0704-xxxx_npsp_psa-10

OMB CONTROL NUMBER: 0704-XXXX
OMB EXPIRATION DATE: XX/XX/XXXX
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, 0704-XXXX, is
estimated to average 60 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. Send comments
regarding the burden estimate or burden reduction suggestions to the Department of
Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dodinformation-collections@mail.mil. Respondents should be aware that notwithstanding
any other provision of law, no person shall be subject to any penalty for failing to
comply with a collection of information if it does not display a currently valid OMB
control number.
Please complete the following items based on your observation of parent-child interactions
during the home visit. For each item, score the parent's use of each stated skill using the
following scale: Not Evident, Emerging, Practicing, or Mastery. Please refer to the codebook
you received during the evaluation training for item-by-item descriptions of each scale point.
Take as much time as you need to complete this survey, but only score behaviors that
happened during the home visit when the observation was conducted.
If a child is too young to complete the PSA-10, please check the box below.

▢

Child is younger than 4 months

Skip To: End of Survey If If a child is too young to complete the PSA-10, please check the box below. =
Child is younger than 4 months

What date did you administer the PSA-10? (MM/DD/YYYY)
________________________________________________________________

What is the child's birthdate? (MM/DD/YYYY)

Page 1 of 6

Communication with child
Not Evident
Words and tone
directed to child
are positive, with
praise and
encouragement.
Communication
between parent
and child is
responsive and
reciprocal
(conversational).
Parent
stimulates
appropriate
vocabulary
development.

Emerging

Practicing

Mastery

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

Parent facilitates
reading/literacy
activities with
child. Range of
time spent/week:
(Only score if
you have
asked/observed
when, how often,
and what is read,
how reading is
done.)
Language
directed to child
is frequent and
ongoing and
varied - e.g.
incorporates
extended
vocabulary,
rhyming, singing
and/or playing
language games
with child in daily
activities.

Page 2 of 6

Child management and supervision
Not Evident
Parent
expresses
realistic, age
appropriate
expectations of
behaviors of
infants and
toddlers.
Child
management
plan consistently
applied for the
purpose of
teaching child
self-control.
Parent follows
child
management
plan that's
essentially nonphysical (does
not rely on
infliction of
physical pain to
control
behavior).
Uses positive
words and tone
in child
management.
Provides for
adequate
supervision of
child at home
and in the care
of others.

Emerging

Practicing

Mastery

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

Page 3 of 6

Parent/child activities (play)

Not Evident
Interactive,
positive,
enjoyable
participation
between parent
and child.
Parent uses
appropriate
methods of
teaching child
new skills.
Expands on
child's activities
to encourage
development.
Activities with
parent and child
happen regularly
and address all
school readiness
domains.
Parent monitors
and limits
television
watching.

Emerging

Practicing

Mastery

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

Page 4 of 6

Nurturing
Not Evident

Emerging

Practicing

Mastery

Parent reads
and responds
appropriately to
child's cues.

o

o

o

o

Positive
interaction is
apparent.

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

Parent displays
empathy identifies with
and cares about
feelings of child.
Parent describes
child in positive
terms, sees
behavior as
normal,
responds
positively to
praise of child
offered by
visitor.
Feeding times
are pleasant for
both parent and
child, child is
nourished
appropriately.

Page 5 of 6

Enriched environment
Not Evident

Emerging

Practicing

Mastery

Environment is
conducive to
learning through
play.

o

o

o

o

Parent provides
space for
exploration.

o

o

o

o

Child is exposed
to a variety of
environments.

o

o

o

o

o

o

o

o

o

o

o

o

Environment is
safe.
Routines and
rituals are
present in daily
activities.

Page 6 of 6