Head Start Forms (2018)

For information on forms or categories listed please call (209) 238-1800.  Contact: Rita Alvarez, Office Supervisor ralvarez [ahtsym] stancoe [dhotsym] org ( (link sends e-mail))

For questions regarding online form links, please Email pim [ahtsym] stancoe [dhotsym] org

*Head Start Order Form 2018

2018-2019 Master Forms

PLEASE NOTE: Forms with this icon download icon are available in a fillable version.  Click the icon to download

Program Governance (PG)

Eligibility Recruitment Selection Enrollment Attendance (ERSEA)
  • ERSEA-1          Head Start Eligibility Criteria (E)  [Hot Sheet] 
  • ERSEA-1          Criterio De Eligibilidad De Head Start (S)  
  • ERSEA-2          Child/Family Services Head Start Application (E)  [Hot Sheet] 
  • ERSEA-2.1       Servicios para Ninos/Familias Aplicación (S)
  • ERSEA-3          Child Information Sheet (E)  [Hot Sheet] 
  • ERSEA-3.1       Hoja de Información del Niño (S)  [Hot Sheet] 
  • ERSEA-4          Parent/Guardian Consent for Release of Information (E)  [Hot Sheet] 
  • ERSEA-4.1       Consentimiento Para Compartir Información (S)  [Hot Sheet] 
  • ERSEA-5          Income Calculation & Family Size Worksheet-RHS & EHS (E)  [Hot Sheet] download icon
  • ERSEA-6          Migrant Program Income Worksheet &Verification (E)  [Hot Sheet]  download icon
  • ERSEA-6.1       Programa Migrante Certificación de Verificación de Ingresos (S) 
  • ERSEA-7          Self-Certification of Income (E) Interim Form  [Hot Sheet] 
  • ERSEA-7.1       Auto-Certificacion de Ingreso (S) Interim Form
  • ERSEA-8          Self-Identification of Current Residency (E)  [Hot Sheet] 
  • ERSEA-8.1       Formulario de Auto-Identificación de Residencia Actual (S)  [Hot Sheet] 
  • ERSEA-9          Caregiver’s Authorization Affidavit (E)  [Hot Sheet] 
  • ERSEA-9.1       Declaración Baja Juramento para Autorizar al Encargado (S) 
  • ERSEA-10        Migrant Preliminary Eligibility Worksheet (E)  [Hot Sheet] 
  • ERSEA-10.1     Migrant Preliminary Eligibility Worksheet (S) 
  • ERSEA-11        Declaration of Intent to Work in Agriculture (E/S)  [Hot Sheet] 
  • ERSEA-12        Declaration of Intent to Work in Agriculture Tracking Sheet (E/S)  [Hot Sheet] 
  • ERSEA-13        Self-Declaration of Migratory Move (E)  [Hot Sheet] 
  • ERSEA-13.1     Self-Declaration of Migratory Move (S) 
  • ERSEA-14        Employee Child Application Approval Form(E)  [Hot Sheet] 
  • ERSEA-15        Application Approval Checklist (E)  [Hot Sheet] 
  • ERSEA-16        Enrollment/Attendance Work Plan (E)  [Hot Sheet] download icon
  • ERSEA-17        Recruitment Work Plan (E)  [Hot Sheet] download icon
  • ERSEA-18         Community Agency Contact Record (E)  [Hot Sheet]  download icon
  • ERSEA-19         File Access Log (E)  [Hot Sheet]  
  • ERSEA-20         Emergency Card (E/S)  [Hot Sheet] 
  • ERSEA-21         Consent Form (E)  [Hot Sheet]  
  • ERSEA-21.1      Forma de Consentimiento (S)  
  • ERSEA-22         Notification of Parent's Rights (Fresno)   [Hot Sheet]  
  • ERSEA-22         Notification of Parent's Rights (Oakland)  
  • ERSEA-22         Notification of Parent's Rights (Sacramento)   
  • ERSEA-22         Notification of Parent's Rights (San Jose)   
  • ERSEA-22.1      Notificación Sobre los Derechos de los Padres (Fresno) (S) 
  • ERSEA-22.1      Notificación Sobre los Derechos de los Padres (Oakland) (S) 
  • ERSEA-22.1      Notificación Sobre los Derechos de los Padres (Sacramento) (S)  
  • ERSEA-22.1      Notificación Sobre los Derechos de los Padres (San Jose) (S)     
  • ERSEA-23         Personal Rights (Fresno) (E)  [Hot Sheet] 
  • ERSEA-23         Personal Rights (Oakland) (E)  
  • ERSEA-23         Personal Rights (Sacramento) (E)  
  • ERSEA-23         Personal Rights (San Jose) (E)  
  • ERSEA-23.1      Derechos Personales (Fresno) (S)  
  • ERSEA-23.1      Derechos Personales (Oakland) (S)  
  • ERSEA-23.1      Derechos Personales (Sacramento) (S) 
  • ERSEA-23.1      Derechos Personales (San Jose) (S)   
  • ERSEA-24         Head Start Infant/Toddler Program Extension (E/S)  [Hot Sheet]  
  • ERSEA-25         Head Start Toddler Option Program Parent Authorization (E/S)  [Hot Sheet]  
  • ERSEA-26         Orientation/Volunteer Checklist (E)  [Hot Sheet]  
  • ERSEA-26.1      Lista de Control de Orientación y Voluntarios (S)  
  • ERSEA-27         Child Action/Follow Through Report (E)  [Hot Sheet]  download icon
  • ERSEA-28         Transfer of Child’s Records (E)  [Hot Sheet]  download icon

