Early Childhood
Inventory
www.thefamilymap.org
version 5.4

Date of Interview:

Home

Other home

School

Public Place
Location of Interview:
Male

Male

Female
Child Name:
Female

Male

Female
Parent/Guardian:
Male
Female

1

2

3

4
Target Child
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EARLY CHILDHOOD FAMILY MAP



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Interviewed by:

Agency Code:
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(Clear identifiers)

Location:

Region:

Center:

Class:
Child age:

Months

White

American Indian or Alaska Native

Asian

Black

Native Hawaiian or Other Pacific Islander

Other:
b) Do you consider your child to be Hispanic or Latino?

Yes

No
1. a) What do you consider your child's race?
Mark all that apply.

c) Were you born in the United States?

Yes

No

Country of Origin
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If No

16 years or less

17-18 years

19-24 years

25-34 years

35-40 years

41 or more
2. How old are you now?

Years
3. What is your relationship to this child?

Biological Parent

Foster Parent

Partner of Parent

Other Relative

Step Parent

Adoptive Parent

Grandparent

Other:

Parent ID
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ECv2.4



36 months or less

37-42 months

43-48 months

49-54 months

55-60 months

61 months or more
(Use '00000' for test records)
Early Childhood
Inventory
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Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
Relationship to mother figure:
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SECTION 1
SELF SUPPORT
S1. Is any language other than English regularly spoken in your home?

No

Spanish

Other:





How often:













a)
Do you feel comfortable speaking English?
Can you understand the written materials the program gives you?
c)
Do you feel comfortable asking the program staff to translate their written materials for you?
d)
Do you use other family members to talk with program staff because they speak better English?
b)
S2. Are you or have you been involved with a similar program in the past?
Head Start, HIPPY, home visiting program

No

Yes
If yes:

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a) Did you set any goals with this program?

No

Yes
S3. How many other children live in the home with you?
Only count people less than 18 years old.
Do not count mother figure or this child.

0

1

2

3

4

5

6

7
Child Name:
No Other Children
S4. Are you currently enrolled in school?
S5. What level of education have you completed?







No High School Degree
High School Degree
GED
Votech, Technical Certificate/License
College
Degree






Not Enrolled
GED
High School
Votech, Technical Certificate/License
College
AA or AS Degree or Some College
Use Response Card
Mark Total.
What program?
Always
Often
Some times
Rarely

If no, skip to S2
If Other
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If any response is shaded area: Consider English as a Second Language as a Goal.
If not Currently Enrolled and High School or less: Consider Education as a Goal.
Early Childhood
Inventory
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Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
S6. How many hours did you work for pay in the last week?
(Or in a typical week if last week unusual.  All job hours.)
Not Working









0-10
11-20
21-30
31-40
41-50
51-60
60 or more
a) How long have you been working at this job?
(newest job if more than 1)






3 months or less
3-6 months
7-12 months
1-3 years
3 years or more
b) How many jobs do you currently have?

1

2

3
c) What shift do you usually work?






A regular day shift
A regular evening shift
A regular night shift
A split shift
Some other shift

S7. How many adults live in the home with you?
Only count people 18 years or older.  Do not count mother figure.

0

1

2

3

4

5

6

7

8

9
S8. Are you or anyone in your family receiving unemployment payments?

Yes

No
S9. Next we want to talk about your child's other parent(s), living with you or not.
Name
How are they
related
to your child?
How long
have you
lived
together?
What is their
highest level of
completed
education?
Are they
currently
enrolled in
school?
How many hours
are they
currently working
for pay?

Parent outside the home

Parent in the home




1 year or less
2-3 years
4 or more




Biological Parent
Step, Foster, or Adoptive Parent
Your partner




Biological Parent
Step, Foster, or Adoptive Parent
Your partner
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If not working, skip to s7.
If any response in the shaded area: Consider Employment as a Goal.
If Not Currently Enrolled and High School or Less: Consider Employment as a Goal.
College
Vocational
High School/ GED
No HS Degree





College
Vocational
High School/ GED
No









50 hours or more
20-50 hours
20 hours or less
0-10 hours





College
Vocational
High School/ GED
No





50 hours or more
20-50 hours
20 hours or less
0-10 hours
No HS Degree
High School/ GED
Vocational
College





Early Childhood
Inventory
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Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
S10. Let's talk about others living in the home that help you or your child.  What are their names?
Name
How are they
related
to your child?
How long
have you
lived
together?
What is their
highest level of
completed
education?
Are they
currently
enrolled in
school?
How many hours
are they
currently working
for pay?




