Healthy Start Mandatory Parent/Child Form | Jan 2020
OMB Control No. 0915-0338, Expiration Date XX/XX/202X
INFORMATION IN THIS GRAY BOX IS FOR GRANTEE USE ONLY—DO NOT UPLOAD
Name of Primary Participant: ______________________________ DOB:_________________
Name of Enrolled Child: __________________________________ DOB:________________
Name of Accompanying Adult: ____________________________ DOB:_________________
Name of Interviewer: ___________________
Names and dates of birth are included above for grantee tracking purposes only and should not be submitted to hrsa. Each person’s unique ID# should remain the same across phases and years, and should include the grantee’s org code plus a unique number. Every mandatory form should include the primary participant’s Unique ID#. the primary participant for this form is an enrolled woman (reproductive age female) with an enrolled child who is receiving postpartum or Parenting/interconception health services; OR the primary participant may be an enrolled father who has primary custody/responsibility for an enrolled child; OR another adult who has primary custody of an enrolled child. the accompanying adult participant is the primary participant’s spouse or partner, and/or the enrolled child’s co-parent. The unique IDs of the enrolled woman, the enrolled child, and any accompanying adult should all be provided below as applicable, so that these can be linked in the electronic database.
Public Burden Statement: The purpose of this data collection is to obtain consistent information across all grantees about Healthy Start and its outcomes. 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 information collection is 0915-0338 and it is valid until XX/XX/202X. This information collection is voluntary. Public reporting burden for this collection of information is estimated to average 0.5 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].
This Mandatory Parent/Child Form is to be completed with Primary Participants who have an infant or child younger than 18 months enrolled in Healthy Start.
For an enrolled child, the Primary Participant is the enrolled mother OR THE ADULT WHO HAS PRIMARY CUSTODY OF THE CHILD, including the father or another adult.
Primary Participants who have an infant or child enrolled in HS will also have completed either an initial or updated Background Information form prior to completing this parent/child form.
one parent/child form should be completed for each enrolled child.
The primary participant completes the ‘child’ section of this form. There are also two questions at the end for enrolled women only. Enrolled fathers do not complete this section, which pertains to the woman’s pregnancy with this child.
This form is completed only with primary participants who do not have a (live) child enrolled in Hs. accompanying adults do not complete this form, nor do primary participants who do not have a (live) child enrolled in hs.
this form is updated with the primary participant when the infant turns 6 months, if there is a change in primary participant/custodial parent, and/or when the infant/child exits the program.
the unique id#s of the primary participant, enrolled child and accompanying adult must all appear together on this form so that the ID#s can be linked in the database.
_______________________________________________________________________________________
GENERAL INFORMATION to be completed by staff before uploading data for this parent/child form:
Primary Participant Unique ID#: ______________________________________
[Enter as One Number: Grantee Org Code + PP + Unique ID]
Accompanying Adult (if applicable) Unique ID#: ________________
[Enter as One Number: Grantee Org Code + AA + Unique ID]
Or indicate no AA
Dates of Enrollment in Healthy Start:
Primary Participant_________________
Enrolled Child _____________
Accompanying Adult _____________
Initial completion of this form by Primary Participant:
Date of initial completion of this Parent/Child form: _____________
this form has been Updated with the primary participant following its initial completion based on [select below as applicable]:
Enrolled infant turns 6 months
Date updated: _________
Change in the child’s custody has occurred (new primary caregiver reports on own activities)
Date updated: _________
Other update (eg, annual reporting occurs with no phase change, other changes)
Date updated: _________
Specify change/reason for update: ________________
update this form when this child exits HS:
Date of child’s exit from HS services: _________
Reason for exit: ____________
primary Participant Type:
Enrolled woman (primary person receiving support is/identifies as a female)
Enrolled father (primary parent receiving support is/identifies as a male)
Other adult with primary custody of child, Specify________________
Enrolled Child Unique ID#: ________________________________________
[Enter as One Number: Grantee Org Code + EC + Unique ID THIS Child’s Unique ID#:
Child is:
Female
Male
Based on date of birth in box above, child is currently:
Less than 6 months old
6 through 12 months old
13-18 months old
This child was enrolled in HS but then died:
Within 0 to 27 days of life (neonatal):_______
28 to 364 days after birth (infant):______
12 months or older (post-infancy): _____
Additional Instructions
This form must be administered by a trained case worker or other Healthy Start grantee staff member, to ensure consistency in responding across participants and grantees when questions or misunderstandings arise. It should not be self-administered or administered by untrained staff.
If the custodial or accompanying adult changes, a new background form will need to be completed with new unique ID for that new person in order to record changes across the enrolled child’s time in HS.
If an enrolled woman completing this form is also pregnant, then she should also complete the mandatory Prenatal Form.
Items in italics are questions for or statements to the participant. Instructions to staff may be [bracketed].
