Lab rubricInstructor Guidelines First enter scores (between 0 and.docx

Lab rubricInstructor Guidelines: First enter scores (between 0
and 4) into yellow cells only in column F. Then, include
student-specific feedback in the appropriate
cell.InappropriateBelow AverageAverageAbove
AverageScoreWeightFinal Score1234The entry is on topic and
includes content to support the unit Learning
Objectives.Submission does not relate to the topic.Answers
some question/topics with some content linked to only one unit
Learning Objective.Answers all questions with some content
linked to at least two unit Learning Objectives.Answers all
questions with opinions/ideas creatively, clearly, and
completely with obvious support of all unit Learning
Objectives.60%0.00The entry demonstrates critical thinking by
supporting opinions with example and explanations.Submission
does not relate to the topic.Answers some question/topics with
some clearly stated opinions. No example is provided.Answers
all questions with opinions and ideas that are stated clearly. At
least one example is provided.Answers all questions with
opinions/ideas creatively, clearly, and completely. More than
one example is provided.20%0.00The entry meets length stated
in assignment requirements.Submission did not meet stated
length.Submission met or exceed the stated
length.10%0.00Spelling/
Grammar/ Formatting/ MechanicsSignificant errors in spelling
and/or grammar. Major flaws in writing mechanics and
formatting.Poor spelling and grammar are apparent. Does not
use APA style formatting when needed.Uses Standard English
with rare errors and misspellings. Minor errors in APA style
formatting.Consistently uses Standard English with rare
misspellings. Appropriate mechanics and APA style
formatting.10%0.00100%0.00Final
Score0Percentage0.00%Total available points =204Rubric
ScoreGrade
pointsPercentageLowHighLowHighLowHigh3.54.0182090%100

%2.53.49161880%89.99%1.72.49141670%79.99%0.01.0001406
9.99%
FEDERAL AND STATE FUNDING FOR CHILD CARE AND
EARLY LEARNING
Early childhood professionals, such as child care providers,
teachers, and consultants, receive federal and state funding to
provide a variety of
services to children in low-income working families. Federal

and state funding for early childhood services are available
through a complex maze
of funding streams and government agencies. The following are
some quick facts about early childhood services and the funding
streams that
support these services.
■ Most federal funds are granted to State agencies to
provide statewide services. Some federal funding is provided
directly to local public and
private entities. 1
■ Federal and state funding for child care services is also
provided directly to parents via tax credits. Some States have
established business tax
credits to support child care providers directly. There are also
tax credits available for businesses that sponsor child care for
their employees.
■ The Federal and the State Departments of Education fund
public (schools) and private (schools and child care programs)
entities to provide early
learning services to children in low-income families. The U.S.
Department of Education (ED) also provides grants to selected
Race to the Top –
Early Learning Challenge (RTT-ELC) fund States to improve
early learning and development programs for young children
through
comprehensive early learning education reform.
■ The U.S. Department of Health and Human Services
(HHS) provides grants to local public and private nonprofit and
for-profit agencies through
the Head Start and Early Head Start programs to provide early
learning services to children in low-income families.

■ In addition to funding early learning programs through
Head Start, HHS also funds child care services for low-income
working families. An
estimated 2.4 million children received child care services
through federal funding streams in an average month in FY
2009 (Office of the
Assistant Secretary for Planning and Evaluation, 2012).
■ Federal funds are also available through the U.S.
Department of Agriculture (USDA) to provide nutritious meals
and snacks to children in child
care programs. Approximately 3.3 million children receive
nutritious meals and snacks through the Child and Adult Care
Food Program (CACFP)
each year.
1 Some of the Federal funding streams listed in this document
(TANF, CCDF, CCAMPIS) also fund child care for school-age
children during out-of-school times.
There are additional federal and state funding streams that help
fund services for school-age children during out-of-school time
(such as 21st Century).
Additional information about out-of-school time funding
sources is available at http://www.findyouthinfo.gov/.
Child Care State Systems Specialist Network, A Service of the
Office of Child Care 1
http://www.findyouthinfo.gov/
http:http://www.findyouthinfo.gov

Federal and State Funding for Child Care and Early Learning
December 2014
■ The majority of the federal and state funding is used to
provide direct services to children and families but some funds
are used to improve the
overall quality of the services provided by early care and
education programs, including the funding of technical
assistance and training.

The following table summarizes available data for the major
federal and state early care and education funding streams in the
United States.
Table 1. Federal and State Early Care and Education Funding
Streams
Federal and State Funding Sources
Programs Amount of Funding Number of Children Served
Comments
Child Care and Federal Funding - 1.5 million CCDF is
administered by the Office of Child Care (OCC) within the
Development $5.3 billion average monthly (FY Administration
for Children and Families (ACF), HHS and provides grants
Fund (CCDF) State Funding -
$2.0 billion
(FY 2014
allocation)
2012) to States, Territories, and Tribes to assist low-income
families, families
receiving temporary public assistance, and those transitioning
from public
assistance in obtaining child care so they can work or attend
education and
training programs. Grantees must serve children younger than
13 years,
however, some grantees may also elect to serve children ages 13
to 19
who are physically or mentally incapacitated or under court
supervision.
http://www.acf.hhs.gov/programs/ccb/ccdf/factsheet.htm

Preschool $250 million To be determined These grants will help
States, local education agencies, and local
Development (FY 2014 governments build the fundamental
components of a high-quality
Grant Program estimate) preschool system or expand proven
early learning programs. To be
eligible for funding, prospective grantees must describe how
they will
expand access to children from low- to moderate-income
families, ensure
an adequate supply of high-quality preschool slots and qualified
teachers,
monitor for continuous improvement, partner with local
education
agencies and other providers, and sustain high-quality services
after the
grant period.
http://www2.ed.gov/programs/preschooldevelopmentgrants/inde
x.html
http://www.acf.hhs.gov/programs/ccb/ccdf/factsheet.htm
x.html

December 2014
Comments
Federal Child
and
Dependent Care
Tax Credit
(CDCTC) 2
$3.3 billion
claimed by
taxpayers

(tax year 2010)
$6.2 billion
claimed by
taxpayers
(tax year 2010)
The Federal CDCTC helps families meet their child and
dependent care
expenses. Families can use any type of child care (such as a
center,
family child care [FCC] home, or a neighbor or relative’s
house). The
care must have been provided for one or more qualifying
persons
(dependent child age 12 or younger when the care was
provided).
http://www.irs.gov/newsroom/article/0,,id=106189,00.html
Head Start/Early
Head Start 3
Federal Funding -
$8.6 billion
(FY 2014
expenditure)
1,034,000
(2012-2013
school year)
The Office of Head Start, within HHS, provides grants to local
public and

private nonprofit and for-profit agencies to administer Head
Start and Early
Head Start programs. These programs provide child-focused
services to
children from birth to age 5, pregnant women and their families,
and have
the overall goal of increasing the school readiness of young
children from
low-income families. http://transition.acf.hhs.gov/programs/ohs
2 Additional tax credits are also available to businesses that
support child care programs.
3 Some States also use state funds to fund Head Start programs
(2010 – 2011 school year: State Funding = $144 million).
http://www.irs.gov/newsroom/article/0%2C%2Cid%3D106189%
2C00.html
http://transition.acf.hhs.gov/programs/ohs

December 2014
Comments
IDEA: Early $438.5 million 338,932 The Individuals with
Disabilities Education Act of 2004 (IDEA) authorizes
Intervention (FY 2014 (FY 2013) formula grants to States and
discretionary grants to higher education
Program for appropriation) institutions and nonprofit
organizations to support demonstrations,
Infants and research, parent training and information centers,
technology and
Toddlers personnel development, and technical assistance and
dissemination
with within the State. Part C of the IDEA (also known as the

Early
Disabilities Intervention Program for Infants and Toddlers with
Disabilities) provides
(IDEA Part grants to States to serve infants and toddlers (ages
birth through 2
C) years) who have developmental delays or have been
diagnosed with a
physical or mental condition that may result in developmental
delays.
The Office of Special Education and Rehabilitative Services,
within ED,
administers the IDEA grants, including Part C grants.
http://www2.ed.gov/about/offices/list/osers/index.html
IDEA: Preschool $353.2 4 million 730,558 The Preschool
Grants for Children with Disabilities program is authorized
Grants for (FY 2014 (FY 2011) under Section 619 of Part B of
IDEA and is administered by the Office of
Children appropriation) Special Education and Rehabilitative
Services within ED. It was
with established to provide grants to States to serve young
children with
Disabilities disabilities, ages 3 through 5 years.
(IDEA Part
http://www2.ed.gov/about/offices/list/osers/osep/index.html
B)
http://www2.ed.gov/about/offices/list/osers/index.html
http://www2.ed.gov/about/offices/list/osers/osep/index.html

December 2014
Comments
Military Child
Development
Program
$532 million (FY
2007) (Updated

information is not
available)
175,000 approx.
(FY 2007)
(Updated
information is
not available
The U.S. Department of Defense spends more than $530 million
annually
to provide child care services to military personnel, making it
the largest
employer-sponsored child care program in the United States.
These
services are provided to military families through both child
development
centers and FCC homes.
http://www.defense.gov/news/QRMCreport.pdf
Race to the Top
– Early
Learning
Challenge
(RTT- ELC)
$370 million
(FY 2013
funding)
211,000
(based on pre-k
enrollment in

6 grantee states)
RTT-ELC are competitive grants offered to States to improve
their early
learning and development programs through comprehensive
early learning
education reform. Nine States (CA, DE, MA, MD, MN, NC, OH,
RI, WA)
won funding through Phase 1 in FY 2011, five states (CO, IL,
NM, OR,
WI) won funding through Phase 2 in FY 2012, and six states
(GA, KY, MI,
NJ, PA, VT) won funding through Phase 3 in FY 2013 of the
RTT–ELC that
would provide funds to certain States that applied for, but did
not receive,
funding under Phase 1.
http://www2.ed.gov/programs/racetothetop-
earlylearningchallenge/index.html
http://www.defense.gov/news/QRMCreport.pdf

December 2014
Comments
Social Services
Block
Grant
(SSBG)
$238 million
(direct child care
spending)
(FY 2012
expenditure)
Information not
available

SSBG is administered by the Office of Community Services
within HHS
and provides grants to States to fund a broad range of social
services
within the State. Each State has the flexibility to determine how
funds are
distributed among services, what services are provided, and who
is
eligible for services. Some of the SSBG fund is used to fund
child care
services directly and part of the SSBG funds are transferred to
Temporary
Assistance for Needy Families (TANF) to provide child care
services.
http://www.acf.hhs.gov/programs/ocs/ssbg/about/factsheets.htm
State Child and
Dependent Care
Tax Credit
(CDCTC)
Not Available Not Available Twenty-eight States have created a
tax credit similar to the Federal
CDCTC. In 13 of these States, the tax credit is refundable. The
eligibility
criteria for the tax credit vary by State.
http://www.nwlc.org/our-
issues/tax-%2526-budget
http://www.acf.hhs.gov/programs/ocs/ssbg/about/factsheets.htm
http://www.nwlc.org/our-issues/tax-%2526-budget
http://www.nwlc.org/our-issues/tax-%2526-budget

December 2014
Comments
State-Funded
Prekindergarten 4
$5.39 billion

(2012 – 2013
school year)
expenditure)
1.34 million
(2012-2013
school year)
An early learning program funded by state general revenue
funds to
increase access and improve quality; it invests public resources
in state-
funded preschool education. The funding often goes to local
school
districts for programming that emphasizes school readiness.
http://nieer.org/yearbook
Temporary
Assistance
for Needy
Families
(TANF)
$2.5 billion
(transfer)
$1.36 billion
(direct)
(FY 2013
expenditure)
Information not
available
TANF is administered by the Office of Family Assistance

within HHS
and provides grants to States, Territories, or Tribes to assist
families
with children so children can be cared for in their own homes;
reduce
welfare dependency by promoting work, job preparation, and
marriage;
reduce and prevent out-of-wedlock pregnancies; and to
encourage the
maintenance and formation of two-parent families. States,
Territories,
and Tribes may transfer TANF funds to CCDF or directly spend
funds
on child care.
http://www.acf.hhs.gov/programs/ofa/tanf/about.html
4 There is some duplication between state-funded
prekindergarten and State CCDF funds since many States use
prekindergarten funding as Match for the CCDF
program.
http://nieer.org/yearbook
http://www.acf.hhs.gov/programs/ofa/tanf/about.html

December 2014
Comments
Title I Preschool $14.4 billion
(FY 2014)
appropriation
Not available Many school districts support preschool programs
with their Title I
(Education for the Disadvantaged) funds. More than 50,000

public
schools across the country use Title I funds to provide
additional
academic support and learning opportunities to help low-
achieving
children master challenging curricula and meet state standards
in core
academic subjects.
http://www2.ed.gov/programs/titleiparta/index.html
Early Head
Start-Child Care
Partnership
$500 million
(Initial Grant
Funding FY
2014)
TBD These grants will allow new or existing Early Head Start
programs to
partner with local child care centers and FCC providers serving
infants
and toddlers from low-income families. These grants will
support States
and communities as they expand high-quality early learning
opportunities
to infants and toddlers through EHS-CC Partnerships. The
partnerships
will support working families by providing a full-day, full-year
program so
that children in low-income families have the healthy and
enriching early
experiences they need to realize their full potential.
http://www.acf.hhs.gov/programs/ecd/early-learning/ehs-cc-

partnerships
References
Barnett, W. S., Brown, K.C., Carolyn, M. E., & Squires, J. H.
(2013). The state of preschool 2013. New Brunswick: National
Institute for Early
Education Research. Retrieved from http://nieer.org/yearbook/.
Early Childhood Technical Assistance Center. (2014, February).
Annual appropriations and number of children served under Part
C of IDEA
federal fiscal years 1987-2014. Retrieved from
http://ectacenter.org/partc/partcdata.asp.
Food Research and Action Center. (2013, December). State of
the states 2013: United States. Retrieved from
http://frac.org/map/.
Internal Revenue Service. (2012, June). Tax Year 2010:
Historical Table 2 (SOI Bulletin). Retrieved from
http://www.irs.gov/taxstats/article/0,,id=171535,00.html.
http://www2.ed.gov/programs/titleiparta/index.html
partnerships

http://nieer.org/yearbook/
http://ectacenter.org/partc/partcdata.asp
http://frac.org/map/
http://www.irs.gov/taxstats/article/0%2C%2Cid%3D171535%2C
00.html
December 2014
National Women’s Law Center. (2012, February). 2012
Supplement to making care less taxing: Improving state child
and dependent care tax
provisions. Retrieved from http://www.nwlc.org/resource/2012-
supplement-making-care-less-taxing-improving-state-child-and-
dependent-care-
tax-provis.

National Women’s Law Center. (2011, April). 2011 Making care
less taxing: Improving state child and dependent care tax
provisions. Retrieved from
http://www.nwlc.org/resource/2011-making-care-less-taxing-
improving-state-child-and-dependent-care-tax-provisions.
New America Foundation. (2014, April) No child left behind
funding. Retrieved from
http://febp.newamerica.net/background-analysis/no-child-left-
behind-funding.
U.S. Department of Agriculture (2014, July). Child and Adult
Care Food Program (CACFP) Web site. Retrieved from
http://www.fns.usda.gov/cacfp/child-and-adult-care-food-
program.
U.S. Department of Defense. (2008). Report of the Tenth
Quadrennial Review of Military Compensation: Volume II
Deferred and Noncash
Compensation. Washington DC: U.S. Department of Defense.
U.S. Department of Education. (2014). Fiscal year 2014
allocations for the grants for infants and families program
Individuals with Disabilities
Education Act – Part C. Retrieved from
http://www2.ed.gov/fund/grant/apply/osep/2014apps.html.
U.S. Department of Education. (2014, September). Preschool
development grants. Retrieved from
x.html.
U.S. Department of Education. (2014, April). President's FY
2015 budget request for the U.S. Department of Education.
Retrieved from:

http://www2.ed.gov/about/overview/budget/budget15/index.html
.
U.S. Department of Education. (2014, April). Fiscal year
allocations for preschool grants Individuals with Disabilities
Education Act - Part B, Section
619. Retrieved from
http://www2.ed.gov/fund/grant/apply/osep/2014apps.html.
U.S. Department of Education. (2014, February). Child care
access means parents in school program: Funding status.
Retrieved from
http://www2.ed.gov/programs/campisp/funding.html.
U.S. Department of Education. (2013, December). Race to the
Top – Early Learning Challenge: Funding Status. Retrieved
from Funding Status:
earlylearningchallenge/funding.html.
U.S. Department of Education, Office of Special Education
Programs, Data Accountability Center. (2013, September).
Table 11.2: Special
education—children and students served under IDEA, Part B, by
age: Fall 2011. Retrieved from
http://uploads.tadnet.org/centers/97/assets/2423/download.
U.S. Department of Health and Human Services, Administration
for Children and Families, Office of Child Care. (2014,
October). Table 1 Child Care
and Development Fund preliminary estimates average monthly
adjusted number of families and children served (FFY 2012).
Retrieved from
http://www.acf.hhs.gov/programs/occ/resource/fy-2012-ccdf-
data-tables-final-table-1.

for Children and Families, Office of Child Care. (2014, July).
Early Head Start -
Child Care partnerships. Retrieved from
partnerships.
http://www.nwlc.org/resource/2012-supplement-making-care-
less-taxing-improving-state-child-and-dependent-care-tax-
provis
http://www.nwlc.org/resource/2012-supplement-making-care-
less-taxing-improving-state-child-and-dependent-care-tax-
provis
http://www.nwlc.org/resource/2011-making-care-less-taxing-
improving-state-child-and-dependent-care-tax-provisions
behind-funding
behind-funding
http://www.fns.usda.gov/cacfp/child-and-adult-care-food-
program
http://www2.ed.gov/fund/grant/apply/osep/2014apps.html
x.html
http://www2.ed.gov/about/overview/budget/budget15/index.html
http://www2.ed.gov/fund/grant/apply/osep/2014apps.html
earlylearningchallenge/funding.html
http://uploads.tadnet.org/centers/97/assets/2423/download
http://www.acf.hhs.gov/programs/occ/resource/fy-2012-ccdf-
data-tables-final-table-1
partnerships

http://www2.ed.gov/programs/campisp/funding.html
December 2014
for Children and Families, Office of Child Care. (2014,
January). Child Care and
Development Fund fiscal year 2012 state spending from all
appropriation years. Retrieved from
http://www.acf.hhs.gov/programs/occ/resource/expenditures-
overview-for-fy-2012-all-appropriation-years.
for Children and Families, Office of Community Services.
(2014, September).
SSBG fact sheet. Retrieved from
http://www.acf.hhs.gov/programs/ocs/resource/social-services-
block-grant-ssbg-fact-sheet.

for Children and Families, Office of Family Assistance. (2014,
July). C.1.b.: Federal
TANF expenditures on assistance in FY 2013 and C.1.c.:
Federal TANF expenditures on non-assistance in FY 2014.
Retrieved from
http://www.acf.hhs.gov/programs/ofa/resource/tanf-financial-
data-fy-2013.
for Children and Families, Office of Head Start. (2014,
September). Head Start
program fact sheet fiscal year 2013. Retrieved from
https://eclkc.ohs.acf.hhs.gov/hslc/data/factsheets/docs/hs-
program-fact-sheet-2013.pdf.
*The Child Care State Systems Specialist Network does not
endorse any non-Federal organization, publication, or resource.
Office of Child Care
9300 Lee Highway, Fairfax VA, 22031 | Phone: 877-296-2401 |
Email: [email protected]
http://www.acf.hhs.gov/programs/occ/resource/expenditures-
overview-for-fy-2012-all-appropriation-years
http://www.acf.hhs.gov/programs/ocs/resource/social-services-
block-grant-ssbg-fact-sheet
http://www.acf.hhs.gov/programs/ofa/resource/tanf-financial-
data-fy-2013
https://eclkc.ohs.acf.hhs.gov/hslc/data/factsheets/docs/hs-
program-fact-sheet-2013.pdf
mailto:[email protected]References

CECS EP003 Funding Sources
Short-Answer Response Assessment Submission FormContact
Information
Please provide your contact information and date of submission
below.
Your Name: First and Last
Your Email address: Your e-mail here
Date: Click here to enter a dateInstructions
This Competency includes a Short-Answer Response
Assessment. Write your response to each prompt below—in the
space provided. Beneath the prompts is the Rubric, which will
be used by the Competency Assessor to evaluate your responses.
Carefully review the Rubric rows associated with each prompt
to provide a complete response.
When writing your response, begin typing where it reads “Enter
Your Response Here.” Write as much as needed to satisfy the
requirements of the prompt.
Note: Save this file as EP003_firstinitial_lastname, and upload
it to this Assessment within the learning platform. For example,
EP003_B_Smith.
Short Answer 1
Describe each of the following public funding sources and its
intended purpose. Responses should be a least 1 paragraph in
length for each funding source.
a. Head Start
b. Child care subsidies
c. Child care tax credits
d. Title 1
e. Early childhood special education (IDEA)
f. State-funded pre-kindergarten

Rubric
0
Not Present
1
Needs Improvement
2
Meets Expectations
3
Exceeds Expectations
Sub-Competency 1: Describe public funding sources to support
early childhood programs and initiatives.
Learning Objective 1.1: Describe various public funding
sources.
Description is missing.
Description of the public funding sources and their purposes are
partial or incomplete.
Response includes a clear description of each public funding
source and its intended purpose.
Demonstrates the same level of achievement as “2,” plus the
following:
Response clearly describes an additional public funding source
and its intended purpose.
Short Answer 2
Read the descriptions of the two early childhood learning
centers below. Both Checkers and Smart Start will be seeking
funding from one of several sources: Head Start, child care tax
credits, Title I, or early childhood special education (IDEA).
Determinewhich funding sources are most appropriate for each
center and explain why. Your response should be 4–6
paragraphs in length.

