Demographics .us
Demographics: Intake (index children)* Required*First Name - __________________________________________________________Middle Name - __________________________________________________________*Last Name - __________________________________________________________* Home Visiting Program TypeEarly Head Start – Home Based Option (EHS)Healthy Families America (HFA)Nurse-Family Partnership (NFP)Parents as Teachers (PAT)* Date of Enrollment – __ __ / __ __ / __ __ __ __ (MM/DD/YYYY)* Birth Date – __ __ / __ __ / __ __ __ __ (MM/DD/YYYY)*GenderMaleFemale*Race (Select all that apply)American Indian or Alaska NativeAsianBlack or African-AmericanNative Hawaiian or Other Pacific IslanderWhite* EthnicityHispanic or LatinoNot Hispanic or Latino* Primary Language Spoken at HomeEnglishSpanishOther (please specify: _____________________)* Health Insurance Status at EnrollmentNo Insurance CoverageMedicaid or CHIPTri-CarePrivateOther (please specify: _____________________)* Usual Source of Medical CareDoctor’s/Nurse Practitioner’s OfficeHospital Emergency RoomHospital OutpatientFederally Qualified Health CenterRetail Store or Minute ClinicNoneOther (please specify: _____________________)* Usual Source of Dental CareHave a Usual Source of Dental CareDo not have a Usual Source of Dental CareDemographics: Intake (primary caregiver)* Required* First Name - __________________________________________________________Middle Name - __________________________________________________________* Last Name - __________________________________________________________* Street Address - __________________________________________________________* City - __________________________________________________________* Zip - __________________________________________________________* County - __________________________________________________________* Home Visiting Program Type (Select all that apply)Early Head Start – Home Based Option (EHS)Healthy Families America (HFA)Nurse-Family Partnership (NFP)Parents as Teachers (PAT)* Date of Enrollment – __ __ / __ __ / __ __ __ __ (MM/DD/YYYY)* Birth Date – __ __ / __ __ / __ __ __ __ (MM/DD/YYYY)* Relationship to ChildBiological MotherOther Female CaregiverBiological FatherOther Male Caregiver* Pregnancy Status at EnrollmentCurrently pregnant (_____ weeks)Not currently pregnant* Estimated Date of Delivery – __ __ / __ __ / __ __ __ __ (MM/DD/YYYY)* Race (Select all that apply)American Indian or Alaska NativeAsianBlack or African-AmericanNative Hawaiian or Other Pacific IslanderWhite* EthnicityHispanic or LatinoNot Hispanic or Latino* Marital Status at enrollmentNever MarriedMarriedNot Married but Living Together with PartnerSeparated/Divorced/Widowed* Educational Attainment at Enrollment (highest level)Less than HS diplomaHS Diploma / GEDSome college/trainingTechnical training or certificationAssociate’s degreeBachelor’s degree or higherOther (please specify: _____________________)* Educational Status at EnrollmentStudent/traineeNot a student/trainee* Employment Status at EnrollmentFull-time (37+ hours per week)Part-time (Less than 36 hours per week)Not employed* Housing Status at EnrollmentNot HomelessOwns or shares own home, condominium, or apartmentRents or shares own home or apartmentLives in public housingLive with parent or family memberSome other arrangementHomelessHomeless and sharing housingHomeless and living in an emergency or transitional shelterSome other arrangement* Total Number of People in the Household – _____* Household IncomeLess than or equal to $6000$6,001 – $12,000$12,001 – $20,000$20,001 – $30,000$30,001 – $40,000Over $40,000Refused to respond* Health Insurance Status at EnrollmentNo Insurance CoverageNot eligibleOther (please specify: __________)Medicaid or CHIPTri-CarePrivateOther (please specify: _____________________)Demographics: Update (index children)* Required*First Name - __________________________________________________________Middle Name - __________________________________________________________*Last Name - __________________________________________________________* Health Insurance StatusNo Insurance CoverageMedicaid or CHIPTri-CarePrivateOther (please specify: _____________________)* Usual Source of Medical CareDoctor’s/Nurse Practitioner’s OfficeHospital Emergency RoomHospital OutpatientFederally Qualified Health CenterRetail Store or Minute ClinicNoneOther (please specify: _____________________)* Usual Source of Dental CareHave a Usual Source of Dental CareDo not have a Usual Source