___________________________________________________________________________________________
Please read the following statement to the participant:
Thank you for participating in the Healthy Start program. The purpose of these forms is to examine how well the Healthy Start program is meeting its goals of helping families improve their health and the health of their babies. This questionnaire should take about 25 minutes to complete. Any information you provide will be kept confidential. You do not have to answer any questions you do not want to, and you can end the interview at any time without any penalty or loss of benefits.
THE CHILD: Setting the Stage
In this questionnaire, we will ask questions about your enrolled child. Enrolled women will also respond to a few questions at the end about their health around the time of the child’s birth.
[Staff, if participant has more than one enrolled child under 18 months of age, say:]
We will complete a separate form for each of your babies/children. Since you have more than one child who is less than 18 months enrolled in Healthy Start, we ask you to focus only on one child at a time. We will then complete a separate questionnaire for each of your babies under 18 months old.
This section focuses on this child and his/her health.
First, I’d like to start with some general background questions about your child.
Was
your child:
Select
one of the options below.
Receiving HS services before birth (i.e., ‘born into the program’)
Part of a family enrolled for services within 30 days following child’s birth
Part of a family enrolled for services more than 30 days following child’s birth
If enrolled more than 30 days following birth, please indicate child’s age at enrollment _____________
Is this child of Hispanic or Latino/a origin?
Select one only.
Yes, of Hispanic or Latino/a origin
No, Not of Hispanic or Latino/a origin
Don't Know
Declined to answer
What is this child’s race?
Select all that apply.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Don’t know
Declined to answer
Which ONE racial classification below do you think best describes your child’s racial background?
Select one only.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
More than one race/biracial/multiracial
Other: ______________________________
Don’t know
Declined to answer
Infant Health at Birth
Next, we’re going to ask you some questions about this child’s health when he/she was born.
How many weeks pregnant were you [was the mother] when he/she was born?
[STAFF:
Please enter number of weeks. If participant does not know number of
weeks, help them calculate backwards from the baby’s original
due date to determine weeks gestation at birth.]
________weeks
Don’t know
Declined to answer
[Staff, was this child preterm (earlier than 37 weeks of pregnancy)?]
Yes
No
Unable to determine
How much did he/she weigh at birth?
______pounds, ______ounces [OR grams __________]
Don’t know
Declined to answer
[Staff: Please check appropriate box below for baby’s birthweight]:
Very low birthweight (Less than 3 pounds 5 ounces or 1500 grams)
Low birthweight (At least 3 pounds 5 ounces but less than 5 pounds 8 ounces or 2500 grams)
Normal weight range (5 pounds 8 ounces to 9 pounds 4 ounces)
High birthweight (More than 9 pounds 4 ounces or 4500 grams)
Don’t know
Declined to answer
Was this child the only baby you were [the mother was] pregnant with at the time, or was it a multiple birth, such as twins, triplets, or more?
Singleton (from a pregnancy involving just one baby)
Twins
Triplets or more
Don’t know
Declined to answer
Is there a place you or another caregiver USUALLY take this child when he or she is sick or you need advice about his or her health?
Yes
No
Don't know
Declined to answer
Where does this child USUALLY go first?
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 _________________
Don't Know
Declined to answer
DURING THE PAST 12 MONTHS, was this child EVER covered by ANY kind of health insurance or health coverage plan?
Yes, this child was covered all 12 months
Yes, but this child had a gap in coverage
No
Don’t know
Declined to answer
What kind of health insurance is your child covered by now?
Please select all that apply.
Insurance Type |
Check if Currently have |
Private health insurance from my job or the job of my husband or partner
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Private health insurance from my parents
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Private health insurance from the <State> Health Insurance Marketplace or <state website> or HealthCare.gov
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Medicaid (Title XIX) (required: state Medicaid name_______________)
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CHIP (Title XXI)
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Subsidized ACA plan (also called ‘subsidized premium or subsidized coverage through the Affordable Care Act’)
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TRICARE or other military health care
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*Indian Health Service or tribal [also check ‘no health insurance’ below]
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Other health insurance, Please tell us:______________________
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I do not have health insurance for this child now
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Don’t know
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Declined to answer
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[*Staff note: If the participant uses Indian Health Service, please indicate above. We understand that Indian Health Service does not constitute insurance, and so if a participant uses IHS, please check both the IHS and the ‘no health insurance coverage’ boxes, so that IHS can be tracked as a separate item in addition to being counted as ‘no health insurance coverage’.]
How old was this child at his/her last well-child check-up? _____________
[Staff: below is the AAP-recommended schedule of well visits for the first 18 months of life.]
First week of
1 month old
2 months old
4 months old
6 months old
9 months old
12 months old
15 months old
18 months old
Yes
No
Unable to determine
Did you [or the biological mother] EVER breast feed or pump breast milk to feed this child after delivery, even for a short period of time?
Select one response only.
