Infant Risk Identifier Worksheet
Demographics
Infant Demographic Information
Screening Date (MM/DD/YYYY) Medicaid ID
First Name M.I. Legal Last Name Sex Female Male
City County
What is your infant’s date of birth? (MM/DD/YYYY) Caregiver Demographic Information
Non-Traditional Caregiver Foster Other
Medicaid ID
First Name M.I. Legal Last Name Sex Female Male
City County
What is your date of birth? (MMDDYYYY) What is your marital status? Married Unmarried Widowed Separated Divorced Refused
Maternal/Infant Basics
Infant Basic Information
What do you identify as the infant’s race/ethnic background? (Check all that apply) ☐Asian ☐American Indian or Alaskan Native ☐Black or African American ☐Native Hawaiian or other Pacific Islander ☐White/Caucasian ☐Arab/Chaldean ☐Hispanic/Latino ☐Refused
Maternal Basic Information
Mother’s age at time of birth Years
How many grades of school have you completed? Less than 8th Jr. high/middle school Trade School High School Diploma/GED Associate’s degree Bachelor’s degree Graduate degree
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What do you identify as your race/ethnic background? (Check all that apply) ☐Asian ☐American Indian or Alaskan Native ☐Black or African American ☐Native Hawaiian or other Pacific Islander ☐White/Caucasian ☐Arab/Chaldean ☐Hispanic/Latino ☐Refused
Maternal Family Planning
Are you or your husband or partner doing anything now to keep from getting pregnant? Yes No
If yes, what kind of birth control are you or your husband or partner using now to keep from getting pregnant?
If No, skip to the next question.
Comments
Maternal Smoking
Which of the following statements would you say best describes your cigarette smoking?
I quit smoking during pregnancy and have not started again. I wasn’t smoking around the time I found out I was pregnant, and I don’t currently smoke cigarettes I smoked during my pregnancy, but quit smoking once the baby was born I smoke every once in a while I smoke regularly now, but I’ve cut down during my pregnancy or since my baby was born I quit smoking during my pregnancy, but have started smoking again since my baby was born I smoke regularly now – about the same amount as before finding out I was pregnant Refused
Comments
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Maternal Alcohol
Which of the following statements would you say best describes your alcohol consumption, INCLUDING beer and wine coolers? I drink alcohol regularly now – about the same as before I was pregnant I drink alcohol regularly now, but I’ve cut down since the pregnancy I drink alcohol every once in a while I quit drinking alcohol during my pregnancy but started drinking again since my baby was born I drank some alcohol during my pregnancy but quit drinking once my baby was born I quit drinking alcohol during my pregnancy and have not started drinking again I wasn’t drinking alcohol around the time I found out I was pregnant and I don’t currently drink Refused
If drinking alcohol…Approximately how many alcoholic drinks do you have in an average week?
14 drinks or more a week 7 to 13 drinks a week 4 to 6 drinks a week 1 to 3 drinks a week Less than 1 drink a week Refused
Since delivery, how many times did you drink 5 alcoholic drinks or more in one sitting? 6 or more 4 to 5 times 2 to 3 times 1 time I don’t have 5 drinks or more in one sitting Refused
How many drinks does it/did take to make you feel high? 1 2 3 or more Refused
Have people annoyed you by criticizing your drinking? Yes No Refused
Have you ever felt you ought to cut down on your drinking? Yes No Refused
Have you ever had a drink first thing in the morning to steady your nerves Yes No Refused or get rid of a hangover?
Are you in treatment? Yes No Refused
Comments
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Maternal Drugs
Does your partner or anyone in your household use drugs? Yes No Refused
During your pregnancy, did you – even just once – use any street drugs, diet pills, or drugs not prescribed by a physician? Yes No Refused
If Yes, what did you use?
If No, skip to the next question.
Since your baby was born, have you used any street drugs, diet pills, or drugs not prescribed by a physician? Yes No Refused
If Yes, what did you use?
If No, skip to the next question.
