Appendix B Data Collection Forms
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Appendix B – Data Collection Forms Page 1 of 11
Demographics: Intake (index children)
* Required
*First Name - ______Middle Name - ______*Last Name - ______
* Home Visiting Program Type
o Early Head Start – Home Based Option o Nurse-Family Partnership (NFP) (EHS) o Parents as Teachers (PAT) o Healthy Families America (HFA)
* Date of Enrollment – __ __ / __ __ / ______(MM/DD/YYYY)
* Birth Date – __ __ / __ __ / ______(MM/DD/YYYY)
*Gender
o Male o Female
*Race (Select all that apply) o American Indian or Alaska Native o Native Hawaiian or Other Pacific Islander o Asian o White o Black or African-American o o * Ethnicity o Hispanic or Latino o Not Hispanic or Latino o o * Primary Language Spoken at Home o English o Other (please specify: ______) o Spanish o o * Health Insurance Status at Enrollment o No Insurance Coverage o Private o Medicaid or CHIP o Other (please specify: ______) o Tri-Care
Demographics: Intake (index children) Revised 09/06/2016 Appendix B – Data Collection Forms Page 2 of 11 o o * Usual Source of Medical Care o Doctor’s/Nurse Practitioner’s Office o Retail Store or Minute Clinic o Hospital Emergency Room o None o Hospital Outpatient o Other (please specify: ______) o Federally Qualified Health Center o o * Usual Source of Dental Care o Have a Usual Source of Dental Care o Do not have a Usual Source of Dental Care o o
Demographics: Intake (index children) Revised 09/06/2016 Appendix B – Data Collection Forms Page 3 of 11
o Demographics: Intake (primary caregiver)
o * Required
o * First Name - ______o Middle Name - ______o * Last Name - ______
o * Street Address - ______o * City - ______o * Zip - ______o * County - ______
o * Home Visiting Program Type (Select all that apply) o
o Early Head Start – Home Based Option o Nurse-Family Partnership (NFP) (EHS) o Parents as Teachers (PAT) o Healthy Families America (HFA) o o * Date of Enrollment – __ __ / __ __ / ______(MM/DD/YYYY) o o * Birth Date – __ __ / __ __ / ______(MM/DD/YYYY) o o * Relationship to Child o Biological Mother o Biological Father o Other Female Caregiver o Other Male Caregiver o o * Pregnancy Status at Enrollment o Currently pregnant (_____ weeks) o Not currently pregnant o o * Estimated Date of Delivery – __ __ / __ __ / ______(MM/DD/YYYY) o o * Race (Select all that apply) o American Indian or Alaska Native o Asian
Demographics: Intake (index children) Revised 09/06/2016 Appendix B – Data Collection Forms Page 4 of 11
o Black or African-American o White o Native Hawaiian or Other Pacific Islander o * Ethnicity o Hispanic or Latino o Not Hispanic or Latino o o * Marital Status at enrollment o Never Married o Not Married but Living Together with o Married Partner o Separated/Divorced/Widowed
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o * Educational Attainment at Enrollment (highest level) o Less than HS diploma o Associate’s degree o HS Diploma / GED o Bachelor’s degree or higher o Some college/training o Other (please specify: ______) o Technical training or certification o o * Educational Status at Enrollment o Student/trainee o Not a student/trainee o o * Employment Status at Enrollment o Full-time (37+ hours per week) o Not employed o Part-time (Less than 36 hours per week) o o * Housing Status at Enrollment o Not Homeless o Owns or shares own home, condominium, or apartment o Rents or shares own home or apartment o Lives in public housing o Live with parent or family member o Some other arrangement o Homeless o Homeless and sharing housing o Homeless and living in an emergency or transitional shelter o Some other arrangement o o * Total Number of People in the Household – _____ o o * Household Income o Less than or equal to $6000 o $30,001 – $40,000 o $6,001 – $12,000 o Over $40,000 o $12,001 – $20,000 o Refused to respond o $20,001 – $30,000 o o * Health Insurance Status at Enrollment
Demographics: Intake (index children) Revised 09/06/2016 Appendix B – Data Collection Forms Page 6 of 11
o No Insurance Coverage o Not eligible o Other (please specify: ______) o Medicaid or CHIP o Tri-Care o Private o Other (please specify: ______) o
o Demographics: Update (index children)
o * Required
o *First Name - ______o Middle Name - ______o *Last Name - ______
o * Health Insurance Status o
o No Insurance Coverage o Private o Medicaid or CHIP o Other (please specify: ______) o Tri-Care o o * Usual Source of Medical Care o Doctor’s/Nurse Practitioner’s Office o Retail Store or Minute Clinic o Hospital Emergency Room o None o Hospital Outpatient o Other (please specify: ______) o Federally Qualified Health Center o o * Usual Source of Dental Care o Have a Usual Source of Dental Care o Do not have a Usual Source of Dental Care o o
