Prenatal
Inventory
www.thefamilymap.org
version 5.4
Page 1 of 18
Prenatal 2.3
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:
Parent ID
Parent ID
Pregnant Mother:
Parent Name
Date of Interview
Due Date:
Target Child - 1
1
Target Child - 2
2
Target Child - 3
3
Target Child - 4
4
Target Child
b) Do you consider yourself 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 race?
Mark all that apply.
c) Were you born in the United States?
were you born in the United States - 1
Yes
were you born in the United States - 0
No
Country of Origin - Name
Country of Origin
If No
your age - 1
16 years or less
your age - 2
17-18 years
your age - 3
19-24 years
your age - 4
25-34 years
your age - 5
35-40 years
your age - 6
41 or more
2. How old are you now?
How old are you in years
Years
PRENATAL FAMILY MAP
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Code of the interviewer
Interviewed by:
AgenCode
Agency Code:
(Clear identifiers)
state
Location:
region
Region:
CenCode
Center:
ClassCode
Class:
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:
Other - Race Identified
Sent - 1
Sent - 0
isSaved - 1
isSaved - 0
Prenatal
Inventory
Page 2 of 18
Prenatal 2.3
Parent ID
Parent ID
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Child One Name
Child one relationship to mother
Child Two Name
Child two relationship to mother
Child Three Name
Child three relationship to mother
Child Four Name
Child four relationship to mother
Child Five Name
Child five relationship to mother
Child Six Name
Child six relationship to mother
Child Seven Name
Child seven relationship to mother
SECTION 1
SELF SUPPORT
S2. Are you or have you been involved with a similar program in the past?
Head Start, HIPPY, home visiting program
Involved in Similar Program Previously - 0
No
Involved in Similar Program Previously - 1
Yes
If yes:
Other - name of previous program involved with
a) Did you set any goals with this program?
Goals with this Program? - 0
No
Goals with this Program? - 1
Yes
S3. How many children live in the home with you?
Only count people less than 18 years old.
Do not count mother figure.
children in home - 0
0
children in home - 1
1
children in home - 2
2
children in home - 3
3
children in home - 4
4
children in home - 5
5
children in home - 6
6
children in home - 7
7
Child Name:
Relationship to mother figure:
No Other Children
S4. Are you currently enrolled in school?
S5. What level of education have you completed?
completed school classification - 1
completed school classification - 2
completed school classification - 3
completed school classification - 4
completed school classification - 5
completed school classification - 6
No High School Degree
High School Degree
GED
Votech, Technical Certificate/License
College
Degree
Current school enrollment - 1
Current school enrollment - 2
Current school enrollment - 3
Current school enrollment - 4
Current school enrollment - 5
Not Enrolled
GED
High School
Votech, Technical Certificate/License
College
AA or AS Degree or Some College
Mark Total.
What program?
If any response in shaded area: Consider English as a Second Language as a Goal.
If not Currently Enrolled and High School or less: Consider Education as a Goal.
S1. Is any language other than English regularly spoken in your home?
Language spoken in home - 0
No
Language spoken in home - 1
Spanish
Language spoken in home - 2
Other:
Other - None English Language Spoken in Home
Comfortable Speaking English - 1
Comfortable Speaking English - 2
Comfortable Speaking English - 3
Comfortable Speaking English - 4
How often:
Do Family Members Translate English for You with Program Staff - 1
Do Family Members Translate English for You with Program Staff - 2
Do Family Members Translate English for You with Program Staff - 3
Do Family Members Translate English for You with Program Staff - 4
Do you understand the written mateials presented - 1
Do you understand the written mateials presented - 2
Do you understand the written mateials presented - 3
Do you understand the written mateials presented - 4
Do you feel comfortable asking program staff to translate written mateials for you - 1
Do you feel comfortable asking program staff to translate written mateials for you - 2
Do you feel comfortable asking program staff to translate written mateials for you - 3
Do you feel comfortable asking program staff to translate written mateials for you - 4
a)
Do you feel comfortable speaking English?
Can you understand the written materials the program gives you?
c)
Do you feel comfortable asking the program staff to translate their written materials for you?
d)
Do you use other family members to talk with program staff because they speak better English?
b)
Use Response Card
Always
Often
Some times
Rarely
NoZone_4
If no, skip to S2
If Other
Prenatal
Inventory
Page 3 of 18
Prenatal 2.3
Parent ID
Parent ID
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S6. How many hours did you work for pay in the last week?
(Or in a typical week if last week unusual. All job hours.)
Not Working
hours worked last week - 1
hours worked last week - 2
hours worked last week - 3
hours worked last week - 4
hours worked last week - 5
hours worked last week - 6
hours worked last week - 7
hours worked last week - 8
0-10
11-20
21-30
31-40
41-50
51-60
60 or more
a) How long have you been working at this job?
(newest job if more than 1)
time at job - 1
time at job - 2
time at job - 3
time at job - 4
time at job - 5
3 months or less
3-6 months
7-12 months
1-3 years
3 years or more
b) How many jobs do you currently have?
number of jobs - 1
1
number of jobs - 2
2
number of jobs - 3
3
c) What shift do you usually work?
what kind of shift do you work - 1
what kind of shift do you work - 2
what kind of shift do you work - 3
what kind of shift do you work - 4
what kind of shift do you work - 5
A regular day shift
A regular evening shift
A regular night shift
A split shift
Some other shift
What shift do you usually work - detail?
S7. How many adults live in the home with you?