1 year or less
2-3 years
4 or more





No HS Degree
High School/ GED
Vocational
College





No
High School/ GED
Vocational
College





0-10 hours
20 hours or less
20-50 hours
50 hours or more




Child's Grandparent
Child's Aunt/ Uncle
Other




1 year or less
2-3 years
4 or more





No HS Degree
High School/ GED
Vocational
College





No
High School/ GED
Vocational
College





0-10 hours
20 hours or less
20-50 hours
50 hours or more




Child's Grandparent
Child's Aunt/ Uncle
Other




1 year or less
2-3 years
4 or more





No HS Degree
High School/ GED
Vocational
College





No
High School/ GED
Vocational
College





0-10 hours
20 hours or less
20-50 hours
50 hours or more




Child's Grandparent
Child's Aunt/ Uncle
Other

(Ask about up to 3 people, Skip if no others in the home)
If Not Currently Enrolled and High School or Less:  Consider Education as a Goal.
1.
2.
3.
Early Childhood
Inventory
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Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
This interview will include questions about your family in the past year, month, and week.
R1.
Before we go on, has the past month been typical for you?

Yes

No
R2.
R3.

Yes

No

Yes

No

Yes

No

Yes

No
Other
You
R4.
How many times has your child moved in the past year ?
R5.
Do you have plans to move in the next year ?
R6.
Have you and your child lived with family or friends, in a shelter, hotel, car, or other temporary housing in the past year ?
R7.
How many times during the past month did your child spend the night someplace else?

0

1

2

3

more

Yes

No

Yes

No

0

1

2

more
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If 3 or more
How many different places did they spend the night someplace else?
a)

1

2

more
Having a set daily routine and organized home can help people in a lot of ways.  The following questions are about things that have happened in the past week .
If the past week was very unusual (e.g., traveled), ask to think about prior week.  If no routine for item, mark none.
None
1 day
2 days
3 days
4 days
5 days
6 days
7 days
R8.
Thinking about the past 7 days ,
how  many days did your child or
(if child less than 6 months) you:
a)
Brush teeth at about the same time?









If any response in shaded area: Consider Support Strategies as a Goal.
If any response in shaded area: Consider Housing as a Goal.
If 2 or more responses in shaded area: Consider Daily Routines as a Goal.
(military, work, or incarceration)?
In the last 6 months , were you or someone else in your home separated from the family for more than a week
In the next 6 months , do you expect you or someone else in your home will be separated from the family for more than a week
(military, work, or incarceration)?
ROUTINES
SECTION 2
b)
Get a bath at about the same time?

















c)
Go to bed at about the same time?
d)
Stick to a regular morning routine?









Early Childhood
Inventory
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Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
R10.
How often is your child in the room while the following types of TV programs or movies are on:
a)
Movies rated G / or TV shows rated Y (Youth)?
b)
Movies rated PG / or TV shows rated Y-7?
c)
Movies rated PG-13 / or TV shows rated 14?
d)
Movies rated R / or mature TV programs?





Never
Once a month
1-2 times a week
3 or more times a week
Use TV Show Card
Show card with example programs













If any response in shaded area: Consider TV Routines/Screen Time as a Goal.
R11.
How many hours is a TV on at home during a usual weekday even if no one is watching?
R12.
How many hours does your child watch TV or play video/computer games at home on a usual weekday ?
If total of R11 and R12 is more than 0 hours (0-2 yrs), or 2 hours (2-3 yrs): Consider TV Routines/Screen Time as a Goal.
Getting enough sleep is a common problem for children and adults.  Let's add up the number of hours your child sleeps each day.
R9.
Thinking about yesterday ,
a)
What time did your child go to sleep
and wake up
b)
How many hours did your child nap?
Teacher can report on nap information or ask about weekend if necessary.
TOTAL HOURS OF SLEEP
8 or less
9-10 hours
11-12 hours
13 hours
14 hours
15 hours
16
hours

Add # of hours child slept to # of hours of nap time









If 2 or more responses in shaded area: Consider Household Organization as a Goal.
Home Very Active
Home Not Well Organized
Home Crowded for # of People
Home Very Calm
Home Very Organized
Home Not Crowded
picture
picture
picture

