4_Revised Parent Child Form (Revised)

Healthy Start Parent/Child Form | May 2024

OMB Control No. 0915-0338, Expiration Date 09/30/2026

INFORMATION IN THIS GRAY BOX IS FOR GRANTEE USE ONLY—DO NOT UPLOAD

Name of Participant/Other Adult: ______________________________ DOB:_________________

Name of Enrolled Child: ____________________________________ DOB:_________________

Name of Interviewer: __________________________________

Names and dates of birth are included above for grantee tracking purposes only and should not be submitted to HRSA.

Public Burden Statement: The purpose of this information collection is to obtain performance data for the following: HRSA grantees and cooperative agreement recipients, program operations, and reporting requirements. In addition, these data will facilitate the ability to demonstrate alignment between MCHB discretionary programs and the Healthy Start Program to quantify outcomes across MCHB. 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 information collection is 0915-0338 and it is valid until 09/30/2026. Public reporting burden for this collection of information is estimated to average 0.42 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.

INSTRUCTIONS

• This parent/child form must be completed with enrolled participants or “other adults” who have an infant or child younger than 18 months enrolled in Healthy Start; This form should be completed as soon as possible after a child’s birth into HS, or at the time of child’s enrollment into HS. Complete only one form per enrolled child.

• This form must be administered by a trained case worker or other Healthy Start grantee staff member to ensure consistency in responses across participants. It should not be self-administered or administered by staff who have not received training.

• Every form should include the participant’s/other adult’s Unique ID# (UID) in Question G1. Each person’s UID should remain the same across phases and years of participation in the program and should be in the format noted in Question G1. The enrolled child’s Unique ID# (ECUID) must be entered in Question G2.

• If the participant/other adult has more than one child younger than 18 months enrolled in HS, a Parent/Child form must be completed for each child.

• If there is more than one enrolled participant in the family unit, the UIDs must appear together on this form so that all associated participants can be linked in the database to the enrolled child. Participant linkages are made using Question G3 of this form.

See the next page for additional instructions.

When to complete this form

• For enrolled case management/care coordination (CM/CC) participants (an individual who is enrolling, or is already enrolled in Healthy Start for case management/care coordination services):

  • If the participant has a child younger than 18 months of age enrolled/enrolling in HS, complete this form when an individual first enrolls in the Healthy Start program.

  • If the participant is pregnant at the time of enrollment, complete this form as soon as possible after a child’s birth into HS.

  • Update/re-screen this form when the enrolled child turns 6 months, 12 months, and when the child exits the Healthy Start program.

• For “other adults” (individuals not enrolled in Healthy Start who have primary responsibility for/custody of an enrolled child):

  • Complete this form when the child first enrolls in the Healthy Start program.

  • Update/re-screen this form when the enrolled child turns 6 months, 12 months, and when the child exits the Healthy Start program.

How to update/re-screen this form

• Re-screen this form at three key milestones:

  • Enrolled child turns 6 months – when an enrolled participant’s/other adult’s enrolled child turns 6 months of age.

  • Enrolled child turns 12 months – when an enrolled participant’s/other adult’s enrolled child turns 12 months of age.

  • Enrolled participant is exiting Healthy Start – when a participant “graduates” or otherwise voluntarily ends participation in the program (for example, the child turns 18 months of age).

• To perform a re-screen:

1. Select “Updated form” in Question G5.

2. Select a reason for the update from the provided list (example: “enrolled child turns 6 months”).

3. Complete the corresponding “Date of update” field by entering the date the form is being updated/re-screened.

4. Re-screen Questions 9-19 with the participant/other adult. Participants who were enrolled in HS while pregnant with this child should also re-screen questions 20 and 21.

• Other update – there are two additional scenarios that require a participant to be re-screened:

  • Updates to single questions or sections – when a staff member would like to update/re-screen a single question or section of the form (such as to add an “Other linked primary participant” in Question G3), select “Updated form” in Question G5, select “Other update” as the reason, complete the “Date of update” field by entering the date the form is being updated, and re-screen the applicable question(s).

