COMPENDIUM OF OUTCOME MEASUREMENT TOOLS FOR CHILD ABUSE AND NEGLECT PREVENTION AND FAMILY SUPPORT PROGRAMS

2008
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Prepared by Organizational Research Services Seattle, Washington
 

TABLE OF CONTENTS
Introduction ...............................................................................................................................1 Evaluation Capacity Building – Observations and Lessons .....................................................2 Protective Factors for the Prevention of Child Abuse and Neglect ..........................................5 Measurement Tools ...................................................................................................................6 Matrix of Outcome Measurement Tools .......................................................................7 Sample Tools and Summaries .......................................................................................8 Section I – Social Connections / Responsive Social Network Section II – Knowledge of Parenting & Child Development Section III - Nurturing & Attachment Section IV - Parental Resilience Appendix A

INTRODUCTION
Organizational Research Services has a long history of working with grant making organizations to build the capacity of their funded programs in the area of outcomebased evaluation. Funders such as Hawaii Children’s Trust Fund and Council for Children and Families (CCF) in Washington State have engaged ORS to support their grantees in measuring outcomes related to research-based protective factors associated with the prevention of child abuse and neglect. ORS coaches grantees in selecting program-appropriate parent- and family-level outcomes, with the next step being identification, adaptation or creation of data collection tools to measure these outcomes. Based on this work, ORS has compiled a Compendium of Measurement Tools for Prevention of Child Abuse & Neglect. This Compendium can be used by both funders and programs interested in outcomebased evaluation. In addition to tools, included in the Compendium are: 1) a summary of “lessons learned” for grant makers interested in the evaluation capacity-building approach, as well as 2) an excerpt from Outcomes for Success! describing data collection methods that may be particularly useful for community-based programs. The Compendium consists of examples of tools developed and used by a diverse array of programs conducting work related to prevention of child abuse and neglect. Some of the tools are nationally recognized and based on formal research, while others have been custom-designed to meet the unique needs of programs. The tools are categorized by four protective factors correlated with the prevention of child abuse and neglect: ™ Improved Social Connections ™ Knowledge of Parenting & Child Development ™ Nurturing & Attachment ™ Parental Resilience The tools are prefaced by an index table that provides a brief description and defining characteristics for each. ORS plans to periodically update this resource as other relevant tools are identified and developed.   This resource is intended to provide examples of ways in which programs have successfully collected data for their programs. As required, ORS has obtained permission to include certain published or copyrighted tools. Please note that some of the tools shown in this compendium may require permission or payment for use. 1

planning and capacity-building services for a variety of organizations. 2 . non-profits and government agencies.Organizational Research Services is an independent consulting company that provides outcomes-based evaluation. including foundations.

These observations could also be useful for community-based organizations seeking to undertake program evaluation efforts on their own or with an external evaluator. we also understand the “real world” settings in which community-based programs exist. If evaluation is a new requirement for grantees. For example. ORS has worked directly with many grant makers who are interested in supporting the development of evaluation capacity among their grantees. Organizational Research Services (ORS) has provided coaching and technical assistance to hundreds of community-based organizations to support the development and implementation of program evaluation plans and the use of data to strengthen program strategies and outcomes. These observations are intended to help grant makers interested in supporting evaluation efforts among their grantees to gauge grantee’s needs with regard to evaluation capacity building efforts and determine optimal ways to support grantees’ outcome measurement efforts either through training and/or individualized coaching. emphasize that program staff can and should make decisions about what they will measure (perhaps with some coaching). there may be some concern about funders’ expectations. While ORS understands that quality evaluation is rooted in strong social science methods. Over time. Based on our experience as coaches. we strive to develop evaluation capacity while at the same time recognizing evaluation approaches that will be workable in these settings. reporting and use of quality outcome data – even data that show less than favorable outcomes – if they clearly understand that the grant maker values building grantee capacity. For example. In addition. 3 . grantees may move from extrinsic motivations (driven by accountability to a funder) to intrinsic motivations (driven by the understanding of how data can improve their programs) to implement evaluation. grantees may be concerned that funding will be contingent on their ability to demonstrate successful achievement of program outcomes. we have documented the following observations about practices that have worked well to support the development of program evaluation capacity among community-based organizations and factors that influence capacity building.EVALUATION CAPACITY BUILDING: OBSERVATIONS LESSONS AND Founded in 1989. Grantees may be more likely to invest in the collection. ¾ Frame evaluation as a way for program staff to gain power rather than a requirement that is imposed on them. As coaches. ORS’ Observations Regarding Promising Capacity Building Practices ¾ Clearly inform grantees of funders’ philosophy and expectations with regard to evaluation.

¾ Understand the range of data collection options that are acceptable/appropriate for a community-based. though extensive validity testing is not typically demanded. it is typical for grantees to conceptualize their work as connected to long-term outcomes to which their programs might contribute. program managers may ask direct service staff to help develop survey questions or observational indicators on a tool they will ultimately be asked to fill out. ¾ Encourage program managers to build organizational support for evaluation by involving staff in decisions about the evaluation. self-evaluation context. While standardized or normed tools can sometimes be applied in communitybased settings. but to which it would be hard to hold themselves accountable (e. For example. providing parent education leads to a stronger community). 4 . When first articulating program outcomes. With coaching. long-term outcomes. grantees may be better able to articulate outcomes that are directly connected to their work while still showing how these outcomes contribute to broad. This approach increases grantee evaluation capacity from the beginning and helps grantees understand a funder’s expectations about evaluation. ¾ Consider what resources and supports grantees need to implement evaluation.g. Recognizing that engaging in program evaluation takes time.¾ Offer training to grant applicants and require logic models and in the grant proposal.” Such data collection tools as customized participant surveys or staff observations are often the most practical option for community-based programs given program realities (including evaluation purposes and available resources). grant makers may need to consider whether/what resources (in addition to direct service program operating grants) are needed to support grantees’ successful evaluation implementation. Good self-evaluation practice should involve careful and thoughtful development of customized tools along with adequate pilot-testing. especially when program staff and/or participants are sensitive to evaluation’s implied “judgment. ¾ Understand the difference between direct and indirect outcomes and the importance of measuring what grantees can directly impact. these tools may not be appropriate in all settings.

it is important for funders to be clear with grantees about expectations for outcome measurement and reporting. Grantee organizations can range from very small agencies with few staff to larger agencies with strong internal systems. ¾ Evaluation is less likely to be integrated into organizational systems without specific requirements. It takes time for community-based organizations to develop intrinsic motivation and commitment towards evaluation. intended outcomes because their activities/interventions are loosely defined. and specialized staff. and therefore measuring. Evaluation is an ongoing process and for it to become a way of doing business. staff often need regular support in how to use evaluation results. create different contexts for doing evaluation work. multiple programs. along with others such as organizational culture and values. To help some programs think about the connection between activities and outcomes. it may be helpful to offer logic model trainings and/or provide technical assistance to programs regarding how to strengthen program efforts. While coaching can help community-based programs develop evaluation plans and data collection tools. For programs that offer drop-in services or other “light touch” activities. the focus of implementation may be on providing the activity for its own sake rather than for the purposes of achieving a particular change among participants. ¾ Some programs may have a harder time articulating. 5 . can help to move grantees towards intrinsic motivation. ¾ The capacity to conceptualize evaluation is a different skill than the capacity to implement it. many programs could benefit from additional coaching and support to pilot and implement the tools. As previously mentioned. analyze and use the data collected. including support around reporting and internal use of data. as well as manage.Factors That Influence Grantee Capacity-Building ¾ Capacity to conduct program evaluation varies among community-based organizations. These organizational variations. A funder’s support of grantees through ongoing training and coaching.

friendsnrc. infant massage. 6 . and activities that develop skills in daily family life management and economic self-sufficiency. referrals and supports for families to access needed formal community resources. etc. child care. Concrete Supports in Times of Need.htm. employment seeking skill development. Activities that assist families to receive concrete supports in times of need are those that reduce social isolation and provide the necessary information. applying for financial assistance. 2007. cuddling. emotional and cognitive impacts of stress. and touching babies and young children. Activities that increase knowledge of parenting and child development include group or individual programs (such as home visiting) that teach parents and caregivers the usual steps in their child's development. keeping a safe home environment. Activities for increasing parental resilience include those that teach parents and caregivers skills for managing both crisis and the everyday challenges of family life. These include services designed to assist participants to effectively manage time. April 24. Additionally. job interview preparation. resume development. understanding sleep needs. the activities should include activities that enable parents to learn developmentally-appropriate and culturally-relevant discipline and guidance methods. finding adequate housing. to learn ways to stimulate healthy brain development and develop a positive and secure attachment with their child. activities that address the physical. Knowledge of Parenting and Child Development. Activities that reduce social isolation and assure families the ability to access needed informal resources are those that give parents opportunities to engage with others in a socially acceptable/positive manner and develop informal relationships with others who are caring for children. and vocational and career assessment and advancement. Social Connections. Parental Resilience. vocational training. attending to routine health needs and knowing when to seek help for serious health concerns.PROTECTIVE FACTORS FOR CHILD ABUSE AND NEGLECT1 Nurturing and Attachment. choosing appropriate toys. how to recognize if their child needs special help and how to promote healthy development.                                                              1 Source: http://www.org/outcome/toolkit/evalplan/why/protect. play with. Activities that increase the quality of nurturing and attachment include those that teach parents and caregivers to respond appropriately to the basic needs of their babies and young children. Examples include: holding a baby. listening to and differentiating their cries and other forms of communication. economical and healthy meal preparation. and increase family stability by learning skills such as budgeting and family income management.

MEASUREMENT TOOLS
Developing Your Data Collection Methods Appendix A contains excerpts from Outcomes for Success! (2000). The excerpt may be helpful for programs interested in designing their own data collection tools or determining how and whether to adapt sample tools included in this compendium. The full publication is available on the ORS website at: www.organizationalresearch.com.

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MATRIX OF OUTCOME MEASUREMENT TOOLS

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COMPENDIUM OF OUTCOME MEASUREMENT TOOLS  FOR FAMILY SUPPORT/CHILD ABUSE NEGLECT PREVENTION
PROTECTIVE FACTORS
Social Connections/  Responsive Social  Network *Knowledge of Parenting  & Child Development Nurturing & Attachment **Parental Resilience

Tool

Original  Developer(s)

Description of Tool

Population

Service  Setting

Format

Tool  #

ADWAS (Abused Deaf  Women's Advocacy  Services) POSITIVE  PARENTING PROGRAM Parent Pre‐Questionnaire

ADWAS (Abused Deaf  Women's Advocacy  Services) Positive  Parenting Program Post‐ Questionnaire

Women who  have been  abused;  Provides parenting classes,  Women living  workshops and one‐on‐one  with  mentoring to deaf parents with  disabilities  children aged birth to five and older (deaf) Class Women  who W h   have been  abused;  Women living  Provides parenting classes,  with  workshops and one‐on‐one  disabilities  mentoring to deaf parents with  Class children aged birth to five and older (deaf)

Survey

P

I‐1

Survey

P

I‐2

Northwest Institute  for Children and  Families; adapted by  Modified version of the Family  Focus Friends and Family  Family Focus Friends and  Center for Human  Family questionnaire Services questionnaire Northwest Institute  for Children and  Families; adapted by  Family Focus Friends and  Center for Human  Forty‐five scaled questions about  Family  questionnaire Services support from friends and family 

ESL  Community

Survey

P

I‐3

ESL  Community

Class

Survey

P

I‐4

P: Primary protective factor outcomes measured (filed under this Protective Factor) X: Additional protective factor outcomes measured

Page 1 of 9

COMPENDIUM OF OUTCOME MEASUREMENT TOOLS  FOR FAMILY SUPPORT/CHILD ABUSE NEGLECT PREVENTION PROTECTIVE FACTORS Social Connections/  Responsive Social  Network *Knowledge of Parenting  & Child Development Nurturing & Attachment **Parental Resilience Tool Original  Developer(s) Description of Tool Population Service  Setting Format Tool  # Kinship Care Support  Group Participant  Feedback FAMILY RESOURCES OF  ORCAS ISLAND Home  Visiting Question Guide Shoreline Sh li  Center C t  for f   Human Services Family  Support for ESL  Community Focus Group  Plan Used for Kinship Family Support  Services support group Identifies and links specific needs  with social support Isolated low‐ income  families Support  group Survey Question  Guide or  Home visit survey P I‐5 P I‐6 Guided conversation to inform and  expand on a brief written survey ESL families Documents service referrals and  follow‐up for Spanish language  parenting education program post‐ class and 3‐month follow‐up A tool documenting "talk story"  conversations about topics  addressed during home visits Class Focus Group P I‐7 Yakima Valley Farm  Worker Clinic Parenting  Program Referral Form Neighborhood Place of  Puna Community  Connections Talk Story  Questions Spanish‐ speaking Class Staff  completed  referral form P I‐8 Hawaiian  families Home Visit Interview P I‐9 P: Primary protective factor outcomes measured (filed under this Protective Factor) X: Additional protective factor outcomes measured Page 2 of 9 .

 setting and communicating  high expectations.  Spanish‐ speaking Home visit Survey X P X II‐2 Low‐income  refugee and  immigrant  parents Survey P II‐3 Spanish‐ speaking Survey P II‐4 P: Primary protective factor outcomes measured (filed under this Protective Factor) X: Additional protective factor outcomes measured Page 3 of 9 .COMPENDIUM OF OUTCOME MEASUREMENT TOOLS  FOR FAMILY SUPPORT/CHILD ABUSE NEGLECT PREVENTION PROTECTIVE FACTORS Social Connections/  Responsive Social  Network *Knowledge of Parenting  & Child Development Nurturing & Attachment **Parental Resilience Tool Original  Developer(s) Description of Tool Population Service  Setting Format Tool  # Central WA  Comprehensive Mental  Health Strong  Families/Familia F ili /F ili  Fuertes F t   Protective Factor  Inventory Parent Trust for  Washington Children  Intensive Parent Training  and Support (IPTS) Parent  Survey REFUGEE WOMEN’S  ALLIANCE: Refugee &  Immigrant Family  Empowerment Project Pre‐  and Post‐ Parent  Education Surveys Yakima Valley Farm  Worker Clinic Parenting  Questionnaire English/Spanish read aloud tool  measuring frequency of actions  related to prosocial bonding. behaviors and  confidence 5 questions focused on discipline  and communication for spanish  language parenting education  program High risk. as well as parental  knowledge. and providing  opportunities English t iti  for f  meaningful i f l  E li h and d  participation (retrospective pre and  spanish  post)  speaking Class Survey   S (questions  read aloud) P X II‐1 Post and retroactive pre test Pre‐ and post‐ parent education  surveys measuring discripline and  guidance.  boundaries. care &  support. life skills.

COMPENDIUM OF OUTCOME MEASUREMENT TOOLS  FOR FAMILY SUPPORT/CHILD ABUSE NEGLECT PREVENTION PROTECTIVE FACTORS Social Connections/  Responsive Social  Network *Knowledge of Parenting  & Child Development Nurturing & Attachment **Parental Resilience Tool Original  Developer(s) Description of Tool Population Service  Setting Format Tool  # Parenting Skills  Observation Observational tool for program staff  focused discipline and general  parenting Question for evaluative focus  Q ti  guide id  f l ti  f group discussion related to discipline  and guidance workshop created by  Ukrainian  the Ukranian Community Center of  parents. The  Incredible Years  (Seattle.  WA immigrants Home visit.  Family Support Center 10 years Home visit Observation P II‐7 Parent rating form measuring  conduct problems among children   ages 2‐16 (child outcome) Parents of  children and  adolescents Survey P II‐8 Parent post‐survey measures general  satisfaction as well as perceptions  about parenting techniques support  group Survey P II‐9 P: Primary protective factor outcomes measured (filed under this Protective Factor) X: Additional protective factor outcomes measured Page 4 of 9 . Created by Brigid Collins  children ages 2‐ interaction. PhD Incredible Years ‐ Parent  Program Satisfaction  Questionnaire ‐ BASIC  Parent Program BASIC Parent  Program. WA) One tool to be used in center setting  (therapist) and another by a home  Parent‐ visitor assessing parent behaviors  Parents with  Child  with child.  Parent‐ Child  interaction Observation P II‐5 Ukrainian Community  Center of WA Parent  Focus Group Survey Pre‐  Post‐Test Group Questions Class Focus Group P II‐6 PCIT Parenting Skill  Competency‐Homevisitor  & Coach Observation  Forms Eyberg Child Behavior  Inventory (ECBI) and  Sutter‐Eyberg Student  Behavior Inventory‐ Revised (SESBI‐R) Sheila Eyberg.

