Appendix 3

YEKOKEB BERHAN CHILD SUPPORT INDEX

Partner organization______________________ Region:____________ Woreda:___________ Kebele:___________

Today’s date: y_____/m_____/d_____ Primary Caregiver name_____________________________________ Gender: M___ F___ ID____________________________

Age of caregiver_______ Volunteer: ___________________________________________________ First assessment?____ Re-assessment?_____ One form per HOUSEHOLD

* Caregiver tested for HIV: YES___ NO___ DON’T KNOW____ or child tested for HIV: YES____ NO____ DON’T KNOW____ Office:
*Disclosed HIV+ caregiver___ or HIV+ child___ DON’T KNOW ___ If yes, is this person on treatment? YES___ NO____ DON’T KNOW ____
# of children in the household ___ # of children with an obvious disability ___ (*do not directly ask these questions, but record if known)

Shelter and Care (GoE: 2.2.1) Economic Strengthening (GoE: 2.2.2)

1. Shelter is warm, safe & dry. 2. Primary caregiver is 18 + & provides 3. Household has access to a latrine 4. Household is able to meet minimum 5. Family has regular income and/or assets.
regular care, attention, support. and safe water. needs (expenses) for most of the year

:: _ :. _ .. _ . _ :: _ :. _ .. _ . _ :: _ :. _ .. _ . _ :: _ :. _ .. _ . _ :: _ :. _ .. _ . _
> Care action planned? __ __ > Care-action planned? __ __ > Care-action planned? __ __ > Care-action planned? __ __ > Care-action planned? __ __
< Care action occurred? __ __ < Care-action occurred? __ __ < Care-action occurred? __ __ < Care-action occurred? __ __ < Care-action occurred? __ __

Coordination of Care (GoE: 2.3)

6. Children have someone/somewhere 7. Services provided to the children are Comments, including major changes in household in last year:
in community to receive services and well coordinated and respond to the
support. children’s needs.
Appendix 3
YEKOKEB BERHAN CHILD SUPPORT INDEX
Partner organization______________________ Region:____________ Woreda:___________ Kebele:___________

:: _ :. _ .. _ . _ :: _ :. _ .. _ . _
> Care action planned? __ __ > Care-action planned? __ __
< Care action occurred? __ __ < Care-action occurred? __ __

Today’s date: y_____/m_____/d_____ Child’s name__________________________ Gender: M___ F___ Relationship to caregiver:_________________ ID_________________________

Date of Birth y_____/m_____/d_____ Volunteer: __________________________________ First assessment?____ Re-assessment?____ One form for each CHILD

Legal Protection (GoE: 2.2.3) Health Care (GoE: 2.2.4)

Appendix 3
YEKOKEB BERHAN CHILD SUPPORT INDEX
Partner organization______________________ Region:____________ Woreda:___________ Kebele:___________

. Child has access to legal support. 9. Child is safe from any abuse, neglect 10. Child is free from visible disease & 11. Child has access to health care 12. Child has received age-appropriate
(Examples: birth registration, or exploitation. is physically healthy for daily activities. services, incl. preventive & curative immunizations
protection from illegal practices) = for under age 6 only =

:: _ :. _ .. _ . _ :: _ :. _ .. _ . _ :: _ :. _ .. _ . _ :: _ :. _ .. _ . _ :: _ .. _ . _ _
>Care action planned? __ __ > Care action planned? __ __ > Care action planned? __ __ > Care action planned? __ __ > Care action planned? __ __
<Care action occurred? __ __ < Care action occurred? __ __ < Care action occurred? __ __ < Care action occurred? __ __ < Care action occurred? __ __
Psycho-social Care ( GoE: 2.2.5) Food and Nutrition (GoE: 2.2.7)
13. Child is cooperative and enjoys playing 14. Child appears emotionally stable & 15. Child is treated the same as other 16. Child has locally available food on a 17. Child is not malnourished (determined
with peers. content (not usually aggressive or withdrawn) children in household; not stigmatized regular and consistent basis. by upper arm measure or other symptoms).

:: _ :. _ .. _ . _ :: _ :. _ .. _ . _ :: _ :. _ .. _ . _ :: _ :. _ .. _ . _ :: _ :. _ .. _ . _
> Care action planned? __ __ > Care action planned? __ __ > Care action planned? __ __ > Care action planned? __ __ > Care action planned? __ __
< Care action occurred? __ __ < Care action occurred? __ __ < Care action occurred? __ __ < Care action occurred? __ __ < Care action occurred? __ __
Education (GoE: 2.2.6) Comments:
18. Child (0-6 & post-primary) is positively 19. Child (primary school age) attends school 20. Child has sufficient school materials,
stimulated (early childhood/ secondary or & is performing well, to graduate to next class. supplies, & school clothes (incl. hygiene
vocational studies or life skills) cloths for teen girls).

:: _ :. _ .. _ . _ : _ :. _ .. _ . _ : _ :. _ .. _ . _
Appendix 3
YEKOKEB BERHAN CHILD SUPPORT INDEX
Partner organization______________________ Region:____________ Woreda:___________ Kebele:___________

> Care action planned? __ __ > Care action planned? __ __ > Care action planned? __ __
< Care action occurred? __ __ < Care action occurred? __ __ < Care action occurred? __ __