Form I - DxInt. Ou Form I - DxInt. Ou Form I - DxInt. Outcomes

OMB # 0930- XXXX

Expiration Date: xx/xx/xxxx

SAMHSA FASD Center for Excellence

Form I

Diagnosis and Intervention Programs

Outcome Measures (Children 0-7 years)

This is an outcomes measure checklist used in the SAMHSA FASD Center for Excellence Diagnosis and Intervention Programs to record measures within 30 days of developing the service delivery plan, every six months from start of service to end of service, at end of intervention, at 6 months follow-up, and 12 months follow-up. To protect privacy, name and any other individually identifying information will not be collected. It is important to us to obtain this information on these measures to monitor progress; however, participation is voluntary.

Child ID: ______________ Date Completed: ________

Administered at the following time points:

1. Within 30 days of developing the service delivery plan (baseline measure)

2. Every six months from start of service to end of service

3. End of Intervention/Program

4. At 6 months follow-up and

5. At 12 months follow-up

1. School Performance Measures (record data for last 6 months)

1. Number of school days ___________

2. Number of days attended __________

3. Number of suspensions ___________

4. Number of expulsions ____________

2. Placement Stability (Housing) (record data for last 6 months)

Number of placements	Date of entry	Date of exit	Reason for change in placement
1
2
3

3. If child had a change in residence/placement since services began, indicate type of setting, date the setting changed, and length of time in each setting.

Type of Setting	Date Setting Changed	Length of Time Enter a number in the hours, days, or weeks column.
		Hours	Days	Weeks
a) Adoptive Home
b) Biological Father
c) Biological Mother
d) Drug/Alcohol Rehabilitation Center
e) Foster Care
f) Group Emergency Shelter
g) Group Home
h) Home of a Family Friend
i) Home of a Relative
j) Independent Living with Friend
k) Independent Living by Self
l) Individual Home Emergency Shelter
m) Inpatient Psychiatric Hospital
n) Jail
o) Juvenile Detention Center
p) Medical Hospital
q) Residential Job Corp/Vocational Center
r) Residential Treatment
s) School Dormitory
t) Specialized Foster Care
u) Supervised Independent Living
v) Therapeutic Foster care
w) Two Biological Parents

4. Placement Stability* (Preschool or Day Care) (record data for last 6 months

Number of preschool/day care placements	Date of entry into preschool or daycare	Date of exit from preschool or daycare	Reason for change in placement
1
2
3

*The percentage of study children with more than one school placement will be computed as the number of children with more than one placement divided by the number of children enrolled in a program. Children with school changes because of a required move will be excluded from the count (e.g., child aged out of the program).

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-xxxx. Public reporting burden for this collection of information is estimated to average 15 minutes per client per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

2