Demographics: Intake (index children) Revised 09/06/2016 Appendix B – Data Collection Forms Page 7 of 11
o Demographics: Update (primary caregiver)
o * Required (Note: all fields are required for new caregivers)
o * First Name - ______o Middle Name - ______o * Last Name - ______
o * Street Address - ______o * City - ______o * Zip - ______o * County - ______
o Home vVsiting Program Type (Select all that apply) o Early Head Start – Home Based Option o Nurse-Family Partnership (NFP) (EHS) o Parents as Teachers (PAT) o Healthy Families America (HFA)
Date of Enrollment – __ __ / __ __ / ______(MM/DD/YYYY)
Birth Date – __ __ / __ __ / ______(MM/DD/YYYY)
Relationship to Child o Biological Mother o Biological Father o Other Female Caregiver o Other Male Caregiver
* Pregnancy Status o Currently pregnant (_____ weeks) o Not currently pregnant
Estimated Date of Delivery – __ __ / __ __ / ______(MM/DD/YYYY)
Race (Select all that apply) o American Indian or Alaska Native o Native Hawaiian or Other Pacific Islander o Asian o White o Black or African-American
Ethnicity o Hispanic or Latino o Not Hispanic or Latino
* Marital Status
Demographics: Intake (index children) Revised 09/06/2016 Appendix B – Data Collection Forms Page 8 of 11
o Never married o Not Married but Living Together with o Married Partner o Separated/Divorced/Widowed * Educational Attainment (highest level) o Less than HS diploma o Associate’s degree o HS Diploma / GED o Bachelor’s degree or higher o Some college/training o Other (please specify: ______) o Technical training or certification
* Educational Status o Student/trainee o Not a student/trainee
* Employment Status o Full-time (37+ hours per week) o Not employed o Part-time (Less than 36 hours per week)
* Housing Status o Not Homeless o Owns or shares own home, condominium, or apartment o Rents or shares own home or apartment o Lives in public housing o Live with parent or family member o Some other arrangement o Homeless o Homeless and sharing housing o Homeless and living in an emergency or transitional shelter o Some other arrangement
* Total Number of People in the Household – _____
* Household Income o Less than or equal to $6000 o $30,001 – $40,000 o $6,001 – $12,000 o Over $40,000 o $12,001 – $20,000 o Refused to respond o $20,001 – $30,000
* Health Insurance Status o No Insurance Coverage o Medicaid or CHIP o Not eligible o Tri-Care o Other (please specify: ______)
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o Private o Other (please specify: ______)
Measure 15: Primary Caregiver Education
* Have you enrolled in, maintained continuous enrollment in, or completed a high school degree or equivalent?
o Yes o No
Demographics: Intake (index children) Revised 09/06/2016 Appendix B – Data Collection Forms Page 10 of 11
Demographics: Exit (index children)
* Required
*First Name - ______Middle Name - ______*Last Name - ______
* Date of Exit – __ __ / __ __ / ______(MM/DD/YYYY)
* Reason for Exit (Select all that apply)
o Child no longer in family’s custody o Child death (parental rights terminated) o Moved out of service area o Client received what s/he needs from the o Pressure from family program Safety of the home visitor o Completed program o Unable to contact/Unable to locate o Dissatisfied with program o Enrolled in another program o Excessive missed appointment/attempted o visits o Client returned to work or school o Home visitor resigned; refused new home o Other (please specify: ______) visitor
Demographics: Intake (index children) Revised 09/06/2016 Appendix B – Data Collection Forms Page 11 of 11
Demographics: Exit (primary caregiver)
* Required
* First Name - ______Middle Name - ______* Last Name - ______
* Date of Exit – __ __ / __ __ / ______(MM/DD/YYYY)
* Reason for Exit (Select all that apply) o Child no longer in family’s custody o Miscarried/fetal death/child death (parental rights terminated) o Moved out of service area o Client received what s/he needs from the o Pressure from family program Safety of the home visitor o Completed program o Unable to contact/Unable to locate o Dissatisfied with program o Enrolled in another program o Excessive missed appointment/attempted o visits o Client returned to work or school o Home visitor resigned; refused new home o Other (please specify: ______) visitor
Measure 15: Primary Caregiver Education
* Have you enrolled in, maintained continuous enrollment in, or completed a high school degree or equivalent? o Yes o No
Demographics: Intake (index children) Revised 09/06/2016