M47-THEO

MIECHV PROGRAM EXIT

Index Parent & Index Child

Name of Home Visitor:

Home Visiting Program:	Early Head Start	Healthy Families Oregon

Parent ID #:

Name of Index Parent:

Name of Index Child:

Question A will ONLY be entered as the M47 Survey Date and as the Enrollment End Date – NOT in the M47 Survey.

A.	Date of Program Exit:	/ / 20

1.	Reason for Program Exit:

Successfully completed program

Terminated services	→ Go to Question 2a.

1a. If Terminated services, Reason:

Client returned to work or school

Client received what they need from the program

Client is receiving services from another program

Moved out of service area

Unable to locate or contact

Excessive missed appointments/attempted visits

Declined new Home Visitor

Dissatisfied with program

Pressure from family

Home Visitor resigned and no room in remaining Home Visitors’ caseload

Concern for safety of Home Visitor

Unable to serve client due to language

Unable to accommodate client’s requested schedule

Miscarried/fetal death

Child no longer in family’s custody

Client incarcerated

Client no longer interested in program

Client feels visit schedule is too much

Other Reason: