Nurturing Families Network- Home Visiting
Baseline Data Form
Hartford Sites
The purpose of this questionnaire is to collect social demographic information about families participating in the Nurturing Families Network Home Visiting program. This questionnaire should be filled out by the Family Support Worker/Family Assessment Worker based on her knowledge of the family and on information contained in the participant's records. It is important that if an FSW is not sure about an answer that she make the necessary inquiries to answer the question accurately. Check only one answer unless otherwise directed.
The Baseline should be completed within the first month the family enters the program. If the family enrolls prenatally, Part A should be left blank and sent in separately when the baby is born.
Family ID# ______
Date Completed: ____/_____/_____
FSW’s Name: ______
Which Administration?
Entry 6 Month1 Year2 Year
3 Year4 Year5 Year
PART A. TARGET CHILD INFORMATION
1. Is this a multiple birth? [Entry Only]
No Yes (If yes, please fill out an additional Section A for each child)
2. Child’s Date of Birth: _____/_____/_____
3. Sex of Child: [Entry Only]
Male Female
4. Is this child the mother’s first child? [Entry Only]
Yes No Not known
If no, how many children has the mother had? ______
5. Did the mother use alcohol, tobacco, or other drugs during this pregnancy? [Entry Only]
A. Cigarettes No Yes Don’t know
B. Alcohol No Yes Don’t know
C. Illicit Drugs No Yes Don’t know
If yes, which ones? ______
6. Baby’s Gestational Age: ______weeks [Entry Only]
7. Baby’s Birth Weight: ______lbs. ______oz. [Entry Only]
8. Was the child born with any medical problems? [Entry Only]
Yes No Don’t Know
10a. If yes, describe ______
9. Does the child currently have any of the following medical conditions (PLEASE CHECK ALL THAT APPLY)
ADHD Allergies Lead poisoning
Asthma Anemia Learning disability
Other (please describe ______)
10. Does the target child have a pediatrician?
Yes No Don’t Know
11. Who has legal custody of the child? (PLEASE CHECK ALL THAT APPLY)
Mother Father
Maternal grandmother Other (please specify ______)
12. Who will be the primary caregivers for the child? (PLEASE CHECK ALL THAT APPLY)
Mother Father Maternal grandmother
Maternal grandfather Paternal grandfather Paternal grandmother
Mother’s sibling Father’s sibling Mother’s extended family
Father’s extended family Mother’s partner Other Please specify:
______
PARTB. MOTHER’S INFORMATION
1. Mother’s Date of Birth: _____/_____/_____
2. Mother’s current marital status:
Single, never married Widowed Separated Married Divorced Not known
3. Mother’s current relation to father of target child
Partner/boyfriend Married Married, but separated Not known Divorced No relationship
Widowed Father is deceased
4. Is the mother’s current partner the father of the target child?
No Yes
Not known Not applicable (Doesn’t currently have a partner)
4a. If no, will the partner be involved as a primary figure in the child’s life?
No Yes --- If yes, please fill out section E: Partner Information
Not known Not applicable (No partner or partner is father of the baby)
5. If the mother has a boyfriend/husband, how satisfied does she appear to be with that relationship? [Mother’s point of view]
Very Satisfied Somewhat Satisfied Rarely Satisfied
Not Satisfied At All Don't Know
Not Applicable ( Mother does not have a boyfriend/ husband)
6. On average, how many relatives does the mother see in a week? ______
6a. In general, how supportive do the mother’s relatives appear to be? [Mother’s point of view]
Very Supportive Somewhat Supportive
Rarely Supportive Not Supportive At All
Don't Know Not Applicable (Mother doesn’t see relatives during the week)
7. How many friends does the mother see regularly? ______
7a. How satisfied does the mother appear to be with those friendships? [Mother’s point of view]
Very Satisfied Somewhat Satisfied Rarely Satisfied
Not Satisfied At All Don't Know
Not Applicable ( Mother does not have a boyfriend/ husband)
8. How many people can the mother count on in times of need? ______
9. Please describe how supportive the following people are to the mother: [FSWs point of view]
VerySomewhatRarelyNot at all Don’t know
Partner (if applicable)
Maternal grandmother
Maternal grandfather
Paternal grandmother
Paternal grandfather
Friends
10. What race/ethnicity does the mother consider herself to be? [Entry Only]
White Asian African-American Native American Hispanic
Multi-Racial(please specify ______)
Other (please specify ______)
Not known
11. In what country was the mother born? [Entry Only]
United States Puerto Rico Mexico
Jamaica West Indian/Caribbean IslandsHaiti
Other (please specify ______)
