M7

MIECHV Baby’s Age 3 Months

Index Child

Name of Home Visitor:

Home Visiting Program:	Early Head Start	Healthy Families Oregon

Child ID #:

Name of Index Child:

Name of Index Parent:

Date data gathered: / / 20

Has your child had the following well-child visits?

By 1 month:	Yes	No

2 months:	Yes	No

2. How often do you place your infant to sleep on their back?

Always

Sometimes

Never

3. How often do you bed-share with your infant?

Always

Sometimes

Never

4. How often does your infant sleep with soft bedding?

Always

Sometimes

Never

5.	During a typical week, how many days do you (and/or a family member) read, tell stories and/or sing songs to your child?

0 – Not at all 1 2 3 4 5 6 7 – Every day