Are you in treatment? Yes No Refused
Comments:
Maternal Stress
In the last month, how often have you felt that you were unable to control the important things in your life? Never (0) Almost Never (1) Sometimes (2) Fairly Often (3) Very often (4)
In the last month, how often have you felt confident about your ability to handle your personal problems? Never (4) Almost Never (3) Sometimes (2) Fairly Often (1) Very often (0)
In the past month, how often have you felt that things were going your way? Never (4) Almost Never (3) Sometimes (2) Fairly Often (1) Very often (0)
In the last month, how often have you felt difficulties were piling up so high that you could not overcome them? Never (0) Almost Never (1) Sometimes (2) Fairly Often (3) Very often (4)
Comments
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Maternal Depression and Mental Health
Have you ever had the “Baby Blues”? Yes ` No Refused
Have you ever been treated for or told that you have a mental health concern? Yes No Refused
If No, skip to Depression Follow Up Screening section below.
If Yes, please check all that apply Depression Bipolar disorder Other : Schizophrenia Anxiety
Have you been in the hospital or ER for this condition in the last six months? Yes No Refused
Comments
Depression Follow Up Screening
I’d like to ask you some follow-up questions about how you’re feeling. I’m going to read some statements and responses. For each statement, please let me know which response is the closest to how you’ve been in the past 7 days.
I have been able to laugh and see the funny side of things As much as I always could (0) Not quite so much now (1) Definitely not so much now (2) Not at all (3)
I have looked forward with enjoyment to things As much as I ever did (0) Rather less than I used to (1) Definitely less than I use to (2) Hardly at all (3)
I have blamed myself unnecessarily when things went wrong Yes, most of the time (3) Yes, some of the time (2) Not very often (1) No, never (0)
I have been anxious or worried for no good reason No, not at all (0) Hardly ever (1) Yes, sometimes (2) Yes, very often (3)
I have felt scared or panicky for no good reason Yes, quite a lot (3) Yes, sometimes (2) No, not much (1) No, not at all (0) 5 IRI Worksheet 1.31.18 rev. 2.6.19 Infant Risk Identifier Worksheet
Things have been getting on top of me Yes, most of the time I haven’t been able to cope at all (3) Yes, sometimes I haven’t been coping as well as usual (2) No, most of the time I have coped quite well (1) No, I have been coping as well as ever (0)
I have been so unhappy that I have had difficulty sleeping Yes, most of the time (3) Yes, sometimes (2) Not very often (1) No, not at all (0)
I have felt sad or miserable Yes, most of the time (3) Yes, quite often (2) Not very often (1) No, not at all (0)
I have been so unhappy that I have been crying Yes, most of the time (3) Yes, quite often (2) Only occasionally (1) No, never (0)
The thought of harming myself has occurred to me Yes, quite often (3) Sometimes (2) Hardly ever (1) Never (0)
Maximum score: 30 possible. Always look at last question (Suicidal thoughts)
Comments
Maternal Abuse and Violence
Are you in a relationship right now? Yes No Refused
Do you feel safe in your present relationship? Yes No Refused
Within the last year, have you been hit, kicked, slapped, or otherwise physically hurt by someone? Yes No Refused
Comments
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Maternal Abuse and Violence
Since your baby was born, have you been hit, kicked, slapped or otherwise physically hurt by someone? Yes No Refused
Has your partner or someone else in your life? (Select all that apply)
Called you names, humiliated you, or made you feel that you don’t count? Yes No Refused
Kept you from seeing or talking to your family, friends, or other people? Yes No Refused
Thrown away or destroyed your belongings, threatened pets, or done things to bully or scare you? Yes No Refused
Controlled your use of money, your access to money or your ability to work? Yes No Refused
Has anyone forced you to have sexual activities? Yes No Refused
Have you ever been emotionally, physically or sexually abused by your partner or someone important to you? Yes No Refused
Are you afraid of your partner or anyone listed above? Yes No Refused
As a child were you ever involved with Children’s Protective Services? Yes No Refused
Have you ever been involved with Children’s Protective Services with any of your children? Yes No Refused