of Dental CareDemographics: Update (primary caregiver)* Required (Note: all fields are required for new caregivers)* First Name - __________________________________________________________Middle Name - __________________________________________________________* Last Name - __________________________________________________________* Street Address - __________________________________________________________* City - __________________________________________________________* Zip - __________________________________________________________* County - __________________________________________________________Home vVsiting Program Type (Select all that apply)Early Head Start – Home Based Option (EHS)Healthy Families America (HFA)Nurse-Family Partnership (NFP)Parents as Teachers (PAT)Date of Enrollment – __ __ / __ __ / __ __ __ __ (MM/DD/YYYY)Birth Date – __ __ / __ __ / __ __ __ __ (MM/DD/YYYY)Relationship to ChildBiological MotherOther Female CaregiverBiological FatherOther Male Caregiver* Pregnancy StatusCurrently pregnant (_____ weeks)Not currently pregnantEstimated Date of Delivery – __ __ / __ __ / __ __ __ __ (MM/DD/YYYY)Race (Select all that apply)American Indian or Alaska NativeAsianBlack or African-AmericanNative Hawaiian or Other Pacific IslanderWhiteEthnicityHispanic or LatinoNot Hispanic or Latino* Marital StatusNever marriedMarriedNot Married but Living Together with PartnerSeparated/Divorced/Widowed* Educational Attainment (highest level)Less than HS diplomaHS Diploma / GEDSome college/trainingTechnical training or certificationAssociate’s degreeBachelor’s degree or higherOther (please specify: _____________________)* Educational StatusStudent/traineeNot a student/trainee* Employment StatusFull-time (37+ hours per week)Part-time (Less than 36 hours per week)Not employed* Housing StatusNot HomelessOwns or shares own home, condominium, or apartmentRents or shares own home or apartmentLives in public housingLive with parent or family memberSome other arrangementHomelessHomeless and sharing housingHomeless and living in an emergency or transitional shelterSome other arrangement* Total Number of People in the Household – _____* Household IncomeLess than or equal to $6000$6,001 – $12,000$12,001 – $20,000$20,001 – $30,000$30,001 – $40,000Over $40,000Refused to respond* Health Insurance StatusNo Insurance CoverageNot eligibleOther (please specify: __________)Medicaid or CHIPTri-CarePrivateOther (please specify: _____________________)Measure 15: Primary Caregiver Education* Have you enrolled in, maintained continuous enrollment in, or completed a high school degree or equivalent?YesNoDemographics: Exit (index children)* Required*First Name - __________________________________________________________Middle Name - __________________________________________________________*Last Name - __________________________________________________________* Date of Exit – __ __ / __ __ / __ __ __ __ (MM/DD/YYYY)* Reason for Exit (Select all that apply)Child no longer in family’s custody (parental rights terminated)Client received what s/he needs from the programCompleted programDissatisfied with programExcessive missed appointment/attempted visitsHome visitor resigned; refused new home visitorChild deathMoved out of service areaPressure from familySafety of the home visitorUnable to contact/Unable to locateEnrolled in another programClient returned to work or schoolOther (please specify: __________________)Demographics: Exit (primary caregiver)* Required* First Name - __________________________________________________________Middle Name - __________________________________________________________* Last Name - __________________________________________________________* Date of Exit – __ __ / __ __ / __ __ __ __ (MM/DD/YYYY)* Reason for Exit (Select all that apply)Child no longer in family’s custody (parental rights terminated)Client received what s/he needs from the programCompleted programDissatisfied with programExcessive missed appointment/attempted visitsHome visitor resigned; refused new home visitorMiscarried/fetal death/child deathMoved out of service areaPressure from familySafety of the home visitorUnable to contact/Unable to locateEnrolled in another programClient returned to work or schoolOther (please specify: __________________)Measure 15: Primary Caregiver Education* Have you enrolled in, maintained continuous enrollment in, or completed a high school degree or equivalent?YesNo ................
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