1

2

3

4

1

2

3

4

1

2

3

4














8 - 9 hours
10 or more
9 - 10 hours
7 - 8 hours
6 - 7 hours
5 - 6 hours
4 - 5 hours
3 - 4 hours
2 - 3 hours
1 - 2 hours
½ - 1 hour
½ hr or less
None














8 - 9 hours
10 or more
9 - 10 hours
7 - 8 hours
6 - 7 hours
5 - 6 hours
4 - 5 hours
3 - 4 hours
2 - 3 hours
1 - 2 hours
½ - 1 hour
½ hr or less
None

17 or more

Hours

Minutes

AM

PM
:

Hours

Minutes

AM

PM
If total hours are less than 12 : Consider establishing Sleep Routines as a Goal.
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Early Childhood
Inventory
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Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
Children learn from things like toys, people in their lives, and places they go.  Remember these things can be store bought, handmade, or used for other things like pots and pans. How many of the following things do you have that your child can get when they want?
L1.
Do you have things:
Indicate number of types for example: drawing paper and crayons = 1, 3 stuffed animal = 1
0
1
2
3 or more





c)
For interactive learning such as See and Say, Leap Frog, read aloud or counting electric toys?





b)
For learning such as games that require comparing or sorting things by size?





a)
For building or putting things together such as nesting blocks, legos, or puzzles?





If any response in shaded area: Consider Learning Materials as a Goal.
0
1-2
3-9
10+
Many people enjoy reading and it is important for children to be exposed to books and reading early.

Yes

No
L2.
How many children's books does your child have of his/her own or share with brothers or sisters?





L4.
In the past month, have you visited a public library?

Yes

No
L3.
Do you have a library card?
If all responses in shaded area: Consider Reading Materials as a Goal.
L5.
In the past week , how many times did the following people read or look at a book with your child?
If all responses in shaded area: Consider Literacy as a Goal.
d)
For muscle development such as a basketball, jump rope, or bicycle?
(not including while in child care)
SCHOOL READINESS
SECTION 3
a)
Mother/figure?
b)
Father/figure?
c)
Anyone else?













Not Available or None
1 - 2 times/week
3 - 5 times/week
6 or more times









e)
For art or creative activities such as crayons, markers, chalk, or play dough?
f)
For music such as a toy musical instrument or electronic music player?
Early Childhood
Inventory
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Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
L6.
In the past week , how many times did you or someone in your family:
a)
Play with toys or games with your child?
b)
Talk to your child while doing ordinary household chores?
c)
Tell your child the name of things, places, or people?
d)
Play chasing or dancing games with your child?
e)
Play outside long and hard enough for your child to get hot and tired?
If 3 or more responses in shaded area: Consider Educational Activities as a Goal.
L7.
Parents can help children be ready for school. In the past week , how many times did you or someone in your family use games, toys, books, or other objects to:
a)
Count things with your child? ( "Look, you have two teeth!" )
b)
Sing the alphabet song or point out letters or words?
c)
Point out and name colors? ( "Let's put on your red shoe." )
d)
Point out and name shapes? ( "Look at the round ball." )
L8.
In the past month , have you or someone in your family done these things with your child:
No
Yes



a)
Taken your child on an outing such as shopping or to a children's movie?
Next we want to ask you about some things that parents do with young children to have fun outside the home.





b)
Attended an athletic or sporting event?
c)
Visited a friend or relative?
L9.
In the past year , have you or someone in your family done these things with your child:
No
Yes



a)
Gone to a play, concert, or other live show?





b)
Visited a zoo or aquarium?
d)
Attended a community event like a fair, festival, parade, or block party?
If 6 or more responses in shaded area: Consider Learning Experiences as a Goal.
c)
Visited an art gallery, museum, or historical site?



Play is a wonderful way for children to learn.
If 2 or more responses in shaded area: Consider Educational Activities as a Goal.
None
1 - 2 times week
3 - 5 times week
6 or more times





































None
1 - 2 times week
3 - 5 times week
6 or more times





f)
Use arts and crafts with your child?





e)
Point out sizes of things? (“The cat is little, but the dog is big!”)
Early Childhood
Inventory
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Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
Children like to do many things on their own. The next questions are about things you allow your child to do when there is no adult or child over 12 in the room or yard with him/her.
M1.
What is the longest amount of time you would allow your child to be:
Never
5 minutes or less
5-1 0 minutes
10-30 Minutes






30 minutes or more











If any response in shaded area: Consider Monitoring Strategies as a Goal.
In the past month, think about all the people that your child stayed with when you were away, even for a short while. Be sure to include when you were at work, school, or running a short errand, and when your child rode with someone else.
M2.
How many people did your child stay with in the past month ?








