Classroom information roster

ATTACHMENT 6
CLASSROOM INFORMATION ROSTER

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OMB No.: 0970-XXXX
Expiration Date: XX/XX/XXXX

A Study of We Grow
Together: The Q-CCIIT
Professional Development
System
Classroom Information Roster
January 25, 2018

FOR OFFICE USE ONLY: LABEL

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such
collection displays a valid OMB control number. The valid OMB control number for this information collection is 0970-XXXX and the
expiration date is XX/XX/XXXX. The time required to complete this collection of information is estimated to average 5 minutes,
including the time to review instructions, search existing data resources, gather the data needed and complete and review the
collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to Mathematica Policy Research, 1100 1st Street, NE, 12th Floor, Washington, DC 20002,
Attention: Tim Bruursema and reference the OMB Control Number 0970-XXXX.

WE GROW TOGETHER

ATTACHMENT 6. CLASSROOM INFORMATION ROSTER

INTRODUCTION
This survey is an important part of a larger study, Professional Development Tools to
Improve the Quality of Infant and Toddler Care, supported under a contract from the
U.S. Department of Health and Human Services, Administration for Children and Families to
Mathematica Policy Research. The overall purpose of this study is to understand the use of
the We Grow Together: The Q-CCIIT professional development system. We Grow Together
aims to help caregivers in center-based and family child care interact with infants and
toddlers in ways that promote positive outcomes for children. Participation in this project is
voluntary.
This questionnaire asks about the ages of the children in your setting on the day of the
observation and some questions about your child care setting. All information you share will
remain private to the extent permitted by law. No one from your program will see or hear your
individual responses, and your name will never be associated with or identified in study
reports. The information we get will be used for research purposes.
Your answers are important to us, but completion of this survey is voluntary. Choosing not
to respond to these questions will not affect your access to the We Grow Together resources.
You do not have to answer questions you do not wish to answer, and none of the responses
you provide will be reported back to program staff. This survey will take approximately 5
minutes to complete.

INSTRUCTIONS

Thank you for taking the time to complete these questions.
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This is only asking about the children in your room today during the observation. Please do not include
information on children who were not here today.

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Please use a blue or black pen.

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Please enter dates : | M | M | / | D | D | /| Y | Y |
For example, January 4, 2018 would be entered: | 0 | 1 | / | 0 | 4 | /| 1 | 8 |

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WE GROW TOGETHER

ATTACHMENT 6. CLASSROOM INFORMATION ROSTER

YOUR CHILD CARE SETTING & CLASSROOM

Please enter today’s date: |
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What are the dates of birth (MM/DD/YY) for each boy who was in the classroom during the observation
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BOYS
DATE OF BIRTH

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What are the dates of birth (MM/DD/YY) for each girl who was in the classroom during the observation
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GIRLS
DATE OF BIRTH
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WE GROW TOGETHER

2.

ATTACHMENT 6. CLASSROOM INFORMATION ROSTER

Which type of child care setting are you currently working in?
SELECT ONE OR MORE
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A Family Child Care (FCC) business
Early Head Start
A state child care program
A child care center, preschool, or nursery school (other than Early Head Start or a State Child Care
program)

Among the children present during our observation, at home, how many families speak . . .
NUMBER OF FAMILIES

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English and another language? .............................................

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English only? ..........................................................................

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Spanish only? .........................................................................

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Only another language (not English or Spanish)? .................

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Among the children present during our observation, how many of the children have an Individual Family
Service Plan (IFSP)? These are written documents that describe plans and goals for the child and the
services he or she should receive.
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| NUMBER OF STUDENTS WITH IFSP

What is the total number of caregivers who regularly work in this classroom?
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| NUMBER OF CAREGIVERS

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WE GROW TOGETHER

6.

ATTACHMENT 6. CLASSROOM INFORMATION ROSTER

Which best describes how the workload is shared among caregivers in this classroom …
MARK ONLY ONE
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You are the only caregiver in the room,
Caregivers share responsibility equally for all children,
Individual caregivers are assigned primary responsibility for small groups of children,
A lead caregiver is primarily responsible for the children while the assistant supports the lead caregiver,
or
Some other arrangement? (please specify)
_______________________________________________________________________

Thank you for your participation. Please return this questionnaire in the envelope
provided. If you no longer have the envelope, please mail this questionnaire to:
Mathematica Policy Research
Attn: Receipt Control – Project 50192
P.O. Box 2393
Princeton, NJ 08543-2393

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