Enrollment and services data: Case enrollment data (Appendix F)

RPG CROSS-SITE EVALUATION CASE ENROLLMENT AND CLOSURE FIELDS

Data collected at enrollment into RPG

Case Enrollment

1. Case ID: [enter 6-digit alpha-numeric id]

2. RPG Enrollment Date: [enter date]

3. Referral Source: Select one.

□ Child welfare agency (public or private)

□ Substance use treatment provider

□ Mental or behavioral health provider

□ Hospital or clinic

□ Family support service agency

□ Indian/Native American Tribally Designated Organization

□ Self-referral/walk-in

□ Court

□ Other (specify)

□ Don’t know

3a. Was the grantee the referring organization? Select one.

□ Yes □ No □ Don’t know

4. Study assignment: Select one.

□ Treatment group □ Comparison group

5. Have any members of this case been previously enrolled in your RPG Project? Select one.

□ Yes □ No □ Don’t know

Individual enrollment

Ask of each individual enrolled

6. Individual ID: [enter 6-digit alpha-numeric id]

7. RPG Enrollment Date: [enter date]

Provide only for those added after initial case enrollment

8. Sex: Select one.

□ Male □ Female

9. Person Type: Select one.

□ Adult □ Child

10. Date of Birth (or due date for unborn child): [enter date]

10a. Is this a due date for an unborn child? Select one.

□ Yes □ No

11. Race: Select all that apply.

□ American Indian or Alaska Native

□ Asian

□ Black or African American

□ White

□ Native Hawaiian or Other Pacific Islander

12. Ethnicity: Select one.

□ Hispanic or Latino □ Not Hispanic or Latino

13. Primary language spoken at home: Select all that apply.

□ English

□ Spanish

□ Other (specify)

Ask of each child enrolled

14. What is the child's current primary type of residence? Select one.

□ Private residence

□ Treatment facility

□ Correctional facility/prison

□ Homeless/shelter

□ Group home

□ Other (specify)

□ Don’t know

15. Who are the primary adults in the household that the child lives with? Select all that apply.

Skip Q15 if answer to Q14 is “Group home”

□ Biological mother

□ Biological father

□ Other relative

□ Non-relative foster parent

□ Other (specify)

□ Don’t know

16. Has the child lived in the same residence for the past 30 days? Select one.

□ Yes □ No □ Don’t know

17. Is the child receiving Medicaid? Select one.

□ Yes □ No □ Don’t know

Ask of each adult enrolled

18. Highest Education Level: Select one.

□ Up to 8th grade

□ Some high school

□ High school diploma/GED

□ Some vocational/technical education

□ Vocational/technical diploma

□ Some college

□ Associate’s degree

□ Bachelor’s degree

□ Graduate-level schooling or degree

19. Employment Status: Select one.

□ Full-time employment

□ Part-time employment

□ Self-employed

□ Not employed but looking for work

□ Not employed and not looking for work, or unable to work

20. Relationship Status: Select one.

□ Never married □ Married □ Divorced/widowed/separated

20a. Do you have a romantic partner that you live with all or most of the time? Select one.

Only respond to Q20a if answer to Q20 is “Never married” or “Divorced/widowed/separated”

□ Yes □ No □ Don’t know

20b. Do you live with your spouse all or most of the time? Select one.

Only respond to Q20b if answer to Q20 is “Married”

□ Yes □ No □ Don’t know

21. In the past month, which sources of income have you had? Select all that apply.

□ Wages/salary

□ Public assistance (TANF, WIC, Food stamps/SNAP)

□ Retirement/pension/spousal survivor’s benefits

□ Disability/SSI

□ Unemployment benefits

□ Child support

□ Support from other individuals

□ Child’s benefits (SSI, survivor’s benefits)

□ Other (specify)

□ None

21a. In the past month, which income source was the largest? Select one.

□ Wages/salary

□ Public assistance (TANF, WIC, Food stamps/SNAP)

□ Retirement/pension/spousal survivor’s benefits

□ Disability/SSI

□ Unemployment benefits

□ Child support

□ Support from other individuals

□ Child’s benefits (SSI, survivor’s benefits)

□ Other (specify)

□ None

Family Member Relationships

22. Select Focal Child: Select one from list of children in case.

23. Relationship to Focal Child: Select one.

□ Self

□ Biological parent

□ Adoptive/pre-adoptive parent

□ Step-parent by marriage

□ Non-relative foster parent

□ Grandparent

□ Aunt/uncle

□ Parent’s partner

□ Biological sibling (including half sibling)

□ Adopted sibling

□ Step-sibling by marriage

□ Cousin

□ Other (specify)

24. Does the Focal Child live with other children in the RPG Case? Select one.

□ All of the children

□ Some of the children

□ None of the children

25. Select Child Well-Being Reporter: Select one.

[List of adults in case] □ Not in case □ No one has had care of child for 30 days

26. Select Recovery Domain Adult: Select one.

[List of adults in case] □ Not in case/don’t know

27. Select Family Functioning Adult: Select one from list of adults in case.

Data collection at exit from RPG

Case Closure

28. RPG Case Closure Date: [enter date]

29. Primary reason for case closure: Select one.

□ Successfully completed RPG program □ Family moved out of area □ Unable to locate □ Excessive missed appointments/unresponsive

□ Family declined further participation □ Transferred to another service provider □ Miscarriage or fetal/child death □ Parental death

□ Child entered out-of-home placement □ Incarceration □ Drug use (ongoing or relapse) □ Other program noncompliance □ Other (specify)

Closure Residence Update

This section updates information collected at enrollment from Questions 14, 15, 16, 17, and 24.

