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 1 IRI Worksheet 1.31.18 rev. 2.6.19 Infant Risk Identifier Worksheet 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 2 IRI Worksheet 1.31.18 rev. 2.6.19 Infant Risk Identifier Worksheet 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 3 IRI Worksheet 1.31.18 rev. 2.6.19 Infant Risk Identifier Worksheet 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 4 IRI Worksheet 1.31.18 rev. 2.6.19 Infant Risk Identifier Worksheet 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 6 IRI Worksheet 1.31.18 rev. 2.6.19 Infant Risk Identifier Worksheet 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 7 IRI Worksheet 1.31.18 rev.