Enrollment and services data: Service log entries (Appendix E)

APPENDIX E
ENROLLMENT AND SERVICES DATA ELEMENTS

RPG4 CROSS-SITE EVALUATION CASE ENROLLMENT AND CLOSURE FIELDS

Data collected at enrollment into RPG
Case Enrollment
1.

Case ID: [enter 6-digit alpha-numeric id]

2.

RPG Enrollment Date: [enter date]

3.

Referral Source: Select one.
 Child welfare agency (public or
 Hospital or clinic
private)
 Family support service agency
 Substance use treatment
 Indian/Native American Tribally
provider
Designated Organization
 Mental or behavioral health
 Self-referral/walk-in
provider
3a. Was the grantee the referring organization? Select one.
 No
 Yes
4.

Study assignment: Select one.
 Treatment group







Court
Other (specify)
Don’t know



Don’t know




Native Hawaiian or Other Pacific
Islander
White



Other [specify]

Comparison group

Individual Enrollment
Ask of each individual enrolled
5.

Individual ID: [enter 6-digit alpha-numeric id]

6.

RPG Enrollment Date: [enter date]

Provide only for individuals added after initial case enrollment
7.
8.
9.

Gender: Select one.
 Male



Female

Person Type: Select one.
 Adult



Child

Date of Birth (or due date for unborn child): [enter date]

10. Race: Select all that apply.
 American Indian or Alaska
Native




Asian
Black or African American



Not Hispanic or Latino

11. Ethnicity: Select one.


Hispanic or Latino

12. Primary Language Spoken at Home: Select all that apply.


English



Spanish

Ask of each child enrolled
13. What is the child's current primary type of residence? Select one.


Private residence



Correctional facility/prison



Group home



Treatment facility



Homeless/shelter



Other (specify)



Other (specify)

No



Don’t know

No



Don’t know

14. Who are the primary adults in household that child lives with? Select all that apply.

Skip Q14 if answer to Q13 is “Group home”


Biological mother



Other relative



Biological father



Non-relative foster parent

15. Has the child lived in the same residence for the past 30 days? Select one.


Yes



16. Is the child receiving Medicaid? Select one.


2018

Yes



DRAFT

NOT TO BE USED FOR DATA COLLECTION

RPG4 CROSS-SITE EVALUATION CASE ENROLLMENT AND CLOSURE FIELDS
Ask of each adult enrolled
17. Highest Education Level: Select one.
 Up to 8th grade
 Some high school
 High school diploma/GED





Some vocational/technical
education
Some college
Associate’s degree




Bachelor’s degree
Graduate-level schooling or
degree

18. Employment Status: Select one.
 Full-time employment
 Self-employed
 Not employed and not looking for
 Part-time employment
 Not employed but looking for work
work, or unable to work
19. Relationship Status: Select one.
 Never married
 Married
 Divorced/widowed/separated
19a. Do you have a romantic partner that you live with all or most of the time? Select one.

Only respond to Q19a if answer to Q19 is “Never Married” or “Divorced/widowed/separated”

 Yes
 No
19b. Do you live with your spouse all or most of the time? Select one.



Don’t know



Don’t know





Support from other individuals
Other (specify)
None





Support from other individuals
Other (specify)
None





Step-sibling by marriage
Cousin
Other (specify)



None of the children



No one has had care of child for
30 days



Child entered out-of-home
placement
Incarceration
(Continued) drug use
Other program noncompliance
Other (specify)

Only respond to Q19b if answer to Q19 is “Married”

 Yes
 No
20. In the past month, which sources of income have you had? Select all that apply.
 Wages/salary
 Disability/SSI
 Public assistance (TANF, WIC,
 Unemployment benefits
Food stamps/SNAP)
 Child support
 Retirement/pension/spousal
 Child’s benefits (SSI, survivor’s
survivor’s benefits
benefits)
20a. In the past month, which income source was the largest? Select one.
 Wages/salary
 Disability/SSI
 Public assistance (TANF, WIC,
 Unemployment benefits
Food Stamps/SNAP)
 Child support
 Retirement/pension/spousal
 Child’s benefits (SSI, survivor’s
survivor’s benefits
benefits)

Family Member Relationships
21. Select Focal Child: Select one from list of children in case.
22. Relationship to Focal Child: Select one.
 Biological parent
 Aunt/uncle
 Adoptive/pre-adoptive parent
 Parent’s partner
 Step-parent by marriage
 Biological sibling (including half
 Non-relative foster parent
sibling)
 Grandparent
 Adopted sibling
23. Does the focal child live with other children in the case? Select one.
 All of the children
 Some of the children
24. Select Child Well-Being Reporter: Select one.
[List of adults in case]
 Not in case
25. Select Recovery Domain Adult: Select one.
[List of adults in case]
 Not in case/don’t know
26. Select Family Functioning Adult: Select one from list of adults in case.

