Home Visitor Logs - Past 15 months

OMB Control No: 0970-0402
Expiration Date: __________
Length of time for instrument: 0.09 hours

ATTACHMENT 2: MIHOPE HOME VISITOR LOG
11/20/2012

OMB Control No: 0970-0402
Expiration Date: _________

HOME VISITOR LOG
The U.S. Department of Health and Human Services has contracted with MDRC to evaluate the federal
Maternal, Infant and Early Childhood Home Visiting program (MIECHV).
The Mother and Infant Home Visiting Program Evaluation (MIHOPE) is designed to build knowledge for
policymakers and practitioners about the effectiveness of MIECHV.
Your answers will be kept private. Only the research team will have access to this information. Your
answers will not be shared with anyone at your program or any other agencies. In our research reports,
the information you provide will not be attributed by name to you or your individual program.
Please complete a log for each study participant on your caseload (until the case is closed) that is
participating in the MIHOPE study. After you complete a log for one client, you will have the
opportunity to complete the same set of questions for any additional clients. At the end of every
month, you will also be prompted to answer a few questions about training you have received during
the past month.
If you spent time with a participating family during the past week, the log should take approximately five
minutes to complete.

This collection of information is voluntary and will be used to learn how home visiting programs benefit
families. Public reporting burden for this collection is estimated to be 5 minutes per response, including the
time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of
information. 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
collection 0970-0402 and it expires XX/XX/XXXX.
MIHOPE OMB Supporting Documents_Home Visitor Log

OMB Control No: 0970-0402
Expiration Date: _________

Home Visitor Web-based Log Home Page
Options:
1. Weekly Family Services Log
2. Case closure form
3. Index child birth reporting form
4. Training and/or education log
R. View report of family logs
E. I am done for now and I'm ready to exit

MIHOPE Home Visitor Log: Page 1

OMB Control No: 0970-0402
Expiration Date: _________

Select a Family
1. Please select family name: (drop-down)

For privacy purposes the client's name is not kept on the same file with your responses about the client.
This is the last time the client's name will be displayed. Please select the Next button to be transferred
to the secure log.

MIHOPE Home Visitor Log: 1

OMB Control No: 0970-0402
Expiration Date: _________

FAMILY SERVICES LOG
1. Please select the calendar week for which you are completing this log (pop-up calendar)
This section will ask you about contact you have had with your client during the week for which you are
reporting, specifically face-to-face and non-face-to-face contacts. You will also be asked to think back to
any visits you had scheduled for the past week that did not occur. Please answer the following
questions to your best ability and only in regards to the particular client assigned to this log.
2. Did you have any contact with your client during the last week?
 Yes
 No [SKIP TO 14]

Face-to-Face Contact
3. Excluding any group activities, how many face-to-face (in-person) visits did you have with your
client during the past week?
NUMBER: __________
[IF NUMBER OF VISITS = 0, SKIP TO 11]
4. Excluding any group activities, how many total minutes did you spend face-to-face (in-person)
with your client during the past week?
NUMBER OF MINUTES: __________
5. Did you provide any of the following materials or services to the family during the last week?
CHECK ALL THAT APPLY. Please provide an approximate monetary value for any materials or
supports you provided to your best ability.
 Did not provide any materials to the client
 Monetary incentives to promote or recognize participation in services( e.g., gift cards,
money orders) (approximate value__________)
 Food/formula (approximate value ______________)
 Transport client (approximate mileage _____________)
 Transportation (e.g., bus fare, taxi voucher, etc.) (approximate value
________________)
 Medical supplies (e.g., breast pump, thermometer, medicine dropper) (approximate
value _______________)
 Items for infant/child (e.g. diapers, books, toys) (approximate value ______________)
 Other ___________ (approximate value ____________________)

MIHOPE Home Visitor Log: 2

OMB Control No: 0970-0402
Expiration Date: _________
6. During any of the face-to-face contacts you had with your client during the last week, which of
the following topics/activities were addressed? Please select topics from the list below. CHECK
ALL THAT APPLY.
Caregiver
 Prenatal health behaviors/prenatal care
 Maternal physical health (outside of pregnancy)
 Family planning
 Tobacco, alcohol, and other drug use
 Mental health or stress
 Domestic violence or anger management
 Social support
 Job training and employment
 Education
 Economic management/financial self-sufficiency
 Housing
 Finding alternate caregivers/child care
Parenting behavior/Child outcomes
 Breastfeeding/feeding/nutrition
 Parent-child interaction
 Discipline/behavior management
 Developmentally appropriate care/routines
 Co-parenting
 Child health
 Child development
 Child/home safety
 Lead exposure in home
Family
 Public/governmental assistance
 Health insurance/Medicaid/SCHIP
7. In the past week, did you refer your client to services or provide agency contact information for
any of the following areas? CHECK ALL THAT APPLY.
 None provided
 Prenatal care
 Maternal preventive care
 Family planning and reproductive health care
 Substance use (alcohol and other drugs) treatment
 Mental health treatment
 Domestic violence shelter
 Domestic violence counseling/anger management
 Adult education services (including GED and ESL)
 Job training and employment
 Pediatric primary care
 Housing
 Childcare
 Early intervention services/Part C services
 Public assistance (Medicaid, SNAP, WIC, , SCHIP, TANF, etc.)
MIHOPE Home Visitor Log: 3

OMB Control No: 0970-0402
Expiration Date: _________
For questions 8, 9, and 10 please refer only to the longest home visit you had with your client during the
last week.
8. Which of the following participated in the visit? CHECK ALL THAT APPLY
 Mother of child/pregnant woman
 Index child
 Father of child/mother’s current partner
 Other adult family member
 Other professional (nurse, early interventionist, child welfare worker, supervisor,
etc.)
9. Client engagement during contact (drop-down)
 Client had little interaction other than being present
 Client was friendly but involvement was purely superficial and/or social
 Client was moderately involved in the visit
 Client was easy to engage in most conversation and activities
 Client was invested in all of the visit, asked questions, and took a very active role
10. Client follow through from previous visit (drop-down)
 N/A. No follow through anticipated/assigned
 Client could not remember previous activities/discussion/referrals
 Client remembered but did not follow through
 Client followed through incompletely
 Client followed through completely

Non-Face-to-Face Contact
11. How many times during the last week did you have any scheduled visits with the client that
were cancelled or the client was not home/did not come to the visit?
NUMBER OF TIMES: _________
12. During the past week, how much total time did you spend communicating with this client via the
telephone (talking, leaving messages, texting), email, writing letters, or social networking sites?
TOTAL NUMBER OF MINUTES:____________
13. How much total time did you spend traveling to and from visits with this client over the past
week? This should include all visits that were completed, cancelled, or not attended by client.
TOTAL NUMBER OF MINUTES:___________

MIHOPE Home Visitor Log: 4

OMB Control No: 0970-0402
Expiration Date: _________
No Contact with Client
14. What was the main reason for there being no contact with your client during the past week?
a) Case closed [IF SELECTED, PROMPT i and ii]
i.

Date of case closure DATE (MM/DD/YY): ___________

ii. Reason for case closure. CHECK ALL THAT APPLY.









Family moved out of service area
Transferred to another home visiting site
Unable to locate
Miscarriage or fetal/child death
Maternal death
Excessive missed appointments/unresponsive
Caregiver lost custody of index child
Caregiver declined further participation (this would include going
back to work, school, getting services from other agencies, pressure
from family members, etc.)
 Other
b) Scheduled in-person visit did not occur. [IF SELECTED, PROMPT i]
i.

How many times did this happen during the last week? NUMBER OF
TIMES:___________

c) No scheduled contact
15. How much total time did you spend traveling to and from scheduled or attempted visits with
this client over the week? TOTAL NUMBER OF MINUTES: ___________

Other Activities Related to Client (All Clients)
 Did other staff/providers from your program have face-to-face contact with your client this
week when you were not present?
 Yes
 No [SKIP TO 16]
 Excluding any group activities, approximately how many total minutes did other staff spend
face-to-face (in-person) with your client during the past week?
NUMBER OF MINUTES: __________
 What was the reason that this staff member had contact with your client?
 Conducted a home visit when I was unable to
 Provide additional services to client

