B6 3Ps_Interconception_Parenting Form_revised

Child Health Status

Child Safety

Child Insurance / Access to Care / Medical Home

Reproductive Life Planning

Social Determinants of Health

Neighborhood and Community

Medical Home / Access to Care

Maternal Health

National Healthy Start Evaluation and Quality Assurance

Please read the following statement to the participant: Thank you for taking time to complete this interview. Any information you provide will be kept confidential to the extent allowed by law. You do not have to answer any question you do not want to, and you can end the interview at any time.

I am going to start off by asking some questions about your child/children.

STAFF:

If any child is deceased, you will need to be aware of the sensitivity of the mother, and potentially delay completing this screening tool until a more appropriate time.

STAFF: Questions 2 - 15 ask about the participants’ baby or babies.

If participant has lost her baby/babies, ask question 2, and go to question 16 [skip questions 2.1- 15]. Ask questions 3 – 15 ONLY if participant’s baby/babies are living.

2. Did you ever breast feed or pump breast milk to feed your child/children after delivery, even for a short period of time?

3. Please tell me the number of times you or a family member read to your child during the past week. Reading includes books with words or pictures but not books read by an audio tape, record, CD, or computer.

4. Your child’s development is important. I have some questions about your child’s development. Please let me know if you or anyone else has concerns about the following.

Good sleep habits are important to your child’s physical health and emotional well-being. An important part of safe sleep is the place where your child sleeps, his sleeping position, the kind of crib or bed, and type of mattress.

STAFF: Ask questions 5, 6, 7 about safe sleep for children less than 12 months old only.

5. In which one position do you most often lie your baby/babies down to sleep now?

6. In the past 2 weeks, how often has your new child/have your new children slept alone in his or her/their own crib or bed? Would you say always, often, sometimes, rarely, or never?

7. Please tell us how your child/children most often slept in the past 2 weeks.
STAFF: PLEASE READ each sleeping location to participant and select a response for each sleeping location for each child.

8. When your child/children rides in a car, truck, or van, how often does he or she ride in an infant car seat? Would you say always, often, sometimes, rarely, or never?

9. Has your child / have your children been tested for lead?

STAFF: If any has been tested for lead, go to question 9.1, otherwise go to question 10.

9.1 Did your child’s lead levels concern the doctor?

A personal doctor or nurse is a health professional who knows your child well and is familiar with your child’s health history. This can be a general doctor, a pediatrician, a specialist doctor, a nurse practitioner, or a physician’s assistant.

12. Do you have one or more persons you think of as your child’s personal doctor or nurse?

13. Is there a place that your child USUALLY goes for care when he or she is sick or when you or another caregiver need advice about your child’s health?

If child has/children have one or more usual place for care, go to question 13.1

If child has/children have no usual place, don’t know, or declined to answer, go to question 14.

13.1. What kind of place does your child go to most often when he or she is sick or you need advice about his or her health? Is it a doctor’s office, emergency room, hospital outpatient department, clinic or some other place?

14. Please tell me what kind of health insurance your child has:

15. When was your child's last visit to a doctor, nurse, or other health provider for a well-child check-up?

15.1 Did your child receive age-appropriate vaccines during this visit?

16. Are you pregnant now?

17. Do you plan to have any more children?

17.1 How many children would you like to have?

17.2 Would you like to become pregnant in the 12 months?

17.3 How long would you like to wait until you become pregnant?

18. Are you currently using any form of contraception or birth control to either prevent pregnancy or prevent sexually transmitted infections?

18.1. Are you satisfied with your birth control method?

Now, I would like to ask a few questions to provide us with some background information.

19. Are you currently married or living with a partner, separated, divorced, widowed, or were you never married?

20. Are you currently…

21. What is your yearly total household income before taxes? Include your income, your husband’s or partner’s income, and any other income you may have received. All information will be kept private and will not affect any services you are now getting.

22. How many people are supported by this income?

23. The next question is about whether you were able to afford the food you need. Which of these statements best describes the food situation in your household IN THE PAST 12 MONTHS?

Now I would like to ask you about your current housing.

24. What is the zip code where you live?

25. Do you own a place, rent a place, live in public housing, stay with a family member, or are you homeless?

25.1 Is this place a regular place to stay? By “a regular place to stay” I am referring to a house, apartment, room, or other housing where you could stay 30 days in a row or more in the same place.

25.2 Do you share housing with someone, live in an emergency or transition shelter, or have some other living arrangement?

