UPDATED CMDB Field

Case Management Database Fields

Demographic and Home Visit Information: To be completed during first meeting (clients can be assigned case number so that this information does not have to be entered more than once).

FOR OFFICE USE ONLYVariable Name Question (Variable Label) Response options

(numeric, text, check box needed, etc.)

Quantified Responses

P1_Fed_ID Federal ID NumericP2_Fed_ID Federal ID NumericUGAFam_ID UGA Family ID

Project YearClusterEnrollment NumberProgram

Participant ID

Numeric, with following check boxes: (#-##-####-###-#)

Numeric (1, 2, 3, 4, 5)Numeric (01, 02, 03)NumericText (ELE or TWC)Numeric (1 or 2)

P_ID Participant ID: UGA Family ID-1 (if P1) or UGA Family ID-2 (if P2)

P1_UGASurv_ID UGA Survey (Back-up) ID: Participant 1

Numeric, with following check boxes: (#-##-##-####-###-#####)

Text (M or F)Numeric (mm)Numeric (dd)Numeric (year)TextNumeric (zip code)

P2_UGASurv_ID UGA Survey (Back-up) ID: Participant 2 (if applicable)

Numeric, with following check boxes: (#-##-##-####-###-#####)

Text (M or F)Numeric (mm)Numeric (dd)Numeric (year)

TextNumeric (zip code)

DFCS_Reg DFCS Region/ Cluster 1- Cluster 12- Cluster 23- Cluster 3

DFCS_Ref DFCS Referral 1- Reunified foster care case/Court-ordered referral (RCT eligible, if couple)2- Family preservation (closed case)3- Substantiated Closed Investigation4- Unsubstantiated Closed Investigation5- Closed Family Support Case

RelStat Relationship Status 1- Single2- Married3- Couple (> 6mth)4- Couple (< 6mth)

ParStat Parent Status 1- Expectant Parent2- New Parent (child 0-5)3- Adoptive Parent4- Foster Parent5- Kinship Caregiver6- Fictive Kin Caregiver7- Other (text)

ProgElig Program Eligibility 1- Elevate2- Elevate RCT3- Elevate Weekend Retreat4- Together We Can

ProgID Program ID (from nFORM, after enrolled)

FAMILY ENGAGEMENT SUMMARYVariable Name Question (Variable Label) Response options



Enroll_Typ Enrollment Type 1- Referral2- Self-referred3- Registered at Community event

Enroll_RefDate Enrollment: Referral Date Numeric (mm/dd/year)

Enroll_RefSrc Enrollment: Referral Source TextEnroll_SelfRefDate Enrollment: Self-referred Date Numeric

(mm/dd/year)Enroll_CE_Date Enrollment: Registered at

Community event DateEnroll_CE_Met Enrollment: Registered at

Community event Location/Person Met

LM Letter Mailed 0- No1- Yes 2- N/A (Weekend Retreat or Self-referral)

LM_Date (IF Yes) Letter Mailed Date Numeric (mm/dd/year)

InIntCall_Date Initial Intake Call Date Completed Numeric (mm/dd/year)

InIntCall_Time Initial Intake Call Time Numeric (_:_ _ AM/PM)

InIntNav Initial Intake Phone Call Completed by

Text

LM_HTR Hard to Reach Letter Mailed 0- No; 1- YesLM_HTR_Date (IF Yes) Hard to Reach Letter Mailed

DateLM_HTR_Nav (IF Yes) Hard to Reach Letter Mailed

Who Prepped/MailedLM_CO Close-Out Letter Mailed 0- No; 1- YesLM_CO_Date (IF Yes) Close-Out Letter Mailed

DateLM_CO_Nav (IF Yes) Close-Out Letter Mailed

Who Prepped/MailedPIV_Nav1 Navigator 1 TextPIV_Nav2 Navigator 2 TextPIV_OS_Date Originally Scheduled Date Numeric

(mm/dd/year)PIV_OS_Time Originally Scheduled Time Numeric (_:_ _

AM/PM)PIV_Date PIV Completed Date Numeric

(mm/dd/year)PIV_Time PIV Completed Time Numeric (_:_ _

AM/PM)PIV_XResch # of Times Rescheduled 0, 1, 2, 3+PIV_Location Location 1- Phone (PIC)

2- Home (PIV)3- Other

PIV_LocationOth Location- Other: TextP1_ProgConsDate Program Consent Date Numeric

