPERATION [Multi-site agencies must complete one profile form for each site.]

a. NUMBER OF SITES

b. NUMBER OF CLASSROOMS

c. NUMBER OF TEACHERS

d. NUMBER OF FAMILY CHILD CARE HOMES (FCCH)

e. NUMBER OF FCCH PROVIDERS

f. NUMBER OF SERVICE MONTHS PER YEAR

g. NUMBER OF SERVICE WEEKS PER YEAR

h. NUMBER OF SERVICE DAYS PER YEAR

i. SERVICE FACILITIES & OPERATION

j. NUMBER OF SERVICE HOURS PER SESSION [Half-day including meals]

k. NUMBER OF SERVICE HOURS PER SESSION [Full-day including meals]

l. NUMBER OF SESSIONS PER DAY [1 or 2]

m-i. BEGINNING DATE OF PROGRAM YEAR FOR FULL DAY PROGRAMS

m-ii. BEGINNING DATE OF PROGRAM YEAR FOR HALF-DAY PROGRAMS

n.i. ENDING DATE OF PROGRAM YEAR FOR FULL DAY PROGRAMS

n.ii. ENDING DATE OF PROGRAM YEAR FOR HALF-DAY PROGRAMS

o. SCHEDULED WEEKDAY HOLIDAYS & OTHER NON-SERVICE DAY(S) [mm/dd/yy]

, , , , , ,

2
HEAD START WORK PROGRAM
PO# / Form 1

Site Name
INFORMATION SUMMARY

3ii. SERVICE FACILITIES & OPERATION [Multi-site agencies must complete one profile form for each site.]

a. NUMBER OF SITES

b. NUMBER OF CLASSROOMS

c. NUMBER OF TEACHERS

d. NUMBER OF FAMILY CHILD CARE HOMES (FCCH)

e. NUMBER OF FCCH PROVIDERS

f. NUMBER OF SERVICE MONTHS PER YEAR

g. NUMBER OF SERVICE WEEKS PER YEAR

h. NUMBER OF SERVICE DAYS PER YEAR

i. SERVICE FACILITIES & OPERATION

j. NUMBER OF SERVICE HOURS PER SESSION [Half-day including meals]

k. NUMBER OF SERVICE HOURS PER SESSION [Full-day including meals]

l. NUMBER OF SESSIONS PER DAY [1 or 2]

m-i. BEGINNING DATE OF PROGRAM YEAR FOR FULL DAY PROGRAMS

m-ii. BEGINNING DATE OF PROGRAM YEAR FOR HALF-DAY PROGRAMS

n.i. ENDING DATE OF PROGRAM YEAR FOR FULL DAY PROGRAMS

n.ii. ENDING DATE OF PROGRAM YEAR FOR HALF-DAY PROGRAMS

o. SCHEDULED WEEKDAY HOLIDAYS & OTHER NON-SERVICE DAY(S) [mm/dd/yy]

, , , , , ,

3
HEAD START WORK PROGRAM
PO# / Form 1
INFORMATION SUMMARY

4. PARTICIPANTS [Provide number of slots within age ranges from funding allocation.]

a. TOTAL NUMBER OF CHILDREN WITH DISABILITIES

b. TOTAL NUMBER OF FAMILIES 0

1) ABOVE FEDERAL POVERTY LEVEL

2) BELOW FEDERAL POVERTY LEVEL

5. STAFF COMPOSITION & NUMBERS
PROFESSIONAL NON-PROFESSIONAL

a. LATINO

b. BLACK / AFRICAN AMERICAN

c. WHITE / CAUCASIAN

d. ASIAN AMERICAN

e. NATIVE AMERICAN ("INDIAN")

f. OTHER

TOTALS 0 0

6. HOME PROVIDERS [If applicable, provide name and address of each FCCH on Form 1, page 5.]

7. LICENSING [Attach a copy of each city and state site license(s) including each FCCH license(s), as applicable.
If renewing a license(s) or if payment exempt, provide a copy of payment receipt(s) or exempt authorization.]