26. Do you have any housing concerns?

26.1 What issues concern you about your housing situation?

27. I am going to read a list of services. Please tell me if you are receiving the service, if you have applied for the service and are waiting to find out if you will receive services, if you need services, or if you don’t need services. I want to remind you that I ask these questions so we can provide the best services for your family.

28. Do you currently have an open case with Child Protective Services?

29. Now I am going to ask you a few questions about your neighborhood or community. Please tell me if you agree or disagree with each of these statements.

30. How often do you feel safe in your community or neighborhood? Would you say never, sometimes, usually, or always?

32. How often do you get together or talk with family, friends or neighbors? Would you say daily, weekly, monthly, a few times a year, less than once a year or never?

Select one only.

A personal doctor or nurse is a health professional who knows you well and is familiar with your health history. This can be a general doctor, a specialist doctor, a nurse practitioner, or a physician’s assistant.

33. Do you have one or more persons you think of as your personal doctor or nurse?

34.1. What kind of place do you go to most often when you are sick or you need advice about your health? Is it a doctor’s office, emergency room, hospital outpatient department, clinic or some other place?

35. Please tell me what kind of health insurance you have:

36. During the past 12 months, did you see a doctor, nurse, or other health care worker for preventive medical care, such as a physical or well visit checkup?

37. In general, would you say that your overall health is excellent, very good, good, fair, or poor?

38. In general, would you say that your mental and emotional health is excellent, very good, good, fair, or poor?

39.1 How tall are you without shoes?

39.2 How much do you weigh?

40. Did you have a postpartum checkup after your child was born?

40.1. Approximately how many weeks postpartum did you have your postpartum checkup?

41. Has a healthcare provider ever told you that you have any of the following medical conditions?

B6. 3Ps_Interconception_Parenting Form_revised

Redesigned Preconception, Pregnancy and Parenting (3P's) Information Forms 3-6

OMB: 0915-0338

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0915-0338 can be found here:

Document [doc]

Download: doc | pdf

Healthy Start Interconception/Parenting Screening Tool | August 2016 | Singleton and Multiples

OMB #: 0915-0338

Expiration Date: XX/XX/XXXX

Name: _________________________________________________________

Completed by: _______________________ Date of Administration: ___________________

This tool should be completed with women and children in the period beyond the immediate postpartum phase. This phase refers to the time period from age 6 months to two years after delivery. During this phase, Healthy Start works with mothers, children and families to strengthen family resilience, creating a foundation for optimal child health and development.

Administer this tool at 6 months after delivery, 1 year after delivery and just prior to the completion of the program at 2 years (to ensure child and Mom are ready to leave program with supports in place).

The questions and answer choices were selected based on factors that may impact a woman’s health or pregnancy outcomes. The information provided by the participant through this screening tool will help Healthy Start identify each participant’s unique needs and ensure that she is connected to the appropriate support services.

Please read the questions to the participant. Only read the responses to the participant if the instructions for any question tell you to do so.

When there is more than one baby born at a single birth (twins, triplets, etc.), the mother should answer about each child. Please remember that Child 1 should be the child that was born 1^st.Child 2 should be the child that was born 2nd. Child 3 should be the child that was born 3rd. And Child 4 should be the child that was born 4th. This applies to all questions regarding the children.

Please tell me the dates of birth for any children older than 6 months and younger than 24 months old.

	Date of Birth	Don’t know	Declined to answer
Child 1	__ / __ / ____
Child 2	__ / __ / ____
Child 3	__ / __ / ____
Child 4	__ / __ / ____

1.1 How would you describe this child’s/these children’s health?

Select one only for each child.

	Yes	No	Declined to answer
Child 1
Child 2
Child 3
Child 4

STAFF: If any children were breastfed, go to question 2.1

If participant responded “no” or declined to answer for all children, go to question 3.

2.1 How many days, weeks or months did you breastfeed or pump breast milk for your child/children?

STAFF: Please write in the number provided by the participant and enter number of days, weeks OR months for each child.

	Number of days, weeks or months (record number and circle appropriate time period)	Still/Currently breastfeeding	Don’t know	Declined to answer
Child 1	Days Weeks ________ Months
Child 2	Days Weeks ________ Months
Child 3	Days Weeks ________ Months
Child 4	Days Weeks ________ Months

STAFF: Record the total number of days, from 0 days (no days) to 7 days (everyday).

	Times per week (Record the number)	Don’t know	Declined to answer
Child 1
Child 2
Child 3
Child 4

STAFF: Please ask each question below and select a response for each question.