0
1-2
3-4
10+
5-6
7-8
9

If zero: Skip to M3
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a)
Were any of these people under 13 years of age?



b)
Have you known any of these people less than one month?
M3.
In the past month, did you have problems finding care for any of your children when they were sick and couldn't go to their regular care or for hours outside of their regular care?



M4.
In the past month, did you have problems finding care for any of your children - day or night?



If any response in shaded area: Consider Child Care as a Goal.
a)
Take a bath without you in the room?
b)
Play inside when you’re outside?
c)
Play outside when you’re inside?
MONITORING
SECTION 4
No
Yes
No
Yes
Early Childhood
Inventory
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Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
If any response in shaded area: Consider Housing or Safety Strategies as a Goal.
The next few questions are about crime and safety issues in your neighborhood. By neighborhood, we mean a few blocks around your house, or the area within short walking distance from your home.
Use Response Card
E3.
In your neighborhood, how much of a problem is the selling and using of drugs? Would you say it is:
Not Serious
Not Too Serious
Fairly Serious
Very Serious





Never
Some of the Time
Most of the Time
All of the Time





Never Happen
Hardly Ever Happen
Happen Fairly Often
Happen Very Often





E4.
How often are there problems with muggings, burglaries, assults, or other criminal activities in your neighborhood? Would you say these things:
Never
Once
Two times
Three times
E5.
Thinking about people in the home or neighborhood, in the past year, how many times:






More than 3 times
a)
Has your child been physically hurt by someone for example, hit, kicked, punched, or spanked in a way that left marks?
b)
Have you or someone living in your home been physically hurt by someone?






c)
Has your child seen someone try to physically hurt another person?






d)
Has your child seen drug or sexual activities?






If any response in shaded area: Consider Family Safety or Counseling as a Goal.
Very Bad
Fairl y Bad
Fairly Good
Very Good





Neighborhood Unsafe

1

2

3

4
Neighborhood Safe
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ENVIRONMENTAL SAFETY
SECTION 5
E2.
Thinking about crime and safety in your neighborhood, how often do you think about moving because of the safety of the neighborhood? Would you say:
E1.
How do you feel about your neighborhood?
Do you feel it is:
Early Childhood
Inventory
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Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
Parenting is stressful and challenging, and all parents experience difficulty at one time or another.  How much do you agree with the following statements?
Disagree
Agree
Strongly Agree
Use Response Card
F8.
During the past month , I have felt stressed out with the day-to-day demands of raising children.
Strongly Disagree
F9.
During the past month , I have felt so stressed out that I was afraid I might lose control.
F10.
I worry I will spoil my child by giving him/her too much attention or picking him/her up when he/she cries.
F11.
I feel that my child is much harder to care for than most children his/her age.
F12.
I expected to have closer and warmer feelings for my child than I do, and this bothers me.
F13.
When I do things for my child, I get the feeling my efforts are not appreciated.
F14.
Sometimes the punishment I give my child depends on my mood.
If 3 or more responses in shaded area: Consider Parent Education as a Goal.
The next questions are about the people that might help you raise your child.  If more than one person shares parenting with you, answer about the person that you disagree with the most .
Never or Rarely
Some Times
Often or Always




Skip only if no other person is identified inside or outside the home.
Use Response Card







F2.
When you and this person talk about how to raise your child, how often is the conversation hostile or angry?
F3.
The next statements are about family members or others you think of as family that you see at least weekly.  Please tell me how often these are true for your family:
Never or Rarely
Some Times
Often or Always




Use Response Card
F4.
People in our family lose their tempers.




F5.
Family members feel very close.




F6.
We raise our voices or yell in anger.




F7.
People in my family help and support each other
F1.
How often do you and this person have disagreements about how to raise your child?





























