B4: RISE CCT Facilitator Interview (facilitator burden)

Attachment b4: RISE FACILITATOR interview

Permanent Connections Inventory Child Version

[RECORD THE AGE OF CHILD:] _____________

[NOTE: Read the following statement aloud to the CHILD:]

[For younger children, under age 8:]
In your life, has there been any adult who has been especially helpful to you?

[For older CHILDREN, age 8+:]
I’m going to ask you about people in your life who you believe are your permanent connections. Permanent connections are adults who have been helpful to you and are committed to you to be a life-long source of support. These people can be someone such as parents, relatives, foster parents, adult siblings, close friends of the family, relatives of your foster family or former foster family, coaches, teachers, or mentors.

1. Can you think of anyone like that in your life?

□ Yes (CONTINUE)

□ No (STOP)

2. Tell me the name of one of these adults?	3. What type of relationship do you have with this person? 1 = biological parent 2 = stepparent 3 = adoptive parent 4 = guardian 5 = relative (specify ________________) 6 = foster parent 7 = adult sibling 8 = fictive kin (e.g. close friend of family, relative of foster or former foster family) (specify _________________________) 9 = mentor (teacher, coach) 10 = professional (CSW, counselor, CASA) 11 = other (specify ________________)	4. What is the likelihood that this person will be a committed source of support to you throughout your life? Would you say not at all likely, a little likely, somewhat likely, or very likely? 0 = Not at all likely 1 = A little likely 2 = Somewhat likely 3 = Very likely
Person 1.		0 1 2 3
[Is there anyone else?]
Person 2.		0 1 2 3
[Is there anyone else?]
Person 3.		0 1 2 3
[Is there anyone else?]
Person 4.		0 1 2 3

[Is there anyone else?]
Person 5.		0 1 2 3

5. For each person we just talked about, how much has that person done the following?
Would you say not at all, a little, some, or a lot?

[CIRCLE RESPONSE]	0 = Not at all 1 = A little 2 = Some 3 = A lot
	Person 1	Person 2	Person 3	Person 4	Person 5
5A. Shown that s/he cares about you and what happens to you?	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3
5B. Explained things to you, told you things that you need to know, or helped you solve a problem?	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3
5C. Spent time with you?	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3
5D. Expressed support for your sexual orientation/gender identity/questioning about these issues? [if applicable]	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3

6. For each person we just talked about, how likely would it be that this person would do the following things with you? Would you say not at all likely, a little likely, somewhat likely, or very likely?

[CIRCLE RESPONSE]	0 = Not at all likely 1 = A little likely 2 = Somewhat likely 3 = Very likely
All Ages	Person 1	Person 2	Person 3	Person 4	Person 5
6A. Invite you for holiday dinner like Thanksgiving	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3
6B. Celebrate your birthday with you	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3
6C. Have you spend the weekend with them	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3
6D. Talk with you when you’re feeling bad	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3
6E. Listen to you when you’re crying	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3
6F. Be someone you could call in the middle of the night if you needed something	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3
6G. Give you a ride to a friend’s house	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3
6H. Pay for an activity you want to do like a camp or an after-school activity	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3
6I. Help you with your homework	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3
6J. Still love you when you make a mistake	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3
6K. Help you understand things about your family	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3
6L. Make you laugh	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3
6M. Take you with them to church or other spiritual events	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3
6N. Make you feel special	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3

6O. Take you with them on a vacation	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3
6P. Help you understand things about where you came from/ your family tree	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3
6Q. Make you feel loved	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3
6R. Take you with them to do something fun like go to a movie or the fair	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3
6S. Help you understand things about your culture or heritage	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3
6T. Make you feel safe just being with them	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3
All Ages	Person 1	Person 2	Person 3	Person 4	Person 5
6U. Make you feel like you have a place in the world where you belong	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3
6V. Help you see your siblings, if that was possible	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3	0 1 2 3

The Permanent Connections Inventory- youth version was developed specifically for the Permanency Innovations Initiative and the RISE project. However, some of the items found in question 6 were adapted from the Inventory of Supportive Figures by Hunter & Everson, 1990 found in Runyan, D., Dubowitz, H., English, D.J., Kotch, J.B., Litrownik, A., Thompson, R., & The LONGSCAN Investigator Group (2011). Longitudinal Studies of Child Abuse and Neglect (LONGSCAN) Assessments 0-14 [Dataset]. Available from National Data Archive on Child Abuse and Neglect Web site, http://www.ndacan.cornell.edu

_____________________________________________________________________________________Burden Statement: Public reporting burden for this collection of information is estimated to average 12 minutes. This estimate includes the time for reviewing instructions and completing 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. The OMB control number for this collection is 0970-0408and it expires XX/XX/XXXX.

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