Head Start Home Visit Documentation Form

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

Visit Information

• Visit Date
• Start Time
• End Time
• Visit Type
• Visit Location
  Enter the general location only. Do not include unnecessary PII.

Participants

• Staff Member Name
• Family Members Present
  List roles or first names only if needed for the record. Avoid collecting unnecessary PII.
• Was the enrolled child present?
• Other Participants
  Include only participants relevant to the visit, such as interpreter, home visitor, or support person.

Parent-Child Interaction Activities

• Activities Completed
• Observations of Parent-Child Interaction
  Describe observable engagement, responsiveness, and participation.
• Child Engagement Level

Health and Nutrition Education

• Topics Covered
• Health and Nutrition Education Delivered
  Summarize the information shared, materials used, and any family questions addressed.
• Materials Provided
• Follow-Up Needed for Health or Nutrition?
• Health or Nutrition Follow-Up Details
  Describe the follow-up action, referral, or resource needed.

Family Strengths, Concerns, and Next Steps

• Family Strengths Observed
  Note strengths related to routines, engagement, communication, or caregiving.
• Family Concerns or Barriers
  Document only concerns relevant to service coordination or follow-up.
• Referrals Made
• Goals for the Next Visit
  State the planned goals, activities, or follow-up items for the next home visit.
• Staff Attestation
  Confirm the documentation is accurate and complete to the best of your knowledge.