Infant Toddler
Sibling Inventory
www.thefamilymap.org
version 5.4
Page 1 of 16
InfToddlerSib v2.2
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
© 2016, BioVentures, LLC, All rights reserved
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
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 SIBLING 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:
(Clear identifiers)
state
Location:
region
Region:
CenCode
Center:
ClassCode
Class:
Infant Toddler
Sibling Inventory
Page 2 of 16
InfToddlerSib v2.2
Parent ID
Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
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
Relationship to child - 1
Relationship to child - 2
Relationship to child - 3
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
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
Infant Toddler
Sibling Inventory
Page 3 of 16
InfToddlerSib v2.2
Parent ID
Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
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?
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
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 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?
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
Sibling Inventory
Page 4 of 16
InfToddlerSib v2.2
Parent ID
Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
R10.
How often
is your child in the room
while the following types of TV programs or movies are on:
a)
Movies rated G
/ or TV shows rated Y (Youth)?
b)
Movies rated PG
/ or TV shows rated Y-7?
c)
Movies rated
PG-13
/ or TV shows rated 14?
d)
Movies rated R
/ or mature TV programs?
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
Infant Toddler
Sibling Inventory
Page 5 of 16
InfToddlerSib v2.2
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
Infant Toddler
Sibling Inventory
Page 6 of 16
InfToddlerSib v2.2
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
Sibling Inventory
Page 7 of 16
InfToddlerSib v2.2
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
Sibling Inventory
Page 8 of 16
InfToddlerSib v2.2
Parent ID
Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
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.
ENVIRONMENTAL SAFETY
SECTION 5
Infant Toddler
Sibling Inventory
Page 9 of 16
InfToddlerSib v2.2
Parent ID
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.
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
FAMILY COHESION
SECTION 6
Infant Toddler
Sibling Inventory
Page 10 of 16
InfToddlerSib v2.2
Parent ID
Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
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
Sibling Inventory
Page 11 of 16
InfToddlerSib v2.2
Parent ID
Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
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?
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
If any response in shaded area or immunizations not current: Consider Child Health Care as a Goal.
SECTION 8
HEALTH
Infant Toddler
Sibling Inventory
Page 12 of 16
InfToddlerSib v2.2
Parent ID
Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
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)
No
Yes
Don't Know
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
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
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.
Infant Toddler
Sibling Inventory
Page 13 of 16
InfToddlerSib v2.2
Parent ID
Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
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
Sibling Inventory
Page 14 of 16
InfToddlerSib v2.2
Parent ID
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?
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...
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?
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
Sibling Inventory
Page 15 of 16
InfToddlerSib v2.2
Parent ID
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
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
Sibling Inventory
Page 16 of 16
InfToddlerSib v2.2
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...
When finished with the interview, please press "save" below or at the top of the page to save the form.
formName
Agen_3
Print/PDF
New
Save
Load
Submit Data
Help
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16