Western Idaho Community Action Partnership, Inc.

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WICAP Letterhead - your e-mail logon & password are required to open this link

Brochure Request Form

Request NCR Forms

Ages & Stages Questionnaire

 

Ages& Stages Questionnaire (Social/Emotional)

ASQ Scoring Sheet

Community Partnerships

(HS 1200 - HS 1299)

 

Education  

(HS 100 - HS 199)

ERSEA  

(HS 200 - HS 299)

Facilities   

(HS 700 - HS 799)

 

Family Services

(HS 1000 - HS 1099)

Health 

(HS 300 - HS 399)

HS Admin 

(HS 500 - HS 599)

 

Mental Health & Disabilities  

(HS 800 - HS 899)

 

Monitoring 

(M 01 - M 99)

 

Nutrition  

(HS 400 - HS 499)

Reports  

(R 01 - R 99)

Training  

(HS 900 - HS 999)

 

Transportation

(HS 01 - HS 99)

WICAP Admin  

(W 1 - W  99)

Ages & Stages Questionnaire

ASQ 4 mo ASQ 14 mo ASQ 2 yr ASQ 5 yr
ASQ 6 mo ASQ 16 mo ASQ 27 mo ASQ 42 mo
ASQ 8 mo ASQ 18 mo ASQ 30 mo ASQ 4 yr
ASQ 10 mo ASQ 20 mo ASQ 33 mo ASQ 54 mo
ASQ 1 yr ASQ 22 mo ASQ 3 yr ASQ Scoring Sheet

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Ages & Stages Questionnaire - Social/Emotional

ASQ:SE 6 mo ASQ:SE 18 mo ASQ:SE 30 mo ASQ:SE 4 yr
ASQ:SE 1 yr ASQ:SE 2 yr ASQ:SE 3 yr ASQ:SE 5 yr

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Community Partnership Forms

=NCR Form

Form Number Description
HS 1200 Intake Application P-5 Yrs
HS 1201 Community Partnership Meeting P-5 Yrs
HS 1202 Home Base Transition Plan
HS 1202(a) Transition Into Combination Plan P-3 Yrs
HS 1203 Combination Transition Plan P-3 Yrs
HS 1203(a) Transition into Center based Plan P-3 Yrs
HS 1204 Transition In Plan P-3 Yrs
HS 1205 Transition Through and/or Out of Head Start P-5 Yrs
HS 1206 Shared Families Transition P-5 Yrs

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Education Forms

=NCR Form

Form Number Description
HS 100 Weekly Lesson Plan 3-5 Years
HS 100(a) Class Planner P-5 Years
HS 101 Weekly Combination Lesson Plan
HS 102 Monthly Classroom Calendar P-5 Years
HS 103 Individual Children’s Observations (E&S) P-5 Years
HS 104 Classroom Outcomes Planning 3-5 Years
HS 105 Class Summary Worksheet 3-5 Years
HS 106 Small Group P-5 Yrs
HS 107 Socialization Form P- 5 Yrs
HS 108 Education Home Visit & Parent-Teacher Conference Form 3-5 Years
HS 109 Required Assessment Entries Form: 0-18 Months
HS 110 Required Assessment Entries 18m-36m Log
HS 111 Required Assessment Entries Form:  18-36 Months
HS 112 Required Assessment Entries 3-5 Years Log
HS 113 Field Trip Request Form P-5 Years
HS 114 Education Supply List P-5 Years

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ERSEA Forms

=NCR Form

Form Number Description
HS 200  Application for Enrollment P-5 Years View Document
HS 200(sp) Application for Enrollment – Spanish Guide P-5 Years View Document
HS 200(a) Application for Enrollment of Pregnant Women P-5 Years View Document
HS 200(b) Enrollment Screening Instrument P-5 Years
HS 201 Homeless Verification Statement P-5 Years
HS 202 Attendance/Transition Report P-5 Years (online)
HS 203 Recruitment Tracking Guide Data Sheet P-5 Years
HS 204 Income Re-verification Form P-5 Years
HS 205 Self-Employed/ Self-Declaration Income Verification Statement P-5 Years
HS 206 Non-Income Verification Statement P-5 Years
HS 207 Enrolled 3 Yr Old Returning List 3-5 Yrs
HS 208 Classroom Roster P-5 Years
HS 209 Recruitment of Children with Diagnosed or Suspected Disabilities P-5 Years
HS 210 Application Checklist P-5 Years
HS 210(sp) Application Checklist –  P-5 Years Spanish