Comments
Basic Needs
Housing
Do you currently have any concerns or worries about your housing situation? Yes No
If Yes, check all that apply
No place to live, no regular nighttime residence Eviction or being forced to move out Affordability of current house or apartment Strained relations with others in household House or apartment is too crowded Safety of house/apartment Safety of neighborhood Sanitation/waste removal Code violations Pest control Ventilation/air conditioning Ease of access into home Lack of continuous functioning basic utility service (e.g., heat, electricity)
Do you have working smoke detectors in the house? Yes No
Do you live in a house built before 1978? Yes No
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Do you or others in your household have an occupation that involves lead exposure? Yes No
Do you live in an old house with ongoing renovations that generate a lot of dust (e.g., sanding and scraping)? Yes No
To your knowledge, has your home been tested for lead in the water? Yes No
If Yes, were you told that the lead level was high? Yes No
Do you use any traditional folk remedies or cosmetics that are not sold in a regular drug store or are homemade, which may contain lead? Yes No
Do you or others in your household have any hobbies or activities likely to cause lead exposure? Yes No
Do you use non-commercially prepared pottery or leaded crystal? Yes No
Food
In the last 12 months, did you (or other adults in your household) ever cut the size of your meals or skip meals because there was not enough money for food? Yes No Refused
If yes, how often did this happen? Almost every month Some months but not very much In only 1 or 2 months
Are you using WIC, SOM Food Assistance Program or other Food Assistance such as Food Pantries, Commodities or Churches? Yes No Refused
Transportation
Do you have access to routine transportation? Yes No
If No, please check all concerns that apply Potential unavailability Unreliable Not affordable
What is the best way to get ahold of you? Phone Text message Email Letter Other Explain:
Comments:
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Infant Family Support, Parenting and Childcare
Do you have any problems finding or paying for reliable child care? Yes No
Would you describe the father of this baby as Involved in the baby’s life and supportive of the baby Involved in the baby’s life but not supportive’ Aware of the baby but not involved with us Unaware that he is the father Refused Don’t Know
Is there someone in your life you can count on to help you with the baby? Yes No
Who spends the most time with your baby? I do My other children My partner or baby’s father My friend(s)/neighbor(s) My parent(s) or the father’s parents Day care staff Other
Are you a first-time parent? Yes No If No:
How many sibling children?
Comments
Infant Birth Health Status
What was your baby’s expected due date? (MM/DD/YYYY) Don’t Know
What was your baby’s gestational age at birth? Weeks Don’t Know Note: calculate from expected due date and actual date of birth information if unknown.
How much did your baby weigh at birth? Pounds Ounces Don’t Know
Did your baby stay in the hospital after you went home? Yes No Don’t Know
How long did your baby stay in the hospital? Days
What was the reason for the stay?
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Has your baby had any new health problems since coming home from the hospital? Yes No
If Yes: please explain
Were you told that the baby needed an additional hearing test? Yes No Don’t Know
If Yes: please explain
Did the baby have the additional test? Yes No
If Yes, what was the result
If No Didn’t have transportation Didn’t know who to call
Didn’t understand what you needed to do Physician/ medical care provider said to wait
Didn’t feel it was important Other Explain:
Were you told that the baby needed any follow-up to the heel poke Yes No Don’t Know (Newborn screening) test done at the hospital?
If Yes: please explain
Did the follow-up testing or appointment occur? Yes No
If Yes, what was the result
If No Didn’t have transportation Didn’t know who to call
Didn’t understand what you needed to do Physician/ medical care provider said to wait Didn’t feel it was important Other Explain:
Comments:
Infant Health Care
How old was your baby when he/she was first seen by their family doctor (sometimes called a medical home)?