How often do you and this person have disagreements related to money to buy thing for or support the child ( like child support if not married )?
FAMILY COHESION
SECTION 6
If 2 or more responses in shaded area: Consider Relationship Counseling as a Goal.
If 2 or more responses in shaded area: Consider Family Counseling as a Goal.
Early Childhood
Inventory
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Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
When your child has done something wrong, how often do you:
D2.







Use Response Card
Children sometimes do things they shouldn't. How often in the past week have you had to punish your child?
D1.
0
1-2
3-4
5-6
7-9
10 or more






Use time-out: make him/her stand or sit in a corner or chair.
a)






Send your child to his/her room.
b)






Take away privileges or object/toy for a period of time, restrict access.
c)
Slap your child’s hand.






If any response in shaded area: Consider Discipline Strategies as a Goal.











i)






h)
Yell at your child.
DISCIPLINE
SECTION 7











d)
Give extra chores.
e)
Re-direct, distract, or turn the child’s attention to something else.
If all responses in shaded area: Consider Discipline Strategies as a Goal.











Spank your child with your hand.
j)
Spank your child with a belt, switch, or other object.
k)
f)
Discuss the problem, ask questions, and/or teach them.
g)
Ignore it.
N/A Never
Rarely
Some times
Often
Always
N/A Never
Rarely
Some times
Often
Always
Early Childhood
Inventory
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Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
Sometimes it is difficult for families to get all of the medical care that they need.  The next part of the interview  is about the health of your family.
H1.
Do you have a health problem or illness that requires regular, ongoing care or medication?
For example, a disability, a mental illness, or chronic health problems like asthma, severe allergies, sickle cell anemia, or cerebral palsy.

No

Yes
If no, skip to H2.
Note Condition:

Determine need: Do you understand what your doctor or therapist wants you to do day-to-day to deal with that health problem?  Do you have a plan from the doctor?  Do you feel comfortable following that plan?  Do you have any problems being able to follow-through with the plan?
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H2.
Does your child have a health problem or illness that requires regular, ongoing care or medication?
For example, a disability, a mental illness, or chronic health problem, like asthma, severe allergies, repeat ear infections, sickle cell anemia, cerebral palsy, or ADHD.

No

Yes
If no, skip to H3.
Note Condition:

Determine need: Do you understand what your child's doctor or therapist wants you to do day-to-day to deal with that health problem?  Do you have a plan from the doctor?  Do you feel comfortable following that plan?  Do you have any problems being able to follow-through with the plan?
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H3.
Does anyone else in the home have a health problem or illness that requires regular, ongoing care or medication?

No

Yes
If no, skip to H4.
Note Condition:

Determine need: Do they have a plan from the doctor?  Do they feel comfortable following that plan?
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Yes, Care Demanding

1

2

3

4
No One in the Home
If any response in shaded area: Consider Medical Assistance as a Goal.
H4.
Do you have a doctor you consider your child's doctor?



H6.
H7.
Has your child recieved a dental check-up within the last 12 months?
H8.
Does your child have health insurance?








Can you get health care when your child is sick or injured that is not from a hospital emergency room?
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Needs Help with Plan

1

2

3

4
Has a Plan and Following
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Needs Help with Plan

1

2

3

4
Has a Plan and Following
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If any response in shaded area or immunizations not current: Consider Child Health Care as a Goal.
SECTION 8
HEALTH
H5.
Has your child received recommended check-ups from a doctor within the last 12 months? These happen when the child is not sick and are also called ‘well-child’ visits. Recommended at 2 1/2, 3, 4 years.




No
Not Sure
Yes
Early Childhood
Inventory
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Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
Yes Currently
No
Not Sure
Yes
H10.
Can you get health care when you are sick or injured that is not from a hospital emergency room?




H11.
Are you currently pregnant?



H12.
Is anyone else in your home currently pregnant?



If pregnant: Consider Prenatal Care as a Goal.
H13.
During the past month , how many times each week did you exercise such as running or walking for at least 30 minutes?
None
1-2 per week
3-4 per week
More









H14.
During the past month , how many times per week have you felt you did not get enough rest or sleep?
If any response in shaded area: Consider Healthy Practices as a Goal.
H15.
Have any family members ever been diagnosed with depression?
No
In the past




H16.
Have you ever been diagnosed with depression?