Only count people 18 years or older. Do not count mother figure.
number of adults in home - 0
0
number of adults in home - 1
1
number of adults in home - 2
2
number of adults in home - 3
3
number of adults in home - 4
4
number of adults in home - 5
5
number of adults in home - 6
6
number of adults in home - 7
7
number of adults in home - 8
8
number of adults in home - 9
9
S8. Are you or anyone in your family receiving unemployment payments?
receiving unemployment payments - 00000001
Yes
receiving unemployment payments - 0
No
S9. Next we want to talk about your baby's other parent(s), living with you or not.
Name
How are they
related
to your baby?
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
NoZone_S6
If not working, skip to e.
If any response in the shaded area: Consider Employment as a Goal.
If Not Currently Enrolled and High School or Less: Consider Employment as a Goal.
College
Vocational
High School/ GED
No HS Degree
education level - 1
education level - 2
education level - 3
education level - 4
College
Vocational
High School/ GED
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
e) Are you currently not working because of your pregnancy?
S6e - 0
No
S6e - 1
Yes
S6d - 0
No
S6d - 1
Yes
d) Have you talked to your doctor about the physical demands of working while pregnant?
If yes, skip e).:
No
Prenatal
Inventory
Page 4 of 18
Prenatal 2.3
Parent ID
Parent ID
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S10. Let's talk about others living in the home that might help you now or might help after the baby is born. What are their names?
Name
How are they
related
to your baby?
How long
have you
lived
together?
What is their
highest level of
completed
education?
Are they
currently
enrolled in
school?
How many hours
are they
currently working
for pay?
Name of Other Adult living in the home - one
other adult one - number of years lived in home - 1
other adult one - number of years lived in home - 2
other adult one - number of years lived in home - 3
1 year or less
2-3 years
4 or more
other adult one - completed education level - 1
other adult one - completed education level - 2
other adult one - completed education level - 3
other adult one - completed education level - 4
No HS Degree
High School/ GED
Vocational
College
other adult one - Classification of Education Currently enrolled in - 1
other adult one - Classification of Education Currently enrolled in - 2
other adult one - Classification of Education Currently enrolled in - 3
other adult one - Classification of Education Currently enrolled in - 4
No
High School/ GED
Vocational
College
other adult one - hours per week currently working - 1
other adult one - hours per week currently working - 2
other adult one - hours per week currently working - 3
other adult one - hours per week currently working - 4
0-10 hours
20 hours or less
20-50 hours
50 hours or more
relationship to child - one - 1
relationship to child - one - 2
relationship to child - one - 3
Baby's Grandparent
Baby's Aunt/ Uncle
Other
relationship to child - other - one
Name of Other Adult living in the home - two
other adult two - number of years lived in home - 1
other adult two - number of years lived in home - 2
other adult two - number of years lived in home - 3
1 year or less
2-3 years
4 or more
other adult two - completed education level - 1
other adult two - completed education level - 2
other adult two - completed education level - 3
other adult two - completed education level - 4
No HS Degree
High School/ GED
Vocational
College
other adult two - Classification of Education Currently enrolled in - 1
other adult two - Classification of Education Currently enrolled in - 2
other adult two - Classification of Education Currently enrolled in - 3
other adult two - Classification of Education Currently enrolled in - 4
No
High School/ GED
Vocational
College
other adult two - hours per week currently working - 1
other adult two - hours per week currently working - 2
other adult two - hours per week currently working - 3
other adult two - hours per week currently working - 4
0-10 hours
20 hours or less
20-50 hours
50 hours or more
relationship to child - two - 1
relationship to child - two - 2
relationship to child - two - 3
Baby's Grandparent
Baby's Aunt/ Uncle
Other
relationship to child - other - two
Name of Other Adult living in the home - three
other adult three - number of years lived in home - 1
other adult three - number of years lived in home - 2
other adult three - number of years lived in home - 3
1 year or less
2-3 years
4 or more
other adult three - completed education level - 1
other adult three - completed education level - 2
other adult three - completed education level - 3
other adult three - completed education level - 4
No HS Degree
High School/ GED
Vocational
College
other adult three - Classification of Education Currently enrolled in - 1
other adult three - Classification of Education Currently enrolled in - 2
other adult three - Classification of Education Currently enrolled in - 3
other adult three - Classification of Education Currently enrolled in - 4
No
High School/ GED
Vocational
College
other adult three - hours per week currently working - 1
other adult three - hours per week currently working - 2
other adult three - hours per week currently working - 3
other adult three - hours per week currently working - 4
0-10 hours
20 hours or less
20-50 hours
50 hours or more
relationship to child - three - 1
relationship to child - three - 2
relationship to child - three - 3
Baby's Grandparent
Baby's Aunt/ Uncle
Other
relationship to child - other - three
(Ask about up to 3 people, Skip if no others in the home)
If Not Currently Enrolled and High School or Less: Consider Education as a Goal.
1.
2.
3.
Many new mothers have problems finding others to care for their child when they need to go out or go back to work. Thinking about all the poeple that you might ask to babysit your baby.
In the first three months after your baby is born, who will care for the baby when you have to go out for a short time without the baby?
In the year after your baby is born, who will care for the baby when you have to go back to work or school?
a) Are any of these caregivers under the age of 12?
s11 - 1
I am not sure
s11 - 2
My partner
s11 - 3
Other family
s11 - 4
Neighbor or friend
s11 - 5
Staff at a center program
s12 - 1
I am not sure
s12 - 2
My partner
s12 - 3
Other family
s12 - 4
Neighbor or friend
s12 - 5
Staff at a center program
S11a - 0
No
S11a - 1
Yes
a) Are any of these caregivers under the age of 12?
S12a - 0
No
S12a - 1
Yes
If any responses in shaded area: Consider childcare as goal.