 University of  Idaho Parents as  Teachers  Demonstration  Project (Boise. action). Measures frequency of behaviors  indicating nurturing/attachment  used by Children's Home Society for  Fathers / male  the Fathering the Future program figures Survey P II‐12 Survey P III‐1 P: Primary protective factor outcomes measured (filed under this Protective Factor) X: Additional protective factor outcomes measured Page 5 of 9 . ID)  (Patterned after the  The University of Idaho  Oregon State  Survey of Parenting  Practice (UISPP) (Parenting  University Health  Start Parent Ladder) Ladder) The Fathering Project  (Survey Information  Request) Participant  Survey Post and retrospective pre‐survey  measures the impact of Parents as  Teachers on 4 levels of parenting  practice (knowledge.  Med. University of  Assesses pareting to disruptive child  school‐age  Interview Alabama behavior children Created by Little Red Schoolhouse  Little Schoolhouse   for the P Promoting First Littl  Red R d  S h lh f  th ti  Fi t  Parent Survey and Staff  Relationships/Parent‐Child  Observation Survey Interaction program Interview P II‐10 Survey/Obser vation P X II‐11 Harriet Shaklee. PhD  & Diane Demarest. ability. PJ.  confidence.COMPENDIUM OF OUTCOME MEASUREMENT TOOLS  FOR FAMILY SUPPORT/CHILD ABUSE NEGLECT PREVENTION PROTECTIVE FACTORS Social Connections/  Responsive Social  Network *Knowledge of Parenting  & Child Development Nurturing & Attachment **Parental Resilience Tool Original  Developer(s) Description of Tool Population Service  Setting Format Tool  # The University of New  orleans Alabama Parenting  Questionnaire (APQ)  Parents of  Parent Telephone  Frick.

  parent nurturing used by Northwest  with special  needs children Outreach Rural Resources Pre‐Post. Developed for Parents as  Teachers implementation and used  by North and Eastside Healthy Start. WA) for the Mother  Mentor Program Mentoring.COMPENDIUM OF OUTCOME MEASUREMENT TOOLS  FOR FAMILY SUPPORT/CHILD ABUSE NEGLECT PREVENTION PROTECTIVE FACTORS Social Connections/  Responsive Social  Network *Knowledge of Parenting  & Child Development Nurturing & Attachment **Parental Resilience Tool Original  Developer(s) Description of Tool Population Service  Setting Format Tool  # Parents Check‐In Used by Group Health Cooperative  (Tacoma.  Friends of Youth program Observation P III‐3 Nurturing and Attachment  Observation Tool PAT.  Home visit Survey P III‐2 Ladder Observation Pregnant and  parenting  teens who are  homeless in  h l  or i danger of  Brief observation tool focusing on  becoming so. home  visit Observation P III‐4 P: Primary protective factor outcomes measured (filed under this Protective Factor) X: Additional protective factor outcomes measured Page 6 of 9 .

 as well as  knowledge and utilization of  Nurturing Parenting practices. The  data from th the pre‐post d t  generated t d  f t  administration of the NSCS allows  parents and staff an opportunity to  measure changes in family life. Family  Development  Nurturing Skills  Resources. WA) feeding observation tool to one year NCAST (Nursing Child  Assessment Satellite  Kathryn Barnard. as well as satisfaction  Bonding  Attachment and Bonding  used by Volunteers of American  support  Class  (Spokane. Inc  Competency Scale (NSCS) (Bavolek) NCAST (Nursing Child  Assessment Satellite  Kathryn Barnard. WA) group P: Primary protective factor outcomes measured (filed under this Protective Factor) X: Additional protective factor outcomes measured The Nurturing Skills Competency  Scale (NSCS) gathers demographic  data of the family.  Training) Parent‐Child  University of  Parents of  Interaction (PCI) Teaching  Washington School of  Standardized teacher/caregiver  children birth  Scale Nursing (Seattle.  knowledge and utilization of  Nurturing Parenting practices.COMPENDIUM OF OUTCOME MEASUREMENT TOOLS  FOR FAMILY SUPPORT/CHILD ABUSE NEGLECT PREVENTION PROTECTIVE FACTORS Social Connections/  Responsive Social  Network *Knowledge of Parenting  & Child Development Nurturing & Attachment **Parental Resilience Tool Original  Developer(s) Description of Tool Population Service  Setting Format Tool  # The Nurturing  Program. Survey P III‐5 Observational P III‐6 Observational P III‐7 Focus Group P III‐8 Page 7 of 9 .  Training) Parent‐Child  University of  Parents of  Interaction (PCI) Feeding  Washington School of  Standardized teacher/caregiver  children birth  Scale Nursing (Seattle. WA) feeding observation tool to three years Volunteers of America  Guide for a brief focus group focused  Focus Group Guide  and  on parent nurturuing and  Spokane Crosswalk  attachment.

  WA).COMPENDIUM OF OUTCOME MEASUREMENT TOOLS  FOR FAMILY SUPPORT/CHILD ABUSE NEGLECT PREVENTION PROTECTIVE FACTORS Social Connections/  Responsive Social  Network *Knowledge of Parenting  & Child Development Nurturing & Attachment **Parental Resilience P P P Tool Original  Developer(s) Description of Tool Population Service  Setting Format Tool  # Doula Observation Form Healthy H lth  Family F il   Relationships  Program (Seattle.  events Survey X IV‐3 P: Primary protective factor outcomes measured (filed under this Protective Factor) X: Additional protective factor outcomes measured Page 8 of 9 . Kindering Center special needs Tool developed in  concert with founder  of Fathers Network  national programs Post‐ and retroactive pre‐ questionnaire related to various  constructs used by the Fathering  Network. Kindering Center Meetings. Mediation Center of  Molokai incarceration Class Survey developed by Parent Trust for  Washington to send out as follow‐up  to use of referral line (Retroactive  pre‐ and post‐test) Observation P III‐9 Reflective  questions P III‐10 (Family) Help Line Survey Help Line Survey IV‐1 Fathers Network  Questionnaire Tool developed in  concert with founder  Pre‐questionnaire related to various  Fathers of  of Fathers Network  constructs used by the Fathering  children with  national programs Network.  WA) (Examples of) Reflective  Questions Captures observations related to  nurturing and attachment of young  mothers by doulas used by  Volunteers of America (Spokane. Includes recommendations for  tool training Young mothers Various Parents P t  Also used by Molokai Fathering  transitioning  from  Initiative.  events Survey X IV‐2 Fathers Network  Questionnaire Fathers of  children with  special needs Meetings.

 and  month to 12  Richard A Abidin.COMPENDIUM OF OUTCOME MEASUREMENT TOOLS  FOR FAMILY SUPPORT/CHILD ABUSE NEGLECT PREVENTION PROTECTIVE FACTORS Social Connections/  Responsive Social  Network *Knowledge of Parenting  & Child Development Nurturing & Attachment **Parental Resilience P P P P Tool Original  Developer(s) Description of Tool Population Service  Setting Format Tool  # Parenting Stress Index  (PSI) Short Form The PSI/SF includes 36 items from  the original PSI and can be  administered in 10 minutes. Institute for  Community  Collaborative Studies. Parenting is one category 21 nt (trained) IV‐7 * Knowledge of Parenting & Child Development  includes: Non‐punitive Discipline & Guidance . Assesses level of  Parenting  State Division of  Case  Children and Family  life skills at intake. EdD difficult child.  years Survey IV‐4 Includes Community Life Skills scale  and Difficult Life Circumstance scale  NCAST. and Network  NCAST‐AVENUW Personal  Washington (Seattle. parent‐child  children ages 1  dysfunctional interaction. 3 months and 6  youth ages 15‐ manageme Interview  Services months. University of  (Parental Resilience).  Standardized tool to help  California State  caseworkers with case management  University Monterey  and measuring the progress of  Bay (Santa Cruz. Effective Communication and Effective Life Management & Self‐sufficiency Skills (CCF Protective Factors) P: Primary protective factor outcomes measured (filed under this Protective Factor) X: Additional protective factor outcomes measured Page 9 of 9 .  Survey and My Friends & Family  Environment Assessments WA) (Social Connections) Family Resource  Network.  It yields  a Total Stress score from three  Parents of  scales: parental distress. Knowledge of Child Development (CCF Protective Factors) ** Parental Resilience  includes: Stress Management . CA) families they serve Case  manageme nt Interview P IV‐5 The Family Development  Matrix Case  manageme Observation/  nt Interview X IV‐6 Independent Living Skills  Assessment Summary  Sheet Based on Washington  Used by Youthnet parenting  education program.

SAMPLE TOOLS AND SUMMARIES 8 .

SECTION I SOCIAL CONNECTIONS / RESPONSIVE SOCIAL NETWORK .

) ☺ Easy Hard 1b). The information you provide will help us learn about how these classes help parents and how we can improve our services for parents.ADWAS POSITIVE PARENTING PROGRAM Parent Pre-Questionnaire NAME: _______________________________________ Class location: Kent___ Everett____ Tacoma____ DATE: _____________________ Other. For you. (what?)_______________ Thank you for your time. Could you provide us with some information about your children to help us explain to others what it is like to be a Deaf or hard of hearing parent? What are the ages of your children? Are your children Deaf. hard of hearing or hearing? Place an X in the box that best describes this child’s hearing abilities: Child: Child #1 Child #2 Child #3 Child #4 1a). is it hard or easy being a parent? (Please place an X on the staircase to show your Age Deaf? Hard of Hearing? Hearing? answer. Your answers will be kept confidential. What makes it hard or easy? Please write one or two examples to explain your answer: Tool #: I-1 Page 1 .

Is it easy or hard to communicate with your child(ren)? (Please place an X on the staircase to show your answer. What?__________________________________ 2b). How do you communicate with your child(ren)?Please mark all of the responses that apply to you and your family. Do you have any specific questions or information needs that you’re hoping will be covered in the class? THANK YOU! Tool #: I-1 Page 2 .2a. 3.) ☺ Easy Hard 2c). Sign Language Speech Gestures Home Signs Paper and Pen Other. What makes it hard or easy? Please write one or two examples to explain your answer.

Is it easy or hard to communicate with your child(ren)? (Please place an X on the staircase to show your answer. Your answers will be kept confidential. is it hard or easy being a parent? (Please place an X on the staircase to show your answer. 1a).) ☺ Easy Hard Tool #: I-2 Page 1 . what about this class has made being a parent easier? 2a). The information you provide will help us learn about how these classes help parents and how we can improve our services for parents.) ☺ Easy Hard 1b). For you. Have you learned things in this class that help make being a parent easier? yes no 1c). If yes.ADWAS POSITIVE PARENTING PROGRAM Parent Post-Questionnaire NAME: _______________________________________ DATE: _____________________ Thank you for your time.

What about this class was most valuable to you? (please write your answer below) 5. Have you learned things in this class that help make communicating with your children easier? yes no 2c). If yes. How would you describe your overall satisfaction with this class? (please circle your answer)  Not satisfied  Somewhat satisfied  Very satisfied 4.2b). What suggestions do you have that could improve this class? (please write your answer below) THANK YOU! Tool #: I-2 Page 2 . what about this class has made communicating with your children easier? 3.

needing help with a practical problem. Your Friends from the Family Center No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this The time you’ve taken to complete this questionnaire  will help the Family Center offer the best services we can!  Tool #: I-3 Page 1 .FRIENDS FROM CENTER QUESTIONAIRE    Your Birth date (Month/Date/Year): _______________ Last Name: ___________________ Thank you for the time you’re taking to help us learn about our services. Would listen to me talk about a difficult parenting issue. All of your responses will remain confidential. Your Friends from the Family Center No friend would do this Some friends MIGHT do this     Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this 4.Would be available to me if I needed a few hours of childcare for an unforeseen emergency. We ask you to write in your birth date and last name so this questionnaire can be matched to others you might complete later. Suppose you had some kind of problem (like being upset about something. how likely would friends you have made at the Family Center be to help you out in each of the specific ways listed below?   For each question. Would give me and my child/ren a ride if we needed one. Your Friends from the Family Center No friend would do this Some friends MIGHT do this     Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this 3. Your Friends from the Family Center No friend would do Some friends MIGHT     Some friends would Some friends would Most friends would 2.     People help each other out in a lot of different ways. or needing some advice about something). please circle the category that best describes how friends you’ve made at the Family Center would respond in each situation.   1. Would call me just to see how I was doing.

how likely would members of your family and your friends be to help you out in each of the specific ways listed below?   Please circle the category that best describes how your family members would respond in each  situation.  Then circle the one that best describes how your friends would respond in each situation. needing help with a practical problem.   They  will  be  sent  directly  to  the  Northwest  Institute  for  Children  and  Families  and  kept  there. or being broke.Your Birth date: _________________ (Month/Date/Year)   FAMILY FOCUS FRIENDS AND FAMILY QUESTIONNAIRE   Thank  you  for  the  time  you’re  taking  to  help  us  learn  about  the  Family  Focus  Program.    We  ask  you  to  write  in  your  birth  date  here  so  this  questionnaire  can  be  matched  to  others  you  might  complete  later  in  the  Family  Focus  meetings. Suppose you had some kind of problem (like being upset about something.    This  questionnaire is part of a program evaluation conducted by Family Focus and the Northwest Institute for  Children  and  Families. or needing some advice about something).  People help each other out in a lot of different ways. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this 2.    All  of  your  responses  are  confidential.  1. Would suggest doing something just to take my mind off my problems. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Tool #: I-4 Page 1 . Would visit with me or invite me over.    Neither  the  Family  Focus  leader  or  any  of  the  group  members  will  have  access  to  your  questionnaires.

Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   4. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   Tool #: I-4 Page 2 . Would give me a ride if I needed one.3. Would have lunch or dinner with me. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   5. Would comfort me if I was upset.

pets. Would look after my belongings (house. Would joke around or suggest doing something Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   Tool #: I-4 Page 3 . Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   7.) for a while.6. Would loan me a car if I needed one. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   8. etc.

Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   10. Would suggest how I could find out more about a situation. Would go to a movie or get a video with me. Would help me out with a move or other big chore.9. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   Tool #: I-4 Page 4 . Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   11.

Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   Tool #: I-4 Page 5 . Would have a good time with me. Would listen if I need to talk about my feelings. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   13. Would pay for my lunch if I was broke.12. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   14.

Would suggest a way I might do something. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   16. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   Tool #: I-4 Page 6 . Would give me advice about what to do.15. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   17. Would give me encouragement to do something difficult.

Would show me that they understood how I was feeling.18. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   19. Would help me figure out what I wanted to do. Would chat with me. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   Tool #: I-4 Page 7 . Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   20.

Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   23. Would help me decide what to do.21. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   22. Would buy me a drink if I was short on money. Would give me a hug or otherwise show me I was cared for. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   Tool #: I-4 Page 8 .

Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   26. Would help me figure out what was going on. Would call me just to see how I was doing. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   25. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   Tool #: I-4 Page 9 . Would help me out with some necessary purchase.24.

Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   28. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   29. Would tell me who to talk to for help. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   Tool #: I-4 Page 10 . Would loan me money for an indefinite period. Would not pass judgment on me.27.

30. Would buy me clothes if I was short of money. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   Tool #: I-4 Page 11 . Would be sympathetic if I was upset. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   32. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   31. Would stick by me in a crunch.

Would give me reasons why I should or should not do something.33. or appliances if I needed them. Would loan me tools. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   35. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   Tool #: I-4 Page 12 . Would tell me about the available choices and options. equipment. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   34.

Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   37. Would bring me little presents of things I needed.36. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   38. Would show affection for me. Would show me how to do something I didn’t know how to do. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   Tool #: I-4 Page 13 .

Would loan me money and want to “forget about it”. Would talk to other people to arrange something for me. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   41.39. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   40. Would tell me the best way to get something done. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   Tool #: I-4 Page 14 .

Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   Tool #: I-4 Page 15 .42. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   43. Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   44. Would offer me a place to stay for a while. Would help me think about a problem. Would tell me what to do.

Your Friends from CHS No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this Other Friends and Family No friend would do this Some friends MIGHT do this Some friends would PROBABLY do this Some friends would CERTAINLY do this Most friends would CERTAINLY do this   Thank You Again! The time you’ve taken to complete this questionnaire  will help Family Focus be the best program it can be!  Tool #: I-4 Page 16 .45. Would loan me a fairly large sum of money (like a month’s rent or mortgage).

This is an anonymous survey. I know others who face the same or similar challenges as they care for/raise a relative’s child(ren).Kinship Care Support Group Participant Feedback   In order to help us understand how our Kinship Care Support Group can best serve participants. I know people that I can talk to about kinship care. Tonight is the first time I’ve come to a Kinship Care Support Group meeting or event I infrequently attend Kinship Care Support Group meetings or events I occasionally attend Kinship Care Support Group meetings or events I usually attend Kinship Care Support Group meetings or events I always attend Kinship Care Support Group meetings or events Using the numbers 1 to 3. we ask that you complete this short survey at the end of tonight’s group. Thank you! DATE: ______/______/______ [Depending on what you decide with Tim Gahm. and how TRUE it was before you started coming to the Kinship Care Support Group. and there is an envelope in which to put it before you leave tonight. 1 2 3 Not true Somewhat true Very true Now Before I started coming to the Kinship Care Support Group 2.: Age Gender Ethnicity Are participants are caring for a child with special needs?] 1. please indicate how TRUE you feel each statement is for you now.g. 3. but by answering these questions you will help us make our services the best they can be. Completing the survey is voluntary. Tool #: I-5 Page 1 . you can capture demographic information for your WCPCAN reporting requirements via a few items that can be added here—e. Please check the response below which best describes how often you attend weekly meetings and other events that are sponsored by the Kinship Care Support Group.

If I know where to go for help. 7. ADHD) Childcare Parenting classes Finding a support group Resolving issues with child’s parent Respite/child care True Not True Tool #: I-5 Page 2 . Through participation in this group. Please indicate how TRUE you feel each statement is for you   9. Through my participation in this group I received helpful information and resources. even outside of the Kinship Care Support Group.. In this group I met people I can talk with about raising a relative’s child(ren).Please indicate how much you agree or disagree with the following statements. In this group I met people I could talk with about kinship care issues. Strongly Agree Agree Don’t Know Disagree Strongly Disagree 4. “I know where to go for help in the following areas”: Very True Affordable legal services Recreational services Respite care services Working with the child’s school Counseling/consultation Financial support Family member’s drug/alcohol use Children’s special needs (i. I feel comfortable seeking help on my own 6. 8. I have made connections with at least one person that I talk with about kinship care issues (other than my spouse).e. 5.