If any response in shaded area: Consider Counseling as a Goal.
H17.
In the past 2 weeks , how often have you been:
Not at all
Several days
More than½ the days
Nearly every day
Use Response Card





Bothered by feeling down, depressed, or hopeless?
a)





Bothered by having little interest or pleasure in doing things?


b)





Bothered by feeling easily annoyed or irritated?


c)





Bothered by feeling suddenly scared for no reason?


d)





Bothered by feeling tense or nervous?


e)





Bothered by moments of terror or panic?


f)





Bothered by getting into arguments often?




g)
If any response in shaded area: Consider Counseling as a Goal.
No
Yes
If any response in shaded area: Consider Maternal Health Access as a Goal.
H9.
Do you have health insurance?



Share Parenting or Health Information

1

2

3

4
Does Not Need Information
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Early Childhood
Inventory
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Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
H18.
Closest friends have a problem with drinking or drugs?


Many people need help coping with family or friends that have problems with drinking or drugs.  Do any of your:
H19.
Close family members have a problem with drinking or drugs (parents, siblings) ?




a)
Do any of these friends or family members live in your home?






No
Yes







If H18 & H19

no, skip to

H20
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The following questions are often used to help people determine if they or someone they know need help.  In the past year :
No
Yes







H20.
Have you felt you ought to cut down on your drinking or drug use?
H21.
Have you felt annoyed by people criticizing your drinking or drug use?
H22.
Have you felt bad or guilty about your drinking or drug use?
H23.
Have you had a drink or used drugs as an eye opener first thing in the morning to steady your nerves?
H24.
Have you felt that you have drunk or used drugs more than you meant to?





If any response in shaded area: Consider Fetal Alcohol Spectrum Disorder or
Alcohol/Drug Information as a Goal.
Share Alcohol or Drug Information

1

2

3

4
Does Not Need Information
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Early Childhood
Inventory
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Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
The next part of the interview is about whether you need help to meet the needs of your family.  In the past year , how many times:
None
1 or more
Don't Know
No
Yes
Don't Know
Were you unable to pay an important monthly bill such as rent, car payment, house repair, child care, or other outstanding payment?
B2.




Were you unable to afford medical care, dental care, or medicine ?
B3.




Did you have problems with transportation because you could not afford to buy gas for the car, pay for car repairs, or pay for a bus, cab, or other transportation?
B4.




Were you owed child support and unable to receive it?
B5.




Have you had an open child protective case?
B6.




Were you or your child's other parent involved with the legal system?
B7.




In the next year , do you expect you will need help paying for basic services such as utilities, rent, transportation, or health care?
B8.




In the next year , do you expect that you will need help paying for necessary clothing like shoes or coats for you or your child?
B9.




If any response in shaded area: Consider Basic Needs as a Goal.
Use Response Card
B10.
The food that you bought just didn't last and you didn't have money to get more.
B11.
You or others in your household cut the size of your meals or skipped meals because there wasn't enough money for food.







Never True
Sometimes True
Often True
If any response in shaded area: Consider Food Assistance as a Goal.
Did you have any of your utilities such as gas, electric, water, or telephone service turned off because there wasn't enough money to pay the bill?


B1.




Thinking about food and nutrition, how often are the following never, sometimes, or often true?  In the past year :
SECTION 9
BASIC NEEDS
Early Childhood
Inventory
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Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
Use Response Card
More than 1 a day
Once a day
2-6
a
week
Once
a
week
None
Serving per day goal
1 1/2 cups
2 oz
2/3 cup

3 cups
1
cup
1 cup
None
Dairy products like milk, cheese, yogurt
a)
Meat like beef, chicken, fish, eggs
b)
Protein like beans, peas, nuts, peanut butter, veggie burger


c)
Grains like bread, rice, pasta, cereals, tortillas
d)
Dark greens or orange/yellow vegetables like greens, carrots, broccoli, squash, sweet potatoes- but do not count french fries
e)
Fruits like apples, oranges, bananas, grapes, peaches, applesauce- but do not count juice
f)
Sugary sweets like cakes and candy,or sugary drinks like soda, sports drinks, juice, or fruit drinks.































If any response in shaded area: Consider Nutrition Education as a Goal.
B12.
About how often does your child eat a food from each of the following groups (baby food or table food)?






g)
Do not count foods eaten at childcare centers.
Early Childhood
Inventory
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Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
Now let’s talk about some safety concerns. Thinking about the past month , how many rides has your child taken even for a short trip:
C1.
In the front seat of a vehicle?
C2.
In the back seat with a seatbelt with a car seat?
C3.
In the bed of a truck or on a motorcycle?
C4.
On an All-Terrain Vehicle, like a 4 wheeler, tractor, riding lawnmower or similar off-road vehicle?





