Form 1 ACF-801

ACF - 801 Child Care Monthly Case Record Form OMB #: 0970-0167 Expires: XX-XXX-XXXX
Head of Family Receiving Assistance
Reporting Period	Month: _ _	Year: _ _ _ _
Unique State Identifier (required in absence of SSN#)	_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Social Security Number (optional)	_ _ _- _ _ - _ _ _ _
FIPS Codes	State: _ _	County: _ _ _
Single Parent	_
Reason for Receiving Subsidized Child Care	_
Total Monthly Child Care Co-payment by Family	$ _, _ _ _
Month/Year Child Care Assistance to the Family Started	Month: _ _	Year: _ _ _ _
Total Monthly Income	$ _ _ ,_ _ _
Family Income Sources			(Y/N)
10. Employment Including Self-Employment			_
11. Cash or Other Assistance Under Title IV of the Social Security Act (TANF)			_
12. State Program for Which State Spending Is Counted Towards TANF MOE			_
13. Housing Voucher or Cash Assistance			_
14. Assistance Under the Food Stamps Act of 1977			_
15. Other Federal Cash Income Programs (such as SSI)			_

Head of Family Receiving Assistance (Continued)

16. Family Size Used to Determine Eligibility

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Dependent Children Receiving Child Care Assistance

Child Receiving Care

17. Social Security Number (0ptional) OR Unique State Identifier (Required in absence of SSN#)

18. Hispanic or Latino Ethnicity

19. American Indian or Alaskan Native

20. Asian

21. Black or African American

22. Native Hawaiian or Other Pacific Islander

23. White

24. Gender

25. Month/Year of Birth

26. Type of Child Care

27. Total Monthly Amount Paid to Provider

28 Total Hours of Care Provided in Month

Child 1

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Child 1, Provider 1

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Child 1, Provider 2

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Child 2

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Child 2, Provider 1

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$ _, _ _ _

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Child 2, Provider 2

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$ _, _ _ _

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Child 3

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Child 3, Provider 1

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$ _, _ _ _

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Child 3, Provider 2

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$ _, _ _ _

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Child 4

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Child 4, Provider 1

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$ _, _ _ _

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Child 4, Provider 2

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$ _, _ _ _

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CHILD CARE AND DEVELOPMENT FUND

ACF-801 CASE-LEVEL REPORTING FORM

Instructions

The ACF-801 case-level data is collected monthly and reported either monthly or quarterly. Quarterly data is reported 60 days after the end of each quarter and monthly data is due 90 days after the reported month. All Lead Agencies in the States, the District of Columbia, and Territories (including Puerto Rico, American Samoa, Guam, Northern Marianna Islands, and the US Virgin Islands) are responsible for collecting and reporting ACF-801 data. States and Territories submit their records electronically to the Child Care Bureau Information System. Lead Agencies may submit either full population or a monthly sample (approximately 200 families) of subsidized child care recipients for the ACF-801. In addition, to the ACF-801, States and Territories must submit aggregate data for all families and children in care annually on the ACF-800.

For more information and guidance on Federal reporting requirements, see the Child Care Bureau’s website at: http://www.acf.hhs.gov/programs/ccb/report

Record Header Information

The following elements (items A - G) refer to the header information.

1. Report Period: This data element identifies the month being reported. For example, if the report covers April 2008, this element would be “200804”.

2. Families Receiving Subsidized Child Care: The number of families receiving subsidized child care in your State for the reported month. The number should be right-justified within the field and padded with zeros. For example, 25,387 would be formatted as “0025387”.

3. Filler: Effective immediately, a Pre-K count no longer will be reported on the ACF-801.  Rather than make format changes to their data reporting systems, Lead Agencies should report a filler in what was formerly the Pre-K count data element.  The filler should be seven zeros:  “0000000”.

4. State Contact Name: The name of the State child care contact who is designated to receive the Summary Assessment reports.

5. State Contact Telephone Number: The telephone number of the State child care contact.

6. State Contact Fax Number: The fax number of the State child care contact.

7. State Contact E-mail Address: The e-mail address of the State child care contact.

Head of Family Receiving Assistance

The following elements (items 1-16) refer to the head of the family receiving child care assistance. The "Head of Family Receiving Assistance," is the person for whom eligibility is determined. If the child is considered a family of one (i.e., a protective service case), then all items refer to the child.

