Infant Toddler
Inventory
www.thefamilymap.org
version 5.4
Page 1 of 21
InfToddler v2.9.1
Date of Interview
Date of Interview:
Location of Interview - 00000001
Home
Location of Interview - 2
Other home
Location of Interview - 3
School
Location of Interview - 4
Public Place
Location of Interview:
Code of the interviewer
Interviewed by:
Male
Child Gender - 1
Male
Child Gender - 2
Female
Child Name:
Female
Name of the child
Parent Gender - 1
Male
Parent Gender - 2
Female
Parent/Guardian:
Male
Female
Parent Name
Parent ID
Parent ID
Sent - 1
Sent - 0
Thefamilymap.org
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Child age:
First Digit of Child Age in Month
Months
child age - 1
1 month or less
child age - 2
2-6 months
child age - 3
7-12 months
child age - 4
13-18 months
child age - 5
19-24 months
child age - 6
25-30 months
child age - 7
31-36 months
child age - 8
37 months or more
What do you consider your child's race - q1a_1
White
What do you consider your child's race - q1a_2
American Indian or Alaska Native
What do you consider your child's race - q1a_3
Asian
What do you consider your child's race - q1a_4
Black
What do you consider your child's race - q1a_5
Native Hawaiian or Other Pacific Islander
What do you consider your child's race - q1a_6
Other:
b) Do you consider your child to be Hispanic or Latino?
Do you consider your child to be Hispanic or Latino - 1
Yes
Do you consider your child to be Hispanic or Latino - 0
No
1. a) What do you consider your child's race?
Mark all that apply.
Other - Race Identified
c) Were you born in the United States?
were you born in the United States - 1
Yes
were you born in the United States - 0
No
Country of Origin - Name
Country of Origin
If No
your age - 1
16 years or less
your age - 2
17-18 years
your age - 3
19-24 years
your age - 4
25-34 years
your age - 5
35-40 years
your age - 6
41 or more
2. How old are you now?
How old are you in years
Years
3. What is your relationship to this child?
Your relationship to child - 1
Biological Parent
Your relationship to child - 2
Foster Parent
Your relationship to child - 3
Partner of Parent
Your relationship to child - 4
Other Relative
Your relationship to child - 5
Step Parent
Your relationship to child - 6
Adoptive Parent
Your relationship to child - 7
Grandparent
Your relationship to child - 8
Other:
INFANT TODDLER FAMILY MAP
INVENTORY
Other - Raltionship to Child
Target Child - 1
1
Target Child - 2
2
Target Child - 3
3
Target Child - 4
4
Target Child
isSaved - 1
isSaved - 0
AgenCode
Agency Code:
(Use '00000' for test records)
(Clear identifiers)
state
Location:
region
Region:
CenCode
Center:
ClassCode
Class:
Infant Toddler
Inventory
Page 2 of 21
InfToddler v2.9.1
Parent ID
Parent ID
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Child One Name
Child one relationship to mother
Child Two Name
Child two relationship to mother
Child Three Name
Child three relationship to mother
Child Four Name
Child four relationship to mother
Child Five Name
Child five relationship to mother
Child Six Name
Child six relationship to mother
Child Seven Name
Child seven relationship to mother
SECTION 1
SELF SUPPORT
S1. Is any language other than English regularly spoken in your home?
Language spoken in home - 0
No
Language spoken in home - 1
Spanish
Language spoken in home - 2
Other:
Other - None English Language Spoken in Home
Comfortable Speaking English - 1
Comfortable Speaking English - 2
Comfortable Speaking English - 3
Comfortable Speaking English - 4
How often:
Do Family Members Translate English for You with Program Staff - 1
Do Family Members Translate English for You with Program Staff - 2
Do Family Members Translate English for You with Program Staff - 3
Do Family Members Translate English for You with Program Staff - 4
Do you understand the written mateials presented - 1
Do you understand the written mateials presented - 2
Do you understand the written mateials presented - 3
Do you understand the written mateials presented - 4
Do you feel comfortable asking program staff to translate written mateials for you - 1
Do you feel comfortable asking program staff to translate written mateials for you - 2
Do you feel comfortable asking program staff to translate written mateials for you - 3
Do you feel comfortable asking program staff to translate written mateials for you - 4
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
Involved in Similar Program Previously - 0
No
Involved in Similar Program Previously - 1
Yes
If yes:
Other - name of previous program involved with
a) Did you set any goals with this program?
Goals with this Program? - 0
No
Goals with this Program? - 1
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.
children in home - 0
0
children in home - 1
1
children in home - 2
2
children in home - 3
3
children in home - 4
4
children in home - 5
5
children in home - 6
6
children in home - 7
7
Child Name:
Relationship to mother figure:
No Other Children
S4. Are you currently enrolled in school?
S5. What level of education have you completed?
completed school classification - 1
completed school classification - 2
completed school classification - 3
completed school classification - 4
completed school classification - 5
completed school classification - 6
No High School Degree
High School Degree
GED
Votech, Technical Certificate/License
College
Degree
Current school enrollment - 1
Current school enrollment - 2
Current school enrollment - 3
Current school enrollment - 4
Current school enrollment - 5
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
NoZone_4
If no, skip to S2
If Other
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.
Infant Toddler
Inventory
Page 3 of 21
InfToddler v2.9.1
Parent ID
Parent ID
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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
hours worked last week - 1
hours worked last week - 2
hours worked last week - 3
hours worked last week - 4
hours worked last week - 5
hours worked last week - 6
hours worked last week - 7
hours worked last week - 8
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)
time at job - 1
time at job - 2
time at job - 3
time at job - 4
time at job - 5
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?
number of jobs - 1
1
number of jobs - 2
2
number of jobs - 3
3
c) What shift do you usually work?
what kind of shift do you work - 1
what kind of shift do you work - 2
what kind of shift do you work - 3
what kind of shift do you work - 4
what kind of shift do you work - 5
A regular day shift
A regular evening shift
A regular night shift
A split shift
Some other shift
What shift do you usually work - detail?
S7. How many adults live in the home with you?
Only count people 18 years or older. Do not count mother figure.
number of adults in home - 0
0
number of adults in home - 1
1
number of adults in home - 2
2
number of adults in home - 3
3
number of adults in home - 4
4
number of adults in home - 5
5
number of adults in home - 6
6
number of adults in home - 7
7
number of adults in home - 8
8
number of adults in home - 9
9
S8. Are you or anyone in your family receiving unemployment payments?
receiving unemployment payments - 00000001
Yes
receiving unemployment payments - 0
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?
name of parental figure outside the home
Parent outside the home
name of parental figure in the home
Parent in the home
time lived together - 1
time lived together - 2
time lived together - 3
1 year or less
2-3 years
4 or more
relationship to child - 1
relationship to child - 2
relationship to child - 3
Biological Parent
Step, Foster, or Adoptive Parent
Your partner
d) Are you currently not working because of the birth of your child?
not working because of child birth - 0
No
not working because of child birth - 1
Yes
Relationship to child - 1
Relationship to child - 2
Relationship to child - 3
Biological Parent
Step, Foster, or Adoptive Parent
Your partner
NoZone_S6
If not working, skip to d.
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
education level - 1
education level - 2
education level - 3
education level - 4
College
Vocational
High School/ GED
No
current enrollment status - 1
current enrollment status - 2
current enrollment status - 3
current enrollment status - 4
hours working per week - 1
hours working per week - 2
hours working per week - 3
hours working per week - 4
50 hours or more
20-50 hours
20 hours or less
0-10 hours
education level - 1
education level - 2
education level - 3
education level - 4
No HS Degree
High School/ GED
Vocational
College
current enrollment status - 1
current enrollment status - 2
current enrollment status - 3
current enrollment status - 4
College
Vocational
High School/ GED
No
hours worked per week - 1
hours worked per week - 2
hours worked per week - 3
hours worked per week - 4
50 hours or more
20-50 hours
20 hours or less
0-10 hours
Page 3 of 21
InfToddler v2.9.1
Infant Toddler
Inventory
Page 4 of 21
InfToddler v2.9.1
Parent ID
Parent ID
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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?
Name of Other Adult living in the home - one
other adult one - number of years lived in home - 1
other adult one - number of years lived in home - 2
other adult one - number of years lived in home - 3
1 year or less
2-3 years
4 or more
other adult one - completed education level - 1
other adult one - completed education level - 2
other adult one - completed education level - 3
other adult one - completed education level - 4
No HS Degree
High School/ GED
Vocational
College
other adult one - Classification of Education Currently enrolled in - 1
other adult one - Classification of Education Currently enrolled in - 2
other adult one - Classification of Education Currently enrolled in - 3
other adult one - Classification of Education Currently enrolled in - 4
No
High School/ GED
Vocational
College
other adult one - hours per week currently working - 1
other adult one - hours per week currently working - 2
other adult one - hours per week currently working - 3
other adult one - hours per week currently working - 4
0-10 hours
20 hours or less
20-50 hours
50 hours or more
relationship to child - one - 1
relationship to child - one - 2
relationship to child - one - 3
Child's Grandparent
Child's Aunt/ Uncle
Other
relationship to child - other - one
Name of Other Adult living in the home - two
other adult two - number of years lived in home - 1
other adult two - number of years lived in home - 2
other adult two - number of years lived in home - 3
1 year or less
2-3 years
4 or more
other adult two - completed education level - 1
other adult two - completed education level - 2
other adult two - completed education level - 3
other adult two - completed education level - 4
No HS Degree
High School/ GED
Vocational
College
other adult two - Classification of Education Currently enrolled in - 1
other adult two - Classification of Education Currently enrolled in - 2
other adult two - Classification of Education Currently enrolled in - 3
other adult two - Classification of Education Currently enrolled in - 4
No
High School/ GED
Vocational
College
other adult two - hours per week currently working - 1
other adult two - hours per week currently working - 2
other adult two - hours per week currently working - 3
other adult two - hours per week currently working - 4
0-10 hours
20 hours or less
20-50 hours
50 hours or more
relationship to child - two - 1
relationship to child - two - 2
relationship to child - two - 3
Child's Grandparent
Child's Aunt/ Uncle
Other
relationship to child - other - two
Name of Other Adult living in the home - three
other adult three - number of years lived in home - 1
other adult three - number of years lived in home - 2
other adult three - number of years lived in home - 3
1 year or less
2-3 years
4 or more
other adult three - completed education level - 1
other adult three - completed education level - 2
other adult three - completed education level - 3
other adult three - completed education level - 4
No HS Degree
High School/ GED
Vocational
College
other adult three - Classification of Education Currently enrolled in - 1
other adult three - Classification of Education Currently enrolled in - 2
other adult three - Classification of Education Currently enrolled in - 3
other adult three - Classification of Education Currently enrolled in - 4
No
High School/ GED
Vocational
College
other adult three - hours per week currently working - 1
other adult three - hours per week currently working - 2
other adult three - hours per week currently working - 3
other adult three - hours per week currently working - 4
0-10 hours
20 hours or less
20-50 hours
50 hours or more
relationship to child - three - 1
relationship to child - three - 2
relationship to child - three - 3
Child's Grandparent
Child's Aunt/ Uncle
Other
relationship to child - other - three
(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.
Infant Toddler
Inventory
Page 5 of 21
InfToddler v2.9.1
Parent ID
Parent ID
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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?
Has the past month been typical for you? - 1
Yes
Has the past month been typical for you? - 0
No
R2.
R3.
