Infant/Toddler HOME Bettye M. Caldwell and Robert H. Bradley ‘Summary Sheet Family ni Date Visitor Address oS Phone Child’s name Birth date Age__ Sex Interviewee. ex than parent, relationship to child Family composition Genoa Ting vex and age of hilren) Family Language Maternal Paternal ethnicity spoken education Is mother employed? Type of wor Hrs/Wk Is father employed? ‘Type of work when employed? Current child care arrangeme; ‘Summarize past year's, Other person(s) py Notes SUMMARY Possible ‘Actual Subscale Score_| Median | Score Comments TNS MONE, A MONEE BRT Se elated 7 te I_RESPONSIVITY ul © [LM besates aus ee cgeisChon es nid IS ally relopendowt and M1, ACCEPTANCE 8 6 | [bey we sere a oe ceed Wea tinade won URS III. ORGANIZATION 6 5 G ERTS SE ae Jey nga] AOE VARY of 1V, LEARNING MATERIALS 9 7 si [Serloprecamnaiig ae MOPUMME FRY AS WELL og Pacem ota V._ INVOLVEMENT 6 4 arial eee i Oe GR cae ied Vi. VARIETY 5 3 Cf |Frmsegries sae atsony © USES are ond a Las TOTAL SCORE 45 Bom iet ‘Copyright 2003.Infant/Toddler HOME Record Form Place a pls (+) or minus (-) inthe box alongside each item depending on whether the behavior is observed during the visit, or ifthe parent reports thatthe conditions or evens are characteristic of the home environment. Ener the subtotals andthe total on the Summary Sheet. Observation (0), Either (E), or Interview (1) Is indicated for each item. FA. Child has a spect place for toys sod weasures 1. RESPONSIVITY E x Parent permis child wo engage ia “mena play 1 Chg play environment in wale 0 = 2 Parent spontaneously voralizes io child al least. twice. 0 k_| 1V. LEARNING MATERIALS 3. Parent responds verbally Yo Ghild's vocalizations ‘or verbalizations. O SE | 26. Muscle activity toys or equipment. E + Paced ORO OOTERE [Tg = visit orpull ty E 28. Scoller or walker, Kidde cr, e001F, oF 5. Parent's speech is distinct. clear, and audible.O | | tricycle E x 6. Parent inites verbal interchanges with Visitor. o E25 cas toy creping on. + 30. Learning facilitators—mobile, table and chair, 7. Parent converses freely und easily. X | high chair, play pen. E Ta &. Parent spontaneously praises child at least twice. > 0 &_| 1 simple eyeshand coordination toys. E + ‘Parent's voice conveys pontine feelings toward child. 0 + | 52. Complex eye-hand coordination toys E +. TO Parent caresses or Kisses child at least once O |} | 33. Toys for iterate and musi. E TI-Parent responds positively to praise of child “4. Parent provides toys fr child to play wih offered by Visitor. O ¥X | during visit O + Al accertance_» ¥, INVOLVEMENT a,moe tan Lace of pysalpuitnent | 135 ere ks to child while doing Bousehold | during past week. 1 76. Parent consciously encourages developmental 13. Family has a pet. E a advance. xt ‘37. Parent invests maturing toys with value via ry 14. Parent does not shout at child. O. + | personal attention. 15. Parent does not express oven annoyance wid ot bona to child © | 5, pee sevens hl’ ply peri ~ TF nee saps or ps aig vi. | [39 Feet oven iy hat halen | ° develop new sil. T7. Parent does not scold or eriicize child during | 40: Pareat keeps child in visual range, looks a visit. 0 often. O tas TP dosnt ihrem | more than 3 times during visit. © 1. VARIETY TEA least 10 books are present and vible-E [A Father provides some care ily T 42. Parent eads sores wo child at least} mes I ORGANIZATION weekly 1 a 20, Child ear, iFused, s provided By one Q'S 4 [PGS a Taso matey wma | regular subsites. and fuer TT Child istaken wo proce sore at Teas ohcou | 4] 4, Fay vis rlaves or veces van oncea | week. 1 month or 1 22. Child gets out of house at least 4 times a week 1 | ¢~ | 45. Child has 3 or more books of hivher own E [4 23 Child stan regularly to doctors oftce or — |= clinic. =] TOTALS Ly + m@Olo wG3 v6 wtl tomy ‘Caldwell & Bradley Copyright 2008.