On a scale from 1 (least valuable) to 5 (most valuable). What was most valuable about this group? 14. What suggestions do you have to make this group better? Thank you!! Tool #: I-5 Page 3 .10. how would you rate the Kinship Care Support Group overall? 1 2 3 4 5 least most valuable valuable 13. would support via the navigator services make it easier to access help? _____Yes _____No 11. Have you ever used Navigator services to help you connect to and/or access help from community resources? _____Yes _______No 12. If you are not comfortable seeking help on your own.

FAMILY RESOURCES OF ORCAS ISLAND Home Visiting Question Guide FAMILY _________________________________ TODAY’S DATE: _____/_____/_____ What’s been going on? What do you need? Primary Need/Issue: Level of Need: Comments: 1 Low 2 3 4 5 Highest Secondary Need/Issue: Level of Need: Comments: 1 Low 2 3 4 5 Highest Other Need/Issue: Level of Need: Comments: 1 Low 2 3 4 5 Highest Tool #: I-6 Page 1 .

Primary Need __________________________________ Level of Need: 1 2 3 4 5 YES Orcas FRC Other person/people/agency (Name) Have you identified person/people/ agency who can help with need/ issue Have you gone to person/people/ agency to seek help? Need/issue has been addressed? Referral (Where? Date?) NO Need cannot be met (Explain) Primary need/issue resolved? Comments: Yes No Secondary Need/Issue __________________________________ Level of Need: 1 2 3 4 5 YES Orcas FRC Other person/people/agency (Name) Have you identified person/people/ agency who can help with need/ issue Have you gone to person/people/ agency to seek help? Need/issue has been addressed? Referral (Where? Date?) NO Need cannot be met (Explain) Secondary need/issue resolved? Comments: Yes No Tool #: I-6 Page 2 .

Other Need/Issue __________________________________ Level of Need: 1 2 3 4 5 YES Orcas FRC Other person/people/agency (Name) Have you identified person/people/ agency who can help with need/ issue Have you gone to person/people/ agency to seek help? Need/issue has been addressed? Referral (Where? Date?) NO Need cannot be met (Explain) Other need/issue resolved? Yes No Tool #: I-6 Page 3 .

] Question Guide for Center for Human Services. Participants in the parenting class in Korean 3. Others might live far from friends and family or feel very shy and have very few people nearby that they can call on for company or a favor. Some people have lots of friends and family nearby that they can call on when they need to talk or need help with something.ask: In addition to learning English (or learning about school readiness). Participants from the First Steps class in Spanish 2. Confidentiality – all data will be reported in the aggregate and anything else you think will help create a comfortable. what do you like about coming to the Center? Now I would like to move on to another subject.5 hours per group Setting: Moderator and Co-moderator: [two people – one to moderate and one to record information. how many of those people. The purpose of the focus group. 2). I would like to ask you to think about the people in your life – the friends and family that keep you company and help you out sometimes. What initially brought you into the Center for Human Services? (Clarify if necessary: What were you hoping for when you first came here?) What keeps you coming back to the Center? (What do you like about coming to the Center?) If many answers center on the subject of class – such as ESL or parenting class -. open atmosphere.] Who are some of the people that you rely on and how do they help you out? As you were listing out those friends and family. if any. for example to learn more about what it is like for you to be in these classes and come to the Center. What to expect during the focus group. Shoreline Intro: Points you’ll want to cover include: 1). so that we can know how we’re doing and improve our efforts.Shoreline Center for Human Services Family Support for ESL Community Focus Group Plan Purpose: 3 Groups (6-8 participants in each group) 1. for example: Questions regarding Center and some questions about friendships. ESL participants (parents with children?) 1. 3). did you meet at the Center? Tool #: I-7 Page 1 .

why they feel uncomfortable and how seriously they take the questionnaire.) In order to learn more about this questionnaire. I’d like to have a discussion about what answers you chose and why.I’m going to hand out a short questionnaire with four questions that I would like you to answer on your own and then we will discuss them together. can you describe how you chose that response? Those who chose a different answer. who would like to share their answer and describe how they chose that answer? How many other people chose that answer? How did you choose your answer? Would anyone like to talk about their choices for some of the other questions? I know that some people find filling out questionnaires like this simple and easy. while others might find it difficult or tiresome. what did you choose and how did you choose it? What about question number 4. What additional comments do you have about those two subjects? Thank you very much for your time. for those of you that chose (fill in answer). Can you describe how you feel when filling out this questionnaire? (Follow up to pursue any comments regarding why people feel good. (Hand out modified focus group questionnaire) Is everyone finished? (Allow for a few more minutes if necessary.) The purposes of our discussion today were to learn more about friends you make here at the Center and to learn more about what it is like for people to fill out this questionnaire. Tool #: I-7 Page 2 . Would one person please share their answer to question number 1? How many other people put (fill in answer: )? So.

Yakima Valley Farm Worker Clinic Parenting Program Referral Form FAMILY: _______________________________________________________________ Referral made? Yes (Date of referral: ______/______/______) If Yes. please complete table below REFERRED TO: COMMENTS: No FAMILY RISK FACTORS Financial Behavioral Health Housing Issues (e. Tenant/Landlord Issues_ Health Substance Abuse Domestic Violence Family Issues Educational Issues Tool #: I-8 Page 1 .g.

why not? Staff comments: 3-MONTH FOLLOW-UP: Did parent/family access services? Yes [ (Initial) date accessed: _____/____/____ ] No If parent/family accessed services. did parent/family find that services were helpful and/or provided necessary support to their families? Yes Please describe No Why not? If parent/family did not access services. why not? Staff comments: Tool #: I-8 Page 2 . did parent/family find that services were helpful and/or provided necessary support to their families? Yes Please describe No Why not? If parent/family did not access services.POST-CLASS: Initials of staff person completing: __________ Did parent/family access services? Yes [ (Initial) date accessed: _____/____/____ ] No If parent/family accessed services.

Score the answers after returning to the office..Neighborhood Place of Puna Home Visiting and Community Connections Talk Story Questions (Rev.) 3 2 1 Parent describes three or more age appropriate activities that they do with their child After coaching parent describes one or two things that are age appropriate that the family does together Parent names activities. your support system. but there is no evidence it is being done or. What kinds of activities are you doing as a family with your children? Parent Response: Circle Rating: (Parents can describe age appropriate activities that they do with their child which fosters learning. Write down the answers below each question. Instructions for Parents: We want to see how we can improve our program and our home visits. So.. Your answers will be kept confidential. This data will be entered into the data management system. etc. Questionnaires and scoring will become part of the family’s files. There is no right or wrong here. Plans to address areas that receive a score of “1” will be developed during clinical supervision.] 1. we want to talk story (kuka kuka) with you about some of the things we have been doing together. and again at closure. etc. we are just trying to find out from you what you think about your child's development. Read back the questions and/or answers to parents if necessary to make certain that both were understood. 04/30/07) Instructions for Home Visitor: Read these questions to the parents with whom you are visiting at visit 2 or 3. [Parents provide care that fosters their child’s optimal development. parent is unable to give age appropriate examples of activities Tool #: I-9 Page 1 .

What community activities are you involved in? Parent Response: Circle Rating: (Participants are involved in community activities) 3 2 Parent describes three or more ways that they are actively involved in the community.[Participants know the importance of having a mutual support network. Parent needs to be coached to give two benefits of mutual support networks. Parent needs considerable coaching to give one benefit. Why it is important to have friends and family as your support? Parent Response: Circle Rating: (Parents can describe why it is important to have a support network. but can then name at least one activity that they do consistently/at least twice each month. [Families feel more connected to their community. Parent needs to be provided with examples of community activities.) 3 2 1 Parent can describe importance of support network without being coached and can give at least two benefits of mutual support networks. 1 Tool #: I-9 Page 2 . Parent cannot name a community activity in which they are involved.] 2.] 3.

Page 3 2 1 Tool #: I-9 . Parent cannot describe how to meet need and does not mention the resource book.) 3 2 1 Parent can describe at least 2 ways that they would meet the need and mentions the resource book. Parent needs coaching to describe how to meet need and mentions resource book.) 3 Can easily list at least three developmentally appropriate behaviors. or voices 1 or 2 inappropriate concerns. what would you do? Parent Response: Circle Rating: (Parents can describe how family needs can be met through formal supports. Needs to be coached to share two developmentally appropriate behaviors.[Participants know how to access formal support systems. Even with coaching has minimal idea of child's development. (Child's name)________ is _____ (age). Parent mentions 1 or 2 inappropriate terms. If your family needed something like ________________ (ask about a specific family need). What are things that he/she should be doing? What things can he/she do? Are there developmental areas that you are concerned about? Parent Response: Circle Rating: (Parent can describe developmental stage of child.] 4. Parent mentions 3 or more things that are not developmentally appropriate. or voices appropriate concerns.] 5. or voices 3 or more things that are not developmentally appropriate. [Parents understand typical developmental stages. Parent talks about child in developmentally appropriate terms.

Section II Knowledge of Parenting & Child Development .

Tracking & Coding Questions • Explain each coding piece carefully. if your first name is KATHY write in A T Walk the participants through this. si su primer nombre es JOSE. • Expain that a second questionnaire will be administered at the end of class and that follow up contacts will be made approximately 6 months after the class is completed. • Write class number. Día Tool #: II-1 Page 1 . • Review points covered in letter to parent. • Use the overhead of the first page to demonstrate how to answer the questions using the visual bar charts (where to place the “x”s) • Use the overhead to point to the locations for their answers for the first few questions. date. and sample on the board or flip chart.questionnaire Birthdate: Month Day SPANISH VERSION Fecha:  Escriba el 2da y 3ra letra de su PRIMER NOMBRE: Por ejemplo. make sure they remember to use it for both the pre. If they have an informal or nick name. Yakima. WA Protective factor inventory Introduction and Overview • Introduce yourself Briefly explain need for and background on the evaluation process. • Use the overhead of the first page of the parent form to illustrate the coding process.& post. Today’s Date (month/date/year) Have the participants enter the date the form is completed Class Number: You will be provided with this number 2nd and 3rd leters of your FIRST NAME: For example. escriba O / / Número de la Clase: Fecha de Nacimiento: Mes S .Central Washington Comprehensive Mental Health: Strong Families/Familias Fuertes Project.

In a typical two week period. how often do you do the following things: SPANISH VERSION Favor de poner una “X” para cada pregunta en el espacio que coresponde con su respuesta. The facilitator will read the questions: Instructions: Please respond to each item using the continuum listed below by placing an “X” in the bar that most closely matches your answer to each question. Please respond to each item using the continuum listed below by placing an “X” in the bar that most closely matches your answer to each question.s. ¿Con qué frecuencia hace usted las siguientes cosas? ANTES de la clase AHORA después de la clase Tool #: II-1 Page 2 . ¿Con qué frecuencia hace usted las siguientes cosas en un período típico de dos semanas? Response scale: Always 1 Never Usually Sometimes Rarely Siempre Generalmente A Veces Raramente Nunca Post-Test Instructions • The questions are not to be given to the parents. The facilitator will read the questions: You will be asked to respond to each item at two different time periods: (1) in a typical two week period BEFORE taking this class. and (2) NOW in the past two weeks at the end of this class.Pre-Questionnaire Instructions • The questions are not to be given to the parents. only the answer sheets. How often do you do the following things: BEFORE the class NOW at the end of the class SPANISH VERSION Le pedirá responder a cada pregunta en dos períodos específicos: (1) en un período típico de dos semanas ANTES DE tomar esta clase y (2) AHORA en las últimas dos semanas al terminar esta clase Favor de poner una "X" para cada pregunta en el espacio que coresponde con su respuesta. only the answer sheet.

¿Comen juntos como una familia? 2. Consistently follow through on limits and established consequences. 7. Listen to/ask for the opinions. (-) Give in to your child’s/children’s demands or excuses for not getting things done. ¿Besa o abraza a su niño/s? 11. Tell your child(ren) that they are doing a good job. ¿Comunica claramente usted a su niño/s sus deseos(instrucciones)? 12.Response scale: BEFORE the class Always Usually 1A Sometimes Rarely Never Protective Factor Inventory Questions In a typical two week period. ideas. and feelings of your child/children. (-) ¿Golpea o azota a su niño/s? 8. 13. (-) ¿Amenaza o critica a su niño/s? 4. ¿Se siente usted desanimado con los resultados de sus esfuerzos por administrar la disciplina? 7. Use natural or logical consequences to enforce family rules. 6. Communicate clear expectations of your child/children. Model effective anger management skills. how often do you do the following things: ENGLISH 1. ideas. Eat together as a family. (-) Feel discouraged with the results of your discipline efforts. ¿Le(s) dice usted a su niño/s que está(n) haciendo buen trabajo? 6. ¿Determina límites claros y constantes con su niño/s? 3. 12. y sentimientos de su niño/s? 13. 3. ¿Emplea usted consecuencias naturales o lógicas para poner en vigor las reglas de la familia? 15. ¿Escucha a. ¿Sigue constantemente los límites y consecuencias establecidas? 9. (-) Hit or spank your child(ren)? 8. Set clear and consistent limits with your child/children. 2. 15. 5. Spend time helping your child(ren) with homework or learning new skills. 10. (-) ¿Grita a su niño/s? 14. SPANISH 1. 11. 5. 9. (-) Yell or holler at your child(ren)? 14. (-) Threaten or criticize your child(ren)? 4. Kiss or hug your child/children. y pregunta a las opinioñes. ¿Dedica usted tiempo para ayudar a su niño/s con sus tareas escolares o para enseñarles destrezas nuevas? Never 1B Rarely NOW at the end of the class Always Usually Sometimes Tool #: II-1 Page 3 . ¿Demuestra usted las destrezas de comunicación respetuosa? 10.

31. Tool #: II-1 Page 4 . ¿Utiliza el reconocimiento o alabanza para aumentar comportamientos positivos en su niño/s? 24. Hold “family meetings” (scheduled time to plan family activities. Help your child/children identify and express feelings. ¿Pasa tiempo escuchando a su niño/s? 34. ¿Se siente capacitado para cambiar o corregir el comportamiento malo de su niño/s? 32. Feel competent that you can change or correct your child’s misbehavior. ¿Provee usted la oportunidad para que participe su niño/s en “trabajo familiar” en casa? 19. 30. Spend time with individual children. Teach your child(ren) about a better way to behave. 34. Say “I love you” to your child/children. Tell your child/children they are important and essential members of your family. Have fun together as a family. 20. Tell others about a child’s positive behavior. 32. ¿Anima usted a su niño/s aprender a resolver conflictos o problemas personales y familiares? 28. Use respectful language when communicating with your child/children. 29. presión de semejantes. ¿Le ayuda a su niño/s a reconocer y expresar sus sentimientos? 22. 27. peer pressure. ¿Les habla de mejores maneras de comportarse? 18. 21. 23. dangers of drugs/gangs.16. ¿Pasa tiempo con su niño/s individualmente? 20. Talk about important issues (sexuality. ¿Emplea usted palabras respetuosas al comunicarse con su niño/s? 23. ¿Les habla acerca de asuntos importantes (la sexualidad. 22. ¿Le dice usted a su niño/s que son miembros importantes y esenciales de su familia? 25. 18. 16. ¿Pasan tiempo libre juntos como una familia? 26. ¿Se divierten juntos como una familia? 31. Make positive. establish rules and/or consequences. ¿Les dice “Te amo” a su niño/s? 21. Spend free time together as a family. ¿Les habla a los demás del comportamiento positivo de un niño/s? 30. Encourage your child/children to problem-solve personal or family problems or conflicts. Participate in community events or activities? 26. ¿Demuestra usted las destrezas de comunicación respetuosa? 29. or discuss family issues)? 27. Spend time just listening to your child/children. 19. 25. Model respectful communication skills.)? 33. 24. los peligros de las drogas y pandillas. etc. 28. reward desired behavior. etc. Use acknowledgement or praise to increase positive behaviors in your child(ren). Provide opportunities for child participation in “family work” around the house.) 33. 17. encouraging statements to your child/children about their behavior. ¿Le anima a su niño/s con comentarios positivos y animadores acerca de su comportamiento? 17.

Closing Pre Test • Collect the completed forms • Thank the participants for their participation • Remind them that they will be asked to complete a similar questionnaire at the end of the parenting series

Post-Test Satisfaction Questions These additional questions are asked on the parents score sheet on the Post-Test form. Ask them to complete these questions and give them a few minutes to respond to the questions.   35. En total, clasificaría esta clase: 35. Overall, I would rate this class: Excelente  Excellent  Muy Bien Good Bien Fair Mal Poor Muy Mal Very Poor 36. The parenting activities or topics I found most valuable are: 37. The parenting activities or topics I found least valuable are: 38. Please provide any feedback or comments you have  regarding your instructors and their class facilitation  skills: 39. Other comments (use back of page if necessary): 36. Las actividades o los asuntos de la clase que clasificaría los más importantes son: 37. Las actividades o los asuntos de la clase que clasificaría los menos importantes son: 38.

39. Otros comentarios (use detrás de la hoja si es necesario.)

Inventory Categories and Items (Operational Definitions) Increase Prosocial Bonding Eat together as a family. 1 7 (-) Hit or spank your child(ren)? 19 Spend time with individual children. 25 Spend free time together as a family. 30 Have fun together as a family. 33 Spend time just listening to your child/children. Set Clear, Consistent Boundaries 2 Set clear and consistent limits with your child/children. 4 (-) Give in to your child’s/children’s demands or excuses for not getting things done. 6 (-) Feel discouraged with the results of my discipline efforts. 8 Consistently follow through on limits and established consequences. 14 Use natural or logical consequences to enforce family rules. 31 Feel competent that you can change or correct your child’s misbehavior.