In the last 6 months, have you been separated from the family more than a week? - 1
Yes
In the last 6 months, have you been separated from the family more than a week? - 0
No
In the last 6 months, has another adult in the household been separated from the family more than a week? - 1
Yes
In the last 6 months, has another adult in the household been separated from the family more than a week? - 0
No
In the next 6 months, do you anticipate being separated from the family more than a week? - 1
Yes
In the next 6 months, do you anticipate being separated from the family more than a week? - 0
No
In the next 6 months, do you anticipate an another adult in the household being separated from the family more than a week? - 1
Yes
In the next 6 months, do you anticipate an another adult in the household being separated from the family more than a week? - 0
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?
In the past year how many times has your child moved residences? - 0
0
In the past year how many times has your child moved residences? - 1
1
In the past year how many times has your child moved residences? - 2
2
In the past year how many times has your child moved residences? - 3
3
In the past year how many times has your child moved residences? - 4
more
Do you plan to move residences in the next year? - 1
Yes
Do you plan to move residences in the next year? - 0
No
Have you and your child lived with family or friends or in a shelter, hotel, car or other temporary housing in the past year? - 1
Yes
Have you and your child lived with family or friends or in a shelter, hotel, car or other temporary housing in the past year? - 0
No
In the past month, how many times did your child spend the night someplace else? - 0
0
In the past month, how many times did your child spend the night someplace else? - 1
1
In the past month, how many times did your child spend the night someplace else? - 2
2
In the past month, how many times did your child spend the night someplace else? - 3
more
If 3 or more
How many different places did they spend the night someplace else?
a)
How many different places did they spend the night someplace else? - 1
1
How many different places did they spend the night someplace else? - 2
2
How many different places did they spend the night someplace else? - 3
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?
In the past 7 days, how many of those days did your child brush teeth at about the same time, if less than 6 months did you do for them? - 0
In the past 7 days, how many of those days did your child brush teeth at about the same time, if less than 6 months did you do for them? - 1
In the past 7 days, how many of those days did your child brush teeth at about the same time, if less than 6 months did you do for them? - 2
In the past 7 days, how many of those days did your child brush teeth at about the same time, if less than 6 months did you do for them? - 3
In the past 7 days, how many of those days did your child brush teeth at about the same time, if less than 6 months did you do for them? - 4
In the past 7 days, how many of those days did your child brush teeth at about the same time, if less than 6 months did you do for them? - 5
In the past 7 days, how many of those days did your child brush teeth at about the same time, if less than 6 months did you do for them? - 6
In the past 7 days, how many of those days did your child brush teeth at about the same time, if less than 6 months did you do for them? - 7
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?
In the past 7 days, how many of those days did your child get a bath at about the same time, if less than 6 months did you do for them? - 0
In the past 7 days, how many of those days did your child get a bath at about the same time, if less than 6 months did you do for them? - 1
In the past 7 days, how many of those days did your child get a bath at about the same time, if less than 6 months did you do for them? - 2
In the past 7 days, how many of those days did your child get a bath at about the same time, if less than 6 months did you do for them? - 3
In the past 7 days, how many of those days did your child get a bath at about the same time, if less than 6 months did you do for them? - 4
In the past 7 days, how many of those days did your child get a bath at about the same time, if less than 6 months did you do for them? - 5
In the past 7 days, how many of those days did your child get a bath at about the same time, if less than 6 months did you do for them? - 6
In the past 7 days, how many of those days did your child get a bath at about the same time, if less than 6 months did you do for them? - 7
In the past 7 days, how many of those days did your child go to bed at about the same time, if less than 6 months did you do for them? - 0
In the past 7 days, how many of those days did your child go to bed at about the same time, if less than 6 months did you do for them? - 1
In the past 7 days, how many of those days did your child go to bed at about the same time, if less than 6 months did you do for them? - 2
In the past 7 days, how many of those days did your child go to bed at about the same time, if less than 6 months did you do for them? - 3
In the past 7 days, how many of those days did your child go to bed at about the same time, if less than 6 months did you do for them? - 4
In the past 7 days, how many of those days did your child go to bed at about the same time, if less than 6 months did you do for them? - 5
In the past 7 days, how many of those days did your child go to bed at about the same time, if less than 6 months did you do for them? - 6
In the past 7 days, how many of those days did your child go to bed at about the same time, if less than 6 months did you do for them? - 7
c)
Go to bed at about the same time?
d)
Stick to a regular morning routine?
In the past 7 days, how many of those days did your child stick to a regular morning routine, if less than 6 months did you do for them? - 0
In the past 7 days, how many of those days did your child stick to a regular morning routine, if less than 6 months did you do for them? - 1
In the past 7 days, how many of those days did your child stick to a regular morning routine, if less than 6 months did you do for them? - 2
In the past 7 days, how many of those days did your child stick to a regular morning routine, if less than 6 months did you do for them? - 3
In the past 7 days, how many of those days did your child stick to a regular morning routine, if less than 6 months did you do for them? - 4
In the past 7 days, how many of those days did your child stick to a regular morning routine, if less than 6 months did you do for them? - 5
In the past 7 days, how many of those days did your child stick to a regular morning routine, if less than 6 months did you do for them? - 6
In the past 7 days, how many of those days did your child stick to a regular morning routine, if less than 6 months did you do for them? - 7
Infant Toddler
Inventory
Page 6 of 21
InfToddler v2.9.1
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Parent ID
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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?
G or Y rated TV Programs or Movies - how often do you watch with your child in the room? - 0
G or Y rated TV Programs or Movies - how often do you watch with your child in the room? - 1
G or Y rated TV Programs or Movies - how often do you watch with your child in the room? - 2
G or Y rated TV Programs or Movies - how often do you watch with your child in the room? - 3
Never
Once a month
1-2 times a week
3 or more times a week
Use TV Show Card
Show card with example programs
PG or Y-7 rated TV Programs or Movies - how often do you watch with your child in the room? - 0
PG or Y-7 rated TV Programs or Movies - how often do you watch with your child in the room? - 1
PG or Y-7 rated TV Programs or Movies - how often do you watch with your child in the room? - 2
PG or Y-7 rated TV Programs or Movies - how often do you watch with your child in the room? - 3
PG-13 or Y-14 rated TV Programs or Movies - how often do you watch with your child in the room? - 0
PG-13 or Y-14 rated TV Programs or Movies - how often do you watch with your child in the room? - 1
PG-13 or Y-14 rated TV Programs or Movies - how often do you watch with your child in the room? - 2
PG-13 or Y-14 rated TV Programs or Movies - how often do you watch with your child in the room? - 3
R or Mature Audience rated TV Programs or Movies - how often do you watch with your child in the room? - 0
R or Mature Audience rated TV Programs or Movies - how often do you watch with your child in the room? - 1
R or Mature Audience rated TV Programs or Movies - how often do you watch with your child in the room? - 2
R or Mature Audience rated TV Programs or Movies - how often do you watch with your child in the room? - 3
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
R9_hours - 1
R9_hours - 2
R9_hours - 3
R9_hours - 4
R9_hours - 5
R9_hours - 6
R9_hours - 7
R9_hours - 8
R9_total
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
How active or calm is your home? - 1
1
How active or calm is your home? - 2
2
How active or calm is your home? - 3
3
How active or calm is your home? - 4
4
How well organized or disorganized is your home? - 1
1
How well organized or disorganized is your home? - 2
2
How well organized or disorganized is your home? - 3
3
How well organized or disorganized is your home? - 4
4
How crowded or uncrowded is your home with people living there or staying over? - 1
1
How crowded or uncrowded is your home with people living there or staying over? - 2
2
How crowded or uncrowded is your home with people living there or staying over? - 3
3
How crowded or uncrowded is your home with people living there or staying over? - 4
4
HrsSleep
How many hours did your child nap?
If total hours are less than 15 (<6 mths), 14 (6-12 mths), 13 (13-24 mths), 12 (25-36 mths): Consider establishing Sleep Routines as a Goal.
How many hours does your child watch TV or play video or computer games at home on a usual weekday? - 0
How many hours does your child watch TV or play video or computer games at home on a usual weekday? - 1
How many hours does your child watch TV or play video or computer games at home on a usual weekday? - 2
How many hours does your child watch TV or play video or computer games at home on a usual weekday? - 3
How many hours does your child watch TV or play video or computer games at home on a usual weekday? - 4
How many hours does your child watch TV or play video or computer games at home on a usual weekday? - 5
How many hours does your child watch TV or play video or computer games at home on a usual weekday? - 6
How many hours does your child watch TV or play video or computer games at home on a usual weekday? - 7
How many hours does your child watch TV or play video or computer games at home on a usual weekday? - 8
How many hours does your child watch TV or play video or computer games at home on a usual weekday? - 9
How many hours does your child watch TV or play video or computer games at home on a usual weekday? - 10
How many hours does your child watch TV or play video or computer games at home on a usual weekday? - 11
How many hours does your child watch TV or play video or computer games at home on a usual weekday? - 12
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
How many hours is a tv on at home during a usual weekday, even if no one is watching? - 0
How many hours is a tv on at home during a usual weekday, even if no one is watching? - 1
How many hours is a tv on at home during a usual weekday, even if no one is watching? - 2
How many hours is a tv on at home during a usual weekday, even if no one is watching? - 3
How many hours is a tv on at home during a usual weekday, even if no one is watching? - 4
How many hours is a tv on at home during a usual weekday, even if no one is watching? - 5
How many hours is a tv on at home during a usual weekday, even if no one is watching? - 7
How many hours is a tv on at home during a usual weekday, even if no one is watching? - 6
How many hours is a tv on at home during a usual weekday, even if no one is watching? - 8
How many hours is a tv on at home during a usual weekday, even if no one is watching? - 9
How many hours is a tv on at home during a usual weekday, even if no one is watching? - 10
How many hours is a tv on at home during a usual weekday, even if no one is watching? - 11
How many hours is a tv on at home during a usual weekday, even if no one is watching? - 12
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
calculate
Calculate
17 or more
Hours - what time did your child go to sleep?
Hours
Minutes - what time did your child go to sleep?
Minutes
AM or PM - what time did your child go to sleep? - AM
AM
AM or PM - what time did your child go to sleep? - PM
PM
:
Hours - what time did your child wake up?
Hours
Minutes - what time did your child wake up?
Minutes
AM or PM - what time did your child wake up? - AM
AM
AM or PM - what time did your child wake up? - PM
PM
Page 6 of 21
InfToddler v2.9.1
Infant Toddler
Inventory
Page 7 of 21
InfToddler v2.9.1
Parent ID
Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
Even very young infants benefit from things and objects they can hear, see and touch. 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 that your child:
Indicate number of types for example: drawing paper and crayons = 1, 3 stuffed animal = 1
0
1
2
3 or more
a)
Can feel and cuddle
such as stuffed animal, soft cloth, or play mat with textures?
Do you have things that your child (less than 12 months) can use their muscles with - ball, crib gym, jumpr rope or swing? - 0
Do you have things that your child (less than 12 months) can use their muscles with - ball, crib gym, jumpr rope or swing? - 1
Do you have things that your child (less than 12 months) can use their muscles with - ball, crib gym, jumpr rope or swing? - 2
Do you have things that your child (less than 12 months) can use their muscles with - ball, crib gym, jumpr rope or swing? - 3
c)
Can feel and cuddle
such as stuffed animal, soft cloth, or play mat with textures?