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Facilities Forms

=NCR Form

Form Number Description
HS 700 Custodial & Paper Supply Order P-5 Years
HS 701 Health and Safety Guidance P-5 Years
HS 702 Lawn Equipment Checklist P-5 Years
HS 703 Disaster Action Drill Checklist P-5 Yrs
HS 704 Receipt of Agency Keys P-5 Yrs
HS 705 Checklist for Closing Sites P-5 Yrs

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Family Services Forms

=NCR Form

Form Number Description
HS 1000 Home Visit Checklist   3-5 Years
HS 1001 Home Visit Form   P-5 Years
HS 1002 Prenatal Home Visit Form P-3 Years
HS 1003 Door Hanger “Sorry, We Missed You”   P-5 Years (Spanish & English) View Document
HS 1004 Orientation Checklist   P-5 Years View Document
HS 1005 Permission Slip P-5 Years
HS 1006 Circle of Support – Family Partnership Plan P-5 Years
HS 1006(sp) Circle of Support – Family Partnership Plan P-5 Years - Spanish
HS 1007 Home Visit Form Combination P-3 Years
HS 1008 Family Partnership Plan P-5 Years View Document
HS 1008(sp) Family Partnership Plan P-5 Years - Spanish
HS 1009 Family Assessment P-5 Years
HS 1009(sp) Family Assessment P-5 Years - Spanish
HS 1010 Family Contact Record Combination P-3 Years
HS 1011 Child/Family Individual Staffing Plan P-5 Years
HS 1012 Shared Families Documentation P-5 Years
HS 1013 Ballot for Committee Officers (form fields) P- 5 Yrs
HS 1014 Parent Elections P-5 Years
HS 1015 Indirect/Direct Service for Referral or Advocacy P-5 Years View Document
HS 1016 My Pregnancy Memory Notebook
HS 1017 Child/Family Form Tracking System & Access Log P-5 Years
HS 1017(a) Child/Family File Access Log P-5 Years
HS 1017(b) Child/Family Form Tracking System –Family Services P-5 Years
HS 1017(c) Child/Family Form Tracking System – Children Services P-5 Years - Debbie
HS 1017(d) Child/Family Form Tracking System –Nutrition P-5 Years - Merlene
HS 1017(e) Child/Family Form Tracking System –Health Services P-5 Years - Merlene
HS 1018 Parent Training Guide of Responsibilities P-5 Years
HS 1019 Parent Activity/Meeting Training Guide P-5 Years
HS 1020 Parent Committee Meeting Agenda P-5 Years
HS 1021 Parent Committee Meeting Minutes P-5 Years
HS 1022 Request for Child Care and/or Transportation (E&S)