Not known
12. What language is the mother most comfortable speaking?
English Spanish English and Spanish Other (specify______)
13. Mother’s highest grade completed in school
No formal schooling Eighth grade or less
Less than high school graduation High school degree
General Equivalency Degree (GED) Post secondary vocational/training certificate
Some College Education College Degree
Graduate Work Not known
14. Was the mother employed during the year prior to her pregnancy? [Entry Only]
No, and mother was not seeking work No, but the mother was seeking work
Yes Not known
14a. If yes, please describe mother’s prior paid employment status:
Was employed in regular full-time job Was employed in regular, part-time job
Worked occasionally Worked more than one job at a time
Not known Not applicable (Didn’t work)
On average, how many hours per week did the mother work? ______
15. Is the mother currently employed?
No
No, but the mother is seeking work
Yes (describe type of work______)
Yes, under the table (describe type of work______)
Yes, but currently on maternity leave
Not known
15a. If no, has the mother ever been employed?
Yes, paid labor
Yes, under the table
Yes, both
No
Not known
15b. If yes, please describe the mother’s current paid employment status:
Regular, full-time job (35 or more hours per week)
Regular, part-time job
Occasional work
Working more than one job
Not applicable (not working)
16. If the mother is employed, does the target child attend daycare?
Yes, enrolled in licensed child care center
Yes, enrolled in licensed home daycare
Yes, enrolled in unlicensed home day care
Yes, family member watches child on a regular basis
Yes, friend watches child on a regular basis
No, not enrolled
No, but mother is currently seeking child care
Not applicable (mother is not working)
17. If mother is employed, what is the mother’s average annual UNASSISTED* income:
* Unassisted income should not include money received from government assistance
Under $5,000 $5,000 to $9,999 $10,000 to $14,999 $15,000 to $24,999 $25,000 to $34,999 $35,000 and over
Not Known Not applicable (Not employed)
18. Please check all other sources of the mother’s income (besides formal jobs) (PLEASE CHECK ALL THAT APPLY)
Income from under the table jobs (i.e. babysitting)
Illegal income (i.e. drug dealing, scamming, running numbers, stolen goods, etc.)
Income from family members (not including child support from father of baby)
Income from friends
Government assistance
Other (please describe ______)
No additional income
Not Known
19. Please check types of government assistance mother receives (PLEASE CHECK ALL THAT APPLY)
TANF General Assistance
SSI (Supplemental Security Income) SSDI (Social Security Disability)
Food StampsWIC
Section 8 Housing Unemployment compensation
Worker’s compensationNo government assistance
Other (please specify ______) Not Known
20. If the mother does not live with the father of the target child, does she receive child support from him?
No
Yes, informal support (indicate the average mother receives per month $______)
Yes, formal support (indicate the average mother receives per month $______)
Not Known
Not applicable (mother lives with father)
21. Is the mother currently enrolled in school?
NoYesNot known
21b. If yes, what type of school is the mother currently attending?
High schoolVocationalGED program Other (please specify ______) College (2 or 4 year)
21a. If no, was the mother enrolled in school prior to her pregnancy? [Entry Only]
NoYesNot known
22. Does the mother currently have any of the following conditions?
1. Financial difficulties YES NO Don’t know
2. Social isolation YES NO Don’t know
3. Learning disability YES NO Don’t know
23. Does the mother currently have any of the following medical conditions (PLEASE CHECK ALL THAT APPLY)
Diabetes Asthma Allergies
Other (please describe ______)
24. Has the mother ever experienced any psychological conditions?
Ever experienced?1=No
2= Yes
3= Not Known / Currently experiencing?
1=No
2= Yes
3= Not Known / Ever received treatment?
1=No
2= Yes
4= Not Known / Currently in treatment?
1=No
2= Yes
3= Not Known
Clinical Depression
Other psychological conditions (please describe ______)
25. Is the mother currently experiencing any partner violence or any violence in the home?
NoYes, I know for certainYes, I suspect soNot known
25a. If yes, what is the perpetrators’ relationship to mother? (CHECK ALL THAT APPLY)
Lives in home with mother?
