"A federal agency may not conduct or sponsor, and a person is not required
to respond to, a collection of information unless it displays a currently
valid OMB control number. Public reporting burden for this collection of
information is estimated to vary from 30 to 60 minutes with an average of 45
minutes per response, including time for reviewing instructions, searching
existing data sources, gathering and maintaining the necessary data, and
completing and reviewing the collection of information. Send comments
regarding the burden estimate or any other aspect of this collection of
information to the ACF Reports Clearance Officer, [GET ADDRESS FOR ACF CLEARANCE OFFICER]
Table of Contents
Confidentiality Script 3
Background 4
Child Welfare History 5
Household of Origin 11
Termination of Parental Rights 12
Educational Status/Special Education 14
Alcohol and Drug 16
Emotional, Behavioral, or Attention Problem 18
Life Skills 20
Educational Support Services 21
Employment 22
Budget and Financial Management Training 24
Housing Services 25
Health and Health Education Services 27
Youth Development Services 29
Worker Assessment of Youth Preparedness for Independence 30
Worker Information 31
Other Persons Knowledgeable About Youth 33
Confidentiality Script
We are asking you to complete this survey as part of the Multi-site Evaluation of Foster Youth Programs. {Name of site}is one of four sites that is participating in this evaluation which is seeking to assess the impact of independent living services on foster youth. Your participation is voluntary, but we hope that you will agree so that the results for {name of site}are complete and accurate. This survey will require approximately one hour to complete. The survey seeks information about [name of youth], a foster child which records show is on your caseload. <Name of youth> is participating in the evaluation. We are seeking information about this child’s child welfare history, assessments completed, and services received. We will refer to this child as the “target youth.” That simply means many of our questions are about him or her, so please keep this youth in mind when answering the questions. It may be helpful if you refer to the case record in responding to these questions. Please be assured that your responses today will be grouped together with responses of other caseworkers and will not be attributed to you individually. The confidentiality of the youth will always be protected. Their names will not be identified in any documents produced.
In addition to yourself, there may be other caseworkers who have knowledge of the target youth. This may include another child welfare caseworker, an independent living program specialist, or a (or another) private agency caseworker. Please answer as many questions as you can. If after completing the survey you believe that another person or persons are needed to respond to certain questions or sections of this survey, please identify them in the space provided at the end of the survey.
Background (B)
B1. Please fill in today’s date: ___ /___ /___ (auto entry when worker signs on to complete survey)
B2. Name of agency: _________________________________________________________
B3. Please fill in your name: ___________________________________________________
B4. When were you assigned to this youth’s case?__/__/__
If exact date unknown, approximately how long have you been the assigned caseworker for this youth?
_____ years _____ months
B5. What has been the frequency of contact with the youth during the past year (or since the time at which you were assigned to be this youth’s worker)?
1 = more than twice a week
2 = twice a week
3 = once a week
4 = twice a month
5 = once a month
6 = less than once a month
B6. If you are not the first worker assigned to this youth, how many previous workers has this youth had?
______
9 = don’t know/not in case record
Child Welfare History (CWH)
CWH1. What was the primary reason for initial entry into out-of-home care (check one)?
1 = Child abuse or neglect (e.g., CHIPS)
1a = physical abuse
1b = sexual abuse
1c = neglect (e.g., abandonment, physical neglect, medical neglect)
2 = Child Dependency (e.g., CHINA (Child In Need of Assistance) /PINS (person in need of supervision))
3 = Juvenile Justice Issue
3a = Juvenile Delinquency
3b = Status Offense (e.g., JIPS (Juvenile In Need of Protective Services)
4 = Voluntary Placement Agreement
4a = Mental Health
4b = Developmental Disability
4c = Other Reason __________________________________
5 = Tribal ICWA case
6 = Other (specify:_____________________)
CWH2. What types of substantiated maltreatment contributed to this youth’s entry into care?
