Image provided by: University of Oregon Libraries; Eugene, OR
About Siletz news / (Siletz, OR) 199?-current | View Entire Issue (June 1, 2008)
TRIBAL PROGRAM NEWS Siletz Tri bal Head Start Family Needs Assessment 2008-2009 Siletz Tribal Head Start is conducting a survey to identify needs that exist in our community. This information is used to determine what programs and ser vices would be relevant for Head Start to offer in the future. Your assistance will help ensure that our program meets your needs. Your input and support is valu able. Thanks! Above: Children are seen observing the “No Diving" sign at the Toledo pool as they await their turns in the water Left photos: Head Start students approach their time at the Toledo pool with varying degrees of trepidation and glee, (photos by Tracey Worman) Siletz Tribal Head Start Health Summary Check One (Optional)_____ Native American Other Where do you live?__ City -------------------- — County Single-Parent Household? NO Foster Parent/Grandparent? NO Total Number of Household Members: Total Number of Children in Family: ___ Age(s) of Primary Caregiver: Age(s) Are any of your children disabled? NO YES Have any of your children been in Head Start? Family Data: YES YES Return this form to : Siletz Tribal Head Start, P.O. Box 549, Siletz, OR, 97380-0549 of Children: ----------------- NO Child's Name:____________________________________ DOB:_______________________ YES Economic Information: Parentis) Employed: ____ Full-time Part-time Not Employed ____ In Training/School Gross Monthly Income:________ Highest Grade Completed by Caregiver:-------- Does Family Receive:____ TANF ____ Food Stamps ____ SSI ____ GA ____ OHP ------ WIC Do you own or rent your home? Monthly Rent/House Payment----------- Transportation: Do you have reliable transportation? NO YES Do you have access to public transportation? NO Childcare: Do you have children in childcare now? NO How much do you pay for care?------------------------- Is it easy to find and use childcare services? NO How would you rate your childcare?_____ Poor Fair This form must be completed and signed by a physician. Please do not defer any tests. Parent/Guardian Name: M __________________ — Phone #: ------------ Medical Personnel Only At risk for Iron Deficiency Anemia [] Yes |) No If yes please perform Het. Or Hgb. Date of Exam: ^ex: Medical Personnel Only At risk for Lead Poisoning [ | Yes 11 No If yes, please perform lead screen/results Examiner’s Name: ------------------------------ Height:_________ Weight:___________ Vision: R L--------------- Hearing: R L Blood Pressure:---------------- Immunizations Needed:________________________________________________ YES YES YES -------- Good _____ Tremendous Please rate the following from highest to lowest priority of need. 1 = highest priority to 14 = lowest need When recording results for the following, please enter: N-normal, A-abnormal, NE-not evaluated. Abdomen: General Appearance: Head:Skin: -------- Glands:_____ Lungs:_______ Nose/Mouth/Pharynx:_______ Heart:----------- Muscular Coordination:Bones/Joints/Muscles: Eves: Ears:Genitalia: ____ Preschool/Head Start ____ Literacy ____ Nutrition ____ Cultural Activities ____ Other___________________ I. Does this child's medical history and/or examination indicate any condition that would limit her/his participation in Head Start activities: None Yes Specify:____________________________________________________________ Should Head Start services be (please circle one for each of the three questions): 2. Full-Year or Part-Year Part-day 1. Full-day or Home-Based 3. Classroom or 2. Is any further medical treatment or specific health recommendation neces sary for this child? None Yes Specify:-------- ____ Education -Employment Housing Recreation Dental Care Health Care -Parenting Childcare ____ AIcohol/Drug Awareness Should Head Start services serve children ages 0 - 3 years? Any other comments?- Yes No Physician Signature: . Clinic/Office Address: Telephone:_________ June 2008 • Siletz News • 7