S11.
S12.
Prenatal
Inventory
Page 5 of 18
Prenatal 2.3
Parent ID
Parent ID
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This interview will include questions about your family in the past year, month, and week.
R1.
Before we go on, has the
past month
been typical for you?
Has the past month been typical for you? - 1
Yes
Has the past month been typical for you? - 0
No
R2.
In the next 6 months, do you anticipate being separated from the family more than a week? - 1
Yes
In the next 6 months, do you anticipate being separated from the family more than a week? - 0
No
In the next 6 months, do you anticipate an another adult in the household being separated from the family more than a week? - 1
Yes
In the next 6 months, do you anticipate an another adult in the household being separated from the family more than a week? - 0
No
Other
You
R3.
How many times have you moved in the
past year
?
R4.
Do you have plans to move in the
next year
?
R5.
Have you and your child lived with family or friends, in a shelter, hotel, car, or other temporary housing in the
past year
?
In the past year how many times has your child moved residences? - 0
0
In the past year how many times has your child moved residences? - 1
1
In the past year how many times has your child moved residences? - 2
2
In the past year how many times has your child moved residences? - 3
3
In the past year how many times has your child moved residences? - 4
more
Do you plan to move residences in the next year? - 1
Yes
Do you plan to move residences in the next year? - 0
No
Have you and your child lived with family or friends or in a shelter, hotel, car or other temporary housing in the past year? - 1
Yes
Have you and your child lived with family or friends or in a shelter, hotel, car or other temporary housing in the past year? - 0
No
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
R6.
Thinking about the
past 7 days
,
how many
days
did you:
If any response in shaded area: Consider Support Strategies as a Goal.
If any response in shaded area: Consider Housing as a Goal.
If any responses in shaded area: Consider Daily Routines as a Goal.
In the
next 6 months
, do you expect you or someone else in your home will be separated from the family for more than a week?
(military, work, or incarceration)?
ROUTINES
SECTION 2
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
a)
Go to bed at about the same time?
s)
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
R8. How likely is it that you will limit TV watching for your child to less than an hour?
R8 - 1
Very likely
R8 - 2
Likely
R8 - 3
Not sure
R8 - 4
Not likely
R8 - 5
Not Likely at all
Very
Likely
Likely
Not
Sure
Not
Likely
Not Likely
at all
Home Very Active
Home Not Well Organized
Home Crowded for # of People
Home Very Calm
Home Very Organized
Home Not Crowded
homeobs2 - 1
1
homeobs2 - 2
2
homeobs2 - 3
3
homeobs2 - 4
4
homeobs3 - 1
1
homeobs3 - 2
2
homeobs3 - 3
3
homeobs3 - 4
4
homeobs4 - 1
1
homeobs4 - 2
2
homeobs4 - 3
3
homeobs4 - 4
4
Space for Baby Needed
homeobs1 - 1
1
homeobs1 - 2
2
homeobs1 - 3
3
homeobs1 - 4
4
Space for Baby Present/Planned
R7.
How many hours is a TV on at home during a usual weekday even if no one is watching?
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
If 2 or more responses in shaded area: Consider Household Organization as a Goal.
Prenatal
Inventory
Page 6 of 18
Prenatal 2.3
Parent ID
Parent ID
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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.
L1.
How many types of things do you have that your baby will be able to:
0
1
2
3 or more
L1d - 0
L1d - 1
L1d - 2
L1d - 3
c)
Feel and cuddle
such as stuffed animal, soft cloth, or play mat with textures?
L1c - 0
L1c - 1
L1c - 2
L1c - 3
b)
Make noise with
such as objects that rattle, spin, jitter, whirr, etc.?
L1b - 0
L1b - 1
L1b - 2
L1b - 3
a)
See
such as a mirror in the crib, mobile, or nightlight that projects light onto ceiling?
L1a - 0
L1a - 1
L1a - 2
L1a - 3
Many people enjoy reading and it is important for children to be exposed to books and reading early.
L4 - 1
Yes
L4 - 0
No
L4.
Do you have a library card?
d)
Use their muscles with
such as a ball, crib gym, or jump swing?
L2.
How often do you read at home?
L2 - 1
Everyday or almost everyday
L2 - 2
A few times a week
L2 - 3
Once a week
L2 - 4
A few times a month
L2 - 5
A few times a year
L2 - 6
Never
Every day or almost every day
A few times a
week
Once a week
A few times a month
A few time a year
Never
0
1-2
3-9
10+
L3.
How many children's wipe-able or washable books do you have for your baby? These are often made of vinyl, cloth, or stiff cardboard.
L3 - 0
L3 - 1
L3 - 2
L3 - 3
Need books in home
More than 10 books or magazines
bookobs - 1
1
bookobs - 2
2
bookobs - 3
3
bookobs - 4
4
4
EARLY LEARNING
SECTION 3
If any response in shaded area: Consider Learning Materials as a Goal.
If all responses in shaded area: Consider Reading Materials as a Goal.
Prenatal
Inventory
Page 7 of 18
Prenatal 2.3
Parent ID
Parent ID
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X1.
X2.
Thinking about how your child will behave in the
first 6 months
, how much do you agree with the following statements:
Every pregnant mother feels differently about their pregnancy. In the
past week
,how often have you:
X1a - 1
X1a - 2
X1a - 3
X1b - 1
X1b - 2
X1b - 3
X1c - 1
X1c - 2
X1c - 3
X1d - 1
X1d - 2
X1d - 3
X1e - 1
X1e - 2
X1e - 3
Some
of the time
Little or none
of the time
Most or all
of the time
c)
Told others what the baby does inside you?
b)
Enjoyed or looked forward to feeling the baby move?
a)
Wondered what the baby will look like?