4
HEAD START WORK PROGRAM
PO# / Form 1
INFORMATION SUMMARY
FY '11 FAMILY CHILD CARE HOME NETWORK PROVIDERS

Agency Name:
Family Child Care Home Network Name:
FSS Child Care Activity Number(s): IT PS SA

Name of Address & Zip Code State [DCFS] State [DCFS] Licensed State [DCFS] Day
Home/Site Provider of Licensed Day Care Age Range Care License
Home/Site License Number yrs - yrs Expiration Date

1.
yrs - yrs
2.
yrs - yrs
3.
yrs - yrs
4.
yrs - yrs
5.
yrs - yrs
6.
yrs - yrs
7.
yrs - yrs
8.
yrs - yrs
9.
yrs - yrs
10.
yrs - yrs
11.
yrs - yrs
12.
yrs - yrs
13.
yrs - yrs
14.
yrs - yrs
Total Capacity: 0

5
HEAD START WORK PROGRAM
PO# / Form 1
INFORMATION SUMMARY

8. AGENCY CONTACT PERSONS LISTING & RELATED

a. AGENCY CONTACT PERSON FOR COMPLETION OF WORK PROGRAM INFORMATION
NAME:
TITLE:
ADDRESS:
ZIP CODE:
PHONE:
FAX:
E-MAIL:

b. AGENCY CONTACT PERSON FOR COMPLETION OF BUDGETARY INFORMATION [If different from above]
NAME:
TITLE:
ADDRESS:
ZIP CODE:
PHONE:
FAX:
E-MAIL:

c. AGENCY CONTACT PERSON FOR COMPLETION OF SUB-GRANT AGREEMENT SIGNATURE ITEMS
INFORMATION [If different from above]
NAME:
TITLE:
ADDRESS:
ZIP CODE:
PHONE:
FAX:
E-MAIL:

d. AGENCY D-U-N-S NUMBER INFORMATION. [This is a unique number that identifies your agency. Your
agency's D-U-N-S Number will be used for ARRA/(Stimulus) reporting.] If you do not have a D-U-N-S Number
you may request one via the Web at: www.fedgov.dnb.com

D-U-N-S#:

6
HEAD START WORK PROGRAM
PO# / Form 1
INFORMATION SUMMARY
9. AGENCY BOARD OF DIRECTORS' MEMBER INFORMATION[For each Board Member including the Board President]
:

a. PRESIDENT OF AGENCY BOARD OF DIRECTORS
MEMBER NAME:
POSITION/OFFICE:
AREA OF EXPERTISE:
ORGANIZATION/BUSINESS AFFILIATION:
MAILING ADDRESS:
ZIP CODE:
PHONE:
E-MAIL:

b. INDIVIDUAL MEMBER OF AGENCY BOARD
MEMBER NAME:
POSITION/OFFICE:
AREA OF EXPERTISE:
ORGANIZATION/BUSINESS AFFILIATION:
MAILING ADDRESS:
ZIP CODE:
PHONE:
E-MAIL:

c. INDIVIDUAL MEMBER OF AGENCY BOARD
MEMBER NAME:
POSITION/OFFICE:
AREA OF EXPERTISE:
ORGANIZATION/BUSINESS AFFILIATION:
MAILING ADDRESS:
ZIP CODE:
PHONE:
E-MAIL:

d. INDIVIDUAL MEMBER OF AGENCY BOARD
MEMBER NAME:
POSITION/OFFICE:
AREA OF EXPERTISE:
ORGANIZATION/BUSINESS AFFILIATION:
MAILING ADDRESS:
ZIP CODE:
PHONE:
E-MAIL:

e. INDIVIDUAL MEMBER OF AGENCY BOARD
MEMBER NAME:
POSITION/OFFICE:
AREA OF EXPERTISE:
ORGANIZATION/BUSINESS AFFILIATION:
MAILING ADDRESS:
ZIP CODE:
PHONE:
E-MAIL:

Use additional page(s), as applicable

7
HEAD START WORK PROGRAM
PO# / Form 2
PROJECT RECRUITMENT AREA

AGENCY NAME:

On the following City of Chicago Wards map draw a recruitment area boundary along streets that encompass the
addresses of funded enrollees. Designate the locale of your site(s)/network inside this boundary with a “”.
Single and multi-site agencies should provide a separate listing (see Form 2, page 3) of sites and addresses if
information is different from site information provided on allocation sheet.