Tool #: II-1

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Teach Life Skills 9 Model effective anger management skills. 15 Spend time helping your child(ren) with homework or learning new skills. 21 Help your child/children identify and express feelings. 27 Encourage your child/children to problem-solve personal or family problems or conflicts. 28 Model respectful communication skills. 32 Talk about important issues (sexuality, peer pressure, dangers of drugs/gangs, etc.) Provide Care & Support 3 (-) Threaten or criticize your child(ren)? 10 Kiss or hug your child/children. 13 (-) Yell or holler at your child(ren)? 16 Make positive, encouraging statements to your child/children about their behavior. 20 Say “I love you” to your child/children. 22 Use respectful language when communicating with your child/children. Set and Communicate High Expectations 5 Tell your child(ren) that they are doing a good job. 11 Communicate clear expectations of your child/children. 17 Teach your child(ren) about a better way to behave. 23 Use acknowledgement or praise to increase positive behaviors in your child(ren). 29 Tell others about a child’s positive behavior. Provide Opportunities for Meaningful Participation 12 Listen to/ask for the opinions, ideas, and feelings of your child/children. 18 Provide opportunities for child participation in “family work” around the house. 24 Tell your child/children they are important and essential members of your family. 26 Hold “family meetings” (scheduled time to plan family activities, establish rules and/or consequences, reward desired behavior, or discuss family issues)? 34 Participate in community events or activities.

Tool #: II-1

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Date:            

 

 

 

Intensive Parent Training and Support
IPTS Parent Survey
 
• The purpose of this survey is to evaluate Parent Trust programs. • The first part of each question is asking how you felt before you started meeting with a Parent Trust IPTS worker. • The second part is asking how you ordinarily feel now. Check all two parts (both lines) of each question. Give only one answer for each part of every question and make sure each page, including the back, is completed before handing in. Your survey is completely confidential. Do not write your name or any other identifying information. If you need assistance, ask your IPTS worker -- but you must answer each question yourself. All completed surveys will be sent directly to the Parent Trust main office. We appreciate your participation in evaluating the Intensive Parent Training & Support Program. Your feedback will allow us to help more parents in the future by giving us the information we need to improve our program.

• •

SURVEY STARTS HERE …………………………………………………………………………….. 1. How many times have you met with your IPTS worker? (PLEASE FILL IN BOTH LINES “A” & “B”) – Write in the number of sessions. Fill in the “months” or “Weeks” lines if you do not know how many times you’ve met (or had a phone call) with your IPTS worker. A. Months Weeks Sessions

B. On average, how many sessions per month (in person or on the phone) do you meet with your Sessions/Phone calls IPTS worker? 2. How many children do you have under 18 years old? 3. What are their ages? …1 to 4 (each child under 18)) …1 to 4 …1 to 4 …1 to 4 …5 to 7 …5 to 7 …8 to 10 …8 to 10 …11 to 13 …11 to 13 …14 to 16 …14 to 16 …17+ …17+

…5 to 7 …8 to 10 …11 to 13 …5 to 7 …8 to 10 …11 to 13 Male Male Male Male Female Female Female Female

14 to 16 …17+ …14 to 16 …17+

4. Gender of child(ren):

Child 1: Child 2: Child 3: Child 4:

TURN OVER

Tool #: II-2

Page 1

e. I have confidence in my parenting skills & knowledge.child washes wall. I regularly use positive discipline techniques. 1 = never. crayons on wall . phone use) Family Meetings Other: ___________________________________ Tool #: II-2 Page 2 . Before: ……………………………………… After: ……………………………………… Never 0 0 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 Always 9 9 10 10 2. Before: ……………………………………… After: ……………………………………… Never 0 0 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 Always 9 9 10 10 Positive discipline techniques I use include: Cool down Ignore Logical consequences (i. then you can ______.” Praising Take away privileges (i. 5 = half the time. miss curfew – time subtracted from curfew) Re-arrange space or place Re-direct behavior “First you must ______.e. 1.Please rate the following on a scale of 1 to 10. fun activities with my Never child(ren). I have good control over my level of stress. I understand what normal behavior is for my child(ren)’s age. I can plan simple. Before: ……………………………………… After: ……………………………………… 0 0 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 Always 9 9 10 10 4. and 10 = always. Before: ……………………………………… After: ……………………………………… Never 0 0 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 Always 9 9 10 10 5. Before: ……………………………………… After: ……………………………………… Never 0 0 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 Always 9 9 10 10 3. loss of TV time.

____________________________________________ 8. I’m comfortable listening to advice from other people about my parenting. I can listen to my child(ren). I feel confident in my ability to set clear limits for my child(ren). Before: ……………………………………… After: ……………………………………… Never 0 0 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 Always 9 9 10 10 10. Before: ……………………………………… After: ……………………………………… Never 0 0 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 Always 9 9 10 10 7. Before: ……………………………………… After: ……………………………………… Never 0 0 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 Always 9 9 10 10 TURN OVER Tool #: II-2 Page 3 .6. Before: ……………………………………… Never 0 1 1 No 2 2  3 3 4 4 5 5 6 6 7 7 8 8 Always 9 9 10 10 After: ……………………………………… 0 a) I know what my strengths are? b) Two of my strengths as a parent are Yes (Please list):  1. Before: ……………………………………… After: ……………………………………… Never 0 0 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 Always 9 9 10 10 9. I have people in my life that I can talk to about my problems. I can focus on my strengths as a parent. ____________________________________________ 2. I can accept my child(ren)’s unique personality. Before: ……………………………………… After: ……………………………………… Never 0 0 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 Always 9 9 10 10 11.

How satisfied are you with this program? Somewhat 0 1 2 3 4 5 6 7 8 9 10 15. I understand my child(ren)’s feelings.12. What did you find most valuable? Comments:   Tool #: II-2 Page 4 . Before: ……………………………………… After: ……………………………………… Never 0 0 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 Always 9 9 10 10 13. Before: ……………………………………… After: ……………………………………… Never 0 0 Not 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 Always 9 9 Always 10 10 14. I can focus on my child(ren)’s strengths.

laws about children’s rights What U.S. 1. laws say is acceptable physical punishment for children.S. During the school year: Attended a parent-teacher conference Attended a school event Contacted a teacher or principal Other.S. laws about parents rights U. Thinking about the past few months.S.REFUGEE WOMEN’S ALLIANCE: REFUGEE AND IMMIGRANT FAMILY EMPOWERMENT PROJECT. Please describe ______________________________________________ 2. How much do you feel you know about the following topics? A lot Child Protective Services (CPS) Gang prevention Domestic violence U. What my role or involvement as a parent in U. Please describe _________________ During summer vacation or other school vacation time: What activities have you done with your child (children)? ____________________________________________________________________________ ____________________________________________________________________________ Have you registered your children in cultural activities offered by your community? Sunday school After school program Coranic education Sports Other. schools should Some None Tool #: II-3 Page 1 . WA Pre Parent Ed Survey  Date: ____________________ Class/Workshop: _____________________________ Name: ___________________________________ A#: _____________________ These questions ask you to think about several aspects of parenting and involvement in your child’s or children’s lives. SEATTLE. check the things that you have done as a parent.

4c. what type of discipline or guidance techniques have you used with your children? (Check all that apply) Getting to know your child(ren)’s friends Yelling Grounding/taking away privileges/Time out Explaining/Reasoning Spanking/Hitting Distraction/redirection Sharing/teaching culture Giving praise Other. My ability to communicate positively with my child(ren) My knowledge of how to protect my family from violence My ability to help my child(ren) avoid gang involvement My knowledge of how to be involved in my child(ren)’s education 4. groups. 4b. I felt successful almost every time I tried a new technique I felt successful most of the time when I tried a new technique I felt successful some of the time when I tried a new technique I didn’t feel very successful when I tried a new technique 5. When you tried new discipline or guidance techniques with your children.3. How much confidence do you have in the following things? Lots of confidence Some confidence Not much confidence My skills to raise children in the U. what concerns about raising children do you hope to address or get information about? Tool #: II-3 Page 2 . Thinking about the past few weeks. Who can you call for help with issues about parenting (individuals. Through this class. did you try any new discipline or guidance techniques? YES NO (SKIP to Question 6) If YES.S. which new techniques did you use? 4a. Please describe: __________________ Setting limits In the past few weeks. agencies)? 6. how successful did you feel you were? Check the response that fits best with how you felt.

etc. 1. Please describe Tool #: II-3 Page 3 . Please describe __________________________________________ 2. How much do you feel you know about the following topics? A lot Child Protective Services (CPS) Gang prevention Domestic violence Different ways to discipline my children How to communicate with my children What my role or involvement as a parent in U. check the things that you have done. etc. During the school year: Attended a parent-teacher conference Attended a school event Attended a PTA meeting _________________________________________ During summer vacation or other vacation time: Gone on a field trip with my child(ren) (to the zoo. Thinking about the past few months.) Gone to the park. WA Post Parent Ed Survey  Date: ____________________ Class/Workshop: _____________________________ Name: ___________________________________ A#: _____________________ These questions ask you to think about several aspects of parenting and involvement in your child’s or children’s lives. schools should be Some Not very much None Called a teacher or principal Written a note to school Other. swimming.REFUGEE WOMEN’S ALLIANCE: REFUGEE AND IMMIGRANT FAMILY EMPOWERMENT PROJECT.S. SEATTLE. with my child(ren) Gone to a sports activity or day camp with my child(ren) Gone to the library with my child(ren) Gone to a festival or celebration in my community with my child(ren) Other.

My ability to communicate positively with my child(ren) My knowledge of how to protect my family from violence My ability to help my child(ren) avoid gang involvement My knowledge of how to be involved in my child(ren)’s education 4.) How much do you feel you know about the following topics? A lot U.S. Thinking about the past few weeks. 3. (cont. laws say is acceptable physical punishment for children. laws about parents rights U. How much confidence do you have in the following things? Lots of confidence My skills to raise children in the U. did you try any new discipline or guidance techniques? YES NO (SKIP to Question 6) If YES.S. Please describe: __________________ Setting limits 4a. laws about children’s rights What U.2. which new techniques did you use? Some confidence Not much confidence Some Not very much None 4b. what type of discipline or guidance techniques have you used with your children? (Check all that apply) Getting to know your child(ren)’s friends Yelling Grounding/taking away privileges/Time out Explaining/Reasoning Spanking/Hitting Distraction/redirection Sharing/teaching culture Giving praise Other. Tool #: II-3 Page 4 .S.S. In the past few weeks.

Who can you call for help with issues about parenting (individuals. agencies)? Overall. groups. how satisfied were you with this class? Very satisfied Satisfied Not satisfied 7.   Tool #: II-3 Page 5 . I felt successful almost every time I tried a new technique I felt successful most of the time when I tried a new technique I felt successful some of the time when I tried a new technique I didn’t feel very successful when I tried a new technique 5. 6.4c. When you tried new discipline or guidance techniques with your children. How satisfied were you with the information you received? Very satisfied Satisfied Not satisfied How satisfied were you with the bicultural advocate? Very satisfied Satisfied Not satisfied How useful was it for you to be able to share information with other parents during the classes? Very useful Useful Not useful   8. 9. how successful did you feel you were? Check the response that fits best with how you felt.

How satisfied are you with the family communication in your home? (Please circle one) Very satisfied Somewhat satisfied Not satisfied at all 2. How often in the last month have you sat down as a family to talk and make decisions? (Please circle one) 5 or more times 3-4 times 1-2 times Never 3.Yakima Valley Farm Workers’ Clinic Spanish Language Parenting Education Parenting Questionnaire Name: ________________________________ Date: __________ This questionnaire is to help us learn the types of discipline and family communication you are using at this time. In the last month. 1. what types of discipline have you used in your home? How well does it work for you? Have you used How well does it work? (check one box for each) it? (check one box for each) YES NO WORKS WORKS DOES DID NOT WELL SOMENOT USE TIMES WORK Time out Hitting Redirection Yelling Withholding privileges “First you must____ then you can____” Ignoring Show and tell Praising “Family Talks” Tool #: II-4 Page 1 .

what type of “reward system” do you use with your children? (Check all that apply) Verbal praise Material reward Physical affection A point system I have not used these methods 7. What was the most important thing you learned from this class?   Tool #: II-4 Page 2 . Do you think “family meetings” increase family communication and cooperation? (Circle one) Yes Sometimes No 5.4. Do you talk with you kids about drugs and alcohol? (Circle one) Yes No 6. In the last month.

  What do you see as this parents’ strengths? Tool #: II-5 Page 1 . have you ever observed this parent using the following discipline strategies with his/her child(ren): hitting. In the last six months have you observed this parent using positive discipline strategies with his/her child(ren)? Please describe. How would you rate the overall parenting skills of this parent? Poor Good Excellent What do you see as the biggest concern with this parents’ parenting skills? 4. spanking. slapping or other form of physical discipline? Please describe behavior. In the last six months. 2. 3. 5.PARENTING SKILLS OBSERVATION Name of Agency: _____________________________________ Staff Name: __________________________________________ Client Name: _________________________________________ Client Address: _______________________________________ Client Phone Number: __________________________________ 1.

Can you name several discipline or guidance strategies that you use? ____________________________________________________________ ____________________________________________________________ Tool #: II-6 Page 1 . Question 1: What do you expect to learn from this workshop? ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Question 2: Can you name several discipline or guidance strategies that you use with your child or children? ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Question 3: Talking to a child about expectations or giving a child a time out are types of discipline and guidance strategies that parents sometimes use when their child is misbehaving.Ukrainian Community Center of WA Parent Focus Group Survey Pre-Test Group Questions Instructions for Facilitator (Note taker): Please record answers at the appropriate spaces during and after questions have been asked by a Parent Educator. Do not make comments as to their “appropriateness”.

____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Question 4: Tell us what you know about U. laws about discipline. ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Question 5: Tell us what you know about what school expect from parents.S. ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Notes taken by: Date: ______________________________________ ______________________________________ Month/Date/Year Tool #: II-6 Page 2 .

Question 1: Have you learned things in this workshop that can help make communicating with your children easier? YES skip to question #3 NO Question 2: Why is that? ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Question 3: If yes.Ukrainian Community Center of WA Parent Focus Group Survey Post-Test Group Questions Instructions for Facilitator (Note taker): Please records answers at the appropriate spaces during and after questions been asked by a Parent Educator. Do not make comments as to their “appropriateness”. what about this workshop do you think will help you to make your communication with your child or children easier? ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Question 4: Think about trying out different kinds of discipline methods. Would this be an acceptable idea to you? YES NO Tool #: II-6 Page 3 .

such as the ones we’ve talked about today? YES NO Question 7: Why or why not? ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Question 8: What discipline methods do you think you could try? ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Tool #: II-6 Page 4 .Question 5: Why or why not? ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Question 6: After your participation at the workshop today. would you be willing to try out other discipline methods.

S. laws about child abuse and neglect What U.S. how much do you feel you know about the following topics? None Child Protective Services (CPS) U. laws about parents’ rights U.S.S. laws regarding acceptable physical punishment? What is expected regarding my role or involvement as a parent in U. laws about children’s rights U. laws say is acceptable physical punishment for children What could happen to my family if I do not follow U.S. schools Not very much Some A lot Notes taken by: Date: ______________________________________ ______________________________________ Month/Date/Year Tool #: II-6 Page 5 .Question 9: After participating in this workshop.S.

11. 5. Gives 1 commands that are age appropriate and that can be consistently followed through. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 1 2 2 2 3 3 3 4 4 4 5 5 5 7. Imitates child’s appropriate behavior without prompting by therapist. Gives clear commands that are directly and positively stated. 2. 8. 1 2 3 4 5 1 1 2 2 3 3 4 4 5 5 1   2 3 4 5  Tool #: II-6 Page 1 . Appropriate use of commands. 3. 9. Child responds to parent’s praise by increasing positive behavior. Conveys interest in child and in his/her play. 6. Uses neutral tone of voice while disciplining child. Praises or describes child’s positive behaviors and attitudes without prompting.PCIT Parenting Skill Competency – Home Visitor Observation Form   Never Sometimes Almost Always 1. 10. thoughts and behavior. Can use strategic attention effectively. Describes child’s desirable behaviors or attitudes without prompting. Follows time out procedure without prompt. 4. Praises child for compliance.

