Head Start Registration Form Questions

OMB Control Number: 0970-0617

Expiration date: [date]

Question Bank for Head Start Registration Forms

The Office of Head Start registers individuals to access Head Start related events and resources. This document contains a bank of questions from which questions for registration forms will be selected. A few notes on how this question bank is used:

• Not all registration fields are selected for registration forms.

• Items with [bracketed red text] are updated to reflect the specific event or resource.

• Although the question bank provides flexibility in the development of registration forms, the number of registration fields selected will average 1 minute response burden and the majority will only contain name, e-mail, organization, and role.

• The “Question Text” column indicates different ways to ask the same question.

• Fields if asked multiple times, e.g., registering multiple people in one form or registering for a waitlist, may be numbered or may include “waitlist” in the question text.

• The following Paperwork Reduction Act (PRA) statement is displayed within the registration form display per requirements of the PRA.

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to [purpose statement]. Public reporting burden for this collection of information is estimated to average [x minutes] including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This collection of information is voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0617 and the expiration date is [date]. If you have any comments on this collection of information, please contact [contact e-mail].

Question Sub-Category	Question Text Options	Response Type or Option Set
State	-- State -- State/Territory	List of applicable states/territories fully spelled out
City	-- City	Textbox
Region	-- ACF Region ID	List of applicable regions: {01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 11, 12}
Grant Number	-- Grant Number/ID	Textbox or List of pre-filled grant numbers
Organization	-- Organization Name -- Agency Name -- Program Name	Textbox or List of pre-filled program names
Organization Type	-- Type of Agency	List of organization types: {Private/Public Non-Profit (Non-CAA) (e.g., church or non-profit hospital), Community Action Agency (CAA), School System, Private/Public For-Profit (e.g. for-profit hospitals), Government Agency (Non-CAA) Tribal Government or Consortium (American Indian/Alaska Native)} and Textbox for other OR {Community Action Program or Community Action Agency (CAP/CAA), EHS-CC Partnership, For-Profit, Local Government, Non-Profit (non-CAP/CAA), Regional or Statewide, School System, Single Purpose, Tribal Government} and Textbox for other
E-mail	-- E-mail -- [Position] E-mail -- Contact E-mail -- Contact Person Email -- Registrant Email	Textbox
Phone Number	-- Phone Number -- Contact Phone Number -- Please provide the best phone number to reach you at for [specify reason for needing phone number] -- Phone number (cell or other number that we could use to contact you about or during the [training event]) -- Primary Phone Number -- Secondary Phone Number	Textbox
Address	-- Mailing Address	Textbox
Event	-- Event Title	Textbox
Registration Type	-- Registration type	List of registration types: {Participant, Speaker, Both}
Date	-- Registration date	Textbox
Name	-- First Name -- Last Name -- [Position] Name -- Contact Name -- Contact Person Name -- Registrant Name	Textbox
Role/Position	-- Role/position/title -- Registrant Title -- Contact Title -- Contact Person Title	Textbox List of roles or position types: {EHS/HS Program Directors, Fiscal Staff, Human Resource Staff, Disabilities Staff, Mental Health Staff, Health Staff, Nutrition Staff, Governance Staff, Parent Family Community Engagement Staff, ERSEA Saff, Center/Site managers/directors, Transportation Staff, Education Staff, Coaching Staff, Homebased managers/coordinators, Facilities staff, [Position]}
Years in Current Role	-- Number of years in current role -- Number of years as [position]	Textbox
Attendance tracking	-- Number viewing in group -- Number of participants -- Number of program participants -- Will you attend [activity]? -- Please choose the session topics you are most interested in	Textbox or List pre-filled with session topics/activities for event
Group Attendance	-- Attending as a group? -- We will participate as a group	List of Yes/No
Program Option	-- Program Option	List of applicable program options: {Center-based Head Start Preschool, Center-based Early Head Start, Home-based, Family Child Care, and EHS-CC Partnership}
Accommodations	-- Please describe any accommodations that will facilitate your full participation in this event -- ADA Accommodations: -- Pursuant to the Americans with Disabilities Act, do you require specific aids or services?	Textbox or List of accommodations: {Audio, Visual, Lactation room, interpretation services, Other [please specify], N/A}
Language	-- In which language would you like to register? -- Preferred language	List of languages: {English, Spanish}
GOH	-- Please select the description that best represents you	List of options: {Central Office Staff, Regional Office Staff, Regional TA Staff, National Centers Staff, Grant Recipient Program Staff, Tribal Leader, Vendor, Other [if other, please explain]}
Event promotion	-- How did you hear about this [activity/event/training]?	List of options: {Headstart.gov website, Email, Social media, Word-of-mouth, Other [if other, please explain]}

The following questions are applicable to specific tools or events and are not used broadly as items listed in the table above.

Tool or Event	Question Text	Response Type or Options
Practice-based Coaching Tool	-- Have you attended any PBC training?	List of Yes/No
Practice-based Coaching Tool	-- Which option are you coaching? (check all that apply)	List of options: {Early Head Start, Head Start, Early Head Start-Child Care Partnership, Center-based, Home-based}
Practice-based Coaching Tool	-- Do you have a dual/multi-role (Coach and...)? -- Please list dual/multi-role if applicable (Coach and...)? -- How many months as a coach?	List of Yes/No Textbox List of options: {0-6 months, 12-24 months, 24+ months, 6-12 months}
Practice-based Coaching Tool	-- Assigned TTA Early Childhood Specialist:	List of TTA Specialists or Textbox
Sponsored Travel	-- Name as it appears on your government issued ID	Textbox
Sponsored Travel	-- Is your primary work location more than 50 miles from [meeting venue]?	List of Yes/No
Sponsored Travel	-- Please note that travel arrangements paid for by GOH on your behalf will be non-refundable and non-transferable. Check the box to confirm that you understand the airline tickets you will be reserving are non-refundable and non-transferable.	Checkbox to indicate agreement
Sponsored Travel	-- For planning purposes, the standard travel dates are to arrive in [meeting city] on [day, date, year] and depart [meeting city] the afternoon/evening on [day, date, year]. Please let us know if you have any schedule conflicts or other circumstances that need to be considered when coordinating your travel itinerary. Please note this is a request and must be approved by OHS.	Checkbox to indicate agreement
Flexibility	-- If needed, I/we can switch to [alternative date/session]	Checkbox to indicate agreement
Payment	-- Expected Payment Type	List of payment types: {Check, Credit Card, Purchase Order (for orders at $400 or more)}
Teacher observations	-- Will you observe teachers once certified?	List of Yes/No
Teacher observations	-- Will you collect data for Grant Recipient/Staff use from the observations?	List of Yes/No
Teacher observations	-- How do you plan to observe classrooms? (check all that apply)	List of observation types: {Live, Recorded, Virtual}
Trainings/ Certification	-- Have you attended Pre-K Observation Training before? -- If yes, please provide years -- If yes, were you certified?	List of Yes/No Textbox List of Yes/No/N/A
Trainings/ Certification	-- Have you taken the QCIT Certification in the Past? -- If yes, please provide years -- If yes, were you certified?	List of Yes/No Textbox List of Yes/No/N/A
Trainings/ Certification	-- Will you utilize QCIT to collect data?	List of Yes/No
Virtual attendance	-- Are you familiar with Zoom?	List of Yes/No List of selections: {I have significant experience with Zoom., I'm a Zoom expert!, I've used Zoom minimally.}