Checkers Early Childhood Learning Center
Checkers Early Childhood Learning Center is a comprehensive
program providing a full range of services to children ages 6
weeks to 5 years and their families. There are several locations
throughout Colorado, New Mexico, and Arizona. Checkers also
provides a full range of educational, social, and health services
to children and families who are low income. Services for adults
and families are available through family medicine and mental
health. Licensed professionals provide comprehensive
evaluation, early intervention, and therapeutic services.
Smart Start Early Childhood Learning Center
Smart Start Early Childhood Learning Center provides a secure,
nurturing, and stimulating preschool environment that helps
children to understand themselves as individuals as well as
members of a community. We believe that a good early-school
experience can set the tone for a lifetime of learning. Through
daily lessons, community involvement, and self-exploration, we
strive to spark and encourage creativity and imagination in each
child. Our preschool programs strive to establish comfortable
environments for each child to reach new developmental
milestones. Services for the community are provided at no out-
of-pocket cost to families who meet income guidelines.Your
Response
Enter Your Response HereRubric
0
Not Present
1
Needs Improvement
2
Meets Expectations
3
Sub-Competency 1: Describe public funding sources to support
early childhood programs and initiatives.

Learning Objective 1.3:
Explain how various public funding sources apply to early
childhood learning centers.
Explanation is missing.
Explanation is incomplete or vague.
Response includes a clear explanation of how the public funding
sources applies to the early childhood learning center in the
scenario.
following:
Response explains why the other funding sources are not
appropriate.
Short Answer 3In addition to public funding, both Checkers
Early Learning Center and Smart Start Early Learning Center
have decided to pursue funding from private sources. Research
private funding sources that would be applicable for each of the
centers. Choose one source for each center and explain why the
center is a good candidate for receiving this funding. Explain
the process for obtaining the private funding sources you
identified. The response should be 6–8 paragraphs in
length.Your Response
0
Not Present
1
Needs Improvement
2
Meets Expectations
3
Sub-Competency 2: Evaluate private funding sources and

processes for obtaining funding to support early childhood
programs and initiatives.
Describe private funding sources.
Response describes a vague or inappropriate private funding
source for the early childhood center.
Response includes an accurate and relevant description of the
private funding source appropriate for the early childhood
center.
following:
Response explains the benefits and challenges of seeking
private funding.
Explain processes for obtaining private funding sources for
early childhood learning centers.
Response includes a limited or incomplete explanation of how
to obtain private funding for each source.
Response includes a clear explanation of how to obtain each
private funding source for an early childhood learning center.
following:
Response identifies stakeholders involved and/or resources to
support centers in the process for obtaining private funding.
Short Answer 4
Read the following reports about Universal Pre-K and its
funding implications. Answer the questions that follow. Your
response should be 4–6 paragraphs in length.

Barnett, W. S., & Hustedt, J. T. (2011). Improving public
financing for early learning programs (Policy Brief Issue 23).
Retrieved from http://nieer.org/resources/policybriefs/24.pdf
Citizen’s Budget Commission. (2013). The challenge of making
universal prekindergarten a reality in New York state. Retrieved
from
http://www.cbcny.org/sites/default/files/REPORT_UPK_102220
13.pdf
a. Explain the challenges New York is experiencing in funding
universal pre-kindergarten.
b. Describe at least three potential funding sources for
Universal Pre-K described in the Citizens Budget Commission
report.
c. How might policies like universal pre-kindergarten impact
funding for early childhood centers and the children and
families they serve?
Your Response
0
Not Present
1
Needs Improvement
2
Meets Expectations
3
Sub-Competency 3: Analyze the impact of political, economic,
and social policies and trends on programmatic funding streams
for early childhood settings.
Explain fiscal challenges in meeting policy initiatives.

Response provides a vague or partial explanation of the fiscal
challenges in meeting policy initiatives.
Response provides an accurate explanation of the fiscal
challenges in meeting policy initiatives.
following:
Response explains how these challenges are relevant to other
initiatives or settings.
Learning Objective 3.2: Describe funding sources to meet
policy initiatives.
Response provides a vague or partial description of funding
sources to meet policy initiatives.
Response provides an accurate and thorough description of three
funding sources to meet policy initiatives.
following:
Response describes more than three funding sources.
Learning Objective 3.3: Explain how policies and initiatives
impact funding for early childhood programs.
Response provides an incomplete explanation of how policies
and initiatives impact funding for early childhood programsand
the children and families they serve.
Response provides a thorough explanation of how policies and
initiatives impact funding for early childhood programsand the
children and families they serve.
following:
Response uses specific examples to support the explanation.

©2014 Walden University 2
Guided Notes
Overview of Potential Funding Sources
Improving Public Financing for Early Childhood Programs
The following provides an overview of different funding
streams for early childhood programs:
Head Start services are administered through the U.S.
Department of Health and Human Services. The funding source
is a federal grant provided to local grantees. Services provided
through this grant include comprehensive child development
programming for children who are low income and their
families. Funding is available for families with incomes at
100% of the poverty line or 130%, if all families at 100% of the
poverty line are served. Children ages 3–5 are served within
Head Start, while services of children birth to age 3 are
provided within Early Head Start.
Child Care Subsidies, including the Children’s Defense Fund
(CDF) and Temporary Assistance for Needy Families (TANF),
are administered through the U.S. Department of Health and
Human Services. This is a federal funding stream which
requires state matching. The purpose of these dollars is to
provide childcare assistance to families who are low income.
Funding is available to working families who have incomes up
to 80% of the state median income or who have been identified
as needy, according to the state. Children between the ages of
birth and 13 can qualify.
Child Care Tax Credits, provided through federal dollars and 28
State Treasury Departments, represent credits for childcare
expenditures against federal and state income taxes. The
primary result is a reduction in families’ childcare expenses.
The families of children who are between the ages of birth and
13 can qualify; credits are based on income level.
Title 1 Preschool is funded through the U.S. Department of

Education. These federal funds provide educational services for
children who are disadvantaged. Funding is provided to schools
where 40% of children are at the poverty level or who have been
identified as academically at risk or are in schools where lower
percentages of children are at the poverty level.
Early Childhood Special Education is funded through the U.S.
Department of Education. These dollars are provided through
federal, state, and local funds. Dollars are used to provide
special education services for qualified preschool-aged children
who have been identified as having disabilities or, at the state's
discretion, developmental delays.
State Pre-K is funded through the State Department of
Education within 29 states and jointly administered within 11
states. Funds are usually provided from the state with some
federal funding. Services are provided to qualifying children,
and some health and social services may be provided.
Generally, states provide services to children who are identified
as being at risk. This is often based on family income.
Adapted from: Barnett, W. S., & Hustedt, J. T. (2011).
Improving public financing for early learning programs (Policy
Brief Issue 23). Retrieved from
http://nieer.org/resources/policybriefs/24.pdf
N I E E R
Improving Public Financing
for Early Learning Programs
by W. Steven Barnett and Jason T. Hustedt
The care and education of young children in the United States is
supported by nearly
$40 billion yearly from a variety of sources at the federal, state,
and local levels. Even

so, about a quarter of 4-year-olds and half of 3-year-olds do not
attend preschool, and
many of those who do attend receive only poor quality services.
Some programs are
of such low quality that they actually harm child development.
The nation’s children
would greatly benefit from additional public funding for
preschool programs. It also
matters how this funding is provided. How we fund early care
and education varies
greatly from program to program, across states, and across
levels of government.
Most funding sources exist independent of one another, in
different departmental
jurisdictions and local, state, and federal governments each
have their own
funding approaches. For these and other reasons,
the various streams of public funding are not
easily harmonized into a coordinated
system for financing early learning
programs. This brief reviews sources
and models of public financing of
early care and education and makes
recommendations for improving upon
what currently exists so as to remove
barriers to increasing program access
and quality.
What We Know:
• Public funding for early care and education reaches barely half
of young children in poverty
at age 4 and the percentage aided is much less for children 3
and under. Children from
middle-income families receive even less public funding and
those above the poverty line
but below the median income have the lowest rates of

enrollment in public or private
programs.
• Different funding streams for early care and education evolved
with different priorities.
Some emphasize providing low-cost child care so parents may
work. Others emphasize
improving children’s learning and development including health
and nutrition.
• At the federal level and in many states, funding streams for
early childhood programs reside
in separate agencies, creating difficulties for cross-program
coordination.
• The states’ role in funding early education grew rapidly over
the last decade, but some of
their funding strategies are more susceptible to large cuts due to
short-term political and
economic fluctuations than are those for K–12 education.
• Not only is access highly limited, but public funding strategies
lead to wide variability in
who has access to high-quality early learning programs based on
where children live and a
variety of eligibility criteria. In addition to the many children
who are un-served, many
others are served by poor-quality programs.
• Child care subsidies and tax credits currently do little to
improve the quality of early
learning programs and can even encourage the use of poor
quality care.
April 2011, Issue 23

P
re
sc
h
o
o
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o
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y
B
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f
Policy Brief series edited by
Ellen C. Frede, Ph.D., and
W. Steven Barnett, Ph.D.
National Institute for
Early Education Research
www.nieer.org
What We Know: (continued)
• Recently, some federal initiatives have striven to improve
coordination across the patchwork of early learning
policies while others that hold promise remain to be enacted.

• Increased public investment in early learning is a pro-growth
strategy not inconsistent with greater fiscal restraint
generally. Although the recession and long-term financial
difficulties may constrain overall spending growth,
providing adequate public funding for early education, which is
modest relative to overall public spending, is
feasible providing any new investments are obtained by cutting
wasteful public spending that does not generate
social benefits comparable to those from high-quality early care
and education.
Policy Recommendations:
• Develop new and more reliable funding streams for early
learning programs that increase the total amount of
public funding available and, at the very least, produce full
coverage of disadvantaged children.
• Provide Head Start, child care, and education programs with
regulatory relief to facilitate coordination and
collaboration across early care and education programs
receiving federal and state funds. Allow states and Head
Start agencies to jointly apply for waivers based on Early
Learning Council plans for systems integration and
improvement.
• Strengthen state Early Learning Councils by providing them
with adequate staffing, authority, and longevity
through state statute.
• Fund federal early learning challenge grants to states for
initiatives that support coordination and increase
program effectiveness.
• Conduct a public review of Head Start, state pre-K, and other
policies to streamline regulations so that these

programs can work in a more coordinated and effective fashion
at the state and community levels. Focus more on
performance and outcomes and less on monitoring compliance
with detailed regulations
• Tie federal and state subsidies for child care to quality,
perhaps using tiered payments linked to state Quality
Rating Systems. Replace tax credits with more direct subsidies
or pay them in tiers linked to program quality.
• Measure the effectiveness of preschool special education
spending, subjecting it to cost-effectiveness analysis.
Funding for preschool special education is substantial, but the
needs are also great, and additional effort to ensure
effective use could have a high return.
• Increase the use of federal Title I funds for quality preschool
programs by requiring school districts to spend these
funds on programs demonstrated to be effective.
• States that do not fund early education through their school
funding formulas should work toward that goal or
develop other dedicated funding mechanisms that are more
stable than annual discretionary appropriations from
general revenue.
• Early childhood finance reform should be pursued as part of a
broader set of policies to increase collaboration and
coordination across agencies for children birth to 8 so as to
improve program effectiveness.
[2]Improving Public Financing For Early Learning Programs

A Patchwork of Funding Streams and Programs
Taxpayer-funded early care and education has grown
dramatically in recent years, resulting in a
multiplicity of programs and funding streams at the federal,
state, and local levels. Each has its own
mission, regulatory requirements, and constituency. Taken
together, they form what has been called a
“patchwork quilt” or “non-system” of early care and education.
They are seldom coordinated with each
other, the result being that opportunities to broadly raise
program quality and access, work collaboratively
to gain efficiencies, and otherwise maximize the public’s
investment are invariably lost. Meanwhile,
preschool providers face the increasingly daunting task of
blending or “braiding” funds from various
sources to create their classrooms, dealing in the process with
often-conflicting regulations. In this
section we provide an overview of funding streams and the
programs they support as a foundation for
the next section that identifies policy problems.
Total federal spending on early childhood programs in 2008 was
about $17 billion and it rose to an
estimated $19.5 billion in 2010 and $20 billion in 2011. This
increase of about $3 billion over three years
was facilitated by American Recovery and Reinvestment Act
(ARRA) funds, which accounted for about
half of the increase.1 State and local spending amounted to at
least another $17 billion in 2010 and 2011.
Our estimates of local spending on early childhood programs
are incomplete, and how much more they
might add to spending is an important unknown. Conceivably,
total public spending on early care and
education could approach $40 billion in 2011. Greater precision
is not possible, as state and local spending

on early education including early intervention and special
education are not carefully tracked at the
national level, as we discuss below. This amount is less than 1
percent of total government spending and
is far from sufficient to ensure that all children in poverty,
much less all children, have access to quality
early care and education (as discussed in a later section).
Whether even the current level of support will
be sustained is not entirely certain with proposals in Congress
to roll back federal funding to pre-ARRA
levels and some states and localities debating future cuts.
This brief’s calls for increased funding and greater coordination
of funding come against a backdrop of
the economic challenges occasioned by the “Great Recession,”
making a review of current programs and
formulation of recommendations for reform especially timely.
The states collectively account for the
greatest growth in early childhood education enrollment over
the last decade, serving nearly 1.3 million
children (as of 2010) with relatively new programs, many of
which have been shown to be effective.2
Given the financial difficulties many states face, it is reasonable
to ask to what extent they can be expected
to continue on their trajectory of expansion. Federal programs,
on the other hand, have been around
longer than many state programs. While they have not
experienced the same growth curve as state
initiatives, they did receive a recent boost, and there is a large
body of evaluative research on which to
base recommendations regarding federal programs. The federal
budget faces its own difficulties, of course.
Table 3 offers a comparison of key features of federal, state and
local programs.

