|
Instructions
for Completing the Adult Enrollment Form
(Family Record) Form 794
1.
Participant completes all unshaded areas of the form with the assistance
of the program assistant and/or volunteers. All fields must be completed
unless instructed otherwise.
2. Instruct
participant to circle Y for Yes, N for No, or circle appropriate
choice from list provided. The participant should be instructed
to check or write in requested information in the blanks.
3. Program
assistant completes the shaded areas before submitting form to the
EFNEP agent. Records are to be submitted
on or before the next office visit. Delayed submission
creates problems for the person entering data in the computer
and delays availability of printed reports (dietary and survey)
to use in teaching plan.
4. EFNEP
agent checks record for completion and accuracy.
5. Secretary
enters information in the computer.
6. Original
record is placed in a participant folder. If you are
using the carbonless paper, the yellow copy is the program
assistant's copy to mark on as needed while the participant is enrolled.
File original records in the county where
the secretary enters the data.
7. Program
assistant completes fields 16, 17, 20, 21 and 22 (on the yellow
copy) for participants who graduate or terminate.
8. Update
the family record when the participant graduates (i.e., pregnancy
and lactation status, total number of lessons and exit information.
Give updated information to secretary with exit dietary recall
and survey for data entry.
9. Original record remains
in the family folder until 12 months after the participant either
graduates or terminates.
KEEP
ALL RECORDS CONFIDENTIAL.
Store and discard them so that information is not available to anyone
outside the Extension office.
Instructions for filling out
each field:
| 1.
PP's Name |
Program
assistant's name |
| ENTRY/EXIT
|
Put
a check on Entry line if enrolling participant., or check on
Exit line for participant leaving EFNEP. The same record for
entry and exit may be filed in the folder. |
| 4.
Family ID |
The
person who enters the record on the computer should fill in
the Family ID for the participant as generated by the computer.
|
| 5.
Enrolled in EFNEP before? |
These
attempt to detect participants who have already graduated from
the program, or who may already be enrolled (usually with another
program assistant at the same or a different site). |
| 6.
If yes, did you receive a certificate of completion? |
Any
who answer that they have received a certificate of completion
would not be entered on the computer again. An exception may
be if the participant received education using the "Eating Right
is Basic" curriculum and becomes pregnant or would benefit from
additional education on feeding young children using the "Smart
Choices" curriculum. If the participant receives a certificate
of completion and enters the program again, the reason should
be documented in the comments section of the record.
A
participant who terminated, re-enrolls and completes the educational
objectives within the same reporting year might have the original
exit date deleted and the new exit date adjusted to reflect
continuous enrollment for the correct total of months enrolled.
|
| 7.
Age |
Participant's
age |
| 8.
Sex |
Participant's
gender, Female or Male |
|
9. Pregnant |
Yes,
if pregnant at any time during enrollment.
This should be verified at Exit. Change the N to Y. |
| 10.
Breastfeeding |
Yes,
if breastfeeding (lactating or nursing) at
any time during enrollment. This should be verified
at Exit. Change the N to Y. |
| Name
|
Participant's
first name, middle initial, and last name. |
| Street |
Participant's
street address. |
| City
|
City |
| Zip
|
Zip
code, XXXXX-XXXX (include zip "plus 4," if known). Labels of
participants can be printed sorted by zip code. |
|
Phone |
Phone
number where participant can be reached. It can be up to 20
characters long, and may include area code and an extension
(XXX) XXX-XXXX xXXXX. Be aware that the phone number adds an
additional line per participant on the Paraprofessional's List
of Families. If not deemed essential, a unit may prefer to omit
it. |
| The
following five items are optional information. |
| Unit
# |
The
FIPs code for the county the EFNEP unit represents. Note: This
is a federal code and not the same as Extension MIS location
codes. |
| Sample
|
Enter
N for No. |
| Print
Report |
Enter
N for No if individual participant's diagnostic report is not
needed. This may occur when EFNEP enrollment is completed in
a very short period, before data could be entered on computer
and the report given to the Paraprofessional to share with the
participant. |
| Problem
|
If
data is missing or incorrect, note what the program assistant
needs to do. Note: This is a good management tool for ensuring
that data is not missing. Item 17 about the number of lessons
is frequently missing. |
| Date
on Computer |
Write
down the date the record was entered on the computer. This will
identify records that you expect to find on the computer listings
and reports. If your hard disk fails and you don't have a complete
current backup, this will identify records that need to be added
(if entry) or edited (if exit) to restore your data.
|
| The following items
are required. |
| 11.
