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  • Family Home Visiting (FHV) Evaluation

    Data collection forms

    Standard packet January 2015 Update

    Version 3.0

    Family Home Visiting Unit Maternal & Child Health SectionCommunity & Family Health Division Minnesota Department of Healthaddress: P.O. Box 64882, St. Paul, MN 55164 phone: 651-201-3760email: health.fhv@state.mn.us web: www.health.mn.us/divs/fh/mch/fhv

  • Table of contentsForm FHV-0-INTPrimary caregiver intake ..............3

    Form FHV-01-PPTChild intake ....................................7

    Form FHV-06-INF6 months infant ..............................9

    Form FHV-12-INF12 months infant ..........................13

    Form FHV-18-TOD18 months toddler ........................17

    Form FHV-24-TOD24 months toddler ........................21

    Form FHV-30-TOD30 months toddler ........................25

    Form FHV-36-PRE36 months preschooler ................29

    Form FHV-42-PRE42 months preschooler ................33

    Form FHV-48-PRE48 months preschooler ................37

    Form FHV-54-PRE54 months preschooler ................41

    Form FHV-60-PRE60 months preschooler ................45

    Form FHV-66-PRE66 months preschooler ................49

    Form FHV-99-CLOPrimary caregiver closure ..........53

    FHV Evaluation Forms Packet (Standard) January 2015 Update Version 3.0 2

  • Form FHV-0-INT

    Primary caregiver intakeHEADER*1 Data entry staff (name) *2 Home visitor (name)

    *3 Site

    3b Name of subcontracting agency, if applicable 360 Communities Catholic Charities Community Action Partnership (CAP)

    MN Visiting Nurses' Association (MVNA) Headway St. David's

    *4 Dateoffirsthomevisit

    DEMOGRAPHICS (PRIMARY CAREGIVER)6 First name 7a Last name 7b Maiden name, if applicable

    *8a Identifier#1 8b Identifier#2

    9 Home address (number and street or rural route)1

    10 City *11 State *12 Zip *13 Birth date

    *14 Home visiting model 01 Healthy Families America (HFA) 02 Nurse-Family Partnership (NFP)

    77 Other, ongoing 88 Other, short-term/limited

    *15 Funding source 01 MIECHV Formula Funding Grant 02 MIECHV Expansion Funding Grant

    03 Non-MIECHV

    *16 Client type at enrollment (relationship to index child) 01 Prenatal woman 02 Postpartum mother (biological) 03 Father (biological)

    04 Other primary caregiver:

    *17 Gender 01 Male 02 Female

    *18 PRENATAL/POSTPARTUM ONLY: How many live births have you had?

    previous live births*19 Hispanic or Latino/a ethnicity

    01 Hispanic or Latino/a 02 Not Hispanic or Latino/a

    88 Client does not know/not sure 99 Client declines to answer

    *20 Race (select one or more) 01 White 02 Black/African American 03 American Indian/Alaska Native 04 Asian

    05 NativeHawaiian/OtherPacificIslander 06 Other: 88 Client does not know/not sure 99 Client declines to answer

    More on next page

    1 Ifhomeless,write"homeless"intheaddressfield.

    FHV-0-INT January 2015 Update Version 3.0 3

    Page 1 of 3

  • *21 Primary language 01 English 02 Hmong 03 Somali

    04 Spanish 05 Other: 99 Client declines to answer

    *22 Legal marital status2

    01 Married (legal or common law) 02 Divorced 03 Widowed

    04 Separated 05 Never married 99 Client declines to answer

    I. IMPROVED MATERNAL & NEWBORN HEALTH23 PRENATAL CLIENTS ONLY: How many weeks pregnant are you (client) now? BENCHMARK I.1

    weeks pregnantII. CHILD INJURIES, CHILD ABUSE, NEGLECT OR MALTREATMENT / REDUCTION OF EMERGENCY ROOM VISITS24 In the past 6 months, have you (client) obtained care at the emergency room/urgent care center for ANY reason? BENCHMARK II.10

    01 Yes 02 No

    88 Client does not know/not sure 99 Client declines to answer

    V. FAMILY ECONOMIC SELF-SUFFICIENCY*25 Are you (client) currently working?

    01 Yes, full-time (37+ hours/week) 02 Yes, part-time (36 hours or less/week)

    03 No, not employed 99 Client declines to answer

    *26 What is your (client's) household size?3 (Note: Count 1 for yourself)

    persons

    27 Do any members of your (client's) household currently serve in the Armed Forces (active or reserve)?3

    01 Yes 02 No 99 Client declines to answer

    *28 Whichcategorybestdescribesyour(client's)totalannualhouseholdincomeandbenefits?3,4 BENCHMARK V.28 02 $1 - $6,000 03 $6,001 - $9,000 04 $9,001 - $12,000 05 $12,001 - $16,000 06 $16,001 - $20,000

    07 $20,001 - $30,000 08 Over $30,000 88 Client does not know/not sure 99 Client declines to answer

    29 In what educational program are you (client) currently enrolled, if any? 01 Not enrolled in a program 02 Middle school (6th through 8th grade) 03 High school (9th through 12th grade) 04 GED program