Table 1. Federal Spending for Early Learning Programs
(Children under 5)
* Includes additional American Recovery and Reinvestment Act
(ARRA) funds for FY2010
** A significant portion of the increases from 2008 is due to
ARRA funding ($1.4 billion of 2010 funding and $1.6 billion of
2011 funding).
*** Total assumes tax credits continuing at 2010 levels.
2008 2010 est. 2011 est.
Head Start
(excluding Early Head Start)
$6.2 billion $6.7 billion* $6.8 billion
Early Head Start $688 million $1.0 billion* $1.56 billion*
Child Care Subsidies $5.2 billion $5.7 billion* $5.7 billion*
Child Care Food Program $1.3 billion $1.4 billion $1.4 billion
Tax Credits
(CTCDC and DCAP) $2.2 billion $2.2 billion + $2.2 billion +
DOD Child Care $300 million $750 million $800 million +
Title I Preschool $400 million $500 million $550 million

Preschool Special Education
(IDEA Part B, Sect. 619)
$374 million $574 million* $373 million
Early Intervention for infants and
toddlers with disabilities
(IDEA Part C)
$436 million $632 million* $439 million
Home Visiting $0 $100 million $250 million
Total** $17.1 billion $19.5 billion $20.0 billion***
Table 2. State and Local Spending for Early Learning (Children
under 5)
Note: State TANF transfers for child care subsidies are included
in federal spending.
2008 2010 est. 2011 (Proposed)
State Pre-K Initiatives
(spending from all sources)
>$5.2 billion >$6.2 billion >$6.2 billion
State and local funding for preschool
special education
$6 billion >$6 billion >$6 billion

State Early Intervention $3 billion $3 billion $3 billion
State Child Care Subsidies $2.4 billion $2.2 billion $2.2 billion
Total >$16.6 billion >$17.2 billion >$17.2 billion
Table 3. Largest Public Early Learning Programs (Funding
Streams)
Note: FPL is federal poverty level and SMI is state median
income.
* Eligibility for early childhood programs can be defined in a
variety of ways, including school/institution/community
characteristics,
family characteristics, and individual child characteristics.
Program Administrative Agency Source of Funds Primary
Service Eligibility Requirements
Head
Start
U.S. Department
of Health and
Human Services
Federal funds
distributed to
local grantees

Comprehensive
child development
program for
children and their
low-income families
Available to families with
incomes up to 100% FPL or
130% if all in 100% level are
served, children ages 3-5 (Head
Start) or 0-3 (Early Head Start)
Child Care
Subsidies
(Includes
CCDF and
TANF)
U.S. Department
of Health and
Human Services
Federal funds
with required
state matches
Child care assistance
for low-income
working families

Available to working families with
incomes up to 85% SMI (CCDF)
or who are needy as defined by
the state (TANF), children ages
0-13. State rules vary.
Child
Care Tax
Credits
Federal and 28
State Treasury
Departments
Credits for child
care expenditures
against federal
and state
income taxes
Reduction of
families’ child
care expenses
For families with expenditures
up to age 13, but CDCTC credit
amounts are based on income
levels. Most states tie their
credit to the federal credit.
Title I
Preschool

U.S. Department
of Education
Federal funds
Education services
for disadvantaged
children
All children in schools where
40% of children are in poverty,
or to academically at-risk children
in schools with lower percentages
of children in poverty
Early
Childhood
Special
Education
U.S. Department
of Education
Federal, state,
and local funds
Special education
services for children
Available to all preschool-age
children with identified
disabilities, or, at states’

discretion, developmental delays
State
Pre-K
State Departments of
Education for 29 states
and 11 states with
other agencies (may be
jointly administered)
State typically
with local and
sometimes
federal funds
Education programs
for qualifying
children, sometimes
with health and/or
social services
Most programs target at-risk
children, most often based
on family income. However, 13
states have only age eligibility.
Local
Programs

School districts
or other local
agencies
Determined at
the local level
Education programs
for qualifying
children
Determined at the local level,
often targeting at-risk children.
Head Start
The nation’s oldest large scale public preschool program, Head
Start, dates back to the 1960s. Administered
by the U.S. Department of Health and Human Services, it serves
preschoolers from low-income families
with a comprehensive child development approach that includes
preschool education and health,
nutritional, and social services. Funding for Head Start
programs goes directly from the federal
government to service providers who in turn must follow
federally mandated program standards. Most
families must have an income below 100 percent of the federal
poverty level in order to be eligible, but
programs deemed to have served all those eligible at the 100
percent of FPL can enroll children from
families earning up to 130 percent of FPL. In addition, up to 10

percent of the children enrolled need
not meet the income guidelines.
Total Head Start enrollment, including Early Head Start, has
been about 875,000 children annually.3
ARRA funds were estimated to increase Early Head Start
enrollment by more than 48,000 children in
2010. Programs vary in the number of hours of services
provided per day with about half of children
enrolled receiving a full day of preschool five days a week.
Numerous studies find that Head Start has
positive long-term impacts on child health and development, but
the most rigorous study to date
indicates that Head Start needs improvement if it is to produce
strong long-term gains.4 The Obama
administration has proposed dramatic changes to ensure that
this happens.5
Direct Child Care Subsidies (CCDF and TANF)
Child care subsidies are another source of funding that can be
used for preschool education. However,
since a primary motivation for child care subsidies is providing
care for sufficient hours per day to
support working parents, education is often not a top priority.
The federal government administers two
large child care funding streams through the Department of
Health and Human Services: the Child Care
and Development Fund (CCDF) and Temporary Assistance to
Needy Families (TANF). CCDF focuses
on working families who earn less than 85 percent of the
median income in the state where they reside.
TANF serves needy families as they are defined at the state
level.6
The passage of welfare reform in 1996 spurred a period of

growth for CCDF and TANF but funding has
leveled off or, in the case of TANF money for child care,
declined. CCDF spending has been about $5
billion a year and the amount of TANF funds spent on child care
is about $3 billion per year.7 The ARRA
added $2 billion to CCDF over two years assuming it is all
spent in 2010 and 2011.
There are few state reporting requirements for TANF. A little
more than half of the children in CCDF
attend child care centers. Quality regulation is essentially left
up to the states, many of which have weak
standards. About one quarter of children in CCDF are in the
care of providers who are not required to
be licensed or regulated. Most funds are distributed through
vouchers.8 Only six states set reimbursement
rates for child care at the federally recommended levels in
2010.9 Studies have raised concerns that
subsidized care can be of such low quality that it has little or no
positive effects on learning and
development of children prior to kindergarten and might even
have modest negative effects.10
Both CCDF and TANF require states to provide matching funds.
Total federal spending on child care
subsidies was about $13 billion in 2007 and about 2.2 million
children through age 13 were served.11
Slightly more than half of child care participants in CCDF were
younger than age 5 as of 2007.12
Child Care Tax Credits

The Dependent Care Assistance Program (DCAP) and the Child
and Dependent Care Tax Credit
(CDCTC) are federal programs that enable parents to pay for
child care and early education with pre-tax
earnings. The DCAP permits employees to pay for child care
from an account in which they can annually
set aside up to $5,000 in pre-tax earnings. Neither federal
income tax nor social security and Medicare
payroll taxes are paid on the money set aside in this manner.
The CDCTC is a tax credit that reimburses
parents for a percentage of qualifying child care expenses of up
to $3,000 per child for a maximum of two
children under age 13. The percentage starts at 35 percent (for
incomes under $15,000) and falls by 1
percent for every additional $2,000 in income until it reaches 20
percent (for incomes over $43,000). The
maximum credit per child falls from $1,050 to $600 as income
rises. The federal tax credit tends to be
accessed more at higher income levels because it is
nonrefundable, and few low-income families have
federal income tax liabilities. Also, actual credits are lower than
the limits would suggest because of the
limited tax liabilities of low-income families.
Relative to the costs of child care, tax credits provide modest
assistance for most families, and they are
not linked to the quality of care purchased. In recent years, the
average credit claimed was about $535 per
family.13 At best, the credits have minimal effects on the
quality of child care purchased by middle-income
families. This makes the federal credits an inefficient approach
to raising the quality of young children’s
early learning experiences. A recent California study indicates
that policymakers should be concerned
about the poor quality of early learning programs purchased by
parents with moderate to high incomes.14

Unless Congress acts, in 2011 the credit amounts will revert to
the significantly lower 2001 levels.
Twenty-seven states (of 41 with a personal income tax) and the
District of Columbia have a dependent
care tax credit or deduction. Most, but not all, of the state tax
provisions provide less per child than the
federal credit. Some cities with income taxes also offer credits.
In 13 states, the credits are refundable so
that even families with no income tax liability can claim the
credit. Maine and Vermont have provisions
that provide higher credits for higher quality child care. One
related policy that has been suggested to
increase the impact of tax credits on quality is to link tax credit
amounts to the quality levels in state
Quality Rating Systems. Most states have these systems in place
and those that don’t are in the process of
developing them.15
Title I
Title 1 of the Elementary and Secondary Education Act (ESEA,
also known as No Child Left Behind)
provides funds that can be used to provide early childhood
education so that disadvantaged children
have a greater opportunity to obtain a high-quality education.
Administered by the U.S. Department of
Education, Title I funds through ESEA can be used to offer an
extensive range of educational services to
children not only in grades K–12, but also from birth to age
5.16 Since these funds are available to most
school districts,17 they are a potentially important source of
funds for districts interested in offering
preschool education. Districts have two potential options
available.18 If at least 40 percent of district
children are in poverty, pre-K can be made available to all

students regardless of their family income
level. Where fewer than 40 percent of children are in poverty,
pre-K can be provided to students
identified as academically at-risk. Of course, there is nothing to
prohibit such districts from funding
services for additional children not meeting the income
eligibility requirement from other sources,
including parent fees.
Title I funds can be used to supplement existing programs such
as state-funded pre-K and Head Start.
An additional $10 billion in Title I funding was made available
through the ARRA.19
Early Childhood Special Education
The Individuals with Disabilities Act (IDEA) provides federal
funding for services to young children with
disabilities. IDEA, Part B provides states with funds for
children with disabilities ages 3 to 5. Thus, the
program includes kindergarteners as well as preschoolers.
Consistent with IDEA, every state guarantees a
free appropriate education to all children with disabilities ages
3 to 5. In fall 2009, 6 percent of 4-year-
olds and 4 percent of 3-year-olds were served nationwide.20
Many of these children also are served by
“regular” state-funded pre-K and Head Start. States vary
considerably in the percentage of preschool
children receiving special education (from 3 percent to 14
percent of those ages 3 and 4), in part because
they have the discretion to serve children with developmental
delays that fall short of constituting a

disability. However, federal financial support for preschool
special education has not kept pace with
enrollment or inflation, and state and local governments have
assumed a greater proportion of the total
cost over time. It is not known how much is spent on preschool
special education by state and local
governments, as this has not been estimated in detail since
1999, but it could easily be $6 billion annually
today.21
IDEA, Part C provides states with funds to serve infants and
toddlers (up to age 3) with developmental
delays or conditions that have a high risk of developmental
delay. States also may choose to serve infants
and toddlers they judge to be “at risk” of a developmental delay
if early intervention is not provided. All
states participate, but, as with Part B, definitions of the eligible
population and the percentage of children
served differ among the states. In fall 2008, the percentage of
children under age 3 served ranged from
less than 1.5 percent in the District of Columbia and Georgia to
about 6.5 percent in Massachusetts and
Hawaii.22 For the nation as a whole, a little more than 2.5
percent of infants and toddlers received publicly
funded early intervention services. The services funded also
vary by state, but they typically are quite
modest, delivering on average 1.5 hours per week of services in
a home visit.23 Total spending on early
intervention likely exceeds $5 billion annually (the figures we
rely on are over a decade old).24 The federal
government pays only about 10 percent of the cost through
IDEA. However, the federal government also
pays through Medicaid and other programs and private
insurance and parents also pay for some costs.
Therefore, it is unlikely that the state share is $5 billion. Our
estimate of $3 billion for state expenditures

should be considered a “ballpark” figure, at best.
State-Funded Prekindergarten
In recent years, the states have been active in providing publicly
funded preschool education. As of the
2009-2010 school year, all but 10 states provided some sort of
program. Taken together, they are the
largest public investment in young children not connected to a
federal program even though some state
programs are quite small. These initiatives take a variety of
approaches and are funded, controlled, and
directed by state government.25 Providers of pre-K services
follow state-specified standards and operate in
a variety of settings in addition to public schools. These include
private child care providers, Head Start
centers, faith-based settings, and family child care providers.
Most state programs target children who are
at risk of starting school behind and failing later. Family
income is the most common criterion for
eligibility but many other criteria are used as well. All state
pre-K programs are voluntary.
Across the nation, 27 percent of 4-year-olds (more than 1.1
million children) were enrolled by state pre-K
as of the 2009-2010 school year. Only 4 percent of 3-year-olds
(about 170,000 children) were enrolled.26
In the vast majority of states, pre-K is primarily or entirely a
program for children one year before
kindergarten. State spending on pre-K initiatives totaled over $5
billion for the country in fiscal year
2009. Local school funding added at least another $500 million,
possibly much more.27

The coverage of state pre-K programs varies greatly from state
to state. A number of states have
committed to serving all children at age 4. Florida, Georgia,
Illinois, Iowa, New York, Oklahoma, and
West Virginia have programs designed to serve all 4-year-olds
now or at some time in the future.28 Not
all of these states currently enroll a high percentage of children
at age 4. Some states that have not
committed to serve all children at age 4 nevertheless serve
larger percentages of the population than
some states that have made universal access a policy goal.
Illinois is the only state committed to serving
all children at ages 3 and 4. A few other states serve significant
percentages of their populations at age 3.
On the other end of the spectrum are 10 predominantly rural
states that did not fund any pre-K
programs as of 2010.29
State pre-K programs also vary widely in their funding per child
and standards.30 As a result, effectiveness
is likely to be very different from one state to another. Several
studies indicate that many state pre-K
programs have positive effects on learning and development,
sometimes quite large.31 A number of state
programs appear to produce larger learning gains than Head
Start and much larger gains than subsidized
child care.32
Local Pre-K Initiatives
Local districts often provide pre-K in the public schools or fund
private providers to serve preschoolers.
They may partner with Head Start and/or use federal Title I
funds to fund their programs (most often
in the schools). A well-known example of local use of Title 1

funds for preschool education is for the
Chicago Child-Parent Centers. Another example is provided by
Montgomery County, Maryland, which
has used Title I money to extend Head Start programs to a full
day.33 Some communities also choose to
serve typically developing children in their pre-K special
education programs where they can be added to
small special education classes at little marginal cost.
Even when states fund pre-K, local schools often provide funds
as well. (In this respect, state pre-K
resembles the way the K–12 finance system works—but since
pre-K is, historically speaking, a more
recent development, it is not included in the school funding
formula in most states.) State-funded pre-K
in 11 states requires local districts to also contribute funds.
Many other state pre-K programs implicitly
rely on matching funds even though local matches are not
statutorily required.34 Disparities between
public school and privately operated programs can be created
when local schools supplement state
funding (either explicitly or by absorbing facilities,
administration, and other costs not directly charged
to the preschool budget) in ways that private providers
receiving state funds cannot. In 2009, 14 states
reported local spending for state-funded pre-K of about $450
million. Maryland and Oklahoma reported
over $100 million in local school spending annually. As the
other 26 states with programs did not collect
this information, the total could be much higher across all
states. In some states, a local match is required
by the state’s school funding formula, but funding of pre-K
through the school funding system is likely to
lead to substantial local spending even if there is no required
local share.

Some local pre-K initiatives across the nation use public funds
and do not depend on state or federal
initiatives. They range in size from single classrooms to
citywide initiatives. Local spending decisions
should not be underestimated as an important component of the
financing picture for pre-K programs.
Local public school programs, including those in states that
fund little or nothing in the way of pre-K, are
perhaps the most important in the aggregate. Counties and
municipalities also sometimes contribute to
pre-K. Many First 5 California county commissions provide
substantial funding for preschool programs
that may or may not receive funding from other public
sources.35 First 5 funds derive from a dedicated
sales tax on cigarettes that generates over $500 million
annually, most of which is devoted to programs
that support the healthy development of children under age 5.
More than $100 million from these funds
was spent on pre-K programs in the 2008-2009 year.36 Another
example is provided by the Children’s
Trust in Miami-Dade County, Florida, which provides over $100
million annually primarily for early
childhood programs financed by a small property tax (0.50
mills). The Children’s Trust financing was
authorized by referendum and was renewed with a remarkable
86 percent favorable vote in 2008.37
Problems with the Status Quo
America now spends some $40 billion annually across 10 major
programs, but still about 25 percent
of 4-year-olds and 50 percent of 3-year-olds attended no early

learning program, public or private, in
the 2008-2009 school year.38 Even fewer children receive
public support for learning and development
prior to age 3. Some receive child care or preschool of such low
quality that it actually harms their
development, and others attend programs that do little to
improve their long-term educational and
economic success.39 Although it is difficult to estimate how
many receive high-quality services, we can say
without risk of error that most young children, including most
young children in poverty, do not attend
high-quality programs even at age 4 where public support is
greatest.
This is unfortunate because rigorous research has demonstrated
that high-quality programs produce
substantial gains in child development that generate long-term
benefits to society far in excess of their
costs.40 Effective policies put parents to work and make the
next generation more productive and less
costly (requiring less remediation, less medical treatment, less
welfare, and fewer prisons).41 Although
more money alone is not the solution to this problem, we will
not have an adequate investment without
more money. As a ballpark figure, increasing our current
investment by $20 billion (in constant dollars)
over the next decade would provide an additional $5,000 per
child for 4 million of the roughly 12 million
children under age 6 in low-income families. As we discuss
below, increased funding is only part of the
solution. Governments must take steps to ensure that public
funds are invested in highly effective early
learning programs and that coordination across levels of
government and different types of programs
results in efficient uses of funds.

Preschool and other services for young children more often than
not operate in separate policy “silos.”42
Because federal, state, and local funding streams have different
or even conflicting regulations,
coordination across them can be a challenge. Head Start and
Title I are federal-to-local grants, bypassing
state government, making it difficult for states to coordinate
efforts. This places much of the burden for
coordination at the local level, where providers must often
combine different funding streams to come up
with sufficient money to offer a single preschool program.
Providers often find themselves casting a wide
net, blending funding streams in order to meet the need for
child care and early education. A state pre-K
program might, for example, use a combination of state and
TANF funds while operating in a Head Start
building. This program could very well be required to comply
with multiple sets of eligibility criteria when
enrolling children and expend considerable resources complying
with multiple sets of administrative
requirements.
Work has begun to improve coordination across the patchwork
of pre-K policies and regulations that
currently exists. One logical place to begin is at the state level.
An interesting model is provided by
Pennsylvania’s Office of Child Development and Early
Learning, which became a statewide Early Head
Start grantee. More broadly, the Head Start Reauthorization Act
of 2007 required that each state establish

an advisory council on early childhood education and care.
Among the duties of each state early learning
advisory council is the identification of opportunities to
coordinate and collaborate across programs
receiving federal and state funds. Thirty-one states have applied
for funds to develop the councils. It
remains to be seen how effective these councils will be, but
they present an important opportunity.
Regardless of funding stream, research shows that when it
comes to effectiveness, publicly funded early
care and education varies greatly. Research on the economics of
early care and education demonstrates
that there are returns to both (1) providing care so that parents
can work and (2) providing early education
that enhances learning and development.43 If either aspect of
early education is neglected, returns are less
than optimal. The lost potential returns from failure to invest in
child development can be quite large,
and public policy is particularly weak in its support for child
development.44 Federal child care subsidy
policies that promote parental choice of informal family care
with little attention to quality have led to
subsidized child care that has now been found to be detrimental
to child development. Given the
tremendous potential for high-quality care to improve child
development, this is an exceptionally
harmful and wasteful policy. Resolving the problem will require
policy making across agencies and
possibly creating an authority over multiple agencies. Shifting
responsibility for both to a single agency
can be difficult given the strength of longstanding agency
cultures. For example, Pennsylvania created an
early childhood agency that spanned both welfare and education
agencies to deal with such a problem.

