M13-THEO

MIECHV Baby’s Age 18 Months

Index Parent

Name of Home Visitor:

Home Visiting Program:	Early Head Start	Healthy Families Oregon

Parent ID #:

Name of Index Parent:

Date data gathered: / / 20

Pregnancy:

A. Enter in M13 Survey: Mother Currently Pregnant? Yes → Go to Question A1.	No

A1. Enter in THEO Pregnancy Module: If Pregnant, Expected Delivery Date: / / 20

1.	Educational Attainment:

Currently enrolled in middle school	Some college/training

Currently enrolled in high school	Associate’s degree

Less than high school diploma	Bachelor’s degree or higher

High school diploma/GED	Other:

Technical training or certification

2. In the past 6 months, were there any days when you were not covered by health insurance?

Yes	No

3.	What are the 2 most recent dates that a validated Parent-Child Interaction Tool (PICCOLO for EHS; CHEERS Check-In (CCI) Tool for HFA) was done with the Parent and Home Visitor?

a. Date of PCI: / / 20

b. Date of PCI: / / 20