(mm/dd/year)P1_ResConsDate Research Consent Date Numeric

(mm/dd/year)P1_CCWaivDate Childcare Waiver (if applicable) Date Numeric

(mm/dd/year)

P2_ProgConsDate Program Consent Date Numeric (mm/dd/year)

P2_ResConsDate Research Consent Date Numeric (mm/dd/year)

P2_CCWaivDate Childcare Waiver (if applicable) Date Numeric (mm/dd/year)

Hotel_Res Hotel Room Reserved 0- No; 1- YesCCare_Need Childcare Needed 0- No; 1- YesNA_Date Needs Assessment Phone Call

Completed Date(mm/dd/year)

NA_Time Needs Assessment Phone Call Completed Time

(_:_ _ AM/PM)

NA_Nav Needs Assessment Navigator TextPAE1_Date PAE (Program Attendance and

Engagement) Session 1: Date(mm/dd/year)

P1_PAE1_Attend Session 1: Attended 0- No; 1- YesP1_PAE1-FUDate Session 1: Follow-up Call Date (mm/dd/year)P2_PAE1_Attend Session 1: Attended 0- No; 1- YesP2_PAE1Followup_Date

Session 1: Follow-up Call Date (mm/dd/year)

PAE2_Date Session 2: Date (mm/dd/year)P1_PAE2_Attend Session 2: Attended 0- No; 1- YesP1_PAE2_FUDate Session 2: Follow-up Call Date (mm/dd/year)P2_PAE2_Attend Session 2: Attended 0- No; 1- YesP2_PAE2_FUDate Session 2: Follow-up Call Date (mm/dd/year)PAE3_Date Session 3: Date (mm/dd/year)P1_PAE3_Attend Session 3: Attended 0- No; 1- YesP1_PAE3_FUDate Session 3: Follow-up Call Date (mm/dd/year)P2_PAE3_Attend Session 3: Attended 0- No; 1- YesP2_PAE3_FUDate Session 3: Follow-up Call Date (mm/dd/year)PAE4_Date Session 4: Date (mm/dd/year)P1_PAE4_Attend Session 4: Attended 0- No; 1- YesP1_PAE4_FUDate Session 4: Follow-up Call Date (mm/dd/year)P2_PAE4_Attend Session 4: Attended 0- No; 1- YesP2_PAE4_FUDate Session 4: Follow-up Call Date (mm/dd/year)PAE5_Date Session 5: Date (mm/dd/year)P1_PAE5_Attend Session 5: Attended 0- No; 1- YesP1_PAE5_FUDate Session 5: Follow-up Call Date (mm/dd/year)P2_PAE5_Attend Session 5: Attended 0- No; 1- YesP2_PAE5_FUDate Session 5: Follow-up Call Date (mm/dd/year)PAE6_Date Session 6: Date (mm/dd/year)P1_PAE6_Attend Session 6: Attended 0- No; 1- YesP1_PAE6_FUDate Session 6: Follow-up Call Date (mm/dd/year)P2_PAE6_Attend Session 6: Attended 0- No; 1- YesP2_PAE6_FUDate Session 6: Follow-up Call Date (mm/dd/year)PAE7_Date Session 7: Date (mm/dd/year)

P1_PAE7_Attend Session 7: Attended 0- No; 1- YesP1_PAE7_FUDate Session 7: Follow-up Call Date (mm/dd/year)P2_PAE7_Attend Session 7: Attended 0- No; 1- YesP2_PAE7_FUDate Session 7: Follow-up Call Date (mm/dd/year)

EVALUATION ASSESSMENTSVariable Name Question (Variable Label) Response options



Jimmy, is there any way for you to set up a reminder email that can be sent to the Cluster coordinator in the Evaluation Assessments section?