Do you have things that your child (less than 12 months) can feel or cuddle - stuffed animal, soft cloth, play mat with textures? - 0
Do you have things that your child (less than 12 months) can feel or cuddle - stuffed animal, soft cloth, play mat with textures? - 1
Do you have things that your child (less than 12 months) can feel or cuddle - stuffed animal, soft cloth, play mat with textures? - 2
Do you have things that your child (less than 12 months) can feel or cuddle - stuffed animal, soft cloth, play mat with textures? - 3
b)
Can make noise with
such as objects that rattle, spin, jitter, whir, etc.?
Do you have things that your child (less than 12 months) can make noise with - rattle, spin, jitter, whir? - 0
Do you have things that your child (less than 12 months) can make noise with - rattle, spin, jitter, whir? - 1
Do you have things that your child (less than 12 months) can make noise with - rattle, spin, jitter, whir? - 2
Do you have things that your child (less than 12 months) can make noise with - rattle, spin, jitter, whir? - 3
a)
Can see
such as a mirror in the crib, mobile, or nightlight that projects light onto ceiling?
Do you have things that your child (less than 12 months) can see - mirror in the crib, mobile, night light that projects light onto ceiling? - 0
Do you have things that your child (less than 12 months) can see - mirror in the crib, mobile, night light that projects light onto ceiling? - 1
Do you have things that your child (less than 12 months) can see - mirror in the crib, mobile, night light that projects light onto ceiling? - 2
Do you have things that your child (less than 12 months) can see - mirror in the crib, mobile, night light that projects light onto ceiling? - 3
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.
Do you have a library card? - 1
Yes
Do you have a library card? - 0
No
L2.
How many children's books does your child have of his/her own or share with brothers or sisters?
How many children's books does your child have of his or her own or share with brothers or sisters? - 0
How many children's books does your child have of his or her own or share with brothers or sisters? - 1
How many children's books does your child have of his or her own or share with brothers or sisters? - 2
How many children's books does your child have of his or her own or share with brothers or sisters? - 3
L4.
In the past month, have you visited a public library?
In the past month, have you visited the library? - 1
Yes
In the past month, have you visited the library? - 0
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)
Can use their muscles with
such as a ball, crib gym, or jump swing?
Do you have things that your child (more than 12 months) can feel or cuddle - stuffed animal, soft cloth, play mat with textures? - 0
Do you have things that your child (more than 12 months) can feel or cuddle - stuffed animal, soft cloth, play mat with textures? - 1
Do you have things that your child (more than 12 months) can feel or cuddle - stuffed animal, soft cloth, play mat with textures? - 2
Do you have things that your child (more than 12 months) can feel or cuddle - stuffed animal, soft cloth, play mat with textures? - 3
Do you have things that your child (more than 12 months) can use their muscles with - ball, crib gym, jumpr rope or swing? - 0
Do you have things that your child (more than 12 months) can use their muscles with - ball, crib gym, jumpr rope or swing? - 1
Do you have things that your child (more than 12 months) can use their muscles with - ball, crib gym, jumpr rope or swing? - 2
Do you have things that your child (more than 12 months) can use their muscles with - ball, crib gym, jumpr rope or swing? - 3
b)
Can use their muscles with
such as a ball, crib gym, jump swing, tricycle, or slide?
0
1
2
3 or more
Do you have things that your child (more than 12 months) can put together - legos, pans with lids, stacking rings, or nesting blocks? - 0
Do you have things that your child (more than 12 months) can put together - legos, pans with lids, stacking rings, or nesting blocks? - 1
Do you have things that your child (more than 12 months) can put together - legos, pans with lids, stacking rings, or nesting blocks? - 2
Do you have things that your child (more than 12 months) can put together - legos, pans with lids, stacking rings, or nesting blocks? - 3
c)
Can put together
in different ways such as legos, pans with lids, stacking rings, or nesting blocks?
Do you have things that your child (more than 12 months) can make art or be creative with - crayons, markers, chalk or play dough? - 0
Do you have things that your child (more than 12 months) can make art or be creative with - crayons, markers, chalk or play dough? - 1
Do you have things that your child (more than 12 months) can make art or be creative with - crayons, markers, chalk or play dough? - 2
Do you have things that your child (more than 12 months) can make art or be creative with - crayons, markers, chalk or play dough? - 3
d)
Can make art or be creative with
such as crayons,markers, chalk, or play dough? *inidicate number of types for example: drawing paper and crayons = 1.
Do you have things that your child (more than 12 months) can play or make music with - instruments or music player? - 0
Do you have things that your child (more than 12 months) can play or make music with - instruments or music player? - 1
Do you have things that your child (more than 12 months) can play or make music with - instruments or music player? - 2
Do you have things that your child (more than 12 months) can play or make music with - instruments or music player? - 3
e)
Can play or make music with
such as toy musical instrument or music player?
(not including while in child care)
NoZone_2_4
Complete for
NoZone_2_2_2
children older
NoZone_2_3_2
than 12 months
NoZone_2
Complete for
NoZone_2_2
children younger
NoZone_2_3
than 12 months
EARLY LEARNING
SECTION 3
a)
Mother/figure?
b)
Father/figure?
c)
Anyone else?
In the past week, how many times did anyone else read or look at a book with your child? - 0
In the past week, how many times did anyone else read or look at a book with your child? - 1
In the past week, how many times did anyone else read or look at a book with your child? - 2
In the past week, how many times did anyone else read or look at a book with your child? - 3
In the past week, how many times did father/figure read or look at a book with your child? - 0
In the past week, how many times did father/figure read or look at a book with your child? - 1
In the past week, how many times did father/figure read or look at a book with your child? - 2
In the past week, how many times did father/figure read or look at a book with your child? - 3
In the past week, how many times did mother/figure read or look at a book with your child? - 0
In the past week, how many times did mother/figure read or look at a book with your child? - 1
In the past week, how many times did mother/figure read or look at a book with your child? - 2
In the past week, how many times did mother/figure read or look at a book with your child? - 3
Not Available or None
1 - 2 times/week
3 - 5 times/week
6 or more times
Page 7 of 21
InfToddler v2.9.1
Infant Toddler
Inventory
Page 8 of 21
InfToddler v2.9.1
Parent ID
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 games like peek-a-boo or patty cake with your child?
b)
Play with toys or games with your child?
c)
Talk to your child while doing ordinary household chores?
d)
Tell your child the name of things, places, or people?
e)
Play chase or dancing games with child?
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
In the past month, have you or someone in your family taken your child on an outing such as shopping? - 0
In the past month, have you or someone in your family taken your child on an outing such as shopping? - 1
a)
Taken your child on an outing such as shopping?
Next we want to ask you about some things that parents do with young children to have fun outside the home.
In the past month, have you or someone in your family taken your child for a walk or to a local park? - 0
In the past month, have you or someone in your family taken your child for a walk or to a local park? - 1
In the past month, have you or someone in your family taken your child to go visit a friend or relative? - 0
In the past month, have you or someone in your family taken your child to go visit a friend or relative? - 1
b)
Gone for a walk or to a local park?
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
In the past year, have you or someone in your family taken your child to a play, concert or other live show? - 0
In the past year, have you or someone in your family taken your child to a play, concert or other live show? - 1
a)
Gone to a play, concert, or other live show?
In the past year, have you or someone in your family taken your child to visit the zoo? - 0
In the past year, have you or someone in your family taken your child to visit the zoo? - 1
In the past year, have you or someone in your family taken your child to visit the an art gallery, museum, or historical site? - 0
In the past year, have you or someone in your family taken your child to visit the an art gallery, museum, or historical site? - 1
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?
In the past year, have you or someone in your family taken your child to attend a community event like a fair, festival, parade or block party? - 0
In the past year, have you or someone in your family taken your child to attend a community event like a fair, festival, parade or block party? - 1
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
In the past week, how many times did you or someone in your family use games, toys, books or other objects to - count things with your child? - 0
In the past week, how many times did you or someone in your family use games, toys, books or other objects to - count things with your child? - 1
In the past week, how many times did you or someone in your family use games, toys, books or other objects to - count things with your child? - 2
In the past week, how many times did you or someone in your family use games, toys, books or other objects to - count things with your child? - 3
In the past week, how many times did you or someone in your family use games, toys, books or other objects to - sing the alphabet song or point out letters or words? - 0
In the past week, how many times did you or someone in your family use games, toys, books or other objects to - sing the alphabet song or point out letters or words? - 1
In the past week, how many times did you or someone in your family use games, toys, books or other objects to - sing the alphabet song or point out letters or words? - 2
In the past week, how many times did you or someone in your family use games, toys, books or other objects to - sing the alphabet song or point out letters or words? - 3
In the past week, how many times did you or someone in your family use games, toys, books or other objects to - point out and name colors? - 0
In the past week, how many times did you or someone in your family use games, toys, books or other objects to - point out and name colors? - 1
In the past week, how many times did you or someone in your family use games, toys, books or other objects to - point out and name colors? - 2
In the past week, how many times did you or someone in your family use games, toys, books or other objects to - point out and name colors? - 3
In the past week, how many times did you or someone in your family use games, toys, books or other objects to - point out and name shapes? - 0
In the past week, how many times did you or someone in your family use games, toys, books or other objects to - point out and name shapes? - 1
In the past week, how many times did you or someone in your family use games, toys, books or other objects to - point out and name shapes? - 2
In the past week, how many times did you or someone in your family use games, toys, books or other objects to - point out and name shapes? - 3
In the past week, how many times did you or someone in your family - play chase or dancing games with child? - 0
In the past week, how many times did you or someone in your family - play chase or dancing games with child? - 1
In the past week, how many times did you or someone in your family - play chase or dancing games with child? - 2
In the past week, how many times did you or someone in your family - play chase or dancing games with child? - 3
In the past week, how many times did you or someone in your family - tell your child the name of things, places or people? - 0
In the past week, how many times did you or someone in your family - tell your child the name of things, places or people? - 1
In the past week, how many times did you or someone in your family - tell your child the name of things, places or people? - 2
In the past week, how many times did you or someone in your family - tell your child the name of things, places or people? - 3
In the past week, how many times did you or someone in your family - talk to your child while doing ordinary household chores? - 0
In the past week, how many times did you or someone in your family - talk to your child while doing ordinary household chores? - 1
In the past week, how many times did you or someone in your family - talk to your child while doing ordinary household chores? - 2
In the past week, how many times did you or someone in your family - talk to your child while doing ordinary household chores? - 3
In the past week, how many times did you or someone in your family - play with toys or games with your child? - 0
In the past week, how many times did you or someone in your family - play with toys or games with your child? - 1
In the past week, how many times did you or someone in your family - play with toys or games with your child? - 2
In the past week, how many times did you or someone in your family - play with toys or games with your child? - 3
In the past week, how many times did you or someone in your family - play games like peek-a-boo or patty cake with your child? - 0
In the past week, how many times did you or someone in your family - play games like peek-a-boo or patty cake with your child? - 1
In the past week, how many times did you or someone in your family - play games like peek-a-boo or patty cake with your child? - 2
In the past week, how many times did you or someone in your family - play games like peek-a-boo or patty cake with your child? - 3
None
1 - 2 times week
3 - 5 times week
6 or more times
Infant Toddler
Inventory
Page 9 of 21
InfToddler v2.9.1
Parent ID
Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
Infants and toddlers can be demanding, and trying to do more than one thing at a time can be difficult. 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
What is the longest amount of time you would allow your child to be asleep in the house while you are outside? - 0
What is the longest amount of time you would allow your child to be asleep in the house while you are outside? - 1
What is the longest amount of time you would allow your child to be asleep in the house while you are outside? - 2
What is the longest amount of time you would allow your child to be asleep in the house while you are outside? - 3
What is the longest amount of time you would allow your child to be asleep in the house while you are outside? - 4
30 Minutes or more
What is the longest amount of time you would allow your child to be in the bathtub without you in the room? - 0
What is the longest amount of time you would allow your child to be in the bathtub without you in the room? - 1
What is the longest amount of time you would allow your child to be in the bathtub without you in the room? - 2
What is the longest amount of time you would allow your child to be in the bathtub without you in the room? - 3
What is the longest amount of time you would allow your child to be in the bathtub without you in the room? - 4
What is the longest amount of time you would allow your child to be awake in the room when you are not in the room? - 0
What is the longest amount of time you would allow your child to be awake in the room when you are not in the room? - 1
What is the longest amount of time you would allow your child to be awake in the room when you are not in the room? - 2
What is the longest amount of time you would allow your child to be awake in the room when you are not in the room? - 3
What is the longest amount of time you would allow your child to be awake in the room when you are not in the room? - 4
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
?