Imitates child’s appropriate play without prompting by therapist. 10. Child responds to parent’s praise by increasing positive behavior. Praise is genuine and timed well. thoughts and behavior. 13. 4. Praises child for compliance. 1 2 3 4 5 1 1 2 2 3 3 4 4 5 5 1 2 3 4 5 1 2 3 4 5 6. Describes behaviors or attitudes related to treatment goals without prompts by therapist. 2. Gives clear commands. Praises or describes child’s positive behaviors and attitudes related to treatment goals without therapist prompting. Conveys interest in child and in his/her play. Can use strategic attention effectively. Follows time out procedure without coach prompt. commands and criticisms. 5. Can follow the child’s lead in CDI play. 8. 9. Describes own behaviors as a way to model 1 appropriate behavior for the child.PCIT Parenting Skill Competency – Coach Observation Form       Never              Sometimes               Almost Always 1. 11. 14. direct and positive. Uses neutral tone of voice while disciplining child. 12. Refrains from questions. 7. 1 1 1 1 1 1 1 1 2 3 4 5 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 Tool #: II-8 Page 1 . 3.

 behaviorally specific rating scales that assess the  current frequency and severity of disruptive behaviors in the home and school settings.”      Retrieved from:  http://www3. Both  instruments consist of items that represent common behaviors in all children.com/products/product. the parent or teacher  indicates how often each behavior currently occurs (7‐point Intensity scale) and whether or not  the behavior is a problem (Yes/No Problem scale). On both the 36‐item ECBI and the 38‐item SESBI‐R.parinc. ECBI and SESBI‐R scores can be quickly and  easily computed by hand in about 5 minutes each.Eyberg Child Behavior Inventory (ECBI) and Sutter‐Eyberg Student Behavior Inventory‐Revised  (SESBI‐R)        “The ECBI and the SESBI‐R are comprehensive. as well  as the extent to which parents and/or teachers find the behavior troublesome. The non‐age‐specific nature of the items also makes them  widely generalizable.aspx?Productid=ECBI  Tool #: II-8 Page 2 . The variety and  frequency of these behaviors distinguishes normal behavior problems from conduct‐disordered  behavior in children and adolescents.

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NOW BEFORE 1 1   3b. I know how to respond to my child’s cues. I am able to identify my child’s developmental needs. How do you respond to your child’s cues for the following? Fatigue/Being Tired: Hunger: Needing Comfort/Soothing: ________________________ ________________________ ________________________ Tool #: II-11 Page 1 . What are your child’s cues for the following? Fatigue/Being Tired: Hunger: Needing Comfort/Soothing:     Not At All True Extremely True ________________________ ________________________ ________________________     T T  2 2 T  3 3 T 4 4 T 5 5 3a. For the questions in grey. I am able to read my child’s cues. think back to how you felt before you began receiving home visits through the Little Red Schoolhouse and circle the number that best reflects how you felt then.Little Red Schoolhouse –Parent Survey Date: _______________ Name: _______________ Please circle the number that best describes your answer. Not At All True Extremely True     T T  2 2 T  3 3 T 4 4 T 5 5 1a. NOW BEFORE T 1 1 T  2 2 T  3 3 T 4 4 T 5 5 2b. What are 1-2 of your child’s developmental needs? Not At All True Extremely True     2a. NOW BEFORE 1 1 1b.

I understand how my experience of being parented influences my parenting. Please use the back of this page below to give us any additional comments you may have. What are 2-3 things you do to stimulate your child’s development? Not At All True Extremely True     T T  2 2 T  3 3 T 4 4 T 5 5 5a. On a scale from 1 (not at all satisfied) to 5 (very satisfied). NOW BEFORE 1 1 5b.   Tool #: II-11 Page 2 . how satisfied were you with the program? 1 2 Not at all satisfied 3 4 5 Very satisfied Thank you very much for your help in completing this survey. I enjoy the time I spend with my child. What are 1 or 2 positive experiences from your childhood that influence your relationship with your child? 5c.  Almost Never Often     T T  2 2 T  3 3 T 4 4 T 5 5 4a. I engage in behaviors that stimulate my child’s development. NOW BEFORE 1 1 4b. What are 1 or 2 negative experiences from your childhood that influence your relationship with your child? Almost Never Often     6. NOW BEFORE T 1 1 T  2 2 T  3 3 T 4 4 T 5 5 7.

NOW BEFORE 1 1 2b.Little Red Schoolhouse – Staff Observation Survey Date: _______________ Client’s Name: _______________ Please circle the number that best describes your answer. Not At All True Extremely True     T T  2 2 T  3 3 T 4 4 T 5 5 1a. The client knows how to respond to his/her child’s cues. For the questions in grey. The client is able to read his/her child’s cues. think back to how you felt before you began receiving home visits through the Little Red Schoolhouse and circle the number that best reflects how you felt then. NOW BEFORE 1 1   3b. NOW BEFORE 1 1 1b. What are 1-2 of your child’s developmental needs that the client can now identify? Not At All True Extremely True     T T  2 2 T  3 3 T 4 4 T 5 5 2a. The client is able to identify his child’s developmental needs. What are some of child’s cues given by the client for the following? Fatigue/Being Tired: Hunger: Needing Comfort/Soothing:   ________________________ ________________________ ________________________ Not At All True Extremely True       T T  2 2 T  3 3 T 4 4 T 5 5 3a. How does the client respond to his/her child’s cues for the following? Fatigue/Being Tired: Hunger: Needing Comfort/Soothing: ________________________ ________________________ ________________________ Tool #: II-11 Page 3 .

Please use the back of this page to give us any additional comments you may have. The client engages in behaviors that stimulate his/her child’s development. Tool #: II-11 Page 4 . NOW BEFORE 1 1 4b. What are 1 or 2 positive experiences from his/her childhood that influence his/her relationship with his/her child? 5c. On a scale from 1 (not at all satisfied) to 5 (very satisfied). how satisfied were you with the PFR program? 1 2 Not at all satisfied 3 4 5 Very satisfied Thank you very much for your help in completing this survey. What are 2-3 things the client does to stimulate his/her child’s development? Not At All True Extremely True     T T  2 2 T  3 3 T 4 4 T 5 5 5a. NOW BEFORE 1 1 5b. NOW BEFORE 1 1 7. The client enjoys the time he/she spends with her/his child.Almost Never Often     T T  2 2 T  3 3 T 4 4 T 5 5 4a. The client understands how his/her experience of being parented influences his/her parenting. What are 1 or 2 negative experiences from his/her childhood that influence his/her relationship with his/her child? Almost Never Often     T T  2 2 T  3 3 T 4 4 T 5 5 6.

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Section III

Nurturing & Attachment

The Fathering Project / CHSW Northwest Region
Survey Information Request
 

Type of father/male figure
___Birth father ___Partner

___Stepfather ___Male relative

Contact w/ child (check all that apply) ___Daily ___Weekly ____ Morning _____Afternoon ____Evening ____One – Two Times per Week ____Three or More Times ____Two or More Times

___Monthly ____One Time per Month

Number of children living in or regularly visiting my Home____ My child/ren’s ages
Two-Three Years____ Dads/Mens Role in Early Learning 1. I read picture books to my child/ren 2. When I read to my child/ren I point to the pictures in the book and talk to them about what’s happening. 3. I ask my child/ren questions about the stories we read together, (What happens next? How did he/she feel? Etc.).

Infant – One Year____
Three-Five Years____ Never

One-Two Years____
Six and Older____ Once or Twice a Week Almost Every Day

Once or Twice a month

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wrestling. (tickling. etc. 9.     Never Once or Twice a Month Once or Twice a Week Almost Every Day Tool #: III-1 Page 2 . I play quiet games with my child/ren. I tell my child/ren that I love them. noises.). say things) to make my child/ren laugh. pretend. (peek-a boo. I praise and encourage my child/ren when they’re attempting something new or doing something well 6. 8. I do things (make faces. I make time in my schedule to spend time with my children. bouncing. etc. letting them ride on my back.Dads/Men’s Role in Early Learning 4. 5. 10. I ask my child/ren questions about what they think and feel.) 7. rolling balls. I play physical games with my child/ren.

2. 4. Babies get spoiled if people pick them up every time they cry. 5. Children need to be hugged and cuddled frequently.Group Health Cooperative Mother Mentor Program PARENTS CHECK-IN The following questions ask you to think about parenting. THIS IS NOT A TEST--please take a few minutes to answer the questions as best you can. 1. 3. sometimes true or never true. Thank you very much! Indicate how you feel about the following statements by circling whether you think each statement is always true. Praising children is a good way to build their self-esteem. Always True Sometimes True Never True Always True Always True Always True Sometimes True Sometimes True Sometimes True Never True Never True Never True Always True Sometimes True Never True Tool #: III-2 Page 1 . Never hit a child. Strong-willed toddlers need to be spanked to get them to behave.

10. 8. 9. When I’m having a hard time.Please indicate how often the following things happen. My needs are more important than my child’s needs. 7. snacks). diapers. clothing. When my child is crying.   SOME OF THE TIME HARDLY EVER Tool #: III-2 Page 2 .g. I pick him/her up. I know what I can do about it or who I can call to ask for help. When I go out. MOST OF THE TIME 6. I am able to understand what my child’s cries mean. I pack a bag with plenty of supplies for my child (e.

Leave the box blank if parent’s skills need improvement.... F Hold baby/child so that eye contact is possible? F Engage baby/child in eye contact? F Use vocal and facial cues to encourage eye contact? Vocal Interaction: Does parent... WA Ladder observation Outcome: Increase parents nurturing and bonding with their children Staff/volunteers record observations each time a parent attends the group Name of parent _______________________________ Observer _____________________________________ DATE: ______/________/________ Rate the skills in each area below.)? F Respond appropriately to child crying? Overall Interaction: Does parent.. F Appear to be able to recognize crying cues (hungry.... cooing) and/or speak to child? F Respond in an encouraging way to child? F Use praise? Reactions to Baby Crying: Does parent. F Respond appropriately to baby/child’s cues? F Appear to have developmentally appropriate expectations for baby/child? F Appear to be comfortable with parenting? F Ask questions about parenting and/or demonstrate desire to improve parenting? F Appear to look to other parents for positive modeling?  Age of Child ______ Site _____________ Tool #: III-3 Page 1 . F Initiate vocal interaction (for example. COLVILLE. F Use touch to comfort baby/child? F Use touch to stimulate baby/child? Eye Contact: Does parent.. Check or mark the box if parent’s skills are adequate. etc.NORTHWEST RURAL RESOURCES. tired.. Touch: Does parent.

under-stimulation. sits and eats with older child. Parent talks through their actions with the child. never visited at feeding time. for example during diapering. For example. joy. parent is sensitive to when child is finished. parent makes eye contact when talking to child. For example.. 6. feeding. Responds to baby’s emotional cues. For example. Responds to baby’s physical cues. Talks to baby/child in a warm manner. For example. parent makes eye contact during daily routines such as diapering or feeding.g. fear. parent uses child’s name or an affectionate nickname. 4.) N/A 1 1.   2 3 4 5 N/A Tool #: III-4 Page 1 . hunger. parent holds baby while feeding. etc. 5. 2. parent realizes that child is signaling sleepiness. comfort and responds appropriately. child was napping. or makes playful sounds for child. Consistently makes eye contact. household tasks and other parts of the daily routine. parent realizes that child is signaling over-stimulation. Narrates to child. For example.North and Eastside Healthy Start Nurturing and Attachment Observation Tool Participant: _______________________________ Date Observed: _____________________ Pre: ______ Post: ______ (check one) Not Observed Yet (after ample opportunity) 1 Observed at least one time 2 Observed about half of the time 3 Observed more than half of the time 4 Observed consistently – most of the time 5 Not Applicable – no opportunity to observe this behavior (e. anxiety. a dirty diaper or needs to go to the bathroom and responds appropriately. 3. Positively interacts with child during feeding. parent moderates tone of voice (uses “parentese”).

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This discussion will help us understand how to be supportive of the parents and families involved in our childcare program.Volunteers of America Focus Group Guide [Moderator Introduction]: Welcome and thank you for being here. My name is ___________________ and assisting me will be___________________. and would like to start by having each of you tell us your name and the ages of the children in the program. Why do children cry? (Probes: why else?) [Listen for answers such as “ a child cries because if various needs. when would you want to comfort him or her? When wouldn’t you want to comfort him or her? [Listen for answers such as “I comfort my child because I am bigger. We will be talking today about some common situations that arise with young children. stronger. We are here to listen and learn from you. We would like to stress that there are no right or wrong answers here. more kind. to communicate” NOT “the child is spoiled or wants their own way”] 2. NOT I don’t comfort them when they are throwing a fit or are spoiled”] 3. and what your perceptions and opinions of those situations are. we will review what we have learned from you and begin to problem solve and develop an action plan based on our leanings. Feel free to say what is on your mind. When your child cries. Where and how do these needs get met? [Listen for answers such as “ When I get my needs met. even if it differs from something someone else has already said. What difference does it make to you to get your needs met? a. What difference does it make to your child to get your needs met? b. We will be recording our discussions to ensure that we do not miss any comments. I am not getting as frustrated” or “It is easier to take time out”] Tool #: III-8 Page 1 . We will be on a first name basis. only differing points of view. There will be no names attached to any reports. After the focus groups. wiser. 1.

Shark Music. How do you make a connection with your child? (Probes: How else?) [Listen for answers referring to “Repairing the circle. What if anything would you change about this group to make it better? Tool #: III-8 Page 2 . if anything? 2. What about the group has made a difference in your life. What about this group has made a difference to you as a parent. picking him/her up and holding him/her. playing”] Customer Satisfaction 1. if anything? 3. and I connect with my child by eye contact.4.

I am able to stand back and think about what I am thinking and feeling when I am upset. I think my child is too much trouble. I think that my child is a brat. I trust that when my child goes out from me that he/she will soon return. When my child is upset I immediately put her/him in another room. When my child wants comfort. I can recognize when my child is giving me a mixed message about feelings. I have an understanding of how my childhood influences my parenting. I feel that I understand most of the different needs that my child has. I am available to him/her. I feel my needs are more important than my child’s needs. I am about to stand back and think about what I am thinking and feeling when my child is upset. I recognize that pain from my past impacts my parenting. Some of the Time Hardly Ever Doesn’t Apply Tool #: III-8 Page 3 . I can see how some of my beliefs about my child get in the way of being an effective parent. My child thinks I am a good parent. When my child and I get upset with each other I make sure that we patch things up.Spokane Crosswalk Attachment & Bonding Class Date: ___/___/___ How often do the following happen? Most of the Time I am willing to wait for eye contact when my child looks away from me. I am able to stand back and think about what my child is thinking and feeling. I take charge when my child needs me to.

My child tries to make eye contact with me. What other parent groups are you currently participating in? Moms Support Group ______ Paternal Instincts ______ Other ______ What is your current living situation? Alexandria’s House ______ My own apartment ______ In a shelter ______ With my parents ______ Apartments for Young Families ______ Other ________ What is your gender? Female ______ Male ______ How many children do you have? ______ What are their ages? ______ ______ ______ Last letter of your first name _____ Month you were born _____ Second letter of first name _____   Tool #: III-8 Page 4 . I take joy in my child. My child likes me. My child’s needs confuse me. When interacting with my child I follow her/his lead. I see the importance of understanding the needs behind my child’s behavior. When my child gets upset I think that she/he is trying to manipulate me.

hugs child. e. Mom initiates contact/touch with her child. This information will be kept totally confidential. doing great in this area Needs work in this area Not applicable/ not observed 1. Mom attends to diaper changing or bathroom needs. Mom tries to determine what child is telling her through verbal/non-verbal cues.g. 6. Tool #: III-8 Page 5 . Mom consoles her child when he/she is distressed. 5. 3.VOA Staff. Mom talks warmly to child. kisses child. THANK YOU for taking a few minutes to complete the observation below based on your recent interactions and conversations with young moms being served by VOA programs. 2. Mom responds appropriately to child’s verbal/non-verbal cues. Project staff will review your responses and use the information to identify ways to continue to strengthen the Doula project in the future. [Add instructions about returning these forms?] [Mom’s identifying information] Date: ___________________ VOA Staff completing the observation: ___________________________ VOA programs in which mom is involved: Housing Crosswalk Other: _______________________ In the past 30days. caresses child. 4. how often have you had the opportunity to observe the mom and her parenting behavior? At least once or twice At least once a week At least 2-3 times per week At least daily Use the following scale to rate the young mom you are matched with in each of the areas below 4 3 2 1 NA 5 Very competent.

14. 15. talks about child’s feelings. e. Mom has other healthy supports (family. Mom seeks help from healthy supports when she needs it. 8. professional services) available to her. 13. 11. Mom manages child’s behavior appropriately. or turn to when she is having a hard time. Mom shows appropriate expectations for her child based on child’s developmental stage. 10. 12. Mom can identify the responses or circumstances that make her child feel unhappy or feel bad.g. Mom thinks about/talks about how the way she was treated by the people who raised her affects her now. Tool #: III-8 Page 6 . shows concern for child’s feelings. Mom can identify the responses or circumstances that make her child feel happy or feel good. friends. Mom considers child’s feelings and emotions. 9. Mom understands how she was raised affects her parenting now. 16. Mom has at least one person in her life that she can count on for support.7.

the slightest variation in a measuring device -whether it is a tape. or other device -. ordinary measuring rulers and their degree of accuracy are reliable enough. it is important that all Doulas have the same understanding about how to use and complete this observation. it is important to ensure that there is consistency in the way people understand and apply the rating categories." obviously the inter-rater reliability would be inconsistent. or other variables might affect their readings. Reliability means that the same data would be collected regardless of who collected the data. such as the discus throw. clock. Doulas will share information about the young moms based on Doula’s observations (see Doula Observation form). They must also be reliable when used by different people. Inter-rater reliability depends upon the ability of two or more individuals to be consistent. For the vast majority of people. while another researcher gives a "5. humidity. in different parts of the world. or the circumstances or environment in which data were collected. This is called interrater reliability. inter-rater reliability is the extent to which two or more individuals (raters) agree. The researchers have a sliding rating scale (1 being most positive. Olympic measuring devices must be reliable from one throw or race to another and from one competition to another. interpretation. Here is an example: Two or more researchers are observing a high school classroom. 7. Doulas will participate in an evaluation of the program so that staff can reflect on how things are going. Because the Doula Observation form asks each person to rate their young moms using their subjective judgment. Reliability refers to the degree of consistency that a particular data collection form provides. 5 being most negative) with which they are rating the student's oral responses. as temperature. Part of the Doula Training involves going over the tool in detail so that CAPA can ensure and enhance inter-rater reliability on the Observation form. Tool #: III-9 Page 1 . if one researcher gives a "1" to a student response. Inter-rater reliability assesses the consistency of how the rating system is implemented. However. Basically. In order to ensure the reliability of this form. for an Olympic event. air pressure. An example of the importance of reliability is the use of measuring devices in Olympic track and field events. For example. WA) Suggestions for CAPA’s Doula Observation Form training Sept. The class is discussing a movie that they have just viewed as a group.Prepared by Organizational Research Services (Seattle.could mean the difference between the gold and silver medals. 2006 At two points during the year.