1= Physical abuse
2 = Physical neglect
3 = Sexual abuse
4 = Abandonment
5 = Runaway
6 = Parent-child conflict
7 = Medical neglect
8 = Emotional abuse
9 = Lack of supervision
10 = Other (specify:_______________________)
CWH3. Was drug or alcohol abuse (of either a parent or caretaker) a factor in this youth’s entry into out-of-home care?
1 = yes
2 = no
3 = don’t know/not in case record
CWH4. What agency was the point of entry for the youth into out-of-home care (check one)?
1 = Child Welfare Agency
2 = Juvenile corrections/Probation
3 = Mental Health Agency
4 = Other (specify:____________________)
CWH5. What was the date of the youth’s first entry into out-of-home care?
___/___/___
If exact date unknown, approximately how long ago was this youth’s first entry into out-of-home care?
_____ years _____ months
CWH6. What is the youth’s current placement type (check one)?
1 = Reunified with parent or caretaker (include trial reunification) {skip to CWH10}
2 = Unrelated family foster home
3 = Kinship/relative home
4 = Supervised Independent Living arrangement
5 = Group home
6 = Residential care facility/residential treatment center
7 = Inpatient psychiatric hospital
8 = Adoptive home (include pre-adoptive placement) {skip to CWH10}
9 = Guardianship placement {skip to CWH10}
10= Emancipated {skip to CWH10}
11= Runaway
12= Other (Specify: ______________________________________){skip to CWH10}
CWH7. On what date did the most recent out-of-home care placement episode start?
___ /___ /___
If exact date unknown, approximately how long ago did the most recent placement episode start?
_____ years _____ months
CWH8a. Does youth have any siblings?
1 = yes
2 = no
3 = don’t know/not in case record
CWH8b. {If CWH8a = yes} Are any of the youth’s siblings placed out-of-home?
1 = yes
2 = no
3 = don’t know/not in case record
4 = not applicable/youth has no siblings
CWH9. {If CWH8b = yes} Are any siblings placed with this youth in the same setting?
1 = yes
2 = no
3 = don’t know/not in case record
CWH10. {If not in out-of home care, CWH6=1, 8, 9, 10, or 12} On what date did the youth leave his or her most recent placement?
___ /___ /___
If exact date unknown, approximately how long ago did the youth leave most recent placement?
_____ years _____ months
CWH11. How many out-of-home placements has this youth had since he/she first entered care?
_______
9 = don’t know/not in case record
CWH12. What type of placements has this youth been in? (check all that apply)
1 = Foster home
2 = Kinship placement/relative
3 = Supervised independent living arrangement
4 = Group home
5 = Residential child care facility/residential treatment center
6 = Inpatient psychiatric hospital
7 = Adoptive home (include pre-adoptive placement)
8 = Guardianship placement
9= Runaway
10= Other (Specify: ________________________________________________)
CWH13. Has paternity been established for this youth?
1 = yes
2 = no {skip TPR3 and TPR4}
3 = don’t know/information not in case record {skip TPR3 and TPR4}
CWH14. {Skip if CWH6=1) Has the youth ever been reunified with his/her parents {Survey directions: include presumed fathers and do not count short trial visits}?
1 = yes
2 = no
9 = don’t know/information not in case record
If yes, how many times has youth been reunified with his/her parents?
____
CWH15. {Skip if CWH6=8} Has the youth ever been placed in a pre-adoptive home?
1 = yes
2 = no
9 = don’t know/information not in case record
If yes, how many times was youth placed in a pre-adoptive home?
____
If yes, did an adoption placement ever disrupt prior to finalization?
1 = yes
2 = no
9 = don’t know/information not in case record
If yes, how many years ago?
____
If yes, was an adoption ever finalized?
1 = yes
2 = no
9 = don’t know/information not in case record
If yes, did a finalized adoption ever terminate?
1 = yes
2 = no
9 = don’t know/information not in case record
If yes, how many years ago?
____
CWH16a. Is this youth pregnant (if female)?