P1_EA1_Typ (Evaluation) Assessment #1 1- Group2- Home Visit

P1_EA1_SchDate Assessment #1 Scheduled Date (mm/dd/year)P1_EA1_EndDate Assessment #1 Completion Date (mm/dd/year)P1_EA2_Typ Assessment #2 1- Group

2- Home VisitP1_EA2_SchDate Assessment #2 Scheduled Date (mm/dd/year)P1_EA2_EndDate Assessment #2 Completion Date (mm/dd/year)P1_EA3_Typ Assessment #3 1- Group

2- Home VisitP1_EA3_SchDate Assessment #3 Scheduled Date (mm/dd/year)P1_EA3_EndDate Assessment #3 Completion Date (mm/dd/year)P2_ EA1_Typ Assessment #1 1- Group



2- Home VisitP2_EA3_SchDate Assessment #3 Scheduled Date (mm/dd/year)P2_EA3_EndDate Assessment #3 Completion Date (mm/dd/year)P1_nfm_AppChDate (nFORM Assessments) Applicant

Characteristic (AppCh) Date(mm/dd/year)

P1_nfm_EntDate Entry Form Date (mm/dd/year)P1_nfm_ExitDate Exit Form Date (mm/dd/year)P2_nfm_AppChDate Applicant Characteristic Date (mm/dd/year)P2_nfm_EntDate Entry Form Date (mm/dd/year)P2_nfm_ExitDate Exit Form Date (mm/dd/year)

SECTION 1: PHONE CALL LOG AND NOTESVariable Name Question (Variable Label) Response options



Call1_Part Phone Call 1- Participant Called 1- Participant 12- Participant 2

Call1_Date Phone Call 1- Date Numeric (mm/dd/year)

Call1_Time Phone Call 1- Time of Call Numeric (_:_ _ AM/PM)

Call1_Nav Phone Call 1- Project F.R.E.E. Staff Name

Text

Call1_Nature Phone Call 1- Nature of Call 1- Initial Intake2- PIV/PIC-related3- Pre-Assessment4- Needs Assessment5- Program reminder/follow-up6- Post-Assessment7- Other

Call1_NatureOth Phone Call 1- Nature of Call- Other TextCall1_Result Phone Call 1- Result of Call 1- No Answer/Kept Ringing

2- Hang Up3- Disconnected4- Voice Message5- Spoke to6- Other

Call1_ResultWho Phone Call 1- Result of Call- Spoke to TextCall1_ResultOth Phone Call 1- Result of Call- Other TextCall1_FUNeed Phone Call 1- Follow Up Needed 0- No; 1- YesCall1_Desc Phone Call 1- Yes (describe) TextCall2_Part Phone Call 2- Participant Called 1- Participant 1

2- Participant 2Call2_Date Phone Call 2- Date Numeric

(mm/dd/year)Call2_Time Phone Call 2- Time of Call Numeric (_:_ _

AM/PM)Call2_Nav Phone Call 2- Project F.R.E.E. Staff

NameText



2- Hang Up3- Disconnected4- Voice Message5- Spoke to

6- OtherCall2_ResultWho Phone Call 2- Result of Call- Spoke to TextCall2_ResultOth Phone Call 2- Result of Call- Other TextCall2_FUNeed Phone Call 2- Follow Up Needed 0- No; 1- YesCall2_Desc Phone Call 2- Yes (describe) TextCall3_Part Phone Call 3- Participant Called 1- Participant 1

2- Participant 2Call3_Date Phone Call 3- Date Numeric

(mm/dd/year)Call3_Time Phone Call 3- Time of Call Numeric (_:_ _

AM/PM)Call3_Nav Phone Call 3- Project F.R.E.E. Staff

NameText



2- Hang Up3- Disconnected4- Voice Message5- Spoke to6- Other

Call3_ResultWho Phone Call 3- Result of Call- Spoke to TextCall3_ResultOth Phone Call 3- Result of Call- Other TextCall3_FUNeed Phone Call 3- Follow Up Needed 0- No; 1- YesCall3_Desc Phone Call 3- Yes (describe) Text

FORM 2A: CONTACT INFORMATIONVariable Name Field Question Response options



P1_PriCont Primary Contact: Participant 1 (Initial Applicant)

0- No; 1- Yes

P1_LName Last Name TextP1_FName First Name TextP1_MidIn Middle Initial Text (one letter)P1_StrAd Street Address Text/NumericP1_Apt Apartment/Unit # Text/NumericP1_Cnty County Text (Dropdown-see

Region 5 County Table)

P1_City City Text (Dropdown- See City table per county)

P1_State State (GA)P1_Zip Zip Code NumericP1_CellPh Cell Phone

P1_CellVoice OK to leave voicemail or text message?

