Infant Toddler
Sibling Inventory
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InfToddlerSib v2.2

Date of Interview:

Home

Other home

School

Public Place
Location of Interview:

Interviewed by:
Male

Male

Female
Child Name:
Female

Male

Female
Parent/Guardian:
Male
Female

Parent ID



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Child age:

Months

1 month or less

2-6 months

7-12 months

13-18 months

19-24 months

25-30 months

31-36 months

37 months or more

White

American Indian or Alaska Native

Asian

Black

Native Hawaiian or Other Pacific Islander

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

Yes

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

16 years or less

17-18 years

19-24 years

25-34 years

35-40 years

41 or more
2. How old are you now?

Years
3. What is your relationship to this child?

Biological Parent

Foster Parent

Partner of Parent

Other Relative

Step Parent

Adoptive Parent

Grandparent

Other:
INFANT TODDLER SIBLING FAMILY MAP
INVENTORY

1

2

3

4
Target Child



Agency Code:
picture
(Clear identifiers)

Location:

Region:

Center:

Class:
Infant Toddler
Sibling Inventory
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InfToddlerSib v2.2

Parent ID
Thefamilymap.org
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S9. Next we want to talk about your child's other parent(s), living with you or not.
Name
How are they
related
to your child?
How long
have you
lived
together?
What is their
highest level of
completed
education?
Are they
currently
enrolled in
school?
How many hours
are they
currently working
for pay?

Parent outside the home

Parent in the home




1 year or less
2-3 years
4 or more




Biological Parent
Step, Foster, or Adoptive Parent
Your partner




Biological Parent
Step, Foster, or Adoptive Parent
Your partner
If Not Currently Enrolled and High School or Less: Consider Employment as a Goal.
College
Vocational
High School/ GED
No HS Degree





College
Vocational
High School/ GED
No









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





No HS Degree
High School/ GED
Vocational
College





College
Vocational
High School/ GED
No





50 hours or more
20-50 hours
20 hours or less
0-10 hours
Infant Toddler
Sibling Inventory
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InfToddlerSib v2.2

Parent ID
Thefamilymap.org
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R4.
How many times has your child moved in the past year ?
R7.
How many times during the past month did your child spend the night someplace else?

0

1

2

3

more

0

1

2

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

1

2

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









If any response in shaded area: Consider Housing as a Goal.
If 2 or more responses in shaded area: Consider Daily Routines as a Goal.
ROUTINES
SECTION 2
b)
Get a bath at about the same time?

















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









Infant Toddler
Sibling Inventory
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InfToddlerSib v2.2

Parent ID
Thefamilymap.org
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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?





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













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

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









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

1

2

3

4

1

2

3

4

1

2

3

4

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.














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














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

17 or more

Hours

Minutes

AM

PM
:

Hours

Minutes

AM

PM
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Infant Toddler
Sibling Inventory
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InfToddlerSib v2.2

Parent ID
Thefamilymap.org
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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?





c)
Can feel and cuddle such as stuffed animal, soft cloth, or play mat with textures?





b)
Can make noise with such as objects that rattle, spin, jitter, whir, etc.?





a)
Can see such as a mirror in the crib, mobile, or nightlight that projects light onto ceiling?





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

Yes

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





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

Yes

No
L3.
Do you have a library card?
If all responses in shaded area: Consider Reading Materials as a Goal.
L5.
In the past week , how many times did the following people read or look at a book with your child?
If all responses in shaded area: Consider Literacy as a Goal.
d)
Can use their muscles with such as a ball, crib gym, or jump swing?









b)
Can use their muscles with such as a ball, crib gym, jump swing, tricycle, or slide?
0
1
2
3 or more





c)
Can put together in different ways such as legos, pans with lids, stacking rings, or nesting blocks?





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.





e)
Can play or make music with such as toy musical instrument or music player?
(not including while in child care)

Complete for

children older

than 12 months

Complete for

children younger

than 12 months
EARLY LEARNING
SECTION 3
a)
Mother/figure?
b)
Father/figure?
c)
Anyone else?













Not Available or None
1 - 2 times/week
3 - 5 times/week
6 or more times
Infant Toddler
Sibling Inventory
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InfToddlerSib v2.2

Parent ID
Thefamilymap.org
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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



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.





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



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





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



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





































None
1 - 2 times week
3 - 5 times week
6 or more times
Infant Toddler
Sibling Inventory
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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






30 Minutes or more











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








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

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



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



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



If any response in shaded area: Consider Child Care as a Goal.
a)
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?






No
Yes
No
Yes
MONITORING
SECTION 4
Infant Toddler
Sibling Inventory
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Parent ID
Thefamilymap.org
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Never
Once
Two times
Three times
E5.
Thinking about people in the home or neighborhood, in the past year, how many times:






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






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






d)
Has your child seen drug or sexual activities?






