Caregiver Initial Information Form

Permanency Innovations Initiative (PII) Evaluation

Kansas Caregiver Initial Information Form 7-19-12

Caregiver Initial Information Form

OMB: 0970-0408

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EXPIRATION DATE:

THE PAPERWORK REDUCTION ACT OF 1995:  Public reporting burden for this collection of information is estimated to average 6 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.



KIPP Caregiver Initial Information Sheet

After consent has been given, complete information for each parent/caregiver.

PERSON A (Parent in Home)

PERSON B (Person A’s Spouse/Partner)


☐ Parent living in home (preferred)


If no parent living in home:

☐ Person with primary child care responsibility living in the home


☐ A’s spouse/partner living in home (preferred)


If no spouse/partner of Person A living in home:

☐ Other person with child care responsibility living in home


If no other child care person in home, skip this column.

1a. Age


(approximate years)

1b. Age


(approximate years)

2a. Gender Male Female

2b. Gender Male Female

3a. Person A race (select one or more)

☐ American Indian or Alaska Native

☐ Asian

☐ Black or African American

☐ Native Hawaiian or Other Pacific Islander

☐ White

3b. Person B race (select one or more)

☐ American Indian or Alaska Native

☐ Asian

☐ Black or African American

☐ Native Hawaiian or Other Pacific Islander

☐ White

4a. Person A ethnicity (select one)

☐ Hispanic or Latino

☐ Not Hispanic or Latino

4b. Person B ethnicity (select one)

☐ Hispanic or Latino

☐ Not Hispanic or Latino

5a. Person A is child’s (select one or more)

  • Biological parent

  • Stepparent

  • Adoptive parent

  • Grandparent

  • Guardian

  • Friend

  • Other relative (specify) ______________

  • Other nonrelative (specify) ___________

  • Unknown/Not Available

5b. Person B is child’s (select one or more)

  • Biological parent

  • Stepparent

  • Adoptive parent

  • Grandparent

  • Guardian

  • Friend

  • Other relative (specify) _______________

  • Other nonrelative (specify) ____________

  • Unknown/Not Available

6a. Person A is (select one)

☐ A single parent/person

☐ Living with spouse

☐Living with unmarried partner

☐ Other (specify) ______________________

☐ Unknown/Not Available

6b. Person B is Person A’s (select one)

☐ Spouse

☐ Unmarried live-in partner

☐ Roomer/boarder/housemate/roommate

☐ Parent

☐ Sibling

☐ Son or daughter

☐ In-law

☐ Other relative (specify) ________________

☐ Other non-relative (specify) ____________

☐ Unknown/Not Available

7a. Person A current living situation (select one)

☐ House/apartment

☐ Staying with friends/family

☐ Homeless shelter/no housing

☐ Residential treatment

☐ Other (specify) _________________

7b. Person B current living situation (select one)

☐ House/apartment

☐ Staying with friends/family

☐ Homeless shelter/no housing

☐ Residential treatment

☐ Other (specify) _________________

8a. Person A education (select one)

☐ Less than high school graduate

☐ High school graduate/GED

☐ More than high school

8b. Person B education (select one)

☐ Less than high school graduate

☐ High school graduate/GED

☐ More than high school

9a. Person A current employment status (select one)

☐ Not employed

☐ Employed full-time

☐ Employed part-time or seasonally

9b. Person B current employment status (select one)

☐ Not employed

☐ Employed full-time

☐ Employed part-time or seasonally

10a. Person A financial hardship – past 12 months (select one or more)

☐ Lacked money for family clothing or shoes

☐ Lacked money to pay rent or mortgage

☐ Lacked money to buy enough food for family

☐ Used food pantry or community meal program

☐ Utilities shut off

☐ Evicted from home

☐ Moved in with family or friends

☐ Furniture, car, other belongings repossessed

☐ Homeless

10b. Person B financial hardship – past 12 months (select one or more)

☐ Lacked money for family clothing or shoes

☐ Lacked money to pay rent or mortgage

☐ Lacked money to buy enough food for family

☐ Used food pantry or community meal program

☐ Utilities shut off

☐ Evicted from home

☐ Moved in with family or friends

☐ Furniture, car, other belongings repossessed

☐ Homeless

11a. Person A history of foster care (select one)

☐ Caregiver spent time in foster care as a child

☐ Caregiver has no history of foster care

11b. Person B history of foster care (select one)

☐ Caregiver spent time in foster care as a child

☐ Caregiver has no history of foster care

12a. Person A history of trauma (Examples: community violence, domestic violence, sexual abuse/assault, severe neglect, serious emotional and psychological abuse, physical abuse, abandonment, combat-related, accidents, death of caregiver, sudden loss, witnessing violence, disasters, etc.) (select one)

☐ Yes No

12b. Person B history of trauma (Examples: community violence, domestic violence, sexual abuse/assault, severe neglect, serious emotional and psychological abuse, physical abuse, abandonment, combat-related, accidents, death of caregiver, sudden loss, witnessing violence, disasters, etc.) (select one)

☐ Yes No

13a. Person A history of psychiatric hospitalization – past 5 years (select one)

☐ Yes No

13b. Person B history of psychiatric hospitalization – past 5 years (select one)

☐ Yes No


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