Home Visiting Points Verification Form (Centers Only)
To translate the form into Spanish or another language (
Para traducir el formulario al español u otro idioma):
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(Abra el formulario con el navegador web Google Chrome.
Descarga Chrome aquí
.)
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Repeat steps 2-4 on each new form page. (Repita los pasos 2 a 4 en cada nueva página de formulario.)
Early Childhood Education Program Name:
Program Administrator Name:
Email:
Date:
Quality Activity Points
Select the number of home visits
per family
attempted/completed by your program:
1 annual home visit (10 points)
2 annual home visits (20 points)
3 annual home visits (30 points)
Points are allocated on number of home visits attempted, not completed. Learn & Grow understands that there are often circumstances that the educators cannot control that prevent the home visit from being completed.
Number of classrooms in program:
Total Points:
Home Visiting Data
Please fill out the data below for each classroom.
Classroom Data
Ages served in classroom:
Infants
Toddlers
Preschool
School-Age
Number
of children:
Enter 0 if not applicable.
Number
of 1st annual
home visits
attempted
(10 points):
Number
of 1st annual home visits
completed
:
Number
of 2nd annual
home visits
attempted
(20 points):
Number
of 2nd annual
home visits
completed
:
Number
of 3rd annual
home visits
attempted
(30 points):
Number
of 3rd annual
home visits
completed
:
Supporting Documentation
Please upload supporting documentation below that includes:
How your program communicates with families regarding home visits
Home Visiting Staff names and training qualifications
Please upload supporting documentation here: