Educator/Provider Request for EPS Services - Region 6 - FY2017
Name and Title of Person requesting for EPS Services
Program Name and Address
Please indicate street, city, state, and zip code at which you are requesting services
What EPS services are you requesting?
Please describe how EPS can support your program improvement plan this year (June 2016-July 2017)
What type of Program are you requesting EPS Services for?
Please check all that apply
Infant/Toddler Center Based
Out-of-School time Center Based (School-Age)
Family Child Care - Independent
Family Child Care - System
School Based (located in a public school)
Early Head Start or Head Start
Your program number can be found on the upper left side of your EEC license, but is a separate number from your License Number
Program Director's Name and Phone Number
Please indicate the best number to reach you
Our primary method of communication will be via e-mail, Please be sure your email address is entered correctly.
Confirm your e-mail address
Please provide your EEC Professional Qualifications Number (PQR #)
For reporting purposes we need to record your PQR #
How many classrooms are in your program?
How many educators are in your program?
What language are you requesting for EPS services ?
If you are participating in QRIS, what level is your program?
Please check which level you have been granted by EEC
Program is not participating in QRIS, but plans to submit an application within the next 3 months
We are not participating in QRIS and do not plan to within the next 3 months
I don't know if we are participating in QRIS at this time
What services are you and your staff interested in?
Please select your top 3 areas of support that you will need this year (June 2016-July 2017).
QRIS support for upward movement
Continuous Quality Improvement (CQI) plan
Staff training and professional development Support
NAEYC Accreditation Support
Other Accreditation Support
Does your program have a Continuous Quality Improvement (CQI) plan or a Program Improvement plan in place?
The CQI plan was formerly called the Program Improvement Plan and serves as a guiding document for QRIS.
Yes, we have a CQI plan in place
Yes, we have a Program Improvement plan in place
No, we don't have either a CQI plan or a Program Improvement plan in place
I don't know if we have a CQI plan or a Program Improvement plan in place
Has your program ever worked with a coach before?
I don't know
If you answered yes above, please indicate who your coach is/was.
What portion of children enrolled in your program are subsidized (voucher or contract)
1 - 25%
26 - 50%%
More than 50%
Please note any other information you think EPS staff may need to know
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