Depending on the time available. doing great in this area Almost every time that I am with her.g. For many of the items on the Observation form. kisses child. caresses child 5: Very competent. Remind Doulas that they do not have to (and are strongly encouraged not to) complete the Observations in the company of the young mom. my young mom: Picks up her child even if he/she is not crying Holds and cuddles her child Some times when I am with her.[Past Job Inventory exercise] Trainers should go over the tool in detail with the Doulas. my young mom: Picks up her child even if he/she is not crying Holds and cuddles her child 4 3 2 1: Needs work in this area Most of the time that I am with her. Mom initiates contact/touch with her child. not much). The group can go over these definitions and the Doulas can use these as a guide when they are completing the Observation forms. e. the rating category definitions could relate to frequency of observed behavior -. she hardly ever: Picks up her child Holds and cuddles her child The rating category definitions could also relate to the degree of observed behavior (a lot vs. or the specific behaviors seen in a particular situation. my young mom usually picks up her child or holds her child only if he/she is crying. my young mom: Picks up her child even if he/she is not crying Holds and cuddles her child When I am with her. if time is short) or the group of Doulas together (during training.   Tool #: III-9 Page 2 . hugs child.for example…. I would suggest that either staff (beforehand. The Observation forms can be done by Doulas when they are on their own. When I am with my young mom. if there is time) further define the rating categories for each item on the Observation form.

Examples of Reflective Questions Healthy Family Relationships Program (Seattle WA) Healthy Family Relationships is a drop-in parent/family support group for parents (with kids of all ages) who are transitioning from incarceration. a memory or a relationship . family or those close to you?     • Thinking about your past family life. family. a tradition. what is one thing – maybe a quality. with whom did you have close relationships?     • When you were a child. or those close to you?    • What are some good ways to express anger with your children. what was your relationship with your parents like?     • How do you think your childhood family relationships or experiences influence the way you act in your current relationships?    • What are some qualities of healthy/strong families?     • How do you bring healthy qualities into your current relationships? Can you think of ways you could do that even more?    • Have you expressed love with a family member or someone close to you? How?     • What are some good ways to express love with your children.that you’d like to keep?     • What is one thing that you’d like to change in your family life?  How might you make that change?   • How likely do you think it is that you will make that change?   Tool #: III-10 Page 1 .   • When you were a child.

Section IV Parental Resilience .

_________________________ B. If you return this form to our office within 2 weeks. you called the Family Help Line for information about parenting and you agreed to answer a few questions to help us improve our service to families. Example: You circle “5” on the first part of the question and you circle “5” again for the second part. • The third part asks if your call to the Family Help Line is a reason for some of this change? • Check either the “yes” or “no”. • Check the “no change” if your answer to the second part of the question is the same as the first part. • Check all three parts of each question. 1. • The second part is asking how you felt after you called.#_____/ OE Mailed_____ Date returned:_____ GC Mailed:______ OE #_____ Family Help Line Survey A short time ago. Please fill out this form and return it to us within 2 weeks. Did you have knowledge of any stress management techniques: Before I called the Family Help Line: After I called the Family Help Line: Never 0 0 1 1 2 2 3 3 4 4 5 5  6 6 7 7 8 8 Always 9 9 10 10 Was the Family Help Line the reason for the Change? Yes  No No Knowledge 2. we will send you a $5. Please list the stress management techniques that you learned from the Family Help Line: 0 0 1 1 2 2 3 3 4 4 No Change Lots of knowledge 6 6 7 7 8 8 9 9 10 10 5 5 Yes  No  No Change A. • The first part of each question is asking how you felt before you called. _________________________ D. Are you able to use stress management techniques to cope with your own stress? Before I called the Family Help Line: After I called the Family Help Line: Was the Family Help Line the reason for the change? 3. _________________________ E. _________________________ Turn over  List here Tool #: IV-1 Page 1 . _________________________ C. The purpose of this survey is to determine whether you have tried any new stress management techniques because you called the Family Help Line.00 gift certificate to Starbucks.

parenttrust. 410 Seattle. We will send you a $5 give certificate to Starbucks.org Tool #: IV-1 Page 2 . Please feel free to add any other comments. Have you contacted any community resources that the Family Help Line gave you? If yes. WA 98101 1-800-932-HOPE www. I felt better after calling the Family Help Line. Ste. which ones? 7. I am able to deal with my anger in a healthy way: Before I called the Family Help Line: After I called the Family Help Line: Was the Family Help Line the reason for the change? 5. Thank you for taking time to fill out our survey! Please place it in the enclosed envelope and return it to our office. _____Yes _____No Never 0 0 1 1  2 2 3 3 4 4 5 5 No  6 6 7 7 8 8 9 9 Always 10 10 Yes No Change _____Unsure _____No change 6.4. Name: Address: Parent Trust for Washington Children 1601 Second Avenue.

... .............. a...............)... ......... Do not write your name on this questionnaire..... if your birthday is June 5 write 5 in the blank) Please write the second letter of your last name here: _______ (for example................ Please write the second and third letters of your first name here: _______ (for example.... Please answer honestly and completely...................Fathers Network Questionnaire Date: _______________ City: ____________________________ This questionnaire is anonymous and confidential......... ......... You will not be graded on your answers....) For Questions 1 through 4.... 1 2 3 4 5 1 1 2 2 3 3 4 4 5 5 5. I know organizations and care providers that can help me find services for my child............................ I know someone that I can call to talk about how things are going with my child. mental health services...... ____________________________________________________________________ Tool #: IV-2 Page 1 ....................... write am in the blank) Please write what day of the month is your birthday here: _______ (for example........... Please write your responses below......... 4..... instead please answer these next three questions to create an anonymous I........ if your name is Sam... ____________________________________________________________________ b...................... Name three positive strategies that you use to help yourself reduce stress....D.. please circle the number that best describes your answer.......................... if your last name is Johnson. . physical or occupational therapy.......... 3.................... 2...... dealing with the education system...... Not At All True Somewhat True Very True     T 1 T 2 T  3 T 4 T 5 1....... I know how to access information regarding my child’s disability... write o in the blank) (These questions are intended to help the Fathers Network learn about how the groups help people....... (For example...... speech... ____________________________________________________________________ c......... I know someone who knows what it’s like to parent a child with a special need and understands the challenges that go with that.

......................       Not At All True Somewhat True Very True T T T  T 4 4 4 T 5 5 5 10.. .. 8......... I spent time alone with my child who has a special need.... I feel like I make a positive difference in my child’s life...... I enjoy the time I spend with my child who has a special 1 2 3 need.......... ............ In the past month........... 1 2 3 12..................  Almost Never A Few Times Often     T 1 1 1 1 T 2 2 2 2 T  3 3 3 3 T 4 4 4 4 T 5 5 5 5 6... .................................. please circle the number that best describes your answer............................ ...... In the past month......... 7..................... Lousy 1 2 Okay 3 4 Great 5 14. I think my child enjoys the time we spend together.............. Please use the back of this page if you need more space. I have spent time with my kids and partner as a family....... ..................   13.For Questions 6 through 12.. ..... In the past month.. How to you feel about the job you’re doing as a dad? Please circle one response...... In the past month.......... I have used at least one of the above strategies identified in Question 5 to help me reduce stress................. Please write any additional comments or stories about your experience with the Fathers Network that you’d like to share... I spent time alone with my partner.. 9..............   Tool #: IV-2 Page 2 .... 1 2 3 11....

if your name is Sam. _________________________________________________________________ Tool #: IV-3 Page 1 .) 2b. I know someone who knows what it’s like to parent a child with a special need and understands the challenges that go with that. 4b. _________________________________________________________________ c. 4a. You will not be graded on your answers. Do not write your name on this questionnaire. For the questions in grey. write o in the blank) (These questions are intended to help the Fathers Network learn about how the groups help people. mental health services. think back to how you felt before you began attending Fathers Network meetings and circle the number that best reflects how you felt then. I know how to access information regarding my child’s disability.) For Questions 1a through 4b. (For example. Please write the second and third letters of your first name here: _______ (for example. if your birthday is June 15 write 15 in the blank) Please write the second letter of your last name here: _______ (for example. NOW BEFORE I joined the Fathers Network 1 1 NOW BEFORE I joined the Fathers Network 1 2 3 4 5 1 2 3 4 5 NOW BEFORE I joined the Fathers Network 1 2 3 4 5 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5 NOW BEFORE I joined the Fathers Network 5. a. 2a. physical or occupational therapy. speech. 3a. please circle the number that best describes your answer. Write your responses below. 3b. if your last name is Johnson. 1b. write am in the blank) Please write what day of the month is your birthday here: _______ (for example. Name three positive strategies that you use to help yourself reduce stress. I know someone that I can call to talk about how things are going with my child. Not At All True Somewhat True Very True     T T  2 2 T  3 3 T 4 4 T 5 5 1a. instead please answer these next three questions to create an anonymous I. _________________________________________________________________ b. Please answer honestly and completely.Fathers Network Questionnaire Date: _______________ Group/Facilitator:____________________________ This questionnaire is anonymous and confidential.D. I know organizations and care providers that can help me find services for my child. dealing with the education system.

. I think my child enjoys the time we spend together.... 9.... how did you feel about the job you were doing as a dad before you started attending Fathers Network meetings? Please circle one response............. 8.......... I spent time alone with my partner.... 11..... Lousy 1 2 Okay 3 4 Great 5 14....... How many Father’s Network special events (baseball games. Less than 1 year (started between May 2004 & now) 1 to 4 years (started sometime between 2001 & May 2004) 5 years or more (since 2000 or before) 16.. Thinking back... I have spent time with my kids and partner as a family............ In the past month... .. 12...... Christmas parties) or speakers none 1 to 3 speakers or events 4 or more speakers or events   15c..       Not At All True Somewhat True Very True 10.............. I enjoy the time I spend with my child who has a special need..... ______________)   Tool #: IV-3 Page 2 ... .......... I have used at least one of the above strategies identified in Question 5 to help me reduce stress...........  Almost Never A Few Times Often     T 1 1 1 1 T  2 2 2 2 T  3 3 3 3 T 4 4 4 4 T 5 5 5 5 6..... In the past month.......... 7... How old is your child who has a special need?__________________ (Fill in ages of any additional children with special needs here: _____________..... I spent time alone with my child who has a special need... T 1 1 1 T  2 2 2 T  3 3 3 T 4 4 4 T 5 5 5 How to you feel about the job you’re doing as a dad? Please circle one response............. Lousy 1 2 Okay 3 4 Great 5   15a... please circle the number that best describes your answer... have you attended? Please circle only one response... In the past month....For Questions 6 through 12.. In the past month.... .... I feel like I make a positive difference in my child’s life............. ...... How many Fathers Network meetings have you attended between September 2004 and now? Please circle only one response... 1-3 meetings 3 to 6 meetings 7 or more meetings 15b.. ... How long have you been involved (attended meetings or events) with the Fathers Network? Please circle only one response......................   13...

17. Not Satisfied 1 2 Somewhat Satisfied 3 4 Very Satisfied 5 18. We are very interested in your comments. thoughts or stories about your experience with the Fathers Network that you’d like to share. How satisfied have you been with your experiences with the Fathers Network? please circle one response. Please use the space below to write any other information you would like to share with us:   Tool #: IV-3 Page 3 .

 It also is  valuable for use in schools and mental health clinics where the parent‐child dyad is not the  primary focus of the assessment.  written at a 5th‐grade reading level. for parents of children 12 years and younger.parinc.  It is ideal for clinicians who work in a variety of primary health care settings and have a limited  time available to patients.com/products/product.aspx?Productid=PSI‐SF    Tool #: IV-4 Page 1 . The PSI/SF  yields a Total Stress score from three scales: parental distress. targeting those families most in need of follow‐up services.Parenting Stress Index/Short Form      “The PSI Short Form (PSI/SF) is a direct derivative of the Parenting Stress Index (PSI) full‐length  test. parent‐child dysfunctional  interaction.       The PSI/SF was developed at the request of clinicians and researchers who regularly use the  full‐length PSI and indicated the need for a valid measure administered in less than 10 minutes. All 36 items on the Short Form are contained on the Long Form with identical wording.”    Retrieved from: http://www3. and difficult child.

  Tool #: IV-5 Page 1 .

Tool #: IV-5 Page 2 .

The Institute helped to develop the Pathway to Prevent Child Abuse and Neglect at Harvard University with Lisbeth Schorr.edu       THE FAMILY DEVELOPMENT MATRIX and the Pathway to Prevent Child Abuse and Neglect The Institute for Community Collaborative Studies (ICCS) at California State University.W. Improved program services resulting from better data to analyze the impact of practices. and collaborative networks over time. evaluate success and failure. strategies and outcomes. etc.582. Director. It represents a knowledge base for goals. We are implementing an integrated FDM/Pathway model across 13 California counties with public/private agency partnerships for early intervention and family support. case management and evaluation tools.csumb. then evaluate and revise indicators with families and test them again using case scenarios for both validity and reliability. verbalize feelings and explain actions.California State University Monterey Bay DEPARTMENT OF HEALTH. Institute for Community Collaborative Studies 100 Campus Center Seaside. This is a practice-based evidence model to assist staff in the following ways: Family Support Workers are more effective in assessing families' strengths and areas for improvement.3624 831. agencies. Enhanced accountability and reporting methods based on outcomes. actions. The FDM is a strength-based assessment designed to build capacity within family resource centers and family support agencies. Tool #: IV-6 Page 1 . Empowerment of family decisions and family action plans. It enables family support workers to measure family progress by tracking family outcomes over time in relation to prevention and/or intervention activities for client and program assessment. We train staff to use the tools for assessment. enabling health and human service providers to both empower at-risk families and track outcomes for families. it helps family members develop the skills they need to make decisions. plan and follow through on activities. Additionally. and. California 93955-8001 Phone (831)582-3624 Fax (831)582-3899 http://hhspp. A shared language to communicate with child welfare partners and other agencies about client outcomes. and guidelines for its use. case planning and data collection.3899 Fax jerry_endres@csumb.edu/community/matrix/ 831. HUMAN SERVICES AND PUBLIC POLICY INSTITUTE FOR COMMUNITY COLLABORATIVE STUDIES JERRY ENDRES M. Institute contracts with programs to design outcomes through the Matrix Creator. The FDM provides a online set of complementary assessment. Monterey Bay has evolved the Family Development Matrix (FDM) outcomes model with community-based partners who continue to refine the language.582. our online design and database. structure.S. program planning and outcome measurements. solve problems.

edu/community/matrix/ Matrix Family and Community Categories—Each category has its own indicators and status levels for outcome measures.csumb. • Health Access • Adolescence • Health Safety • Adult Education & Employment • Health Care Policy • Agency Organizational Standards • Immigration • Ambitions • Individual Health • Attachment Status (child) • Intergenerational Programs • Basic Needs • Long Term Care (senior) • Caregiver Support (senior) • Parent Involvement • Children’s Care and Safety • Parents/Child Relationships • Children’s Education • Prenatal Healthcare • Children’s Development • School Healthy Environment • Children’s Skill Building • Sexual Activity • Community Engagement • Shelter • Community Environment • Social & Emotional Health • Community Health • Social Family Support • Cultural Competence • Student Development • Elder Support • Substance Abuse • Family Environment • Transportation • Family Relations • Volunteers • Financial Stability Tool #: IV-6 Page 2 . Human Services and Public Policy 100 Campus Center Seaside.California State University Monterey Bay Institute for Community Collaborative Studies Department of Health. California 93955-8001   Phone (831)582-3624 Fax (831)582-3899 http://hhspp.

