Free ForwardHealth Child Care Coordination Family Questionnaire, F-1118 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1118 (02/09)

STATE OF WISCONSIN

FORWARDHEALTH

CHILD CARE COORDINATION FAMILY QUESTIONNAIRE
Instructions: Type or print clearly. Refer to the Family Questionnaire Completion Instructions, F-1118A. Refer to the key at the end of the form for symbol descriptions. Elements in bold indicate initial screen questions. SECTION I -- GENERAL INFORMATION 1. Name -- Mother (Last, First, Middle Initial) 2. Address -- Mother (Street, City, State, and ZIP Code)

3. Date of Birth -- Mother

4. Age -- Mother
< 18 years = (70) 18-20 years = (15)

5. Mother's Member Identification Number

6. Telephone Number -- Home No telephone or telephone is often disconnected = (15)

7. How can we contact you?

8. Are other agency staff visiting your home? If yes, list if known. 9. Name -- Infant



Yes



No

10. Gender -- Infant Female Male

11. Birth Weight
If very low birth weight < 3.3 lbs. (1500 grams) = (70) If low birth weight < 5.5 lbs. (2500 grams) = (30) If birth weight > 10 lbs. (4540 grams) = (10)

12. Date of Birth

If pre-term (gestational age < 37 weeks) = (70)

13. Name -- HMO

14. Name -- Primary Care Doctor / Clinic
If none or unable to answer = (10)

SECTION II -- EMPLOYMENT 1. Are you employed? No Yes If yes, what is your occupation? 3. What shift? (Days, Evenings, Nights)

2. If you are employed, how many hours do you usually work in a week?

4. Do you feel your child care arrangements are safe and nurturing? No = (15) Yes 6. What was the last grade you finished?
8th grade or less = (40) > 8 grade but < 12th grade = (15)
th

5. If returning to work / school, when will you go back?

7. What are your sources of income? (Check all that apply.) Parents Unemployment Benefits Job Child Support Payments Partner / Spouse ts Other Points (Subtotal) Continued

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FAMILY QUESTIONNAIRE F-1118 (02/09)

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SECTION III -- FAMILY FUNCTIONING 1. Are you married or single? Married Single (Includes Never Married, Separated, Divorced, Widowed) 3. Do you read English? Very well A little = (10) Not at all = (15) 2. Do you speak English? Very well A little = (10) Not at all = (15) 4. If of school age now, are you enrolled and do you attend school regularly? No = (10) Yes I am working on GED or have completed it I have dropped out = (10) 6. How many children do you have?

5. Have you in the past, or are you currently, receiving special or exceptional education services? No Yes = (10)

If first child = (10) If > 4 children = (40) If > 2 children and mother is < 18 = (40)

7. Within the last 12 months, have any of your children been taken away from you? No Yes = (40) If yes, how many? _____

8. Where do you live? House / Mobile Home Apartment Mobile Home With friends = (10) With other family members = (10) Homeless (including shelter, hotel / motel) = (70) Other (Specify) ________________________ 10. Where you live now, do you have the following? Running water? Hot water? Working appliances (stove, refrigerator)? Working bathroom / bathing facilities? Working smoke detector? Working fire extinguisher? Each "No" = (5) Yes Yes Yes Yes Yes Yes No No No No No No

9. Who is currently living in your home? (Name, Age, Relationship)

Total points ______

11. Is there chipping paint inside / outside your home? No Yes = (10) 13. Do you think you will need to move in the next 12 months? No Yes 15. What do you think of your neighborhood? It's a good place to live. It's an okay place to live. It's a bad place to live. 17. What is the worst thing about your neighborhood?

12. How many times have you moved in the last year?

> 2 times = (20)

14. How long have you been living in the present neighborhood?

16. What is the best thing about your neighborhood?

18. In the past two years, has your neighborhood become
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A better place to live. Stayed the same. A bad place to live. Points (Subtotal) Continued

FAMILY QUESTIONNAIRE F-1118 (02/09)

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SECTION III -- FAMILY FUNCTIONING (Continued) 19. Do your children have a safe play are both inside and outside the home? No = (5) Yes

20. If not at home, where else can they play? (Check all that apply.) Relatives Park Community Center

Nowhere = (15) School Playground Other _________________ 21. Have you witnessed acts of violence in your neighborhood? (If so, describe these acts and the impressions they had on you.)

