Question	Answer
Form Name	Ef 1143 A Form
Form Length	13 pages
Fillable?	Yes
Fillable fields	543
Avg. time to fill out	37 min 17 sec
Other names	eg, reliancestandard, Annuitant, reliance standard forms

Observer: ___________________________________	Observer Code: ___ ___ ___
Center/School: _______________________________	Center Code: ___ ___ ___
Room: ______________________________________	Room Code: ___ ___
Teacher(s): ___________________________________	Teacher Code: ___ ___

m m	d d	y	y
Number of children with identified disabilities: ___ ___
Check type(s) of disability:	physical/sensory				cognitive/language
	social/emotional				other:___________________
Birthdates of children enrolled: youngest			__ __ / __ __ / __ __
			m	m	d	d	y	y
	oldest		__ __ / __ __ / __ __
			m	m	d	d	y	y
Time observation began: ___ ___ : ___ ___					AM		PM
Time observation ended: ___ ___ : ___ ___					AM		PM
Time interview began: ___ ___ : ___ ___					AM		PM
Time interview ended: ___ ___ : ___ ___					AM		PM

									SPACE AND FURNISHINGS

1. Indoor space		1	2	3	4	5	6	7
		1	2	3	4	5	6	7

Y N	Y N NA		Y N				Y N
1.1	3.1	5.1				7.1
1.2	3.2	5.2				7.2
1.3	3.3	5.3
1.4	3.4
	3.5

2. Furniture for care,		1	2	3	4	5	6	7		y
play, & learning		1	2	3	4	5	6	7	5.1 Child sized? ______		______ =	______


Y N	Y N NA		Y N NA						(# child sized)		(# children)	(% child sized)
Y N	Y N NA		Y N NA					Y N
1.1	3.1	5.1					7.1
1.2	3.2	5.2					7.2
	3.3	5.3

3. Furnishings for					1	2	3	4	5	6	7
	Relaxation				1	2	3	4	5	6	7	5.1 Total time – cozy area: _________


	Y N	Y N				Y N				Y N
1.1	3.1		S 5.1						7.1
1.2	3.2			5.2					7.2
				5.3
S = substantial portion of the day

4. Room arrangement					1	2	3	4	5	6	7
					1	2	3	4	5	6	7	3.1, 5.1, 7.1 List defined interest centers:

	Y N	Y N NA				Y N				Y N
	Y N	Y N NA				Y N				Y N
1.1	3.1			5.1					7.1
1.2	3.2			5.2					7.2
	3.3			5.3					7.3
	3.4

5. Space for privacy					1	2	3	4	5	6	7
					1	2	3	4	5	6	7	5.2 Total time – space for privacy: _________

	Y N	Y N				Y N				Y N
	Y N	Y N				Y N				Y N
1.1	3.1			5.1					7.1
	3.2		S 5.2						7.2
S = substantial portion of the day

6. Child-related display					1	2	3	4	5	6	7
					1	2	3	4	5	6	7

	Y N	Y N				Y N				Y N
1.1	3.1			5.1					7.1
1.2	3.2			5.2					7.2
				5.3

7. Space for gross motor					1	2	3	4	5	6	7	1.1, 3.2 Safety hazards:	major	minor
												outdoors
	Y N	Y N				Y N				Y N		outdoors
1.1	3.1			5.1					7.1
1.2	3.2			5.2					7.2
1.2	3.2			5.2					7.2
				5.3					7.3
												indoors

8. Gross motor equipment			1	2	3	4	5	6	7	3.1	Total time – gross motor equipment: ___________________________																						7.1 stationary:
										3.1
										5.2	List variety of skills:
										5.2	List variety of skills:
Y N	Y N		Y N NA					Y N			1)								5)
1.1	3.1	5.1					7.1				2)								6)														portable:
1.2	3.2	5.2					7.2				2)								6)														portable:
1.2	3.2	5.2					7.2
1.3	3.3	5.3									3)								7)
											4)								8)

A. Subscale (Items 1 - 8) Score __ __								B. Number of items scored __ __										SPACE AND FURNISHINGS Average Score (A y B) __.__ __

											PERSONAL CARE ROUTINES

9. Greeting/departing			1	2	3	4	5	6	7	1.1, 3.1, 5.1, 5.3, 7.3 Greetings observed (											=yes,			=no)
			1	2	3	4	5	6	7		Child		Parent	Info shared