I do not know if my child My child meets age My child is not meeting My child is meeting meets age appropriate appropriate development appropriate development developmental skills in most developmental guidelines and I know how to use N/A skills and I need resources to areas and I am using child and I do not know how to child development assist development resources find the information resources My child’s behavior My child’s behavior My child’s behavior is My child’s behavior is requires immediate. emotional and N/A witnessed physical. my child was experienced or witnessed My child is exposed to or My child is safe from exposed to and/or has abuse and received or now is witnessing physical. Basic Household Necessities: Do you have enough food? Do you find your household runs short of food between pay periods? Do you and your family have enough food to eat? Do you know about the food pyramid? Does anyone in your family need extra clothing? Do your children’s clothes fit OK? Too big or small? Shoes? How are you doing with school and work clothes? Are you able to keep up with utility payments? Is it difficult to make utility payments? Have any utilities been cut off? Do you use the low income programs through the utility companies? Sometimes I have enough I have plenty of food. 1 yr. sometimes requires intensive satisfactory with age excellent with age N/A intensive adult intervention adult intervention appropriate adult response appropriate adult response Tool #: IV-6 Page 3 . I need food immediately I have enough food food including fresh produce I/we need clothing I/we need more clothing for I/we have enough clothing for I/we have plenty of clothing immediately school/work school/work for school/work/play I maintain regular utility I have no utility services I make irregular payments I maintain utility service service using payment and cannot pay the and have a disconnection without interruption and N/A arrangements with utility deposit/past due amount notice pay utility bills regularly companies Caregiver Well Being: How do you handle things when you feel family stress? Who can watch your children if when you are feeling bad? How do you manage your stress? Have you ever felt like hurting yourself or others? Are you under stress? How do you feel at this time? How do you feel about your wellbeing as a parent or caregiver? When you are stressed do you receive support from family or friends? Do you know what to do if your child gets hurt? Do you know how to prevent accidents? Do you need information about baby proofing your home? Do you know about cabinet locks? Do you have a fire escape plan? Have you heard about making plans for safety in your home? I cannot manage I often cannot manage I manage parent/caregiver I manage parent/caregiver parent/caregiver stress parent/caregiver stress stress on my own with stress only with the help of N/A and/or have hurt myself or and/or have felt like hurting support from family and local community resources others myself or others friends I have a basic understanding I do not know how to I understand accident of accident prevention and I have safety-proofed my prevent accidents and my prevention and have started to do not know how to make a home and completed a N/A children have experienced make a safety plan that safety plan that addresses plan to address accidents injury addresses accidents accidents Children’s Care and Safety: Have your children ever been hurt? Have your children been exposed to violence in or outside of your home? Have you sought help or counseling? Has anyone in your home experienced abuse? In the past. receives formal support to emotional or sexual abuse sexual abuse emotional or sexual abuse build skills preventing future abuse Children’s Development: Have you noticed any areas that seem difficult for your child? Do you feel your child is developing appropriately? Have you heard about the developmental stages of childhood? Do you talk with your doctor about child development issues? What activities do you do with your child? Do you read or play? Would you like some ideas for activities? Who do you ask about what to expect with infants and children? Tell me about your child’s behavior. my child In the past.Family Development Matrix Assessment Tool  Indicators with Probing Questions    Career Goals/Advancement: Are your satisfied with your current employment? Are you currently working or enrolled in school? How are you getting income to support your family? What kind of work do you do? How long have your worked at your present job? What kind of job are you looking for? I have maintained steady I have maintained steady I have seasonal or temporary I am unemployed employment for more than 6 employment for more than N/A employment mo. Do you need help with your child’s behavior? Do you feel your child needs help dealing with his/her emotions? Does your child follow directions willingly? Do you have concerns about how your child relates to adults? Does your child get along well with other children and siblings? Does your child have friends? Does your child talk about friends at school? Are you comfortable with how your child interacts with other children? Tell me how your child reacts when he/she is in a group of children. physical.

but has difficulty children with support children maintaining friendships Children’s Education: Does your child like school? How is your child’s school attendance? Which school does your child attend? Does your child stay home from school sometimes? What situations? How are your child’s grades? Are you interested in tutoring and academic help? Do you experience difficulty getting your child to school in the morning? My child has excellent My child is not attending My child’s school attendance My child often misses school school attendance and N/A school is satisfactory or improving rarely misses a day Community Engagement: Do you like your child’s teacher this year? Who is your child’s teacher? What activities do you participate in at school? Do you ask your child’s teacher any questions? When is the next school activity? Do you need information about school activities? Do you feel comfortable contacting your child’s school? I do not know my child’s I know my child’s teacher. I know my child’s teacher and I know my child’s teacher teacher or participate in but I do not participate in participate in some school and participate regularly in N/A school activities school activities activities school activities Cultural Competence: Do you have difficulties receiving services? Do feel there are any barriers for family to receive services. My child has health N/A My child does not interact positively with other children Tool #: IV-6 Page 4 . emergencies and that meets only basic needs emergencies. health care needs health care and non-essential items Health Access: How did you find out about the Family Resource Center? Do you have a regular doctor? Does your child have health insurance? Can I help you get no.or low-cost health insurance for your child? If you need to go to the doctor. etc? Are you able to read school and medical information? Where do you get your check-ups? I experience ongoing I have only occasional I am unable to access difficulty in accessing difficulty accessing services I have no barriers to services due to language services due to language or due to language or other accessing services or other barriers other barriers barriers Family Environment: Do you feel your family communicates well? Is your family communication respectful or do you feel it is strained? Can you describe how your family communicates? Does your family communicate openly and express feelings? Is your home environment comforting? Do feel like you can talk with your family members? Does your family solve problems as a group? What happens when your family feels stressed? Is there stress in your family that bothers you? How do you and your family solve stress? Do family members treat each other with respect? Does any person in your home express emotions inappropriately? Does any family member threaten others? Do your children make you feel bad sometimes? My family members Communication among my Communication among my My family members generally communicate openly and family members is difficult family members is strained communicate with respect respectfully and abusive and lacks respect My family relationships are My family relationships are My family manages stress My family is managing stress extremely stressful and we strained and we have a and solves problems and learning to solve problems do not solve problems difficult time solving effectively and with support effectively problems independently A member of the family is My family members no longer No one is experiencing A member of the family is experiencing threats of experience violence or threats violence or threats of experiencing violence violence and/or there is a of violence with help from violence history of violence support services Family Relations: Do you and your husband/partner/wife spend enjoyable time together? Do you and your partner communicate easily? Do you enjoy talking with your partner? Do you and your partner make time to talk about things? Does your partner make you feel bad sometimes? My partner and I do not My partner and I seldom My partner and I communicate or communicate or our My partner and I generally communicate openly and N/A communication is difficult communication is strained communicate with respect respectfully or abusive and lacks respect Financial Stability: Does your income meet your family’s monthly needs? Are you able to buy what you need for your family? Are you comfortable with your finances? What is your current financial situation? My household income My household is financially My household income meets My household has income meets basic needs. make appointments. unable to meet basic basic needs. do you know where to go? Do you know about services in your community? Are you able to keep up with your monthly premiums? I have limited knowledge of I am aware of health I am unaware of health I am aware of health services health services available in services and use them services available in the and schedule less than the the community and/or have regularly for recommended community and/or have recommended amount of not scheduled health amounts of health not had health screening screening screening screening I have no health insurance My child has health My child has health insurance.My child interacts positively My child maintains positive My child maintains positive with other children relationships with other relationships with other N/A sometimes.

permanent place to live? Is your shelter temporary or permanent? Do you feel your home is big enough for your family? My family is living in a My shelter is permanent. I am scheduling established primary care and/or I am paying monthly preventive/sick child and/or it is difficult to pay premiums on schedule appointments and/or monthly premiums paying premiums/co-pays Parents/Child Relationship: Tell me a little about your child(ren). do you need help right now? I or a family member residing I or a family member residing I or a family member in my household I or family members in my household has been residing in my household acknowledges substance residing in my home have clean and sober for 12 mo. recovery. or is abusing alcohol. but My shelter is permanent temporary situation or in My family is without shelter somewhat small for my family and my family fits easily shelter that is overcrowded size into the space for my family size Social and Emotional Health: Does your child’s behavior concern you? Do you feel your child is healthy? Do you think your child could benefit from help from a doctor or counselor? Do any of your children have a disability? How do you manage a family crisis? Do you feel capable in your day-to-day activities? Are daily activities difficult sometimes? Does anyone in your family have a mental health diagnosis? Do you wish you could make different decisions in a crisis? Do you feel you are coping well with daily activities? Are you struggling with stress or depression? My child has physical and/or My child is physically and My child has untreated My child is maintaining mental health issues and I mentally healthy and does physical and/or mental physical and/or mental health N/A am seeking support services not require support health issues with support services for him/her services I experience difficulty I usually handle activities of I have no difficulty I have little difficulty managing handling crisis and daily living. How do you feel when your child is recognized for positive achievements? How do you feel if you get a negative report about your child? How do you feel your child’s self-esteem is? What is your child good at? Do you encourage your child when he/she is doing well? Do you remind your child about his/her strengths? How do you usually discipline your child? How were you disciplined as a child? How do you react to your child when he misbehaves? Do you worry sometimes about how you speak or act with your child? Do you feel comfortable with your parenting skills? Do you feel you would like to know more about disciplining your child? Have you taken a parenting class? Do you have an experienced person to ask parenting advice? Do you need more information about encouraging your child’s strengths? I feel unable to recognize I experience difficulty I consistently recognize I recognize and sometimes and encourage my recognizing and encouraging and encourage my encourage my child(ren)’s N/A child(ren)’s strengths and my child(ren)’s strengths and child(ren)’s strengths and strengths and positive qualities positive qualities positive qualities positive qualities I react without thinking to I respond inconsistently to I successfully use age I use age appropriate my child’s behavior and/or my child’s behavior and/or appropriate discipline discipline techniques and seek N/A worry that I may lash out I’m unsure how to handle techniques that teach my information or help for support verbally or physically discipline child natural consequences I have no knowledge about I am confident in my I have some knowledge of I am developing parenting parenting and/or child knowledge of parenting parenting skills and/or child skills and child development N/A development information skills and child development knowledge with support and skills development Prenatal Healthcare: Did you visit your doctor regularly when you were pregnant? Are you visiting the doctor during your pregnancy? Did you have any problems with your pregnancy? How was your labor and delivery? I understand the importance I understand the importance of I understand the I have not received of prenatal care and tried prenatal care and scheduled importance of prenatal care N/A prenatal care unsuccessfully to make an doctor’s appointments with and attended all prenatal appointment assistance doctor’s appointments Shelter: Where do you live? Does each person in your home have his or her own personal space? Do you have a safe. I have not I established primary care insurance. but find crisis managing daily activities daily activities and have activities of daily living.insurance. in crisis I with or without support and support resources identified to poor decisions negatively have difficulty identifying make thoughtful decision address crisis challenges affect my life strengths or resources when confronted with crisis Substance Abuse: Are you concerned that drug or alcohol use is affecting you or a family member’s ability to function day to day? Is alcohol or drug use causing difficulties? Are you worried about anyone’s use of alcohol or drugs? If you have a concern. illegal abuse and may be in early no history of substance more and feels confident and/or prescription drugs. difficult to handle. about recovery relapse for my child     Tool #: IV-6 Page 5 . but worries about abuse.

Each of you should review the form before the next meeting to make sure you’ve each taken the steps agreed on. place ______________________________________________________________________________________________ Tool #: IV-6 Page 6 . Begin your next meeting by reviewing the last plan. phone number. etc. (Note date each will take place) Steps family will take & when ______________________________________________________________________________________________ ______________________________________________________________________________________________ Steps worker will take & when ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Family strengths and resources (in family member’s word) ______________________________________________________________________________________________ Family strengths and resources (in worker’s words) ______________________________________________________________________________________________ Concerns (in family member’s words) ______________________________________________________________________________________________ Concerns (in worker’s words) ______________________________________________________________________________________________ Services available (include details such as names. hours. Ask the family member for any corrections. read out loud what you have written.FAMILY DEVELOPMENT – EMPOWERMENT PLAN HOW TO USE THE FAMILY DEVELOPMENT PLAN: Family worker. time. addresses. and make the corrections they request on all the sections except “in the worker’s words. If you write. be sure to use their words. Today’s date Family member’s name Child’s name Major goal (in the family member’s words) ______________________________________________________________________________________________ Help family brainstorm and then choose steps to take.) ______________________________________________________________________________________________ Notes ______________________________________________________________________________________________ Family member’s signature & date ______________________________________________________________________________________________ Worker’s signature & date ______________________________________________________________________________________________ Next meeting date. If the family member wants you to do the writing.” Give a copy to the family member and keep a copy in your file. please ask the family if they want to fill out the form or want you to write.

Matrix Visit Summary Back Parent Name:_____________________ Parent Signature:__________________ Staff Name: ______________________ Assessment Date: 07/13/2006 Assessment Number 1 Date: ______________ Date: ______________ Indicator Children's Care and Safety ChildCare Notes: enrolled in pre-k program InjuryPrevention Strengths 4 3 Concerns Notes: Safety plan is being prepared Children's Development BehaviorSkills Notes: Inconsistent response to parent/discipline Recreation Notes: Few options for recreation in neighborhood Children's Education AfterSchool BooksRead Notes: Parents read 1-2 books per week with children Comprehension Notes: ConnectedSchools Notes: Parent communicates with teacher DesireToRead Notes: Parents read 2-3 books per week with children EducationalServices Notes: Final Assessment Notes: Parents need assistance with child discipline 3 3 3 2 4 2 Notes: Older child attends structured programs 2 2 Tool #: IV-6 Page 7 .

B. YFS (Truancy. Include categories CPersonal Appearance and Hygiene.  Healthcare/ Insurance  Housekeeping  Housing  Vocational  Interpersonal  Transportation  Safe and Legal Recreation  Pregnancy Prevention  Pregnancy  Parenting                              Tool #: IV-7 Page 1 .:_______ D. Skagit/Island. Interviewers must complete the assessment training before administering the tool.:_____________________ Other person(s) involved:_________________ __________________ Date of Assessment:______________ __________________ Date of Intake:__________________   KEY: + If answer is acceptable Interviewer:___________________ Program: (circle) ILPEP.Independent Living Skills Assessment Summary Sheet Name of Youth:____________________ Average Hrs. Snoho.     A  B  C  D  E  F  G  H  I  J  K  L  M  N  CATEGORY                                                             STAGE SKILL LEVEL ATTAINED  Level 0 Level 1 Level 2 Level 3  Lacks Basic Awareness Basic  Awareness  Initial   Experience  Practicing Level 4 Sustained Experience  Budgeting  Daily Living  Education  Health and Nutrition/Food Mang. K.Legal Skills from the state assessment. For DCFS participants use the state Life Skills Inventory ILS Assessment Tool cover sheet to report to DCFS. and N. JP. Whatcom.O. Yes or No answers are not acceptable. 0 Place a circle where you stop asking questions in a specific category Directions: Interviewer needs to ask for examples or explanations. Youth must give acceptable answers for all questions to advance to the next level. ARIS) - Leave blank if answer is unacceptable. Interviewer will complete all levels of each category during Intake interview.Emergency and Safety Skills.

     3.    2.  ______    6mo.  ______ ______ ______ ______ _______ _______   ______    ______      _______     ______    ______      _______     ______    ______      _______   Level 3 1. Can name different methods of filing       personal Income Tax. Created mock or personal budget based on estimated       income and expenses.    ______ ______ _______   ______    ______      _______   Tool #: IV-7 Page 2 . mail)    5.          4.Budgeting     Level 1   Intake_   ______   3mo. 2. 4.  Uses budget to save money for unexpected         expenses and /or purchase goal of choice. Implement savings plan in budget. Can estimate monthly expenses. Practices personal budget for 2 months. 3. Can explain concept of budgeting. Learned about fees and cost related to financial      services and compared different providers. internet. (telefile. Stayed within cost of living budget for three months. adjusts budget as needed. 2. Name essentials and non‐essentials       to budget for when living on own. ______ ______ ______ ______ _______ _______ ______ ______ _______ ______ ______ _______ Level 4 1.Category A .Utilized a financial service provider in the comunity.   ______    ______      ______    ______     ______  ______    ______   _______   _______ Level 2 1.   _______   1. Practiced mock or actual filing of income tax with IL staff or financial service provider. Can predict income based on hours worked and or other resources. Aware of payroll deductions and income tax. 2. 3. Know location and services of a       financial service provider.    4.

3.  Filed taxes 2 years in a row.    ______    ______      _______   Tool #: IV-7 Page 3 .

______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ _______ _______ _______ 2. public postings. 3. Can name 2 resources for finding and contacting community services. Has made own appointments by phone and in person. 3. _______ _______ 4. Internet. Can name 3 emergency resources in community that help with food. (health. Have a mailing address and message machine. introduce self and state business) ______ ______ ______ ______ ______ ______ ______ ______ _______ Level 2 1. 5. 3. etc. ______ ______ _______ ______ ______ _______ Level 3 1. Can describe how to contact a community service and make an appointment (Phone ahead. news paper) 2. Accessed 3 or more social services.) 4. both at least one time. ______ _______ ______ ______ _______ ______ ______ _______ Tool #: IV-7 Page 4 . Demonstrates ability to communicate needs when addressing social service providers. Intake 3mo. Has schedule book to keep track of appointments. or health. _ 6mo. vocational. housing. ______ ______ ______ ______ ______ ______ ______ ______ _______ _______ _______ 2. transport. Responds to business messages and mail. (Phone Book.  Category B – Daily Living Level 1 1. Visited a social service provider and inquired about services. Able to make appointments and attend them on time. Has alarm clock and can wake self for morning appointments.

 _    6mo. transcripts. note taking. 2. study habits personal organization. 3. Knows how many credits required and needed to graduate secondary ed. home schooling). Has set personal education goal to finish secondary ed. contract based. 2. Has 15 credits toward diploma or completed 2 of the 5 GED test. Can explain how amount of education effects employment standing and pay. Can name 3 education alternatives for completing secondary education: (diploma. 4. Complies with requirements from social service provider and follows through with service. Researching post-secondary options.(in person & on phone) Level 4 1. proof of ID.  3.   ______    ______      _______     ______    ______      _______   ______ ______ _______ Category C – Education   Level 1   1. college. GED. (vocational program. ______ ______ _______ Level 2   1.. Establishing academic routine: time management.   3. Knows where to obtain documents for education enrollment: i. Does one productive activity towards personal goals daily. ______ ______ _______ Tool #: IV-7 Page 5 .e. Uses schedule book to attend appointments regularly     for 3 months     2. Alternative school. Social Security Card. Has obtained necessary documents for enrollment in education program.  Intake      3mo. university) ______ ______ _______ ______ ______ _______ ______ ______ _______ Level 3 1. immunizations. based on credits needed.  ______ ______ _______ ______ ______ _______   ______    ______      _______   4.