If 3 or more responses in shaded area: Consider Prenatal Education as a Goal.
Strongly Disagree
Disagree
Agree
Strongly Agree
Use Response Card
Use Response Card
EXPECTATIONS
SECTION 4
If 2 or more responses in shaded area: Consider Prenatal Education as a Goal.
e)
Stroked the baby through your tummy?
a)
A baby can cry for 20 or 30 minutes at a time, no matter how much you try to comfort.
X2a - 1
X2a - 2
X2a - 3
X2a - 4
b)
Taking care of a baby can leave the parent feeling tired, frustrated, or overwhelmed.
X2b - 1
X2b - 2
X2b - 3
X2b - 4
c)
A baby can understand words they cannot say.
X2c - 1
X2c - 2
X2c - 3
X2c - 4
d)
Babies cry or soil their diapers just to annoy parents.
X2d - 1
X2d - 2
X2d - 3
X2d - 4
d)
Tried to imagine what the baby is doing?
Prenatal
Inventory
Page 8 of 18
Prenatal 2.3
Parent ID
Parent ID
Thefamilymap.org
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The next few questions are about crime and safety issues in your neighborhood. By neighborhood, we mean a few blocks around the house, or the area within short walking distance from the home.
Use Response Card
E3.
In your neighborhood, how much of a problem is the selling and using of drugs? Would you say it is:
Not Serious
Not Too Serious
Fairly Serious
Very Serious
E3 - 1
E3 - 2
E3 - 3
E3 - 4
Never
Some of the Time
Most of the Time
All of the Time
E2 - 1
E2 - 2
E2 - 3
E2 - 4
Never Happen
Hardly Ever Happen
Happen Fairly Often
Happen Very Often
E4 - 1
E4 - 2
E4 - 3
E4 - 4
E4.
How often are there problems with muggings, burglaries, assults, or other criminal activities in your neighborhood? Would you say these things:
Very Bad
Fairly Bad
Fairly Good
Very Good
E1 - 1
E1 - 2
E1 - 3
E1 - 4
E1.
How do you feel about your neighborhood?
Do you feel it is:
E2.
Thinking about crime and safety in your neighborhood, how often do you think about moving because of the safety of the neighborhood? Would you say it is:
E5.
In the
past year
, how many times have
you or someone living in your home
been physically hurt by someone?
E5 - 0
E5 - 1
E5 - 2
E5 - 3
E5 - 4
Never
Once
Two times
Three times
More than 3 times
ENVIRONMENTAL SAFETY
SECTION 5
Neighborhood Unsafe
neigh1 - 1
1
neigh1 - 2
2
neigh1 - 3
3
neigh1 - 4
4
Neighborhood Safe
If any response in shaded area: Consider Housing or Safety Strategies as a Goal.
Prenatal
Inventory
Page 9 of 18
Prenatal 2.3
Parent ID
Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
The next questions are about the people that might help you raise your baby. If more than one person shares parenting with you, answer about the person that you
disagree with the most
.
Never or Rarely
Some Times
Often or Always
Regarding people that help you raise your child - how often do you and this person have disagreements about how to raise your child? - 1
Regarding people that help you raise your child - how often do you and this person have disagreements about how to raise your child? - 2
Regarding people that help you raise your child - how often do you and this person have disagreements about how to raise your child? - 3
Skip
only
if no other person is identified inside or outside the home.
Use Response Card
Regarding people that help you raise your child - how often does conversations turn hostile or angey with them? - 1
Regarding people that help you raise your child - how often does conversations turn hostile or angey with them? - 2
Regarding people that help you raise your child - how often does conversations turn hostile or angey with them? - 3
Regarding people that help you raise your child - how often do disagreements related to money to buy things for or support the child occurre? - 1
Regarding people that help you raise your child - how often do disagreements related to money to buy things for or support the child occurre? - 2
Regarding people that help you raise your child - how often do disagreements related to money to buy things for or support the child occurre? - 3
F2.
When you and this person talk about how to raise your baby, how often is the conversation hostile or angry?
F3.
The next statements are about
family members or others you think of as family
that you see at least weekly. Please tell me how often these are true for your family:
Never or Rarely
Some Times
Often or Always
Regarding family members or others you consider family that you see at least weekly - how often is it true for people to lose their tempers? - 1
Regarding family members or others you consider family that you see at least weekly - how often is it true for people to lose their tempers? - 2
Regarding family members or others you consider family that you see at least weekly - how often is it true for people to lose their tempers? - 3
Use Response Card
F4.
People in our family lose their tempers.
Regarding family members or others you consider family that you see at least weekly - how often is it true for people to feel very close? - 1
Regarding family members or others you consider family that you see at least weekly - how often is it true for people to feel very close? - 2
Regarding family members or others you consider family that you see at least weekly - how often is it true for people to feel very close? - 3
F5.
Family members feel very close.
Regarding family members or others you consider family that you see at least weekly - how often is it true for people to raise their voices to yell or in anger? - 1
Regarding family members or others you consider family that you see at least weekly - how often is it true for people to raise their voices to yell or in anger? - 2
Regarding family members or others you consider family that you see at least weekly - how often is it true for people to raise their voices to yell or in anger? - 3
F6.
We raise our voices or yell in anger.
Regarding family members or others you consider family that you see at least weekly - how often is it true for people to be supportive of each other? - 1
Regarding family members or others you consider family that you see at least weekly - how often is it true for people to be supportive of each other? - 2
Regarding family members or others you consider family that you see at least weekly - how often is it true for people to be supportive of each other? - 3
F7.
