M20

MIECHV Baby’s Age 30 Months

Index Child

Name of Home Visitor:

Home Visiting Program:	Early Head Start	Healthy Families Oregon

Child ID #:

Name of Index Child:

Name of Index Parent:

Date data gathered: / / 20

1.	In the past 6 months, have you (parent) taken your (index) child to the emergency department for an injury?

Yes (If yes, please note the reason and date)	No

NOTE: ER visits for illness should not be noted

Reason:	Date: / / (month/day/year)

Reason:	Date: / / (month/day/year)

Reason:	Date: / / (month/day/year)

Has your child had the following well-child visit?

24 months:	Yes	No

3.	During a typical week, how many days do you (and/or a family member) read, tell stories and/or sing songs to your child?

0 – Not at all 1 2 3 4 5 6 7 – Every day