1 = yes
2 = no
9 = don’t know/information not in case record
CWH16b. Is this youth a parent?
1 = yes
2 = no
9 = don’t know/information not in case record
If yes, does the youth live with his/her child (or children)?
1 = yes
2 = no
9 = don’t know/information not in case record
If yes, have there been any child protective services reports on the youth’s child (or children)?
1 = yes
2 = no
9 = don’t know/information not in case record
CWH17. At this point in time, what is the youth’s primary permanency goal?
1 = Reunification
If reunification, what do you think the chances are that the youth will be reunified?
1a = Very likely
1b = Somewhat likely
1c = Somewhat unlikely
1d = Very unlikely
1e = Don’t know/information not in case record
2 = Foster care by relative
3 = Foster care by non-relative
4 = Guardianship by relative
5 = Guardianship by non-relative
6 = Adoption by relative
7 = Adoption by non-relative
8 = Independent living
8a. When did independent living become this youth’s permanency goal? ___ /___ /___
If exact date unknown, approximately how long has this youth’s permanency goal been independent living?
____ years ____ months
9 = Goal not yet established
10 = Other (Specify: ___________________)
11 = Don’t know/information not in case record
HO1. Immediately prior to placement, with whom did the youth live? {check all that apply}
1 = Birth mother
2 = Birth father {or presumed birth father if CWH13 = 2 or 3}
3 = Step or adoptive parent
4 = Partner of mother or father
5 = Other adult relatives
6 = Siblings
7 = Other (specify:____________________________)
9 = don’t know/not in case record
HO2. What is the current age of the youth’s birth mother?
___years
9 = don’t know/not in case record
HO3. What is the current age of youth’s birth father {or presumed birth father if CWH13=2 or 3}?
____years
9 = don’t know/not in case record
TPR1. Has the birth mother relinquished her parental rights (terminated with consent) or had her rights terminated (terminated without consent) on this youth?
1 = Yes, birth mother relinquished parental rights
2 = Yes, birth mother had parental rights terminated
3 = No, birth mother still has parental rights {skip to TPR3}
4 = Don’t know/information not in case record {skip to TPR3}
5 = Not applicable, birth mother deceased {skip to TPR3}
TPR2. When were parental rights either relinquished or terminated for the birth mother?
___/___/___
If exact date is unknown, approximately how long ago were parental rights relinquished/terminated?
____ years ____ months
9 - don’t know/information not in case record
TPR3. Has the birth father relinquished his parental rights (terminated with consent) or had his rights terminated (terminated without consent) on this youth?
1 = Yes, birth father relinquished parental rights
2 = Yes, birth father had parental rights terminated
3 = No, birth father still has parental rights {skip to next section}
4 = Don’t know/information not in case record {skip to next section}
5 = Not applicable/birth father deceased {skip to next section}
TPR4. When were parental rights either relinquished or terminated for the birth father?
___/___/___
If exact date is unknown, approximately how long ago were parental rights relinquished/terminated?
____ years ____ months
9 - don’t know/information not in case record
Educational Status/Special Education (Ed)
ED1. Is the youth currently enrolled in school?
1 = Yes
2 = No
9 = don’t know/information not in case record
IF YOU ANSWERED YES TO QUESTION ED1:
a. What is the youth’s current grade or grade equivalent?
1 = 7
2 = 8
3 = 9
4 = 10
5 = 11
6 = 12
7 = Other (specify:_______________________)
9 = don’t know/information not in case record
IF YOU ANSWERED NO TO QUESTION ED1:
a. What was the last grade or grade equivalent completed?
1 = 7
2 = 8
3 = 9
4 = 10
5 = 11
6 = 12
7 = Other (specify:______________________)
9 = don’t know/information not in case record
b. What was the youth’s highest educational certificate received?
1 = None
2 = GED
3 = High School Equivalency Degree
4 = High School Degree
5 = Vocational Certificate
6 = AA
7 = Other (specify:_________________________)
9 = don’t know/information not in case record
ED3. In the past 12 months has [target youth] received an Individualized Education Plan (IEP)?