The federal Head Start program provides more support for
learning and development than typical child
care, but it is not nearly as strong as it could be when it comes
to educating children. The Head Start
Impact Study, mandated by Congress in 1998 and conducted on
a large sample of children beginning
in 2002, found modest positive impacts on some measures of
cognitive ability and parent behavior.
However, by first grade, children who had attended Head Start
demonstrated virtually no overall
cognitive, social, or emotional impacts from having attended the
program over children who had not
attended.45 Other non-experimental studies have found some
modest positive impacts from the program,
but there is no question that Head Start can do better. However,
this will require changes in policy. The
Obama administration has proposed some of the most sweeping
changes in Head Start in 40 years. The
administration can make most of these changes without
requesting additional authority from Congress.
Others have suggested more changes including greater state
involvement and more integration with state
pre-K.46
A number of state-funded pre-K programs have demonstrated
considerably larger effects on children’s
learning and development than Head Start or child care,
including effects that last well into elementary
school.47 Of course, there is considerable variation in program
quality and effectiveness from one state to
another, and some state pre-K programs—poorly funded and
with weak standards—may be less effective
than the federal Head Start program. Nevertheless, over the past
two decades, the states have developed
programs that, taken together, serve nearly one and one-quarter
million children through a variety of

funding models (See Appendix A) that often utilize funds from
federal and local sources. Their success
in doing so suggests that, if the federal government provided
incentives for state-funded pre-K to expand
and collaborate with other programs, they could serve as the
leading edge of more effective early learning
policy. The tremendous impact on state and local services of
relatively modest federal funding for young
children with special needs suggests that a new federal initiative
could leverage substantial improvements
in early learning policy. Even a $2 billion annual federal
investment in an Early Learning Challenge Fund,
perhaps through the Elementary and Secondary Education Act,
could significantly increase the level and
effectiveness of state and local early childhood funding.
In general, returns on public investments in early learning
programs could be increased if the amounts
paid were linked to program quality and performance. The
introduction of more competition to Head
Start and pay for performance (using multiple measures of
learning and teaching) at the center or school
level in state programs could lead to improvements in program
effectiveness. States with tiered tax credits
linked to state quality rating systems or accreditation offer one
example. This model could be extended to
federal and state expenditures of CCDF and TANF, and any new
federal initiative to support state-funded
pre-K or early care and education programs more generally.
Although this approach may be less well-
suited to preschool special education and early intervention,
some policy change is needed to ensure that

these programs are highly effective as well.
State and local spending on programs for children with
disabilities under age 5 is one of the nation’s
largest investments in early learning programs; it may exceed
state and local funding of programs for all
young children without disabilities, despite the relatively small
number of children with disabilities.
Therefore, the lack of evidence that programs for young
children with disabilities are highly effective is
disconcerting. Recently, the federal government introduced new
requirements for accountability under
the IDEA.48 As a result, data are now collected on the learning
and development of young children in
early intervention and special education. However, it is as yet
unclear how this information will be used
for real program improvement. Greater attention is needed for
the development of evaluation strategies
that will permit valid inferences derived from this data about
program effectiveness. In addition, it would
be useful to have better information on how much is actually
spent on preschool special education and
early intervention by each level of government. These are tasks
that might usefully be addressed by state
advisory councils as they work on the development of integrated
data and evaluation systems for state
early learning programs. However, unless states provide early
learning councils with sufficient staff,
authority, and longevity through statute, they are unlikely to be
strong enough to make the necessary
improvements.
Financing and Regulations
The policies that finance programs vary considerably in the
extent to which they also regulate or influence
the nature and quality of those programs and the extent to which

decisions about operations and quality
are made at the federal, state, and local levels. Head Start
programs are subject to extensive regulations
established at the federal level. Details such as procedures used
to determine eligibility, types of educational
and family support activities and teacher education are federally
determined49 and Head Start funding
flows directly from the federal government to local grantees. If
states choose to supplement the federal
Head Start program with additional funds to enable more
children to participate or to improve services,
federal regulations must still be followed.50
That is not the case with CCDF and TANF. These programs
allow for state-level decision making by
providing annual funding that states may use for a variety of
activities that are approved by the federal
government. These include paying for child care, improving the
quality of child care services, and
providing preschool education.51 This flexibility enables states
to use federal money more broadly than
Head Start funds (which must be used for a specific program
rather than a range of activities). Unfortunately,
the CCDF and TANF experience also indicates that flexibility
has done little to boost quality, as state
standards and reimbursement rates tend to be quite low. Of
course, it should be acknowledged that
federal policy emphasizes maximizing parental choice through
vouchers given to relatives. This policy
also places a high priority on moving parents from welfare to
work. These emphases are not consistent

with state efforts to raise quality, which would limit choice and
raise cost per child. This is not to say that
parental choice or moving parents to work are not important
priorities, but policy makers need to ensure
that these do not override the need for public funds to support
quality. Some states have used their QRIS
to limit the use of subsidies to higher levels of quality,
including New Mexico, North Carolina, and
Oklahoma.
The federal government asserts some limited authority over
state-funded preschool education, including
preschool special education, but there are wide variations
among states and within states at the local level.
Preschool special education receives some federal funds, but
they are a small fraction of the costs of
programs. State pre-K initiatives are essentially unsupported by
the federal government (aside from what
districts choose to spend from Title I). State pre-K relies on
state revenues even more heavily than does
K–12, though it is often supported by local contributions, too,
as part of the public education system.52
Decision-making authority rests primarily at the state level but
can, to varying degrees, be delegated
to the local level. This enables states to assert control over early
childhood education in key areas such
as standards and accountability, yet leave other policy decisions
to local discretion.53 While states do
sometimes rely in part on federal funds that come with
restrictions (e.g., TANF and special education
dollars), each state has broad latitude to develop its own pre-K
policies.54 State pre-K policies vary greatly
with respect to standards and the adequacy of funding per child,
but in all states standards for pre-K are
higher than those for subsidized child care.

Funding Models for State Prekindergarten Initiatives
States use a number of approaches to financing early education.
Some are more successful than others in
providing adequate and consistent funding streams. Among the
most notable alternatives are: including
pre-K with K–12 in the state’s funding formula for public
schools; designating funds from a particular
revenue source such as a state lottery or sales tax on a particular
product or service; appropriating funds
from general revenue; and, reallocating unspent TANF funds.
The School Funding Formula
Including pre-K initiatives in the statewide school funding
formula for public schooling is a particularly
effective way of providing consistently adequate funding. This
approach places no limits on enrollment
of the eligible population, and is particularly useful for
preschool programs that are open to all children
regardless of income. In a number of states this means that
school districts are not required to offer pre-K,
but if they do offer pre-K they receive a set amount for each
child enrolled based on the school funding
formula. As enrollment increases, so does total funding. This is
not the case with most other funding
approaches for pre-K. However, the state funding formula can
have other significant advantages or
disadvantages that depend on the specifics of each state’s
formula. In many cases, funding pre-K through
the school funding formula means funding would flow to school
districts, which in turn would need to
subcontract with community-based pre-K providers. Districts
not used to managing and monitoring
external providers would need to develop this capability. This
has been done successfully in New Jersey.55

Thus, it is essential to know how a particular state’s formula
works when deciding whether or not it is the
best approach to funding pre-K.
A state’s school funding formula determines the state’s
contribution to per-pupil spending in each district.
States vary widely in the amount of the state’s contribution,
average statewide contribution, and in how
much and in what ways those contributions vary by district.
States also differ in their requirements for
district contributions to per-pupil spending. A substantial local
contribution can provide a strong base on
which states can build with a relatively modest (if appropriately
distributed) share. As a national average,
states provide 48 percent of per-pupil funding with local
districts providing 44 percent and 8 percent
coming from the federal government.56 However, few states are
average and many depart considerably
from the average. Differences in state policies lead to wide
variations in state average per-pupil funding
and local share and to wide variations within states in
allocations to districts. Some state formulas are
highly progressive, resulting in much higher spending in high-
poverty, low-wealth districts. Some are
basically neutral or flat (though this may equalize total
spending across districts). Others are more
regressive with high-poverty, low-wealth districts having less to
spend over all.57 Nevertheless, financing
early learning programs—pre-K programs in particular—
through the school funding formula would
in many states provide more adequate and equitable financing

than existing alternatives, assuming that
preschoolers were included in the base enrollment rather than in
a categorical program with capped
funding or enrollment.
Despite concerns about state school funding formulas they tend
to have one clear advantage over most
alternatives. When legislatures set total funding rather than a
formula for funding per child, an increase
in enrollment can result in a decrease in dollars per child. Cuts
in funding or even flat-funding in the
face of inflation can lead to cuts in the number of children
served. Even though school funding formulas
primarily rely on general revenues rather than dedicated sources
such as lotteries,58 they are less likely to
suffer from draconian cuts and there is an incentive for each
district to maintain or increase enrollments.
In this framework, cutting enrollment is not usually considered
an option. Also, any cuts tend to affect
pre-K through grade 12 so there is a larger constituency to
prevent cuts and maintain adequate funding.
By contrast, when funding is separate it often appears to those
seeking cuts or funds for some other
purpose as well-defined, discrete, and weakly defended targets.
All of the major financing models used
by the states for early childhood programs are discussed in
Appendix A.
School Funding Formula
Three states that have sought to have experienced success
toward reaching their goals of providing pre-K
to all their children by using their school funding formulas:
Oklahoma. The statewide school funding formula played a
critical role in expanding state pre-K to the
point where 71 percent of 4-year-olds are enrolled in the state-

funded Early Childhood Four-Year-Old
Program. When Head Start enrollments are considered, 85
percent of 4-year-olds in Oklahoma are
enrolled in a public early education initiative.59 Oklahoma’s
pre-K initiative first began in 1980 as a pilot
program. In 1990, pre-K for 4-year-olds was added to the state
school funding formula as a statewide
targeted initiative for children from low-income families.60 In
1998, a bipartisan bill authorized districts
to provide pre-K to all 4-year-olds, regardless of family income.
At the same time, Oklahoma experienced
declining K–12 enrollments, creating a more favorable
environment for pre-K expansion in public
schools as this tends to produce excess capacity in
administration and facilities.61 After the state made the
commitment to universal pre-K, enrollment grew quickly to 56
percent of 4-year-olds in the 2001-2002
school year and 71 percent in the 2009-2010 school year.62 All
but two percent of the state’s districts offer
pre-K.
West Virginia. West Virginia took an approach similar to
Oklahoma’s by setting universal pre-K for all
4-year-olds as a statutory goal. The state started a public school
pre-K program in 198363 and in 2002
began a 10-year phase-in process toward universal pre-K.64
Like Oklahoma, West Virginia was also
experiencing declines in K–12 enrollment—a circumstance that
again made the school funding formula a
particularly attractive means of expanding toward universal pre-
K. Schools were able to draw down funds

for 4-year-olds to offset funding losses due to declines in
enrollment by older children. Since the state
began its phase-in process, enrollment in state pre-K has grown
from 24 percent of 4-year-olds to 55
percent.65 Another 23 percent of 4-year-olds are in Head Start.
The state defines universal access as a
participation rate of 80 percent of all 4-year-olds, and is
working to reach this goal by the 2012-2013
school year.66 All districts offer the program, and during the
phase-in process districts may limit entry
to children at elevated risk of school failure based on locally
developed criteria. Half of all children must
be served in private centers through collaboration agreements.
Wisconsin. Wisconsin first offered public pre-K in 1873 but
pre-K provision declined after the 1890s and
was suspended entirely from 1957 to 1984. Nevertheless, the
financing mechanism by which funds for
pre-K were distributed directly to the public schools remained
in place.67 Use of these funds has grown in
recent years, as evidenced by the fact that the percentage of 4-
year-olds enrolled in the state’s Four-Year-
Old Kindergarten (4K) grew from 18 percent in the 2001-2002
school year to 51 percent in the 2009-2010
school year.68 State government encourages districts to offer
4K, but it is up to districts to decide, and 77
percent of districts offered 4K in 2009-2010. If a district offers
4K, all age-eligible children who apply
must be served. All state funding models are discussed in
Appendix A.
Conclusions and Recommendations
It should go without saying that developing more reliable, well-
considered revenue streams for early
learning programs is a good thing. They not only maintain
enrollment and program quality, they also

provide the predictability that is essential to ensuring
continuous improvement and a high level of
program effectiveness. The lack of cohesive system-building
that has typified the expansion of early
childhood education in the United States has perpetuated the
patchwork of preschool policies and
finance mechanisms at all levels. This likely resulted in fewer
children served than had a more systemic
approach been used. And, it has delayed the collaboration and
adaptation of successful approaches across
programs that can lead to enhanced program effectiveness.
Develop New Revenues and Reallocate from Waste to Early
Investments
Far more improvement is necessary than can be accomplished
with current revenues. As Tables 1 and 2
show, recent growth in funding for early learning programs has
been primarily at the federal level, and
most state funding is to serve children with special needs. And,
despite these increases, only about 40
percent of 4-year-olds and 14 percent of 3-year-olds attends
publicly funded pre-K or Head Start. About
a quarter of 4-year-olds and half of 3-year-olds attended no
public or private program in 2008-2009.
Access to quality programs is even more limited for infants and
toddlers. Participation rates are
particularly low for children from low- to moderate-income
families. Although this does not take into
account tax credits, it is unlikely that they do much to increase
access to quality programs. Underlying
the national averages is great unevenness in public support for
early learning programs, and program
standards and effectiveness vary dramatically across and within
funding silos.

In both the short term and long term, difficult choices regarding
public spending will be required at the
local, state, and federal levels. Some experts argue that
austerity budgets and tax cuts are required. Others
argue that this is exactly the wrong time for austerity budgets,
as they will only exacerbate the recession,
and that new public investments are needed to spur economic
growth. On balance, we conclude that in
the long term both spending restraint and revenue increases will
be required. Whatever view one takes,
we believe that increased public investments in early learning
programs have a place because their
benefits far exceed their costs in the long run. Investment in
high-quality early care and education is an
effective pro-growth strategy that can reduce future government
costs and increase future revenues.
Government costs are reduced when fewer children repeat
grades or need special education, delinquency
and crime are reduced, teen pregnancy and smoking decline, and
fewer people need welfare or
unemployment payments. Revenues are increased when more
parents work and when a better educated
workforce generates more income.
Even large increased investments in early care and education
are quite small in the context of current
government budgets. In 2009, federal government spending
topped $3.7 trillion and state and local
governments added another $1.6 trillion from their own
sources.69 An additional $10 billion annually for
early learning programs would amount to just one penny out of

every $500 dollars spent by government.
While this would be a significant improvement, more is needed.
As mentioned previously, increasing our
current investment by $20 billion over the next decade would
provide an additional $5,000 per child for
4 million of the 12 million children under age 6 in low-income
families. Increased funding is only part of
the solution. Governments must take steps to ensure that public
funds are invested in highly effective early
learning programs and that coordination across levels of
government and different types of programs
results in efficient uses of funds.
The fiscal situation of states and the federal government are not
projected to improve in the foreseeable
future without major policy changes. A recent report from the
National Governors Association and
National Association of State Budget Officers concluded that
“Fiscal 2010 presented the most difficult
challenge for states’ financial management since the Great
Depression.”70 The next several years also are
expected to be difficult as state revenues tend to lag a recovery
that is itself relatively slow.71 Even after
the recovery, long-term demands on state budgets from rising
costs of health care, pensions, and other
obligations are projected to produce a persistent structural
imbalance between state revenues and
expenditures. The long-term federal budget outlook is difficult
for similar reasons. However, this does
not mean that additional investments in early care and education
are not feasible or politically practical.
States vary greatly in their current tax efforts, and it could be
argued that some should do more. At both
the federal and state levels there is considerable potential for
increased funding for early childhood
programs by reducing unproductive current expenditures.

Where might the money for additional investments come from?
Unlike early care and education,
few other government programs (including special tax rules that
cost billions) are backed by rigorous
evidence that they contribute to human development and
economic growth.72 Although the value of
many government programs can be debated, some are
ineffective and inefficient while others are of no
value except to narrow special interests. A wide range of
business incentives and tax loopholes provide
few benefits and misallocate private resources.73 Farm
subsidies alone amounted to over $20 billion in
2010, and the vast majority went to wealthy agribusinesses.74
These giveaways to millionaires do not serve
the public good, and have negative social and environmental
impacts. Cost savings also are to be gained
by choosing more effective approaches in education,
corrections, social welfare, and, no doubt, even
defense. For example, states spend over $50 billion a year on
corrections, a rapidly rising cost that could
be reined in by criminal justice reform, making room for
investments in preventative programs like pre-
K.75 Even the cost of filing income taxes now amounts to as
much as 10 percent of the tax so that tax
simplification itself could make it possible to raise more
revenue while leaving the taxpayer better off.76
Revisit State Funding Mechanisms
A comprehensive approach to increasing state and local funds
for early learning programs could begin by

including pre-K and other programs in the school funding
formula. This would be a good start to solving
the early care and education financing problem, though it is not
a complete solution, and other funding
streams for federal and state child care subsidies will remain
vitally important. Keep in mind that most
early learning services are not provided in the public schools.
Early childhood public education increasingly
takes place outside the public schools, but with their support.
The revenues for a more adequate early
learning system could be raised by reducing other spending that
does not generate long-term economic
benefits or from new revenue sources. Given the relatively
small cost of expanded early learning programs,
neither revenue enhancements nor expenditure reallocations
would require major changes.
What is best for each state will likely vary somewhat. We do
not expect that “one size fits all” when it
comes to financing early childhood education. Models that work
well in one locale may be less successful
in others—or less successful over time as political climates
shift. Education lotteries responsible for the
early growth of public pre-K in some states may not support
sustained growth over time. (See Appendix
A) States that do not fund pre-K through their school funding
formulas should work toward that goal or
develop other dedicated funding mechanisms that are less
susceptible to the shifting tides of the economy
than current arrangements. This approach should lead to more
widespread availability of high-quality
pre-K programs.
Foster Collaboration, Coordination Through Policy
Collaboration and coordination can improve access to early

learning programs and raise quality. New
initiatives for large scale coordination are taking shape through
federally funded state advisory councils
for early learning programs. These councils represent a critical
step toward a better-coordinated system.
They are charged with developing recommendations to increase
participation in early childhood programs
from birth to age 5; developing recommendations for
professional development plans and unified statewide
data systems; and identifying opportunities for improved
coordination and collaboration.77 A key part of
their mission should be to develop plans for adequate financing
of expanded state early learning systems.
The deep recession of 2008 has highlighted the extent to which
current programs and their funding
streams exist in separate silos. When funds are limited, difficult
tradeoffs must be made when deciding
whether to serve more children or to provide higher quality
preschool programs. This makes it a challenge
to blend funds from separate streams that serve similar
objectives. When one early learning program is
cut, the consequences ripple through the rest of the early care
and education system and impact other early
learning programs. The broad perspective permitted by having
council members across early childhood
constituencies should enable the state advisory councils to
reduce overlap, identify gaps, and craft policies
that improve educational initiatives for young children.78 As
they do so, they should identify needs for
federal regulatory relief that would facilitate more effective
coordination and collaboration to increase
access and improve effectiveness. The federal government can
then support these state efforts by granting
regulatory relief.

A federal early learning challenge fund should be established
that awards substantial federal-to-state grants
for innovative initiatives that support coordination and
collaboration to improve access and quality. This
additional financing would leverage the ability of state early
learning councils to achieve their mission and
act as a catalyst for policy reform. In general, the federal
government could play a much more important
role in promoting equal access and high quality across the
states. The early learning challenge fund is one
means to this end, but it should not be the only one. The federal
government should also act more
directly by linking federal child care subsidy and tax credit
amounts to quality standards or rating systems
and raising the bar for Head Start performance.
Review Head Start, State Pre-K Policies
A public review of Head Start and state pre-K policies should
be conducted in anticipation of fulfilling the
mandate that Head Start and state pre-K work in a more
coordinated fashion at the state, community,
and provider level. This could take place in the context of an
even broader program review supported by
state advisory councils and, at the federal level, by the Early
Learning Interagency Policy Board (ELIPB).79
Announced in August 2010, the federal ELIPB is to be
composed of senior staff from the Departments of
Education and Health and Human Services. Early intervention
and preschool special education should

be included in the policy reviews and planning, keeping in mind
that these children also are served in
child care, Head Start, and pre-K “regular” education. As data
systems are developed that cross systems,
programs serving children with special needs should be
included. This public review provides a unique
opportunity to streamline regulations in ways that facilitate
coordination and collaboration while shifting
emphasis toward evaluation and continuous improvement
processes rather than monitoring and auditing.
Tie Child Care Subsidies to Program Quality
Tying federal and state subsidies for child care to quality by
linking them in some way to state Quality
Rating Systems (QRIS) holds promise for increasing the quality
of child care over time. More than half
the states have a fully operational QRIS, and those that don’t
are in the process of designing them. QRIS
have the potential to provide a common standard for public
funding. Initially, QRIS were designed for
child care only, taking state regulations as the floor and
building up additional levels of program standards,
creating a path to national accreditation. QRIS in some states
are designed for all sectors of early care and
education, incorporating standards for pre-K as well as national
standards such as the Head Start Program
Performance Standards. Using QRIS as a funding standard
would require ensuring that all QRIS not only
incorporate the highest standards, but also that states move
toward consistency in their systems and that
they apply to settings in which early care and education are
provided. A tiered payment system that
recognizes the various levels of quality in QRIS reporting may
be feasible.