Weeks Days My baby hasn’t been seen by a family doctor and we don’t have an appointment. My baby hasn’t been seen by a family doctor and has an appointment. Refused
Has your baby been seen by a healthcare provider other then the family doctor (medical home) mentioned above? Yes No 10 IRI Worksheet 1.31.18 rev. 2.6.19 Infant Risk Identifier Worksheet
Here is a list of problems some women can have getting for their infants. For each item, please let us know if it has been true for you at any time since the birth of your baby. [READ LIST] (check all that apply)
I couldn't get an appointment when I wanted one I couldn’t find a doctor or clinic that accepted Medicaid It is hard to communicate with the doctor or clinic staff It is hard to understand the information the doctor or clinic gave to me I haven’t had enough money or insurance to pay for my visits I’ve had no way to get to the clinic or doctor's office I couldn't take time off from work I’ve had no one to take care of my other children I have had too many other things going on in my life Other, please tell us None Refused
Is your baby currently enrolled in Children’s Special Health Services (CSHCS)? Yes No
Is your baby up to date on immunizations? Yes No Don’t Know
Comments
Infant Safety
Where does your baby usually sleep?
Crib In bed with someone On floor Bassinette In a car seat Other Explain:
How often does your newborn sleep in the same bed with you or someone else?
Never Sometimes Most or every night
In what position do you usually lie your infant down to sleep? Front Back Side
When your baby is upset, what do you do to quiet him or her?
Do you have a car seat for the baby? Yes No
Do you smoke around the baby (the same room, same house, same car)? Yes No
Is there a smoker in the home or someone that regularly visits that smokes? Yes No
Is there someone in the home or someone who regularly visits that gets drunk around your baby? Yes No
Are you afraid you or anyone in your household may hurt your baby? Yes No Refused
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Comments
Infant Feeding and Nutrition
What do you primarily feed your baby?
Have you ever breastfed your baby? Yes No
Is your baby currently enrolled in WIC? Yes No
Do you hold your baby while you feed him/her a bottle? Yes No
Does your baby receive anything else in the bottle besides formula or breast milk? Yes No
In the past month, how often has your child gone to bed with a bottle of juice, formula, milk or other liquid besides water? Often Sometimes Rarely Never
Comments
General Infant Development
INSTRUCTIONS: Please proceed to the developmental section corresponding to the infant/ toddler’s age, as outlined in the tables below:
IF INFANT/ TODDLER AGE IS Bright Futures Less than 3 weeks BF 0* 3 to 4 weeks BF 1* 1 month 0 days to 2 months 30 days BF 2* 3 months 0 days to 4 months 30 days BF 4** 5 months 0 days to 7 months 30 days BF 6** 8 months 0 days to 10 months 30 days BF 9** 11 months 0 days to 12 months 30 days BF 12** 13 months 0 days to 15 months 30 days BF 15**
* If the infant is less than two months old and at least one Bright Futures “not yet” box is checked, administer the ASQ-3 within two weeks. If the infant is less than one month old, use the age-appropriate Bright Futures questions from the Infant Risk Identifier.
** If the infant is two months or older and at least two Bright Futures “not yet” boxes are checked, administer the ASQ-3 within two weeks. If the infant is at least two months old, also use the ASQ: SE-2.