Data collected at exit from RPG
Case Closure
27. RPG Case Closure Date: [enter date]
28. Primary reason for Case Closure: Select one.
 Successfully completed RPG

program
 Family moved out of area

 Unable to locate
 Excessive missed

appointments/unresponsive


2018

Family declined further
participation
Transferred to another service
provider
Miscarriage or fetal/child death
Parental death

DRAFT






NOT TO BE USED FOR DATA COLLECTION

RPG4 CROSS-SITE EVALUATION CASE ENROLLMENT AND CLOSURE FIELDS
Closure Residence Update
This section updates information collected at enrollment from Questions 13, 14, 15, and 23.
29. What is the child’s current primary type of residence? Select one.
 Private residence
 Correctional facility/prison
 Treatment facility
 Homeless/shelter




Group home
Other (specify)



Other (specify)

31. Has the child lived in the same residence for the past 30 days? Select one.
 Yes
 No



Don’t know

32. Does the focal child live with other children in the case? Select one.
 All of the children
 Some of the children



None of the children



No one has had care of child for
30 days

30. Who are the primary adults in household that child lives in? Select all that apply.

Skip Q30 if answer to Q29 is “Group home”



Biological mother
Biological father




Other relative
Non-relative foster parent

Revisit Child Well-Being Reporter
This section updates who will be reporting on the child well-being instruments at exit.
33. Select Child Well-Being Reporter: Select one.
[List of adults in case]
 Not applicable

Unborn Child Update
These questions will be asked only for families that had an unborn child at the time of enrollment into RPG.
34. Has [individual ID of unborn child] been born? Select one.
 Yes
 No



Don’t know



Don’t know



Very low (less than 3 pounds 5
ounces (1500 grams))



Don’t know

34f. Did the child spend time in the Neonatal Intensive Care Unit (NICU)? Select one.
 Yes
 No


Don’t know

34a. Is the mother still pregnant with [individual ID of unborn child]? Select one.

Only respond to Q34a if answer to Q34 is “No”


Yes



No

Only ask the remaining questions if the child has been born (Q34 = Yes).
34b. Child’s date of birth: [enter date]
34c. Child’s gender: Select one.
 Male
34d. Child’s birth weight: Select one.
 Normal (5 pounds 8 ounces
(2500 grams) or more)



Female

Low (3 pounds 5 ounces (1500
grams) to 5 pounds 7.99 ounces
(2499 grams))
34e. Was the child born prematurely (less than 37 weeks gestation)? Select one.
 Yes
 No


34g. Has the child been given a diagnosis of one or more of the following conditions related to substance exposure?

Select all that apply.



Neonatal abstinence syndrome
Fetal alcohol syndrome disorder




Neither
Don’t know

34h. Was the child exposed prenatally to opiates? Select one.

Only respond to Q34h if answer to Q34g is “Neonatal abstinence syndrome”


Yes



No



Don’t know



Don’t know

34i. Was the mother receiving supervised MAT during her pregnancy? Select one.

Only respond to Q34i if answer to Q34h is “Yes”


2018

Yes



No

DRAFT

NOT TO BE USED FOR DATA COLLECTION

RPG4 CROSS-SITE EVALUATION SERVICE LOG FIELDS
1.

Date of Service [enter date]

2.

Length of service interaction[enter length in minutes]

3.

Case members in attendance [Select all that apply from list of members in the case]

4.

Location of service: Select one.

Client’s place of residence



Residential treatment facility



Other location

5.

Service provider [Select from list of grantee’s individuals providing services to families enrolled in RPG]

6.

Service Approach: Select one.

Service with individual family

7.

Service Type: Select one.

Case management or service
coordination

Support group or workshop

Therapy or counseling

Parenting training/home
visiting program

Mentoring



Service with multiple families







Screening or assessment
Medication assisted treatment
Medical care or appointment
Employment training
Academic education (child or
adult)
Housing









Transportation
Court or legal
Financial or material supports
(such as vouchers or stipends)
Child care
Other services

8.

Model or Program Name [Select all that apply from list of grantee's program models, if applicable]

9.

Service Focus Select all that apply.

Parenting skills

Child care

Family activities

Visit facilitation

Adult SUD

Discharge or recovery planning

Youth SUD prevention

Medication assisted treatment

Personal development and life
skills

Behavior management








Mental health treatment
Trauma processing
Family group decision-making
or planning
Safety planning
Financial planning
Employment training
Academic education (child or
adult)
Health education
Medical care or appointment









Housing
Transportation
Financial or material supports
(such as vouchers or stipends)
Needs assessment
Child developmental screening
Evaluation data collection
Dealing with family crisis
Court or legal
Referrals
Other







Academic education services
Life skills development
Early intervention services
Employment training
Job placement services





Legal services
Medical/health care
Other









10. Referral Type Select all that apply.

Only respond if "Referrals" is selected in Q9






SUD treatment
Therapy or counseling
Parenting skills training
Home visiting program
Housing

11. How engaged would you say the client(s) was/were on average during this service interaction?

Engaged

Somewhat engaged

Not engaged
12. Why do you think the client(s) was/were not fully engaged? Select all that apply.

Only respond to Q12 if answer to Q11 is "somewhat engaged" or "not engaged"







Client is distracted or upset about life events (i.e., a
sick child, pending child welfare case, housing
instability, etc.)
Client is tired or not feeling well
Client drug use or withdrawal
Time constraints
Client did not see the value in the content and/or
activities presented in the session

June 2018

DRAFT







Presence of other individuals interfered with session
activities
Disagreement between group members
Difficult for client to concentrate in service encounter
space (i.e., outside noise, crowded space, frequent
interruptions, etc.)
Other (Specify)

NOT TO BE USED FOR DATA COLLECTION