People in my family help and support each other
F1.
How often do you and this person have disagreements about how to raise your baby?
How often do you and this person have disagreements related to money to buy things for or support the child (
like child support if not married
)?
FAMILY COHESION
SECTION 6
If 2 or more responses in shaded area: Consider Relationship Counseling as a Goal.
If 2 or more responses in shaded area: Consider Family Counseling as a Goal.
Prenatal
Inventory
Page 10 of 18
Prenatal 2.3
Parent ID
Parent ID
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© 2016, BioVentures, LLC, All rights reserved
PREPARING FOR DISCIPLINE
SECTION 7
Strongly Disagree
Disagree
Agree
Strongly Agree
Use Response Card
Thinking about how your child will behave in the
first 6 months
, how much do you agree with the following statements:
D2.
Spanking is alright for babies.
D2 - 1
D2 - 2
D2 - 3
D2 - 4
D1.
Comforting a crying baby will spoil them.
D1 - 1
D1 - 2
D1 - 3
D1 - 4
D3.
Parents sometimes need to ask another person to care for a crying baby to give themselves a break.
D3 - 1
D3 - 2
D3 - 3
D3 - 4
D4.
Spanking is a good way to change my child’s behavior as they get older.
D4 - 1
D4 - 2
D4 - 3
D4 - 4
D5.
Moving breakables is better than slapping my child’s hand.
D5 - 1
D5 - 2
D5 - 3
D5 - 4
D6.
I will spoil my child by holding them too much.
D6 - 1
D6 - 2
D6 - 3
D6 - 4
If any response in shaded area: Consider Parenting Education as a Goal.
Prenatal
Inventory
Page 11 of 18
Prenatal 2.3
Parent ID
Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
Sometimes it is difficult for families to get all of the medical care that they need. The next part of the interview is about the health of your family.
H1.
Do
you
have a health problem or illness that requires regular, ongoing care or medication?
For example, a disability, a mental illness, or chronic health problems like asthma, severe allergies, sickle cell anemia, or cerebral palsy.
H1 - 0
No
H1 - 1
Yes
If no, skip to H2.
Note Condition:
H1_CO1
Determine need:
Do you understand what your doctor or therapist wants you to do day-to-day to deal with that health problem? Do you have a plan from the doctor? Do you feel comfortable following that plan? Do you have any problems being able to follow-through with the plan?
H2.
Does
anyone else
in the home have a health problem or illness that requires regular, ongoing care or medication?
H2 - 0
No
H2 - 1
Yes
If no, skip to H3.
Note Condition:
H2_CO1
Determine need:
Do they have a plan from the doctor? Do they feel comfortable following that plan?
Yes, Care Demanding
H2_obs - 1
1
H2_obs - 2
2
H2_obs - 3
3
H2_obs - 4
4
No One in the Home
SECTION 8
HEALTH
No
Yes
Do you understand what your doctor wants you to do day-to-day to have a healthy pregnancy?
H7a - 0
No
H7a - 1
Yes
a)
Have you received prenatal care by a doctor, nurse, or midwife?
H7.
No
Yes
H7 - 0
No
H7 - 1
Yes
Have you talked to your doctor, nurse, or midwife about any of the following?
NoZone_4_2
If no, skip to H8
Thinking about when you talked to a doctor, nurse, or midwife
e)
Planning for the delivery of this child?
H7e - 0
No
H7e - 1
Yes
f)
The signs and symptoms of labor more than 3 weeks before the baby is due (premature)?
H7f - 0
No
H7f - 1
Yes
g)
What to do if you labor starts early?
H7g - 0
No
H7g - 1
Yes
h)
What to do if you feel depressed during your pregnancy or after your baby is born
H7h - 0
No
H7h - 1
Yes
i)
Family planning after the birth of this child
H7i - 0
No
H7i - 1
Yes
b)
Nutrition and weight gain
H7b - 0
No
H7b - 1
Yes
c)
Smoking or drinking alcohol
H7c - 0
No
H7c - 1
Yes
d)
Medicines or other drugs
H7d - 0
No
H7d - 1
Yes
No
Yes
Needs Help with Plan
H1_obs - 1
1
H1_obs - 2
2
H1_obs - 3
3
H1_obs - 4
4
Has a Plan and Following
H3.
Have you seen a dentist in the last 6 months for regular care?
H3 - 0
No
H3 - 1
Yes
H5.
Do you have health insurance now?
H5 - 0
No
H5 - 1
Yes
Do you expect to have health insurance for yourself after your baby is born?
H6 - 0
No
H6 - 1
Yes
H6.
Can you get health care when you are sick or injured that is not from a hospital emergency room?
H4.
H4 - 0
No
H4 - 1
Yes
If any response in shaded area: Consider Medical Care as a Goal.
If any response in shaded area: Consider Prenatal Care as a Goal.
If any response in shaded area: Consider Medical Assistance as a Goal.
Prenatal
Inventory
Page 12 of 18
Prenatal 2.3
Parent ID
Parent ID
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© 2016, BioVentures, LLC, All rights reserved
Yes
H15.
During the
past month,
how many times each week did you exercise such as running or walking for at least 30 minutes?
None
1-2 per week
3-4 per week
More
H16.
During the
past month,
how many times per week have you felt you did not get enough rest or sleep?
H17.
Does anyone smoke cigarettes inside your
home
?
No
H18.
Does anyone smoke cigarettes inside your
car
?
No
Yes
H8.
Is anyone else in your home currently pregnant?
H8 - 0
H8 - 1
H9.
Have you identified a doctor to care for your child after delivery?
H9 - 0
H9 - 1
H10.
