Redesign of the Head Start Family and Child Experiences Survey (FACES 2012)

ATTACHMENT A.2

CLASSROOM SELECTION FORM

OMB No: 0970-0355 Expiration Date: 1/31/15 Head Start Family and Child Experiences Survey Pilot Study Classroom Selection Form
Program:
Address:				Phone:
City:		State:		Fax:

Selected Center 1: [INSERT CENTER 1 NAME] Center Director: Address 1: Address 2: Phone: Fax: Email Address:

Selected Center 2: [INSERT CENTER 2 NAME] Center Director: Address 1: Address 2: Phone: Fax: Email Address:

Now that centers in your program have been selected for participation in the FACES Pilot Study, we need some information about the classrooms in each of the selected centers. We will use this information to select two classrooms in each center for participation.

1. Please confirm all contact information pre-filled above for your program and the selected centers.

2. On page 2, list each classroom currently in operation at each selected center.

3. Return the completed form to your Mathematica Coordinator no later than [DATE].

Mathematica Coordinator: Name: Address 1: Address 2: Phone: Fax: Email Address:

On-Site Coordinator: Name: Address 1: Address 2: Phone: Fax: Email Address:

BOX A. CLASSROOMS AT [INSERT CENTER NAME]
		Number of Children
Teacher Name	AM, PM or Full-Day	3-Year-Olds	4-Year-Olds	5-Year-Olds	Percentage of Dual Language Learner Children	Days Classroom Operates

BOX B. CLASSROOMS AT [INSERT CENTER NAME]
		Number of Children
Teacher Name	AM, PM or Full-Day	3-Year-Olds	4-Year-Olds	5-Year-Olds	Percentage of Dual Language Learner Children	Days Classroom Operates