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