This survey has been created to streamline requests for support from parents and/or early childhood programs who are working hard to support children who are at high risk of being suspended or expelled due to behavioral or health challenges. The information collected helps the PA Key triage the best OCDEL support service that will benefit the child, family and program.  Please answer as honestly as you can and know that the information provided helps us to meet the needs of all parties.  This information will only be shared with staff and partners of the Office of Child Development and Early Learning for the purposes of providing the appropriate supports to the provider and/or the child.

After you complete these questions, your request will be reviewed within 2 business days and you will be connected with the appropriate support.

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* 1. First and Last name of person completing this form

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* 2. Please provide your contact information

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* 3. I am a parent/guardian requesting support.

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* 4. Are you a representative or business partner of OCDEL?

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* 5. Early Learning Program Information (if unknown, please indicate)

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* 7. Early Learning Program Type

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* 8. Keystone STAR Level

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* 9. Are you interested in general training or coaching around reducing Expulsion/Suspension due to behavioral or health challenges?

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* 10. If you are seeking support for a child who is at risk for expulsion/suspension, what challenging behaviors are being observed? What happens right before and after the behaviors occur? How often does this occur?

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* 11. Age of child you are concerned about

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* 12. Has this child been expelled or suspended in the past?

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* 13. Does the child you are concerned about have an Individualized Education Plan (IEP) or an Individualized Family Support Plan (IFSP)?

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* 14. Please check any additional community supports the early childhood program or the child's family have accessed or are in the process of accessing.

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* 15. Please describe how the family and early childhood program are working together to support the child who is struggling.

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