Focus Early Childhood Finance Reform on Birth to Age 8
High-quality early care and education prepares children to enter
K–12 education ready to learn. There
are, however, compelling reasons for pursuing early childhood
finance reform as part of a broader set of
policies aimed at increasing collaboration and coordination
across agencies for children from birth to age
8. Doing so would enable children as well as the schools and
policymakers who serve them to avoid the
transition problems that so often occur when kids leave pre-K
and enter the K–12 system. Such a policy
focus would facilitate coordination of curricula, teacher
communication across the pre-K/K–12 divide,
and professional development.
Appendix A
Funding Models Used to Provide State Pre-K
School Funding Formula
Three states that have sought to have experienced success
toward reaching their goals of providing pre-K
to all their children by using their school funding formulas:
Oklahoma. The statewide school funding formula played a
critical role in expanding state pre-K to the
point where 71 percent of 4-year-olds are enrolled in the state-
funded Early Childhood Four-Year-Old
Program. When Head Start enrollments are considered, 85
percent of 4-year-olds in Oklahoma are
enrolled in a public early education initiative.80 Oklahoma’s
pre-K initiative first began in 1980 as a pilot

program. In 1990, pre-K for 4-year-olds was added to the state
school funding formula as a statewide
targeted initiative for children from low-income families.81 In
1998, a bipartisan bill authorized districts
to provide pre-K to all 4-year-olds, regardless of family income.
At the same time, Oklahoma experienced
declining K–12 enrollments, creating a more favorable
environment for pre-K expansion in public
schools as this tends to produce excess capacity in
administration and facilities.82 After the state made
the commitment to universal pre-K, enrollment grew quickly to
56 percent of 4-year-olds in the 2001-
2002 school year and 71 percent in the 2009-2010 school
year.83 All but two percent of the state’s
districts offer pre-K.
West Virginia. West Virginia took an approach similar to
Oklahoma’s by setting universal pre-K for all
4-year-olds as a statutory goal. The state started a public school
pre-K program in 198384 and in 2002
began a 10-year phase-in process toward universal pre-K.85
Like Oklahoma, West Virginia was also
experiencing declines in K–12 enrollment—a circumstance that
again made the school funding formula
a particularly attractive means of expanding toward universal
pre-K. Schools were able to draw down
funds for 4-year-olds to offset funding losses due to declines in
enrollment by older children. Since the
state began its phase-in process, enrollment in state pre-K has
grown from 24 percent of 4-year-olds to
55 percent.86 Another 23 percent of 4-year-olds are in Head
Start. The state defines universal access as
a participation rate of 80 percent of all 4-year-olds, and is
working to reach this goal by the 2012-2013
school year.87 All districts offer the program, and during the
phase-in process districts may limit entry to

children at elevated risk of school failure based on locally
developed criteria. Half of all children must be
served in private centers through collaboration agreements.
Wisconsin. Wisconsin first offered public pre-K in 1873 but
pre-K provision declined after the 1890s and
was suspended entirely from 1957 to 1984. Nevertheless, the
financing mechanism by which funds for
pre-K were distributed directly to the public schools remained
in place.88 Use of these funds has grown in
recent years, as evidenced by the fact that the percentage of 4-
year-olds enrolled in the state’s Four-Year-
Old Kindergarten (4K) grew from 18 percent in the 2001-2002
school year to 51 percent in the 2009-2010
school year.89 State government encourages districts to offer
4K, but it is up to districts to decide, and 77
percent of districts offered 4K in 2009-2010. If a district offers
4K, all age-eligible children who apply must
be served.
Lotteries
Lotteries have been used to create dedicated funding streams for
pre-K. Until recently, lotteries were
believed to be relatively recession proof and protected from
state budget shortfalls in difficult times.
However, many state lotteries saw declines in revenue
beginning in 2008 due to the “Great Recession.”
This has threatened both current funding and future growth of
programs. Another concern with the
lotteries as a funding source for pre-K is that they are often
viewed as regressive taxes on low-income
populations. In addition, lottery revenues typically are devoted

to more than one education program.
This creates a larger constituency, but it also can lead to
competition among the various education
programs that are the beneficiaries.90 State lotteries have been
a prominent source of revenue for pre-K
programs in southern states.
Georgia. In 1993, Georgia became the first state to offer a pre-K
initiative supported by lottery funds. Two
years later, the state expanded its targeted pre-K initiative,
becoming the first state to offer a voluntary
pre-K program to all its 4-year-olds. Georgia’s Pre-K Program
grew quickly and had a lottery-supported
enrollment of more than 60,000 children by 1998. Even though
revenues from the state lottery kept
increasing, growth in pre-K funding slowed considerably
starting in 2000, and enrollment increases since
then have not quite managed to keep pace with Georgia’s
growing 4-year-old population.
Demand for Georgia’s Pre-K Program has outstripped supply,
and children’s participation is now
determined by methods such as waiting lists and enrollment
lotteries.91 In the 2009-2010 school year, 55
percent of the state’s 4-year-olds were enrolled with the total
reaching 63 percent when special education
and Head Start are included.92 Since then, Georgia’s governor
has proposed diverting lottery funds to help
balance the state budget and experts have predicted that the
costs of the lottery-funded programs (including
a popular college scholarship initiative) would exceed lottery
revenues in 2010.93 Georgia’s experience
illustrates how lottery-based financing can limit the growth of
pre-K and hinder a state from reaching its
goal of serving all children who seek to enter the program.

North Carolina. In 2006, North Carolina began using lottery
funds to finance state pre-K. The state’s
More at Four (MAF) initiative started on a small scale in
January 2002, serving about 1 percent of the
state’s 4-year-olds. By 2006, when the state’s lottery was
approved, 12 percent of North Carolina’s 4-year-
olds were enrolled. About half of the proceeds from the lottery
are committed to MAF and class size
reduction in grades K–3. By 2009, MAF was serving 25 percent
of the state’s 4-year-olds and had some
of the highest program standards in the nation. Lottery
proceeds, however, proved to be lower than
anticipated, and the state has struggled to find solutions to the
revenue shortfall.94
Other States. Several other states have used lotteries to fund
pre-K programs.95 Tennessee began its pre-K
program as a pilot project in 1998. The program grew slowly
until funds from the new state lottery
became available in 2005, after which it expanded rapidly,
serving 21 percent of the state’s 4-year-olds in
the 2009-2010 school year. Virginia also has moved toward
using lottery funds to support pre-K in recent
years.96 Oklahoma began a lottery in 2005 to supplement
general revenues, with proceeds supporting
public education from pre-K through college.97
Financing Universal Prekindergarten in New York and Florida
The experiences of New York and Florida inform any discussion
of funding large scale state pre-K
initiatives. New York was one of the earliest states to make
universal pre-K a statutory goal. Yet the state

has had considerable difficulty making consistent headway
toward achieving that goal. Florida, on the
other hand, rolled out a universal program in a very short time
span that enrolled a relatively high
proportion of 4-year-olds but had low program standards.
New York. New York’s Universal Prekindergarten (UPK)
initiative began in 1998, the same year Oklahoma
adopted a universal approach. Unlike Oklahoma and Georgia,
New York did not include pre-K in the
school funding formula or have a dedicated funding stream for
pre-K such as a lottery. This left the
program subject to shifting political priorities in each year’s
budget allocations process.98 After an initial
period of growth in districts with the most economically
disadvantaged families, UPK was flat-funded
from 2002 until 2005. Expansion into more affluent districts
was limited. The 2007-2008 budget committed
additional funds to UPK, and a goal was set for universal access
by 2011.99 That year, UPK served 39
percent of the state’s 4-year-olds.100 Since then, UPK has
battled for funding.101
Florida. Florida launched its Voluntary Prekindergarten (VPK)
program in 2005 in response to a
constitutional amendment requiring the state to make pre-K
available to all children at age 4. Five years
later, more than 155,000 children had enrolled, representing 68
percent of Florida’s 4-year-olds. Although
Florida offers a large pre-K program, it is not well funded. Per-
child spending ranks among the lowest in
the country and standards for teacher qualifications are low.102
The state provides a minimal allocation for
every child projected to enroll and that has been reduced while
staff-child ratios have been increased.103

Florida chose a low base student allocation that allowed for a
rapid roll-out of VPK but did so at a price.
This rapid expansion was possible because children were served
in existing child care programs with little
or no increase in program quality—making the educational
effectiveness questionable.
Other State Finance Models
A number of other funding mechanisms have been used over the
years for state-financed pre-K. Arkansas
implemented a “sin tax” on beer. Missouri levied fees on
gambling. Several states have taxed tobacco or
used funds from the national tobacco settlement to help fund
pre-K. These approaches have limitations
as supports for long-term pre-K expansion because such taxes
tend to decrease expenditures on the
specific products that are taxed, and tobacco settlement money
is finite. South Carolina and Arkansas
have used more general sales taxes. Ohio and Louisiana have
made extensive use of unspent TANF funds
by allocating them to pre-K, a strategy that can create problems
when unspent TANF funds are no longer
available.104
As mentioned previously, many states rely on local revenue as
well as state revenue to fund preschool
programs, most often as part of a more general approach to
funding public education. However, some
communities have levied local taxes dedicated to children’s
programs including early care and education,
as for example, the Children’s Trust in Miami-Dade, Florida,
mentioned earlier.105 Such local funding can
be a useful supplement to state and local education funding and
can provide a buffer from economic
downturns that can more adversely affect state income and sales
taxes, though local property taxes have

been by no means immune to downturns in the housing market.
Endnotes
1 As we write it is still unclear exactly how ARRA funds will
have been spent. The federal government
appropriated $2.1 billion for Head Start and Early Head Start
and $2 billion for child care in 2009 and
2010. However, some of these funds will have been spent in FY
2011. For FY 2011 we estimate ARRA
spending at $415 million for Head Start and $768 for Early
Head Start. The federal allocation for Head
Start and Early Head Start in FY 2011 without ARRA funds was
$7.575 billion.
2 Barnett, W.S., Epstein, D.J, Carolan, M.E., Fitzgerald, J.,
Ackerman, D.J., & Friedman, A.H. (2010). The
state of preschool 2010: State preschool yearbook. New
Brunswick: Rutgers, State University of New Jersey,
National Institute for Early Education Research.
3 This number includes children funded by state additions to
federal funding as well as children who are
federally funded. The number reflects actual slots rather than
“total enrollment” which Head Start
computes including children who dropout and are replaced.
CLASP (2010). Head Start by theNumbers
2009PIRProfile: United States. Washington, DC: Author. U.S.
Department of Health and Human
Services, Administration for Children and Families, Office of
Head Start. (2008). Head Start program fact
sheet. Retrieved January 29, 2010, from
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4 Haskins, R. & Barnett, W.S. (2010).
5 http://www.federalregister.gov/articles/2010/09/22/2010-

23583/head-start-program
6 Greenberg, M., & Schumacher, R. (2003). Financing universal
pre-kindergarten: Possibilities and
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andDevelopment Fund andTemporary
Assistance forNeedy Families BlockGrant. Washington, DC:
Center for Law and Social Policy.
7 Besharov, D. J., Higney, C. A., & Myers, J. A. (2007).
Federal and state child care and early education
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8 U.S. Department of Health and Human Services,
Administration for Children and Families, Office of
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(2009). State advisory councils: Responses to
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http://www.ed.gov/news/speeches/working-together-
early-learning-secretary-arne-duncans-remarks-early-childhood-
2010-in
81 Barnett, Epstein et al., 2010; Stone, 2008.
82 Gormley, W. T., Jr., & Phillips, D. (2003). The effects of
universal pre-K inOklahoma: Research highlights
and policy implications. (CROCUSworking paper #2).
Washington, DC: Center for Research on Children
in the United States, Georgetown University.

85 Cavalluzzo, L., Clinton, Y., Holian, L., Marr, L., & Taylor,
L. (2009). WestVirginia’s progress toward
universal prekindergarten (Issues & Answers Report, REL
2009–No. 070). Washington, DC: U.S.
Department of Education, Institute of Education Sciences,
National Center for Education Evaluation and
Regional Assistance, Regional Educational Laboratory
Appalachia.
87 Cavalluzzo et al., 2009.
88 Barnett, Epstein, et al., 2010; Stone 2008.
89 Barnett, Epstein, et al., 2010; Barnett, W. S., Robin, K. B.,
Hustedt, J. T., & Schulman, K. L. (2003). The
state of preschool: 2003 state preschool yearbook. New
Brunswick, NJ: National Institute for Early Education
Research, Rutgers University.
90 Stone, 2008.
91 Southern Education Foundation. (2008). Time to lead again:
The promise ofGeorgia Pre-K. Atlanta:
Author.
92 Barnett, Epstein, et al., 2010.
93 Salzer, J. (2010, January 24). Perdue wants to tap lottery
funds. TheAtlanta Journal-Constitution.
Retrieved February 12, 2010, from
http://www.ajc.com/news/perdue-wants-to-tap-281720.html .
94 Barnett, Epstein, et al., 2010; Cobb, C. (2009). North
Carolina’s More at Four Prekindergarten
Program: A case study of funding versus quality and other
issues in large-scale implementation. In R. C.
Pianta & C. Howes (Eds.), The promise of pre-K (pp. 123-144).
Baltimore, MD: Brookes Publishing.
95 Mitchell, A. (2009). Models for financing state-supported
prekindergarten programs. In R. C. Pianta &
C. Howes (Eds.), The promise of pre-K (pp. 51-63). Baltimore,
MD: Brookes Publishing.

96 Barnett, Epstein, et al., 2010.
97 Mitchell, 2009.
98 Ackerman, D. J., Barnett, W. S., Hawkinson, L. E., Brown,
K., & McGonigle, E. A. (2009). Providing
preschool education for all 4-year-olds: Lessons from six state
journeys. Preschool policy brief no. 18. New
Brunswick, NJ: National Institute for Early Education Research,
Rutgers University.
99 Cochran, M. (2009). Implementing large-scale
prekindergarten initiatives: Lessons from New York. In
R. C. Pianta & C. Howes (Eds.), The promise of pre-K (pp. 145-
167). Baltimore, MD: Brookes Publishing.
101 Winning Beginning New York. (2010). 2010 state budget
update. Retrieved February 14, 2010, from
http://www.winningbeginningny.org/documents/2010_state_bud
get_update.pdf .
103 State of Florida Agency for Workforce Innovation. (n.d.).
Voluntary Prekindergarten Program:
Frequently asked questions. Retrieved February 12, 2010, from
http://www.floridajobs.org/earlylearning/VPK/FAQs.html.
105 Mitchell, A., Stoney, L., & Dichter, H. (2001). Financing
child care in theUnited States: An expanded
catalog of current strategies. Kansas City, MO: Ewing Marion
Kauffman Foundation. Merzer, M. (nd).
The billion dollar bet on a community’s future. Miami, FL: The
Children’s Trust.

120 Albany Street, Suite 500 New Brunswick, New Jersey
08901
(Tel) 732-932-4350 (Fax) 732-932-4360
Website: nieer.org
Information: [email protected]
by W. Steven Barnett, Ph.D., and Jason T. Hustedt, Ph.D.
W. Steven Barnett is a Board of Governors Professor and Co-
Director of the National Institute for Early Education Research
(NIEER) at Rutgers University. His research includes studies of
the economics of early care and education including
costs and benefits, the long-term effects of preschool programs
on children’s learning and development, and the
distribution of educational opportunities.
Jason Hustedt is an Assistant Professor in the Department of
Human Development and Family Studies at the
University of Delaware. His work focuses on the impacts of
state-funded pre-K initiatives on young children, federal
and state early childhood policy, and preschoolers' and toddlers'
interactions with their parents and peers.
Improving Public Financing for Early Learning Programs is
issue 23 in a series of briefs developed by the National
Institute for Early Education Research. It may be used with
permission, provided there are no changes in the content.
Available online at nieer.org.
This document was prepared with the support of The Pew
Charitable Trusts. The Trusts’ Advancing Pre-Kindergarten for
All

initiative seeks to advance high quality prekindergarten for all
the nation’s three-and four-year-olds through objective,
policy-focused research, state public education campaigns and
national outreach. The opinions expressed in this report
are those of the authors and do not necessarily reflect the views
of The Pew Charitable Trusts.
N AT I O N A L I N S T I T U T E F O R
E A R LY E D U C AT I O N R E S E A R C H
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SScchhooooll FFaacciilliittiieess
National Clearinghouse for Educational Facilities
at the National Institute of Building Sciences
1090 Vermont Avenue, NW, Suite 700, Washington, DC 20005-
4905 888-552-0624 www.ncef.org
Funded by the U.S. Department of Education ©2009, National
Institute of Building Sciences
Arthur H. Roach
Fundraising Consultant
2009

There is one problem many private schools are happy to
face: coping with growth. When the size of the student
body is increasing and the waiting list for enrollment
grows longer, a school may assume that it is
accomplishing its mission and educational goals. For
private schools, a full complement of tuition and fees
permits operating and program costs to be covered.
Schools usually accommodate growth with new
buildings or with renovated facilities adapted to support
instructional needs. This may require a construction loan
from a bank, an encumbrance not usually funded by an
institution’s annual operating budget. A construction loan
may be reduced or may be unnecessary if fund raising
generates enough capital to cover the costs of the
project before building begins. Or, a major portion of the
loan may be repaid later through funds given to the
school as charitable contributions.
Individuals, corporations and foundations in the United
States contributed more than $295 billion to nonprofits in
2006. This figure includes contributions to all non-profit
corporations holding IRS 501(c)(3) status, such as arts
organizations, healthcare and social service agencies,
churches and church-related institutions, as well as
schools and libraries. Foundation grants account for
$36.5 billion, or only about 12 percent of this 2006 total.
Corporate contributions were even less at $12.7 billion,
or approximately four percent. Gifts from individuals
(including bequests), at $246 billion, accounted for 84
percent of all charitable giving.
The term contributed income is important. It is a gift. The
donor does not buy a magazine subscription, a program
ad or a candy bar. According to the official language of
the IRS, the donor has received neither goods nor

services in consideration for the gift. The donor does,
however, receive a thank you, an acknowledgment, and
the option to reduce taxable income by itemizing
deductions on IRS Form 1040 Schedule A.
Most K-12 institutions seeking tax-deductible
contributions are private or church-related schools that
have obtained nonprofit incorporation within their state
and have been designated a 501(c)(3) organization by
the IRS. As such, they have articles of incorporation,
bylaws, and independent, deliberative—not advisory—
boards of directors with fiduciary responsibility.
• Some schools are wholly owned and operated by a
church. If the church is part of a denomination that
predates the IRS, it might not need 501(c)(3) status
in order to receive tax-deductible contributions.
Contributions to an unincorporated church school
are actually designated gifts to the sponsoring
church. These schools will encounter foundations
and corporations whose guidelines do not permit
contributions to churches.
• Tax-deductible gifts may be made to public schools.
Fund raising in public schools is usually associated
with projects that, for example, provide new band
uniforms or bleachers. As individual donors,
Americans expect their taxes to cover costs related
to public school buildings, so they are
unaccustomed to being asked for charitable financial
support to build or renovate schools.
• Public schools considering a campaign to fund

capital projects with contributed income should
identify a fundraising consultant who has specific
experience in this highly specialized area.
Raising money for new or renovated facilities is called a
capital campaign. In addition to funding the project that
motivated it, a successful capital campaign
• builds and refines a school’s development program
for the foreseeable future;
• builds visible volunteer leadership that should
continue to support the institution as well as build
the school’s credibility in the philanthropic sector;
and
• stretches, redefines, and expands the level of
contributed income a school should expect to
receive after the campaign is completed.
2 Fundraising Basics for Private School
Facilities
4905 888-552-0624 www.ncef.org

Setting up a Comprehensive
Development Program
Obtain fundraising software (e.g., Blackbaud’s The
Raiser’s Edge, www.blackbaud.com or DonorPerfect,
www.donorperfect.com) or subscribe to one of the web-
based programs (e.g., www.etapestry.com ). These are
more than glorified address books. They anticipate the
way you will want to record and report donor and
potential donor information. You will accurately record
gifts and pledges, as well as generate
acknowledgements and payments. A good software
program greatly enhances the efficiency of the persons
assigned with fundraising responsibilities, provided they
receive good training in its use. Such a program has the
effect of adding staff without the expense.
Invest in the staff time to record data and build
donor profiles. In addition to names and addresses,
information like preferred salutations, relationship to the
school (e.g., board member, parent, past parent, alumni
and class year, vendor, area business, friend), and
contribution history will help you build a strategy for
identifying and contacting donors to a capital campaign.
Knowing their college, graduate school, profession, and
interests will assist in making connections with other
constituents. Having complete, accurate, and accessible
data is critical for developing solicitation strategies.
There is no such thing as “too much information.”
Implement all components of a comprehensive
development program.