Y N	Y N		Y N NA					Y N NA		1	___		___	___
Y N	Y N		Y N NA					Y N NA		2	___		___	___
1.1	3.1	5.1					7.1			2	___		___	___
1.1	3.1	5.1					7.1			3	___		___	___
1.2	3.2	5.2					7.2			3	___		___	___
1.2	3.2	5.2					7.2			4	___		___	___
1.3	3.3	5.3					7.3			4	___		___	___
1.3	3.3	5.3					7.3			5	___		___	___
										5	___		___	___
										6	___		___	___

10. Meals/snacks			1	2	3	4	5	6	7	1.3, 3.3 Sanitary conditions observed (										=yes,		=no)										Tables sanitized?
			1	2	3	4	5	6	7
																2	3	4		5	6	7	8		9	10	11	12	13	14	15
Y N NA	Y N NA			Y N NA					Y N						1	2	3	4		5	6	7	8		9	10	11	12	13	14	15
Y N NA	Y N NA			Y N NA					Y N	Children’s hands washed																						Other problems?
1.1	3.1	5.1						7.1		Children’s hands washed																						Other problems?
1.1	3.1	5.1						7.1		Teachers’ hands washed
1.2	3.2	5.2						7.2		Teachers’ hands washed
1.2	3.2	5.2						7.2
1.3	3.3	5.3						7.3
1.4	3.4	5.4
1.5	3.5
	3.6

11. Nap/rest			1	2	3	4	5	6	7 NA									Y N
			1	2	3	4	5	6	7 NA		3.2	All cots/mats		18" apart?


Y N	Y N		Y N				Y N				5.3	All cots/mats		36" apart?
Y N	Y N		Y N				Y N
1.1	3.1	5.1				7.1
1.2	3.2	5.2				7.2
1.3	3.3	5.3
	3.4

12. Toileting/diapering			1	2	3	4	5	6	7
			1	2	3	4	5	6	7

Y N	Y N			Y N				Y N
1.1	3.1	5.1					7.1
1.2	3.2	5.2					7.2
1.3	3.3	5.3

1.3, 3.3 Handwashing observed (									=yes,		=no)
			2	3	4	5	6	7	8	9	10	11	12	13	14	15
		1	2	3	4	5	6	7	8	9	10	11	12	13	14	15
	Child
	Teacher

3.1 Sanitary conditions ( =yes,	=no)
Toilets flushed? ____	Same sink sanitized? ____
Other issues:

13. Health practices			1	2	3	4	5	6	7	1.1, 3.1, 3.2 Handwashing observations (tally)								Adult handwashing
			1	2	3	4	5	6	7				Adult		Child			Completed ____ out of ____ times


Y N	Y N		Y	N			Y	N NA				Yes		No		Yes	No
Y N	Y N		Y	N			Y	N NA		Upon arrival in class or								Percentage completed = ____ %
1.1	3.1	5.1					7.1			re-entry from outdoors								Child handwashing
1.2	3.2	5.2					7.2			After sand or messy play								Child handwashing
	3.3	5.3																Completed ____ out of ____ times
	3.3	5.3								Before/after water play
	3.4

																		Percentage completed = ____ %

										After dealing w/ bodily
										After dealing w/ bodily
										fluids or skin contact
										After touching pets or
										contaminated objects
14. Safety practices			1	2	3	4	5	6	7	1.1, 3.1 Safety hazards:			major				minor
										outdoors
Y N	Y N		Y N				Y N			outdoors
1.1	3.1	5.1					7.1
1.2	3.2	5.2					7.2
1.2	3.2	5.2					7.2
1.3	3.3
										indoors

Subscale (Items 9 - 14) Score __ __								Number of items scored __ __						PERSONAL CARE ROUTINES Average Score (A yB) __.__ __

											LANGUAGE-REASONING

15. Books & pictures			1	2	3	4	5	6	7	5.1 Total time – books and pictures = ___________								5.5 Informal reading observed? {y / n}
										5.1 Total time – books and pictures = ___________								5.5 Informal reading observed? {y / n}
Y N	Y N		Y N				Y N			5.1 Wide selection (tally):			fantasy _______
Y N	Y N		Y N				Y N
1.1	3.1	S 5.1					7.1			nature/science _______				factual _______			race/culture _______
1.2	3.2	5.2					7.2			people _______				abilities _______			animals _______
		5.3								people _______				abilities _______			animals _______
		5.3
		5.4								5.4 Violence? _______
		5.5								Also see Item 26, 3.1 and 5.1, and Item 28, 3.1 and 5.1.
										Also see Item 26, 3.1 and 5.1, and Item 28, 3.1 and 5.1.