1 = yes
2 = no
9 = don’t know/information not in case record
IF YOU ANSWERED NO TO QUESTION ED3:
ED3a. Why was this service not received? [code all that apply]
1 = service not needed
2 = service not available in the area
3 = child is wait-listed for service
4 = child is ineligible for services
5 = services could not be financed
6 = child refused
7 = caregiver refused
8 = scheduling problem
9 = transportation problem
10 = other (specify:________________________)
99 = don’t know/information not in case record
AoD1. Was a formal assessment done for an alcohol problem?
1 = yes
2 = no
9 = don’t know/information not in case record
AoD1a. In the past 12 months did [target youth] receive services for an alcohol problem?
1 = yes
2 = no
9 = don’t know/information not in case record
IF YOU ANSWERED NO TO QUESTION AoD1a:
AoD2. Why was this service not received? [code all that apply]
1 = service not needed
2 = service not available in the area
3 = child is wait-listed for service
4 = child is ineligible for services
5 = services could not be financed
6 = child refused
7 = caregiver refused
8 = scheduling problem
9 = transportation problem
10 = other (specify:_________________________)
99 = don’t know/information not in case record
AoD3. Was a formal assessment done for a drug problem?
1 = yes
2 = no
9 = don’t know/information not in case record
AoD3a. In the past 12 months did [target youth] receive services for a drug problem?
1 = yes
2 = no
9 = don’t know/information not in case record
IF YOU ANSWERED NO TO QUESTION AoD3a:
AoD4. Why was this service not received? [code all that apply]
1 = service not needed
2 = service not available in the area
3 = child is wait-listed for service
4 = child is ineligible for services
5 = services could not be financed
6 = child refused
7 = caregiver refused
8 = scheduling problem
9 = transportation problem
10 = other (specify:__________________________)
99 = don’t know/information not in case record
Emotional, Behavioral, or Attention Problem (EBA)
EBA1. Was a formal assessment done for an emotional, behavioral, or attention problem? This would have been done by a psychologist or a medical professional at school or some other place?
1 = yes
2 = no
9 = don’t know/information not in case record
EBA1a. In the past 12 months did [target youth] receive services for an emotional, behavioral, or attention problem?
1 = yes
2 = no
9 = don’t know/information not in case record
IF YOU ANSWERED NO TO QUESTION EBA1a:
EBA2. Why was this service not received? [code all that apply]
1 = service not needed
2 = service not available in the area
3 = child is wait-listed for service
4 = child is ineligible for services
5 = services could not be financed
6 = child refused
7 = caregiver refused
8 = scheduling problem
9 = transportation problem
10 = other (specify:____________________________)
99 = don’t know/information not in case record
IF YOU ANSWERED YES TO QUESTION EBA1a:
EBA3. In the past 12 months, did [target youth] receive any of the following services? [check all that apply]
1 = Individual Therapy
2 = Group Therapy
3 = Crisis Counseling
4 = Family Therapy
5 = Non-medical support groups
6 = Inpatient Psychiatric Services
7 = Other (specify:__________________________)
EBA4. At the present time, does youth routinely take any type of prescription medication for mental health related issues?
1 = yes
2 = no {skip to EBA6}
9 = don’t know/information not in case record
EBA5a. For what purpose does youth take prescription medicine? {check all that apply)
1 = ADD, ADHD (e.g., Ritalin )
2 = anti-psychotic (e.g., Haldol, Lithium)
3 = anti-depressives/anti-anxiety (e.g., Prozac, Paxil, Zoloft)
4 = other (specify:____________________________)
EBA5b. Has a physician ever assigned this youth with a mental health or emotional diagnosis?
1 = yes
2 = no {skip to LS1}
9 = don’t know/information not in case record
EBA5c. If yes, what was the category of that diagnosis?
1 = anxiety/depression
2 = bipolar disorder
3 = ADD/ADHD
4 = attachment disorder
5 = oppositional defiant disorder
6 = conduct disorder
7 = other (specify:____________________________)
EBA6. If EBA4 = no, has he/she ever taken such medication in the past?
1=yes
2=no {skip to LS1}
EBA7. For what purposes did youth take prescription medicine? {check all that apply)
1 = ADD, ADHD (e.g., Ritalin)
2 = anti-psychotic (e.g., Haldol, Lithium)
3 = anti-depressives/anti-anxiety (e.g., Prozac, Paxil, Zoloft)
4 = other (specify:____________________)
Life Skills (LS)
LS1. Was a Life Skills Assessment completed for the youth?
1 = Yes
2 = No
9 = don’t know/information not in case record
LS1a. At what age was the assessment completed?
1 = 15 years old
2 = 16 years old
3 = 17 years old
9 = don’t know/information not in case record
IF YOU ANSWERED NO TO QUESTION LS1:
LS1b. Why was a Life Skills Assessment not completed?
1 = Youth refused
2 = Youth unable to complete assessment
3 = Social worker did not recommend as part of plan
4 = Other (specify:________________________)
9 = don’t know/information not in case record
LS2. In the past 12 months did [target youth] receive life skills training?
1 = yes
2 = no {Skip to next section}
9 = don’t know/information not in case record {Skip to next section}
LS3. What is the name of the life skills training program or provider?
____________________________________________________________
Which of the following skills does the training focus on: {check all that apply}
1 = Budgeting/money management
2 = Job seeking and retention
3 = Further education
4 = Meal planning and preparation
5 = Housekeeping/laundry
6 = Obtaining health care
7 = Obtaining housing
8 = Problem solving
9 = Anger management
10 = Developing interpersonal relationships
11 = Knowledge of community resources and supports
12 = Knowledge of human sexuality and family planning
13 = Other (specify:___________________________________)
Educational Support Services (ES)
ES1. In the past 12 months, did [target youth] receive any of the following educational support services? [check all that apply]
1 = Career Counseling
2 = Help With Homework
3 = Study Skills Training
4 = Literacy Training
5 = Assistance With Accessing Educational Resources
6 = School To Work Support
7 = Assistance With Applying/Studying For GED Examination
8 = GED Preparation
9 = SAT Preparation/PSAT preparation
10 = Assistance With College Counseling
11 = Assistance With College Application
12 = Assistance With Financial Aid/Loan Application
13 = University/College Fairs
14 = Other (specify:_____________________________)
99 = N/A, youth already received services (prior to 12 months ago)
ES1a. Please list the name of the programs/providers youth have received educational support services from.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Employment (EM)
EM1. Is the youth currently employed?
1=Yes
2=No
9=Don’t know/information not in case record
IF YOU ANSWERED YES TO QUESTION EM1:
Approximately how many hours per week?
_____ hours
99 = Don’t know/information not in case record
IF YOU ANSWERED NO TO QUESTION EM1:
Was the youth ever employed?
1 = Yes
2 = No (skip to EM3)
9 = Don’t know/information not in case record (skip to EM3)
Approximately how many hours per week was the youth employed during the most recent period of employment?
_______ hours
9 = Don’t know/information not in case record
EM3. If pregnant or parenting teen {question CWH15=1} In the past 12 months, did agency staff refer [target youth] for day care services?