22. Does your family own an automobile? No Yes

23. If yes, what is the condition of the automobile? Good Average Below Average

24. If you do not have an automobile, how do you get around? Get a ride from friends / relatives Use public transportation Walk Other __________________________________________________________________ 26. If you use a car, does everyone use car seats or seat belts? Always Sometimes Never = (5) Explain

25. How often do you have problems getting transportation? Never Occasionally Most of the time = (10)

SECTION IV -- HEALTH 1. Where do you go for your regular health care (e.g., checkups, shots)? Family Doctor / Primary Care Provider / Clinic Emergency Room Other 2. Have any of your children been hospitalized in the past six months? No Yes = (10) If yes, for what type of problem(s)?

3. Have your children between 6 months and 6 years of age been tested for lead poisoning? No = (5) Yes Don't know = (5) Not applicable (Skip to Element 6) 5. If the results require follow-up, has this occurred? No = (5) Yes

4. If yes, have you received the results? No = (5) Yes

6. Do you have a record of your child's immunizations?
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No = (5) Yes Points (Subtotal) Continued

FAMILY QUESTIONNAIRE F-1118 (02/09)

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SECTION IV -- HEALTH (Continued) 7. If your child(ren) are 3 years or older, are they seeing a dentist? No = (5) Yes Not applicable 8. How many months pregnant were you when you started seeing a medical provider (doctor, nurse practitioner, nurse midwife) for prenatal care? _____________ weeks or ___________ months
13-15 weeks = (5) 15-23 weeks = (10) > 24 weeks = (20)

9. Did you receive prenatal care coordination services during this pregnancy? No Yes = (70)

10. How was your health during this pregnancy? Fine, no problems Some problems (e.g., nausea, tiredness) Serious problems (e.g., high blood pressure, diabetes) = (10) Explain:

11. Did your baby stay in a "special care" nursery for more than one day? No = (5) Yes If yes, how many?

12. Which of the following was your pregnancy? Planned Unplanned = (5) Result of sexual assault = (40)

13. How do you feel now that the baby is born? Happy Unsure -- a little bit happy, a little bit unhappy = (10) Very upset about it = (20)

14. How does the father of the baby (or your partner) feel about the newborn? Happy Unsure -- a little bit happy, a little bit unhappy = (10) Very upset about it = (20) 16. Do you plan to have another baby? No Yes If yes, how soon? 18. Do you understand how to use the product? No = (5) Yes 20. Do you or your children receive Supplemental Security Income (SSI) benefits or special services for a health problem? No Yes = (20) If yes, who? What services?

15. Do you have any history of prenatal or postpartum depression, raging, or "scary" thoughts about the baby? No Yes = (40)

17. Are you currently using birth control? No Yes 19. Have you experienced any problems getting the necessary supplies, medication, or services? No Yes = (5)

If receiving mental health-related services = (50)

21. Are your children in a Women, Infants, and Children Supplemental Nutrition Program (WIC) No Yes If yes, where?

22. How are you currently feeding your baby? Breast feed Bottle feed Both breast and bottle

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Points (Subtotal) Continued

FAMILY QUESTIONNAIRE F-1118 (02/09)

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SECTION IV -- HEALTH (Continued) 23. At what age do you plan to start feeding cereal / baby food to your new baby? Birth-3 months = (5) 4-6 months I don't know = (5) 24. Are any of your children on a special diet or receiving special foods or drinks? No Yes = (5) If yes, what?

25. Do you or your children ever eat non-food items (e.g., dirt, sand, starch, paint chips)? No Yes = (20)

26. Do you sometimes run out of food before you are able to buy more? No Yes = (10)

SECTION V -- PARENTING ATTITUDES / SKILLS 1. How do you feel about the way you were raised as a child? 2. If you plan to parent differently than you were raised, how much support / encouragement will you get from your family / friends?

Very positive; I had a happy childhood; my parents were A lot very caring. A little Okay; my parents tried to do their best; my parents were Very little = (10) caring. None = (20) Negative; I received no nurturing = (10) Very negative; I was punished frequently and received little or no nurturing = (40) 3. When you want advice about parenting, who do you go to? (Check all that apply.) Parents Community "Helping Organizations" Grandparents / Family Friends I Don't Have Anyone to Ask = (10) Father of the Child / Partner Doctor / Nurse "It Comes Naturally" = (10) Books / Magazines

4. Do you ever feel your infant cries or is demanding "on purpose" or just to irritate you? No Yes = (40) If yes, explain.