How many people did your child stay with in the past month? - 0
How many people did your child stay with in the past month? - 1
How many people did your child stay with in the past month? - 2
How many people did your child stay with in the past month? - 3
How many people did your child stay with in the past month? - 4
How many people did your child stay with in the past month? - 5
How many people did your child stay with in the past month? - 6
0
1-2
3-4
10+
5-6
7-8
9
NoZone
If zero: Skip to M3
How many people did your child stay with in the past month - were any of these under 13 years of age? - 0
How many people did your child stay with in the past month - were any of these under 13 years of age? - 1
a)
Were any of these people under 13 years of age?
How many people did your child stay with in the past month - were any of these poeple you have known less than one month? - 0
How many people did your child stay with in the past month - were any of these poeple you have known less than one month? - 1
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?
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? - 0
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? - 1
M4.
In the past month, did you have problems finding care for
any
of your children - day or night?
In the past month, did you have problems finding care for any of your children, day or night? - 0
In the past month, did you have problems finding care for any of your children, day or night? - 1
If any response in shaded area: Consider Child Care as a Goal.
a)
Asleep in the house while you are outside?
b)
In the bathtub without you in the room?
c)
Awake in the room when you're not in the room?
d)
Outside when you're inside?
What is the longest amount of time you would allow your child to be outside when you are inside? - 0
What is the longest amount of time you would allow your child to be outside when you are inside? - 1
What is the longest amount of time you would allow your child to be outside when you are inside? - 2
What is the longest amount of time you would allow your child to be outside when you are inside? - 3
What is the longest amount of time you would allow your child to be outside when you are inside? - 4
No
Yes
No
Yes
MONITORING
SECTION 4
Infant Toddler
Inventory
Page 10 of 21
InfToddler v2.9.1
Parent ID
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
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:
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
Is your neighborhood have issues with people selling or using drugs? - 1
Is your neighborhood have issues with people selling or using drugs? - 2
Is your neighborhood have issues with people selling or using drugs? - 3
Is your neighborhood have issues with people selling or using drugs? - 4
Never
Some of the Time
Most of the Time
All of the Time
Thinking about crime and safety in your neighborhood, how often do you think about moving because of the safety of the neighborhood? - 1
Thinking about crime and safety in your neighborhood, how often do you think about moving because of the safety of the neighborhood? - 2
Thinking about crime and safety in your neighborhood, how often do you think about moving because of the safety of the neighborhood? - 3
Thinking about crime and safety in your neighborhood, how often do you think about moving because of the safety of the neighborhood? - 4
Never Happen
Hardly Ever Happen
Happen Fairly Often
Happen Very Often
How often are there problems with muggings, burglaries, assaults, or other criminal activities in your neighborhood? - 1
How often are there problems with muggings, burglaries, assaults, or other criminal activities in your neighborhood? - 2
How often are there problems with muggings, burglaries, assaults, or other criminal activities in your neighborhood? - 3
How often are there problems with muggings, burglaries, assaults, or other criminal activities in your neighborhood? - 4
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:
In the past year, how many times has your child been physically hurt by someone for example hit, kciked, punched or spanked in a way that left marks by somone in your home or neighborhood? - 0
In the past year, how many times has your child been physically hurt by someone for example hit, kciked, punched or spanked in a way that left marks by somone in your home or neighborhood? - 1
In the past year, how many times has your child been physically hurt by someone for example hit, kciked, punched or spanked in a way that left marks by somone in your home or neighborhood? - 2
In the past year, how many times has your child been physically hurt by someone for example hit, kciked, punched or spanked in a way that left marks by somone in your home or neighborhood? - 3
In the past year, how many times has your child been physically hurt by someone for example hit, kciked, punched or spanked in a way that left marks by somone in your home or neighborhood? - 4
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?
In the past year, how many times have you or someone living in your home been physically hurt by someone? - 0
In the past year, how many times have you or someone living in your home been physically hurt by someone? - 1
In the past year, how many times have you or someone living in your home been physically hurt by someone? - 2
In the past year, how many times have you or someone living in your home been physically hurt by someone? - 3
In the past year, how many times have you or someone living in your home been physically hurt by someone? - 4
c)
Has your child seen someone try to physically hurt another person?
In the past year, has your child ever seen someone try to physically hurt another person? - 0
In the past year, has your child ever seen someone try to physically hurt another person? - 1
In the past year, has your child ever seen someone try to physically hurt another person? - 2
In the past year, has your child ever seen someone try to physically hurt another person? - 3
In the past year, has your child ever seen someone try to physically hurt another person? - 4
d)
Has your child seen drug or sexual activities?
In the past year, has your child ever seen someone involved in drug or sexual activities? - 0
In the past year, has your child ever seen someone involved in drug or sexual activities? - 1
In the past year, has your child ever seen someone involved in drug or sexual activities? - 2
In the past year, has your child ever seen someone involved in drug or sexual activities? - 3
In the past year, has your child ever seen someone involved in drug or sexual activities? - 4
If any response in shaded area: Consider Family Safety or Counseling as a Goal.
Very Bad
Fairly Bad
Fairly Good
Very Good
How do you feel about your neighborhood - doe you feel it is good or bad? - 1
How do you feel about your neighborhood - doe you feel it is good or bad? - 2
How do you feel about your neighborhood - doe you feel it is good or bad? - 3
How do you feel about your neighborhood - doe you feel it is good or bad? - 4
E1.
How do you feel about your neighborhood?
Do you feel it is:
Neighborhood Unsafe
How Safe or Unsafe is your neighborhood? - 1
1
How Safe or Unsafe is your neighborhood? - 2
2
How Safe or Unsafe is your neighborhood? - 3
3
How Safe or Unsafe is your neighborhood? - 4
4
Neighborhood Safe
ENVIRONMENTAL SAFETY
SECTION 5
Infant Toddler
Inventory
Page 11 of 21
InfToddler v2.9.1
Parent ID
Parent ID
Thefamilymap.org
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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
Regarding people that help you raise your child - how often do you and this person have disagreements about how to raise your child? - 1
Regarding people that help you raise your child - how often do you and this person have disagreements about how to raise your child? - 2
Regarding people that help you raise your child - how often do you and this person have disagreements about how to raise your child? - 3
Skip
only
if no other person is identified inside or outside the home.
Use Response Card
Regarding people that help you raise your child - how often does conversations turn hostile or angey with them? - 1
Regarding people that help you raise your child - how often does conversations turn hostile or angey with them? - 2
Regarding people that help you raise your child - how often does conversations turn hostile or angey with them? - 3
Regarding people that help you raise your child - how often do disagreements related to money to buy things for or support the child occurre? - 1
Regarding people that help you raise your child - how often do disagreements related to money to buy things for or support the child occurre? - 2
Regarding people that help you raise your child - how often do disagreements related to money to buy things for or support the child occurre? - 3
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:
Regarding family members or others you consider family that you see at least weekly - how often is it true for people to lose their tempers? - 1
Regarding family members or others you consider family that you see at least weekly - how often is it true for people to lose their tempers? - 2
Regarding family members or others you consider family that you see at least weekly - how often is it true for people to lose their tempers? - 3
Use Response Card
F4.
People in our family lose their tempers.
Regarding family members or others you consider family that you see at least weekly - how often is it true for people to feel very close? - 1
Regarding family members or others you consider family that you see at least weekly - how often is it true for people to feel very close? - 2
Regarding family members or others you consider family that you see at least weekly - how often is it true for people to feel very close? - 3
F5.
Family members feel very close.
Regarding family members or others you consider family that you see at least weekly - how often is it true for people to raise their voices to yell or in anger? - 1
Regarding family members or others you consider family that you see at least weekly - how often is it true for people to raise their voices to yell or in anger? - 2
Regarding family members or others you consider family that you see at least weekly - how often is it true for people to raise their voices to yell or in anger? - 3
F6.
We raise our voices or yell in anger.
Regarding family members or others you consider family that you see at least weekly - how often is it true for people to be supportive of each other? - 1
Regarding family members or others you consider family that you see at least weekly - how often is it true for people to be supportive of each other? - 2
Regarding family members or others you consider family that you see at least weekly - how often is it true for people to be supportive of each other? - 3
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 much do you agree - during the past month, I felt stressed out with the day-to-day demands of raising chidlren? - 1
How much do you agree - during the past month, I felt stressed out with the day-to-day demands of raising chidlren? - 2
How much do you agree - during the past month, I felt stressed out with the day-to-day demands of raising chidlren? - 3
How much do you agree - during the past month, I felt stressed out with the day-to-day demands of raising chidlren? - 4
How much do you agree - during the past month, I felt so stressed out that I was afraid I might lose control? - 1
How much do you agree - during the past month, I felt so stressed out that I was afraid I might lose control? - 2
How much do you agree - during the past month, I felt so stressed out that I was afraid I might lose control? - 3
How much do you agree - during the past month, I felt so stressed out that I was afraid I might lose control? - 4
How much do you agree - during the past month, I worry I will spoil my child by giving them too much attention? - 1
How much do you agree - during the past month, I worry I will spoil my child by giving them too much attention? - 2
How much do you agree - during the past month, I worry I will spoil my child by giving them too much attention? - 3
How much do you agree - during the past month, I worry I will spoil my child by giving them too much attention? - 4
How much do you agree - during the past month, I felt that your child was much harder to care for than most children their age? - 1
How much do you agree - during the past month, I felt that your child was much harder to care for than most children their age? - 2
How much do you agree - during the past month, I felt that your child was much harder to care for than most children their age? - 3
How much do you agree - during the past month, I felt that your child was much harder to care for than most children their age? - 4
How much do you agree - during the past month, I expected to have closer or warmer feelings for your child and that bothers you? - 1
How much do you agree - during the past month, I expected to have closer or warmer feelings for your child and that bothers you? - 2
How much do you agree - during the past month, I expected to have closer or warmer feelings for your child and that bothers you? - 3
How much do you agree - during the past month, I expected to have closer or warmer feelings for your child and that bothers you? - 4
How much do you agree - during the past month, I felt unappreciated when I do things for my child. - 1
How much do you agree - during the past month, I felt unappreciated when I do things for my child. - 2
How much do you agree - during the past month, I felt unappreciated when I do things for my child. - 3
How much do you agree - during the past month, I felt unappreciated when I do things for my child. - 4
How much do you agree - during the past month, that sometimes the punishment given to your child depended on your mood. - 1
How much do you agree - during the past month, that sometimes the punishment given to your child depended on your mood. - 2
How much do you agree - during the past month, that sometimes the punishment given to your child depended on your mood. - 3
How much do you agree - during the past month, that sometimes the punishment given to your child depended on your mood. - 4
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.