Education (E)

Health and Safety (HS)
  • CF/HS-1             Health History/Nutrition Assessment (E)  [Hot Sheet]             
  • CF/HS-1.1          Historial de Salud/Evaluacion de Nutricion (S)         
  • CF/HS-2             Infant Health History (E)  [Hot Sheet] 
  • CF/HS-2.1          Infantil Historia de Salud (S)  [Hot Sheet] 
  • CF/HS-3             Immunization Referral (E/S)  [Hot Sheet]  download icon             
  • CF/HS-4             CA Immunization Registry Refusal/Information Request Form (E)  [Hot Sheet] 
  • CF/HS-4.1          CA Immunization Registry Refusal/Information Request Form (S)  [Hot Sheet] 
  • CF/HS-5             California Immunization Registry Disclosure Statement (E/S)  [Hot Sheet]      
  • CF/HS-6             Dental Care Report (E)  [Hot Sheet]                          
  • CF/HS-7             On-Site Dental Examination Result (E/S)  [Hot Sheet]            
  • CF/HS-8             Vision Screening Referral (E/S)  [Hot Sheet]   download icon           
  • CF/HS-9             Pediatric Hearing & Vision Screening Results Form (E/S)  [Hot Sheet]             
  • CF/HS-10           Diagnostic Follow-Up Form (referral from hearing screening) (E)  [Hot Sheet]  download icon
  • CF/HS-11           Hearing Referral Information to Parents (E/S)  [Hot Sheet] 
  • CF/HS-12           Consent  for Medication  (E/S)  [Hot Sheet]       
  • CF/HS-13           Medication Chart (E/S)  [Hot Sheet]     
  • CF/HS-14           Individualized Health Care Plan (E)  [Hot Sheet]  download icon          
  • CF/HS-15           Temporary Individual Health Care / Emergency Plan for Respiratory Distress (E)  [Hot Sheet]  download icon
  • CF/HS-15.1        Temporary Individual Health Care / Emergency Plan for Respiratory Distress (S)  download icon
  • CF/HS-16           Temporary Individualized Health Care Plan for Anaphylaxis (E)  [Hot Sheet]  download icon
  • CF/HS-16.1        Temporary Individualized Health Care Plan for Anaphylaxis (S)   download icon
  • CF/HS-17           Appointment Reminder (E/S)  [Hot Sheet]  download icon                
  • CF/HS-18           Physical Screening For Children (E/S)  [Hot Sheet] 
  • CF/HS-19           Newborn Health Visit (E)  [Hot Sheet] 
  • CF/HS-19.1        Newborn Health Visit (S)
  • CF/HS-20           Notice of Needed Information/Exclusion (E)  [Hot Sheet] 
  • CF/HS-20.1        Notice of Needed Information/Exclusion (S)   
  • CF/HS-21           Home Based Notice of Needed Information (E)  [Hot Sheet]   
  • CF/HS-21.1        Home Based Notice of Needed Information (S) 
  • CF/HS-22           Medical Billing Form (E)  [Hot Sheet]  download icon           
  • CF/HS-23           Tuberculosis Risk Assessment (E)  [Hot Sheet] 
  • CF/HS-23.1        Evaluacion del Riesgo de Tuberculosis (S) 
  • CF/HS-24           Head Start Tuberculosis Concern Referral (E)  [Hot Sheet]  download icon
  • CF/HS-25           Snack Menu (E)  [Hot Sheet]   download icon
  • CF/HS-26           Food Temperature Record (E)  [Hot Sheet] 
