Sample Weighted Eligibility Form

Preschool for All Sample Eligibility Form

Instructions for developing an eligibility form. This is a sample form. Each program will develop its own eligibility form that consists of weighted criteria based on the risk factors present in their own community. The weighted criteria form will be completed with information obtained from the parent interview form and information gleaned from the child screening instrument. Programs will serve those children and families most in need in the community determined by those exhibiting the most at-risk factors as determined by a weighted criteria form uniquely created by each individual program. Programs will develop weighted criteria based upon the risk factors required in the PFA RFP, the risk factors present in the community, and those factors identified by research as causing children and families to be at risk.

Programs will utilize the individualized weighted criteria system for (a) Enrolling families identified as having most at risk factors, (b) Ensuring families with the most at risk factors are prioritized on a waiting list (if applicable). After a family is enrolled in the program they are allowed the opportunity to continue services for the duration of the program until Kindergarten eligible or otherwise defined in the child’s IEP. The family may voluntarily leave the program. Screening for eligibility and this form are only completed one time.

Child’s Full Name: ______Birth Date: ______Age: ______

School/Program Name :______

Parent Name: Parent Name: ______Phone: ______

Phone: Address: ______City______Zip ______

Address: ______

City______Zip ______The following are worth 50 points each: (If a child presents with any one of these risk factors (numbers 1-3) the family should be considered the highest priority and be directly enrolled in the PFA program or placed at the top of the PFA waiting list.) 1. _____ (50) Homeless (McKinney-Vento Homeless Education Assistance Act, http://www.isbe.state.il.us/homeless) 2. _____ (50) Ward of the state/foster child 3. _____ (50) Two or more delays on research-based screening tool

The following are worth 5 points each: 4. _____ (5) Low income (Qualifies for

Illinois State Board of Education Early Childhood Division September 2013 free and reduced lunches, public housing, child care subsidy, WIC, SNAP, TANF, Medicaid) 5. _____ (5) History of child abuse or neglect 6. _____ (5) History of domestic violence 7. _____ (5) History of alcohol/drug abuse in family 8. _____ (5) DCFS involvement 9. _____ (5) Chronic or terminal illness of child 10. _____ (5) Chronic or terminal illness of family member 11. _____ (5) Child has documented disability/CFC referral 12. _____ (5) Caregiver has disability 13. _____ (5) Caregiver has mental illness 14. _____ (5) Death in immediate family (parent, child, sibling) 15. _____ (5) Caregiver other than parent raising child 16. _____ (5) Teen parent at birth of first child 17. _____ (5) Low birth weight/failure to thrive 18. _____ (5) Recent immigrant or refugee family 19. _____ (5) English not spoken in home 20. _____ (5) Family active military 21. _____ (5) Parent incarcerated 22. _____ (5) Primary caregiver did not complete high school/ No GED 23. _____ (5) High mobility or transience 24. _____ (5) Program specific (This space is provided for programs to add community risk factors.) ______25. _____ (5) Program specific (This space is provided for programs to add community risk factors.) ______

The following are worth 4 points each: 26. _____ (4) Receiving services from another agency Explain ______27. _____ (4) Socially or geographically isolated 28. _____ (4) Other Health Issue Explain ______29. _____ (4) Program specific (This space is provided for programs to add community risk factors.) ______

The following are worth 3 points each: 30. _____ (3) One delay on screening tool 31. _____ (3) Single parent 32. _____ (3) Program specific (This space is provided for programs to add community risk factors.) ______

_____ TOTAL SCORE

Notes:

Illinois State Board of Education Early Childhood Division September 2013 ______Staff Signature Date