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
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Siletz News
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