Q#	Are you or anyone else concerned about:	Yes	No	Don’t know	Declined to answer
4.1	How your child talks, makes speech sounds, or understands?
4.2	How your child uses his or her arms or legs?
4.3	How your child uses his or her hands or fingers to do things?
4.4	How your child is learning to do things for himself or herself?
4.5	How your child behaves or gets along with others?

FOLLOW UP

Provided information/education about child development
Provided information/education about parenting

Date ______________

Provided counseling about parenting

Date ______________

Referred to:

Parent Information Resource Center
Parent support group
Parenting classes
Other: Please specify ___________________

Date ______________

STAFF: Please read responses to participant. Select one response only for each child.

	On his or her side	On his or her back	On his or her stomach	Declined to answer
Child 1
Child 2
Child 3
Child 4

Select one response only for each child.

Responses	Always	Often	Sometimes	Rarely	Never	Don’t know	Declined to answer
Child 1
Child 2
Child 3
Child 4

Sleeping Location	Child 1	Child 2	Child 3	Child 4
In a crib, bassinet, or pack and play
On a twin or larger mattress or bed
On a couch, sofa, or armchair
In an infant car seat or swing
With a blanket
With toys, cushions, or pillows, including nursing pillows
With crib bumper pads (mesh or non-mesh
In a sleeping sack or wearable blanket

Select one response only for each child.

	Always	Often	Sometimes	Rarely	Never	Don’t know	Declined to answer
Child 1
Child 2
Child 3
Child 4

Select one response only for each child

	Yes	No	Don’t know	Declined to answer
Child 1
Child 2
Child 3
Child 4

	Yes	No	Don’t know	Declined to answer
Child 1
Child 2
Child 3
Child 4

10. On average, how many hours per day is your child/are your children in the same room or vehicle with another person who is smoking?

Please enter number of hours child is in the same room or vehicle with another person who is smoking, or select one response only for each child.

	Number of hours per day	Child spends less than one hour per day in a room or vehicle with somebody who is smoking	Child is never in a room or vehicle with someone who is smoking	Declined to answer
Child 1
Child 2
Child 3
Child 4

11. Do you keep guns in your home?

Select one only.

Yes
No
Don’t know
Declined to answer

FOLLOW UP

Provided information/education about:

Safe sleep positions
Car seat safety (installation, placement in car, rear facing, weight and height limits)
Lead poisoning
Effects of tobacco exposure
Gun Safety

Date ______________

Provided:

Crib
Car seat
Lead testing

Date ______________

Referred for:

Crib
Crib assembly
Car seat
Car seat installation
Car seat installment education

Name of local organization(s) providing services_____________________________________________

Primary care provider for lead testing______________________________________________________

Date ______________

Select one response only for each child.

	Yes, one person	Yes, more than one person	No	Don’t Know	Declined to Answer
Child 1
Child 2
Child 3
Child 4

Select one response only for each child.

	Yes	No	There is more than one place	Don’t Know	Declined to Answer
Child 1
Child 2
Child 3
Child 4

Select one response only for each child.

	Child 1	Child 2	Child 3	Child 4
Doctor’s Office
Hospital Emergency Room
Hospital Outpatient Department
Clinic or Health Center
Retail Store Clinic or “Minute Clinic”
School (Nurse’s Office, Athletic Trainer’s Office)
Some other place

Select all that apply for each child.

	Child 1	Child 2	Child 3	Child 4
Private health insurance through my job, or the job of my husband, partner or parents
Insurance purchased directly from an insurance company
Medicaid, Medical Assistance, or any kind of government assistance plan for those with low incomes or a disability
TRICARE or other military health care
Indian Health Service
Other, specify
No insurance
Don’t know
Declined to answer

Select one response only for each child.

	Date of child’s last visit	Don’t know	Declined to answer
Child 1	__ / __ / ____
Child 2	__ / __ / ____
Child 3	__ / __ / ____
Child 4	__ / __ / ____

Select one response only for each child.

	Yes	No	Don’t know	Declined to answer
Child 1
Child 2
Child 3
Child 4

FOLLOW UP

Provided information/education about:

Importance of regular visits to primary care provider
Importance of receiving vaccines on schedule

Medicaid eligibility

Date ______________

Enrolled in Medicaid

Date ______________

Provided vaccines:

Hepatitis B
Diphtheria, Tetanus, Pertussis (DTaP)
Haemophilus influenzae Type B (Hib)
Pneumococcal
Inactivated Poliovirus (IPV)
Influenza (Flu)
Measles, Mumps, Rubella (MMR)
Varicella
Hepatitis A

Date _____________

Referred for:

Medicaid enrollment
Primary Care Provider
Pediatrician

Date_______________

Select one only.