Race |
The
program has codes for the five main racial-ethnic categories.
Ask participant to check the one that best describes her/him.
Race codes :
1-00 White (not of Hispanic Origin)
2-00 Black (not of Hispanic Origin)
3-00 American Indian/Alaskan Native
4-00 Hispanic (of any Race)
5-00 Asian or Pacific Islander
|
| 12.
Residence |
Enter
code that describes Participant's place of residence
1 Farm
2 Towns under 10,000 and
rural non-farm
3 Towns and Cities 10,000
to 50,000
4 Suburbs of Cities over
50,000
5 Central Cities over 50,000
|
13.
Household Income
(This information is optional if you can
establish that they family is low-income.) |
Enter
total income for all persons in the residence for the previous
month (last month). Include wages, salaries, social security,
welfare, insurance payments, pensions and cash support from
others. Do not include the value of Food Stamps, WIC, or other
supplemental foods program benefits. For families with income
from farming, use 1/12th of last year's income after expenses. |
| 14.
Household Members |
List
first name and current age of each child living with the participant
(include all through age 19). |
| 15.
Number of Adults in Household (Do not
count Participant) |
Number
of other Adults (age 20 and over) living with the participant. |
| 16.
Instruction Type
|
1
Group (Receives group instruction ONLY)
2
Individual (Receives individual instruction ONLY)
3
Both (Receives a mixture of Group and Individual instruction)
4
Other (Non-traditional type of instruction, ex. by mail)
|
| 17.
Number of Lessons |
Filled
in at the end of the year for continuing participants and when
participant leaves EFNEP |
| 18.
Entry Date |
Date
enrolled in EFNEP, usually same as date of the first food recall |
| 19.
Assistance Programs that any of the family participate in at
ENTRY |
Circle
as many of the following programs as applicable:
*
WIC/CSFP (Women,
Infants & Children)
The WIC/CSFP programs provide supplemental food or voucher
to pregnant and breast-feeding (lactating, nursing) women,
infants, and children up to the age of five. Eligibility is
determined by income and nutritional risk.
*
Food Stamps
Food stamps are used to supplement the food buying power
of eligible low-income households. It is administered locally
through State welfare agencies.
*
FDPIR (Food
Distribution Program on Indian Reservations)
FDPIR provides commodity foods to Native American families
who live on or near Indian reservations, and to Pacific Islanders.
*
TEFAP (The
Emergency Food Assistance Program)
TEFAP provides commodity foods to low-income households.
*
Head Start
Head Start provides low-income preschool children with
balanced meals and nutrition education, health services (medical,
dental, nutrition and mental health), parent involvement and
social services.
*
Child Nutrition
(School Lunch/Breakfast)
Child Nutrition Programs include the free and reduced
price School Lunch Program, School Breakfast Program, Child
Care Food Program, Summer School Food Service Program, and
Special Milk Program.
*
AFDC (Aid to
Families with Dependent Children)
Now referred to as TANF, and "Families First"
in Tennessee.
*
Other Public
Assistance
Other Public Assistance is to be defined within a state.
It could include public housing, or other programs that require
low income for eligibility.
|
| 20.
Exit Date |
Date
participant left EFNEP, usually same as date of the final food
recall if participant met educational objective. If participant
terminated, it would be the date of the last EFNEP lesson attended. |
| 21.
Exit Reason |
If
participant met the educational objective (graduated), select
1. If participant did not meet the educational objective (terminated),
select exit reason from 2-8.
1
Educational Objective Met (Graduated)
2
Returned to School (Terminated)
3
Took a Job (Terminated)
4
Family Concerns(Terminated)
5
Staff Vacancy (Terminated)
6
Moved (Terminated)
7
Lost Interest (Terminated)
8
Other (Terminated) Use other when 1-7 do not apply.
|
| 22.
Did the participant's family receive other assistance as a result
of a referral or suggestion from EFNEP personnel?
|
If
yes, check program(s). Leave blank any that were not influenced
by EFNEP personnel, even if family is participating in it at
Exit. Public Assistance programs are the same as described for
Entry, #19. |
| Comments
|
|