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Health Forms

=NCR Form

Form Number Description
HS 300 Emergency Record P-5 Years
HS 301 Adams Co Authorization to Release/Share Information and/or Records P-5 Years
HS 301 Admin Authorization to Release/Share Information and/or Records P-5 Years
HS 301 Admin (sp) Authorization to Release/Share Information and/or Records - Spanish P-5 Years
HS 301 Boise Co Authorization to Release/Share Information and/or Records P-5 Years
HS 301 Emmett Authorization to Release/Share Information and/or Records P-5 Years
HS 301 Happy Day Authorization to Release/Share Information and/or Records P-5 Years
HS 301 Marble Front Authorization to Release/Share Information and/or Records P-5 Years
HS 301 Marsing Authorization to Release/Share Information and/or Records P-5 Years
HS 301 Payette Authorization to Release/Share Information and/or Records P-5 Years
HS 301 Valley Co Authorization to Release/Share Information and/or Records P-5 Years
HS 301 Weiser Authorization to Release/Share Information and/or Records P-5 Years
HS 301 Wilder Authorization to Release/Share Information and/or Records P-5 Years
HS 302  Individual Child Health Plan P-5 Years
HS 303 Administering Medication and Medical Procedures Consent Form P-5 Years
HS 303 (a) Medication Dispensing Sheet P-5 Years
HS 304 Dental Screening P-3 Years
HS 305 Daily Health Check P-5 Years
HS 306 Program Child Referral P-5 Years View Document
HS-306(a) Referral for Special Services P-5 Years View Document
HS 307 Child Health Record 3-5 Years
HS 308 Insurance Documentation P-5 Years
HS 309 Hearing Screening Systems 3-5 Years
HS 310 Denial of Consent for Dental and/or Physical Exam P-5 Years
HS 311 Hearing Screening Tracking Sheet 3-5 Years
HS 312 Vision Screening Tracking Sheet 3-5 Years
HS 313 2 Week Mother’s Well Being Assessment P-5 Years
HS 314 Checklist for Center First Aid Kit P-5 Years
HS 314(a) Checklist for Backpack First Aid Kit P-5 Years
HS 314(b) Checklist for Bus/Vehicle First Aid Kit P-5 Years
HS 315 Heights and Weights Screening Form 3-5 Years
HS 316 Prenatal Assessment Form P-3 Years
HS 317 Initial Summary Form – Screening for Vision/Hearing Concerns P-3 Years
HS 317(a) Parent Interview – Vision and Hearing Concerns P-3 Years
HS 317(b) Medical/Family History Review – Vision and Hearing Concerns P-3 Years
HS 317(c) Observations That May Indicate Visual Impairment or Hearing Loss in Young Children P-3 Years
HS 318 Diapering Schedule P-5 Years
HS 319 Health Action Plan P-5 Years
HS 320 Infant Health Assessment – 2 Week Visit P-3 Years
HS 321 Child Health History P-5 Years
HS 322 Certificate of Exemption, School Immunization Requirement P-5 Years (Adobe P)
HS 322(sp) Certificate of Exemption, School Immunization Requirement P-5 Years - Spanish
HS 323 Adams Co Health Status Determination P-5 Years (Site Specific)
HS 323 Boise Co Health Status Determination P-5 Years (Site Specific)
HS 323 Emmett Health Status Determination P-5 Years (Site Specific)
HS 323 Happy Day Health Status Determination P-5 Years (Site Specific)
HS 323 Marble Front Health Status Determination P-5 Years (Site Specific)
HS 323 Marsing Health Status Determination P-5 Years (Site Specific)
HS 323 Payette Health Status Determination P-5 Years (Site Specific)
HS 323 Valley Co Health Status Determination P-5 Years (Site Specific)
HS 323 Weiser Health Status Determination P-5 Years (Site Specific)
HS 323 Wilder Health Status Determination P-5 Years (Site Specific)
HS 324 Adams Co Oral Health Status Determination P-5 Years (Site Specific)
HS 324 Boise Co Oral Health Status Determination P-5 Years (Site Specific)
HS 324 Emmett Oral Health Status Determination P-5 Years (Site Specific)
HS 324 Happy Day Oral Health Status Determination P-5 Years (Site Specific)
HS 324 Marble Front Oral Health Status Determination P-5 Years (Site Specific)
HS 324 Marsing Oral Health Status Determination P-5 Years (Site Specific)
HS 324 Payette Oral Health Status Determination P-5 Years (Site Specific)
HS 324 Valley Co Oral Health Status Determination P-5 Years (Site Specific)
HS 324 Weiser Oral Health Status Determination P-5 Years (Site Specific)
HS 324 Wilder Oral Health Status Determination P-5 Years (Site Specific)
HS 325 Health Overview P-5 Years
HS 326 Health and Nutrition Summary P-5 Years

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Head Start Administration Forms