MIHOPE Home Visitor Log: 5

OMB Control No: 0970-0402
Expiration Date: _________
Preparation:
16. How much total time did you spend preparing for and following up from contact/meetings with
this client during the past week? This may include conducting research, locating resources,
communicating with other providers about family, preparing handouts for a visit, completing
progress notes/clinical documentation, etc.
TOTAL NUMBER OF MINUTES: ___________
Supervision:
17. Compared to your other clients, how much time would you say you spent discussing this
particular client with your supervisor during the past week?
 Much less time than my average client
 Somewhat less time than my average client
 About the same amount of time as my average client
 Somewhat more time than my average client
 Much more time than my average client

18. Do you need to complete a log on additional clients?
 Yes [New form beginning with Question #1 will load]
 No

MIHOPE Home Visitor Log: 6

OMB Control No: 0970-0402
Expiration Date: _________

TRAINING AND EDUCATION LOG
1. Please select the calendar month for which you are completing this log: (drop down of months)
Instructions: Please complete the following questions regarding all training and/or education sessions
you received as part of your current employment position during the past month.
2. Did you participate in training or education sessions within the last month?
 Yes
 No [END LOG]

The following questions should include the combined totals for all trainings and/or education sessions
you participated in during the past month.
3. How many total training or education sessions did you attend within the last month?
NUMBER OF SESSIONS: _____________
4. How many total hours did you spend in training or education sessions in the last month?
NUMBER OF HOURS: _____________
5. What topics were covered during these trainings? Please choose the response(s) that most closely
align with the training you received. CHECK ALL THAT APPLY.
Caregiver
 Prenatal health behaviors/prenatal care
 Postpartum physical health
 Family planning
 Tobacco, alcohol, and other drug use
 Mental health or stress
 Domestic violence or anger management
 Social support
 Housing
 Job training and employment
 Education
 Economic management/financial self-sufficiency
 Finding alternate caregivers/child care
 Other ____________________
Parenting behavior/Child outcomes
 Breastfeeding/feeding/nutrition
 Parent-child interaction
 Discipline/behavior management
 Developmentally appropriate care/routines
 Co-parenting
 Child health
MIHOPE Home Visitor Log: 7

OMB Control No: 0970-0402
Expiration Date: _________
 Child development
 Child abuse/neglect/maltreatment
 Other ____________________
Family
 Public/governmental assistance
 Medicaid/SCHIP
 Child/home safety
 Lead in home
 Other ____________________
Home Visitor
 General clinical and communication skills
 Stress management for home visitor
 Cultural sensitivity/diversity
 Other ____________________
6. Did the training involve any of the following? CHECK ALL THAT APPLY.
 Reading material
 Lecture
 Demonstration
 Test or assessment of knowledge gained
 Role playing/practice/behavioral rehearsal [IF SELECTED, PROMPT i]
 None of the above
i.

Was there an observation of the role play or rehearsal by the trainer?
 Yes
 No
 Unknown


IF YES, PROMPT. Were there set performance standards you were
required to meet (e.g., scores, ratings, etc.)?
 Yes
 No
 Unknown

MIHOPE Home Visitor Log: 8

OMB Control No: 0970-0402
Expiration Date: _________

Case Closure Form
1. Please select the family name for which you are reporting a case closure (drop-down family name)
2. Date of case closure: (pop-up calendar)
3. Reason for case closure. CHECK ALL THAT APPLY.









Family moved out of service area
Transferred to another home visiting site
Unable to locate
Miscarriage or fetal/child death
Maternal death
Excessive missed appointments/unresponsive
Caregiver lost custody of index child
Caregiver declined further participation (this would include going back to work, school,
getting services from other agencies, pressure from family members, etc.)
 Other
If you have spent any time on this case this week in face-to-face contact or non-face-to-face work
related to the case you should complete a family service log for this week.
Would you like to complete a Family Services log for this family right now?
 Yes [Family Service Log will load]
 No [End Log]

MIHOPE Home Visitor Log: 9

OMB Control No: 0970-0402
Expiration Date: _________

Birth of Index Child Log


Infant DOB: (pop-up calendar)

MIHOPE Home Visitor Log: 10