20. Art			1	2	3	4	5	6	7	5.1	Total time – art materials = ________
			1	2	3	4	5	6	7	5.1	Total time – art materials = ________
Y N	Y N		Y N				Y N NA			5.1	Types of art materials (list 3 to 5 of each):
Y N	Y N		Y N				Y N NA			x
1.1	3.1	S 5.1				7.1				x	drawing (required) _____________________________
1.2	3.2	5.2				7.2				x	paints _____________________________
						7.3				x	paints _____________________________
										x	3-D _____________________________
										x		x tools _______________________________
S = substantial portion of the day										x	collage _____________________________	x tools _______________________________

21. Music/movement			1	2	3	4	5	6	7	3.1, 5.1 Total time – music materials = ________
			1	2	3	4	5	6	7

Y N	Y N		Y N				Y N			5.1 Types of music materials:
Y N	Y N		Y N				Y N
1.1	3.1	5.1				7.1				x	instruments __________________________________
1.2	3.2	5.2				7.2				x music to listen to, and for older kids to play ______________________________
	3.3					7.3
	3.3					7.3
										x dance props with music _______________________________
										7.1	Music available as a free choice? _____ As a group activity? _____

16. Encouraging children			1	2	3	4	5	6	7	5.1 Communication activities
to communicate			1	2	3	4	5	6	7	Examples during free play:


Y N	Y N		Y N				Y N			Examples during group time:
1.1	3.1	5.1				7.1				Examples during group time:
1.1	3.1	5.1				7.1
1.2	3.2	5.2				7.2
	3.3									7.2 Examples of written communication:

17. Using language to			1	2	3	4	5	6	7	3.1, 5.1 Examples of logical relationships:
develop reasoning			1	2	3	4	5	6	7


skills
Y N	Y N		Y	N			Y	N		5.2 Examples of child’s explanations:
1.1	3.1	5.1				7.1
1.2	3.2	5.2				7.2

18. Informal use of			1	2	3	4	5	6	7	5.3 Examples of staff expanding on children’s ideas:
language			1	2	3	4	5	6	7


Y N	Y N		Y N				Y N
1.1	3.1	5.1				7.1				7.2 Examples of staff questioning for longer answers:
1.2	3.2	5.2				7.2				7.2 Examples of staff questioning for longer answers:
1.2	3.2	5.2				7.2
1.3		5.3
		5.4

A. Subscale (Items 15 - 18) Score __ __								B. Number of items scored __ __			LANGUAGE-REASONING Average Score (A yB) __.__ __

										ACTIVITIES

19. Fine Motor			1	2	3	4	5	6	7	5.1 Total time – fine motor activities = ___________
			1	2	3	4	5	6	7	5.1 Types of fine motor material (list 3 to 5 of each):

Y N	Y N		Y N				Y N
Y N	Y N		Y N				Y N			x Small building materials _____________________________________
1.1	3.1	S 5.1				7.1
1.1	3.1	S 5.1				7.1
1.2	3.2	5.2				7.2				x Art: ____________________________________________________
		5.3								x Manipulatives _____________________________________________

22. Blocks			1	2	3	4	5	6	7
			1	2	3	4	5	6	7

Y N	Y N		Y N				Y N
1.1	3.1	5.1				7.1
	3.2	5.2				7.2
	3.3	5.3				7.3
		S 5.4

23. Sand/water			1	2	3	4	5	6	7
			1	2	3	4	5	6	7

Y N	Y N		Y N				Y N
1.1	3.1	5.1				7.1
1.2	3.2	5.2				7.2
		5.3

24. Dramatic play			1	2	3	4	5	6	7
			1	2	3	4	5	6	7

Y N	Y N		Y N				Y N
1.1	3.1	5.1				7.1
	3.2	S 5.2				7.2
	3.3	5.3				7.3
		5.4				7.4

25. Nature/science			1	2	3	4	5	6	7	5.1 Types of nature/science materials (list 3 to 5 of each):
			1	2	3	4	5	6	7
										x Collections of natural objects _____________________________________
Y N	Y N		Y N				Y N
Y N	Y N		Y N				Y N			x
1.1	3.1	5.1				7.1				x	Living things __________________________________________________
	3.2	S 5.2				7.2				x Books, games, toys _____________________________________________
	3.3	5.3
	3.3	5.3
		5.4								x	Activities _____________________________________________________
S = substantial portion of the day										5.2 Total time – nature/science: ______
26. Math/number			1	2	3	4	5	6	7	5.1 Types of math/number materials (list 3 to 5 of each):
			1	2	3	4	5	6	7	x
											Counting ______________________________________________________
Y N	Y N		Y N				Y N
Y N	Y N		Y N				Y N			x	Written numbers ________________________________________________
1.1	3.1	5.1				7.1				x
1.1	3.1	5.1				7.1				x
1.2	3.2	S 5.2				7.2				x	Measuring _____________________________________________________
		5.3								x	Comparing quantities _____________________________________________
		5.4								x	Shapes ________________________________________________________
										x
S = substantial portion of the day										5.2 Total time – math/number: ______
27. Use of TV, video,			1	2	3	4	5	6	7 NA
and/or computers			1	2	3	4	5	6	7 NA


