___________________________________________________________
ELCD 4000
Revised November 2019
Program Self-Evaluation
Fiscal Year 2019–20
1.
Contractor Legal Name (Full Spelling of Legal Name required. Acronyms or site names not
accepted):
2. Four-Digit Vendor Number:
3.
Program Director Name (as listed in the Child Development Management Information System
[CDMIS]):
4. Program Director Phone Number:
5. Program Director Email:
6. Statement of Completion:
I certify that an annual plan has
been developed and im
plemented for the Program Self-
Evaluation (PSE) that includes the use of the Program Review Instrument (PRI), age
appropriate Environment Rating Scales, Desired Results Parent Survey, Alternative Payment
and/or Resource and Referral Parent Survey, and the Desired Results Development Profile for
all applicable contract types, per
California Code of Regulations
, Title 5 (5
CCR), Section 18279.
I also certify that all doc
uments required as part of the PSE have been completed and are
available for review and/or for submittal upon request.
The Program Review Instrument (https://www.cde.ca.gov/sp/cd/ci/#monitoring)
includes Items 1 through 20 as applicable to your contract type(s):
7.
Signature of Program Director,
as listed in the CDMIS (Wet signature):
8.
Date of Signature:
9.
Name and Title of contact person completing the P
SE:
10.
Contact Person Telephone number:
11.
Contact Person Email Address:
12.
Scan and email the signed PSE, all four (4) pages, including additional sheets, together to
FY1920PSE@cde.ca.gov using the fiscal year and the contractor's legal name in the subject line.
NOTE: All supporting documents required as part of the PSE are to be kept on site and shall not
be included with the submission of the PSE.
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