=NCR Form

Form Number Description
HS 500 Sign In and Sign Out Form P-5 Yrs
HS 501 Equipment Checkout and Return Agreement P-5 Years
HS 502 Petty Cash Ledger P-5 Years
HS 503 Message Reply Form P-5 Years
HS 504 Office Supply Order Form P-5 Years
HS 505 Unconditional Positive Regard Policy and Confidentiality Policy P-5 Years
HS 506 Parent Evaluation of WICAP Head Start
HS 506(a) Parent Evaluation of WICAP Head Start (Spanish) P-5 Years
HS 507 Staff Annual Program Survey P-5 Years
HS 508 Community Survey P-5 Years
HS 509 Employee of the Month Application Form
HS 510 Reimbursement Request for Child Care Expenses Incurred By Parents/Guardians Off Site
HS 511 Policy Council Profile P-5 Years
HS 512 Team Meeting Agenda P-5 Years
HS 513 Management Team Meeting Agenda – Admin P-5 Years
HS 514 In-Kind Contribution Record P-5 Years
HS 515 In-Kind Use of Home Visit/Home Visit Documentation P-5 Years
HS 516 Regular Volunteer Time Sheet P-5 Years
HS 517 Volunteer Activity Record P-5 Years
HS 518 Family/Child Goal In-Kind Record P-5
HS 519 Family Goal In-Kind Record P-5 Years
HS 520 Request for Dollars P-5 Yrs
HS 521 Mental Health Consultant Questionnaire P-5 Yrs

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Mental Health/Disabilities Forms  

=NCR Form

Form Number Description
HS 800 Special Services P-5 Years View Document
HS 801 Developmental and Mental Health Screener P-6 Months
HS 802 Developmental and Mental Health Screening Results P-5 Years (Bilingual)
HS 803 Articulation Screener-English & Spanish P-5 Years
HS 804 Comprehensive Social/Emotional Screening Form P-5 Years
HS 805 Edinburg Postnatal Depression Scale (EPDS) P-3 Years
HS 806 Temperament Screener P-3 Years
HS 807 Special Services Contact Record P-5 Years

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Monitoring

=NCR Form

Form Number Description
M 01 Site/Visit Observation Documentation P-5 Years
M 02 Pre-Approval Visit Form
M 03 Team Meeting Monitoring/Observation
M 04 Transportation Bus Driver Monitoring Record P-5 Years
M 05 Teacher-Monitor Monitoring Record
M 06 Custodial Monitoring Record P-5 Years
M 07 Monitoring of Home Visits and Family Partnership Plan P-5 Yrs 
M 08 Home Visit Monitoring Observation Form P-5 Yrs
M 09 Orientation Observation
M 10 Parent Activity Monitoring/Observation Form P-5 Yrs
M 11 Safe Environment Inspection
M 12 Referral Monitoring Form
M 13 Sponsoring Organization Review Form
M 14 Checklist for EHS Classrooms P-3 Yrs
M 15 Checklist for Preschool Classrooms 3-5 Yrs
M 16 Guiding Behaviors, Part 1-EHS & Preschool P-5 Yrs
M 17 Guiding Behaviors, Part 2-EHS & Preschool P-5 Yrs

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Nutrition Forms

=NCR Form

Form Number Description
HS 400 Temperature Inspection Record P-5 Years
HS 401 Menu Substitution P-5 Years
HS 401(a) Cook's/Center's Choice Menu P-5 Years
HS 401(b) Emergency Menu Planning P-5 Years
HS 402 Application for Free or Reduced Price Meals P-5 Years
HS 403 Blended Rate Meal Count Sheet P-5 Years
HS 404 Production Sheet - Breakfast P-5 Years
HS 405 Production Sheet - Lunch and Supper P-5 Years
HS 406 Production Sheet - AM or PM Snack P-5 Years
HS 407 Infant Production Record P-3 Years
HS 408 Health Nutrition Assessment P-5 Years     
HS 409 Nutrition Experience P-5 Years
HS 410 Food Inventory P-5 Years
HS 411 Special Diet Statement for Older Children (1+ years)
HS 412 Special Diet Statement for Infants
HS 413 Medical Statement for Food Substitutions P-5 Years
HS 414 Nutrition Assessment Prenatal P-3 Years
HS 415 Nutrition Assessment:  Postpartum P-3 Years
HS 416 Parent’s Observation of Eating Habits P-18 Months
HS 417 Standard Grocery List
HS 418 Grocery List for Menu