INDICATE THE PROJECT RECRUITMENT AREA(S) BY STREET NAME

Area #1 Streets
North:
South:
East:
West:

Area #2 Streets
North:
South:
East:
West:

Area #3 Streets
North:
South:
East:
West:

Area #4 Streets
North:
South:
East:
West:

1
HEAD START WORK PROGRAM
PO# / Form 2
AGENCY NAME:

[PLACE MAP OBJECT HERE]

2
HEAD START WORK PROGRAM
PO# / Form 2
SEPARATE LISTING OF UPDATED SITE INFORMATION
This listing should be completed only to indicate corrections to site information provided in your FY '11 allocation sheet.

AGENCY NAME:

Activity Program Child HS/
Number Type Site Name Site Address Care Collab
Slots Slots

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

3
HEAD START WORK PROGRAM
PO# / Form
POLICY COMMITTEE APPROVAL

We, the undersigned, have met, discussed, reviewed and approved the Work Program & Budget developed by
AGENCY NAME:
for FY '11 base Head Start/Early Head Start and all ARRA/(Stimulus) funds. The subsequent approval date
was:

1
HEAD START WORK PROGRAM
PO# / Form
POLICY COMMITTEE MEMBERSHIP ROSTER

AGENCY NAME:

Please Note: If Policy Committee elections have not occurred for the 2010-2011 progam year, then this Policy
Committee Membership Roster should reflect your 2009-2010 Policy Committee membership. The Policy Committee
signatures on the FY '11 sub-grant agreement Policy Committee Approval sheet (Form 3, Page 1) should reflect the
names listed here. A quorum for this delegate agency Policy Committee is:

(TYPED NAME)

Policy Committee Chairperson

Policy Committee Vice-Chairperson

Policy Committee Secretary

Policy Committee Treasurer (optional position)

Parliamentarian / Sergeant-at-Arms (optional position)
Citywide Parent Policy Council
Representative-Delegate
Citywide Parent Policy Council
Representative-Alternate

Member

Community Representative

2
rm 3

.
rm 3

.
HEAD START WORK PROGRAM
PO# / Form
PARENT INVOLVMENT ACTIVITY BUDGET

AGENCY NAME:

Total number of Head Start Children Funded:
Total number of Early Head Start Children Funded:

This is to certify that the Agency has delineated the following program cost descriptions for Parent Involvement
Activities in their FY '11 sub-grant agreement budget at a minimum of $5 per child per month:

Cost Description Cost

Out-of-town air fare and per diem $

Non-program adult food

Child care, local travel, and cultural
event tickets or fees

Training activities

*Total $ 0

*The Parent Involvement Activity Budget total must equal cost code 1240 of
the sub-grant agreement.

Please note that the Parent Involvement Activity budget is to be allocated for all
parent involvement activities which include: parent committee activities, policy
committee activities and parent activities that occur at the site and delegate
agency levels.

Signature, Chairperson of Policy Committee Date

1
rm 4
HEAD START WORK PROGRAM
PO# / Form 5
*TRAINING PLAN for DECEMBER 1, 2010 through NOVEMBER 30, 2011
HEAD START or EARLY HEAD START [Indicate program selected with a "x"]

AGENCY NAME:

RESULTS RESOURCE
DATE TRAINING ACTIVITY PARTICIPANTS LOCATION COST
ANTICIPATED PROVIDERS

* Agencies with Head Start and/or Early Head Start programs should submit a separate training plan for each respective program type. Use additional pages, as applicable.
The following lists those trainings that policy committee members, board members and parents need to have - 1) Program Governance training for Policy
Committee/Board Members: Orientation, Leadership, Parliamentary Procedures, Fiscal, Sub-Grant Agreement Process, Self Assessment and 2) Training for
parents to include but not limited to the areas of: Nutrition, Pedestrian Training, Parent Education, Early Childhood Development, Health & Safety, Goal Setting,
Career/Academic Development, Literacy, etc.
1