1 = yes
2 = no
9 = don’t know/information not in case record
EM4. In the past 12 months, did [target youth] receive any of the following employment and training services? [check all that apply]
1 = Vocational/Career Counseling
2 = Resume Writing Workshop
3 = Assistance With Identifying Potential Employers
4 = Assistance With Completing Job Application
5 = Developing Interviewing Skills
6 = Job Referral/Placement
7 = Use of Career Resource Library
8 = Explanation of Benefits Coverage
9 = Securing Work Permits/ Social Security Cards
10 = Explanation of Workplace Values (i.e., attendance, timeliness, customer relations))
11 = Occupational Skills Courses
12 = Internships/Work Study
13 = Summer Employment Programs
14 = Job Corps
15 = Other (specify:______________________________)
99 = N/A, youth already had services (prior to 12 months ago)
EM6a. Please list the name of the programs/providers youth have received employment services from.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Budget and Financial Management Training (BFM)
BFM1 In the past 12 months, did [target youth] receive any of the following budget and financial management services? [check all that apply]
1 = Money Management Courses
2 = Assistance With Completing Tax Returns
3 = Training On Use of a Budget
4 = Training on Opening a Checking and Savings Account
5 = Training on Balancing a Checkbook
6 = Developing Consumer Awareness
7 = Accessing Information on Credit, Consumer credit counseling
8 = Other (specify:____________________________-)
99 = N/A, youth already received services (prior to 12 months ago)
BFM1a. Please list the name of the programs/providers youth have received budget and financial management services from.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
HS1. In the past 12 months, did [target youth] receive any of the following housing services? [check all that apply]
1 = Assistance With Finding An Apartment
2 = Financial Assistance Available to Help Youth Pay for Rent
3 = Help With Completing Apartment Application
4 = Learning About Security
5 = Deposits and Utilities
6 = Handling Landlord Complaints
7 = Training on Health and Safety Standards
8 = Training on Tenants Rights and Responsibilities
9 = Cooking Classes
10 = Cleaning Classes
11 = Courses on Home Maintenance and Repairs
12 = Courses on Meal Planning or Learning About Grocery Shopping
13 = Other (specify:____________________________)
99 = N/A, youth already received services (prior to 12 months ago)
HS1a. Please list the name of the programs/providers youth have received housing services from.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
HS2. In that past 12 months, have agency staff refer [target youth] to a supervised living, scattered site apartment, of housing program that allows youth to live independently?
1 = yes
2 = no
9 = don’t know/information not in case record
IF YOU ANSWERED NO TO QUESTION HS2:
HS2a. Why was a referral not made?
1 = child was already receiving/has already services
2 = child does not need services
3 = child too young for services
4 = child not prepared to live independently
5 = service not available in the area
6 = child is not eligible for service
7 = services could not be financed
8 = other (specify:_________________________)
9 = don’t know/information not in case record
Health and Health Education Services (H)
H1. Does [target youth] currently receive Medicaid?
1 = yes
2 = no
9 = don’t know/information not in case record
H2. At any time in the last 12 months, did agency staff work to get [target] signed up for Medicaid?
1 = yes
2 = no
9 = don’t know/information not in case record
H3. In the past 12 months, did [target youth] receive any of the following services? [check all that apply]
1 = routine medical check-ups (i.e., vaccinations)
2 = [female youth only] routine gynecological exams
3 = routine eye exams
4 = hearing screens
5 = other (specify:______________________)
H4 In the past 12 months, did [target youth] receive any of the following services? [check all that apply]
1 = Training on Personal Care Needs (Basic Hygiene)
2 = Training on Nutritional Needs
3 = Training on Health/Fitness
4 = Training on Preventive and Routine Healthcare
5 = Accessing Information About Health/Dental Insurance
6 = Courses on First Aid, Maintaining Personal Health Records
7 = Education on Sexual Development
8 = Information on Birth Control and Family Planning
9 = Information on STD's and AIDS
10 = Education on Substance Abuse
11 = Training in Communication and Discipline Strategies
12 = Parent Aid Services
13 = Support Groups For Teen Parents
14 = Prenatal Care Instruction
15 = Other (specify:_______________________________)
99 = N/A, youth already received services (prior to 12 months ago)
H4a. Please list the name of the programs/providers youth have received health and health education services from.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
H5. Does youth have any acute or chronic health problem that may limit or impede his/her education or employment?
