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The Chickasaw Nation Head Start Parent Interview (The Chickasaw Nation)

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The Chickasaw Nation Head Start
Parent Interview
Interviewer will complete highlighted questions. Enrollment will be completed at the interview.
Student name: Birth date: IE OI
Enrollment date: Entry date: Dropped date:
Years of Head Start: _______ Center: Classroom:
Home school district:
Gender: Male Female CDIB: Yes No Tribe: Degree:
Parent/guardian:
Address:
Email address:
Home phone: Work phone: Cell phone:
Legal guardianship documentation form: (Bring documentation to enrollment)
Official birth certificate
Parent DL confirmation
Divorce decree
dated: ___/___/___
Custody court order
dated: ___/___/___
Foster care letter
dated: ___/___/___
Witnessed and notarized parent
note dated: ___/___/___
Temporary custody order
dated: ___/___/___
Emergency contacts:
Relationships Name Address/Town Phone
Other:
Bus: a.m. p.m. Brought to school Picked up CNDH After School
Other child care (list name): Phone no.:
Pick-up restriction:
Are there any health concerns? Yes No If yes, explain:
Date of child’s last physical exam prior to enrollment:
Date of child’s last dental exam prior to enrollment:
Date of the interview: Interviewer:
Updated on: Updated by staff:
Re-enrollment interview: Interviewer:
Page 1 of 7 Form no. 04466PI CS-EDU Rev. 8/2015
The Chickasaw Nation Head Start
Parent Interview
Established medical home at enrollment: Yes No
Established dental home at enrollment: Yes No
Medical coverage and policy ID number:
Routine medications (including prescribed vitamins and supplements):
Allergies:
Current
Physician
Place address and phone number label here
Current
Dentist
Place address and phone number label here
Preferred Clinic
Place address and phone number label here
Preferred Hospital
Place address and phone number label here
Describe the child’s use of communication/language:
Did the mother have any health problems during the pregnancy? Yes No
Explain:
Baby was born full-term early; by weeks late; by weeks
Explain:
What was the child’s birth weight and length?
Weight: pounds ounces Length/height: inches
Has the child been diagnosed as having a growth or weight issue? Yes No
If yes, explain:
Describe any problem at birth:
What non-hospitalized accidents has the child experienced?
Page 2 of 7 Form no. 04466PI CS-EDU Rev. 8/2015
The Chickasaw Nation Head Start
Parent Interview
The child’s milestones: (indicate with the number of months of age)
Age of mastery
Parent concern
Crawl
Stand
Walk
Talk
Feed self
Dress self
Scribble
Potty train
Follow simple
instruction
Expectation ranges for milestones skills to be observed:
• Hearing and speech capacity is fully developed after three months
• Vision capacity is fully developed after seven months
• Crawling six to nine months
• Standing eight to 12 months
• Walking nine to 18 months
• Talking 12 to 24 months
• Feeding self 10 to 18 months
• Dressing self 24 to 36 months
• Scribbling 12 to 36 months
• Potty training 12 to 36 months
• Following simple commands 18 to 24 months
Does the child have difficulty seeing? Yes No
Does the child wear prescription glasses? Yes No
Who prescribed the eyewear?
How is eyewear to be worn?
What ear problems, if any, has child had?
What serious illnesses has the child had, if any?
Page 3 of 7 Form no. 04466PI CS-EDU Rev. 8/2015
The Chickasaw Nation Head Start
Parent Interview
Has the child ever been seen in the emergency room or been hospitalized or admitted for surgery?
Yes No If yes, explain:
Does the child have frequent? (check all that apply)
Cough Sore throats Eye/ear infections
Colds Stomach aches Vomiting
Diarrhea Constipation Rash
Toileting accidents Urinary infections
Bruises
Insect bites None at this time
Has the child had any of these? (check all that apply)
Chicken Pox Eczema Measles Mumps
Scarlet fever Sickle cell Liver disease Boils
Whooping cough Hives Pin worms Transfusions
Heart problems Diabetes Polio Bleeding tendencies
Ulcers Pneumonia Dental pain Major injuries
Broken bones Cancer Kidney problems Rheumatoid arthritis
Scoliosis High fever Syndrome diagnosis
( )
Contagious disease (explain, if not listed above):
None noted at this time (items added after the initial interview will be dated and initialed at the time of the addition).
How often does the child follow directions well? Most of the time Sometimes Not very
often
What chores does the child do at home?
How does the child react to new environments?
