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).
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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