Direct assessments of caregivers - MIHOPE-K

OMB No.: 0970-0402

E xpiration Date: 11/30/2021

Mother and Infant Home Visiting Program Evaluation

MIHOPE-K

DIRECT ASSESSMENTS OF CAREGIVERS: VISIT PROTOCOL

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0970-0402. The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

July 2019

Client MPR ID: | | | | | | | | |

Date of interview: | | | / | | | / | | | | |

Month Day Year

FIELD INTERVIEWER ID: | | | | | | | | |

Note: At this point respondents will have already heard the OMB introduction language. See SSA Attachment 2 – MIHOPE – K Direct assessments of children for this language.

SAY TO THE CAREGIVER: We’re almost done, but I have a quick memory activity for us to do. I will need your full attention during this activity, but it is quick. (ANSWER ANY QUESTIONS.)SAY TO CHILD: Thank you for playing these games with me. I’m going to play a quick game with your (mom/caregiver). I have (a sticker sheet/some crayons) for you to play with while I do this game with her. Do you want to play with them now? You can also keep them after I leave.

MIHOPE DIGIT SPAN ASSESSMENT

ADMINISTER BACKWARD DIGIT SPAN

Items in this section are from the backward Digit Span assessment.

SAY TO CAREGIVER: Great! We are all done with this activity. Before we finish, I have a couple of questions for you.

P11. [CHILD] is getting pretty big. Even so, does [he/she] ever want you to just sit and hold [him/her]?

YES 1 P11a

NO 0

DON’T KNOW D

REFUSED R

P11=YES

P11a. When this occurs, for about how many minutes do you just sit and hold [him/her] in a typical day?

|___|___|___| MINUTES A DAY

(1-180)

DON’T KNOW D

REFUSED R

SAY TO CAREGIVER: Great! We are all done with the activities.