Home Visit Observation Sheet

OMB Control No.: 0970-xxxx

Expiration Date: xx/xx/20xx

A-7: 2

Home Visiting: Approaches to Father Engagement and Father’s Experiences

Pre and Post Home Visit Observation Protocol

2 Respondents per Program

10 minutes

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This information collection is voluntary. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Reports Clearance Officer (Attn: OMB/PRA 0970-XXXX), Administration for Children and Families, Department of Health and Human Services, 370 L'Enfant Promenade, S.W., Washington, D.C.

Instructions: I’d like to learn a little about the family we will visit such as their family situation and living arrangements. I have this form I need to complete which should take only a couple of minutes of your time.

Pre-Home Visit Observation

1. What is the family structure? (Married couple, unmarried/cohabiting couple, no longer in relationship)

2. Is the father a resident? (resides with child, does not reside with child)

3. What is the mother’s age?

4. What is the father’s age?

5. What is the age of the focal child?

6. What is the gender of the focal child?

7. What are the ages of the other children in the family?

8. What is the race/ethnicity of the mother?

9. What is the race/ethnicity of the father?

Post-Home Visit Observation

1. Would you describe this visit as typical? Why or why not? What are your impressions of how this visit went?