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Run: Head Start Eligibility Determination and Verification Record

Head Start Eligibility Determination and Verification Record template for documenting eligibility basis, verification efforts, and supporting evidence in one...

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Child and Family Record

Child's Full Name (required)

Child's Date of Birth

Collect only if needed to confirm age eligibility for the program.

Parent/Guardian or Primary Contact Name (required)

Primary Contact Phone Number

Primary Contact Email

Program Site or Center (required)

Eligibility Basis

Eligibility Basis (required)

Categorical Eligibility Type (required)

Income Reference Period (required)

Household Size Used for Determination (required)

Income Eligibility Threshold Used

Document the applicable poverty guideline or income threshold reference used for the determination.

Verification Efforts

Verification Method (required)

Number of Verification Attempts (required)

Verification Result (required)

Verification Notes

Summarize contacts made, dates, and any barriers to verification. Do not include unnecessary PII.

Verification Date (required)

Supporting Documents

Documents Reviewed (required)

Upload Supporting Documents

Attach redacted copies when possible. Avoid uploading documents that contain unnecessary sensitive data.

Document Retention Location

Identify where the source documents are stored for audit trail purposes.

Eligibility Determination and Attestation

Eligibility Determination (required)

Determination Date (required)

Determined By (required)

Staff Title or Role (required)

Staff Attestation (required)

Yes No N/A

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Email (required)

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