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Instructions for PSE Form EESD 4000

Instructions for Early Education and Support Division (EESD) form EESD 4000 for the annual Program Self-Evaluation (PSE) process.

Instructions for the Program Self-Evaluation (PSE) Process

Form EESD 4000

Form EESD 4000 Fiscal Year (FY) 2017–18 (PDF)

Page 1 of 4

Enter the required contractor information at the top of the EESD 4000.

  • Contractor Legal Name (Full Spelling of Legal Name only. Acronyms and site names are not accepted)
  • Four-digit Vendor Number
  • Contract Type(s): Check all that apply to your agency

    • CSPP: California Sate Preschool Program
    • CCTR: California Center-based Child Care
    • CHAN: California Severely Handicapped
    • CFCC: California Family Child Care Home Education Networks
    • CMIG: California General Migrant Child Care
    • CMAP: California Migrant Alternative Payment
    • CRRP: California Resource and Referral Program
    • CAPP: California Alternative Payment Program
    • C2AP: CalWORKs Stage 2
    • C3AP: CalWORKs Stage 3

  • Age Group(s): Check all that apply to your agency (for Center-based contractor's only)

    • Infant/Toddler
    • Preschool
    • School Age

  • Program Director:

    • Name as listed in the Child Development Management Information System (CDMIS)
    • Phone Number
    • E-mail Address

  • Check each box verifying the collection, analysis, and integration of each assessment data toward ongoing program improvement for all applicable contract types.

Resources provided to complete the requirements for each component of the PSE

  • The Executive or Program Director, as listed in the Child Development Management Information System (CDMIS), must sign, in blue ink, the Statement of Completion certifying that all documents required as a part of the PSE have been completed and are available for review and/or submittal to the California Department of Education (CDE), Early Education and Support Division (EESD) upon request.

    • The CDMIS help phone number is 916-445-1907 and the e-mail is cdmis@cde.ca.gov.

Instructions for Summary of the Program Self-Evaluation

Page 2 of 4

  • Using a narrative format, summarize the staff and board member participation in the PSE process. For example describe:

    • Who was involved
    • How were they involved
    • When do they get involved

Pages 3 of 4

  • Reflect on findings from the Program Self Evaluation and then provide brief responses to items 1 and 2. Answers are not limited to space provided. Attach additional sheets as necessary.

    Note: All contractors are required to modify their programs to address all areas identified as needing improvement during the self-evaluation. Written tasks needed to modify the program would be specific or unique to the contract type and age group. Additionally, all contractors are required to identify areas that are satisfactory and provide procedures for ongoing monitoring of the program for assuring that those areas continue to meet standards.

Submission Requirements

All contractors are required to complete one (1) EESD 4000, per contractor.

  • Scan and submit the signed EESD 4000, all four (4) pages including any addtional sheets as necessary from pages two (2) through four (4) together electronically in PDF format, to FY1718PSE@CDE.CA.GOV using the fiscal year and the legal contractor name in the subject line (example: 17-18 XYZ School District).
  • All other documents/instruments (i.e., EESD 3900, EESD 4001 – 4004) must be kept on-site, are not included with the submission of the EESD 4000, and made available for review and/or submittal to the CDE/EESD upon request.

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Questions:   Early Education and Support Division | 916-322-6233
Last Reviewed: Friday, March 9, 2018
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