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ECERS-3 Assessment Request Form
ECERS-3 Assessment Request
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Directions: Please complete this form to request that a valid and reliable observation tool that will measure overall quality of the program, be conducted. One form per program. The cost of this observation is $500, which includes a minimum of three hours of observation and a written report, completed within 3 business days of the visit. Please complete this form in its entirety.
Type of Care
*
Child Care Center
Group Child Care Home
What environmental rating scale do you need?
*
Early Childhood Environment Rating Scale Third Edition (ECERS3)
Cost for ECERS3 $500.00 per classroom
What is the number of preschool classrooms to receive ECERS3?
*
Please enter the number of children that will be present during observation? Cannot be less than 2 present to conduct the assessment.
*
How will you use the ECERS-3 results in your program?
*
Please give three (3) dates you would like to hold for the observation.
Contact Name
*
First
Last
Contact Email
*
Contact Phone
*
Program Name
*
Program Address (Physical location of program)
*
Street Address
Address Line 2
City
ZIP Code
Is the Billing Address different from the Program Address?
*
Yes
No
Program Address is the physical location of the program. Billing Address is the location notice and invoice are mailed to.
Billing Address
*
Street Address
Address Line 2
City
ZIP Code
Hours of Operation Start Time
*
:
Hours
Minutes
AM
PM
Hours of Operation End Time
*
:
Hours
Minutes
AM
PM
I agree to terms and service
*
I acknowledge payment will be paid directly to the United Way of Connecticut. The cost of this observation is $500 per classroom, which includes a minimum of three hours of observation and a written report, completed within 3 business days of the visit.
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