Yes
No
Don’t know
Declined to answer
Is this child currently being breastfed or fed pumped milk?
Yes
No
Don’t know
Declined to answer
How many months [up till current date] was this child breastfed or fed pumped milk?
Not at all
Less than 1 month
____ Months (for mothers still breastfeeding, indicate how many months so far)
Don’t know
Declined to answer
[Staff: Was this child breastfed or fed pumped milk for first 6 months of life?]
Select one response only.
Yes
Not yet. Child is currently less than 6 months old and is currently being breastfed.
No, child was not breastfed for the first 6 months of life
Don’t know
Unable to determine
[Staff: if mother is currently breastfeeding, be sure to update questions 17 and 18 once she has stopped so that the total amount of time is captured.]
[For children 12 months and older, check ‘not applicable’ in each box and move to next section.]
[For babies less than 12 months old, say: ]
Next we’re going to ask some questions about sleeping.
Good sleep habits are important to your baby’s physical health and emotional well-being. An important part of safe sleep is the place where your baby sleeps and his or her sleeping position, the kind of crib or bed, and type of mattress.
In which one position do you most often lay your baby down to sleep now?
Select ONE answer.
On his or her side
On his or her back
On his or her stomach
Not applicable [child is 12 months or older]
In the past 2 weeks, how often has your baby slept alone in his or her own crib or bed? [Note: That is, the baby is the only person in the crib or bed; the baby’s crib or bed may be in the parent(s) room]
Always
Often
Sometimes
Rarely
Never
Not applicable [child is 12 months or older]
19a. Is your baby’s crib free of pillows, extra bedding, stuffed animals?
Yes
No
Don’t know
Declined to answer
Not applicable [child 12 months or older]
Next, we have a couple questions about your child’s home life. These are the last questions that focus on the child. After that, we will ask enrolled women a few additional questions about the pregnancy.
During the past week, how many days did you or other family members read or look at books with your (this) child? [Staff: Reading includes books with words or pictures and/or textures for the baby to see and feel but NOT books read by an audio tape, record, CD, or computer.]
Did not read to the baby in the past week
1-2 days in the past week
3 days in the past week
4-7 days in the past week
Don’t know
Declined to answer
Next, we have a question about home relationships that the baby/child experiences. Would you describe your partner or the father of this child as:
Involved and supportive of me and the child
Involved with child but not supportive of me
Involved and supportive of me but not the child
Not regularly involved/supportive in either mine or the child’s life
Don’t know
ENROLLED WOMAN pregnancy health
[Staff: Enrolled fathers and other adults with primary custodial responsibility for the child DO NOT COMPLETE THIS SECTION.]
[Staff, continue with enrolled woman and say:]
In this final section, I’d like to ask a couple questions about your pregnancy with this child.
Select all that apply.
Yes, within the first 3 weeks following delivery
Yes, between 4 weeks and 6 weeks following delivery
Yes, between 7 weeks and 8 weeks following delivery
Yes, between 9 and 12 weeks following delivery [Note: if participant responds, “Yes, after 12 weeks,” explain that it is not considered a postpartum checkup after 12 weeks]
Not yet, but one is already scheduled for the following date: _____________
Not yet, but let’s work on making an appointment
No, I did not have a postpartum visit with an obstetric care provider within 12 weeks of the birth of my most recent child
Don’t know
Declined to answer
[Staff: If mother is within 12 weeks of delivery but has not yet had a postpartum visit, please Update question 23 as appropriate once she has either had her postpartum visit or is past 12 weeks postpartum.]
These next two questions ask about tobacco and nicotine use during the last three months of your pregnancy with this child.
In the last 3 months of your pregnancy with this child, how many cigarettes did you smoke on an average day? A pack has 20 cigarettes.
41 cigarettes or more
21 to 40 cigarettes
11 to 20 cigarettes
6 to 10 cigarettes
1 to 5 cigarettes
Less than 1 cigarette
I didn’t smoke then
Don’t know
Declined to answer
During the last 3 months of your pregnancy with this child, on average, how often did you use other tobacco or nicotine products?
E-cigarettes (electronic cigarettes) and other electronic nicotine vaping products (such as vape pens, e-hookahs, hookah pens, e-cigars, e-pipes) are battery-powered devices that use nicotine liquid rather than tobacco leaves, and produce vapor instead of smoke.
A hookah is a water pipe used to smoke tobacco. It is not the same as an e-hookah or hookah pen.
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More than once a day |
Once a day
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2-6 days a week |
1 day a week or less |
Not at all |
Don’t Know |
Declined to Answer |
E-cigarettes or other electronic nicotine products |
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Hookah |
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Chewing tobacco, snuff, snus, or dip |
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Cigars, cigarillos, or little filtered cigars |
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | JSI;HRSA |
| File Modified | 0000-00-00 |
| File Created | 2021-01-14 |