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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1 Primary Caretaker 1 s Identifier FOLLOW-UP FORM PC1 Date form completed PC1 Initials (2 let) Yr of Birth (2 num) Program Code Unique 6 Digit Identifier Follow up interval (Indicate target child s age) 6 months old 1 year old 18 months old 2 years old 3 year old 4 year old 5 year old At discharge PC1 1. Is PC1 living in household at time of follow up? 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? (Skip PC1 4 and enter job(s) below) (Skip 8) Date job began Still at job? PC1 5. Highest grade completed as of this follow up 1 Less than HS Grad Check here if Prenatal Discharge Primary Caretaker 1 Month Day Year Family Support Worker name PC1 2. PC1 marital status (Check only one) 1 Married 2 t Married Primary Caretaker 1 Employment PC1 4. If PC1 held no jobs in the follow up period, did s/he look for a job during this period? Date Job Ended Hours per month $ $ Primary Caretaker 1 Education (Check only highest level) 5 Vocational school after HS 6 Some college 7 Associates degree Average wages per month before taxes 4 GED 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? (Enter program below) Program Type (See codes below) If Program Type Other Program Type Codes: 1 Middle school 4 ESL 2 High School 5 Adult education in 3 GED basic math and reading 6 College 7 Vocational training, technical or trade school (not training received during HS) Identify Program Name 8 Job search or job placement 9 Work experience 10 Other Date Form Submitted Reviewer s Initials Date of Data Entry Initials of Data Entry Operator Monthly Hours in Program Follow-up Form Page 1 of 6 11/01/12
2 FOLLOW-UP FORM 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 PC1 8. Does PC 1 have a medical provider? 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 o. Inadequate food, clothing, or household disability/retardation goods g. Domestic violence p. Smoking h. Marital or relationship difficulties q. Other ( ) i. Financial difficulties/insufficient inc. Primary Caretaker 1 Medical Provider/Service System Involvement/Health Insurance PC1 9. Current PC1 service PC1 10. Is PC 1 receiving involvement Medicaid? Unk (If yes, skip PC1 11) Mental Health Substance abuse Domestic violence CPS/ACS 2 ltrs 5 numbers 1 ltr Subsequent Pregnancies/Births/ Birth Control PC1 12a. Was PC1 pregnant at any time during this period? (Exclude target child pregnancy) PC1 11. Health insurance (Check all that apply Family/Child Health Plus Private Insurance Other ( ) Uninsured/Self pay PC1 12b. If yes, how many? PC1 12c. Did any of the pregnancies noted in pc1 12 result in a live birth? (Enter birth(s) below) Live Birth 1 Live Birth 2 Live Birth 3 DOB First Name Last Name Gestation 1Full Term 2 Premature 1Full Term 2 Premature 1Full Term 2 Premature If premature, weeks gestation If premature, weeks gestation If premature, weeks gestation Birth weight lbs oz lbs oz lbs oz Follow-up Form Page 2 of 6 11/01/12
3 Primary Caretaker 1 s Identifier: PC1 13. Was PC1 consistently using birth control during this period? (If yes, answer PC1 14, PC1 15) (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 Implant (Implanon) Birth control patch (Ortho Evra) Birth Control Pill Cervical Cap (FemCap) Female Condom Spermicide Withdrawal (Pull out method) Birth Control Vaginal ring (NuvaRing) Condom Emergency contraception (Morning After Pill) Sterilization for Women (Tubal Ligation) Rhythm 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? (answer TC 2, skip TC 3) (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 Target Child(ren) Medical Provider/Health Insurance/Lead Assessment TC 3. If no, why? (Check only one) 1 MOB choice 2 Medical reasons /Complications TC 4. Does Target Child(ren) have a Medical Provider? TC 5. Is Target Child(ren) receiving Medicaid? (If yes, Skip TC 6) MA Number (If no, answer TC6) (If unknown, answer TC6) TC 6. Health insurance (Check all that apply) Family/Child Health Plus Private Insurance Uninsured/Self pay Other ( ) 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. Follow-up Form Page 3 of 6 11/01/12
4 FOLLOW UP FORM OBP Primary Caretaker 1 s Identifier: OPB 1. Is Other Biological Parent living in household at time of follow up? Other Biological Parent OPB 2. Other Biological Parent marital status (Check only one) 1 Married 2 t Married Other Biological Parent Employment OPB 3. Did Other Biological Parent hold a job at any OPB 4. If Other Biological Parent held no jobs in the follow up time since intake (if this is the 6 month follow up) or period, did s/he look for a job during this period? since the last follow up? (Skip OBP 4 and enter job(s) below) Date Job Began Still at Job? Date Job Ended Hours per month Average wages per month before taxes $ $ Other Biological Parent Education OPB 5. Highest grade completed as of this follow up (Check only highest level) 1 Less than HS Grad 5 Vocational school after HS 6 Some college 7 Associates degree 4 GED 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? (Enter program below) Program Type If Program Type Identify Program Name Monthly Hours in Program (See codes below) Other Program Type Codes: 1 Middle school 4 ESL 2 High school 5 Adult education in 3 GED basic math and reading 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 Follow-up Form Page 4 of 6 11/01/12
5 Follow up Form PC2 Primary Caretaker 1 s Identifier: PC2 1. Is PC2 living in the household at time of follow up? 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 followup? (Skip PC2 4 and enter job(s) below) Date Job Began Still at Job?, Why? List of reasons, Why?List of reasons Primary Caretaker 2 Education PC2 5. PC2 Highest grade completed as of this followup (Check only highest level) 1. Less than HS Grad 4. GED 5. Vocational school after HS 6. Some college 7. Assoc. degree 8. Bachelors degree or higher Primary Caretaker 2 PC2 2. PC2 marital status (Check only one) 1. Married 2. t Married PC2 4. If PC2 held no jobs in the follow up period, did s/he look for a job during this period? Date Job Ended Hours per month $ $ Average wages per month before taxes 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? (Enter program below) Program Type (See codes below) If Program Type Other Identify Program Name Monthly Hours in Program 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) Follow-up Form Page 5 of 6 11/01/12
6 FOLLOW-UP FORM Family Primary Caretaker 1 s Identifier: FAM 1. Involvement of Other Biological Parent (Check only one) 1 Emotionally and financially involved 2 Emotionally involved only 3 Financially involved only 4 t involved 5Does not know about child 6 Deceased 7 Other ( ) 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? 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 $) Round to Nearest $) 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? (If, Answer FAM 7 11 ) (Skip to FAM 12) FAM 7. TANF FAM 8. Food Stamps FAM 9. Emergency Assistance FAM 10. WIC 1. Currently receiving Received since last followup but not currently receiving receipt since last followup FAM 12. Does this Family Meet the Criteria to Receive TANF Services? (If, Answer Q13) FAM 13. If 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 FAM 11. SSI/SSD 2. Immigration Status 4. Other Reason ( ) FAM 14. Has a safety plan been discussed, completed or reviewed? FAM 15. If this is the 6 month follow up, was the 6 month HOME completed? Follow-up Form Page 6 of 6 11/01/12
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