Do you know how to enroll your child in a health insurance program?
H10 - 0
H10 - 1
Thinking about after the birth of your child
H11 - 0
H11 - 1
No
Yes
Don't
Know
H12 - 0
H12 - 1
H13 - 0
H13 - 1
H13 - 2
H11.
Have you talked to a doctor, nurse, or another professional about breastfeeding?
H12.
Have you talked to a medical professional about contraception while breastfeeding?
H13.
Do you plan to breastfeed?
H14.
How old do you think your baby will be
a)
when you feed him/her formula?
b)
when you introduce him / her to other food
besides breast milk or formula?
Less than 1 month
1 month
2 - 5
months
6 months
or older
H14a - 1
H14a - 2
H14a - 3
H14a - 4
H14b - 1
H14b - 2
H14b - 3
H14b - 4
H15 - 0
H15 - 1
H15 - 2
H15 - 3
H16 - 0
H16 - 1
H16 - 2
H16 - 3
H19.
H20.
In the 3 months before you got pregnant,
how many cigarettes did you smoke on an average day?
A pack has 20 cigarettes.
In the last month, how many cigarettes did you smoke on an average day?
H17 - 0
H17 - 1
H18 - 0
H18 - 1
None
Less than 1
1 - 5
6 - 10
11 - 20
21 - 40
41 or
more
H19 - 0
H19 - 1
H19 - 2
H19 - 3
H19 - 4
H19 - 5
H19 - 6
H20 - 0
H20 - 1
H20 - 2
H20 - 3
H20 - 4
H20 - 5
H20 - 6
If any response in shaded area: Consider Smoking Cessation as a Goal.
If any response in shaded area: Consider Health Care Access as a Goal.
If any response in shaded area: Consider Breastfeeding Support as a Goal.
If any response in shaded area: Consider Healthy Practices as a Goal.
Prenatal
Inventory
Page 13 of 18
Prenatal 2.3
Parent ID
Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
H21.
Closest friends have a problem with drinking or drugs?
H22.
Close family members have a problem with drinking or drugs
(parents or siblings)
?
a)
Do any of these friends or family members live in your home?
No or Don't drink
Yes
7 - 13
14 or more
H23.
Before you were pregnant, did you feel you ought to cut down on your drinking or drug use?
H24.
In the 3 months before you got pregnant, how many alcoholic drinks did you have in an average week?
H25.
In the last month, how many alcoholic drinks did you have in an average week?
Many people need help coping with family or friends that have problems with drinking or drugs.
Do any of your:
H21 - 0
H21 - 1
H22a - 0
H22a - 1
H23 - 0
H23 - 1
4 - 6
1 - 3
Less than 1
None
H24 - 0
H24 - 1
H24 - 2
H24 - 3
H24 - 4
H24 - 5
H25 - 0
H25 - 1
H25 - 2
H25 - 3
H25 - 4
H25 - 5
H22 - 0
H22 - 1
Share Alcohol or Drug Information
OBS_DRUG - 1
1
OBS_DRUG - 2
2
OBS_DRUG - 3
3
OBS_DRUG - 4
4
Does Not Need Information
In the Past
No
H26.
Have any
family members
ever been diagnosed with depression?
H27.
Have
you
ever been diagnosed with depression?
Nearly every day
More than 1/2 the days
Several Days
Not at all
Yes
Currently
H28.
In the
past 2 weeks
, how often have you been:
a)
Bothered by feeling down, depressed, or hopeless?
b)
Bothered by having little interest or pleasure in doing things?
c)
Bothered by feeling easily annoyed or irritated?
d)
Bothered by feeling suddenly scared for no reason?
e)
Bothered by feeling tense or nervous?
f)
Bothered by moments of terror or panic?
g)
Bothered by getting into arguments often?
H28a - 0
H28a - 1
H28a - 2
H28a - 3
H28b - 0
H28b - 1
H28b - 2
H28b - 3
H28c - 0
H28c - 1
H28c - 2
H28c - 3
H28d - 0
H28d - 1
H28d - 2
H28d - 3
H28e - 0
H28e - 1
H28e - 2
H28e - 3
H28f - 0
H28f - 1
H28f - 2
H28f - 3
H28g - 0
H28g - 1
H28g - 2
H28g - 3
Share Parenting or Health Information
H28_obs - 1
1
H28_obs - 2
2
H28_obs - 3
3
H28_obs - 4
4
Does Not Need Information
Depression concerns: Add the responses for a and b. Higher scores indicate more depressive symptoms. 0 = no action, 1 = information about depression, 2 or 3 = suggest services.
If any response in shaded area: Consider Counseling as a Goal.
If response to any of 'a' to 'g' in shaded areas: Consider Counseling as a Goal.
If any response in shaded area:
Consider Fetal Alcohol Spectrum Disorder or Alcohol/Drug Information as a Goal.
Have any family members ever been diagnosed with depression? - H26_Y
Have any family members ever been diagnosed with depression? - H26_P
Have any family members ever been diagnosed with depression? - H26_N
Have you ever been diagnosed with depression? - H27_Y
Have you ever been diagnosed with depression? - H27_P
Have you ever been diagnosed with depression? - H27_N
Prenatal
Inventory
Page 14 of 18
Prenatal 2.3
Parent ID
Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
B11.
Glass or bottle of water
a)
Dairy products like milk, cheese, yogurt
b)
Meats like beef, chicken, fish, eggs
c)
Protein like beans, peas, nuts, peanut butter, veggie burger
d)
B9.
The food that you bought just didn't last and you didn't have money to get more.
B10.
You or others in your household cut the size of your meals or skipped meals because there wasn't enough money for food.