5. At what age do you think your baby will do the following? Be potty trained Sleep all night Begin to walk
If answer is unrealistic = (15)

6. Do you have an adequate supply or access to toys, books, games, or other play equipment? No Yes

7. When your children are playing or having fun, do you join them? Most of the time Occasionally = (5) Rarely = (10)

8. How helpful is the child's father (or your partner) in raising this child and other children in your household? Very helpful Helps when requested to help Not helpful = (10)

9. Finish this sentence. I think my / our children are ...

Use of strong negatives, such as "interfere with my activities," "too demanding," "too much work," "ugly," "stupid," "bad" = (20)

Points (Subtotal)
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Continued

FAMILY QUESTIONNAIRE F-1118 (02/09)

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SECTION VI -- TOBACCO, ALCOHOL, AND OTHER DRUGS 1. Do you or anyone else in your household smoke? No Yes 2. If yes, do you have "rules" governing when and where not to smoke? No = (20) Yes

I need to ask you a few questions about drinking and drug use. It will help us take better care of you and your children. Be sure to include beer, wine, and liquor in your answers to the following questions. 3. How many drinks does it take to make you feel high? 4. How much can you hold?

> 2 = (20)

> 2 = (20)

I never drink 5. Have people annoyed you by criticizing your drinking? No Yes = (20) I never drink 7. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?

I never drink I don't know 6. Have you ever felt you ought to cut down on your drinking? No Yes = (20) I never drink 8. In the past 12 months, have you injected a nonprescribed drug or used any other street drugs (e.g., marijuana, hash, cocaine, heroin, crack, amphetamines)?

No Yes = (20) No Yes = (70) I never drink 9. Does anyone who is involved in caring for your children abuse alcohol or other drugs? No Yes = (20) If yes, explain.

SECTION VII -- PERSONAL SUPPORT / COPING SKILLS 1. How do you deal with stress and anger? (Check all that apply.) Talk it out Calm down by taking a walk, doing some activity Not talk about it at all = (5) Take it out on somebody by yelling = (5) Get violent (e.g., hitting, threatening with object or weapon) = (50) Have a drink or get high to calm my nerves = (20) Other

2. How does the father of the baby (or your partner) deal with stress and anger? (Check all that apply.) Talk it out Calm down by taking a walk, doing some activity Not talk about it at all = (5) Take it out on somebody by yelling = (5) Get violent (e.g., hitting, threatening with object or weapon) = (50) Have a drink or get high to calm my nerves = (20) Other Points (Subtotal)
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Continued

FAMILY QUESTIONNAIRE F-1118 (02/09)

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SECTION VII -- PERSONAL SUPPORT / COPING SKILLS (Continued) 3. Have you or your children ever been emotionally or verbally abused by the father of the baby, your partner, or someone close to you? No Yes = (70) 5. Have you or other household members been raped or forced to have sex against your / their will? No Yes = (30) 7. Has anyone in your immediate household (parent, spouse, partner, sibling) been incarcerated / jailed for a crime in the past year or more than three times in the past five years? No Yes = (40) 9. Is there a gun in your home? No Yes = (10) 11. How many people do you know well enough to visit with in your neighborhood? None = (5) 13. Do you have someone you can talk with when you need to? No = (20) Yes 15. Is there anyone you can count on in case of an emergency? No = (10) Yes 4. Does the father of the baby (or your partner) physically, verbally, or emotionally abuse you or your children? No Yes = (70)

6. Does the abuser(s) still have access to you or your children? No Yes = (40) 8. Are you afraid of the father of the baby, your partner, or anyone else in your household? No Yes = (20)

10. If yes, are the guns unloaded and stored in a locked place? No = (15) Yes 12. How often do you spend time with friends or relatives? Never = (10) 14. Do you find yourself feeling lonely? Quite often Sometimes Almost never 16. Is there someone who could help you for as long as you needed their help? No Yes 18. How often do you go to neighborhood activities such as spiritual ceremonies, support groups, or "club" functions?

17. Are you known or do you think of yourself as a resource to others?

No Never = (5) Yes 19. How would you describe yourself to someone who does not know you?

20. Does your family have special traditions that they observe? No Yes If yes, explain.

21. Tell me about your family's strengths.

None = (10)
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Points (Subtotal) Continued

FAMILY QUESTIONNAIRE F-1118 (02/09)

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SECTION VII -- PERSONAL SUPPORT / COPING SKILLS (Continued) 22. Which of these things worry you a lot? (Check all that apply.) Money problems = (2) Transportation = (2) My job = (2) My partner's job or unemployment = (2) Caring for this baby / my other children = (2) Housing problems / getting evicted = (2) Getting child care = (2) My physical or mental health / safety = (2) My drinking / drug use = (2) My relationship with my partner = (2) My child's relationship with his / her father = (2) My partner is in jail = (2) 23. Would you like help or information with any of these things? Discipline Child development Parenting skills Playing with your children Health issues Employment training Coping with stress Family planning / pregnancy prevention Community resources for parents Assessment Date Reassessment Date

SECTION VIII -- SIGNATURES SIGNATURE -- STAFF SIGNATURE -- STAFF

Points (Subtotal) Total Points (All Pages)
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Key:

> = Greater Than < = Less Than
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