6141.312 Form 1

Programs for Migrant Students - Family Interview Form

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

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Child 1 Name Birth Date Grade School

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Child 2 Name Birth Date Grade School

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Child 3 Name Birth Date Grade School

Name of Parent/Guardian _____________________________ Language(s) _____________________________________

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Telephone Number or other contact information Today's Date

Needs Assessment Please check response

1. Do any of your children have health problems that interfere with their ability to learn? Explain: Yes No

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

3. Are your child(rens) 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

If not, would you be interested in information on primary healthcare? Yes No Don t know

Resources and Referrals Please circle/check response

1. Would you be interested in information on:

Head Start Yes No Enrolled

District Preschool Yes No Enrolled

Parents as Teachers Yes No Enrolled

GED/ESL Classes Yes No Enrolled

2. Would you be interested in information on:

Public/County Health Dept. Yes No

Division of Family Services Yes No

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

4. When is the best time to reach you at home? AM PM

Days of the week:

Monday Tuesday Wednesday Thursday Friday

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Name of Person Completing Form Name of Person Being Interviewed and His/Her Relationship to Family/Children