FOLLOW-UP FORM PC1. Check here if Prenatal Discharge. Primary Caretaker 1. Date Job Ended (mm/dd/yy) / / $ Primary Caretaker 1 Education

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Follow-up Form Page 1 of 6 11/01/12

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PC1

Primary Caretaker 1’s Identifier

PC1 Initials (2 let) Yr of Birth (2 num) Program Code Unique 6 Digit Identifier Date form completed

Month Day Year Follow‐up interval (Indicate target child’s age)

Family Support Worker name 6 months old

1 year old 18 months old 2 years old

3 year old

4 year old 5 year old At discharge Check here if Prenatal Discharge

Primary Caretaker 1 PC1‐1. Is PC1 living in household at time of follow‐up? Yes No

PC1‐2. PC1 marital status (Check only one) 1 Married 2 Not Married

Primary Caretaker 1 Employment PC1‐3. Did PC1 hold a job at any time since intake (if this is the 6‐month follow‐up) or since the last follow‐up? Yes (Skip PC1‐4 and enter job(s) below) No (Skip 8)

PC1‐4. If PC1 held no jobs in the follow‐up period, did s/he look for a job during this period? Yes No

Date job began (mm/dd/yy) Still at job? Date Job Ended (mm/dd/yy) Hours per month Average wages per month before taxes

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Yes No

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$

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Yes No

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$

Primary Caretaker 1 Education PC1‐5. Highest grade completed as of this follow‐up (Check only highest level) 1 Less than 8 2 8‐11 3 HS Grad 4 GED 5 Vocational school after HS 6 Some college 7 Associates degree 8 Bachelor’s degree or higher PC1‐6. Has Primary Caretaker 1 been involved in an educational or employment and training program since intake (if this is 6‐ month follow‐up) or since the last follow‐up? Yes (Enter program below) No

Program Type

(See codes below)

If Program Type Other

Identify Program Name Monthly Hours in Program

Specify

Specify Program Type Codes:

6 College 7 Vocational training, technical

or trade school (not training received during HS) 8 Job search or job placement 9 Work experience

10 Other 1 Middle school 2 High School 3 GED 4 ESL 5 Adult education in basic math and reading

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ORM Primary Caretaker 1’s Identifier

PC1‐7. PC 1 Current Issues: Check “Y” for yes if the PC1 tells you that she has a particular issue; someone else like the FAW, friend or relative reports the issue; or you observe or suspect the issue exists. Check “N” for no if the issue is not present. Check “Unk” for unknown if you do not know. Please check only one box for each issue listed. Are any of the following current issues for the Primary Caretaker 1? (Check all items with either Y or N or UK)

Y N Unk Y N Unk

a. Alcohol abuse j. Homelessness or inadequate housing b. Substance abuse k. Criminal activity c. Physical disability/health problems l. Other legal problems d. Depression m. Social isolation/inadequate social support e. Other mental illness/disability n. Stress or emotional difficulties f. Developmental disability/retardation o. Inadequate food, clothing, or household goods g. Domestic violence p. Smoking h. Marital or relationship difficulties q. Other (Specify___________________________) i. Financial difficulties/insufficient inc. Primary Caretaker 1 Medical Provider/Service System Involvement/Health Insurance PC1‐8. Does PC 1 have a medical provider? Yes No PC1‐9. Current PC1 service involvement Yes No Unk

Mental Health Substance abuse Domestic violence CPS/ACS PC1‐10. Is PC 1 receiving Medicaid? Yes (If yes, skip PC1‐11)

2 ltrs 5 numbers 1 ltr No Unknown

PC1‐11. Health insurance (Check all that apply Family/Child Health Plus Private Insurance Other (Specify __________) Uninsured/Self‐pay

Unknown

Subsequent Pregnancies/Births/ Birth Control PC1‐12a. Was PC1 pregnant at any time during this period? (Exclude target child pregnancy) Yes No

PC1‐12b. If yes, how many?

PC1‐12c. Did any of the pregnancies noted in pc1‐12 result in a live birth? Yes (Enter birth(s) below) No

Live Birth 1

Live Birth 2 Live Birth 3

DOB

_/ _/

First Name

Last Name

Gestation _1Full Term _2 Premature

If premature, weeks gestation

1Full Term 2 Premature If premature, weeks gestation

Birth weight

lbs oz lbs oz lbs oz

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Primary Caretaker 1’s Identifier:

PC1‐13. Was PC1 consistently using birth control during this period?