Never or Rarely
Some Times
Often or Always
Page 11 of 21
InfToddler v2.9.1
Infant Toddler
Inventory
Page 12 of 21
InfToddler v2.9.1
Parent ID
Parent ID
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When your child has done something wrong, how often do you:
D2.
How often in the past week, have you had to punish your child for misbehavior? - 0
How often in the past week, have you had to punish your child for misbehavior? - 1
How often in the past week, have you had to punish your child for misbehavior? - 2
How often in the past week, have you had to punish your child for misbehavior? - 3
How often in the past week, have you had to punish your child for misbehavior? - 4
How often in the past week, have you had to punish your child for misbehavior? - 5
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
When you child has done something wrong, how often do you - use time out - make your child stand or sit in a corner or chair? - 0
When you child has done something wrong, how often do you - use time out - make your child stand or sit in a corner or chair? - 1
When you child has done something wrong, how often do you - use time out - make your child stand or sit in a corner or chair? - 2
When you child has done something wrong, how often do you - use time out - make your child stand or sit in a corner or chair? - 3
When you child has done something wrong, how often do you - use time out - make your child stand or sit in a corner or chair? - 4
Use time-out: make him/her stand or sit in a corner or chair.
a)
When you child has done something wrong, how often do you - take away privileges or object/toy for a period of time, restrict access? - 0
When you child has done something wrong, how often do you - take away privileges or object/toy for a period of time, restrict access? - 1
When you child has done something wrong, how often do you - take away privileges or object/toy for a period of time, restrict access? - 2
When you child has done something wrong, how often do you - take away privileges or object/toy for a period of time, restrict access? - 3
When you child has done something wrong, how often do you - take away privileges or object/toy for a period of time, restrict access? - 4
Take away privileges or object/toy for a period of time, restrict access.
b)
When you child has done something wrong, how often do you - redirect, distract, or turn the child's attention to something else? - 0
When you child has done something wrong, how often do you - redirect, distract, or turn the child's attention to something else? - 1
When you child has done something wrong, how often do you - redirect, distract, or turn the child's attention to something else? - 2
When you child has done something wrong, how often do you - redirect, distract, or turn the child's attention to something else? - 3
When you child has done something wrong, how often do you - redirect, distract, or turn the child's attention to something else? - 4
Re-direct, distract, or turn the child's attention to something else.
c)
When you child has done something wrong, how often do you - discuss the problem - ask questions - teach them? - 0
When you child has done something wrong, how often do you - discuss the problem - ask questions - teach them? - 1
When you child has done something wrong, how often do you - discuss the problem - ask questions - teach them? - 2
When you child has done something wrong, how often do you - discuss the problem - ask questions - teach them? - 3
When you child has done something wrong, how often do you - discuss the problem - ask questions - teach them? - 4
When you child has done something wrong, how often do you - ignore it? - 0
When you child has done something wrong, how often do you - ignore it? - 1
When you child has done something wrong, how often do you - ignore it? - 2
When you child has done something wrong, how often do you - ignore it? - 3
When you child has done something wrong, how often do you - ignore it? - 4
Spank your child with a belt, switch, or other object
If all responses in shaded area: Consider Discipline Strategies as a Goal.
When you child has done something wrong, how often do you - yell at your child? - 0
When you child has done something wrong, how often do you - yell at your child? - 1
When you child has done something wrong, how often do you - yell at your child? - 2
When you child has done something wrong, how often do you - yell at your child? - 3
When you child has done something wrong, how often do you - yell at your child? - 4
If any response in shaded area: Consider Discipline Strategies as a Goal.
When you child has done something wrong, how often do you - Slap your child's hand? - 0
When you child has done something wrong, how often do you - Slap your child's hand? - 1
When you child has done something wrong, how often do you - Slap your child's hand? - 2
When you child has done something wrong, how often do you - Slap your child's hand? - 3
When you child has done something wrong, how often do you - Slap your child's hand? - 4
When you child has done something wrong, how often do you - spank your child with your hand? - 0
When you child has done something wrong, how often do you - spank your child with your hand? - 1
When you child has done something wrong, how often do you - spank your child with your hand? - 2
When you child has done something wrong, how often do you - spank your child with your hand? - 3
When you child has done something wrong, how often do you - spank your child with your hand? - 4
i)
When you child has done something wrong, how often do you - spank your child with a beld, switch or other object? - 0
When you child has done something wrong, how often do you - spank your child with a beld, switch or other object? - 1
When you child has done something wrong, how often do you - spank your child with a beld, switch or other object? - 2
When you child has done something wrong, how often do you - spank your child with a beld, switch or other object? - 3
When you child has done something wrong, how often do you - spank your child with a beld, switch or other object? - 4
e)
Ignore it.
f)
Yell at your child.
g)
Slap your child's hand.
h)
d)
Discuss the problem, ask questions, and/or teach them.
Spank your child with your hand.
DISCIPLINE
SECTION 7
N/A Never
Rarely
Some times
Often
Always
N/A Never
Rarely
Some times
Often
Always
Infant Toddler
Inventory
Page 13 of 21
InfToddler v2.9.1
Parent ID
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.
Do you have a health issue or illness that requires regular, ongoing care or medication? - 0
No
Do you have a health issue or illness that requires regular, ongoing care or medication? - 1
Yes
If no, skip to H2.
Note Condition:
Notate Condition - Details
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?
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.
Does your child have a health issue or illness that requires ongoing care or medication? - 0
No
Does your child have a health issue or illness that requires ongoing care or medication? - 1
Yes
If no, skip to H3.
Note Condition:
Notate Condition - Details
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?
H3.
Does
anyone else
in the home have a health problem or illness that requires regular, ongoing care or medication?
Does anyone else in the home have health issues or illness that requires ongoing care or medication? - 0
No
Does anyone else in the home have health issues or illness that requires ongoing care or medication? - 1
Yes
If no, skip to H4.
Note Condition:
Notate Condition - Details
Determine need:
Do they have a plan from the doctor? Do they feel comfortable following that plan?
Yes, Care Demanding
Has a Plan of Action or Needs help with Planning - 1
1
Has a Plan of Action or Needs help with Planning - 2
2
Has a Plan of Action or Needs help with Planning - 3
3
Has a Plan of Action or Needs help with Planning - 4
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?
No
Yes
Do you have a doctor you consider your child's doctor? - 0
No
Do you have a doctor you consider your child's doctor? - 1
Yes
H6.
H7.
Do you have a dentist you consider to be your child's dentist?
H8.
Does your child have health insurance?
Do you have a dentist you consider to be your child's dentist? - 0
Do you have a dentist you consider to be your child's dentist? - 1
Does your child have health insurance? - 0
Does your child have health insurance? - 1
Can you get health care when your child is sick or injured that is not from a hospital emergency room? - 0
Can you get health care when your child is sick or injured that is not from a hospital emergency room? - 2
Can you get health care when your child is sick or injured that is not from a hospital emergency room? - 1
Can you get health care when your child is sick or injured that is not from a hospital emergency room?
No
Not Sure
Yes
H5.
Well child medical visits are for check-ups and immunizations, not visits for an illness. These visits are recommended at the ages below. When was your child's last well-child visit? To consider this as a goal, compare the last visit to the age of the child.
How old was your child at their last well child visit? - 0
How old was your child at their last well child visit? - 1
How old was your child at their last well child visit? - 2
How old was your child at their last well child visit? - 3
How old was your child at their last well child visit? - 4
How old was your child at their last well child visit? - 5
How old was your child at their last well child visit? - 6
How old was your child at their last well child visit? - 7
How old was your child at their last well child visit? - 8
How old was your child at their last well child visit? - 9
How old was your child at their last well child visit? - 10
3-7
days
2-4
weeks
2
months
4
months
6
months
9
months
12
months
15
months
18
months
24 months
30 months
Needs Help with Plan
Has a Plan of Action or Needs help with Planning - 1
1
Has a Plan of Action or Needs help with Planning - 2
2
Has a Plan of Action or Needs help with Planning - 3
3
Has a Plan of Action or Needs help with Planning - 4
4
Has a Plan and Following
Needs Help with Plan
Has a Plan of Action or Needs help with Planning - 1
1
Has a Plan of Action or Needs help with Planning - 2
2
Has a Plan of Action or Needs help with Planning - 3
3
Has a Plan of Action or Needs help with Planning - 4
4
Has a Plan and Following
If any response in shaded area or immunizations not current: Consider Child Health Care as a Goal.
SECTION 8
HEALTH
Page 13 of 21
InfToddler v2.9.1
Infant Toddler
Inventory
Page 14 of 21
InfToddler v2.9.1
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Parent ID
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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?
Can you get health care when you are sick or injured that is not from a hospital emergency room? - 0
Can you get health care when you are sick or injured that is not from a hospital emergency room? - 2
Can you get health care when you are sick or injured that is not from a hospital emergency room? - 1
H11.
Are you currently pregnant?
Are you currently pregnant? - 0
Are you currently pregnant? - 1
H12.
Is anyone else in your home currently pregnant?
Is anyone else in your home pregnant? - 0
Is anyone else in your home pregnant? - 1
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
In the past month, how many times each week did you exercise such as running or walking for at least 30 minutes? - 0
In the past month, how many times each week did you exercise such as running or walking for at least 30 minutes? - 1
In the past month, how many times each week did you exercise such as running or walking for at least 30 minutes? - 2
In the past month, how many times each week did you exercise such as running or walking for at least 30 minutes? - 3
In the past month, how many times per week have you felt you did not get enough rest or sleep? - 0
In the past month, how many times per week have you felt you did not get enough rest or sleep? - 1
In the past month, how many times per week have you felt you did not get enough rest or sleep? - 2
In the past month, how many times per week have you felt you did not get enough rest or sleep? - 3
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
Have any family members ever been diagnosed with depression? - H15_Y
Have any family members ever been diagnosed with depression? - H15_P
Have any family members ever been diagnosed with depression? - H15_N
H16.
Have
you
ever been diagnosed with depression?