If any response in shaded area: Consider Family Safety or Counseling as a Goal.
ENVIRONMENTAL SAFETY
SECTION 5
Infant Toddler
Sibling Inventory
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InfToddlerSib v2.2

Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
Parenting is stressful and challenging, and all parents experience difficulty at one time or another.  How much do you agree with the following statements?
Disagree
Agree
Strongly Agree
Use Response Card
F8.
During the past month , I have felt stressed out with the day-to-day demands of raising children.
Strongly Disagree
F9.
During the past month , I have felt so stressed out that I was afraid I might lose control.
F10.
I worry I will spoil my child by giving him/her too much attention or picking him/her up when he/she cries.
F11.
I feel that my child is much harder to care for than most children his/her age.
F12.
I expected to have closer and warmer feelings for my child than I do, and this bothers me.
F13.
When I do things for my child, I get the feeling my efforts are not appreciated.
F14.
Sometimes the punishment I give my child depends on my mood.
If 3 or more responses in shaded area: Consider Parent Education as a Goal.





























FAMILY COHESION
SECTION 6
Infant Toddler
Sibling Inventory
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Page 10 of 16
InfToddlerSib v2.2

Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
When your child has done something wrong, how often do you:
D2.







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






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






Take away privileges or object/toy for a period of time, restrict access.
b)






Re-direct, distract, or turn the child's attention to something else.
c)











Spank your child with a belt, switch, or other object
If all responses in shaded area: Consider Discipline Strategies as a Goal.






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











i)






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
Sibling Inventory
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Parent ID
Thefamilymap.org
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H2.
Does your child have a health problem or illness that requires regular, ongoing care or medication?
For example, a disability, a mental illness, or chronic health problem, like asthma, severe allergies, repeat ear infections, sickle cell anemia, cerebral palsy, or ADHD.

No

Yes
If no, skip to H3.
Note Condition:

Determine need: Do you understand what your child's doctor or therapist wants you to do day-to-day to deal with that health problem?  Do you have a plan from the doctor?  Do you feel comfortable following that plan?  Do you have any problems being able to follow-through with the plan?
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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

No

Yes
H6.
H7.
Do you have a dentist you consider to be your child's dentist?
H8.
Does your child have health insurance?








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












3-7
days
2-4
weeks
2
months
4
months
6
months
9
months
12
months
15
months
18
months
24 months
30 months
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Needs Help with Plan

1

2

3

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
Infant Toddler
Sibling Inventory
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Parent ID
Thefamilymap.org
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No

Yes
If no, skip to B14.
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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?
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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)
No
Yes
Don't Know
Were you owed child support and unable to receive it?
B5.




No

Yes













If no, skip to B12e
e)
How old was your child when you stopped breastfeeding?

Didn't breastfeed

Until 2 months

2-5 months

6 months or more
SECTION 9
BASIC NEEDS
If any response in shaded area: Consider Infant feeding Safety and Health as a Goal.
Infant Toddler
Sibling Inventory
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InfToddlerSib v2.2

Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
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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.




































If any response in shaded area: Consider Nutrition Education as a Goal.
Formula

No

Yes

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)?






h)
Do not count foods eaten at childcare centers.
Infant Toddler
Sibling Inventory
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Page 14 of 16
InfToddlerSib v2.2

Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
Now let’s talk about some safety concerns. Thinking about the past month , how many rides has your child taken even for a short trip:
C1.
In the front seat of a vehicle?
C2.
In the back seat with a seatbelt with a car seat?
C3.
In the bed of a truck or on a motorcycle?
C4.
On an All-Terrain Vehicle, like a 4 wheeler, tractor, riding lawnmower or similar off-road vehicle?





Never
1-9 Rides
More than 10
Every Ride





If any response in shaded area: Consider Vehicle Safety as a Goal.
SECTION 10
HOME AND CAR SAFETY
C12.
When your child sleeps, do you or anyone else...
C13.
When you or anyone else puts your baby down to sleep, do you...
Complete C12 & C13 for children 12 months or younger
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?







If any response in shaded area: Consider Safe Infant Sleep as a Goal.
Yes
No

No

Don't Know

Yes
Don't
Know

No

Don't Know

Yes

No

Don't Know

Yes

No

Don't Know

Yes
Infant Toddler
Sibling Inventory
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InfToddlerSib v2.2

Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
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



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)











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)


































If any response in shaded area: Consider Household Safety as a Goal.
Don't own
Yes
No
Safety Concerns in Home

1

2

3

4
No Safety Concerns in Home
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Safety Concerns outside Home

1

2

3

4
No Safety Concerns outside Home
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Infant Toddler
Sibling Inventory
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InfToddlerSib v2.2

Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
If response in shaded area: Consider Monitoring as a Goal.
W1 ..
Focus Child present in home during visit:

No

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




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






















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

1

2

3

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