1. Reporting Period: The month and year being reported. The report should include information about the families and children who actually received child care services during the reporting month, irrespective of when payment is made for those services.

2. Unique State Identifier: A unique identifying number, up to fifteen characters, assigned by the State to the family receiving child care assistance. States may use alphanumeric characters. The Social Security Number may not be required of families as a condition of eligibility. However, in the absence of the Social Security Number, the Child Care Bureau requires that States use a Unique State Identifier to ensure that cases are unduplicated for reporting purposes in accordance with the Statute governing the Child Care and Development Fund. If a case has neither a Social Security Number nor a Unique State Identifier, the data related to the case cannot be processed.

3. Social Security Number: The Social Security Number of the head of the family. Again, States are reminded that CCDF eligibility may not be denied because a parent chooses not to provide their Social Security Number. (See ACYF-PI-CC-00-04 issued October 27, 2000). In cases in which care is being provided to a child as a family of one, the child’s Social Security Number is used for this element.

4. Federal Information Processing Standards (FIPS) Code: The FIPS Code geographic identifier issued by the National Bureau of Standards to designate where the head of the family receiving assistance is residing. A list of all FIPS codes can be found at the Census Bureau web site at http://www.census.gov/geo/www/fips/fips.html or by contacting the Child Care Automation Technical Assistance Center (1-877-249-9117). This includes a two digit State code and three digit county code.

5. Single Parent: A single parent/adult who is legally/financially responsible for and living with a child where there is no other adult legally/financially responsible for the child in that eligible family. If there is someone else in the household who does not have legal/financial responsibility for the child, the legally/financially responsible applicant is still considered a single parent. A one-digit code indicates if the head of the family receiving assistance is single or not.

0 -- No

1 -- Yes

9 -- Not applicable; child is reported as head of household. (If “9” is selected, indicate the Child’s Social Security Number in Item 3).

6. Reason for Receiving Subsidized Child Care: The one-digit code indicating the reason for receiving subsidized child care. If more than one category applies, report the primary reason. States/Territories should report responses that correspond to the State’s definitions of “working”, “job training and educational program”, and “protective services” that are included in its approved CCDF Plan. Categories 5, 6, 7, 8, 9, and 0 should be used for families affected by a federally declared emergency.

Effective October 1, 2010, the response categories “5—Other” and “0—Federal Declared Emergency and Other” will be eliminated, and States/Territories will report using only the remaining categories. Grantees should be prepared to implement this element modification on October 1, 2010. After this date, any values of “0” or “5” will be considered invalid.

The response categories include: 

1 – Employment

2 – Training/Education

3 – Both Employment and Training/Education

4 – Protective Services

5 – Other (response category eliminated effective October 1, 2010)

6 – Federal Declared Emergency and Employment

7 – Federal Declared Emergency and Training/Education

8 – Federal Declared Emergency and both Employment and Training/Education

9 – Federal Declared Emergency and Protective Services

0 – Federal Declared Emergency and Other (response category eliminated effective October 1, 2010)

7. Total Monthly Child Care Co-payment by Family: The monthly dollar amount the family receiving assistance must pay for child care services for the month being reported (the co-payment assigned by the Lead Agency or its designee).

8. Month/Year Child Care Assistance to the Family Started: The numbers for the month and year child care assistance started for the family receiving assistance. If there was a short interruption of up to three months in child care assistance (for reasons such as a vacation or illness) indicate the original month/year the assistance started, rather than when the assistance resumed.

9. Total Monthly Income: Report total monthly income amount received by the family.  This is the total income that is used for determining eligibility and/or co-payment before any deductions that may be allowed are subtracted.  The amount should be rounded to the nearest dollar.

ITEMS 10-15: Family Income Sources: This item reports sources of income, and requires a “yes” (1) or “no” (2) answer as they relate to the family receiving assistance for the month being reported. Even if a source of income is disregarded for eligibility determination purposes, the correct answer is “yes” for a family that received income from that source in the reporting month. For Protective Services cases only, if on a case-by-case basis, income is not used to determine eligibility, and no income is reported, items 10-15 do not have to be completed.