Yes (Skip questions 17 – 58, go to questions 59 - 59.1, then complete Prenatal Screening Tool)
No (Go to question 17)
Don’t know (Go to question 17)
Declined to answer (Go to question 17)

We have a few questions about your thoughts about having more children. This information will help us support you in making decisions about whether and when you might have more children.

Select one only.

Yes (Go to question 17.1)
No (Go to question 18)
Unable to get pregnant (Go to question 19)
Don’t know (Go to question 18)
Declined to answer (Go to question 18)

STAFF: Please enter the number of children.

_____________Children

Don’t know
Declined to answer

Select one only.

Yes (Go to question 18)
No (Go to question 18)
I am okay either way (Go to question 17.3)
Don’t know (Go to question 18)
Declined to answer (Go to question 18)

Select one only.

1 year -17 months
18 months to 2 years
More than 2 years
Don’t know
Declined to answer

Select one only’

Yes (Go to question 18.1)
No (Go to question 19)
Declined to answer (Go to question 19)

Select one only.

Yes
No
Don’t know
Declined to answer

FOLLOW UP

Provided information/education about birth control or family planning/birth spacing.

Date ___________

Provided counseling about family planning
Provided birth control

Referred for birth control
- Primary Care Provider
- Planned Parenthood
- Other: please specify ______________________

Date ___________

Select one only.

Married or living with a partner
Separated
Divorced
Widowed
Never married
Declined to answer

STAFF: Please read responses out loud to participant.

Select only one.

Employed for wages
Self-employed
Out of work for 1 year or more
Out of work for less than 1 year
A Homemaker
A Student
Retired
Unable to work

Staff: DO NOT READ OUT LOUD

Declined to answer

Select one only.

Less than $10,000
$10,000 to less than $15,000
$15,000 to less than $20,000
$20,000 to less than $25,000
$25,000 to less than $35,000
$35,000 to less than $50,000
$50,000 or more
Don’t know
Declined to answer

STAFF: Enter number of people.

_____ Adults age 18 or older

_____ Children age 18 or younger

Don’t know
Declined to answer

STAFF: Please read responses to participant.
Select one only.

We could always afford to eat good nutritious meals.
We could always afford enough to eat but not always the kinds of food we should eat.
Sometimes we could not afford enough to eat.
Often we could not afford enough to eat.
Declined to answer

--------------

Don’t know
Declined to answer

Select one only.

Owns or shares own home, condominium or apartment (Go to question 25.1)
Rents or shares own home or apartment (Go to question 25.1)
Lives in public housing (receives rental assistance, such as Section 8) (Go to question 25.1)
Lives with parent or family member (Go to question 25.1)
Homeless (Go to question 25.2)
Some other arrangement (Please specify): ____________________ (Go to question 25.1)
Declined to answer (Go to question 25.2)

Select one only.

Yes (Go to question 26)
No (Go to question 26)
Don’t know (Go to question 26)
Declined to answer (Go to question 26)

Select one only.

Homeless and shares housing with someone
Lives in an emergency or transition shelter
Some other arrangement (please specify): ________________
Declined to answer

Select one only.

Yes (Go to question 26.1)
No (Go to question 27)
Don’t know (Go to question 27)
Declined to answer (Go to question 7)

Select all that apply.

Received an eviction notice
Non-payment of rent or past due rent
Unable to pay future rent because lost housing subsidy, job, or other income source
Non-payment of utilities or utility shut-off
Housekeeping concerns (failure to maintain cleanliness of the unit)
Housing is or will be condemned
Friend or family member being evicted or threatened with eviction
Threat of abuse by partner, family member, or other
Being discharged or service is being terminated
Personal conflict with others
Other health or safety concerns
Other lease violation(s) (please describe):_____________________
Other (please describe):__________________________________________________
Don’t know
Declined to answer

STAFF: Please read each of the following support services to participant and enter an answer for each service.

