6:145-E1 Programs for Migrant Students – Family Interview Form

To be completed by Building Principal or designee: (please print)

Child #1 Name:  ________________________________  Birth Date:  _____________

Grade:  ______________   School District/Building:  ___________________________

Child #2 Name:  ________________________________ Birth Date:  ______________

Grade:  _____________   School District/Building:  ____________________________

Child #3 Name:  ______________________________  Birth Date:  _______________

Grade:  ____________  School District/Building:  _____________________________

Name of Parent/Guardian:  _____________________ Language(s):  ______________

Phone Number or other contact information:  ____________ Today’s Date:  _________

Needs Assessment                                              Please circle or check response

1.  Do any of your children have health problems that interfere with their ability to learn?

Yes            No     Explain:

2.  In what areas might your child(ren) need additional help in school?

Yes            No     Explain:

3.  Are your child(ren)’s immunizations up to date?           Yes       No     Don’t Know

4.  Do you have immunization records:                               Yes       No    Don’t Know

5.  Have you established a source of primary healthcare:    Yes     No     Don’t Know

Resources and Referrrals

1.  Would you be interested in information on:

Head Start                                                                       Yes     No     Already Enrolled

District Preschool                                                            Yes     No     Already Enrolled

Parents as Teachers                                                         Yes     No     Already Enrolled

GED/ESL Classes                                                           Yes     No     Already Enrolled

2.   Would you be interested in information on:

Public/County Health Department                                   Yes     No

Division of Family Services                                             Yes     No     Welcome Pack Given

3.  May we share your name and address with these        Yes     No

agencies?

4.  When is the best time to you reach you?                   AM   ___:___       PM  ___:___

Days of the week:    Mo    Tu    We    Th    Fr

Name of Person Completing Form:  ______________________________________

Name of Person Being Interviewed:  _____________________________________

Relationship to Family/Children:  _______________________________________

Date Adopted:  04/10/2007