Maternal Infant Health Program

Michigan Department of Community Health

Maternal Infant Health Program

Infant Risk Identifier – Infant Component

1 / IDENTIFICATION/ DEMOGRAPHIC INFO

MOTHER’S IDENTIFICATION

Medicaid ID Number: Screening Date (MM/DD/YYYY): / /

Middle

First Name Initial Last Name

Social Security Number: - - Date of birth? (MM/DD/YYYY) / /

Mother’s age at time of birth:

What do you identify as your race/ethnic background? (check all that apply, question is optional)

Asian Native Hawaiian or other Pacific Islander

American Indian or Alaska Native White/Caucasian

Black or African American Arabic

Hispanic/Latino REFUSED

INFANT’S IDENTIFICATION

Medicaid ID Number:

Middle

First Name Initial Last Name

Social Security Number: - - Infant’s date of birth? (MM/DD/YYYY) / /

REFUSED

Infant’s age at time of Risk Identifier

Less than 3 weeks 3 to 4 weeks

1 month 0 days to 2 months 30 days 3 months 0 days to 4 months 30 days

5 months 0 days to 7 months 30 days 8 months 0 days to 10 months 30 days

11 months 0 days to 12 months 30 days 13 months 0 days to 15 months 30 days

What do you identify as the infant’s race/ ethnic background?

Asian Native Hawaiian or other Pacific Islander

American Indian or Alaska Native White/Caucasian

Black or African American Arabic

Hispanic/Latino REFUSED

REFUSED

2 / FAMILY SUPPORT, PARENTING AND CHILD CARE SECTION

Are you currently attending school? Yes No

Do you currently work outside the home? Yes No

If Yes, how many hours do you work in a typical week? Hours

Are planning to begin work or school in the near future? Yes No

Who cares or will care for your baby while you are at work/ school?: Don’t know

Do you have any problems finding or paying for reliable child care? Yes No

Would you describe the father of this baby as:

Involved in the baby’s life and supportive of the baby *Aware of the baby bit not involved

Involved in the baby’s life but not supportive Unaware he is the fathert

REFUSED

Is there someone in your life who you can count on to help you with your baby? Yes No

Who do you count on for support? (check all that apply)

Partner and/or the baby’s father Other relative(s)

Parent(s) Friend(s)/Neighbor(s)

Other child or children Clergy and/or people at my place of worship

Other:

Who spends the most time with your baby?

I do My partner/ the baby’s father

My parent(s) or the father’s parent(s) My other children

My friend(s)/ neighbor(s) Daycare staff

Are you a first-time parent? Yes No

How many children? What are their ages?

3 / BIRTH HEALTH STATUS

What was your baby’s expected due date? (MM/DD/YYYY) / / REFUSED

What was your baby’s gestational age at birth? Weeks Note: Calculate from the expected due date and actual date of birth information if unknown

How much did your baby weight at birth? Pounds Ounces Unknown

What was your baby’s height (length) at birth? Inches unknown

How much does your baby weigh now? Pounds Ounces unknown

What is your baby’s height (length) now? Inches unknown

Was this baby delivered by vaginal birth or C-section? vaginal C-section

Did your baby stay in the hospital after you went home? Yes No

How long did your baby stay in the hospital? Days

What was the reason for the stay?

Since coming home from the hospital, has your baby been seen by a doctor for problems he/she had in the hospital?? Yes No If yes, please explain:

Has your baby had any new health problems since coming home from the hospital? Yes No

If yes, please explain:

Has your baby been diagnosed with any birth defects (congenital anomalies, etc.)? Yes No

If yes, please explain:

Were you told that the baby needed an additional hearing test? Yes No If yes, explain:

Did the baby have the additional test? Yes No If Yes, what was the result?

If No, why not?

Didn’t have transportation Didn’t know who to call

Didn’t understand what you needed to do Physician/ medical care provider said to wait

Didn’t feel it was important Other:

Were you told that the baby needed any follow-up to the heel poke (Newborn Screening) test done at the hospital?

Yes No If yes:

Did the follow up testing or appointment occur Yes No

If Yes, please explain:

What was the result?

If No, why not?

Didn’t have transportation Didn’t know who to call

Didn’t understand what you needed to do Physician/ medical care provider said to wait

Didn’t feel it was important Other:

4 / INFANT HEALTH CARE

How old was your baby when he/she was first seen by their family doctor (sometimes called a medical home)?

weeks

My baby hasn’t been seen by a family doctor and has an appointment.

My baby hasn’t been seen by a family doctor and we don’t have an appointment.

REFUSED

Has your baby been seen by a healthcare provider other than the one the family doctor (medical home) mentioned above? Yes No

If Yes, Who?

Doctor’s office Emergency room

Health clinic Other:

Readicare facility REFUSED

Hospital

What was the reason?

