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Head Start Eligibility Verification (fr_HeadStartEligibilityVerification)


The Head Start Program Eligibility Verification form is used as the signed statement by an employee identifying those documents which were reviewed to determine eligibility. The form is provided by U.S. Department of Health and Human Services with instructions to include the form in each child's record. (Ref Log No. ACF-IM-HS-09-01)

Data Set Items

    Birthdate(Click the link to view the associated Common Attribute) - Date of birth of child

Documentation Used to Determine Eligibility - Documentation used to determine eligibility (select all that apply)

Code Set:

  • Documentation of no income
  • Foster care reimbursement
  • Income Tax Form 1040
  • Other
  • Pay stub or pay envelopes
  • + 5 More Codes...

Explanation of Documentation of No Income - Explanation of documentation of no income

Explanation of Other Documentation - Explanation of other documentation used, if relevant

Name of Child - Name of child

Program Entry Date - Date of child's entry into program

Staff Name - Name of staff member who completed the document review

Staff Signature - Signature of staff member who completed the document review

Staff Signature Date - Date that form is signed.

Staff Title - Title of staff member who completed the document review

Status of Child as Foster Child - Child is in foster care

Status of Child as Homeless - Child or family is homeless

Status of Child on Public Assistance - Child or family is receiving public assistance

Status of Income - Income status relating to federal poverty guidelines

Code Set:

  • American Indian/Alaska Native Over Income
  • Below federal poverty guidelines
  • Between 100-130% of federal poverty guidelines
  • Over income