0- No; 1- Yes

P1_HmPh Home Phone P1_HmVoice OK to leave voicemail or text

message?0- No; 1- Yes

P1_AltPh Alternate PhoneP1_AltVoice OK to leave voicemail or text

message?0- No1- Yes

P1_PrefCont Preferred Contact 1- Cell Phone2- Home Phone3- Alternate Phone

P1_BestCallDay Best Day(s) to Call 1- Mon2- Tues3- Wed4- Thur5- Fri

P1_BestCallTime Best Time(s) to Call 1- 10AM-12PM2- 12PM-3PM3- 3PM-6PM4- 6PM-8PM

P1_Email Email Text/NumericP1_EmailInfo OK to email with class information 0- No; 1- YesP2_PriCont Primary Contact: Participant 2 0- No; 1- YesP2_LName Last Name TextP2_FName First Name TextP2_MidIn Middle Initial Text (one letter)P2_P1Address Same address as P1 0- No; 1- YesP2_StrAd Street Address Text/NumericP2_Apt Apartment/Unit # Text/NumericP2_Cnty County Text (Dropdown-see

Region 5 County Table)

P2_City City Text (Dropdown- See City table per county)

P2_State State (GA)P2_Zip Zip Code NumericP2_CellPh Cell PhoneP2_CellVoice OK to leave voicemail or text


P2_HmPh Home Phone P2_HmVoice OK to leave voicemail or text


P2_AltPh Alternate PhoneP2_AltVoice OK to leave voicemail or text


P2_PrefCont Preferred Contact 1- Cell Phone2- Home Phone3- Alternate Phone

P2_BestCallDay Best Day(s) to Call 1- Mon2- Tues3- Wed4- Thur5- Fri

P2_BestCallTime Best Time(s) to Call 1- 10AM-12PM2- 12PM-3PM3- 3PM-6PM4- 6PM-8PM

P2_Email Email Text/NumericP2_EmailInfo OK to email with class information Check Boxes:

Yes/No0- No; 1- Yes

P1_EmerConNm Emergency Contact Information: Full Name

P1_EmerConPh Emergency Contact Information: Phone Number

P1_EmerConRel Emergency Contact Information: Relationship to you?

P2_EmerConNm Emergency Contact Information: Full Name

P2_EmerConPh Emergency Contact Information: Phone Number

P2_EmerConRel Emergency Contact Information: Relationship to you?

FORM 2B: ELIGIBILITY INFORMATIONVariable Name Question (Variable Label) Response options



I. Relationship StatusRelStat Are you currently in a committed

couple relationship?0- No; 1- Yes

RelStatTyp IF YES: How would you describe your current couple relationship?

1- Dating2- Engaged3- Married4- Other

RelStatTyp_Oth Current couple relationship- Other TextLenMar_Yr If married: How long have you been

married (years)?Numeric

LenMar_Mth If married: How long have you been married (months)?

Numeric

LenRel_Yr In total, how long have you been Numeric

with your partner (years)?LenRel_Mth In total, how long have you been

with your partner (months)?Numeric

LvTg Do you and your partner currently live together?

0- No; 1- Yes

II. Parenting StatusHaveCh Excluding children in foster care,

how many children do you (and/or your partner) have?

Numeric

YChAge_Yr Excluding children in foster care, what is the age of your (and/or your partner’s) youngest child (years)?

Numeric

YChAge_Mth Excluding children in foster care, what is the age of your (and/or your partner’s) youngest child (months)?

Numeric

YChSex Youngest Child Gender 0- Female1- Male

YChRel Youngest Child Relationship 1- Biological2- Adopted 3- Stepchild4- Other

YChRel_Oth Youngest Child Relationship- Other TextYCh_Part Youngest Child- Whose 1- Part. 1

2- Part. 23- Both

OChAge_Yr Excluding children in foster care, what is the age of your (and/or your partner’s) oldest child (years)?

Numeric

OChAge_Mth Excluding children in foster care, what is the age of your (and/or your partner’s) oldest child (months)?

Numeric

OChSex Oldest Child Gender 0- Female1- Male

OChRel Oldest Child Relationship 1- Biological2- Adopted 3- Stepchild4- Other

OChRel_Oth Oldest Child Relationship- Other TextOCh_Part Oldest Child- Whose 1- Part. 1

2- Part. 23- Both

CurrPreg Are you (or your partner) currently pregnant?

0- No; 1- Yes

FPar Are you an approved and currently active (i.e., eligible for placement) foster parent?

0- No; 1- Yes

III. Foster Caregiver Status

Num_FCh In the past 12 months, how many children in foster care have you cared for?