  • If a loss of the child occurs – Select “Updated form” in Question G5, select “Other update” as the reason, complete the “Date of update” field by entering the date the form is being updated, and complete Question 22 and Question 23 at the end of this form.

[GENERAL INFORMATION to be completed by staff:]

g1. This parent’s/caregiver’s Unique ID#: ______________________________________

[Enter as One Number: Grantee Org Code + PP + Client’s Unique ID (e.g., 123PP45678)]

G2. This enrolled child’s Unique ID#: ________________________________________

[Enter as One Number: Grantee Org Code + EC + Child’s Unique ID# (e.g., 123EC45678)]

G3. Other enrolled participants/“other adults” linked to this enrolled child:

(Enter up to 3 & use format in Question G1; do not enter enrolled child IDs)

• Other Linked Participant/Adult ID#: ______________________________________

• Other Linked Participant/Adult ID#: ______________________________________

• Other Linked Participant/Adult ID#: ______________________________________

- OR -

• No other participants/adults are linked to this enrolled child

G4. Date of this child’s enrollment in Healthy Start:

(Use format mm/dd/yyyy)

 Child’s Enrollment Date: ____________________

G5. This form should be treated as an…

(Select one)

• Initial form (this is the first time the form is being completed for the child)

 Date of initial form completion: _____________ (mm/dd/yyyy)

• Updated form (this form was completed for the child before and is being screened again)

Reason for update (Select one):

• Enrolled child turns 6 months

 Date of update: _____________ (mm/dd/yyyy)

• Enrolled child turns 12 months

 Date of update: _____________ (mm/dd/yyyy)

• Enrolled participant/child is exiting Healthy Start

 Date of update: _____________ (mm/dd/yyyy)

• Other update

 Date of update: _____________ (mm/dd/yyyy)

(ADMINISTRATIVE) Check the box below if this form is a correction to a version already uploaded to the Healthy Start Monitoring and Evaluation Data System (HSMED). Otherwise, leave this box blank.

• This form is a correction.

[Staff – Please read the following statement to the participant:]

Thank you for participating in the Healthy Start program. The purpose of these forms is to examine how well the Healthy Start program is meeting its goals of helping families improve their health and the health of their babies. This questionnaire should take about 25 minutes to complete. Any information you provide will be kept confidential. You do not have to answer any questions you do not want to, and you can end the interview at any time without any penalty or loss of benefits.

THE CHILD: Setting the Stage

This questionnaire is used to collect health information about your enrolled child. If you were enrolled in Healthy Start while pregnant with this child, I will also ask you a few questions at the end about your health around the time of your child’s birth.

[Staff – If the individual has more than one enrolled child under 18 months of age, read the following statement to the participant:]

We will complete a separate form for each of your babies/children. Since you have more than one child who is less than 18 months old enrolled in Healthy Start, we ask you to focus only on one child at a time. We will then complete a separate questionnaire for each of your babies under 18 months old.

First, I’d like to start with some general background questions about your child.

1. Was your child…

(Select one)

• Part of a family enrolled for HS services before the child’s birth (i.e., ‘born into the program’)

• Part of a family enrolled for HS services within 30 days following the child’s birth

• Part of a family enrolled for HS services more than 30 days following the child’s birth

 What was your child’s age at enrollment (in months)? _____________ (# of months)

1a. What year was your child born?

(Enter the year of birth)

• __________ (yyyy)

2. What sex is listed on your child’s birth certificate?

(Select one)

• Female

• Male

• Declined to answer

3. Is your child of Hispanic, Latino/a, or Spanish origin?

(Select all that apply)

• No, not of Hispanic, Latino/a, or Spanish origin

• Yes, Mexican, Mexican American, Chicano/a

• Yes, Puerto Rican

• Yes, Cuban

• Yes, Another Hispanic, Latino/a, or Spanish origin

• Declined to answer

4. What is your child’s race?

(Select all that apply)

• White

• Black or African American

• American Indian or Alaska Native

• Asian Indian

• Chinese

• Filipino

• Japanese

• Korean

• Vietnamese

• Other Asian

• Native Hawaiian

• Guamanian or Chamorro

• Samoan

• Other Pacific Islander

• Declined to answer

Infant Health at Birth

Next, I’m going to ask you some questions about your child’s health when he/she was born.