  • CF/HS-27           Medical Statement to Request Special Meals and/or Accommodations (E) Interim Form  [Hot Sheet]     
  • CF/HS-28           Nutrition Concern Form (E)  [Hot Sheet]              
  • CF/HS-29           Food Preference Request (E/S)  [Hot Sheet] 
  • CF/HS-30           Daily Indoor Safety Checklist (E)  [Hot Sheet] 
  • CF/HS-30.1        Lista Diaria de Seguridad Interior (S)    
  • CF/HS-31           Daily Outdoor Safety Checklist (E)  [Hot Sheet] 
  • CF/HS-31.1        Daily Outdoor Safety Checklist (S)  [Hot Sheet]   
  • CF/HS-32           Child Active Supervision Plan (E)  [Hot Sheet]  download icon         
  • CF/HS-32.1        Plan Activo de Supervisión del Niño (S)  [Hot Sheet]  download icon
  • CF/HS-33           Active Supervision Plan (FCCH) (E/S)  [Hot Sheet (E)]  [Hot Sheet (S)]  download icon          
  • CF/HS-34           Parent/Guardian Release of Lead Level Results (E)  [Hot Sheet]    
  • CF/HS-35           Child Asthma Plan-front (E)  [Hot Sheet] 
  • CF/HS-35           Child Asthma Plan-back (E) 
  • CF/HS-36           Fax Cover Sheet  Requesting Info from Doctor (E)  [Hot Sheet]  download icon
  • CF/HS-37           Fieldtrip Checklist (E)  [Hot Sheet] 
  • CF/HS-38           Infant Meal Record (E) Interim Form  [Hot Sheet] 
  • CF/HS-39           Treatment Refusal (E)  [Hot Sheet] 
  • CF/HS-39.1        Rechazo De Tratamiento (S) 

Mental Health (MH)
  • CF/MH-1           Request for an Individual Child Observation (E)  [Hot Sheet]  download icon 
  • CF/MH-2           Head Start & Leaps and Bound Collaboration, Permission for Participation in Head Start Leaps & Bounds Collaboration (E)  [Hot Sheet]  download icon
  • CF/MH-2.1        Colaboracion De Head Start y Leaps & Bounds, El Permiso Para La Participacion en la Colaboracion de ... (S)  download icon

Family Engagement (FE)
  • CF/FE-1             Family Summary and Partnership Agreement (E) Interim Form  [Hot Sheet]  download icon          
  • CF/FE-1.1          Resumen y Acuerdo de Asociación Familiar (S) Interim Form  [Hot Sheet]  download icon          
  • CF/FE-2             Social Service Referral (E/S)  [Hot Sheet]  download icon

Disabilities (D)
  • CF/D-1               Child Success Team Request (E)  [Hot Sheet]  download icon
  • CF/D-1.1            Child Success Team Request (S)  [Hot Sheet] download icon
  • CF/D-2               Notification of a Child Success Team Meeting (E)  [Hot Sheet]  download icon
  • CF/D-2.1            Notificación de la Junta del Grupo de Triunfos del Niño (S)  download icon
  • CF/D-3               Results of Child Success Team Meeting (E)  [Hot Sheet]  download icon
  • CF/D-3.1            Resultados de la Reunión del Equipo del Éxito del Niño (S)  download icon
  • CF/D-4               Head Start Referral for Special Education Services (E)  [Hot Sheet]  download icon
  • CF/D-5               Special Education Meeting Record (E)  [Hot Sheet]  download icon
  • CF/D-6               Parent Permission Form (E/S)  [Hot Sheet]   download icon