Numeric

CurrNum_FCh Currently how many children in foster care are living in your home?

Numeric

LenFPar_Yr How long have you been an approved foster caregiver (years)?

Numeric

LenFPar_Mth How long have you been an approved foster caregiver (months)?

Numeric

AgencyCertU Which agency are you certified under?

1- DFCS2- CPA3- Other

AgencyCertU_Oth Agency certified under- Other TextFPar_Reg Foster Caregiver registering for

weekend retreat?0- No; 1- Yes

Both_Attend IF YES: Are both you and your partner planning to attend?

0- No; 1- Yes

Prov_CCard Would you be able to provide a credit card to reserve your hotel room?

0- No; 1- Yes

CCare_Need From your application I see you wanted/needed to bring your children to the retreat, is this correct?

0- No; 1- Yes

CCare_ChAges IF Yes: Ages of each child you would need to bring with you:FORM 2C-1: RELATIONSHIP SAFETY SCREENING (PARTNER)

Variable Name Question (Variable Label) Response options (numeric, text, check box needed, etc.)


P1_2C1_RSS1 In general, how would you describe your relationship?

0- No tension1- Some tension2- A lot of tension

P1_2C1_RSS2 Do you and your partner work out arguments with…

0- No difficulty1- Some difficulty2- Great difficulty

P1_2C1_RSS3 Do arguments ever result in you feeling down or bad about yourself?

0- Never1- Sometimes2- Often

P1_2C1_RSS4 Do arguments ever result in hitting, kicking or pushing?


P1_2C1_RSS5 Do you ever feel frightened by what your partner says or does?



0- No tension1- Some tension

2- A lot of tensionP2_2C1_RSS2 Do you and your partner work out

arguments with…0- No difficulty1- Some difficulty2- Great difficulty







FORM 2C-2: RELATIONSHIP SAFETY SCREENING (CO-PARENT)




0- No tension1- Some tension2- A lot of tension

P1_2C2_RSS2 Do you and your partner work out arguments with…

0- No difficulty1- Some difficulty2- Great difficulty







FORM 2D: ENGAGEMENT WITH DFCS/ADDITIONAL SOCIAL SERVICES



SNAP_Recv Food Stamps or Supplemental Nutritional Assistance Program

0- No1- Yes Past2- Yes Current

WIC_Recv Women, Infants, and Children 0- No1- Yes Past2- Yes Current

TANF_Recv Temporary Assistance for Needy Families


Medicaid_Recv Medicaid 0- No1- Yes Past2- Yes Current

OthDFCSSer_Recv Other services from DFCS or the Health Department


CurrOC_FC DFCS Open Case: Foster Care 0- No1- Yes Past2- Yes Current

CurrOC_FamPres DFCS Open Case: Family Preservation


CurrOC_Investig DFCS Open Case: Open DFCS Investigation


CurrOC_FamSup DFCS Open Case: Family Support Case


CurrOC_ActCrtInv DFCS Open Case: Active Court Involvement


CurrOC_Oth DFCS Open Case: Other 0- No1- Yes Past2- Yes Current

CMngr_Nm DFCS Case Manager Name TextCMngr_Ph DFCS Case Manager Phone Number TextFrstStps_Recv First Steps 0- No

1- Yes Past2- Yes Current

ParAsTeach_Recv Parents as Teachers 0- No1- Yes Past2- Yes Current

HFamGa_Recv Healthy Families Georgia 0- No1- Yes Past2- Yes Current

GenHmSer_Recv General counseling, parenting, early intervention, or other types of home services


HdStrt_Recv Early Head Start or Head Start 0- No1- Yes Past2- Yes Current

OthHmVSer_Recv Other service where someone comes to your home


SSI_Recv Supplemental Security Income 1- No2- Yes Past3- Yes Current

SSDI_Recv Social Security Disability Insurance 1- No2- Yes Past3- Yes Current

UnempIns_Recv Unemployment Insurance 1- No2- Yes Past3- Yes Current

VITA_Recv Voluntary Income Tax Assistance 1- No2- Yes Past3- Yes Current

FreeFinCnsl_Recv Free financial Counseling 1- No2- Yes Past3- Yes Current

HousEdc_Recv Housing Education 1- No2- Yes Past3- Yes Current

HousVouch_Recv Housing choice voucher 1- No2- Yes Past3- Yes Current

HousAthy_Recv Housing Authority 1- No2- Yes Past3- Yes Current

FinAssist_Recv Financial Assistance 1- No2- Yes Past3- Yes Current

FreeCCare_Recv Free or subsidized childcare resources


FreeEmpSer_Recv Free job coaching or employment services


OthFinSer_Recv Other financial support service 1- No2- Yes Past3- Yes Current

ProjSafe_Recv Project Safe 1- No2- Yes Past3- Yes Current

UGAExt_Recv UGA Extension 1- No2- Yes Past3- Yes Current

OthAddSer_Recv Other support service 1- No2- Yes Past3- Yes Current

GenNeeds What, if any, are potential obstacles that might prevent you and your family from participating in this program?