Have you ever been diagnosed with depression? - H16_Y
Have you ever been diagnosed with depression? - H16_P
Have you ever been diagnosed with depression? - H16_N
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
In the past 2 weeks, how often have you been - bothered by feeling down, depressed, or hopeless? - 0
In the past 2 weeks, how often have you been - bothered by feeling down, depressed, or hopeless? - 1
In the past 2 weeks, how often have you been - bothered by feeling down, depressed, or hopeless? - 2
In the past 2 weeks, how often have you been - bothered by feeling down, depressed, or hopeless? - 3
Bothered by feeling down, depressed, or hopeless?
a)
In the past 2 weeks, how often have you been - bothered by having little interest or pleasure in doing things? - 0
In the past 2 weeks, how often have you been - bothered by having little interest or pleasure in doing things? - 1
In the past 2 weeks, how often have you been - bothered by having little interest or pleasure in doing things? - 2
In the past 2 weeks, how often have you been - bothered by having little interest or pleasure in doing things? - 3
Bothered by having little interest or pleasure in doing things?
b)
In the past 2 weeks, how often have you been - bothered by feeling easilly annoyed or irritated? - 0
In the past 2 weeks, how often have you been - bothered by feeling easilly annoyed or irritated? - 1
In the past 2 weeks, how often have you been - bothered by feeling easilly annoyed or irritated? - 2
In the past 2 weeks, how often have you been - bothered by feeling easilly annoyed or irritated? - 3
Bothered by feeling easily annoyed or irritated?
c)
In the past 2 weeks, how often have you been - bothered by feeling suddenly scared for no reason? - 0
In the past 2 weeks, how often have you been - bothered by feeling suddenly scared for no reason? - 1
In the past 2 weeks, how often have you been - bothered by feeling suddenly scared for no reason? - 2
In the past 2 weeks, how often have you been - bothered by feeling suddenly scared for no reason? - 3
Bothered by feeling suddenly scared for no reason?
d)
In the past 2 weeks, how often have you been - bothered by feeling tense or nervous? - 0
In the past 2 weeks, how often have you been - bothered by feeling tense or nervous? - 1
In the past 2 weeks, how often have you been - bothered by feeling tense or nervous? - 2
In the past 2 weeks, how often have you been - bothered by feeling tense or nervous? - 3
Bothered by feeling tense or nervous?
e)
In the past 2 weeks, how often have you been - bothered by momments of terror or panic? - 0
In the past 2 weeks, how often have you been - bothered by momments of terror or panic? - 1
In the past 2 weeks, how often have you been - bothered by momments of terror or panic? - 2
In the past 2 weeks, how often have you been - bothered by momments of terror or panic? - 3
Bothered by moments of terror or panic?
f)
In the past 2 weeks, how often have you been - bothered by getting into arguments often? - 0
In the past 2 weeks, how often have you been - bothered by getting into arguments often? - 1
In the past 2 weeks, how often have you been - bothered by getting into arguments often? - 2
In the past 2 weeks, how often have you been - bothered by getting into arguments often? - 3
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?
Do you have health insurance? - 0
Do you have health insurance? - 1
Share Parenting or Health Information
Share Parenting Health Information or Parent doesn't need information - 1
1
Share Parenting Health Information or Parent doesn't need information - 2
2
Share Parenting Health Information or Parent doesn't need information - 3
3
Share Parenting Health Information or Parent doesn't need information - 4
4
Does Not Need Information
Infant Toddler
Inventory
Page 15 of 21
InfToddler v2.9.1
Parent ID
Parent ID
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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
Do any of your closest friends have a problem with drinking or drugs? - 0
Do any of your closest friends have a problem with drinking or drugs? - 1
Do any of your close family members have a problem with drinking or drugs? - 0
Do any of your close family members have a problem with drinking or drugs? - 1
Do any of these friends or family members live in your home? - 0
Do any of these friends or family members live in your home? - 1
NoZone_1
If H18 & H19
NoZone_1_2
no, skip to
NoZone_1_3
H20
The following questions are often used to help people determine if they or someone they know need help. In the
past year
:
No
Yes
In the past year, have you felt you ought to cut down on your drinking or drug use? - 0
In the past year, have you felt you ought to cut down on your drinking or drug use? - 1
In the past year, have you felt annoyed by people criticizing your drinking or drug use? - 0
In the past year, have you felt annoyed by people criticizing your drinking or drug use? - 1
In the past year, have you felt bad or guilty about your drinking or drug use? - 0
In the past year, have you felt bad or guilty about your drinking or drug use? - 1
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 drank or used drugs more than you meant to?
In the past year, have you had a drink or used drugs as an eye opener firt thing in the morning to steady your nerves? - 0
In the past year, have you had a drink or used drugs as an eye opener firt thing in the morning to steady your nerves? - 1
In the past year, have you felt that you have drank or used drugs more than you meant to? - 0
In the past year, have you felt that you have drank or used drugs more than you meant to? - 1
If any response in shaded area: Consider Fetal Alcohol Spectrum Disorder or
Alcohol/Drug Information as a Goal.
Share Alcohol or Drug Information
Share Alcohol or Drug Cessation Information - Does Not Need Information. - 1
1
Share Alcohol or Drug Cessation Information - Does Not Need Information. - 2
2
Share Alcohol or Drug Cessation Information - Does Not Need Information. - 3
3
Share Alcohol or Drug Cessation Information - Does Not Need Information. - 4
4
Does Not Need Information
Infant Toddler
Inventory
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InfToddler v2.9.1
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Does you child use a bottle? - 0
No
Does you child use a bottle? - 1
Yes
If no, skip to B14.
B12.
Are you currently breastfeeding?
Have you discussed with a doctor or nurse the dangers of the following while breastfeeding:
No
Yes
Effects of smoking?
a)
Effects of drinking?
b)
Effects of breathing fumes or chemicals?
c)
Your currents prescriptions?
d)
B13.
Does your child use a bottle?
No
Yes
Do you serve your child juice or cereal in a bottle or a sippy cup?
a)
Do you prop the bottle for your child or put them to bed with a bottle or a sippy cup?
b)
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.
In the past year, how many times - were you unable to pay an important monthly bill such as rent, car payment, house repair, child care, or other outstanding payment? - 0
In the past year, how many times - were you unable to pay an important monthly bill such as rent, car payment, house repair, child care, or other outstanding payment? - 1
In the past year, how many times - were you unable to pay an important monthly bill such as rent, car payment, house repair, child care, or other outstanding payment? - 2
Were you unable to afford
medical care, dental care, or medicine
?
B3.
In the past year, how many times - were you unable to afford medical care, dental care or medicine? - 0
In the past year, how many times - were you unable to afford medical care, dental care or medicine? - 1
In the past year, how many times - were you unable to afford medical care, dental care or medicine? - 2
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.
In the past year, how many times - did you have problems with transportation because you could not afford to buy gas for the car or pay for repairs or for a bus, cab or other transportation? - 0
In the past year, how many times - did you have problems with transportation because you could not afford to buy gas for the car or pay for repairs or for a bus, cab or other transportation? - 1
In the past year, how many times - did you have problems with transportation because you could not afford to buy gas for the car or pay for repairs or for a bus, cab or other transportation? - 2
Were you owed child support and unable to receive it?
B5.
In the past year, how many times - were you owed child support and unable to receive it? - 0
In the past year, how many times - were you owed child support and unable to receive it? - 1
In the past year, how many times - were you owed child support and unable to receive it? - 2
Have you had an open child protective case?
B6.
In the past year, how many times - have you had an open child protective case? - 0
In the past year, how many times - have you had an open child protective case? - 1
In the past year, how many times - have you had an open child protective case? - 2
Were you or your child's other parent involved with the legal system?
B7.
In the past year, how many times - were you or your child's other parent involved with the legal system? - 0
In the past year, how many times - were you or your child's other parent involved with the legal system? - 1
In the past year, how many times - were you or your child's other parent involved with the legal system? - 2
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, how many times - do you expect you will need help paying for basic services such as utilities, rent, transportation or health care? - 0
In the next year, how many times - do you expect you will need help paying for basic services such as utilities, rent, transportation or health care? - 1
In the next year, how many times - do you expect you will need help paying for basic services such as utilities, rent, transportation or health care? - 2
In the
next year
, do you expect that you will need help paying for necessary supplies for your child like diapers, formula, and bedding?
B9.
In the next year, how many times - do you expect you will need help paying for necessary clothing like shoes, or coats for you or your child? - 0
In the next year, how many times - do you expect you will need help paying for necessary clothing like shoes, or coats for you or your child? - 1
In the next year, how many times - do you expect you will need help paying for necessary clothing like shoes, or coats for you or your child? - 2
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.
In the past year - nutritious food - how many times did the food that you bought just didn't last and you didn't have money to get more? - 0
In the past year - nutritious food - how many times did the food that you bought just didn't last and you didn't have money to get more? - 1
In the past year - nutritious food - how many times did the food that you bought just didn't last and you didn't have money to get more? - 2
In the past year - nutritious food - how many times did you or others in your household cut the size of your meals or skipped meals because there wasn't enough money for food? - 0
In the past year - nutritious food - how many times did you or others in your household cut the size of your meals or skipped meals because there wasn't enough money for food? - 1
In the past year - nutritious food - how many times did you or others in your household cut the size of your meals or skipped meals because there wasn't enough money for food? - 2
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.
In the past year, how many times - 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? - 0
In the past year, how many times - 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? - 1
In the past year, how many times - 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? - 2
Are you currently breastfeeding? - 0
No
Are you currently breastfeeding? - 1
Yes
In regards to breastfeeding, have you discussed with your doctor or nurse - the effects of smoking? - 0
In regards to breastfeeding, have you discussed with your doctor or nurse - the effects of smoking? - 1
In regards to breastfeeding, have you discussed with your doctor or nurse - the effects of drinking? - 0
In regards to breastfeeding, have you discussed with your doctor or nurse - the effects of drinking? - 1
In regards to breastfeeding, have you discussed with your doctor or nurse - the effects breathing in fumes or chemicals? - 0
In regards to breastfeeding, have you discussed with your doctor or nurse - the effects breathing in fumes or chemicals? - 1
In regards to breastfeeding, have you discussed with your doctor or nurse - the effects from your current prescriptions? - 0
In regards to breastfeeding, have you discussed with your doctor or nurse - the effects from your current prescriptions? - 1
Do you serve your child juice or cerial in a bottle? - 0
Do you serve your child juice or cerial in a bottle? - 1
Do you prop the bottle for your child or put them to bed with a bottle? - 0
Do you prop the bottle for your child or put them to bed with a bottle? - 1
Thinking about food and nutrition, how often are the following never, sometimes, or often true? In the
past year
:
If no, skip to B12e
e)
How old was your child when you stopped breastfeeding?
How old was your child when you stopped breastfeeding? - 1
Didn't breastfeed
How old was your child when you stopped breastfeeding? - 2
Until 2 months
How old was your child when you stopped breastfeeding? - 3
2-5 months
How old was your child when you stopped breastfeeding? - 4
6 months or more
SECTION 9
BASIC NEEDS
If any response in shaded area: Consider Infant feeding Safety and Health as a Goal.
Page 16 of 21
InfToddler v2.9.1
Infant Toddler
Inventory
Page 17 of 21
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B14.
Have you introduced solid food such as baby food or table food?
Use Response Card
More than 1 a day
Once a day
2-6
a
week
Once
a
week
None
Serving per day goal
1 cup
2 oz
1/4 cup
1 1/4 cups
3/4
cup
3/4 cup
None
a)
Dairy products like milk, cheese, yogurt
b)
Meat like beef, chicken, fish, eggs
c)
Protein like beans, peas, nuts, peanut butter, veggie burger
d)
Grains like bread, rice, pasta, cereals, tortillas
e)
Dark greens or orange/yellow vegetables like greens, carrots, broccoli, squash, sweet potatoes-
but do not count french fries
f)
Fruits like apples, oranges, bananas, grapes, peaches, applesauce-
but do not count juice
g)
Sugary sweets like cakes and candy,or sugary drinks like soda, sports drinks, juice, or fruit drinks.
