Educator/Provider Request for EPS Services - Region 6 - FY2017
Name and Title of Person requesting for EPS Services
Your answer
Program Name and Address
Please indicate street, city, state, and zip code at which you are requesting services
Your answer
What EPS services are you requesting?
Please describe how EPS can support your program improvement plan this year (June 2016-July 2017)
Your answer
What type of Program are you requesting EPS Services for?
Please check all that apply
Program Number
Your program number can be found on the upper left side of your EEC license, but is a separate number from your License Number
Your answer
Program Director's Name and Phone Number
Please indicate the best number to reach you
Your answer
E-mail Address
Our primary method of communication will be via e-mail, Please be sure your email address is entered correctly.
Your answer
Confirm your e-mail address
Your answer
Please provide your EEC Professional Qualifications Number (PQR #)
For reporting purposes we need to record your PQR #
Your answer
How many classrooms are in your program?
Your answer
How many educators are in your program?
Your answer
What language are you requesting for EPS services ?
Your answer
If you are participating in QRIS, what level is your program?
Please check which level you have been granted by EEC
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).
Required
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.
Has your program ever worked with a coach before?
If you answered yes above, please indicate who your coach is/was.
Your answer
What portion of children enrolled in your program are subsidized (voucher or contract)
Please note any other information you think EPS staff may need to know
Your answer
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