Program & Classroom Profile

Person completing this form: Michelle Belanger Youth and Family Program Name/School Name: Outreach 207-874207-8742373 Phone: Fax: 1073 1. Is your program a contracted agency with DHHS? Date: License # Email:
Yes

TA# ______
For office use

1/28/2013 207461
Michelle@yfo utreach.org No

2. Is your program an approved Child Development Services (CDS) special No Yes instruction (developmental therapy) site? 3. How many of your program staff are registered in the Maine Roads to Quality None Half All (MRTQ) training registry? 4. Does your program currently have a DHHS childcare quality certificate or Quality Rating System (QRS) Level? Please indicate how you qualify by checking all that apply:
Quality Certificate Step on the Quality Rating System

National Association for Family Child Care (NAFCC) Accreditation National Association for the Education of Young Children (NAEYC) Accreditation National AfterSchool Association (NAA) Council on Accreditation (COA) Head Start Program of Excellence (Gold or Blue Designation) American Montessori Society Accreditation

5. Does your program use a written curriculum? If yes, which one?

Creative Curriculum High Scope Montessori Opening the World of Learning (OWL) Other (describe):

Yes

No

6. Your program has been in operation for:

Under 1 year 1-2 years 3-5 years Over 5 years

7. Hours of operation are: 6:30am

to

5:30pm

8. Our program/school is able to serve children between the ages of:

Infant (6 weeks to 12 months) Preschool (30 months to 5 years) Mixed age group; please specify: Other; please specify: Toddler (12 months to 30 months) School age (5-12 years)

9. Our program is licensed to serve the following numbers of children:

3-12 13-20 21-49 50 or more

10. Our current total program enrollment:

63

11. Our current total number of "permanent/regular" staff 14 members: * Permanent means employed by the program on a permanent basis and are not practicum students, volunteers, or substitutes. 12. Please indicate the total number of children in your entire program who are part of each of the following groups:
Children with diagnosed special needs/disabilities Children with a mental health diagnosis Children who have been referred to Child Development Services (CDS) and are in the screening/evaluation process Children receiving early intervention or special education services and have an IFSP or IEP Children in foster care Children/families receiving ASPIRE/TANF (Temporary Assistance for Needy Families) Children involved with child protective services Children receiving child care vouchers Children on the waiting list for child care vouchers Children in contracted child care slots Children who are English Language Learners

Total #: Total #: Total #: Total #: Total #: Total #: Total #: Total #: Total #: Total #: Total #:

10 13 1 10

18 1 5

16

13. In the past year, have any children been expelled from your program?
Yes No

If yes how many?

how many_____ how many_____

Reasons:
Child behavior Child medical issues

Other (describe)_____________________________________________

14. Does your program have regularly scheduled staff meetings? How often?
weekly monthly quarterly

Yes

No

other (describe)

15. Does your program have regular classroom planning time? How often?
daily 2x weekly weekly monthly other (describe)

Yes

No

16. Have any of the following been completed in your program? (check all that apply) Early Childhood Environment Rating Scale (ECERS) Date: Nov-12
Infant/Toddler Environment Rating Scale (ITERS) Family Child Care Rating Scale (FCCRS) School-Age Care Rating Scale CLASS Other (describe)

Date: Date: Date: Date:

17. Have you and/or your staff received training to care for children with special needs? (Please check all that apply)
ADA Other (describe) IDEA MRTQ Inclusion MRTQ Leadership DECA Yes No

18. Have you or your staff received training in the Early Childhood Learning Guidelines?
Yes No

19. Have you or your staff received training in the Infant/Toddler Guidelines?
Yes No

20. How many staff members have experience with the IFSP/IEP process? (number of staff)
None 1-3 4-6 7 or more

21. Is your program currently involved in the Maine Roads to Quality (MRTQ) Accreditation Project? Yes No If yes, please identify your cohort leader: 22. Does your program received technical assistance or consultation from any No other individual agency or organization? Yes If yes, please identify your consultant: Classroom(s) Information If this request involves a single classroom or multiple classrooms, please complete the following section(s):

Classroom #1 Name: Name of Classroom Teacher/Contact Person: 1. Please indicate the age group of this classroom:
Infant (6 weeks to 12 months) Preschool (30 months to 5 years) Mixed age group; please specify: Other; please specify: Toddler (12 months to 30 months) School age (5-12 years)

2. Current total classroom enrollment: 3. Current total number of "permanent/regular" program staff members in classroom:______________ 4. Please indicate the total number of children in this classroom who are part of each of the following groups:
Children with diagnosed special needs/disabilities Children with a mental health diagnosis Children who have been referred to Child Development Services (CDS) and are in the screening/evaluation process Children receiving early intervention or special education services and have an IFSP or IEP

Total #: Total #: Total #: Total #:

Classroom #2 Name: Name of Classroom Teacher/Contact Person: 1. Please indicate the age group of this classroom:
Infant (6 weeks to 12 months) Preschool (30 months to 5 years) Mixed age group; please specify: Other; please specify: Toddler (12 months to 30 months) School age (5-12 years)

2. Current total classroom enrollment: 3. Current total number of "permanent/regular" program staff members in classroom:______________ 4. Please indicate the total number of children in this classroom who are part of each of the following groups:
Children with diagnosed special needs/disabilities Children with a mental health diagnosis Children who have been referred to Child Development Services (CDS) and are in the screening/evaluation process Children receiving early intervention or special education services and have an IFSP or IEP

Total #: Total #: Total #: Total #:

Classroom #3 Name: Name of Classroom Teacher/Contact Person: 1. Please indicate the age group of this classroom:
Infant (6 weeks to 12 months) Preschool (30 months to 5 years) Mixed age group; please specify: Other; please specify: Toddler (12 months to 30 months) School age (5-12 years)

2. Current total classroom enrollment: 3. Current total number of "permanent/regular" program staff members in classroom:_____________ 4. Please indicate the total number of children in this classroom who are part of each of the following groups:
Children with diagnosed special needs/disabilities Children with a mental health diagnosis Children who have been referred to Child Development Services (CDS) and are in the screening/evaluation process Children receiving early intervention or special education services and have an IFSP or IEP

Total #: Total #: Total #: Total #:

Please complete the following to assist us in knowing how best to plan our technical assistance support. 1. What has prompted you to call now about this issue? Michelle has offered this assistance to Youth and Family Outreach at a time when budgets are tight and resources are low.

2. What steps have been taken with teaching staff and administrators to address your concern?

Talked to other center directors and staff about needs and resources needed. Also tried to get out in the community to put YFO name out there.

3. Who else have you consulted/talked to about your concern? Other Staff and other directors

Notes: