Fidelity Checklist (FC)

Fidelity Checklist
OMB CONTROL NUMBER: 0704-XXXX
OMB EXPIRATION DATE: XX/XX/XXXX
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, 0704-XXXX, is
estimated to average 2 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. Send comments
regarding the burden estimate or burden reduction suggestions to the Department of
Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding
any other provision of law, no person shall be subject to any penalty for failing to
comply with a collection of information if it does not display a currently valid OMB
control number.
Instructions: Please complete the following survey after each home visit you have. This should
only take approximately 2 minutes to complete
Please select the visit number below:

o Intake visit(s)
o Visit 1
o Visit 2
o Visit 3
o Visit 4
o Visit 5
o Visit 6
o Visit 7
o Visit 8
o Visit 9+
Page 1 of 8

Who was present and engaged during this visit?
Indicate
Indicate who
how many
Indicate their level of engagement during the
was present
were
visit:
for the visit:
present for
the visit:
Present

Number

Not at all

Somewhat

Very

Mother(s)

▢

_____

o

o

o

Father(s)

▢

_____

o

o

o

Grandparent(s)

▢

_____

o

o

o

Sibling(s)

▢

_____

o

o

o

Other

▢

_____

o

o

o

Goal setting
Yes
Goals set or reviewed during
this visit

o

No

o

Problem Solving
Yes
Problem-solving strategies
discussed during this visit

o

No

o

Were referrals to any other services made?

o Yes
Page 2 of 8

o No
Please indicate any referrals that were made during the visit:

▢
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Anger or Stress Management Class
Couples classes/support groups
EFMP
Family Readiness Group
Fatherhood classes/groups education
Infant Massage
Lending Closet
Parenting classes/support groups
Play Morning/Group
Prenatal/Pregnancy/Baby bootcamp Class
SLO
WIC

Other resource on the installation
________________________________________________

▢

Other resource off the installation

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________________________________________________
Approximately how long did the visit last?
0

15 30 45 60 75 90 105 120 135 150

Minutes

Was the visit completed as planned?

o Yes
o No
Please explain why the visit was not completed as planned. Please do not include any
personally identifiable information (PII) in your response.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Page 4 of 8

Please check the content areas covered in the visit.
Family Strengths and Protective Factors

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Concrete Support
Knowledge of Parenting and Child Development
Parental Resilience
Parenting Efficacy
Social Connections
Social and Emotional Competence of Children

Parent-Child Interactions

▢
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Communicating
Designing/Guiding
Nurturing
Responding
Supporting Learning

Development-Centered Parenting

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Attachment
Discipline

Page 5 of 8

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Health
Healthy Births
Nutrition
Safety
Sleep
Transitions/Routines

Child Development

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Cognitive
Language
Motor
Social-Emotional

Family Well-Being

▢
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Basic Essentials
Early Care and Education
Education and Employment
Mental Health and Wellness

Page 6 of 8

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Physical Health
Recreation and Enrichment
Relationships with Family and Friends

Military Family Life

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Development with a Military Lens
Geographic Transitions
Parental Absence
New to Military Life
Reuniting Post-Deployment
Transitioning to Civilian Life
Trauma and Loss

Where did you draw resources from for today's visit?

▢
▢
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Nurturing Parenting Program
Take Root Home Visitation
Other ________________________________________________

Do you have any additional comments regarding this visit? Please do not include any PII
in your response.
________________________________________________________________
Page 7 of 8

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Page 8 of 8