    05 Post-high school vocational/cert./technical training

    06 College 07 Other: 99 Client declines to answer

    *30 What is the highest level of education you (client) have attained? 01 Never attended school or kindergarten 02 Grades 1 through 8 (Elementary) 03 Grades 9 through 11 (Some high school) 04 Grade 12 (High school) 05 GED

    06 Some college/training (no degree) 07 Technical training cert./Associate's degree 08 Bachelor's degree or higher 09 Other: 99 Client declines to answer

    More on next page

    2 Select "01 Married" if the client is legally married in the United States.3 A"household"isdefinedasagroupofrelatedornon-relatedindividualswhoarelivingtogetherasoneeconomicunitsharingincomeandconsumptionofgoods

    and/or services (who stay there at least 4 nights per week on average and contribute to the support of the child or primary caregiver). Tenants/boarders shall not be counted as members of the household. Household size: total number of individuals sharing income and consumption of goods and/or services.

    4 "Incomeandbenefits"shouldincludeannualearningsfromwork,plusothersourcesofcashsupport,whetherprivate(e.g.,rentfromtenants/borders,cashassistance from friends/relatives) or public (e.g., child support payments, TANF, Social Security (SSI/SSDI/OAI) and Unemployment Insurance).

    FHV-0-INT January 2015 Update Version 3.0 4

    Page 2 of 3

  • 31 In the past 6 months, have you (client) completed any educational programs or classes, such as grade advancement, certificate,ESOL5, etc.? BENCHMARK V.29

    01 Yes: 02 No

    99 Client declines to answer

    *32 Do you (client) have health insurance? BENCHMARK V.30 01 Yes, insured 02 No, uninsured6 (END form)

    88 Client does not know/not sure (END form) 99 Client declines to answer (END form)

    *33 What is your major medical care resource for health insurance? (select one or more) BENCHMARK V.30 01 Private insurance 02 Public insurance7 03 TRICARE (Military)

    04 Other: 88 Client does not know/not sure 99 Client declines to answer

    FHV-0-INT January 2015 Update Version 3.0 5

    Page 3 of 3

    5 ESOL = English for Speakers of Other Languages, also sometimes referred to as English as a Second Language (ESL) or English as a New Language (ENL)6 Includes clients who have applied for insurance (pending)7 Minnesota Health Care Programs (MHCP): Medical Assistance (MA), Prepaid Medical Assistance Program (PMAP), MinnesotaCare, Minnesota Family Planning

    Program

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  • Form FHV-01-PPT

    Child intakeHEADER*1 Data entry staff (name) *2 Home visitor (name)

    *3 Site

    3b Name of subcontracting agency, if applicable 360 Communities Catholic Charities Community Action Partnership (CAP)

    MN Visiting Nurses' Association (MVNA) Headway St. David's

    *4 Date of home visit *5 Total#homevisitsto-date

    Demographics (Child)6 First name (child) 7 Last name (child) *8a Identifier#1(child) 8b Identifier#2(child)

    *9 Primary caregiver ID

    *10 Birth date (child)

    *11 Gender 01 Male 02 Female

    *12 Hispanic or Latino/a ethnicity 01 Hispanic or Latino/a 02 Not Hispanic or Latino/a

    88 Client does not know/not sure 99 Client declines to answer

    *13 Race (child) (select one or more) 01 White 02 Black/African American 03 American Indian/Alaska Native 04 Asian

    05 NativeHawaiian/OtherPacificIslander 06 Other: 88 Client does not know/not sure 99 Client declines to answer

    I. IMPROVED MATERNAL & NEWBORN HEALTH14 BIOLOGICAL MOTHERS ONLY: Did you (client) smoke cigarettes at all during pregnancy, including before you found

    out you were pregnant? BENCHMARK I.2 01 Yes 02 No

    99 Client declines to answer

    II. CHILD INJURIES, CHILD ABUSE, NEGLECT OR MALTREATMENT / REDUCTION OF EMERGENCY ROOM VISITS15 ANSWER ONLY IF ENROLLED PRENATALLY: Since enrollment, have you (client) obtained care at the emergency room/

    urgent care center for ANY reason? BENCHMARK II.10 01 Yes 02 No

    88 Client does not know/not sure 99 Client declines to answer

    V. FAMILY ECONOMIC SELF-SUFFICIENCY16 ANSWER ONLY IF ENROLLED PRENATALLY: Since enrollment, have you (client) completed any educational programs

    orclasses,suchasgradeadvancement,certificate,ESOL1, etc.? BENCHMARK V.29 01 Yes: 02 No

    99 Client declines to answer

    More on next page

    1 ESOL = English for Speakers of Other Languages, also sometimes referred to as English as a Second Language (ESL) or English as a New Language (ENL)

    FHV-01-PPT January 2015 Update Version 3.0 7

    Page 1 of 2

  • *17 ANSWER ONLY IF ENROLLED PRENATALLY: Do you (client) have health insurance? BENCHMARK I.8, V.30 01 Yes, insured 02 No, uninsured2 (SKIP to #19)

    88 Client does not know/not sure (SKIP to #19) 99 Client declines to answer (SKIP to #19)

    *18 ANSWER ONLY IF ENROLLED PRENATALLY: What is your major medical care resource for health insurance? (select one or more) BENCH-MARK I.8, V.30

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