About how often does your child eat food from the food group - Formula? - 1
About how often does your child eat food from the food group - Formula? - 2
About how often does your child eat food from the food group - Formula? - 3
About how often does your child eat food from the food group - Formula? - 4
About how often does your child eat food from the food group - Formula? - 5
About how often does your child eat food from the food group - Dairy Products like milk, cheese, yogurt? - 1
About how often does your child eat food from the food group - Dairy Products like milk, cheese, yogurt? - 2
About how often does your child eat food from the food group - Dairy Products like milk, cheese, yogurt? - 3
About how often does your child eat food from the food group - Dairy Products like milk, cheese, yogurt? - 4
About how often does your child eat food from the food group - Dairy Products like milk, cheese, yogurt? - 5
About how often does your child eat food from the food group - Meat like beef, chicken, fish, eggs? - 1
About how often does your child eat food from the food group - Meat like beef, chicken, fish, eggs? - 2
About how often does your child eat food from the food group - Meat like beef, chicken, fish, eggs? - 3
About how often does your child eat food from the food group - Meat like beef, chicken, fish, eggs? - 4
About how often does your child eat food from the food group - Meat like beef, chicken, fish, eggs? - 5
About how often does your child eat food from the food group - protein like beans, peas, nuts, peanut butter, veggie burger? - 1
About how often does your child eat food from the food group - protein like beans, peas, nuts, peanut butter, veggie burger? - 2
About how often does your child eat food from the food group - protein like beans, peas, nuts, peanut butter, veggie burger? - 3
About how often does your child eat food from the food group - protein like beans, peas, nuts, peanut butter, veggie burger? - 4
About how often does your child eat food from the food group - protein like beans, peas, nuts, peanut butter, veggie burger? - 5
About how often does your child eat food from the food group - grains like bread, rice, pasta, cereals, tortillas? - 1
About how often does your child eat food from the food group - grains like bread, rice, pasta, cereals, tortillas? - 2
About how often does your child eat food from the food group - grains like bread, rice, pasta, cereals, tortillas? - 3
About how often does your child eat food from the food group - grains like bread, rice, pasta, cereals, tortillas? - 4
About how often does your child eat food from the food group - grains like bread, rice, pasta, cereals, tortillas? - 5
About how often does your child eat food from the food group - Dark Green Vegetables or Orange-Yellow Vegetables like greens, carrots, broccoli, squash, sweet potatoes - but not french fries? - 1
About how often does your child eat food from the food group - Dark Green Vegetables or Orange-Yellow Vegetables like greens, carrots, broccoli, squash, sweet potatoes - but not french fries? - 2
About how often does your child eat food from the food group - Dark Green Vegetables or Orange-Yellow Vegetables like greens, carrots, broccoli, squash, sweet potatoes - but not french fries? - 3
About how often does your child eat food from the food group - Dark Green Vegetables or Orange-Yellow Vegetables like greens, carrots, broccoli, squash, sweet potatoes - but not french fries? - 4
About how often does your child eat food from the food group - Dark Green Vegetables or Orange-Yellow Vegetables like greens, carrots, broccoli, squash, sweet potatoes - but not french fries? - 5
About how often does your child eat food from the food group - Fruits like apples, oranges, bananas, grapes, peaches, applesauce - but not juice? - 1
About how often does your child eat food from the food group - Fruits like apples, oranges, bananas, grapes, peaches, applesauce - but not juice? - 2
About how often does your child eat food from the food group - Fruits like apples, oranges, bananas, grapes, peaches, applesauce - but not juice? - 3
About how often does your child eat food from the food group - Fruits like apples, oranges, bananas, grapes, peaches, applesauce - but not juice? - 4
About how often does your child eat food from the food group - Fruits like apples, oranges, bananas, grapes, peaches, applesauce - but not juice? - 5
If any response in shaded area: Consider Nutrition Education as a Goal.
Formula
Have you introduced solid food such as baby food or table food? - 0
No
Have you introduced solid food such as baby food or table food? - 1
Yes
NoZone_3
If no, skip to next section.
B15.
About how often does your child eat a food from each of the following groups (baby food or table food)?
About how often does your child eat food from the food group - sugary sweets like cakes, candy or sugary drinks like soda, sportsdrinks, juice or fruit drinks? - 1
About how often does your child eat food from the food group - sugary sweets like cakes, candy or sugary drinks like soda, sportsdrinks, juice or fruit drinks? - 2
About how often does your child eat food from the food group - sugary sweets like cakes, candy or sugary drinks like soda, sportsdrinks, juice or fruit drinks? - 3
About how often does your child eat food from the food group - sugary sweets like cakes, candy or sugary drinks like soda, sportsdrinks, juice or fruit drinks? - 4
About how often does your child eat food from the food group - sugary sweets like cakes, candy or sugary drinks like soda, sportsdrinks, juice or fruit drinks? - 5
h)
Do not count foods eaten at childcare centers.
Infant Toddler
Inventory
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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?
In the past month, how many rides has your child taken even on short trips - in the front seat of a vehicle? - 0
In the past month, how many rides has your child taken even on short trips - in the front seat of a vehicle? - 1
In the past month, how many rides has your child taken even on short trips - in the front seat of a vehicle? - 2
In the past month, how many rides has your child taken even on short trips - in the front seat of a vehicle? - 3
Never
1-9 Rides
More than 10
Every Ride
In the past month, how many rides has your child taken even on short trips - in the back seat with a seatbelt with a car seat? - 0
In the past month, how many rides has your child taken even on short trips - in the back seat with a seatbelt with a car seat? - 1
In the past month, how many rides has your child taken even on short trips - in the back seat with a seatbelt with a car seat? - 2
In the past month, how many rides has your child taken even on short trips - in the back seat with a seatbelt with a car seat? - 3
If any response in shaded area: Consider Vehicle Safety as a Goal.
SECTION 10
HOME AND CAR SAFETY
C12.
When your child sleeps, do you or anyone else...
C13.
When you or anyone else puts your baby down to sleep, do you...
If any response in shaded area: Consider Safety Strategies as a Goal.
Complete C12 & C13 for children 12 months or younger
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?
Does anyone living in your home smoke cigarettes? - C5_N
Does anyone living in your home smoke cigarettes? - C5_Y
Does anyone living in your home smoke cigarettes? - C5_oth
No
You
Other
Does anyone smoke cigarettes inside your home? - C6_N
Does anyone smoke cigarettes inside your home? - C6_Y
Does anyone smoke cigarettes inside your home? - C6_oth
Does anyone smoke cigarettes inside your car? - C7_N
Does anyone smoke cigarettes inside your car? - C7_Y
Does anyone smoke cigarettes inside your car? - C7_oth
No
Don't Know
Yes
Is there a working smoke detector in your home for each level? - 0
Is there a working smoke detector in your home for each level? - 2
Is there a working smoke detector in your home for each level? - 1
Have you tested your smoke detectors in the last 2 months? - 0
Have you tested your smoke detectors in the last 2 months? - 2
Have you tested your smoke detectors in the last 2 months? - 1
Are there two clear exits that can be used in case of a fire? - 0
Are there two clear exits that can be used in case of a fire? - 2
Are there two clear exits that can be used in case of a fire? - 1
Can you hold your hand under the hottest running water for several seconds without getting burned - water heater set below 120 degrees? - 0
Can you hold your hand under the hottest running water for several seconds without getting burned - water heater set below 120 degrees? - 2
Can you hold your hand under the hottest running water for several seconds without getting burned - water heater set below 120 degrees? - 1
Do you live in a building built before 1978 - lead based paint risk? - 0
Do you live in a building built before 1978 - lead based paint risk? - 2
Do you live in a building built before 1978 - lead based paint risk? - 1
a)
b)
Co-sleep with your baby in the same bed or on a couch?
Let the baby sleep in the room with you but not in same bed?
a)
b)
Always place your baby on his/her back to sleep?
Let the baby sleep on soft bedding or with any stuffed toys?
In the past month, how many rides has your child taken even on short trips - in the bed of a truck or on a motorcycle? - 0
In the past month, how many rides has your child taken even on short trips - in the bed of a truck or on a motorcycle? - 1
In the past month, how many rides has your child taken even on short trips - in the bed of a truck or on a motorcycle? - 2
In the past month, how many rides has your child taken even on short trips - on an All-Terrain Vehicle or 4-Wheeler, tractor, riding lawnmower or similar off-road vehicle? - 0
In the past month, how many rides has your child taken even on short trips - on an All-Terrain Vehicle or 4-Wheeler, tractor, riding lawnmower or similar off-road vehicle? - 1
In the past month, how many rides has your child taken even on short trips - on an All-Terrain Vehicle or 4-Wheeler, tractor, riding lawnmower or similar off-road vehicle? - 2
If any response in shaded area: Consider Safe Infant Sleep as a Goal.
Yes
No
When you child sleeps, do you or anyone else - co-sleep with your baby in the same bed or couch? - 0
No
When you child sleeps, do you or anyone else - co-sleep with your baby in the same bed or couch? - 2
Don't Know
When you child sleeps, do you or anyone else - co-sleep with your baby in the same bed or couch? - 1
Yes
Don't
Know
When you child sleeps, do you or anyone else - let the baby sleep in the room with you but not in the same bed? - 0
No
When you child sleeps, do you or anyone else - let the baby sleep in the room with you but not in the same bed? - 2
Don't Know
When you child sleeps, do you or anyone else - let the baby sleep in the room with you but not in the same bed? - 1
Yes
When you or anyone else puts your baby down to sleep - is the baby always placed on the child's back to sleep? - 0
No
When you or anyone else puts your baby down to sleep - is the baby always placed on the child's back to sleep? - 2
Don't Know
When you or anyone else puts your baby down to sleep - is the baby always placed on the child's back to sleep? - 1
Yes
When you or anyone else puts your baby down to sleep - let teh baby sleep on soft bedding or with any stuffed toys? - 0
No
When you or anyone else puts your baby down to sleep - let teh baby sleep on soft bedding or with any stuffed toys? - 2
Don't Know
When you or anyone else puts your baby down to sleep - let teh baby sleep on soft bedding or with any stuffed toys? - 1
Yes
Infant Toddler
Inventory
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C14.
Crib/Bed with slats no more than the width of your hand that is 2 3/8 inches wide
a)
Complete for all children
Yes
No or
Don't have
Regarding where your child sleeps and plays - in your home, do you have - Crib or Bed with slats no more than the width of your hand apart? - 0
Regarding where your child sleeps and plays - in your home, do you have - Crib or Bed with slats no more than the width of your hand apart? - 1
Take a moment to think about where your child sleeps and plays. Which of the following do you have in your home?
Crib/Bed near windows with blind cords or near heating unit
b)
Stairs without gates
c)
Changing table with guardrails or rails less than 2 inches tall
d)
Kitchen or bathroom cabinets/drawers without stops/locks
e)
A pet that could become aggressive
f)
Regarding where your child sleeps and plays - in your home, do you have - crib or bed near windows with blind cords or near any heating units? - 0
Regarding where your child sleeps and plays - in your home, do you have - crib or bed near windows with blind cords or near any heating units? - 1
Regarding where your child sleeps and plays - in your home, do you have - stairs without gates? - 0
Regarding where your child sleeps and plays - in your home, do you have - stairs without gates? - 1
Regarding where your child sleeps and plays - in your home, do you have - changing table with guard rails or rails less than 2 inches tall? - 0
Regarding where your child sleeps and plays - in your home, do you have - changing table with guard rails or rails less than 2 inches tall? - 1
Regarding where your child sleeps and plays - in your home, do you have - Kitchen or Bathroom Cabinets and Drawers without Stops or Locks? - 0
Regarding where your child sleeps and plays - in your home, do you have - Kitchen or Bathroom Cabinets and Drawers without Stops or Locks? - 1
Regarding where your child sleeps and plays - in your home, do you have - A pet that could become aggressive? - 0
Regarding where your child sleeps and plays - in your home, do you have - A pet that could become aggressive? - 1
If any response in shaded area: Consider Child Safety as a Goal.