• Annual fund. Begin asking people for money now,
regularly, twice a year. Simply ask for unrestricted
gifts to your school; but not for your capital
campaign—not yet.
An annual fund builds the donor database and
acquaints people with the idea of giving to and being
thanked for their contributions to your school.
Regularly asking for money keeps you focused on
the reasons you are seeking financial support
through contributions. You become accustomed to
describing your needs; that is, composing a case for
support. You may choose to target alumni, parents,
and friends differently. Whatever your plan, an
annual fund builds donor relations and donor giving
histories—an important first step in preparing for the
major gifts needed in a capital campaign.
• Major gifts. The Board of Directors should always
have a standing committee devoted to identifying,
cultivating, and ultimately soliciting contributions
from persons capable of making major gifts. The
board must define the term “major gift” within the
school’s context and needs. It might be $10,000 (or
less) or $100,000 (or more).
If a capital campaign is anticipated within two or
three years, delay asking for an assured major gift
until it can be incorporated into the campaign either
as an “advance” or “leadership” gift. Part of
cultivating donors might include keeping them
abreast of campaign plans and the important role
they will play as leadership donors. When the
campaign is completed, your school will have

experience in developing relationships with major
donors. There will always be a need for major gifts.
• Deferred or planned giving. Another standing
committee of the Board of Directors should be
assigned the task of encouraging deferred or
planned gifts, such as bequests and annuities.
Creating a “society” that recognizes planned giving
donors can be an effective tool to promote these
gifts. An official from the bank where your school
has its accounts may be willing to sit on your board
and assign a staff member to preside over that
committee. While the bank officer can oversee the
technical considerations, someone else may
assume responsibility for a proactive stance towards
deferred gifts.
An active and visible development program for
deferred gifts adds to the credibility and long-range
context for a capital campaign.
• Special event. Identify and establish a special
annual fundraising event. In addition to the amount
of money that is to be raised, be clear about other
goals, such as good publicity and public relations.
Be aware that a large percentage of the ticket
price for special events may not be tax deductible,
and much of the other money collected at a special
event is “earned income” from sales (not tax
deductible) rather than "contributed income." The
IRS expects vigilant oversight of this. If someone
buys a ticket and receives a meal, the value of the
meal must be indicated. If your special event is a
silent or live auction and an attendee successfully
bids on a pair of opera tickets, you may not indicate

a charitable contribution up to the value of the
tickets.
The value of the special event to your future
capital campaign includes identifying volunteer
leaders and workers, adding names of school
friends to the database, and recording amounts of
Fundraising Basics for Private School Facilities
3
4905 888-552-0624 www.ncef.org
money transacted by attendees at the special event.
• Foundation Grants. Identify a volunteer who enjoys
on-line research. The Foundation Center
(www.fdncenter.org) has branches in several cities
and their on-site resources are free. Except for the
most basic information, however, the search function
here and at www.guidestar.org has a subscription
fee. If you spot foundations or corporations in the
Chronicle of Philanthropy or other news outlets, see

if their annual report is available on-line. If so, study
it carefully. Do you recognize the names of any of
the foundation’s board members? Are you
absolutely sure that your project matches every item
in the giving guidelines? Be aware that foundations
and corporations are much more likely to fund
educational activities than capital campaigns.
• Read the Chronicle of Philanthropy. Published
every two weeks, the Chronicle
(http://philanthropy.com) is the newspaper of record
for the non-profit world. By reading it you will
become familiar with the fundraising universe, learn
about the most up-to-date topics being addressed in
the philanthropic sector, discover how professionals
and volunteers in schools and other organizations
are accomplishing what you wish to do, and develop
ideas for planning and implementing your own
capital campaign.
• Budget now for future capital campaign costs.
Your fundraising counsel will work for a negotiated,
fixed fee. Professionals do not collect a percentage
of the money raised. The amount, method, and
schedule of payment to the consultant will be
determined in a letter of agreement. The
professional fee should be in hand before you
proceed with counsel.
Planning a Capital Campaign
Engage fundraising counsel. Do not undertake a
capital campaign alone! The size of your campaign will

indicate whether you need full-time or part-time, on-site
counsel or an aggressive, external consultant who
oversees staff, volunteers, and development of materials
and procedures.
• Talk to other schools that have conducted
capital campaigns. If they were happy with their
consultants, get the names and contact them.
Contact the national office or the local chapter of the
Association of Fundraising Professionals (AFP) for
names of consultants with experience in K-12 capital
campaigns (www.afpnet.org). The Association of
Philanthropic Counsel (www.apcinc.org), which
carefully screens independent fundraising
consultants and "small shops," may also be helpful.
• Consider different kinds of consultants. Large
firms, small firms, and independent, self-employed
consultants will each bring different strengths to the
task.
• A good consultant will interview you and a few
of your colleagues at the first meeting.
Consultants need a great deal of information before
proposing a plan for a capital campaign. It will be
helpful if you have taken the steps described in
“Setting Up a Comprehensive Development
Program,” above, before meeting with a consultant.
If the consultant arrives and, instead of asking
questions, immediately tells you how he or she will
raise money, politely move on to the next candidate.

• At a second meeting, the consultant will outline
a plan, including a projected timetable, for
conducting your capital campaign. How the firm
or the individual consultant will staff the campaign
should be described. The fixed fees and projected
expenses are presented at this time.
• If you are meeting with a large consulting firm’s
sales team, insist on meeting the consultant who
would be assigned to your campaign. If you
proceed to contract with a firm, specify the
designated consultant in the letter of agreement and
retain the right to approve any change in personnel
and the right to terminate the contract if the firm
changes its personnel assigned to your campaign.
• In addition to considering skill and experience,
you have one more important consideration—do
you like and trust this consultant?
Draft or assemble the following materials.
• Temporary case statement. This short document
summarizes why you are undertaking a capital
campaign, what the effects will be, and why donors
should contribute.
• List of needs. This summary of the projected costs
of the project helps potential donors understand how
the financial goal was set.

• Architect’s rendering. A rendering of the proposed
structure or a before-and-after drawing of the
4 Fundraising Basics for Private School
Facilities
4905 888-552-0624 www.ncef.org
renovation will help inspire donor confidence that
this is a “real” project.
• Potential campaign volunteer leaders. A basic
fundraising axiom is “People give to people.” Recruit
prominent volunteer leaders who will make
contributions and then ask other people to contribute
to your campaign.
• Potential campaign donors. Do you have a
preliminary and reasonable idea of who will
contribute the leadership gifts needed to reach your
campaign goal? This list may include corporations

and foundations.
Conduct a feasibility or planning study. An assured
formula for failure is simply to begin asking for money
with no strategy or plan for attracting major gifts at the
beginning. If you simply “pass the hat” or “go fishing for
dollars,” you will not reach your fundraising goal.
A feasibility or planning study is the tool for developing a
strategy to identify and solicit major donors and donors
at subsequent lower levels. Your consultant will develop
a gift chart of pyramid giving based on your campaign
goal and the number of potential donors. Your first 10
donors should contribute 40 percent of your goal.
Identifying campaign solicitors is another critical
component of the study. Your solicitors should be
credible, respected leaders who will contribute and then
ask others to make contributions.
The consultant’s strategy and plan should include results
of a number of confidential interviews that cover the
documents outlined in the previous section. The appeal
and credibility of the case statement, list of needs and
architect's drawings are tested. Possible memorial gifts
might be proposed (e.g., the John Doe Memorial
Classroom for a gift of $100,000). The list of leaders and
donors is discussed for confidential opinions on their
capacity and inclination to give and for possible
expansion of the list. The confidential interview should
also include a discussion of the interviewee’s possible
level of financial support and interest in accepting a
leadership role in the campaign. When you compile a list
of study interviewees, the following types of persons
should be included:

• Sources of affluence. Persons perceived as
capable of making major gifts to your campaign if a
relationship is established and an effective case for
support is made.
• Sources of influence. Persons perceived as able to
influence the philanthropic behavior of other people.
• Sources of information. Persons with a great deal
of institutional and corporate memory, familiar with
relationships to the school, or attuned to the local
potential philanthropic profile of the local business
community, perhaps the executive director of the
local Chamber of Commerce.
• Sources of negativity. Persons who might already
think the project should not proceed or that it will not
succeed. A study interview can soften their feelings
or even convert them to supporting the campaign.
Develop a campaign strategy and plan based on the
results of the study. At the conclusion of the study, a
plan for campaign organization and a reasonable,
approximate timetable for the cultivation and solicitation
of leadership gifts should be in place. Promptly evaluate
and rate your first 10 potential donors with a goal of
raising 40 percent of your goal from them. Assign a
campaign leader to them and create a plan that
ultimately results in a meeting to ask for the gift.

Because the successes and failures of the first phase of
the campaign will be vital to developing a strategy and
plan for lower levels, beware of a campaign plan that is
too detailed after the first nine months or that otherwise
seems formulaic and inflexible.
Conducting a Capital Campaign
Expect a quiet but busy leadership gift phase.
Seeing gifts arrive makes you feel great, but stay
focused on the slow, albeit profitable, major gift activity
of the first phase. Each major gift solicitation is a mini-
campaign, with a painstakingly careful strategy and plan
for implementation. Do not move into lower levels of
solicitation until you have exhausted the potential major
gifts targeted in the first phase.
Do not give up on sequential, pyramid giving. If a
donor offers a gift that is smaller than the category within
which you are working, thank the donor and indicate that
you would like to return at a future date to discuss that
gift.
If an awareness of the campaign leads to the arrival of
unsolicited small gifts, acknowledge them quietly. Do not
publish donor lists. If a potential major donor sends a
small gift before you have met together, contact him or
her, express your gratitude, and request a meeting to
discuss the campaign. Perhaps the donor is unaware of
the level of gifts needed to have a successful campaign.
Fundraising Basics for Private School Facilities
5

4905 888-552-0624 www.ncef.org
Avoid anything that will divert donors to small gifts.
Well-intentioned campaign support can backfire.
Persons who are asked to purchase a memorial brick
costing $50 or a special event ticket at $100 are unlikely
to contribute at higher levels later in the campaign.
Conduct these collateral events late—when you are
celebrating the success of your leadership gift phase!
Know that you—and your consultant—will need to
be flexible.
• Consultants do not have crystal balls or magic
wands.
• Not everything learned in the study will be
completely accurate.
• A potential major donor may decide not to
contribute.
• An important campaign leader may move away.

• A large gift you were not expecting might show up.
Be prepared to go over goal. If you raise more money
in major gifts than you had planned for, do not reduce
your goal in lower categories. Remain aggressive and
goal-driven throughout every phase.
Say "thank you" a lot and take time to celebrate your
successes.
When staff, consultant, and volunteer leadership
have reached a consensus that every potential major
gift has been solicited, move to the next phase.
In summary, a capital campaign needs major gifts,
successfully solicited at the beginning of the campaign,
to be successful.
• Avoid the temptation to try to raise $2 million with
two million $1 gifts. Rather, let your strongest
supporters take leadership roles in making
contributions and asking for major contributions.
• Avoid a sales mentality for raising the money. Even
though “having a fund raiser” is commonly
understood to mean selling something, it really
means commerce, not contributed tax-deductible
income. Don’t sell. Rather, using your pyramid and
gift range table, ask for gifts.

• Avoid using campaign leaders who offer to lend their
name and nothing else. Rather, recruit leaders and
volunteers who are not overextended, who feel
passionately about the project, and who will commit
to working with you to achieve your campaign goal.
When you have demonstrated a credible need and
financial goal, engaged the services of a fundraising
professional at an appropriate level of involvement,
recruited committed volunteer leadership, and identified
potential major donors, you have the key ingredients for
achieving maximum fundraising success in your capital
campaign.
References
Brakeley, George A. Jr. 1997. “Major Gifts from Individuals.”
In
The Nonprofit Handbook: Fund Raising, ed. James
M.Greenfield, 422-41. New York: John Wiley & Sons, Inc.
Kielstedt, Andrea 2004. Capital Campaigns: Strategies that
Work. Boston, Massachusetts: Jones and Bartlett Publishers.
______________. 1997. “Capital Fund Appeals.” In The
Nonprofit Handbook: Fund Raising, ed. James M. Greenfield,
442-74. New York: John Wiley & Sons, Inc.
McCormick, Dan H., David G. Bauer, and Daryl E.Ferguson.
2000. Creating Foundations for American Schools.
Gaithersburg, Md.: Aspen Publishers, Inc.
Novom, Martin 2007. The Fundraising Feasibility Study. New
York: John Wiley & Sons, Inc..
Sternberg, David 2008. Fearless Fundraising for Nonprofit

Boards. Washington, DC: BoardSource.
Southwest Educational Development Laboratory. Philanthropic
Support for Public Education in the Southwest Region.
Available at www.sedl.org.
Additional Information
A full array of fundraising topics and blogs may be found
at the website of the NonProfit Times, free online at
http://www.nptimes.com. The Chronicle of Philanthropy
frequently features articles on capital campaigns and
major gifts, online at http:// philanthropy.com.
See the NCEF resource list Private School Facilities
Fundraising at http://www.ncef.org.
Publication Notes
Reviewers: Bobbi Watt Geer, John-Joseph van
Haelewyn, and David M. Levite (original 2001 edition).
First published 2001; revised 2009.
Guided Notes
Overview of Potential Funding Sources
Improving Public Financing for Early Childhood Programs
The following provides an overview of different funding
streams for early childhood programs:
Head Start services are administered through the U.S.
Department of Health and Human Services. The funding source
is a federal grant provided to local grantees. Services provided

through this grant include comprehensive child development
programming for children who are low income and their
families. Funding is available for families with incomes at
100% of the poverty line or 130%, if all families at 100% of the
poverty line are served. Children ages 3–5 are served within
Head Start, while services of children birth to age 3 are
provided within Early Head Start.
Child Care Subsidies, including the Children’s Defense Fund
(CDF) and Temporary Assistance for Needy Families (TANF),
are administered through the U.S. Department of Health and
Human Services. This is a federal funding stream which
requires state matching. The purpose of these dollars is to
provide childcare assistance to families who are low income.
Funding is available to working families who have incomes up
to 80% of the state median income or who have been identified
as needy, according to the state. Children between the ages of
birth and 13 can qualify.
Child Care Tax Credits, provided through federal dollars and 28
State Treasury Departments, represent credits for childcare
expenditures against federal and state income taxes. The
primary result is a reduction in families’ childcare expenses.
The families of children who are between the ages of birth and
13 can qualify; credits are based on income level.
Title 1 Preschool is funded through the U.S. Department of
Education. These federal funds provide educational services for
children who are disadvantaged. Funding is provided to schools
where 40% of children are at the poverty level or who have been
identified as academically at risk or are in schools where lower
percentages of children are at the poverty level.
Early Childhood Special Education is funded through the U.S.
Department of Education. These dollars are provided through
federal, state, and local funds. Dollars are used to provide
special education services for qualified preschool-aged children
who have been identified as having disabilities or, at the state's
discretion, developmental delays.
State Pre-K is funded through the State Department of

Education within 29 states and jointly administered within 11
states. Funds are usually provided from the state with some
federal funding. Services are provided to qualifying children,
and some health and social services may be provided.
Generally, states provide services to children who are identified
as being at risk. This is often based on family income.
Adapted from: Barnett, W. S., & Hustedt, J. T. (2011).
Improving public financing for early learning programs (Policy
Brief Issue 23). Retrieved from
http://nieer.org/resources/policybriefs/24.pdf
Bates’ Visual Guide to Physical Examination
— SHORTNESS OF BREATH —
OSCE 10
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Physical
Examination
Which transitions into the secondary screen
of the OSCE title.
Shortness of Breath
NARRATOR: (V.O.): This video format is
designed to help you prepare for objective
structured clinical examinations or OSCEs.
2.
DISSOLVE TO:
WIDE SHOT – EXAMINATION ROOM
STUDENT and PATIENT (a 48-year old
woman) Talk
NARRATOR: (V.O.): You are going to

observe and participate in a clinical
encounter of a 48-year-old woman who
comes to the office with a complaint of
shortness of breath. As you observe the
encounter, you will be asked to answer
questions while the image on the screen
freezes. These questions will allow you to
practice the skills of history taking and
physical examination as well as clinical
reasoning as you develop your assessment
or differential diagnosis, and a plan—that
is, an appropriate diagnostic workup.
You will have time to record your findings
and receive feedback.
3. GRAPHICS: INSERT FULL SCREEN
CHAPTER HEADING: HEALTH
HISTORY
STUDENT: So Mrs. Kelly, tell me your
special concerns today.