 Practices study routine at least 3 times per week.   4. Graduated secondary education or GED.  3.2. Has researched costs of post secondary education       and financial resources.    _____    ______  ______  ______  ______   _______   ______    ______      _______   Tool #: IV-7 Page 6 .

Can name 2 benefits of exercise and healthy eating.Level 4 1.   2. ______ ______ ______ ______ _______ _______ ______ ______ ______ ______ _______ _______ Level 3 1. grants or loans. Knows of local emergency food resources. _  ______   6mo. How can your body be affected by poor hygiene? 4. Knows food hygiene and can identify food spoilage. ______ ______ ______ ______ _______ _______ ______ ______ ______ ______ _______ _______ Category D – Health & Nutrition/ Food Management   Level 1    1. Applied for at least one post-sec. (ex. 3. different meals. Has prepared at least one meal with most food groups. Obtains food handlers permit. 3. Exercises or does something active two or three times a week. eats foods that provide varied nutrition) 2. Program. Obtained information on healthy eating. Has established a personal hygiene routine. Knows importance of personal hygiene. (handling perishable foods. 4. foods) Intake    ______   3mo. Has filled out FAFSA and has a source of income through job. (food banks. 4. 3. 3. 2. emergency food stamps) 2. Eats a balanced meal 2 nights of the week. 4. temps for cooking diff. Has experienced at least one form of physical exercise within the last month. Attending post-secondary education program. ______ ______ _______ ______ ______ _______ ______ ______ ______ ______ _______ _______ Tool #: IV-7 Page 7 . Has visited 2 post secondary education programs and understands requirements to be admitted. Has made a grocery list for meal preparation.  _______ ______ ______ _______ ______ ______ _______ ______ ______ _______ Level 2 1.

______ ______ ______ ______ _______ _______ Level 2 1. Aware of how and where to get emergency healthcare. 3. Consistently prepares own meals daily. Has visited Basic Health website or read through application. 4. Know options for obtaining medical insurance.e. Has chosen a regular medical care provider that works with insurance plan. 2. ______ _______ ______ ______ _______ Tool #: IV-7 Page 8 . Can name at least 2 sexually transmitted diseases. 2.  Level 4 1. benefits. Has sustained personal hygiene routine for 6 months. Planned Parenthood) 6. Maintains personal exercise routine for 3 months. 5. ______ ______ ______ ______ ______ ______ ______ ______ _______ _______ _______ _______ Category E – Healthcare/ Insurance Level 1   1.   Intake ______ 3mo. ______ 6mo. _______ ______   ______   ______ ______  ______    ______ _______   _______   _______      4. Can describe what health insurance is. Has read personal insurance policy and knows current med. (i. Can adjust recipe to fit different amounts of people. Knows location of local teen clinic. 3. 4. 3. On waiting list for basic Health or has insurance through other means. 5. ______ 2. Has visited and inquired about services at a teen clinic. Has collected information on different types of sexually transmitted diseases. Research potential medical care providers. (Dental? co-pay? Deductible? Premium?) ______ ______ ______ ______ ______ _______ ______ ______ ______ ______ _______ _______ ______ ______ _______ Level 3 1. 2. Can name risks involved with drug and alcohol abuse.

) 5. use appliances after 9pm. Has cleaned all the different communal spaces of a house or apartment. 4. Has dealt with waste and recyclable materials at least one time. 2. Aware of house maintenance as a part of a rental agreement. _______ ______ ______ _______ ______ ______ ______ ______ _______ _______ ______ ______ _______ Level 2 1. Has obtained health insurance through Basic health or employment. 3. etc. turn off lights. Knows importance of cleaning up after self. pharmaceutical. 2. dental. (ex. optical. recycling and garbage disposal) 4. Know what waste management is. Practices Prevention of sexually transmitted disease. 2. ______ ______ _______ ______ ______ _______ ______ ______ _______ Tool #: IV-7 Page 9 . ______ ______ _______ ______ ______ _______ Level 4 1. Intake ______ 3mo. living room. ______ ______ _______ ______ ______ _______ ______ ______ _______ Level 3 1. Prevents sinks and toilets from clogging and stop them from running. Used insurance plan for a check up or other healthcare reason. (ex. _ ______ 6mo. Keeps up on all medical needs. Knows what cleaning supplies clean what parts of the house. Knows how to conserve energy. Visits physician regularly. Disposes of garbage and recycles according to county’s recycling opportunities each week.3. 3. (ex. bathroom. Has identified a safe and consistent place to keep important mail. ______ ______ _______ ______ ______ _______ Category F – Housekeeping Level 1 1. Washes laundry using correct water temperature according to fabric and color. kitchen. bills and documents.) 2. 3.

utilities hook up) 4. Taken tour of house/apt. (cost. Is aware of places to search for housing.Level 4 1. 3. Internet) 3. Keeps home free of pests. (first and last payment. 4. 2. shelters) Intake ______ 3mo. rent due by) 4. (Newspaper. Understands option for temporary/emergency housing. Maintains outside residence according to rental agreement. (cockroaches? Fleas? Lice? Mice? Rats?) 2. ______ ______ _______ ______ ______ _______ ______ ______ ______ ______ _______ _______ Category G – Housing   Level 1 1. Comm. Has read and identified the key information in a lease. _______ _______ ______ ______ ______ ______ _______ ______ ______ _______ Level 2 1. Disposes of waste regularly for 3 months. (transitional housing. Has looked into eligibility for community housing and utilities assistance. deposit. Have done a mock or actual house or apartment search. for rent. _ ______ 6mo. Knows what contributes to start-up costs. Uses proper cleaning supplies for all household cleaning jobs regularly. College posting board. 2. HUD. Has attained housing. HUD)  ______ ______ ______ ______ _______ _______ ______ ______ _______ ______ ______ _______ Level 3 1. Actions. ______ ______ ______ ______ _______ _______ Tool #: IV-7 Page 10 . utilities paid.   3. 2. Understands concept of renting. length of lease.     (DSHS. Set up phone and utilities.

apt.e: shared housing. studio. Has calculated and compared costs of renting different types of housing i.. 2. ______ ______ _______ ______ ______ _______ Tool #: IV-7 Page 11 . ______ ______ ______ _______ _______ Level 4 1. Pays rent on time for 3 months.3. ______ 4. Completes first housing lease. house. Left the house clean and received damage deposit back or potential refund.

Updates resume and references as needed. 2.) ______ ______ ______ ______ ______ ______ _______ _______ _______   _____     ______   ______   5. 3. 3. _ 6mo. and resume needed for a job. Knows how and where to look for a job. education and experience. 4. Has completed more than 1 interview or gets a job.3. management. hard copy and/or online. Obtain required certifications for potential job. Obtained employment. ______ ______ _______ Level 3 1. Flagging Cert. hygiene and presentation for interviews. ______ ______ _______ ______ ______ ______ ______ ______ ______ _______ _______ _______ ______ ______ _______ Tool #: IV-7 Page 12 . ______ ______ _______ Category H – Vocational Level 1 1. Aware of references. (ex: entry-level. Done mock and/or actual interview. Constructed resume. WA Driver’s License. Saves damage deposit refund for next housing opportunity. Has filled out 1 or more applications for employment. Food handler’s permit.   ______     ______  ______    ______   _______   _______ ______ ______ _______ ______ ______ _______ Level 2 1. Intake 3mo. 4. 3. application. Using resources specializing in employment hunting: Career Centers DVR Colleges Work Source Employment Sec. Can practice and be prepared for professionalism: Punctuality Communication with Boss Dress Reliability 5. 2. Has used 2 different employment community resources. supervisor)        2. 4.  (Ex. Aware of job potential based on age. Aware of appropriate attire.

  Trying different de‐escalation methods. Understands importance of social interaction. ______ ______ ______ ______ _______ _______ Level 4 1. Identify self and interpersonal escalation cues. ______ ______ ______ ______ _______ _______ ______ ______ _______ Category I – Interpersonal Skills Level 1 1. Can identify characteristics of hurtful and negative relationships. 3. 2. Has attended a conflict resolution class. volunteering. Can name and a supportive person in your life. Intake ______ 3mo. 2. Is researching vocational certifications/degrees for job/ career advancement.Level 4 1. ______   ______   ______ ______ ______ ______  ______    ______ ______ ______ _______   _______   _______ _______ _______ Level 3 1. in community) ______ ______ ______ ______ _______ _______ Tool #: IV-7 Page 13 . 4. (band.  3. 2. Uses personal strengths in community: (@ job. Can identify characteristics of kind and positive relationships. Practices method(s) of de-escalation. 2. _______ ______ ______ _______ ______ ______ _______ ______ ______ ______ Level 2 1. etc. _ ______ 6mo. 4. Does something nice for someone else. volunteer club. Joins a social group. 2.) 5. education. 3. Sets aside time to spend with loved ones on a regular basis. Invite a friend to a social event. Maintains employment for 90 days or throughout probationary period. Makes self eligible for promotions and raises.

Has a personal transportation plan IL needs i. bike. Walking. (ex. Have planned for and traveled out of area. boat. recreation. (ex. Aware of steps to take to get Drivers license. family. ______ ______ _______ ______ ______ _______ ______ ______ _______ Level 3 1. ______ ______ _______ ______ ______ _______ Category J – Transportation   Level 1 1. bus. riding bike. Schedules regular maintenance of transport. (Bike. medical care.. Able to maintain transportation. plane. and provider.3. 4. skooter. dial-a-ride) 4. Knows whom they could access for personal transportation via services. _ ______ 6mo. _______    2.. driving car… does not rely on others) 3. train. Take and complete driver’s ed. friends./or turn 18yrs. Research options for Driver’s Education: cost. etc. Aware of recreational transportation as alternative. (road trip. (bus. 2. Comfortable with face-to-face interaction to effectively communicate with service providers in community. Tried using public transit to get to a destination at least one time. taxi. 2. skateboard. Automobile) 3. Able to get to appointments relying on self. Aware of public transit options in community and their costs. skates) 3. Complete driver’s test for driver’s license. 2. old. ______ ______ _______ ______ ______ ______ ______ _______ _______ Level 4 1. 3. Uses de-escalation method consistently to refrain from physical or verbal violence.) ______ ______ ______ ______ _______ _______ ______ ______ _______ Tool #: IV-7 Page 14 . work.e. ______ ______ _______ ______ ______ ______ ______ _______ _______ Level 2 1. Intake ______ 3mo.

______ ______ _______ ______ ______ _______ ______ ______ _______ ______ ______ _______ Level 3 1. Volunteering with special interests and talents 2. IL groups. Has found at least one activity or event listed in a local media. Recognizes own interests and talents. Intake ______ ______ 3mo. programs and parks. 2. Trying at least one new healthy recreation activity. 3. Participates in a community program or activity. kayaking. 4. Can name a media that lists local events and activities. Has attended 2 or more public events. Recognizes participation in illegal activities as non-productive. at least once. Has eliminated illegal activities. ______ ______ _______ Tool #: IV-7 Page 15 . art. ______ ______ ______ ______ ______ ______ ______ ______ _______ _______ _______ _______ 3. 4. youth groups) 2. (sports. festival. 4.) 3. Sets aside time to do enjoyable activity at least once a week. exercise. Has used community recreation facilities. 5. Aware of addictions to activities or substances 3. _ ______ ______ 6mo. Involves others into activities. Concert.) 2. (ex. Connected interests and talents to recreational hobby. Recognizes decrease of addictive behavior through healthy activities. (ex. Regularly uses media of choice to plan attendance at community events.Category K – Safe and Legal Recreation Level 1 1. _______ ______ ______ _______ ______ ______ _______ ______ ______ _______ Level 2 1. etc. public speaker) ______ ______ _______ ______ ______ _______ ______ ______ _______ Level 4 1. etc. hiking. yoga. theatre. (musical instrument. parenting classes.

provided at medical offices (exams. Aware of availability of contraceptives (name 2) and abstinence as a choice. _ ______ 6 mo. test done. Has chosen pregnancy prevention method. Have taken basic sex education course. HIV testing and emerg. (exams. Name three options to choose from when faced with ______ an unwanted pregnancy (abortion. fatigue) and two places to have a preg. or family ______ planning office and discussed svcs. (stays on schedule. 3. Aware of rights of client confidentiality.Category L – Pregnancy Prevention Level 1 1. Consistently practices pregnancy prevention choice. Has discussed with professional or IL staff. _______ ______ ______ _______ 3. ______ ______ _______ ______ _______ ______ ______ _______ Level 2 1. STD screening. Can name symptoms of pregnancy (nausea. clinic. Aware of svcs. provider. and emergency contraceptives) 5. parenting) 4. test. replenishes supply as needed). contraceptives) 3. Has gathered info. Have visited a local med. 4. 2. Has accessed regular annual exams/screenings.adoption. Has visited Dr. Intake ______ 3 mo. 2. Have discussed contraceptives/abstinence with partner. ______ ______ ______ ______ _______ _______ Level 3 1. ______ ______ ______ ______ _______ _______ ______ ______ ______ ______ _______ _______ Level 4 1. 4. ______ ______ _______ Tool #: IV-7 Page 16 . HIV testing. Feels comfortable and understands the importance of confiding in family planning professional. ______ ______ ______ _______ _______ 2. preg.’s office. STD screening. clinic or family planning office and used services. Re: pregnancy choices.

mid-wife) 3. ______ ______ _______ ______ ______ ______ ______ _______ _______ Tool #: IV-7 Page 17 . parenting relative care) 5. Aware of cost of prenatal care /delivery. Have made some change in diet for benefit of pregnancy (e. office. 3. alcohol. 2. Have discussed read about. Consistently visits Dr. parenting relative care) 4. ______ ______ 6 mo. ______ ______ _______ ______ ______ _______ Category M – Pregnancy Level 1 1. adoption. called about and /or asked question re. Aware of what prenatal care is. eat vegetables). medical coupons. Aware of where prenatal care is offered (clinics.) Intake ______ ______ 3 mo. asked questions about pregnancy options (abortion. Has not experienced a pregnancy scare in the last three months. ______ 2. Dr. Practices keeping a healthy lifestyle for benefit of pregnancy. Aware of ways to cover costs (sliding fee scale. co-parenting. 3. _______ _______ ______ ______ _______ ______ ______ _______ ______ ______ ______ ______ _______ _______ Level 2 1. Have called or visited prenatal care providers. 6. Aware of substances that may harm developing fetus (medication. Came up with plan for pregnancy choice. caffeine. insurance.’s office. clinic or family planning office for information and services. Have selected and begun appointment with pregnancy care provider.2. quit smoking/drinking. adoption.g. Aware of options for pregnancy (abortion. co-parenting. costs of pregnancy care. 2. eat breakfast. ______ _______ ______ ______ _______ ______ ______ _______ ______ ______ _______ Level 3 1. 3. Have picked up application. some herbs) 4. drugs.

birth certificate. Has list of needed supplies. Aware of benefits from quality time and interactive play. card.S. S. food/bottle. card) 2. _ ______ ______ ______ 6mo. Aware of need for supervision and childproofing.  ______ ______ ______ ______ ______ ______ ______ _______ _______ ______ ______   ______ ______ _______ _______   Tool #: IV-7 Page 18 . birth certificate. have found medical care provider for child. 4. Aware of needed supplies for child (appropriate sized car seat.g. weather approp.Parenting (specific to parenting & expecting youth) Level 1 1. talking. Clothes. 3. Aware of needed documents and available services (Med. replaces household item with appropriate toy). Intake ______ ______ ______ 3mo. Has maintained medical coverage. WIC. ______ _______ _______ ______ ______ ______ ______ ______ _______ Level 2 1. 5. and diaper supplies). clothing. Has acquired basic necessities for delivery (blankets. WIC. Practices removing danger from child (e. Have applied for documents and svcs. 3. 5. 3. bathing and proper proper feeding). drawing etc. Is enrolled in medical coverage plan. Have begun initial tasks for pregnancy choice. singing. 4. car seat) ______ ______ ______ ______ ______ ______ _______ _______ _______ ______ ______ _______ Category N . 2. food. Aware of tasks to keep good hygiene and health of child (frequency of diapering.S. (S. ______ ______ _______ Level 4 1. coupons) 2. Have come up with pregnancy/ birthing plan with pregnancy care provider.) 4. coupons. Makes time daily to interact with child (reading.4. med. Has acquired appropriates sized car seat and diapers for child. Have bathed and diapered baby on your own.

Reapplies for services and documents as needed. __ Social Security card __ Immunization records __ WIC __ Medical Ins.g.Level 3 1. has a list of resources. 4. coupons ______ ______ _______ 2. 4. ______ ______ ______ Level 4 1. Has appropriate person to supervise child when parent is gone (daycare. 5. Able to manage child’s schedule and household tasks. ______ 6mo. 2. /med. Plans ahead for needed supplies (e.) 3. Continues to child proof home as needed to accommodate growing child. ______ _____ ______ ______ ______ ______ ______ ______ 5. adult relative or friend) ______ 3. budgeting money for outgrowth of carseat or formula to supplement WIC) Intake ______ 3mo. Have documents for your child and enrolled in services (must have all of below to pass question) __ Birth Certificate. Has decided on discipline style. Child is up to date on immunizations. Knows where to acquire new supplies for growing child. Has begun infant tooth care. Consistently uses discipline plan for situations as they arise (public temper tantrums etc. Plans child focused activities in advance. _______ ______ ______ _______ ______ ______ _______ ______ ______ _______ ______ ______ __ Tool #: IV-7 Page 19 .

APPENDIX A .

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