Text

ExistingRes What, if any, are existing resources Text

that might assist you and your family in participating in this program?

FORM 3A: RELATIONSHIP AND FAMILY INFORMATIONVariable Name Question (Variable Label) Response options



Participant 1P1_MarStat Currently married 0- No; 1- YesP1_RelHist_SPar If single: Have you ever been

married?0- No; 1- Yes

P1_XMar All: How many times (if married: including your current marriage), have you been married?

Numeric

P1_NumAdH How many adults, including yourself, live in the home at least half of the time?

Numeric

P1_NumChH How many children under the age of 18 are living in the house at least half of the time?

Numeric

P1_NumBioCh_Cpl If couple: How many biological children do you and your current partner share?

Numeric

P1_NumBioCh_SPar If single: How many biological children do you have?

Numeric

P1_NumAdpCh_Cpl If couple: How many adoptive children do you and your current partner share?

Numeric

P1_NumAdpCh_SPar If single: How many adoptive children do you currently have?

Numeric

P1_NumChPrvRelH How many children do you have from a previous relationship living with you in the household?

Numeric

P1_NumChPrvRelNH How many children do you have from your previous relationships who are not living in the household?

Numeric

P1_Preg Expecting/Pregnant 0- No; 1- YesP1_FrstPreg If Expectant Parent: Is this your first

child?0- No; 1- Yes

P1_LenPreg If Expectant Parent:How many months are you (your partner) into your pregnancy?

Numeric (2 digits for MTHS)

P1_CaredFCh In the past 12 months, have you (and your partner) cared for a child in foster care?

0- No; 1- Yes

P1_NumFCh If Foster Caregiver: In the past 12 months, how many children in

Numeric

foster care have you cared for?P1_CurrNumFCh If Foster Caregiver: Currently how

many children in foster care are living in your home?

Numeric

P1_LenFPar_Yr If Foster Caregiver: How long have you been an approved foster caregiver (years)?

Numeric

P1_LenFPar_Mth If Foster Caregiver: How long have you been an approved foster caregiver (months)?

Numeric

Participant 2P2_MarStat Currently married 0- No; 1- YesP2_XMar All: How many times (if married:

including your current marriage), have you been married?

Numeric

P2_NumAdH How many adults, including yourself, live in the home at least half of the time?

Numeric

P2_NumChH How many children under the age of 18 are living in the house at least half of the time?

Numeric

P2_NumBioCh_Cpl If couple: How many biological children do you and your current partner share?

Numeric

P2_NumAdopCh_Cpl If couple: How many adoptive children do you and your current partner share?

Numeric

P2_NumChPrvRelH How many children do you have from a previous relationship living with you in the household?

Numeric

P2_NumChPrvRelNH How many children do you have from your previous relationships who are not living with you in the household?

Numeric

P2_Preg Expecting/Pregnant 0- No; 1- YesP2_FrstPreg If Expectant Parent:

Is this your first child?0- No; 1- Yes

P2_LenPreg If Expectant Parent:How many months are you (your partner) into your pregnancy?

Numeric (2 digits for MTHS)

P2_CaredFCh In the past 12 months, have you (and your partner) cared for a child in foster care?

0- No; 1- Yes

P2_NumFCh In the past 12 months, how many children in foster care have you cared for?

Numeric

P2_CurrNumFCh Currently how many children in Numeric

foster care are living in your home?P2_LenFPar_Yr How long have you been an

approved foster caregiver (years)?Numeric

P2_LenFPar_Mth How long have you been an approved foster caregiver (months)?