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DISSOLVE TO: TWO SHOT
FREEZEPOINT: ACTION ON SCREEN
FREEZES.
PATIENT: I just can’t seem to get my
breath. Of course, I’ve always been a little

short of breath when I exercise, but it’s
getting worse now. I can’t climb the steps
to my house without getting short of
breath. That’s why I’m coming to see you.
4. GRAPHIC: INSERT REASONING PANEL
WITH TEXT:
QUESTION:
What clinical conditions are you considering
at this time?
NARRATOR: (V.O.): What clinical
conditions are you considering at this time?
5. CHANGE TEXT:
ANSWER :
Asthma
COPD
Anxiety
Coronary artery disease
Pulmonary embolus
NARRATOR: (V.O.):

Asthma. COPD. Anxiety. Coronary artery
disease. And pulmonary embolus.
6.
CUT BACK TO:
WIDE SHOT OF STUDENT AND
PATIENT
STUDENT: Have you been seriously sick
in any other way? Weight loss? Or fevers?
PATIENT: Well, I’m forty-eight now, and
my periods aren’t that regular. My friend at
the holistic clinic gave me some herbal
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VIDEO AUDIO
medicine, but I don’t know what’s in it.
STUDENT: Nothing else? No other drugs?
PATIENT: Not really.
STUDENT: Tell me about some of the
things you like to do.
PATIENT: Oh my husband and I like to
hike in the mountains here in Colorado on
the weekends. I do my work as an office
manager during the week. Everything’s fine
at home. Our sons are both in college and
my husband and I are doing pretty well.

STUDENT: Have you ever had any
breathing problems before?
PATIENT: No. Well, I did have some
asthma as a child for a year or two.
STUDENT: Have you ever been a smoker?
PATIENT: No.
STUDENT: Have you ever been to doctors
about this shortness-of-breath problem?
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PATIENT: No, but I have wondered if it’s
from hormones.
STUDENT: Tell me more about what it’s
like.
PATIENT: Well, sometimes I just can’t get
my breath. It’s like…like I just can’t keep
doing what I’m doing, like I have to
concentrate on breathing, making sure I’m
doing it right, do you know?
7.
TWO SHOT
STUDENT: What would happen if you
didn’t do that—concentrate on it?
PATIENT: Doctor! Please! I have to take a
deep breath right now. (takes a breath)
There!

STUDENT: Did you feel like you could
really take in all the air with lungs just
now? Like you got it all in?
PATIENT: No. I didn’t. That’s the worst
thing about it.
STUDENT: Am I making you nervous here
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with what we’re doing right now?
PATIENT: Well, how would you like it if

you couldn’t get your breath? Wouldn’t you
concentrate on things? Make sure you were
getting enough air?
STUDENT: Well, I suppose I would.
PATIENT: Thank you.
STUDENT: Do you think that it could be
that you were always a little nervous?
PATIENT: Well, maybe a little.
STUDENT: Even as a child?
PATIENT: Yes, I guess so.
STUDENT: Were you afraid of things?
PATIENT: No. Except sleeping alone. That
I couldn’t do as a child.
STUDENT: Did you worry about things?

PATIENT: No more than anyone else.
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STUDENT: How about now? What do you
worry about now?
PATIENT: Breathing is my biggest worry
now. That’s why I’m here.
8.
WIDE SHOT

STUDENT: Do you ever worry about the
health of your two sons?
PATIENT: Doctor! That gives me a strange
feeling when you ask about that! You don’t
think anything’s wrong with them, do you?
STUDENT: No, no. But when you do
worry, do you get sweaty? Does your heart
race?
PATIENT: Of course. Wouldn’t your heart
race if you were worried about your sons?
And yes, I do get sweating, too.
STUDENT: Did you say that your shortness
of breath has gotten worse lately?

PATIENT: Yes. That’s why I came.
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STUDENT: Tell me about that.
PATIENT: I don’t know why, but it’s
gotten worse about every day for the last
month. It’s worse today than it was
yesterday. (takes a deep breath)
9.
INTERCUT CLOSE-UPS OF STUDENT
AND PATIENT

STUDENT: Are you still doing your job?
Are you still hiking?
PATIENT: Yes.
STUDENT: I wonder why it’s getting
worse?
PATIENT: I don’t know. My husband says
I’m more irritable and I haven’t been
sleeping that well. You’ve got to find out.
You’ve got to do something.

Otherwise…otherwise.
STUDENT: Otherwise what?
PATIENT: If people can’t breathe…you
know what happens to them.
STUDENT: Are you feeling depressed?
PATIENT: Yes, yes I have to say. Yes. I’m
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still doing everything I’m supposed to do,
but it’s getting harder and harder.
STUDENT: Are you thinking of killing
yourself?
PATIENT: Doctor! How can you say such a
thing? (cries a little)
STUDENT: Are…are you losing weight?
PATIENT: Yes, yes. I just don’t feel like
eating.
STUDENT: Are you having trouble
concentrating?
PATIENT: Yes. I can hardly do my work. I
don’t know if I can work for much longer.
STUDENT: There must be something that’s

making you sad.
PATIENT: There is, there is. It’s my
husband. He has to have an operation, and
I’m so afraid he’ll die.
STUDENT: Tell me more about that.
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PATIENT: He’s older than I am. I always
dated older men, I can’t tell you why.
Anyway, he’s ten years older, and he was a
smoker, and now, he has to have the heart

operation.
10.
INTERCUT MEDIUM SHOTS OF
STUDENT AND PATIENT
STUDENT: It sounds like his operation is
really worrying you. I’m going to ask you a
few more health questions, and we can get
back to how you’re feeling now. So you
mentioned that your heart races. Have you
ever had any heart problems before?
PATIENT: No, just this racing, like
palpitations. But it’s just when I feel short
of breath.

STUDENT: Are you having skipped beats
or rapid beats?
PATIENT: No, my heart just goes fast. I
checked my pulse yesterday and it was
about 130 for a while.
STUDENT: Do you have chest pain?
PATIENT: No, no chest pain.
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STUDENT: How about pain when you take

a deep breath?
PATIENT: No, I haven’t had that.
STUDENT: Have you had any recent
infections, such as a sinus infection or a
cough?
PATIENT: No, not really.
STUDENT: Uh, have you coughed up any
blood? Or had any swelling of your calves?
PATIENT: No, if I had, I would have been
here much sooner!
STUDENT: How about any recent car or
plane trips?
PATIENT: No, we like to stay right here in
the mountains.
11. WIDE SHOT OF STUDENT AND

PATIENT
STUDENT: Have you ever had any
problems with your thyroid? Too much
thyroid hormones can cause palpitations,
sometimes with symptoms being like
Downloaded From:
VIDEO AUDIO
sensitive to heat, changes in hair and skin,

weight loss, tremor, or even diarrhea.
PATIENT: No, I’ve never had thyroid
problems, and the heat has never bothered
me. My hair and skin are fine. But I have
lost about five pounds.
STUDENT: How is your appetite?
PATIENT: I’ve always had to eat three
meals a day or I feel really tired. Right now
I just don’t feel like eating that much
though.
STUDENT: Let’s talk about your
medications. You mentioned that you are
taking an herbal medicine. Are you taking
any other medicines, either over the counter
or prescribed?
PATIENT: No, just a multivitamin.

STUDENT: What about birth control?
PATIENT: I’ve never wanted to take the
pill. I have an IUD.
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STUDENT: How about drugs like cocaine,
amphetamines, heroin?
PATIENT: Never. They can ruin your
family life and kill you.

STUDENT: How about your family
history? Any problems with heart or lung
disease?
PATIENT: No, my family is really, pretty
healthy.
12.
TWO SHOT
STUDENT: Just to summarize, it sounds
like you’ve been a little nervous your entire
life, but you’ve handled it well, carried on
well. Seems like you’ve done well at work,
and it sounds like you have a good
marriage, and your sons are doing well.
Your husband may have always been the
source of your strength; someone you could
rely on; someone who could reassure you.
But now he has to have a heart operation,

and the roles are reversed a little, with you
reassuring him more; perhaps taking care of
him more in the future? And as that
happened, your nervousness and your
shortness of breath have gotten worse, and
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VIDEO AUDIO
you’ve gotten depressed.
PATIENT: Yes, yes, yes. That’s just what’s
been happening.
STUDENT: Is there anything we missed?

PATIENT: No, I think you understand. But
what shall I do?
STUDENT: We’ll talk more in a few
minutes to see how we can help you. Let’s
turn to your physical exam.
13. GRAPHICS: INSERT FULL SCREEN
CHAPTER HEADING: PHYSICAL
EXAMINATION
STUDENT USES HAND SANITIZER.
NARRATOR: (V.O.): With the patient’s
health history in mind, and after good hand
hygiene, you are ready for the physical
examination.
14.
DISSOLVE TO: WIDE SHOT -
EXAMINATION ROOM
PATIENT IS IN A GOWN, SITTING ON
THE EXAM TABLE.
THE STUDENT FINISHES TAKING THE

PATIENT’S TEMPERATURE.
FREEZEPOINT: ACTION ON SCREEN
FREEZES.
STUDENT: Your blood pressure is 135
over 80, which is good. Your heart rate is
88, just a little fast. Your respiratory rate is
normal at 20, and your temperature is
normal. Your palms are a little sweaty. Are
you okay?
PATIENT: Well, I’m wondering what you
are going to find, but I’m okay.
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VIDEO AUDIO
15.
GRAPHIC: INSERT REASONING PANEL
WITH TEXT:
QUESTION:
What regions of the physical
examination are important in this
patient?
NARRATOR: (V.O.):
What regions of the physical examination
are important in this patient?
16. CHANGE TEXT:
ANSWER:
Vital signs
Head and neck
Heart and lungs

Brief neurological examination
NARRATOR (V.O): Vital signs. Head and
neck. Heart and lungs. Brief neurological
examination.
17.
As STUDENT talks to the PATIENT who is
sitting up on the table.
LOWER THIRD GRAPHIC: INSERT
TEXT:
Examine the eyes
Student has patient look at him/her, then has
patient follow finger from eye level up about
a foot, then down to neck level, looking for
lid lag, or rim of white sclera above iris as
finger moves down. This will not be present.
STUDENT: First, I want to check your
eyes.

STUDENT: I can see that there is no stare,
which we sometimes see with thyroid
problems. Can you look at my finger? Can
you follow my finger up…and down?
18.
CUT TO: TWO SHOT
As STUDENT examines:
STUDENT: Everything checks out so far.
Now I’m going to check your thyroid.
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VIDEO AUDIO
TEXT:

Examine the thyroid gland
Patient takes a sip of water and holds it in
her mouth, camera focuses on anterior neck.
Camera focuses on butterfly shaped thyroid
moving up then down in neck as patient
swallows.
STUDENT: Could you take a sip of water
for me please, and swallow?
PATIENT: Okay.
19.
Student examines posterior lungs in ladder
pattern starting at bases, can just show
lower lung fields.
TEXT:
Examine the lungs
NARRATOR: (V.O.): Examine the lungs.
PATIENT: (Takes a deep breath in)

STUDENT: Out.
PATIENT: (Takes a deep breath out)
20.
With patient with head at 30 degrees and
drape folded back in diagonal from right
shoulder across to above left nipple, show
student examining just upper right sternal
border, upper left sternal border, and down
to the 3rd left interspace.
TEXT:
Examine the heart
NARRATOR: (V.O.): Examine the heart.
21.
With the head of bed a little to about 15
degrees and with correct draping, just show
student listening to the RUQ then moving
NARRATOR: (V.O.): Examine the
abdomen.

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VIDEO AUDIO
across to the LUQ
TEXT:
Examine the abdomen
22.
As STUDENT performs biceps jerk on both
sides
TEXT:
Perform biceps jerk
NARRATOR: (V.O.): Perform biceps jerk

on both sides.
23.
As STUDENT performs knee jerks on both
sides. These should be normal, not too
reactive.
TEXT:
Test knee and ankle reflexes
NARRATOR: (V.O.): Test knee and ankle
reflexes.
24.
As STUDENT examines:
TEXT:
Check for tremors

NARRATOR: (V.O.): Check for tremors.
STUDENT: Could you hold your arms out
like this with your wrists up?
STUDENT: Great, I don’t see any tremor.
25.
GRAPHICS: INSERT FULL SCREEN
CHAPTER HEADING: DIAGNOSTIC
CONSIDERATIONS
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FULL SCREEN GRAPHIC: INSERT
REASONING PANEL WITH TEXT:
QUESTION:
List your diagnostic considerations in
order of importance and explain your
rationale.
ADD TEXT:
Press pause and list your answers.
Resume when you are ready to receive
feedback.
(KEEP ON SCREEN FOR 3 seconds)
FREEZEPOINT ON THIS GRAPHIC.
NARRATOR: (V.O.): List your diagnostic
considerations in order of importance and
explain your rationale.
NARRATOR: (V.O.): Press pause and list
your answers. Resume when you are ready
to receive feedback.
26.
CHANGE TEXT:
Consideration 1: Anxiety disorder

One of the most common disorders in
primary care
Lifetime population prevalence is 5–10%
CHANGE TEXT:
Excessive anxiety and worry that is
difficult to control and that causes
clinically significant distress and
impaired functioning for at least six
months
Restlessness, being easily fatigued,
difficulty concentrating, irritability,
muscle tension, and sleep disturbance
Over half of patients with generalized
anxiety have co-existing depression or
NARRATOR: (V.O.): Anxiety disorder.
Anxiety is one of the most common
disorders in primary care, with a lifetime
population prevalence of 5 percent to 10
percent.
This patient displays many of the features

of generalized anxiety disorder specified by
the 5th edition of the American Psychiatric
Association’s Diagnostic and Statistical
Manual of Mental Disorders, namely:
excessive anxiety and worry that is difficult
to control and that causes clinically
significant distress and impaired
functioning for at least six months.
Although her duration of symptoms is only
Downloaded From:
VIDEO AUDIO
other anxiety disorders such as phobias

or panic disorder
CHANGE TEXT:
Use brief, well-validated screening tools
for anxiety and depression such as the
GAD-2, GAD-7, and PHQ-2
Also screen for substance abuse
a month, she has at least three of the
following required symptoms:
restlessness, being easily fatigued, difficulty
concentrating, irritability, muscle tension,
and sleep disturbance. It is important to
pursue possible related depression,
especially in women, as present here, since
over half of patients with generalized
anxiety have co-existing depression or other
anxiety disorders such as phobias or panic
disorder. Brief well-validated screening
tools for anxiety and depression consisting

of 2 to 7 questions such as the GAD-2,
GAD-7, and PHQ-2, are useful adjuncts for
office practice. Screening for substance
abuse is also important due to its high
correlation with anxiety disorders.
27.
CHANGE TEXT:
Consideration 2: Personality disorder
Patients are often problematic in office
settings
An enduring pattern of inner experience
and behavior that deviates markedly
from the expectations of the individual’s
culture
Is pervasive and inflexible
Has an onset in adolescence or early
adulthood, is stable over time, and leads
to distress or impairment
NARRATOR: (V.O.): Personality disorder.
Patients with personality disorders are often

problematic in office settings. These
disorders are characterized in the DSM IV-
TR by “an enduring pattern of inner
experience and behavior that deviates
markedly from the expectations of the
individual’s culture, is pervasive and
inflexible, has an onset in adolescence or
early adulthood, is stable over time, and
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Patients have dysfunctional interpersonal
coping styles that disrupt and destabilize
their relationships

Involve unusual cognition, affect, and
impulse control
CHANGE TEXT:
Odd and eccentric (paranoid, schizoid,
schizotypal)
Dramatic, emotional, or erratic
(antisocial, borderline, histrionic,
narcissistic)
Anxious or fearful (avoidant, dependent,
obsessive-compulsive)
leads to distress or impairment.”
These patients have dysfunctional
interpersonal coping styles that disrupt and
destabilize their relationships, including
those with health care providers that involve
unusual cognition, affect, and impulse
control.
Personality disorders fall into three
categories: odd and eccentric (paranoid,

schizoid, and schizotypal); dramatic,
emotional, or erratic (antisocial, borderline,
histrionic, and narcissistic); and anxious or
fearful (avoidant, dependent, and obsessive-
compulsive).
Although this patient is anxious, this
disorder is unlikely since she has had stable
intimate relationships and a stable work
history.
28.
CHANGE TEXT:
Consideration 3: Asthma or COPD
Asthma
Chronic inflammatory airway disease
Wheezing, chest tightness, and cough
that limit activity
NARRATOR: (V.O.): Asthma or COPD.

Asthma is a chronic inflammatory airway
disease that typically presents with
difficulty breathing but also wheezing, chest
tightness, and cough that limit activity.
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Symptoms are intermittent, often
triggered by cold, exercise, or
environmental allergens
Diagnosis rests on confirmation of
reversible airway obstruction during
bronchodilator testing during spirometry

or methacholine challenge during
pulmonary function tests
CHANGE TEXT:
COPD
Airway obstruction is progressive and
irreversible
80% is related to tobacco smoke and
20% to other occupational exposures
Distant breath sounds, hyperresonance,
and delayed expiration markedly
increase the likelihood of diagnosis
Diagnosis rests on spirometry and further
pulmonary function testing
CUT TO SHOTS OF STUDENT AND
PATIENT TALKING
Symptoms are intermittent, often triggered
by cold, exercise, or environmental

allergens. On examination wheezing and
accessory muscle use may be present.
Diagnosis rests on confirmation of
reversible airway obstruction during
bronchodilator testing during spirometry or
methacholine challenge during pulmonary
function tests.
In COPD, airway obstruction is progressive
and irreversible. Roughly 80 percent is
related to tobacco smoke and 20 percent to
other occupational exposures.
On examination, distant breath sounds,
hyperresonance, and delayed expiration
markedly increase the likelihood of
diagnosis. Diagnosis rests on spirometry
and further pulmonary function testing.

Asthma or COPD are unlikely in this
patient as her symptoms were initiated by
news of her husband’s operation and not
clearly exertional, and because she has
associated sweating and loss of
concentration, no history of smoking, and a
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normal lung examination.
29.
CHANGE TEXT:
Consideration 4: Hyperthyroidism

Anxiety, palpitations and diaphoresis,
weight loss
Lid lag
Heat intolerance, increased appetite,
elevated systolic blood pressure with a
widened pulse pressure
Tachycardia (heart rate > 90)
Stare (or eyelid retraction from
proptosis), goiter, tremor
CHANGE TEXT:
Commonly caused by Graves’ disease
Other causes include toxic multinodular
goiter and destructive subacute,
postpartum, or silent thyroiditis
NARRATOR: (V.O.): Hyperthyroidism.
This patient presents with several features
of hyperthyroidism: anxiety, palpitations

and diaphoresis, and weight loss. Her
overall clinical picture, however, makes this
diagnosis unlikely. She lacks lid lag, present
in almost all cases, as well as the common
findings of heat intolerance, increased
appetite, elevated systolic blood pressure
with a widened pulse pressure, tachycardia
(heart rate > 90), stare (or eyelid retraction
from proptosis), goiter, and tremor, which
markedly raise the likelihood of diagnosis.
Nevertheless, because of her weight loss,
further testing is warranted. The most
common cause of hyperthyroidism is
Graves’ disease, an autoimmune process
involving TSH receptor antibodies that
stimulate secretion of T4 and T3. Other
causes include toxic multinodular goiter and
destructive subacute, postpartum, or silent

thyroiditis.
30. CHANGE TEXT:
Consideration 5: Pulmonary embolus (PE)
New episodes of anxiety, shortness of
NARRATOR: (V.O.): Pulmonary embolus.
This patient has new episodes of anxiety
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breath, hormone preparation
Mortality as high as 60%
Onset ranges from subtle dyspnea to
catastrophic syncope, hemoptysis, chest

pain, and hypotension
Onset is acute
Pleuritic chest pain, calf or thigh
swelling and pain, tachypnea
Findings of right heart failure (jugular
venous distention and an accentuated S2
pulmonic closure sound)
coupled with shortness of breath, and she is
taking an unknown plant hormone
preparation, raising the remote but
potentially fatal possibility of pulmonary
embolism. New or worsening dyspnea is
one of the hallmarks of PE, which carries a
mortality as high as 60 percent. Onset
ranges from subtle, with only mild dyspnea,
to catastrophic, with syncope, hemoptysis,
chest pain, and hypotension. Onset is acute,

within seconds, which is not evident here.
Over 40 percent of patients have pleuritic
chest pain, calf or thigh swelling and pain,
and especially tachypnea, also absent in this
patient. Large PEs can produce findings of
right heart failure like jugular venous
distention and an accentuated S2 pulmonic
closure sound. Clinical suspicion in this
patient is low, but it is important to consider
this diagnosis in patients with dyspnea.
31.
GRAPHICS: INSERT FULL SCREEN
CHAPTER HEADING: DIAGNOSTIC
WORKUP
CHANGE TEXT TO READ:
QUESTION:
List 5 next steps in your diagnostic
workup.

