Form J - DxInt. Ou Form J - DxInt. Outcomes J. 8-18yrs.

OMB # 0930- XXXX

Expiration Date: xx/xx/xxxx

SAMHSA FASD Center for Excellence

Form J

Diagnosis and Intervention Programs

Outcome Measures (Children 8-18 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: ________

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(record data for last 6 months)

1. Number of placements with more restriction ___________

2. Number of placements with same amount of restriction _________

3. Number of placements with less restriction ___________

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. Adjudication Measures (record data for last 6 months)

a. Petition Offense (Select as many as applicable)

• Murder and non-negligent manslaughter

• Robbery

• Forcible rape

• Burglary

• Assault

• Larceny-theft

• Motor Vehicle-theft

• Arson

• Other (simple) assault

• Forgery and counterfeiting

• Fraud

• Embezzlement

• Stolen Property ( buying, receiving, possessing)

• Vandalism

• Weapons (buying, possessing, etc.)

• Prostitution and commercialized vice

• Sex offense (except forcible rape and prostitution)

• Drug abuse violation

• Gambling

• Offense against family and children

• Driving under the influence

• Liquor Laws

• Drunkenness

• Disorderly conduct

• Trespass (dwelling, motor vehicle, unspecified)

• Vagrancy

• All other offenses (except traffic)

• Suspicion

• Curfew and loitering law violation

• Runaway

b. Adjudicated Charge(s)

• Murder and non-negligent manslaughter

• Robbery

• Forcible rape

• Burglary

• Assault

• Larceny-theft

• Motor Vehicle-theft

• Arson

• Other (simple) assault

• Forgery and counterfeiting

• Fraud

• Embezzlement

• Stolen Property ( buying, receiving, possessing)

• Vandalism

• Weapons (buying, possessing, etc.)

• Prostitution and commercialized vice

• Sex offense (except forcible rape and prostitution)

• Drug abuse violation

• Gambling

• Offense against family and children

• Driving under the influence

• Liquor Laws

• Drunkenness

• Disorderly conduct

• Trespass (dwelling, motor vehicle, unspecified)

• Vagrancy

• All other offenses (except traffic)

• Suspicion

• Curfew and loitering law violation

• Runaway

• Other

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.

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