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BF0 GENERAL INFANT DEVELOPMENT – Newborn (Less than 3 weeks)
1. Does your baby respond to sound (for example, by blinking, crying, quieting, changing respiration, or showing a startle response)? Yes Sometimes * Not yet Not sure 2. Does your baby focus on your face and follow it with his/her eyes? Yes Sometimes * Not yet Not sure 3. Does your baby look at you and respond to your voice? Yes Sometimes * Not yet Not sure 4. Does your baby lift his/her head momentarily? Yes Sometimes * Not yet Not sure 5. Can your baby move his/her arms, legs and head? Yes Sometimes * Not yet Not sure BF1 GENERAL INFANT DEVELOPMENT – Newborn (3 to 4 weeks)
1. Does your baby respond to sound (for example, by blinking, crying, quieting, changing respiration, or showing a startle response)? Yes Sometimes * Not yet Not sure 2. Does your baby focus on your face and follow it with his/her eyes? Yes Sometimes * Not yet Not sure 3. Does your baby look at you and respond to your voice? Yes Sometimes * Not yet Not sure 4. Is your baby’s body generally relaxed? Yes Sometimes * Not yet Not sure 5. Can your baby move his/her arms, legs and head? Yes Sometimes * Not yet Not sure 6. When lying on his/her tummy, can your baby lift his/her head momentarily? Yes Sometimes * Not yet Not sure 7. When your baby is crying, can he/she be consoled most of the time by being spoken to or held? Yes Sometimes * Not yet Not sure 8. Does your baby cry, coo, and smile? Yes Sometimes * Not yet Not sure
BF2 GENERAL INFANT DEVELOPMENT – 2 Months (1 month 0 days to 2 months 30 days)
1. If you copy the sounds your baby makes, does your baby repeat the sounds back to you? Yes Sometimes * Not yet Not sure 2. Does your baby seem to pay attention to voices around him/her? Yes Sometimes * Not yet Not sure 3. Does your baby show an interest in sounds and moving objects? Yes Sometimes * Not yet Not sure 4. When you smile at your baby, does he/she smile back at you? Yes Sometimes * Not yet Not sure 5. Does your baby seem to enjoy interacting with you and with other people that take care of him/her? Yes Sometimes * Not yet Not sure 6. When lying on his/her tummy, can your baby lift his/her head, neck, and upper chest by using his/her forearms for support? Yes Sometimes * Not yet Not sure
7. When your baby is in an upright position, can he/she control his/her head sometimes? Yes Sometimes * Not yet Not sure
BF4 GENERAL INFANT DEVELOPMENT – 4 Months (3 months 0 days to 4 months 30 days)
1. Does your baby smile and laugh? Yes Sometimes * Not yet Not sure 2. Does your baby interact with you? Yes Sometimes * Not yet Not sure 3. Does your baby have different cries for different needs (e.g. hungry, wet, tired)? Yes Sometimes * Not yet Not sure 4. Does your baby like to look at and be with you? Yes Sometimes * Not yet Not sure 5. Does your baby show you what he/she likes?
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Yes Sometimes * Not yet Not sure 6. Does your baby babble (e.g. “aaa”, “eee”, “ooo”)? Yes Sometimes * Not yet Not sure 7. Does your baby have good head control? Yes Sometimes * Not yet Not sure 8. Does your baby move both sides of his/her body equally? Yes Sometimes * Not yet Not sure
9. Does your baby push his/her chest up when on his/her tummy? Yes Sometimes * Not yet Not sure 10. Does your baby bat at objects? Yes Sometimes * Not yet Not sure 11. Does your baby roll or try to roll from tummy to back? Yes Sometimes * Not yet Not sure
BF6 GENERAL INFANT DEVELOPMENT – 6 Months (5 months 0 days to 7 months 30 days)
1. Does your baby smile, laugh, squeal? Yes Sometimes * Not yet Not sure 2. Does your baby recognize familiar faces? Yes Sometimes * Not yet Not sure 3. Does your baby enjoy taking turns “talking” with you? Yes Sometimes * Not yet Not sure 4. Does your baby string sounds together (babbling “ah”, “oh”, “dada”, “baba”)? Yes Sometimes * Not yet Not sure 5. Is your baby beginning to recognize his/her name? Yes Sometimes * Not yet Not sure 6. Can your baby sit with support? Yes Sometimes * Not yet Not sure 7. Can your baby roll over? Yes Sometimes * Not yet Not sure