1= yes
2=no {skip to next section}
H6. What type(s) of acute or chronic health problems does youth have? {check all that apply)
AIDS/HIV
Asthma
Blindness/impaired vision
Cancer
Cerebral Palsy
Cystic Fibrosis
Deafness/impaired hearing
Developmental delays
Diabetes
Epilepsy
Heart problems
Other (specify:__________)
Youth Development Services (YD)
YD1. In the past 12 months, did [target youth] receive or participate in any of the following services? [check all that apply]
1 = Youth Conferences
2 = Youth Leadership Activities
3 = Mentoring
4 = Other (specify:________________________)
YD2. How connected do you feel the youth is to. . .
|
Not at all connected |
Somewhat connected |
Well connected |
Don’t know |
|
Church |
1 |
2 |
3 |
DK |
|
Friends |
1 |
2 |
3 |
DK |
|
Foster family |
1
|
2 |
3 |
DK |
NA |
Group home residents/staff |
1 |
2 |
3
|
DK |
NA |
School |
1 |
2 |
3 |
DK |
NA |
Sports (team, coach) |
1 |
2 |
3 |
DK |
|
Mentors (e.g., CASAs, Guardian ad litem, Big Brother/Big Sister |
1 |
2 |
3 |
DK |
|
Worker Assessment of Youth Preparedness for Independence(WA)
WA1. How prepared do you feel the youth is for living on his/her own in the future?
1= Not at all prepared
2= Minimally prepared
3= Somewhat prepared
4= Well prepared
5= Very well prepared
WA2. What are the youth’s personality strengths? {check all that apply}
1 = Intelligent
2 = Hard working
3 = Creative
4 = Mature
5 = Empathetic
6 = Other (specify:_____________________________)
7 = don’t know youth well enough to answer
WA3. What are the youth’s other strengths? {check all that apply}
1= ability to develop friendships
2 = use of community or social supports
3 = use of family supports
4 = other (specify:_____________________________)
5 = don’t know youth well enough to answer
WI1. Are all/most of the children on your caseload youth, or are you assigned children of all ages?
1=All/mostly youth
2=Children of all ages
WI1a. Do all/most of the youth on your caseload have a goal of independent living?
1=yes
2=no
WI2. How many years have you been in the child welfare field?
1 = 0-5 years
2 = 6-10 years
3 = 11-15 years
4 = 16-20 years
5 = More than 20 years
WI3. What is your highest level of education?
1 = high school diploma
2 = some college, no degree
3 = B.S.W.
4 = B.A. or B.S. (other than social work)
5 = M.S.W.
6 = Master's degree (other than social work)
7 = Ph.D.
8 = Other (specify: _________________)
WI4. What is your gender?
1 = Female
2 = Male
WI5. WI5. What option below best describes your ethnicity? MARK ONE
HISPANIC OR LATINO
NOT HISPANIC OR LATINO
DK
What is your race? MARK ALL THAT APPLY
1 American Indian or Alaska Native
2 Asian
3 Black or African American
4 Native Hawaiian or Other Pacific Islander
5 White
6 DK
Please list the names of other persons you think are knowledgeable about the youth who may be better able than you to answer questions asked in this survey. Please provide their name, contact information, and the section or sections you believe they can answer,
Name_________________________________
Adress________________________________
_______________________________
_______________________________
Phone: ( ) -
Email:
Section(s) person can answer:______________
Name_________________________________
Adress________________________________
_______________________________
_______________________________
Phone: ( ) -
Email:
Section(s) person can answer:
Household of Origin
Termination of Parental Rights
Educational Status/Special Education
Alcohol and Drug
Emotional, Behavioral, or Attention Problem
Life Skills
Educational Support Services
Employment
Budget and Financial Management Training
Housing Services
Health and Health Education Services
Mental Health/Emotional Well-being Services
Youth Development Services
Worker Assessment of Youth Preparedness for Independence
| File Type | application/msword |
| File Title | Outline of Survey Sections |
| Author | Karin Malm |
| Last Modified By | KMalm |
| File Modified | 2006-07-28 |
| File Created | 2006-06-05 |