Never
1-9 Rides
More than 10
Every Ride





If any response in shaded area: Consider Vehicle Safety as a Goal.
SECTION 10
HOME AND CAR SAFETY
If any response in shaded area: Consider Safety Strategies as a Goal.
C5.
C6.
C7.
C8.
C9.
C10.
C11.
Does anyone living in your home smoke cigarettes?
Does anyone smoke cigarettes inside your home ?
Does anyone smoke cigarettes inside your car ?
Is there a working smoke detector in your home for each level?
Are there two clear exits that can be used in case of a fire?
This could be two doors or a window that you could safely climb out.
Can you hold your hand under the hottest running water for several seconds without getting burned (water heater set below 120 degrees)?
Do you live in a building built before 1978 when lead based paint was banned?
a) Have you tested your smoke detector(s) in the last 2 months?




No
You
Other







No
Don't Know
Yes






















Early Childhood
Inventory
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Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
If any response in shaded area: Consider Child Safety as a Goal.
Take a moment to think about the location of the following household items.  Which of the following items could your child find and get if they tried?
a)
C12.
Laundry detergent or cleaning supplies
Don't Own
No
Yes
b)
BBQ lighter fluid
c)
Matches or lighters
d)
Iron




e)
Medicines




g)
Knives, scissors, or other sharp objects




h)
Tools like saws, screwdrivers, etc.




i)
Firearms like guns or other weapons




j)
Toiletries such as mouthwash, perfume, hair spray, or nail polish




k)
Toys or objects small enough to be choking hazards




f)
Beer, wine, or other alcohol




Safety Concerns in Home

1

2

3

4
No Safety Concerns in Home
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Safety Concerns outside Home

1

2

3

4
No Safety Concerns outside Home
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Early Childhood
Inventory
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Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
People sometimes look to others for companionship, assistance, or other types of support.
Little or none of the time
Some of the time
Most or all of the time




Use Response Card







a)
Listen to you when you needed to talk?
b)
Help with daily chores if you were sick?
Use Response Card
I1.
In the past month , how often was someone available to:
c)
Loan you $100 if you needed it?
If any response in shaded area: Consider Support System as a Goal.
Once or twice a month
Weekly
More than once a week
Neighborhood or community organization, committee, club or sports team
Church service or other religious club or activity
In the past month , how often have you participated in the following activities?
Visit a friend or neighbor's house
None
a)
b)
c)
I2.
Hobby or sport with a friend
d)

















If all responses in shaded area: Consider Community Involvement as a Goal.
Mother/figure visited with people working with
( name your program )
Mother/figure volunteered at this program or other places
Father/figure visited with people working with
( name your program )
e)
f)
g)
Father/figure volunteered at this program or other places
h)

















If all responses in shaded area: Consider Program Engagement as a Goal.
Share Program Volunteer Information

1

2

3

4
Does Not Need Information
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SOCIAL INTEGRATION
SECTION 11
Early Childhood
Inventory
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Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
If response in shaded area: Consider Monitoring as a Goal.
W1 ..
Focus Child present in home during visit:

No

Yes
W2 ..
Focus Child location during visit:
If the child is not present, do not complete this page. When child is present and in room for at least 20 minutes during the visit, rate the following based on definitions found on the observational summary sheet.
W3 ..
Touches child affectionately.
W4 ..
Speaks in a warm tone of voice.
W5 ..
Smiles at child.
W6 ..
Praises child.
W7 ..
Uses positive expression with child.
W8 ..
Is attentive to what the child is doing.
W9 ..
Changes pace or activity to meet child's interests.
W10.
Replies to child's words or vocalizations.




Absent
-Did Not Happen
Barely There
-Happened a Little
Completely
There
-Happened a Lot






















If 5 or more responses in shaded area: Consider Parenting Education as a Goal.
Child NOT in room
most of visit

1

2

3

4
Child in room entire visit
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OBSERVATIONS - COMPLETE AT THE END OF THE VISIT
SECTION 12
Parent...
When finished with the interview, please press "save" below or at the top of the page to save the form.