Numeric

FORM 3B: ABOUT YOUVariable Name Question (Variable Label) Response options



Part1 Participant 1 1- Participant 12- Participant 2

P1_DOB Date of BirthP1_Age Age (in years) NumericP1_Sex What is your gender? 0- Female

1-Male2- Other

P1_SexOth Gender Other TextP1_SexOr How would you describe your sexual

orientation?1- Heterosexual2- Gay/Lesbian3- Bisexual4- Other

P1_SexOrOth Sexual orientation Other TextP1_Race How would you describe your race? 1- White/Caucasian

2- African-American/ Black 3- Asian-American4- Native-American/ Alaskan Native5- Native Hawaiian/Other Pacific Islander6- Other

P1_RaceOth Race Other TextP1_Eth How would you describe your

ethnicity?1- Non-Hispanic 2- Hispanic3- Other

P1_EthOth Ethnicity Other TextP1_Student Are you currently in school or

college?0- No1- Yes, Full-time2- Yes, Part-time

P1_Edc What is the highest level of education you have completed?

1- High School General Education Development2- Attended high school, but did not earn diploma3- High school diploma4- Vocational/ technical school certification5- Some college but no degree completion

6- Associate’s degree7- Bachelor’s degree8- Master’s degree/Advanced degree

P1_EmpStat What is your current employment status?

1- Not currently employed2- Full-time (35+ hours/week)3- Part-time (1-34 hours/week)4- Temporary, occasional, seasonal, or odd jobs for pay

P1_UnempStat If unemployed, are you: 1- Actively looking for work2- Disabled3- Retired4- None of the above

P1_EmpBen If employed, do you have benefits through your job such as paid vacation, sick leave, or life insurance?

0- No1- Yes2- I don’t know

P1_Occp If employed, what is your occupation?

Text

P1_HH_AnnInc What is your total household annual income (if married or living together)?

1- Less than $7,000 2- $7,000 – $13,9993- $14,000 – $24,9994- $25,000 – $39,999 5- $40,000 – $74,9996- $75,000 – $99,9997- $100,000+

P1_Last30_Inc In the past 30 days, how much money did you make?

1- Less than $5002- $500 - $1,0003- $1,001 - $2,0004- $2,001 - $3,0005- $3,001 - $4,0006- $4,001 - $5,0007- More than $5,000

P1_LvStat What is your current living situation?

1- Home Owner2- Rent3- Other

P1_LvStatOth Living situation Other TextP1_DietRes Do you have any dietary

restrictions?0- No1- Vegetarian2- Vegan3- Nut Allergy4- Other

P1_DietResOth Dietary restrictions Other TextP1_Transp Do you have access to

transportation that would allow you and your family to attend classes for this program?

0- No; 1- Yes

P1_SNeed Do you have any special needs that impair your daily functioning?

0- No1- Have a physical disability2- Have a learning disability3- Have a developmental disability4- Have been diagnosed with a mental illness5- Have a medical illness6- Other

P1_SNeedOth Special needs Other TextP1_GNeed Which of the following, if any, do

you feel describe your greatest needs right now?

1- Unstable housing2- Rent/mortgage assistance3- Immediate shelter4- Utilities assistance5- Access to phone6- Connection to educational resources7- Unemployment8- Childcare9- Career/vocational training10- Food11- Clothing12- Access to medical care13- Social support14- Physical safety15- Access to mental health treatment16- Access to transportation17- Child(ren)’s developmental needs

P2 Participant 2 1- Participant 12- Participant 2

P2_DOB Date of BirthP2_Age Age (in years) NumericP2_Sex What is your gender? 0- Female

1-Male2- Other

P2_SexOth Gender Other TextP2_SexOr How would you describe your sexual

orientation?1- Heterosexual2- Gay/Lesbian3- Bisexual4- Other

P2_SexOrOth Sexual orientation Other TextP2_Race How would you describe your race? 1- White/Caucasian

2- African-American/ Black 3- Asian-American4- Native-American/ Alaskan

Native5- Native Hawaiian/Other Pacific Islander6- Other

P2_RaceOth Race Other TextP2_Eth How would you describe your

ethnicity?1- Non-Hispanic 2- Hispanic3- Other

P2_EthOth Ethnicity Other TextP2_Student Are you currently in school or

college?0- No1- Yes, Full-time2- Yes, Part-time

P2_Edc What is the highest level of education you have completed?

1- High School General Education Development2- Attended high school, but did not earn diploma3- High school diploma4- Vocational/ technical school certification5- Some college but no degree completion6- Associate’s degree7- Bachelor’s degree8- Master’s degree/Advanced degree

P2_EmpStat What is your current employment status?