B9 - 0
B9 - 1
B9 - 2
B10 - 0
B10 - 1
B10 - 2
Never True
Sometimes True
Often True
Thinking about food and nutrition, how often are the following never, sometimes, or often true? In the
past year
:
e)
Grains like bread, rice, pasta, cereals, tortillas
SECTION 9
BASIC NEEDS
Use Response Card
No
Yes
Don't Know
Have you had an open child protective case?
B5.
B5 - 0
B5 - 1
B5 - 2
Were you or your child's other parent involved with the legal system?
B6.
B6 - 0
B6 - 1
B6 - 2
In the
next year
, do you expect you will need help paying for basic services such as utilities, rent, transportation, or health care?
B7.
B7 - 0
B7 - 1
B7 - 2
In the
next year
, do you expect that you will need help paying for necessary supplies for your child like diapers, formula, and bedding?
B8.
B8 - 0
B8 - 1
B8 - 2
In the
past year
,
f)
Dark green or orange / yellow vegetables like greens, carrots, broccoli, squash, sweet potatoes -
but do not count french fries
g)
Fruits like apples, oranges, bananas, grapes, peaches, applesauce -
but do not count juice
h)
Sugary sweets like cakes and candy, or sugary drinks like soda, sports drinks, juice, or fruit drinks.
Use Response Card
About how often do you eat or drink from each of the following groups?
Serving size per day goal
More than 1 a day
Once
a day
2 - 6
a week
Once
a week
None
10 cups
3 - 4 cups
Total 6 1/2 oz.
6 - 8 cups
3 cups
2 cups
None
B11a - 1
B11a - 2
B11a - 3
B11a - 4
B11a - 5
B11b - 1
B11b - 2
B11b - 3
B11b - 4
B11b - 5
B11c - 1
B11c - 2
B11c - 3
B11c - 4
B11c - 5
B11d - 1
B11d - 2
B11d - 3
B11d - 4
B11d - 5
B11e - 1
B11e - 2
B11e - 3
B11e - 4
B11e - 5
B11f - 1
B11f - 2
B11f - 3
B11f - 4
B11f - 5
B11g - 1
B11g - 2
B11g - 3
B11g - 4
B11g - 5
B11h - 1
B11h - 2
B11h - 3
B11h - 4
B11h - 5
The next part of the interview is about whether you need help to meet the needs of your family. In the
past year
,how many times:
None
1 or more
Don't Know
Were you unable to pay an
important montly bill
such as rent, car payment, house repair, child care, or other outstanding payment?
B2.
B2 - 0
B2 - 1
B2 - 2
Were you unable to afford
medical care, dental care, or medicine
?
B3.
B3 - 0
B3 - 1
B3 - 2
Did you have problems with
transportation
because you could not afford to buy gas for the car, pay for car repairs, or pay for a bus, cab, or other transportation?
B4.
B4 - 0
B4 - 1
B4 - 2
Did you have any of your
utilities
such as gas, electric, water, or telephone service turned off because there wasn't enough money to pay the bill?
B1.
B1 - 0
B1 - 1
B1 - 2
If any response in shaded area: Consider Basic Needs as a Goal.
If any response in shaded area: Consider Food Assistance as a Goal.
If any response in shaded area: Consider Nutrition Education as a Goal.
Prenatal
Inventory
Page 15 of 18
Prenatal 2.3
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 have you taken even for a short trip:
C1.
With a seatbelt worn correctly low across the hips and across the collarbone?
C2.
Do you have a child safety seat?
C1 - 0
C1 - 1
C1 - 2
C1 - 3
Never
1-9 Rides
More than 10
Every Ride
C2 - 0
No
C2 - 1
Yes
Yes
No
C3.
C4.
C5.
C7.
C6.
C8.
Is there a
working
smoke detector in your home for each level?
Are there two clear exits that can be used in case of a fire?
This could be two doors or a window that you could safely climb out.
Can you hold your hand under the hottest running water for several seconds without getting burned (water heater set below 120 degrees)?
After your baby is born, will you or anyone else
Do you live in a building built
before 1978
when lead based paint was banned?
Take a moment to think about where your child will sleep and play.
Which of the following do you have in your home?
a) co-sleep with your baby in the same bed or on a couch?
C3 - 0
C3 - 2
C3 - 1
No
Don't Know
Yes
C4 - 0
C4 - 2
C4 - 1
C5 - 0
C5 - 2
C5 - 1
C6 - 0
C6 - 2
C6 - 1
C7a - 0
C7a - 2
C7a - 1
C7b - 0
C7b - 2
C7b - 1
C7c - 0
C7c - 2
C7c - 1
C7d - 0
C7d - 2
C7d - 1
a)
b)
Crib / Bed with slats no more than the width of your hand that is no more than 2 3/8 inches wide.
Crib / Bed near windows with blind cords or near heating unit
C8c - 0
No
C8c - 2
Don't Know
C8c - 1
Yes
Don't
Know
C8d - 0
No
C8d - 2
Don't Know
C8d - 1
Yes
C8e - 0
No
C8e - 2
Don't Know
C8e - 1
Yes
C8f - 0
No
C8f - 2
Don't Know
C8f - 1
Yes
c)
d)
Stairs without gates
Changing table without guardrails or rails less than 2 inches tall
SECTION 10
HOME AND CAR SAFETY
b) let the baby sleep in the room with you but not in the same bed?
a) Have you tested your smoke detector(s) in the last 2 months?
C3a - 0
C3a - 2
C3a - 1
No
Don't Know
Yes
c) always place your baby on his / her back to sleep?
d) let the baby sleep on soft bedding or with stuffed toys?