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Reports

=NCR Form

Form Number Description
R 02 Children Services Field Advisor Monthly Report P-5 Years
R 03 Family Service Field Advisor Monthly Report P-5 Yrs
R 04 Policy Council Report From Parent Committee P-5 Years
R 05 Parent Committee Report from Policy Council P-5 Years
R 06 Teacher's Monthly Report & File Monitoring P-5 Yrs
R 07 Family Advocate Tracking
R 08 Family Advocate Monthly Report
R 09 Home base/Combination Monthly Report

R 10

Pg1

Pg2

 Transportation Field Advisors Monthly Report P-5 Yrs
R 11 Bus Driver's Monthly Report P-5 Yrs
R 12 60 Day Inspection & Vehicle Maintenance Report
R 13 Bus Driver's Report on School Bus Passing Violation P-5 Yrs
R 14 Vehicle Accident Report P-5 Yrs
R 15 Cooks Nutrition Monthly Report
R 16 Attendance/Transition Report
R 17 Volunteer/Children’s Injury/Accident Report P-5 Years
R 18 Sick Child Report P-5 Years
R 19 Facilities Field Advisor Month End Report
R 20 Suspected Child Abuse/Neglect Report P-5 Years View Document

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Training Forms

=NCR Form

Form Number Description
HS 901 Checklist for Required Records 
HS 902 Agenda P-5 Years
HS 903 Application for Training P-5 Years
HS 904 Approval of Training Application P-5 Years
HS 905 Professional Development Plan P-5 Yrs
HS 905(a) Progress Toward Professional Development Plan P-5 Yrs
HS 906 Individual Annual Training Assessment P-5 Yrs
HS 907 Individual Staff Training Record P-5 Years
HS 908 Training Presenter Contract P-5 Years
HS 909 Bus Driver Training P-5 Yrs 
HS 910 Teacher Monitor Training P-5 Yrs
HS 911 Training Attendance Log P-5 Years
HS 912 Training Evaluation P-5 Years
HS 912(sp) Training Evaluation P-5 Years
HS 912(a) Individual Presentation Workshop Evaluation P-5 Years
HS 913 Parent Training Plan – Method for Developing the Parent Training Plan for Site P-5 Years
HS 913(a) Parent Training Plan – Appendix A, P-5 Years
HS 914 Parent Training – Site Tracking Sheet, P-5 Years
HS 915 Parent Training Agenda (Bi-Lingual) P-5 Yrs

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Transportation Forms

=NCR Form

Form Number Description
HS 01 Daily Pre and Post Trip Maintenance Checklist P-5 Years
HS 02 Bus Roster Checklist P-5 Years
HS 03 Bus Driver Roster List P-5 Years
HS 04 Weekly Bus Activities Planning 3-5 Yrs
HS 05 Transportation Agreement Between WICAP Head Start and Head Start Family P-5 Years
HS 06 Vehicle Log P-5 Years
HS 07 Vehicle/Bus Assigned to Bus Drivers and Staff

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WICAP Administration Forms

=NCR Form

Form Number Description
W 01 Time & Activity Record -  HMS, YC, HS
W 01(a) Time & Activity Record - Indirect, CSBG, HSG, TEFAP, EA
W 02 Travel Expense Statement - Mileage (auto-calculating spreadsheet, can be printed for Hand Completion)
W 03 Long Distance Telephone Record
W 04 IRS form W 4
W 09 Office Supply Order Form
W 10 Inventory Check Out
W 11 Donated Inventory Items
W 13 Inventory Transfer/Disposal Form
W 15 Statement of Contribution
W 16 Hold Harmless Agreement
W 17 Volunteer Record
W 18 In-Kind Contribution Report
W 23(a) Change of Address
W 24 Checklist for Termination of Employee
W 26 Automobile Insurance Form (Used in Admin Office Only)
W 27 Request for Travel
W 28 Travel Back Voucher
W 30 Petty Cash Voucher
W 31 Incoming Mail Log 
W 35 Cellular Phone Policy/Procedure
W 36 Cellular Phone Agreement
W 38 Application for Volunteers

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