Here is a list of problems some women can have getting for their infants. For each item, please let us know if it has been true for you at any time since the birth of your baby. [READ LIST]

(check all that applies)

I couldn't get an appointment when I wanted one

I couldn’t find a doctor or clinic that accepted Medicaid

It is hard to communicate with the doctor or clinic staff

It is hard to understand the information the doctor or clinic give to me

I haven’t had enough money or insurance to pay for my visits

I’ve had no way to get to the clinic or doctor's office

I couldn't take time off from work

I’ve had no one to take care of my other children

I have had too many other things going on in my life

Other. Please tell us

None

REFUSED

Is your baby currently enrolled in Children’s Special Health Services (CSHCS)? Yes No

Did your baby receive a Hepatitis B immunization before leaving the hospital? Yes No Don’t Know

Is your baby up to date on immunizations? Yes No Don’t Know

5 / INFANT SAFETY

Where does your baby usually sleep? Crib In bed with someone On floor In a car seat

Other:

How often does your newborn sleep in the same bed with you or someone else? Never Sometimes

Most or every night

In what position do you lie your infant down to sleep? Front Back Side

Do you have a car seat for the baby? Yes No

Do you live in or regularly visit a house that was built before 1978 or that has peeling or chipped paint? Yes No

What type of water is used for drinking in your household? City water Bottled water Well water

Don’t know

Do you smoke around the baby (the same room, same house, same car)? Yes No

Is there a smoker in the home or someone that regularly visits that smokes? Yes No

Is there someone in the home or someone who regularly visits that gets drunk around your baby? Yes No

Does anyone in your home own a gun or other weapon? Yes No

Is the gun loaded? Yes No

Is the ammunition kept with or near the gun? Yes No

Is the weapon locked up? Yes No

Have you considered getting rid of the gun/weapon for the safety of your child? Yes No

Are you a first time parent? Yes No

Have you ever been involved with Children’s Protective Services with any of your children? Yes No Refused

If yes, what was the result? (Check all that apply)

Out of home placement Court- mandated placement

Intensive at-home services Nothing, but talking with them

Other—Specify: Refused

Are you afraid of that you or anyone in your household who may hurt your baby? Yes No REFUSED If yes. Who?

Father of the baby Partner

Roommate Self

Caretaker Family member - Specify:

Refused Other - Specify:

6 / INFANT FEEDING AND NUTRITION

How do you primarily feed your infant?

Breastfeeding Formula

Solid Foods Other:

Any concerns? Please Explain:

Have you ever breastfed your baby? Yes No

Are you breastfeeding now? Yes No

If yes, how many times every 24 hours?

If you are returning to work/school, do you have a plan to help you continue to breastfeed? Yes No

Have you ever bottle fed your baby? Yes No

Has your baby ever received formula? Yes No

If Yes:

At what age did your baby start taking formula?

What is the name of your baby’s formula?

How often does your baby eat?

How many ounces per feeding?

Do you hold your baby while you feed him/her a bottle? Yes No

Does your baby receive anything else in the bottle besides formula or breast milk? Yes No

If yes, What?

Cereal Sugar water Soda Kool-Aid/ fruit drinks

Juice Herbal Teas Other:

At what age do you plan to introduce solid foods to your baby? months

Is your baby currently enrolled in WIC? Yes No

When was the last WIC appointment? Last week This week Last month Two months ago

Three months ago Have not been to WIC yet

When is your next WIC appointment? This week Next week Next month Two months from

now Three months from now Do not have an appointment

In the past month, how often has your child gone to bed with a bottle of juice, formula, milk or other liquid besides water?

Often Sometimes Rarely Never

At what age do you plan to first take your baby to the dentist? Years

Do you currently have any concerns or worries about how to care for your child’s teeth? Yes No

INSTRUCTIONS: Please proceed to the developmental section corresponding to the infant/ toddler’s age, as outlined in the tables below:

IF INFANT/ TODDLER AGE IS / Bright Futures
Less than 3 weeks / BF0*
3 to 4 weeks / BF1*
1 month 0 days to 2 months 30 days / BF2*
3 months 0 days to 4 months 30 days / BF4**
5 months 0 days to 7 months 30 days / BF6**
8 months 0 days to 10 months 30 days / BF9**
11 months 0 days to 12 months 30 days / BF 12**
13 months 0 days to 15 months 30 days / BF 15**

* Infants with more than one “not yet” under the age of two months needs to be reevaluated in 2 weeks. Use the ASQ-3 if the infant is at least one month old. If less than one month, use the Bright Futures questions.

** After 2 months of age, 2-3 Bright Futures questions have to be checked “not yet” for that age to trigger an ASQ and/or ASQ-SE at the completion of this risk identifier.

BF0 GENERAL INFANT DEVELOPMENT – Newborn (Less than 3 weeks)

1. Does your baby respond to sound (for example, by blinking, crying, quieting, changing respiration, or showing a startle response)?