Support Service	Receiving	Have applied for	Need	Do not need	Not applicable	Declined to answer
Childcare voucher
Emergency Aid to the Elderly, Disabled, and Children (EAEDC)
Food stamps/SNAP
Heating assistance
Immigration services
Legal services
Public housing
Section 8 Voucher
Social Security Disability Insurance (SSDI)
Social Security Income (SSI)
Transitional Aid to Families with Dependent Children (TAFDC)
Temporary Assistance to Needy Families (TANF)
Tribal Housing
Utility Assistance
Nutrition Supplemental Program for Women Infants and Children (WIC)
Other (please specify)

Select one only.

Yes
No
Don’t know
Declined to answer

FOLLOW UP

Provided information/education about:

Childcare voucher
Emergency Aid to the Elderly, Disabled, and Children (EAEDC)
Food stamps/SNAP
Heating assistance
Immigration services
Legal services
Public housing
Section 8 Voucher
Social Security Disability Insurance (SSDI)
Social Security Income (SSI)
Transitional Aid to Families with Dependent Children (TAFDC)
Temporary Assistance to Needy Families (TANF)
Tribal Housing
Utility Assistance
Nutrition Supplemental Program for Women Infants and Children (WIC)
Other (please specify)

Date _____________

Referral made for:

Childcare voucher
Emergency Aid to the Elderly, Disabled, and Children (EAEDC)
Food stamps/SNAP
Heating assistance
Immigration services
Legal services
Public housing
Section 8 Voucher
Social Security Disability Insurance (SSDI)
Social Security Income (SSI)
Transitional Aid to Families with Dependent Children (TAFDC)
Temporary Assistance to Needy Families (TANF)
Tribal Housing
Utility Assistance
Nutrition Supplemental Program for Women Infants and Children (WIC)
Other (please specify)

Date _____________

STAFF: Please read each of the following statements to participant and enter an answer for each statement.

Q#	Statement	Agree	Disagree	Don’t know	Declined to answer
29.1	People in this neighborhood or community help each other out
29.2	We watch out for each other’s children in this neighborhood or community
29.3	If my child was outside playing and got hurt or scared, there are adults nearby who I trust to help my child.
29.4	I feel comfortable letting my child play outside alone.

Select one only.

Never
Sometimes
Usually
Always
Declined to answer

31. How often do you participate in school, community, or neighborhood activities? Would you say daily, weekly, monthly, a few times a year, less than once a year, or never?
Select one only.

Daily
Weekly
Monthly
A few times a year
Less than once a year
Never
Declined to answer

Daily
Weekly
Monthly
A few times a year
Less than once a year
Never
Declined to answer

Select one only.

Yes, one person
Yes, more than one person
No
Don’t know (Go to question 34)
Declined to answer (Go to question 34)

34. Is there a place that you USUALLY go for care when you are sick or need advice about your health?

Yes (Go to question 34.1)
No (Go to question 35)
There is more than one place (go to question 34.1)
Don't know (Go to question 34)
Declined to answer (Go to question 34)

Select one only.

Doctor’s Office
Hospital Emergency Room
Hospital Outpatient Department
Clinic or Health Center

Retail Store Clinic or “Minute Clinic”

School (Nurse’s Office, Athletic Trainer’s Office)
Some other place

Select all that apply.

Private health insurance through my job, or the job of my husband, partner or parents
Insurance purchased directly from an insurance company
Medicaid, Medical Assistance, or any kind of government assistance plan for those with low incomes or a disability
TRICARE or other military health care
Indian Health Service
Other, specify: ___________________
No insurance
Don’t know
Declined to answer

Select one only.

Yes
No
Don't know
Declined to Answer

FOLLOW UP

Provided information/education about:

Importance of regular preventative care
Importance of having a regular provider/medical home
Medicaid eligibility
Birth spacing

Date ______________

Provided Service:

Enrolled in Medicaid

Date _____________

Referred for:

Medicaid enrollment
OB/GYN provider
Primary Care Provider

Date _____________

Select one only.

Excellent
Very good
Good
Fair
Poor
Don’t know
Declined to answer

Select one only.

Excellent
Very good
Good
Fair
Poor
Don’t know
Declined to answer

Please enter height in feet and inches.

_________Feet ________ Inches

Don’t Know
Declined to answer

Please enter weight in pounds.

_________ Pounds

Don’t Know

Declined to answer

Select one only.

Yes (Go to question 40.1)
No (Go to question 41)
Declined to answer (Go to question 41)

_______________Number of Weeks

Excellent

Very Good

Child is deceased

Child 1

Child 2

Child 3

Child 4

Select one response only for each question. If participant has a condition, please as if they currently have this condition.

Asthma (breathing problems/wheezing)

Yes
No
Don’t know
Declined to answer