Head Start Home Visit Documentation Form

Documents home-based Head Start visits, including parent-child interaction activities, health and nutrition education delivered, observations, and goals for the next visit in alignment with 45 CFR Part 1302.

Visit Details

• Visit Date
  Select the date the home visit occurred.
• Start Time
  Optional: record the time the visit began.
• End Time
  Optional: record the time the visit ended.
• Visit Type
  Choose the type of home visit documented.
• Staff Member Completing This Form
  Enter the name or identifier of the staff member documenting the visit.

Participants and Family Engagement

• Who Participated in the Visit?
  Select all participants present during the visit.
• Parent-Child Interaction Activities
  Describe the activities used to support parent-child interaction, such as reading, play, routines, or learning activities.
• Family Engagement Observations
  Record notable observations about engagement, strengths, or barriers observed during the visit.

Health and Nutrition Education

• Was Health Education Provided?
  Select yes if any health education was delivered during the visit.
• Was Nutrition Education Provided?
  Select yes if any nutrition education was delivered during the visit.
• Health Education Topics
  Select the health topics discussed during the visit.
• Nutrition Education Topics
  Select the nutrition topics discussed during the visit.
• Education Summary
  Summarize the key points, resources, or materials shared. Avoid collecting unnecessary PII.

Child and Family Needs

• Child Observations
  Record relevant observations about the child's development, behavior, or participation during the visit.
• Family Strengths
  Describe strengths, protective factors, or successful routines observed during the visit.
• Concerns or Barriers
  Document any concerns or barriers affecting participation, follow-through, or family goals.
• Referrals or Resources Provided
  List any referrals, resources, or follow-up supports provided during the visit.

Next Visit Goals and Follow-Up

• Primary Goal for the Next Visit
  Describe the main goal to address at the next home visit.
• Next Visit Focus Area
  Choose the primary focus for the next visit.
• Follow-Up Actions Needed
  Describe any actions to complete before the next visit.

Attestation

• I confirm this documentation is accurate to the best of my knowledge.
  Required attestation for the audit trail.