| Program | Program ID | Child ID | Alt ID | Last Name | Middle Name | First Name | Status | DOB        | Weeks Premature | Adjusted Age | Gender | Birth Weight | Ethnicity  | Address1      | Address2 | Address3 | City   | County/District | State/Province | Zip/Postal Code | Country       | Phone          | Primary Home Language | Language(s) Spoken In The Home | Primary Care Physician | Clinic/Practice Name | Clinic Address1 | Clinic Address2 | Clinic Address3 | Clinic City | Clinic State/Province | Clinic Zip/Postal Code | Clinic Phone | Clinic Fax | Clinic Email | Medical Risk Factors | Environmental Risk Factors | Medical Conditions | Other Agencies Involved | Date Of Admission To Monitoring Program | Previous care and education: | Other: | Caregiver ID | Caregiver Prefix | Caregiver First Name | Caregiver Middle Name | Caregiver Last Name | Relationship To Child | Caregiver Phone | Caregiver Alternate Phone | Caregiver Email | Caregiver Primary Home Language | Secondary Home Language | Primary Caregiver | Caregiver Address1 | Caregiver Address2 | Caregiver Address3 | Caregiver City | Caregiver County/District | Caregiver State/Province | Caregiver Zip/Postal Code | Caregiver Country |
|---------|------------|----------|--------|-----------|--------------|------------|--------|------------|-----------------|---------------|--------|--------------|------------|----------------|----------|----------|--------|------------------|----------------|----------------|---------------|------------------|---------------------|-------------------------|-----------------------|----------------|------------|--------------|---------------------|-------------------------|-------------------|---------------------|-----------------------------------|-------------------------|-------|--------------|-----------------|-------------------|--------------------|------------------|----------------------|----------------|-----------------------|----------------|----------------------------|--------------------|----------------|----------------|------------------|-----------------|----------------|-----------------|------------------|----------------------|------------------|
| Head Start Daycare Center | 3423212    |          |        | McAdams   |              | Timmy      | Active | 09/01/2010 | 0               |               | Male   |              | Caucasian | 123 Main St.  |          |          | Topeka |                  | Kansas         | 66621          | United States | 000-000-0000    |                      |                         |                       | Private Homecare |                |                  |                  |              |                      |                      |              |            |              |                     |                         |                   |                     |                                   |                         |       |              | Mrs.            | Mary              |                    | McAdams          | Mother               | 000-000-0000   |                       |                   |                            |                    |                | 123 Main St.  |                  |                  | Topeka           |                      | Kansas            | 66621               | United States |