10. Employment income, including self-employment.

11. Cash or other monetary assistance under Title IV of the Social Security Act (TANF)

12. State program for which State spending is counted towards TANF MOE

13. Housing voucher or cash assistance

14. Assistance under the Food Stamps Act of 1977

15. Other Federal Cash Income Programs (such as SSI)

13. Family Size Used to Determine Eligibility: Number of family members upon which eligibility is based. The field size is two (2) with a required value within the range of 1 to 99.

Dependent Children Receiving Child Care Assistance (One record per child)

These items, 17 through 25, refer to dependent children in the family receiving child care assistance and indicate the demographic characteristics of children receiving care. States and Territories are required to request information about ethnicity and race. However, if a parent refuses to report ethnicity and/or race for their child, the field should be left blank. The displayed form includes space for only four children, but the number of children may exceed this in the electronic submittal.

17. Child’s Social Security Number (Optional): Indicate the Social Security Number of the child receiving assistance.

18. Hispanic or Latino Ethnicity: Indicate the one digit code for the ethnicity of each child. (Ethnicity should be determined for every child in the family).

0 – No

1 –Yes

ITEMS 19-23: Race Of Child: This item applies to each child receiving care. Indicate the code for yes (1) or no (0) for each race listed below. Select yes for as many races as reported by the family. (Each child should have at least one race coded yes. Multi-racial children should have a “1” in more than one race field.)

19. American Indian or Alaskan Native

20. Asian

21. Black or African American

22. Native Hawaiian or Other Pacific Islander

23. White

24. Child’s Gender: Indicate the one digit code for the gender of the child receiving care.

1– Male

2 – Female

25. Month/Year of Birth: Enter the numbers for the month and year of birth of the child receiving care.

Child Care Provider (One record for each provider for each child)

This group of questions applies to the child care provided to each child. Include all providers receiving subsidies for each child in the family receiving care. The displayed form includes space for only two providers, but the number of providers may exceed this in the electronic submittal.

26. Type Of Child Care: The two-digit code indicating the type of child care setting. Provider types are divided into two broad categories: “licensed/regulated” and “legally operating without regulation.” For reporting purposes, a legally operating, unregulated provider is a provider that, if not participating in the CCDF program, would not be subject to any State or local child care regulations. The “licensed/regulated” and “legally operating without regulation” categories each include four types of providers (each State's definition of these terms apply): in-home, family home, group home, and centers. A relative provider is defined as being the grandparent, great-grandparent, aunt or uncle, or sibling (living outside of the child’s home) of the child in care. The following codes specify the type of care provided by each provider for each child during the report month.

Codes:

01 -- Licensed/regulated in-home child care

02 -- Licensed/regulated family child care

03 -- Licensed/regulated group home child care

04 -- Licensed/regulated center-based care

05 -- In-home care provided by a non-relative in a setting legally operating without regulation

06 -- In-home care provided by a relative in a setting legally operating without regulation

07 -- Family home child care provided by a non-relative in a setting legally operating without regulation

08 -- Family home child care provided by a relative in a setting legally operating without regulation

09 -- Group home child care provided by a non-relative in a setting legally operating without regulation

10 -- Group home child care provided by a relative in a setting legally operating without regulation

11 -- Child care center legally operating without regulation

27. Total Monthly Amount Paid to Provider: For each child receiving care, indicate the total monthly dollar amount (rounded to the nearest dollar) paid or to be paid to the provider for the care of the child. The Total Monthly Amount should include Federal, State, and locally funded amounts. Prior to October 1, 2010, Lead Agencies should continue, as they have done in the past, to report the family co-payment as part of this item. Effective October 1, 2010, this amount will no longer include the family co-payment and should reflect only the subsidy that is paid to the provider for services rendered. Grantees should be prepared to implement this element modification on October 1, 2010.

28. Total Hours of Care Provided in Month: Indicate the total number of hours of care provided for the reporting period (rounded to the nearest whole number).

The Paperwork Reduction Act of 1995

Public reporting burden for this collection of information is estimated to average 20 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

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