C15.
Laundry detergent or cleaning supplies
a)
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?
BBQ lighter fluid
b)
Matches or lighters
c)
Iron
d)
Medicines
e)
Beer, wine, or other alcohol
f)
Knives, scissors, or other sharp objects
g)
Tools like saws, screwdivers, etc.
h)
Firearms like guns or other weapons
i)
Toiletries such as mouthwash, perfume, hair spray, or nail polish
j)
Toys or objects small enough to be choking hazards
k)
Regarding Household Item Location Within Your Home - Could your child find and access - laundry detergent or cleaning supplies, if they tried? - 2
Regarding Household Item Location Within Your Home - Could your child find and access - laundry detergent or cleaning supplies, if they tried? - 0
Regarding Household Item Location Within Your Home - Could your child find and access - laundry detergent or cleaning supplies, if they tried? - 1
Regarding Household Item Location Within Your Home - Could your child find and access - BBQ Lighter Fluid, if they tried? - 2
Regarding Household Item Location Within Your Home - Could your child find and access - BBQ Lighter Fluid, if they tried? - 0
Regarding Household Item Location Within Your Home - Could your child find and access - BBQ Lighter Fluid, if they tried? - 1
Regarding Household Item Location Within Your Home - Could your child find and access - matches or lighters, if they tried? - 2
Regarding Household Item Location Within Your Home - Could your child find and access - matches or lighters, if they tried? - 0
Regarding Household Item Location Within Your Home - Could your child find and access - matches or lighters, if they tried? - 1
Regarding Household Item Location Within Your Home - Could your child find and access - Iron, if they tried? - 2
Regarding Household Item Location Within Your Home - Could your child find and access - Iron, if they tried? - 0
Regarding Household Item Location Within Your Home - Could your child find and access - Iron, if they tried? - 1
Regarding Household Item Location Within Your Home - Could your child find and access - medications, if they tried? - 2
Regarding Household Item Location Within Your Home - Could your child find and access - medications, if they tried? - 0
Regarding Household Item Location Within Your Home - Could your child find and access - medications, if they tried? - 1
Regarding Household Item Location Within Your Home - Could your child find and access - alcoholic beverages, if they tried? - 2
Regarding Household Item Location Within Your Home - Could your child find and access - alcoholic beverages, if they tried? - 0
Regarding Household Item Location Within Your Home - Could your child find and access - alcoholic beverages, if they tried? - 1
Regarding Household Item Location Within Your Home - Could your child find and access - knives, scissors, or other sharp objects, if they tried? - 2
Regarding Household Item Location Within Your Home - Could your child find and access - knives, scissors, or other sharp objects, if they tried? - 0
Regarding Household Item Location Within Your Home - Could your child find and access - knives, scissors, or other sharp objects, if they tried? - 1
Regarding Household Item Location Within Your Home - Could your child find and access - tools like saws, screwdrivers and such, if they tried? - 2
Regarding Household Item Location Within Your Home - Could your child find and access - tools like saws, screwdrivers and such, if they tried? - 0
Regarding Household Item Location Within Your Home - Could your child find and access - tools like saws, screwdrivers and such, if they tried? - 1
Regarding Household Item Location Within Your Home - Could your child find and access - firearms like guns or other weaponry, if they tried? - 2
Regarding Household Item Location Within Your Home - Could your child find and access - firearms like guns or other weaponry, if they tried? - 0
Regarding Household Item Location Within Your Home - Could your child find and access - firearms like guns or other weaponry, if they tried? - 1
Regarding Household Item Location Within Your Home - Could your child find and access - toiletries such as mouthwash, perfume, hair spray, or nail polish, if they tried? - 2
Regarding Household Item Location Within Your Home - Could your child find and access - toiletries such as mouthwash, perfume, hair spray, or nail polish, if they tried? - 0
Regarding Household Item Location Within Your Home - Could your child find and access - toiletries such as mouthwash, perfume, hair spray, or nail polish, if they tried? - 1
Regarding Household Item Location Within Your Home - Could your child find and access - toys or objects small enough to be a choking hazard, if they tried? - 2
Regarding Household Item Location Within Your Home - Could your child find and access - toys or objects small enough to be a choking hazard, if they tried? - 0
Regarding Household Item Location Within Your Home - Could your child find and access - toys or objects small enough to be a choking hazard, if they tried? - 1
If any response in shaded area: Consider Household Safety as a Goal.
Don't own
Yes
No
Safety Concerns in Home
Safety Concerns in the Home - 1
1
Safety Concerns in the Home - 2
2
Safety Concerns in the Home - 3
3
Safety Concerns in the Home - 4
4
No Safety Concerns in Home
Safety Concerns outside Home
Safety Concerns Outside of Home - 1
1
Safety Concerns Outside of Home - 2
2
Safety Concerns Outside of Home - 3
3
Safety Concerns Outside of Home - 4
4
No Safety Concerns outside Home
Infant Toddler
Inventory
Page 20 of 21
InfToddler v2.9.1
Parent ID
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
In the past month, how often was someone available to - Listen to you when you needed to talk? - 1
In the past month, how often was someone available to - Listen to you when you needed to talk? - 2
In the past month, how often was someone available to - Listen to you when you needed to talk? - 3
Use Response Card
In the past month, how often was someone available to - help with daily chores if you were sick? - 1
In the past month, how often was someone available to - help with daily chores if you were sick? - 2
In the past month, how often was someone available to - help with daily chores if you were sick? - 3
In the past month, how often was someone available to - Loan you $100 if you needed it? - 1
In the past month, how often was someone available to - Loan you $100 if you needed it? - 2
In the past month, how often was someone available to - Loan you $100 if you needed it? - 3
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)
In the past month, how often have you participated in - neighborhood or comunity organization, committee, club or sports team? - 0
In the past month, how often have you participated in - neighborhood or comunity organization, committee, club or sports team? - 1
In the past month, how often have you participated in - neighborhood or comunity organization, committee, club or sports team? - 2
In the past month, how often have you participated in - neighborhood or comunity organization, committee, club or sports team? - 3
In the past month, how often have you participated in - church service or other religious club or activity? - 0
In the past month, how often have you participated in - church service or other religious club or activity? - 1
In the past month, how often have you participated in - church service or other religious club or activity? - 2
In the past month, how often have you participated in - church service or other religious club or activity? - 3
In the past month, how often have you participated in - visit a friend or neighbor's house? - 0
In the past month, how often have you participated in - visit a friend or neighbor's house? - 1
In the past month, how often have you participated in - visit a friend or neighbor's house? - 2
In the past month, how often have you participated in - visit a friend or neighbor's house? - 3
In the past month, how often have you participated in - hobby or sport with a friend? - 0
In the past month, how often have you participated in - hobby or sport with a friend? - 1
In the past month, how often have you participated in - hobby or sport with a friend? - 2
In the past month, how often have you participated in - hobby or sport with a friend? - 3
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)
In the past month, how often have you participated in - mother figure visited with people working with program you are involved in? - 0
In the past month, how often have you participated in - mother figure visited with people working with program you are involved in? - 1
In the past month, how often have you participated in - mother figure visited with people working with program you are involved in? - 2
In the past month, how often have you participated in - mother figure visited with people working with program you are involved in? - 3
In the past month, how often have you participated in - mother figure volunteered at this program or other places? - 0
In the past month, how often have you participated in - mother figure volunteered at this program or other places? - 1
In the past month, how often have you participated in - mother figure volunteered at this program or other places? - 2
In the past month, how often have you participated in - mother figure volunteered at this program or other places? - 3
In the past month, how often have you participated in - father figure visited with people working with program you are involved in? - 0
In the past month, how often have you participated in - father figure visited with people working with program you are involved in? - 1
In the past month, how often have you participated in - father figure visited with people working with program you are involved in? - 2
In the past month, how often have you participated in - father figure visited with people working with program you are involved in? - 3
In the past month, how often have you participated in - father figure volunteered at this program or other places? - 0
In the past month, how often have you participated in - father figure volunteered at this program or other places? - 1
In the past month, how often have you participated in - father figure volunteered at this program or other places? - 2
In the past month, how often have you participated in - father figure volunteered at this program or other places? - 3
If all responses in shaded area: Consider Program Engagement as a Goal.
Share Program Volunteer Information
Need for Sharing Volunteer Information - No Need - 1
1
Need for Sharing Volunteer Information - No Need - 2
2
Need for Sharing Volunteer Information - No Need - 3
3
Need for Sharing Volunteer Information - No Need - 4
4
Does Not Need Information
d)
Ask for advice about typical child care, for example,
how to give a bath?
e)
Call if you need a good night sleep?
In the past month, how often was someone available to - Ask for advice about typical child care, for example, how to give a bath? - 1
In the past month, how often was someone available to - Ask for advice about typical child care, for example, how to give a bath? - 2
In the past month, how often was someone available to - Ask for advice about typical child care, for example, how to give a bath? - 3
In the past month, how often was someone available to - call if you need a good night's sleep? - 1
In the past month, how often was someone available to - call if you need a good night's sleep? - 2
In the past month, how often was someone available to - call if you need a good night's sleep? - 3
SOCIAL INTEGRATION
SECTION 11
Infant Toddler
Inventory
Page 21 of 21
InfToddler v2.9.1
Parent ID
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:
Child Present in home during visit? - 0
No
Child Present in home during visit? - 1
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.
During Visit, Does the parent touch child affectionately? - 0
During Visit, Does the parent touch child affectionately? - 1
During Visit, Does the parent touch child affectionately? - 2
Absent
-Did Not Happen
Barely There
-Happened a Little
Completely
There
-Happened a Lot
During Visit, does the parent speak in a warm tone of voice toward the child? - 0
During Visit, does the parent speak in a warm tone of voice toward the child? - 1
During Visit, does the parent speak in a warm tone of voice toward the child? - 2
During Visit, does the parent smile at the child? - 0
During Visit, does the parent smile at the child? - 1
During Visit, does the parent smile at the child? - 2
During Visit, Does the parent praise the child? - 0
During Visit, Does the parent praise the child? - 1
During Visit, Does the parent praise the child? - 2
During Visit, Does the parent use positive expression with child? - 0
During Visit, Does the parent use positive expression with child? - 1
During Visit, Does the parent use positive expression with child? - 2
During Visit, is the parent attentive with the child and what the child is doing? - 0
During Visit, is the parent attentive with the child and what the child is doing? - 1
During Visit, is the parent attentive with the child and what the child is doing? - 2
During Visit, Does the parent change pace or activity to meet child's interests? - 0
During Visit, Does the parent change pace or activity to meet child's interests? - 1
During Visit, Does the parent change pace or activity to meet child's interests? - 2
During Visit, Does the parent replies to child's words or vocalizations? - 0
During Visit, Does the parent replies to child's words or vocalizations? - 1
During Visit, Does the parent replies to child's words or vocalizations? - 2
If 5 or more responses in shaded area: Consider Parenting Education as a Goal.
Child NOT in room
most of visit
Child in the room during visit? - 1
1
Child in the room during visit? - 2
2
Child in the room during visit? - 3
3
Child in the room during visit? - 4
4
Child in room entire visit
OBSERVATIONS - COMPLETE AT THE END OF THE VISIT
SECTION 12
Parent...
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