5. How many weeks pregnant were you (was the mother) when this child was born? [Staff: Please enter number of weeks. If participant does not know number of weeks, help them calculate backwards from the baby’s original due date to determine weeks gestation at birth.]

(Select one)

• ___________ weeks

• Don’t know

• Declined to answer

6. How much did your child weigh at birth?

(Select one)

• _____________ pounds (lbs), _____________ounces (oz) [OR _____________ grams]

• Don’t know

• Declined to answer

7. Was this the only baby you were (the mother was) pregnant with at the time, or was the child part of a multiple birth, such as twins, triplets, or more?

(Select one)

• Singleton (from a pregnancy involving just one baby)

• Twins

• Triplets or more

• Don’t know

• Declined to answer

8. After delivery, was your child put in an intensive care unit (NICU)?

(Select one)

• Yes

• No

• Don’t know

• Declined to answer

Infant Health Care

These next few questions are about your child’s age and health care.

9. What is your child’s current age in months?

(Select one)

• ___________________ months [Staff: enter number of months]

• Child is less than 1 month of age

10. During the past 12 months, was this child EVER covered by ANY kind of health insurance or health coverage plan?

(Select one)

• Yes, this child was covered all 12 months

• Yes, but this child had a gap in coverage

• No

• Don’t know

• Declined to answer

11. What kind of health insurance is your child covered by now?

(Select all that apply)

	Insurance Type	Participant’s Response(s)
a.	Private health insurance from my job or the job of my husband or partner
b.	Private health insurance from my parents
c.	Private health insurance from the <State> Health Insurance Marketplace or <state website> or HealthCare.gov
d.	Medicaid (Title XIX) (Specify state Medicaid name: ____________________________________)
e.	Medicare (for youths with end stage renal disease diagnosis)
f.	CHIP (Title XXI)
g.	Subsidized ACA plan (also called ‘subsidized premium or subsidized coverage through the Affordable Care Act’)
h.	TRICARE or other military health care
i.	Indian Health Service or tribal
j.	Other health insurance (do not include private plans that only pay for one type of service such as family planning, accidents, or dental care.) (Specify other insurance name: __________________________________)
k.	I do not have health insurance for this child now
l.	Don’t know
m.	Declined to answer

12. How old was this child at his/her last well-child check-up?

(Select one)

• ______________ months [Staff: enter number of months]

• Child was less than 1 month of age at his/her last well-child check-up

• Declined to answer

12a. [Staff: Compare the child’s current age (Q9) with age at his/her most recent well-visit (Q12). Was this child’s last well-child visit within the AAP-recommended time frame for this child’s age (e.g., a 10 month old baby has had her 9 month visit)?]

(Select one)

• Yes

• No

• Unable to determine

[Staff: Below is the AAP-recommended schedule of well visits for the first 18 months of life for reference.]

• The first week visit (3 to 5 days old)

• 1 month old

• 2 months old

• 4 months old

• 6 months old

• 9 months old

• 12 months old

• 15 months old

• 18 months old

Infant Feeding

The next few questions are about breastfeeding.

13. Did you (or the biological mother) EVER breast feed or feed pumped breast milk to this child after delivery, even for a short period of time?

(Select one)

• Yes

• No

• Don’t know

• Declined to answer

14. Is this child currently being breastfed or fed pumped breast milk?

(Select one)

• Yes

• No

• Don’t know

• Declined to answer

15. How many months [up until the current date] was this child breastfed or fed pumped breast milk?

(Select one)

• Not at all

• Less than 1 month

• _________________ months (for mothers still breastfeeding, indicate how many months so far)

• Don’t know

• Declined to answer

16. [Staff: Was this child breastfed or fed pumped breast milk at 6 months of age?]