Partner
Mother
Father
Other family member (please specify ______)
Other non family member (please specify ______)
26. Has the mother been hit, slapped, kicked, or otherwise physically hurt by a partner within the past year?
No
Yes, I know for certain (By current or past partner? Current Past)
Yes, I suspect so (By current or past partner? Current Past)
Not knownNot applicable (has not had a partner in the last year)
27. Which of the following conditions characterize the mother’s relationship with her current partner?
(CHECK ALL THAT APPLY)
No abuse is noticeablePartner is physically abusive
Partner is emotionally or verbally abusiveMother is sexually abused by partner
Not knownNot applicable (does not have a partner)
28. Has the mother pursued any of the following interventions because of spousal/partner abuse within the past year?
No, none was necessaryNo, even though incident(s) of abuse occurred
Spoken to a social worker/counselorStayed in a shelter at least one night
Took part in a Domestic Violence Program Other (please specify ______)
Not knownNot applicable (does not have a partner)
29. Has the mother ever been arrested or convicted of a crime?
NoYesNot known
29a. If yes, please complete the following information for all arrests and convictions
(Please check off arrested, convicted and incarcerated categories- please provide actual numbers of convictions)
Arrested?Convicted?How many Incarcerated due
times convicted?to conviction?
1. Domestic violence______
2. DWI/DUI______
3. Failure to appear______
4. Risk of injury______
5. Vandalism______
6. Burglary______
7. Sexual assault/rape______
8. Murder______
9. Weapons possession______
10. Arson______
11. Assault______
12. Parole/probation violations______
13. Drug possession______
14. Drug trafficking______
15. Shoplifting______
16. Prostitution______
17. Forgery______
18. Contempt of court______
19. Other: ______
30. What is the mother’s current criminal status? (PLEASE CHECK ALL THAT APPLY)
Incarcerated (describe reason ______)
Arrested, awaiting trial
On probation
On parole
Living in a halfway house
Other (please describe ______)
None of the above
Not Known
31. Has the mother ever been incarcerated?
Yes No Not known
31a. If yes, how many times? ______
31b. List length of incarceration for each time incarcerated
1. _____ years ______months
2. _____ years ______months
3. _____ years ______months
4. _____ years ______months
5. _____ years ______months
32. Please describe your knowledge of the mother’s experience with alcohol:
History of Abuse?1. No
2. Yes
3. Not Known / Do you suspect current abuse?
1. No
2. Yes
3. Not Known / Has the mother ever received treatment for alcohol abuse?
1. No
2. Yes
3. Not Known
99. Not applicable / Is the mother currently receiving treatment for alcohol abuse?
1. No
2. Yes
3. Not Known
99. Not applicable / Any household members currently abuse alcohol?
1. No
2. Yes
3. Not Known
(please specify relationship of user to mother)
Alcohol
33. Please describe your knowledge of the mother’s experience with the following substances. PLEASE CODE ALL CATEGORIES
History of abuse?1. No
2. Yes
3. Not Known / Do you suspect current use?
1. No
2. Yes
3. Not Known / Has the mother ever received treatment?
1. No
2. Yes
3. Not Known
99. Not applicable / Is the mother currently receiving treatment?
1. No
2. Yes
3. Not Known
99. Not applicable / Any household members currently use?
1. No
2. Yes
3. Not Known
(please specify relationship of user to mother)
1. Marijuana
2. Sedatives (i.e. “downers”, Quaaludes, reds, etc.)
3. Stimulants (i.e. “uppers”, speed, crystal meth., etc.)
4. Heroin/Methadone
5. Cocaine/crack
6. Opiates (i.e. morphine, percodan, etc.)
7. Hallucinogens (i.e. PCPs, shrooms, etc.)
8. Inhalants
9. Ecstacy, Special K, Rohypnol, GHB
PART C: FATHER’S INFORMATION
Fill out this section of the questionnaire even if the father is not the primary figure in the baby’s life.
1. Father’s Date of Birth: ______/______/______
2. What race/ethnicity does the father consider himself to be? [Entry Only]
WhiteAsianAfrican-AmericanNative American
HispanicMulti-Racial(specify ______)
Other (specify ______)Not known
3. In what country was the father born? [Entry Only]
United States Puerto Rico Mexico
Jamaica West Indian/Caribbean Islands Haiti
Other (please specify ______)
Not Known
4. What language is the father most comfortable speaking? [Entry Only]
English Spanish English and Spanish
Other (specify ______) Not known
5. Father’s highest grade completed in school (CHECK ONLY ONE)
No formal schooling Eighth grade or less
Less than high school graduation High school degree
General Equivalency Degree (GED) Post secondary vocational/training certificate
Some College Education College Degree
Graduate Work Not known
6. Is the father currently employed?
NoNo, but the father is seeking work
Yes (describe type of work______)
Yes, under the table (describe type of work______)
Not known
6a. If no, has the father ever been employed?