C8b - 0
No
C8b - 2
Don't Know
C8b - 1
Yes
C8a - 0
No
C8a - 2
Don't Know
C8a - 1
Yes
e)
Kitchen or bathroom cabinets / drawers without stop / locks
f)
A pet that could become aggressive
If any response in shaded area: Consider Vehicle Safety as a Goal.
If any response in shaded area: Consider Safety Strategies as a Goal.
If any response in shaded area: Consider Safe Infant Sleep as a Goal.
If any response in shaded area: Consider Child Safety as a Goal.
Prenatal
Inventory
Page 16 of 18
Prenatal 2.3
Parent ID
Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
C9.
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
Don't Own
Yes
No
Safety Concerns in Home
safet1 - 1
1
safet1 - 2
2
safet1 - 3
3
safet1 - 4
4
No Safety Concerns in Home
Safety Concerns outside Home
safet2 - 1
1
safet2 - 2
2
safet2 - 3
3
safet2 - 4
4
No Safety Concerns outside Home
sleepobs - 1
1
sleepobs - 2
2
sleepobs - 3
3
sleepobs - 4
4
Infant Safe Sleep Concerns
No Infant Safe Sleep Concerns
If any response in shaded area: Consider Household Safety as a Goal.
Prenatal
Inventory
Page 17 of 18
Prenatal 2.3
Parent ID
Parent ID
Thefamilymap.org
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People sometimes look to others for companionship, assistance, or other types of support.
Little or none of the time
Some of the time
Most or all of the time
In the past month, how often was someone available to - Listen to you when you needed to talk? - 1
In the past month, how often was someone available to - Listen to you when you needed to talk? - 2
In the past month, how often was someone available to - Listen to you when you needed to talk? - 3
Use Response Card
In the past month, how often was someone available to - help with daily chores if you were sick? - 1
In the past month, how often was someone available to - help with daily chores if you were sick? - 2
In the past month, how often was someone available to - help with daily chores if you were sick? - 3
In the past month, how often was someone available to - Loan you $100 if you needed it? - 1
In the past month, how often was someone available to - Loan you $100 if you needed it? - 2
In the past month, how often was someone available to - Loan you $100 if you needed it? - 3
a)
Listen to you when you needed to talk?
b)
Help with daily chores if you were sick?
I1.
In the
past month
, how often was someone available to:
c)
Loan you $100 if you needed it?
If any response in shaded area: Consider Support System as a Goal.
SOCIAL INTEGRATION
SECTION 11
Help with the baby on a daily basis for the first few weeks?
Call if you need a good night's sleep?
After the birth of your baby, how often do you think you will have someone availabile to:
Ask for advice about baby care, for example, how to give baby a bath?
a)
b)
c)
I2.
Care for the baby when you need a break, for example, if your baby is very fussy?
d)
Accompanied you to a doctor's visit?
Discussed with you how the pregnancy is going?
Listened to the baby's heartbeat?
a)
b)
c)
Talked about the future with the baby?
d)
Little of the time
Some of the time
Most or all of the time
Thinking about this pregnancy,
how often do you have contact with the father?
I3.
Little of the time
Some of the time
Most or all of the time
No Contact
Thinking about the contact you have, how often has he:
I3_noco - 1
I3_Contact
If none, skip to I4.
I2a - 1
I2a - 2
I2a - 3
I2b - 1
I2b - 2
I2b - 3
I2c - 1
I2c - 2
I2c - 3
I2d - 1
I2d - 2
I2d - 3
I3a - 1
I3a - 2
I3a - 3
I3b - 1
I3b - 2
I3b - 3
I3c - 1
I3c - 2
I3c - 3
I3d - 1
I3d - 2
I3d - 3
I3 - 1
I3 - 2
I3 - 3
If any response in shaded area: Consider Respite Care as a Goal.
If any responses in shaded area: Consider Relationship Counseling as a Goal.
Prenatal
Inventory
Page 18 of 18
Prenatal 2.3
Parent ID
Parent ID
Thefamilymap.org
© 2016, BioVentures, LLC, All rights reserved
More than once a week
Weekly
Once or Twice a month
None
I4.
In the
past month
, how often have you participated in the following activities?
a)
Prenatal class or other classes to learn about parenting
b)
Neighborhood or community organization, committee, club, or sports team
c)
Church service or other religious club or activity
d)
Visit a friend or neighbor's house
e)
Hobby or sport with a friend
f)
Mother visited with people working with
name your program
g)
Mother volunteered at this program or other places
I4a - 0
I4a - 1
I4a - 2
I4a - 3
I4b - 0
I4b - 1
I4b - 2
I4b - 3
I4c - 0
I4c - 1
I4c - 2
I4c - 3
I4d - 0
I4d - 1
I4d - 2
I4d - 3
I4e - 0
I4e - 1
I4e - 2
I4e - 3
I4f - 0
I4f - 1
I4f - 2
I4f - 3
Ifg - 0
Ifg - 1
Ifg - 2
Ifg - 3
h)
Father / figure visited with people working with
name your program
i)
Father / figure volunteered at this program or other places
I4h - 0
I4h - 1
I4h - 2
I4h - 3
Ifi - 0
Ifi - 1
Ifi - 2
Ifi - 3
Share Program Volunteer information
VOLUN1 - 1
1
VOLUN1 - 2
2
VOLUN1 - 3
3
VOLUN1 - 4
4
Does Not Need
Information
If all responses in shaded area: Consider Community Involvement as a Goal.
If all responses in shaded area: Consider Program Engagement as a Goal.
When finished with the interview, please press "save" below or at the top of the page to save the form.
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