8. Can your baby stand and bear weight when held in that position? Yes Sometimes * Not yet Not sure
BF6 GENERAL INFANT DEVELOPMENT – 6 Months (5 months 0 days to 7 months 30 days)
9. Does your baby mouth objects he/she is interested in? Yes Sometimes * Not yet Not sure 10. Does your baby shake, bang, throw and drop objects/ toys? Yes Sometimes * Not yet Not sure
BF9 GENERAL INFANT DEVELOPMENT – 9 Months (8 months 0 days to 10 months 30 days)
1. Has your baby developed concern about strangers? Yes Sometimes * Not yet Not sure 2. Does your baby seek you for play and comfort? Yes Sometimes * Not yet Not sure 3. Does your baby use a wide variety of sounds (babbles, “mama”, “dada”)? Yes Sometimes * Not yet Not sure 4. Is your child starting to point out objects? Yes Sometimes * Not yet Not sure 5. Does your baby know that an object still exists if it is hidden or out of their sight? Yes Sometimes * Not yet Not sure 6. Does your baby play games like “peek-a-boo” and “pat-a-cake”? Yes Sometimes * Not yet Not sure 7. Is your baby crawling? Yes Sometimes * Not yet Not sure 8. Does your baby sit without help? Yes Sometimes * Not yet Not sure 14 IRI Worksheet 1.31.18 rev. 2.6.19 Infant Risk Identifier Worksheet
9. Does your baby move him/herself into a sitting position? Yes Sometimes * Not yet Not sure 10. Does your baby move him/herself to a standing position? Yes Sometimes * Not yet Not sure 11. Does your baby feed him/herself food with his/her fingers? Yes Sometimes * Not yet Not sure
BF12 GENERAL INFANT DEVELOPMENT – 12 Months (11 months 0 days to 12 months 30 days)
1. Does your baby play games like “peek-a-boo” and “so big”? Yes Sometimes * Not yet Not sure 2. Does your baby repeat a game or activity that they see you or another child do? Yes Sometimes * Not yet Not sure 3. Does your baby wave “bye-bye”? Yes Sometimes * Not yet Not sure 4. Does your baby get upset when you leave him/her? Yes Sometimes * Not yet Not sure 5. Does your baby point at a desired object and watch to see if you see it? Yes Sometimes * Not yet Not sure 6. Does your baby use one to two words (e.g. “mama”, “dada”)? Yes Sometimes * Not yet Not sure 7. Does your baby jabber as if he/she is talking? Yes Sometimes * Not yet Not sure 8. Does your baby follow simple requests (e.g. “give me the ball”)? Yes Sometimes * Not yet Not sure 9. Does your baby stand alone? Yes Sometimes * Not yet Not sure 10. Does your baby bang two blocks together? Yes Sometimes * Not yet Not sure 11. Does your baby eat a variety of foods? Yes Sometimes * Not yet Not sure
BF15 GENERAL INFANT DEVELOPMENT – 15 Months (13 months 0 days to 15 months 30 days)
1. Does your toddler listen to a story? Yes Sometimes * Not yet Not sure 2. Does your toddler pretend to feed a doll a bottle or move cars/trucks around? Yes Sometimes * Not yet Not sure 3. Does your toddler show you what he/she wants by pulling, pointing or grunting? Yes Sometimes * Not yet Not sure 4. Does your toddler bring you things to show you? Yes Sometimes * Not yet Not sure 5. Does your toddler say 2-3 words (other than “mama” or “dada”) and use them correctly? Yes Sometimes * Not yet Not sure 6. Does your toddler understand and follow simple commands? Yes Sometimes * Not yet Not sure 7. Does your toddler scribble? Yes Sometimes * Not yet Not sure 8. Does your toddler walk well, stoop/squat, and then, stand again? Yes Sometimes * Not yet Not sure 9. Does your toddler crawl down steps backwards? Yes Sometimes * Not yet Not sure 10. Does your toddler stack two blocks? Yes Sometimes * Not yet Not sure 11. Does your toddler feed himself/herself with fingers/spoon and drink from a cup? Yes Sometimes * Not yet Not sure
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Finalize/Update Screen
Beneficiary Name Medicaid Id Date of Birth (DDMMYYYY)
Comments
Completed by
Screener Name Professional’s Credentials RN Social Worker
Entered by Name Location Home Office Community
I agree that, to the best of my knowledge, the information submitted for this Screening is correct.
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