Home-Based (HB)
  • CF/HB-1            Home Based Program Admission Agreement/Contract for Services (E)  [Hot Sheet] 
  • CF/HB-1.1         Home Based Program Admission Agreement/Contract for Services (S)  [Hot Sheet]   
  • CF/HB-2            Pregnant Women Emergency Form (E)  [Hot Sheet] 
  • CF/HB-2.1         Pregnant Women Emergency Form (S)  [Hot Sheet] 
  • CF/HB-3            Pregnant Minor Emergency Form (E)  [Hot Sheet] 
  • CF/HB-3.1         Pregnant Minor Emergency Form (S)   
  • CF/HB-4            Teen Father/Minor Emergency Form  (E)  [Hot Sheet] 
  • CF/HB-4.1         Teen Father/Minor Emergency Form  (S)
  • CF/HB-5             Parent Guidelines for Successful Home Visits (E)  [Hot Sheet] 
  • CF/HB-5.1         Parent Guidelines for Successful Home Visits (S)
  • CF/HB-6            Home Visit/Class Conference Release Form (E/S)  [Hot Sheet] 
  • CF/HB-7            EHS Pregnant Women Program Curriculum Tracking Sheet (E)  [Hot Sheet] 
  • CF/HB-8            Family Home Visit Plan (E) Interim Form  [Hot Sheet] 
  • CF/HB-8.1         Family Home Visit Plan (S) Interim Form
  • CF/HB-9            Prenatal Home Visit Plan (E) Interim Form  [Hot Sheet] 
  • CF/HB-9.1         Prenatal Home Visit Plan (S) Interim Form
  • CF/HB-10          Home-Based School Readiness Goals (E) Interim Form  [Hot Sheet]  download icon 
  • CF/HB-10.1       Home-Based School Readiness Goals (S) Interim Form  download icon
  • CF/HB-11          Playgroup Learning Experiences Plan (E) Interim Form  [Hot Sheet]  download icon
  • CF/HB-12          Early Head Start Prenatal Health History (E)  [Hot Sheet] 
  • CF/HB-12.1       Early Head Start Prenatal Historia de Salud (S)
  • CF/HB-13          Patient Health Questionnaire - 9 (PHQ-9) (E)  [Hot Sheet] 
  • CF/HB-13.1       Cuestionario Sobre La Salud Del Paciente - 9 (PHQ-9) (S)
  • CF/HB-14          Home-Based Parent Survey (E) Interim Form  [Hot Sheet]
  • CF/HB-14.1       Home-Based Parent Survey (S) Interim Form
  • CF/HB-15          Parent Survey Compilation (E) Interim Form  [Hot Sheet]
  • CF/HB-16          Home-Based Unannounced Active Supervision Monitoring Report Interim Form  [Hot Sheet] 

Program Management (PM)

Fiscal (F)
  • CF/F-1               Non-Federal Share (E)  [Hot Sheet]  download icon
  • CF/F-1.1            Reporte de horas Voluntarias (S) download icon
  • CF/F-2               Donated Goods and Services Non-Federal Share (E)  [Hot Sheet]  download icon
  • CF/F-2.1             Forma de Servicios y Mercancias Donados (S)  download icon
  • CF/F-3               Non-federal Summary  (E)  [Hot Sheet]  download icon
  • CF/F-4               Delegate Property Inventory (E)(8 1/2" x 11")  [Hot Sheet]  download icon
  • CF/F-5               Delegate Budget Revision Request (E)  [Hot Sheet]  download icon
  • CF/F-6               Delegate Agency Claim (E)  [Hot Sheet]  download icon
  • CF/F-7               Non-Federal Share (NFS) Waiver Request (E)  [Hot Sheet] download icon