Page 4 of 7 Form no. 04466PI CS-EDU Rev. 8/2015
The Chickasaw Nation Head Start
Parent Interview
Who usually spends time with the child during the day? (identify the relationship to child):
Describe the child’s sleep pattern (sound, light, restless, etc.):
Identify the hours that the child usually sleeps (a time range):
Describe what activities interest the child:
Describe the length of the child’s attention span:
What type of toy does the child prefer?
Do you have any specific concerns or questions about the child attending Head Start at this time?
Yes No, not at this time
If yes, explain:
Page 5 of 7 Form no. 04466PI CS-EDU Rev. 8/2015
The Chickasaw Nation Head Start
Parent Interview
Rate the following areas by placing a check mark beneath the response that best describes the child’s preference or
behavior in the situation:
Areas of Consideration: Often At times Seldom
Not
Observed
1
Listens and follows directions quickly
2
Expresses feelings and mood changes appropriately
3
Expresses affection to familiar people
4
Is friendly and smiles a lot
5
Is happy and carefree
6
Is sad
7
Wants help and gets frustrated without assistance
8
Feels the need to fight or argue
9
Throws tantrums
10
Likes quiet places
11
Likes loud places
12
Likes very warm temperature indoors
13
Likes very cool temperature indoors
14
Likes to play indoors in dark places
15
Likes to play indoors in places with a lot of light
16
Enjoys being with other children
Areas of Consideration:
Yes
No
1
Is scared easily
2
Is resourceful and independent
3
Is very shy and bashful
4
Has moved more than one time
5
Has had a family pet that ran away or died recently
6
Has had a family member die recently
7
Lives with only one parent now
8
Has close relationship with grandparent
9
Speaks clearly
10
Worries about getting embarrassed
11
Chooses from more than two choices
12
Transitions to new tasks or situations
13
Likes to pretend and has a good imagination
14
Likes to listen to a book
15
Likes to use scissors and glue
16
Takes turns with one person
17
Likes to help others
18
Listens to books at home
19
Likes to talk
20
Likes to tell stories
21
Likes to sing songs
22
Likes to play outdoors with more than one person
23
Likes to draw
24
Is a picky eater
25
Likes to stack blocks
26
Shares with one or more people
27
Answers questions about stories
28
Performs on cue
29
Remains belted during car rides
Page 6 of 7 Form no. 04466PI CS-EDU Rev. 8/2015
The Chickasaw Nation Head Start
Parent Interview
Dietary Habits:
1. What foods does your child especially like to eat?
2. Are there any foods your child dislikes or should not eat?
Read the question and place
a check mark beneath the
appropriate response.
Yes No
Check the numeral that best approximates number of servings
the child eats per week.
3. Does your child take
vitamins and mineral
supplements?
12. About how often does your child eat foods from each of the
following groups:
a.) Milk, cheese,
yogurt
0*
1*
2*
3
4
5
6
7
+
a.) Contain iron?
b.) Meat, poultry,
fish, eggs or dried
beans/peas,
peanut butter.
0*
1*
2*
3
4
5 6 7 +
b.) Contain fluoride?
c.) Rice, grits, bread,
cereal, tortillas
0*
1*
2*
3
4
5
6
7
+
c.) Prescribed?
d.) Greens, carrots,
broccoli, winter
squash, pumpkin,
sweet potatoes
0*
1*
2*
3
4
5 6 7 +
4. Is there any food your
child should not eat for
medical, religious or
personal reasons?
e.) Oranges,
grapefruit,
tomatoes,
(fruit/juice)
0*
1*
2*
3
4
5 6 7 +
5. Is your child on a special
diet?
f.) Other fruits and
vegetables
0*
1*
2*
3
4
5 6 7 +
a.) What kind?
6. Has there been a big
change in your child’s
appetite in the last month?
g.) Oil, butter,
margarine, lard
0
1
2
3
4*
5* 6* 7* +
7. Does your child take a
bottle?
h.) Cakes, cookies,
sodas, fruit
drinks, candy
0
1
2
3
4*
5* 6* 7* +
8. Does your child eat or
chew things that are not
food?
*Starred answers may require follow-up. Explain details or give
additional comments here.
9. Does your child have
trouble chewing or
swallowing?
10. Does your child often
have:
a.) Diarrhea?
b.) Constipation?
11. Do you have any concerns
about what your child
eats?
Page 7 of 7 Form no. 04466PI CS-EDU Rev. 8/2015
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Completed 31 January 2021

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