Yes (If yes, answer PC1‐14, PC1‐15) No (If no, skip PC1‐14, PC1‐15)

PC1‐14. How long (in months) has Primary Caretaker 1 consistently been using birth control (since TC birth)?

months PC1‐15. Which types of birth control methods are being used: (check all that apply) Abstinence Birth Control Pill Cervical Cap (FemCap) Female Condom Spermicide Withdrawal (Pull out method) Birth Control Implant (Implanon) Birth Control Vaginal ring (NuvaRing) Condom Emergency contraception (Morning After Pill) Sterilization for Women (Tubal Ligation) Rhythm Birth control patch (Ortho Evra) Birth control shot (Depo‐Provera) Diaphragm IUD Vasectomy

Follow‐Up Form

Target Child

Breastfeeding (includes exclusive breastfeeding as well as any combination of breast milk, water, vitamins, formula, solid food, or other non‐breast milk nutrition in the target child's diet.) Skip this question if 18 month follow‐up or later.

TC‐1. Was target child(ren) ever breastfed? Yes (answer TC‐2, skip TC‐3) No (skip TC‐2, answer TC‐3)

TC‐2. If yes, how long? (Check only one) 1 Less than 1 month 2 One month up to 2 months 3 Two months up to 3 months 4 Three months up to 6 months 5 Six months up to 1 year 6 One year or greater TC‐3. If no, why? (Check only one) 1 MOB choice 2 Medical reasons /Complications Target Child(ren) Medical Provider/Health Insurance/Lead Assessment

TC‐4. Does Target Child(ren) have a Medical Provider?

Yes No

TC‐5. Is Target Child(ren) receiving Medicaid?

_Yes (If yes, Skip TC‐6) MA Number

No (If no, answer TC6)

Unknown (If unknown, answer TC6)

TC‐6. Health insurance

(Check all that apply) Family/Child Health Plus _{Private Insurance}

Other (Specify _______________________) Uninsured/Self‐pay

Unknown Lead Assessment (Home visitors should ask the risk assessment questions of the primary caretaker on the suggested schedule and record the date below. If the primary caretaker answers “yes” to any of the questions, the home visitors should tell the primary caretaker to bring this to the attention of the pediatrician or might want to call the physician directly to inform him/her of the result.) Does your child: 1. Live in or regularly visit a house with peeling or chipping paint built before 1978? This could include a day care center, preschool, the home of a babysitter or relative, etc. 2. Live in or regularly visit a house built before 1978 with recent, ongoing or planned renovation or remodeling? 3. Have a brother or sister, housemate, or playmate being followed or treated for lead poisoning? 4. Frequently come into contact with an adult whose job or hobby involves exposure to lead? Examples are construction, welding, pottery, or other trades practiced in your community? 5. Live near an active lead smelter, battery recycling plant, or other industry likely to release lead? 6. Live near a heavily traveled major highway where soil and dust may be contaminated with lead? 7. Has your family/child ever lived outside the United States or recently arrived from a foreign country

TC‐7. Assessed positive or negative:

Positive

Negative

If the answer to any of the above questions is YES, then the child is considered to be at risk of high dose lead exposure and should be screened with a blood test by his/her medical provider.

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OBP

Other Biological Parent OPB‐1. Is Other Biological Parent living in household at time of follow‐up? Yes No

OPB‐2. Other Biological Parent marital status (Check only one) 1 Married 2 Not Married Other Biological Parent Employment

OPB‐3. Did Other Biological Parent hold a job at any time since intake (if this is the 6‐month follow‐up) or since the last follow‐up? Yes (Skip OBP‐4 and enter job(s) below) No OPB‐4. If Other Biological Parent held no jobs in the follow‐up period, did s/he look for a job during this period? Yes No

Date Job Began (mm/dd/yy) Still at Job? Date Job Ended (mm/dd/yy) Hours per month Average wages per month before taxes

/

Yes No

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$

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Yes _No

/

$

Other Biological Parent Education OPB‐5. Highest grade completed as of this follow‐up (Check only highest level) 1 Less than 8 2 8‐11 3 HS Grad 4 GED 5 Vocational school after HS 6 Some college 7 Associates degree 8 Bachelors degree or higher OPB‐6. Has Other Biological Parent been involved in an educational or employment and training program since intake (if this is 6‐month follow‐up) or since the last follow‐up? Yes (Enter program below) No