(Select one)

• Yes

• Not yet. Child is less than 6 months old and is currently being breastfed

• No, child was not breastfed at 6 months of age

• Don’t know or unable to determine

[Staff: If mother is currently breastfeeding, update Questions 14, 15, and 16 once she has stopped to capture the total amount of time the child was breastfed.]

Infant Sleep

[Staff: For children 12 months and older, check ‘not applicable’ in each box and move to next section.]

[For babies less than 12 months old, say:]

Next, I’m going to ask some questions about sleeping.

Good sleep habits are important to your baby’s physical health and emotional well-being. An important part of safe sleep is the place where your baby sleeps and his or her sleeping position, the kind of crib or bed, and type of mattress.

17. In which one position do you most often lay your baby down to sleep now?

(Select one)

• On his or her side

• On his or her back

• On his or her stomach

• Declined to answer

• Not applicable [child is 12 months or older]

18. In the past 2 weeks, how often has your baby slept alone in his or her own crib or bed? [Note: That is, the baby is the only person in the crib or bed; the baby’s crib or bed may be in the parent(s) room.]

(Select one)

• Always

• Often

• Sometimes

• Rarely

• Never

• Declined to answer

• Not applicable [child is 12 months or older]

19. Is your baby’s crib free of pillows, extra bedding, stuffed animals?

(Select one)

• Yes

• No

• Don’t know

• Declined to answer

• Not applicable [child 12 months or older]

End of Child Questions

• “Other adults” with custody of an enrolled child and enrolled father/partner participants: This form is now complete.

• Enrolled postpartum/interconception participants: Complete the “Pregnancy Health” section below if participant gave birth to this child.

• All individuals/participants: If child passed away, complete Q22 below.

Pregnancy Health

[Staff: Complete the following section with the participant who gave birth to this child.]

In this final section, I’d like to ask a couple questions about your pregnancy with this child.

20. The next question is about the postpartum care you may have received following your most recent delivery. Recently, doctors have been talking about what they now call ‘the fourth trimester,’ and this includes ongoing contact with an obstetric care provider (e.g., OB/GYN, nurse midwife) during the 12 weeks following labor and delivery. Postpartum care is important to ensure your ongoing health. Did you receive postpartum care from an obstetric care provider following your most recent delivery?

(Select all that apply)

• Yes, within the first 3 weeks following delivery

  • Yes, between 4 weeks and 6 weeks following delivery

  • Yes, between 7 weeks and 8 weeks following delivery

• Yes, between 9 and 12 weeks following delivery [Staff: if participant responds, “Yes, after 12 weeks,” explain that it is not considered a postpartum checkup after 12 weeks]

• Not yet, but one is already scheduled for the following date: ________________________ (use format mm/dd/yyyy)

• Not yet, specify reason:______________________________________________________

• No, I did not have a postpartum visit with an obstetric care provider within 12 weeks of the birth of my most recent child

• Don’t know

• Declined to answer

[Staff: If mother is within 12 weeks of delivery but has not yet had a postpartum visit, please update Q20 once she has either had her postpartum visit or is past 12 weeks postpartum.]

This next question asks about tobacco and nicotine use during the last three months of your pregnancy with this child.

21. During the last 3 months of your pregnancy with this child, on average, how often did you use any tobacco or nicotine products (for example, cigarettes, e-cigarettes/vapes, cigars, pipes, or smokeless tobacco)?

(Select one)

• Never

• Daily or almost daily

• Weekly

• Monthly

• Less than monthly

• Declined to answer

The Healthy Start Mandatory Parent/Child Form is Complete

Infant/Child Follow-up

[Staff – Complete Q22 and Q23 below ONLY if this enrolled child passed away.]

22. This enrolled child died:

(Select one)

• Within 0 to 27 days of life (neonatal)

• 28 to 364 days after birth (infancy)

• 12 months or older (post-infancy)

23. In what year did this enrolled child die?

(Enter the year of death)

• __________ (yyyy)

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