30. Primary reason for case closure: Select one.

□ Private residence □ Treatment facility □ Correctional facility/prison

□ Homeless/shelter □ Group home

□ Other (specify) □ Don’t know

31. Who are the primary adults in the household that the child lives with? Select all that apply.

Skip Q31 if answer to Q30 is “Group home”

□ Biological mother

□ Biological father

□ Other relative

□ Non-relative foster parent

□ Other (specify)

□ Don’t know

32. Has the child lived in the same residence for the past 30 days? Select one.

□ Yes

□ No

□ Don’t know

33. Does the focal child live with other children in the case? Select one.

□ Yes

□ No

□ Don’t know

Revisit Child Well-Being Reporter

This section updates who will be reporting on the child well-being instruments at exit.

34. Select Child Well-Being Reporter: Select one.

[List of adults in case]

□ Not applicable

□ No one has had care of child for 30 days

Unborn Child Update

35. Has [individual ID of unborn child] been born? Select one.

 Yes

 No

 Don’t know

35a. Is the mother still pregnant with [individual ID of unborn child]? Select one.

Only respond to 35a if answer to 35 is “No”

 Yes

 No

 Don’t know

Only ask the remaining questions if the child has been born (Q35 = Yes).

35b. Child’s date of birth: [enter date]

35c. Child’s sex: Select one.

 Male

 Female

35d. Child’s birth weight: Select one.

 Normal (5 pounds 8 ounces [2500 grams] or more)  Don’t know

 Low (3 pounds 5 ounces [1500 grams] to 5 pounds 7.99 ounces [2499 grams])

 Very low (less than 3 pounds 5 ounces [1500 grams])

35e. Was the child born prematurely (less than 37 weeks gestation)? Select one.

 Yes

 No

 Don’t know

35f. Did the child spend time in the Neonatal Intensive Care Unit (NICU)? Select one.

 Yes

 No

 Don’t know

35g. Has the child been given a diagnosis of one or more of the following conditions related to substance exposure? Select all that apply.

 Neonatal abstinence syndrome

 Fetal alcohol syndrome disorder

 Neither

 Don’t know

35h. Was the child exposed prenatally to opiates? Select one.

Only respond to Q35h if answer to Q35g is “Neonatal abstinence syndrome”

 Yes

 No

 Don’t know

35i. Was the mother receiving supervised MAT during her pregnancy? Select one.
Only respond to Q35i if answer to Q35h is “Yes”

 Yes

 No

 Don’t know

1. Date of Service [enter date]

2. Length of service interaction [enter length in minutes]

3. Case members in attendance [Select all that apply from list of members in the case]

4. Location of service: Select one.

• Client’s place of residence

• Residential treatment facility

• Phone

• Other location

5. Service provider [Select from list of grantee’s individuals providing services to families enrolled in RPG]

6. Service Approach: Select one.

• Service with individual family

• Service with multiple families

7. Service Type: Select one.

• Case management or service coordination

• Support group or workshop

• Therapy or counseling

• Parenting training/home visiting program

• Mentoring

• Screening or assessment

• Medication assisted treatment

• Medical care or appointment

• Employment training

• Academic education (child or adult)

• Housing

• Transportation

• Court or legal

• Financial or material supports (such as vouchers or stipends)

• Child care

• Other services

8. Model or Program Name [Select all that apply from list of grantee’s program models, if applicable]

9. Service Focus Select all that apply.

• Parenting skills

• Child care

• Family activities

• Visit facilitation

• Adult SUD

• Discharge or recovery planning

• Youth SUD prevention

• Medication assisted treatment

• Personal development and life skills

• Behavior management

• Mental health treatment

• Trauma processing

• Family group decision-making or planning

• Safety planning

• Financial planning

• Employment training

• Academic education (child or adult)

• Health education

• Medical care or appointment

• Housing

• Transportation

• Financial or material supports (such as vouchers or stipends)

• Needs assessment

• Child developmental screening

• Evaluation data collection

• Dealing with family crisis

• Court or legal

• Referrals

• Other

10. Referral Type Select all that apply.

Only respond if “Referrals” is selected in Q9

• SUD treatment

• Therapy or counseling

• Parenting skills training

• Home visiting program

• Housing

• Academic education services

• Life skills development

• Early intervention services

• Employment training

• Job placement services

• Legal services

• Medical/health care

• Other

11. Did the client exhibit any of the following behaviors during the service interaction? Select all that apply.

• Client arrived to the session on time

• Client demonstrated understanding of the information being presented

• Client stayed focused during the service interaction

• Client participated in the session and asked questions if needed

• Client took an active part in the setting of goals

• Client demonstrated they trusted the service provider

• Other (Specify)

• None of the above

12. Why do you think the client(s) was/were not fully engaged? Select all that apply.

Only respond to Q12 if answer to Q11 is “somewhat engaged” or “not engaged”

• Client is distracted or upset about life events (i.e., a sick child, pending child welfare case, housing instability, etc.)

• Client is tired or not feeling well

• Client drug use or withdrawal

• Time constraints

• Client did not see the value in the content and/or activities presented in the session

• Presence of other individuals interfered with session activities

• Disagreement between group members

• Difficult for client to concentrate in service encounter space (i.e., outside noise, crowded space, frequent interruptions, etc.)

• Other (Specify)

• None of the above

NOT TO BE USED FOR DATA COLLECTION