Program Type

(See codes below)

Identify Program Name Monthly Hours in Program

Specify

Specify Program Type Codes:

6 College 7 Vocational training, technical

or trade school (not counting training received during HS)

8 Job search or job placement 9 Work experience

10 Other

1 Middle school 2 High school 3 GED 4 ESL 5 Adult education in basic math and reading

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Follow‐up Form

PC2

Primary Caretaker 2 PC2‐1. Is PC2 living in the household at time of follow‐up?

Yes No

PC2‐2. PC2 marital status (Check only one) 1. Married 2. Not Married

Primary Caretaker 2 Employment

PC2‐3. Did PC2 hold a job at any time since intake (if this is the 6‐month follow‐up) or since the last follow‐ up? Yes (Skip PC2‐4 and enter job(s) below) No PC2‐4. If PC2 held no jobs in the follow‐up period, did s/he look for a job during this period? Yes No

Date Job Began (mm/dd/yy) Still at Job? Date Job Ended (mm/dd/yy) Hours per month Average wages per month before taxes

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Yes No, Why? List of reasons

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$

/

Yes No, Why?List of reasons

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$

Primary Caretaker 2 Education PC2‐5. PC2 Highest grade completed as of this follow‐ up (Check only highest level) PC2‐6. Has PC2 been involved in an educational or employment and training program since intake (if this is 6‐month follow‐up) or since the last follow‐up? 1. Less than 8 2. 8‐11 3. HS Grad 4. GED 5. Vocational school after HS 6. Some college 7. Assoc. degree 8. Bachelors degree or higher Yes (Enter program below) No Program Type (See codes below)

Identify Program Name Monthly Hours in Program

Specify

Program Type Codes:

6 College 8 Job search or job placement

1 Jr. high 4 ESL 7 Vocational training, technical 9 Work experience

2 HS 5 Adult education in or trade school (not counting 10 Other

3 GED basic math and reading training received during HS)

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Family

FAM‐1. Involvement of Other Biological Parent (Check only one) 1 Emotionally and financially involved 2 Emotionally involved only 3 Financially involved only 4 Not involved 5Does not know about child 6 Deceased 7 Other (Specify _____________________) FAM‐2. Did Home Visiting Staff make a report to CPS/ACS on this family since last intake if this is the 6 month Follow‐up or since the last follow‐up?

Yes No

Household Income

FAM‐3. Number of people who lives with Primary Caretaker 1 (Include Primary Caretaker 1)

FAM‐4a. What is the average total monthly income of your household (including all earnings and other sources of cash support from family/friends etc.)?

FAM‐4b.What is the average total value of benefits of your household, i.e. TANF, food stamps, emergency assistance, WIC, SSI/SSD, etc.

FAM‐5. . Number of persons contributing to monthly household income (item29a) (Enter 0 if all income comes from charities or government)

_{Round to Nearest $)}

Unknown

Round to Nearest $)

Unknown

FAM‐6. Is Primary Caretaker 1 receiving any of the following benefits since intake (if this is the 6-month follow-up) or since the last follow-up?

Yes (If Yes, Answer FAM‐7‐11 ) No (Skip to FAM‐12) FAM‐7. TANF FAM‐8. Food Stamps FAM‐9. Emergency Assistance FAM‐10.

WIC FAM‐11. _SSI/SSD 1. Currently receiving 1. 1. 1. 1. 1. 2. Received since last follow‐ up but not currently receiving 2.

2. 2. 2.

2. 3. No receipt since last follow‐ up 3. 3. 3. 3. 3.

FAM‐12. Does this Family Meet the Criteria to Receive TANF Services? Yes No (If No, Answer Q13)

FAM‐13. If No is Answered in FAM12, Why Doesn’t this Family Meet the Criteria to Receive TANF Services?

1. Income above 200% of Poverty 3. Refused to complete application

2. Immigration Status 4. Other Reason (Specify________________________________________)

FAM‐14. Has a safety plan been discussed, completed or reviewed? Yes No

FAM‐15. If this is the 6 month follow‐up, was the 6 month HOME completed? Yes No