Profit/Non-profit Sponsors and Child Care Centers

APPENDIX C3. CENTER ENROLLMENT FORM

OMB Number: 0584-XXXX

Expiration Date: XX/XX/XXXX

ERRONEOUS PAYMENTS IN CHILD CARE CENTERS STUDY (EPICCS)

CENTER ENROLLMENT FORM

Summary

Field Data Collectors will collect this data from the master list of enrolled. While onsite, the data will be abstracted and entered on computerized data entry forms. This data will be compared to eligibility status recorded on the income eligibility application, and meal claiming records during data analysis.

Data variables that can be pre-loaded into this instrument are: Sponsor Name, Sponsor Study ID, sampled child care center name, child care center study ID, and target month.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-XXXX. The time required for the child care center director or manager to access to the center’s administrative records is estimated to average 5 minutes per response including the time to review instructions, search existing data resources, gather and maintain the data needed, and complete and review the collection of information.

Center Name: Center Study ID: | | | | | | | | | Date of Data Collection: | | | / | | | / | | |

MONTH DAY YEAR

Sponsor Name: Sponsor ID: | | | | | | | | |

Target Month: | | |/ | | | | |

MONTH YEAR

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1. CHILD ENROLLMENT

Complete the following table for each enrolled child. Do not include non-enrolled students who may attend the center on a special visit.

Child Name: Click here to enter text.	Age (at Last Birthday): Click here to enter text.	Enrollment Date: Click here to enter text.	Eligibility Status (Check One): Certification Status Date: ☐ Free ☐ Reduced ☐ Paid | | | / | | | / | | |
Parent/Guardian Name: Click here to enter text.	Phone: Click here to enter text.	Email: Click here to enter text.	Address: Click here to enter text.

*This table/grid repeats for each child enrolled.

2. SPECIAL NOTES / COMMENTS:

Provide any additional comments regarding center enrollment.

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