Yes, paid labor
Yes, under the table
Yes, both
No
Not known
6a. If yes, please describe the father’s current paid employment status:
Regular, full-time job (35 or more hours per week)
Regular, part-time job
Occasional work
Working more than one job
Not applicable (not working)
7. If employed, what is the father’s average annual UNASSISTED* income:
* Unassisted income should not include money received from government assistance
Under $5,000$5,000 to $9,999$10,000 to $14,999
$15,000 to $24,999 $25,000 to $34,999 $35,000 and over
Not KnownNot applicable (Not employed)
8. Please check all other sources of the father’s income (besides formal jobs) (PLEASE CHECK ALL THAT APPLY)
Income from under the table jobs (i.e. painting, bartending, etc.)
Illegal income (i.e. drug dealing, scamming, running numbers, stolen goods, etc.)
Income from family members
Income from friends
Government assistance
Other (please describe ______)
No additional income
Not Known
9. Please check types of government assistance father receives (PLEASE CHECK ALL THAT APPLY)
TANF General Assistance
SSI (Supplemental Security Income) SSDI (Social Security Disability)
Food StampsWIC
Section 8 Housing Unemployment compensation
Worker’s compensationNo government assistance
Other (please specify ______) Not Known
10. Is the father currently enrolled in school?
NoYesNot known
10a. If yes, what type of school is the father currently attending?
High school Vocational GED program
Other (please specify ______) College (2 or 4 year)
Not applicable (not in school)
11. Does the father currently have any of the following conditions?
1. Financial difficulties YES NO Don’t know
2. Social isolation YES NO Don’t know
3. Learning disability YES NO Don’t know
12. Has the father ever experienced any psychological conditions?
Ever experienced?1=No
2= Yes
3= Not Known / Currently experiencing?
1=No
2= Yes
3= Not Known / Ever received treatment?
1=No
2= Yes, in the past
3= Yes, currently receiving treatment
4= Not Known
Clinical Depression
Other psychological conditions (please describe ______)
13. To what extent is the father a primary caregiver for the baby?
Very involvedSomewhat involvedSees the child occasionally
Very rarely involvedDoes not see the baby at all
Not applicable (prenatal family)
14. How often is the child contacted by his/her father?
Daily Weekly Monthly
Less than monthlyNever
15. Has the father established legal paternity for the target child?
NoYesNot known
16. Does the father have any other children other than the target child?
NoYesNot known
11a. If yes, how many? ______
17. Has the father ever been arrested or convicted of a crime?
NoYesNot known
17a. If yes, please complete the following information for all arrests and convictions
(Please check off arrested, convicted and incarcerated categories- please provide actual numbers of convictions)
Arrested?Convicted?How many Incarcerated due
times convicted?to conviction?
1. Domestic violence______
2. DWI/DUI______
3. Failure to appear______
4. Risk of injury______
5. Vandalism______
6. Burglary______
7. Sexual assault/rape______
8. Murder______
9. Weapons possession______
10. Arson______
11. Assault______
12. Parole/probation violations______
13. Drug possession______
14. Drug trafficking______
15. Shoplifting______
16. Prostitution______
17. Forgery______
18. Contempt of court______
19. Other: ______
18. What is the father’s current criminal status? (PLEASE CHECK ALL THAT APPLY)
Incarcerated (describe reason ______)
Arrested, awaiting trial
On probation
On parole
Living in a halfway house
Other (please describe ______)
None of the above
Not Known
19. Has the father ever been incarcerated?
Yes No Not known
19a. If yes, how many times? ______
19b. List length of incarceration for each time incarcerated
1. _____ years ______months
2. _____ years ______months
3. _____ years ______months
4. _____ years ______months
5. _____ years ______months
20. Please describe your knowledge of the father’s experience with alcohol:
History of Abuse?1. No
2. Yes
3. Not Known / Do you suspect current abuse?
1. No
2. Yes
3. Not Known / Has the father ever received treatment for alcohol abuse?
1. No
2. Yes
3. Not Known
99. Not applicable / Is the father currently receiving treatment for alcohol abuse?
1. No
2. Yes
3. Not Known
99. Not applicable / Any household members currently abuse alcohol?
1. No
2. Yes
3. Not Known
(please specify relationship of user to father)
Alcohol
21. Please describe your knowledge of the father’s experience with the following substances? PLEASE CODE ALL CATEGORIES