Caregiver Initial Information Form

OMB No:

EXPIRATION DATE:

THE PAPERWORK REDUCTION ACT OF 1995:  Public reporting burden for this collection of information is estimated to average 6 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An 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.

KIPP Caregiver Initial Information Sheet

After consent has been given, complete information for each parent/caregiver.

PERSON A (Parent in Home)			PERSON B (Person A’s Spouse/Partner)
☐ Parent living in home (preferred) If no parent living in home: ☐ Person with primary child care responsibility living in the home			☐ A’s spouse/partner living in home (preferred) If no spouse/partner of Person A living in home: ☐ Other person with child care responsibility living in home If no other child care person in home, skip this column.
1a. Age		(approximate years)	1b. Age		(approximate years)
2a. Gender ☐ Male ☐ Female			2b. Gender ☐ Male ☐ Female
3a. Person A race (select one or more) ☐ American Indian or Alaska Native ☐ Asian ☐ Black or African American ☐ Native Hawaiian or Other Pacific Islander ☐ White			3b. Person B race (select one or more) ☐ American Indian or Alaska Native ☐ Asian ☐ Black or African American ☐ Native Hawaiian or Other Pacific Islander ☐ White
4a. Person A ethnicity (select one) ☐ Hispanic or Latino ☐ Not Hispanic or Latino			4b. Person B ethnicity (select one) ☐ Hispanic or Latino ☐ Not Hispanic or Latino
5a. Person A is child’s (select one or more) Biological parent Stepparent Adoptive parent Grandparent Guardian Friend Other relative (specify) ______________ Other nonrelative (specify) ___________ Unknown/Not Available			5b. Person B is child’s (select one or more) Biological parent Stepparent Adoptive parent Grandparent Guardian Friend Other relative (specify) _______________ Other nonrelative (specify) ____________ Unknown/Not Available
6a. Person A is (select one) ☐ A single parent/person ☐ Living with spouse ☐Living with unmarried partner ☐ Other (specify) ______________________ ☐ Unknown/Not Available			6b. Person B is Person A’s (select one) ☐ Spouse ☐ Unmarried live-in partner ☐ Roomer/boarder/housemate/roommate ☐ Parent ☐ Sibling ☐ Son or daughter ☐ In-law ☐ Other relative (specify) ________________ ☐ Other non-relative (specify) ____________ ☐ Unknown/Not Available
7a. Person A current living situation (select one) ☐ House/apartment ☐ Staying with friends/family ☐ Homeless shelter/no housing ☐ Residential treatment ☐ Other (specify) _________________			7b. Person B current living situation (select one) ☐ House/apartment ☐ Staying with friends/family ☐ Homeless shelter/no housing ☐ Residential treatment ☐ Other (specify) _________________
8a. Person A education (select one) ☐ Less than high school graduate ☐ High school graduate/GED ☐ More than high school			8b. Person B education (select one) ☐ Less than high school graduate ☐ High school graduate/GED ☐ More than high school
9a. Person A current employment status (select one) ☐ Not employed ☐ Employed full-time ☐ Employed part-time or seasonally			9b. Person B current employment status (select one) ☐ Not employed ☐ Employed full-time ☐ Employed part-time or seasonally
10a. Person A financial hardship – past 12 months (select one or more) ☐ Lacked money for family clothing or shoes ☐ Lacked money to pay rent or mortgage ☐ Lacked money to buy enough food for family ☐ Used food pantry or community meal program ☐ Utilities shut off ☐ Evicted from home ☐ Moved in with family or friends ☐ Furniture, car, other belongings repossessed ☐ Homeless			10b. Person B financial hardship – past 12 months (select one or more) ☐ Lacked money for family clothing or shoes ☐ Lacked money to pay rent or mortgage ☐ Lacked money to buy enough food for family ☐ Used food pantry or community meal program ☐ Utilities shut off ☐ Evicted from home ☐ Moved in with family or friends ☐ Furniture, car, other belongings repossessed ☐ Homeless
11a. Person A history of foster care (select one) ☐ Caregiver spent time in foster care as a child ☐ Caregiver has no history of foster care			11b. Person B history of foster care (select one) ☐ Caregiver spent time in foster care as a child ☐ Caregiver has no history of foster care
12a. Person A history of trauma (Examples: community violence, domestic violence, sexual abuse/assault, severe neglect, serious emotional and psychological abuse, physical abuse, abandonment, combat-related, accidents, death of caregiver, sudden loss, witnessing violence, disasters, etc.) (select one) ☐ Yes ☐ No			12b. Person B history of trauma (Examples: community violence, domestic violence, sexual abuse/assault, severe neglect, serious emotional and psychological abuse, physical abuse, abandonment, combat-related, accidents, death of caregiver, sudden loss, witnessing violence, disasters, etc.) (select one) ☐ Yes ☐ No
13a. Person A history of psychiatric hospitalization – past 5 years (select one) ☐ Yes ☐ No			13b. Person B history of psychiatric hospitalization – past 5 years (select one) ☐ Yes ☐ No

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