Classroom sampling form

APPENDIX 16

CLASSROOM SAMPLING FORM

Classroom

Sampling Form

Program Name:

Center Name:

Center ID:

Center City:

Center State:

Center Phone:

Center Contact Name:

INSTRUCTIONS FOR ON-SITE COORDINATOR: Please include information below ONLY for children funded through FEDERAL ACF MSHS FUNDS.

When finished, please return this form to the Westat study team through the Huddle site, using the login credentials that were sent to you in a separate email. Please do NOT email this information to the study team. If you have questions about this form or accessing Huddle, please call us toll-free at 1-888-XXX-XXXX.

Lead Teacher	Teacher Preferred Language	Classroom Session
First Name Last Name	(Select One) English, Spanish, Other (please specify)	(Select One) AM, PM, Full Day, Other (please specify)	Number of MSHS Infants/Young Toddlers (0-23 Months) Enrolled	Number of MSHS Toddlers (24-35 Months) Enrolled	Number of MSHS Preschool Children (36 Months and older) Enrolled
1.	______________	______________	______________	______________	______________
2.	______________	______________	______________	______________	______________
3.	______________	______________	______________	______________	______________
4.	______________	______________	______________	______________	______________
5.	______________	______________	______________	______________	______________
6.	______________	______________	______________	______________	______________
7.	______________	______________	______________	______________	______________
8.	______________	______________	______________	______________	______________
9.	______________	______________	______________	______________	______________
10.	______________	______________	______________	______________	______________
11.	______________	______________	______________	______________	______________
12.	______________	______________	______________	______________	______________
13.	______________	______________	______________	______________	______________
14.	______________	______________	______________	______________	______________

Paperwork Reduction Act Statement: The referenced collection of information is voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this collection is 0970-0151 and it expires XX/XX/XXXX.

Paperwork Reduction Act Statement: The referenced collection of information is voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this collection is 0970-0151 and it expires XX/XX/XXXX.

Paperwork Reduction Act Statement: The referenced collection of information is voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this collection is 0970-0151 and it expires XX/XX/XXXX.

Paperwork Reduction Act Statement: The referenced collection of information is voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this collection is xxxx-xxxx and it expires XX/XX/XXXX. The time required to complete this collection of information is estimated to average 30 minutes, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the collection of information. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Abt Associates, 55 Wheeler Street, Cambridge MA 02138 Attention: Linda Caswell.