ADD TEXT:
NARRATOR (V.O.): List 5 next steps in
your diagnostic workup.
NARRATOR (V.O.): Press pause and list
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Press pause and list your answers.
feedback.
(KEEP ON SCREEN FOR 3 seconds)
FREEZEPOINT ON THIS GRAPHIC.

your answers.
feedback.
32.
CHANGE TEXT:
Diagnostic Workup 1: Cognitive behavioral
therapy (CBT)
The best of the nonpharmacologic
therapies for treating generalized anxiety
Gives patients a set of coping skills to
reduce triggers and symptoms of anxiety
Strategies include education, relaxation
exercises, coping skills training,
cognitive restructuring, imagery
exposure, and stress management
Combining CBT with pharmacotherapy
is superior to either treatment alone
NARRATOR (V.O.): Cognitive behavioral
therapy. Clinical trials show that cognitive
behavioral therapy (CBT) is the best of the

nonpharmacologic therapies for treating
generalized anxiety.
CBT gives patients a set of coping skills to
reduce triggers and symptoms of anxiety.
CBT strategies include education,
relaxation exercises, coping skills training,
cognitive restructuring, imagery exposure,
and stress management. Evidence shows
that combining CBT with pharmacotherapy
is superior to either treatment alone.
33.
CHANGE TEXT:
Diagnostic Workup 2: Trial of medication
Selective serotonin reuptake inhibitors
(SSRIs) and benzodiazepines are
effective treatments for anxiety
SSRIs: side effects are weight gain,
NARRATOR (V.O.): Trial of medication.

Both selective serotonin reuptake inhibitors
(SSRIs) and benzodiazepines are effective
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sexual dysfunction, insomnia, nausea,
and diarrhea
Benzodiazepines:
significant risks of dependence and
tolerance
Tricyclic antidepressants are a third
option, but have risks of cardiac
arrhythmias
treatments for anxiety, but both have
disadvantageous side effects. For SSRIs

these include weight gain, sexual
dysfunction, insomnia, nausea, and
diarrhea. Benzodiazepines carry significant
risks of dependence and tolerance.
Tricyclic antidepressants are a third option,
but have risks of cardiac arrhythmias.
34.
CHANGE TEXT:
Diagnostic Workup 3: O2 saturation and
spirometry
Pulse oximetry helps identify hypoxemia
when the oxygen saturation falls below
90%
Oxygen saturation can be high even
when the pO2 is considerably lower
These tests are helpful in the initial
assessment of asthma and COPD
These tests have a limited role in the
assessment of a pulmonary embolus (PE)
NARRATOR (V.O.): O2 saturation and

spirometry.
In an office setting, pulse oximetry, which
measures the oxygen saturation of
hemoglobin, helps identify hypoxemia
when the oxygen saturation falls below 90
percent, particularly in smokers and patients
with COPD or known lung disease.
However oxygen saturation can be high
even when the more important indicator of
oxygenation, the pO2, measured by arterial
blood gas, is considerably lower due to the
S-shape of the oxyhemoglobin dissociation
curve. Currently these tests, plus
spirometry, are helpful in the initial
assessment of asthma and COPD, but have
a limited role in the assessment of a PE.
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VIDEO AUDIO
35.
CHANGE TEXT:
Diagnostic Workup 4: CBCd, complete
metabolic panel, TSH, D-dimer
CBCd considered since patient reports
weight loss
TSH is reasonable since it is the most
sensitive measure of thyroid function
In patients with suspicious clinical
findings, free T4 and T3 should also be
obtained
For possible PE, current protocols
recommend a sequential workup that
begins with assessing clinical probability
with a validated scoring system

CHANGE TEXT:
Contrast-enhanced helical CT scanning
or ventilation-perfusion (V/Q) scanning
is reserved for patients with abnormal D-
dimer levels
NARRATOR (V.O.): CBCd, complete
metabolic panel, TSH, D-dimer.
Since this patient reports weight loss, obtain
a complete blood count with differential to
assess any anemia related to her
perimenopausal status and a complete
metabolic panel. Checking the TSH is also
reasonable since it is the most sensitive
measure of thyroid function and is almost
always suppressed in hyperthyroidism. In
patients with suspicious clinical findings,
free T4 and T3 should also be obtained. For
patients with possible PE who are
hemodynamically stable, current protocols

recommend a sequential workup that begins
with assessing clinical probability with a
scoring system like the Wells criteria and
D-dimer testing for fibrin fragments. In this
patient probability is low so D-dimer testing
is optional. Contrast-enhanced helical CT
scanning or ventilation-perfusion (V/Q)
scanning is reserved for patients with
abnormal D-dimer levels.
36.
CHANGE TEXT:
Diagnostic Workup 5: EKG and rhythm strip
Can be considered in patients reporting
racing of the heart and palpitations
NARRATOR (V.O.): EKG and rhythm
strip.
An EKG and rhythm strip can be
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VIDEO AUDIO
If symptoms persist or worsen, further
cardiac workup should be pursued
Women with coronary artery disease
present with atypical symptoms
considered since the patient reports racing
of her heart and palpitations. If her
symptoms persist or worsen, further cardiac
workup should be pursued. She has no
cardiac risk factors and her history is
atypical for coronary artery disease, but
women with coronary artery disease present

with atypical symptoms.
37.
CUT TO:
FULL SCREEN GRAPHIC:
SUMMARY
DISSOLVE TO:
MONTAGE OF SHOTS
NARRATOR (V.O.): This patient is a 48-
year-old married office manager with a one-
month history of intermittent difficulty
breathing in, accompanied by racing of her

heart and sweatiness, irritability, insomnia,
and a 5-pound weight loss. She has always
tended to worry. Her increased symptoms
have been triggered by learning that her
husband needs an operation. She is
physically active and has no symptoms of
infection and no history of smoking or
cardiac or pulmonary disease. On physical
examination she appears anxious with
sweaty palms. Her respiratory rate and heart
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VIDEO AUDIO

FULL SCREEN GRAPHIC
CHANGE TEXT IN OVERLAY:
Diagnostic Considerations
(Differential Diagnosis)
Anxiety disorder
Personality disorder
Asthma or COPD
Hyperthyroidism
Pulmonary embolus
CHANGE TEXT:
Diagnostic Workup
Cognitive behavioral therapy
Trial of medication
O2 saturation and spirometry
CBCd, complete metabolic panel, TSH,
D-dimer
EKG and rhythm strip
rate are normal. She has no stare or lid lag
and her thyroid, heart, lung, and lower
extremity examinations are normal. She has
no tremor.

Diagnostic Considerations include: Anxiety
disorder, personality disorder, asthma or
COPD, hyperthyroidism, and pulmonary
embolus.
The diagnostic workup includes: Cognitive
behavioral therapy, medication, O2
saturation, spirometry, CBCd, complete
metabolic panel, TSH, D-dimer if indicated
and EKG with rhythm strip.
38.
GRAPHICS: FULL SCREEN:
References/Acknowledgments:
Bickley L, Szilagyi P. Ch 5, Behavior and
Mental Status; Ch. 7, Head and Neck; Ch 8,
Thorax and Lungs; and Ch 9, Cardiovascular
System. Bates’ Guide to Physical
Examination and History Taking, 11th ed.
Philadelphia: Wolters Kluwer/Lippincott

Williams & Wilkins, 2013.
Agnelli G, Becatrini C. Acute pulmonary
embolus. N Engl J Med 2010:363:266–274.
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VIDEO AUDIO
American Psychiatric Association.
Diagnostic and Statistical Manual of Mental
Disorders, 4th ed, Text Revision (DSM-IV-
TR). Washington, DC: American Psychiatric
Press, 2000.
American Psychiatric Association.
Diagnostic and Statistical Manual of Mental
Disorders, 5th ed. Arlington, VA: American
Psychiatric Publishing, 2013.
McDermott MT. In the clinic.
Hyperthyroidism. Ann Intern Med

2012:157:ITC-1–ITC-16.
Panetteri PA. In the clinic. Asthma. Ann
Intern Med 2007;146:ITC6-1–ITC 6-16.
Spitzer RL, Kroenke K, Williams JB, Löwe
B. A brief measure for assessing generalized
anxiety disorder: The GAD-7. Arch Intern
Med 2006;166:1092–1097.
Stein PD, Beemath A, Matta F et al. Clinical
characteristics of patients with acute
pulmonary embolism: data from PIOPED II.
Am J Med 2007;120:871.
U.S. Preventive Services Task Force.
Screening for depression in adults: U.S.
Preventive Services Task Force
recommendation statement. Ann Intern Med
2009;151:784–792.
39.
DISSOLVE TO: Closing credits.
40.
FADE OUT
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Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserv
ed. Page 1
BATES’ VISUAL GUIDE TO PHYSICAL EXAMINATION
OSCE 1: Chest Pain
This video format is designed to help you prepare for objective
structured clinical examinations, or
OSCEs.
You are going to observe and participate in a clinical encounter
of a patient who comes to the office
with a complaint of chest pain.
As you observe the encounter, you will be asked to answer quest
ions while the image on the screen
freezes. Such questions will allow you to practice history taking
and physical examination skills as well as
your clinical reasoning skills in developing an assessment or dif
ferential diagnosis and a plan—that is, an
appropriate next diagnostic workup.
You will have time to record your findings and receive feedback
.
Health History
Tell me your special concerns today.

I’m a little worried because I have been having sharp pains in m
y chest for the last two weeks.
What findings might be important to look for as you observe thi
s patient?
Level of distress.
Labored breathing.
Skin color: central and peripheral cyanosis.
Respiratory rate.
Two weeks ago I was reading a story in the paper about a car cr
ash, when I noticed sharp pains in my
left chest. I was sweating and short of breath for about 5 minute
s. And my heart felt like it was racing.
What possible causes of chest pain are you considering?
Angina.
GERD.
Panic attack.
Musculoskeletal chest wall pain.
Can you tell me how severe the pain was, on a scale from 1 to 1
0, with 1 being very faint and 10 being
severe?
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ed. Page 2
I was 5 over 10.
Did it move into your neck or down your left arm?
No, no it was just in my chest.
How have you been since then?
I’ve had two other episodes, one of them was about 10 days ago
when I was lifting some books, the
other was about 5 days ago when I was talking with my sister ab
out our father’s death. He died 3
months ago in a car crash.
Did you have any other symptoms when you had these chest pai
ns?
Yes, I had the same sweating and shortness of breath, with some
light‐headedness during the most
recent one.
What was the level of pain?
The same, about 5 out of 10 for about 5 minutes. Then the pain j
ust went away while I was sitting there.
I keep feeling so lost and panicked since my father died.
How are you feeling today?

Today I’m feeling fine, but I haven’t been sleeping well. It’s str
ange, I never felt anxious or depressed
before.
What cardiovascular risk factors do you need to consider in this
patient? And which one has the highest
risk for coronary artery disease?
The risk factors are:
Family history of coronary artery disease.
Hyperlipidemia, hypertension, smoking, diabetes.
For women, preeclampsia and collagen vascular disease.
Family history conveys highest risk.
Do you have any problems with acid reflux? Or have you done a
ny heavy lifting or strenuous exercise?
No, I’ve never had any stomach problems and I don’t really exer
cise much.
Do you have a history of high blood pressure? I noticed today y
our blood pressure was 140 over 95.
Yes, well I did have high blood pressure during my three pregna
ncies, I think it was about 145 over 90,
but the deliveries were fine.
What about smoking?
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ed. Page 3
When I was in my 20s I smoked about a pack a day for about 4
years.
Do you drink any alcohol?
I have 1…or 2 glasses of wine maybe 3 nights a week, more rec
ently to help me relax.
Is there any heart disease in your family?
Yes, my brother had bypass surgery when he was 48, and my mo
m died of a heart attack when she was
62.
What about high cholesterol, or is there any diabetes in the fami
ly?
No, I’ve never had trouble with my cholesterol and we don’t ha
ve diabetes in my family.
You’ve given me a good picture of your symptoms, and I can se
e why you’re concerned. Is there
anything you think we may have missed?
No, but I can’t get away from these flashbacks about my father’
s accident.
It’s common to visualize scenes like a crash with a loved one. L
et’s do your physical examination, and
then we can talk more.

Physical Examination
I see your blood pressure is 150 over 95 and your heart rate is 9
5 today. These are both somewhat
elevated. I would like to begin by examining your lips and nails
for color and then listen to your lungs.
Okay.
Examine lips and nails for cyanosis.
Okay, looks good.
Percuss then auscultate posterior lungs in ladder pattern.
Take a deep breath.
Listen to the lungs making sure to listen to the right middle lobe
under axilla.
One more time.
[BREATHING IN AND OUT]
I’ll be examining the vessels in your neck, and then your heart.
So please lie back with your feet straight
out.
Examine the neck first.
Assess the jugular venous pressure.
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ed. Page 4
Find the highest point of oscillation in the internal jugular vein
…
…and measure the vertical distance from the sternal angle.
Palpate carotid upstroke.
The normal upstroke is brisk, smooth, and rapid, and follows S1
almost immediately.
Large bounding upstrokes indicate aortic insufficiency.
Listen for a bruit, which is a whooshing, murmur‐like sound oft
en from atherosclerotic narrowing of the
carotid artery. A bruit sounds like this:
[BRUIT, WHOOSHING MURMUR]
Okay, I’m going to check the tapping impulse point of your hear
t.
Palpate the point of maximal impulse. You can do this and liste
n to the heart sounds by listening under
the gown without exposing the chest.
You may notice “tapping” which is timed at the beginning of sy
stole. The point of maximal impulse may
be sustained or diffuse, meaning spread over more than one inte
rcostal space.

Listen for S1 and S2 in each of the six listening areas: in the aor
tic area in the right second interspace
close to the sternum; in the pulmonic area in the left second inte
rspace close to the sternum; in the left
third interspace; in the tricuspid area in the left fourth and left f
ifth interspaces; and in the mitral area at
the apex.
Use the diaphragm at the right upper sternal border and the lowe
r left sternal border.
Use the bell at the apex.
Listen to and palpate the abdomen.
The following findings may be heard in the cardiac auscultation
of this patient. Can you identify these
heart sounds?
[HEARTBEAT]
S4 is a low pitched diastolic sound reflecting changes in ventric
ular compliance, best heard with the bell
with the patient in a left lateral decubitus position. It may be pr
esent during ischemia or in the setting of
hypertension.
Identify these heart sounds.
[HEARTBEAT]
Mitral regurgitation is a holosystolic murmur reflecting mitral v
alve dilatation, best heard at the apex
that may radiate to the axilla and lower left sternal border. It ma
y occur with transient ischemia.

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ed. Page 5
Assess congestive heart failure (CHF) in patients with extensive
myocardial infarction that compromises
cardiac output due to decreased stroke volume or heart rate. Wh
ich findings on the cardiac exam have
the best evidence for congestive heart failure?
Rales, an elevated JVP, and an S3 consistently predict heart fail
ure.
[HEARTBEAT]
S3 is a low‐pitched diastolic sound reflecting changed ventricul
ar compliance, best heard with the bell
with the patient in a left lateral decubitus position.
Palpate the ankles for edema.
Diagnostic Considerations
List your diagnostic considerations in order of importance and e
xplain your rationale.
Press pause and list your answers. Resume when you are ready t
o receive feedback.

Angina. This woman has stress‐induced non‐exertional chest pai
n. Recent evidence shows that women
present with more subtle symptoms of cardiovascular disease. S
he has cardiac risk factors of
hypertension, past smoking, preeclampsia, and family history.
Panic attack. She had stress related symptoms and flashbacks to
the recent death of her father in a car
accident. She has suggestive anxiety, chest pain, and diaphoresi
s.
GERD. Her alcohol intake has recently increased. She has some
reflux symptoms but her symptoms are
not triggered by meals and she does not report heartburn.
Musculoskeletal chest wall pain. There is no history of chest pai
n triggered by movement of the upper
torso or related exercise, and no notation of chest wall tenderne
ss.
Dissecting aortic aneurysm. There is no asymmetry of blood pre
ssures noted and no history of pain
shooting into the neck, up the side of the head, or into the back.
Diagnostic Workup
List 5 next steps in your diagnostic workup.
Press pause and list your answers. Resume when you are ready t
o receive feedback.
EKG. About 80% of patients with an acute MI have an initial E
KG that shows evidence of new infraction
or ischemia, if read correctly. However, among patients mistake

nly discharged from the emergency
department, up to 50% have normal or non‐diagnostic EKG find
ings.
Stress echo. This is the test of choice for women with atypical c
hest pain. The echocardiography stress
test has a sensitivity of 90% and specificity of 79% for women,
and 85% and 96% for men.
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ed. Page 6
Consider a trial of a proton pump inhibitor for 4‐6 weeks for po
ssible GERD.
Chest x‐ray may be helpful to look for widened mediastinum, w
hich can be evidence of aortic dissection.
Behavioral therapy—
to learn management strategies for anxiety and panic disorder.
Summary
In sum, this is a 50‐year old school counselor with three episode
s of left substernal chest pain over the
prior two weeks, rated 5 to 10 in intensity, with associated swea
ting and shortness of breath.
The first episode was precipitated by reading about a car crash,

the cause of her father’s recent death.
The patient had hypertension during pregnancy and a brief smok
ing history in her 20s.
There is a strong family history of coronary artery disease. Her
mother died of a myocardial infarction at
age 62 and her brother had a coronary bypass at age 48.
There is no history of diabetes. Her physical examination is unr
emarkable except for her blood pressure
of 150 over 95.
The differential diagnosis includes angina, especially suspect du
e to her symptoms, history of
hypertension during pregnancy, and family history. It also inclu
des panic attack, GERD, musculoskeletal
chest pain, and dissecting aortic aneurysm.
The diagnostic workup includes an EKG, stress echo, trial of a
PPI, chest x‐ray, and behavioral therapy.
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