Y N	Y N		Y N NA					Y N NA
1.1	3.1	5.1				7.1
1.2	3.2	5.2				7.2
	3.3	5.3
		5.4

28. Promoting acceptance			1	2	3	4	5	6	7	5.1 Diversity in materials (tally)
of diversity			1	2	3	4	5	6	7					Other
												Books	Pictures

Y N	Y N		Y N				Y N							materials
Y N	Y N		Y N				Y N			Races
1.1	3.1	5.1				7.1				Races
1.1	3.1	5.1				7.1				Cultures
1.2	3.2	5.2				7.2				Cultures
1.2	3.2	5.2				7.2				Ages
1.3	3.3									Ages
1.3	3.3									Abilities
										Abilities
										Gender

A. Subscale (Items 19 - 28) Score __ __									B. Number of items scored __ __						ACTIVITIES Average Score (A y B) __.__ __

A. Subscale (Items 29 - 33) Score __ __									B. Number of items scored __ __				INTERACTION Average Score (A y B) __.__ __

											PROGRAM STRUCTURE

34. Schedule			1	2	3	4	5	6	7	5.3 Time – indoor play =		______
			1	2	3	4	5	6	7	5.3 Time – indoor play =		______
Y N	Y N		Y	N			Y	N			Time – outdoor play = ______
1.1	3.1	5.1				7.1					Total time – play =	______
	3.2	5.2				7.2					Total time – play =	______
	3.2	5.2				7.2
	3.3	S 5.3
	3.4	5.4

S = substantial portion of the day

35. Free play			1	2	3	4	5	6	7	5.1 Time – free play indoors =			______
			1	2	3	4	5	6	7	5.1 Time – free play indoors =			______
											Time – free play outdoors = ______
Y N	Y N		Y	N			Y	N			Time – free play outdoors = ______
1.1	3.1	S 5.1				7.1					Total time – free play =		______
1.2	3.2	5.2				7.2					Total time – free play =		______
1.2	3.2	5.2				7.2
	3.3	5.3


S = substantial portion of the day

36. Group time			1	2	3	4	5	6	7
			1	2	3	4	5	6	7

Y N	Y N		Y N				Y N
1.1	3.1	5.1				7.1
1.2	3.2	5.2				7.2
		5.3				7.3

37. Provisions for children			1	2	3	4	5	6	7 NA
with disabilities
with disabilities
Y N	Y N		Y N				Y N
1.1	3.1	5.1				7.1
1.2	3.2	5.2				7.2
1.3	3.3	5.3				7.3
1.4	3.4

A. Subscale (Items 34 - 37) Score __ __									B. Number of items scored __ __				PROGRAM STRUCTURE Average Score (A y B) __.__ __

38. Provisions for parents			1	2	3	4	5	6	7
			1	2	3	4	5	6	7

Y N	Y N		Y N				Y N
1.1	3.1	5.1				7.1
1.2	3.2	5.2				7.2
	3.3	5.3				7.3
	3.4	5.4

39. Provisions for			1	2	3	4	5	6	7
personal needs			1	2	3	4	5	6	7


of staff
Y N	Y N NA			Y N				Y N
1.1	3.1	5.1				7.1
1.2	3.2	5.2				7.2
	3.3	5.3				7.3
	3.4	5.4
	3.5
40. Provisions for			1	2	3	4	5	6	7
professional needs			1	2	3	4	5	6	7


of staff
Y N	Y N		Y N				Y N
1.1	3.1	5.1				7.1
1.2	3.2	5.2				7.2
1.3	3.3	5.3

41. Staff interaction			1	2	3	4	5	6	7	NA
and cooperation			1	2	3	4	5	6	7	NA


Y N	Y N		Y N				Y N
1.1	3.1	5.1				7.1
1.2	3.2	5.2				7.2
1.3	3.3	5.3				7.3

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