M22-THEO

MIECHV Baby’s Age 36 Months

Index Parent

Name of Home Visitor:

Home Visiting Program:	Early Head Start	Healthy Families Oregon

Parent ID #:

Name of Index Parent:

Date data gathered: / / 20

Pregnancy:

A. Enter in M22 Survey: Mother Currently Pregnant? Yes → Go to Question A1.	No

A1. Enter in THEO Pregnancy Module: If Pregnant, Expected Delivery Date: / / 20

Questions about Family:

Which members of your (index parent’s) family are currently serving or formerly served in the military – active or reserve? (Check all that apply.)

Index parent	Father of child

Index parent’s spouse	Mother of child

Index parent’s parent(s)	None

Questions about Index Parent:

2.	Index Parent’s Additional Children?	DOB	/ / 20

(Born after Parent’s Enrollment &	DOB	/ / 20

not previously recorded)

3.	Marital Status:

Single/Never Married	Separated/Divorced/Widowed

Married	Not Married but living together with partner

4.	Index Parent’s Current Health Insurance status:

Not insured	State Children’s Insurance Program (SCHIP)

Private or employer’s insurance	TRICARE or other military health care

OHP/Medicaid	Other insurance:

CAWEM/CAWEM Plus

5.	In the past 6 months, were there any days when you were not covered by health insurance?

Yes	No

M22-THEO

MIECHV Baby’s Age 36 Months, continued

Index Parent	ID#

6.	Educational Attainment:

Currently enrolled in middle school	Some college/training

Currently enrolled in high school	Associate’s degree

Less than high school diploma	Bachelor’s degree or higher

High school diploma/GED	Other:

Technical training or certification

7.	Current Education/Training status:

Enrolled student/trainee (full or part-time)	Not enrolled

8.	Current Employment status

Employed full time	Employed part time	Not employed

9.	Does anyone living in the household have a history of substance abuse or need substance abuse treatment?

Yes	No	Unknown

10. Does anyone living in the household use tobacco products?

Yes	No	Unknown

11.	Has anyone living in the household had a history of child abuse or neglect & involvement with child welfare services either as a child or as an adult?

Yes	No	Unknown

12.	Has a doctor or health professional ever told you (index parent) that your child/any of your children has any developmental delay or developmental disability?

Yes	No	Unknown

13.	Is there anyone in your household (including adults and children) who had/has a low student achievement level?

Yes	No

M22-THEO

MIECHV Baby’s Age 36 Months, continued

Index Parent ID#

14. Last month, what was your (parent’s/guardian’s) gross TOTAL HOUSEHOLD income from employment and any benefits you receive? All information will be kept private and will not affect any services you (parent) are now getting.

Include all of these income sources:

Paycheck or money from a job	Benefits such as TANF or SSI	Money from a business, fees, dividends, or rental income	Child support or alimony

Social security, workers’ compensation, disability, veteran benefits or pensions	Unemployment benefits

$250 or less

$251 - $500

$501 - $750

$751 - $1,000

$1,001 - $1,250

$1,251 - $1,500

$1,501 - $1,750

$1,751 - $2,000

$2,001 - $2,250

$2,251 - $2,500

$2,501 - $2,750

$2,751 - $3,000

$3,001 or more

Don’t Know

14a. Number of adults in household:	Adults

14b. Number of children in household: Children

15.	Current Housing Status:

You own or share your home, condominium or apartment

You rent or share your home or apartment

You live in public housing

You live with a parent or family member

You have a different living arrangement, but are not homeless

You are homeless and sharing housing

You are homeless and living in an emergency or transition shelter

You are homeless and living in some other arrangement

M22-THEO

MIECHV Baby’s Age 36 Months, continued

Index Parent	ID#

16.	What are the 2 most recent dates that a validated Parent-Child Interaction Tool (PICCOLO for EHS; CHEERS Check-In (CCI) Tool for HFA) was done with the Parent and Home Visitor?

a. Date of PCI: / / 20

b. Date of PCI: / / 20

Tool to Complete at 36 Months

17.	Relationship Assessment Tool completed (with mother)?

Yes, completed → Date tool completed:	/ / 20 → Go to Question 16a.

16a. If Yes, result of Relationship Assessment Tool:

Score of 20 or higher → Go to Question 16b.

Score of 19 or lower

16b. If a Score of 20 or higher, did you give referral information?

Yes

No, client declined or is not ready for a referral and/or services

No, an earlier referral is still in process or the client is currently receiving services

No, other reason

No, not completed → Go to Question 16c.

16c. If No, reason why Relationship Assessment Tool not completed:

Concern previously identified

Other