1- Not currently employed2- Full-time (35+ hours/week)3- Part-time (1-34 hours/week)4- Temporary, occasional, seasonal, or odd jobs for pay

P2_UnempStat If unemployed, are you: 1- Actively looking for work2- Disabled3- Retired4- None of the above

P2_EmpBen If employed, do you have benefits through your job such as paid vacation, sick leave, or life insurance?


P2_Occp If employed, what is your occupation?

Text

P2_HH_AnnInc What is your total household annual income (if married or living together)?

1- Less than $7,000 2- $7,000 – $13,9993- $14,000 – $24,9994- $25,000 – $39,999 5- $40,000 – $74,9996- $75,000 – $99,9997- $100,000+

P2_Last30_Inc In the past 30 days, how much money did you make?

1- Less than $5002- $500 - $1,0003- $1,001 - $2,0004- $2,001 - $3,0005- $3,001 - $4,0006- $4,001 - $5,0007- More than $5,000

P2_LvStat What is your current living situation?

1- Home Owner2- Rent3- Other

P2_LvStatOth Living situation Other TextP2_DietRes Do you have any dietary

restrictions?0- No1- Vegetarian2- Vegan3- Nut Allergy4- Other

P2_DietResOth Dietary restrictions Other TextP2_Transp Do you have access to

transportation that would allow you and your family to attend classes for this program?

0- No; 1- Yes

P2_SNeed Do you have any special needs that impair your daily functioning?

0- No1- Have a physical disability2- Have a learning disability3- Have a developmental disability4- Have been diagnosed with a mental illness5- Have a medical illness6- Other

P2_SNeedOth Special needs Other TextP2_GNeed Which of the following, if any, do

you feel describe your greatest needs right now?

1- Unstable housing2- Rent/mortgage assistance3- Immediate shelter4- Utilities assistance5- Access to phone6- Connection to educational resources7- Unemployment8- Childcare9- Career/vocational training10- Food11- Clothing12- Access to medical care13- Social support14- Physical safety15- Access to mental health

treatment16- Access to transportation17- Child(ren)’s developmental needs

FORM 3C-1: YOUR RELATIONSHIP EXPERIENCES (PARTNER)Variable Name Question (Variable Label) Response options



P1_3C1_YE1 How safe do you feel in your current relationship?

1, 2, 3, 4, 5, 6, 7, 8, 9, 10

P1_3C1_YE2 My partner never admits when she or he is wrong.

1, 2, 3, 4, 5

P1_3C1_YE3 My partner is unwilling to adapt to my needs and expectations.

1, 2, 3, 4, 5

P1_3C1_YE4 My partner is more insensitive than caring.

1, 2, 3, 4, 5

P1_3C1_YE5 I am often forced to sacrifice my own needs to meet my partner's needs.

1, 2, 3, 4, 5

P1_3C1_YE6 My partner refuses to talk about problems that make him or her look bad.

1, 2, 3, 4, 5

P1_3C1_YE7 My partner withholds affection unless it would benefit her or him.

1, 2, 3, 4, 5

P1_3C1_YE8 It is hard to disagree with my partner because she or he gets angry.

1, 2, 3, 4, 5

P1_3C1_YE9 My partner resents being questioned about the way he or she treats me.

1, 2, 3, 4, 5

P1_3C1_YE10 My partner builds himself or herself up by putting me down.

1, 2, 3, 4, 5

P1_3C1_YE11 My partner retaliates when I disagree with him or her.

1, 2, 3, 4, 5

P1_3C1_YE12 My partner is always trying to change me.

1, 2, 3, 4, 5

P1_3C1_YE13 My partner believes he or she has the right to force me to do things.

1, 2, 3, 4, 5

P1_3C1_YE14 My partner is too possessive or jealous.

1, 2, 3, 4, 5

P1_3C1_YE15 My partner tries to isolate me from family and friends.

1, 2, 3, 4, 5

P1_3C1_YE16 Sometimes my partner physically hurts me.

1, 2, 3, 4, 5

P2_3C1_YE1 How safe do you feel in your current relationship?

1, 2, 3, 4, 5, 6, 7, 8, 9, 10

P2_3C1_YE2 My partner never admits when she 1, 2, 3, 4, 5

or he is wrong.P2_3C1_YE3 My partner is unwilling to adapt to

my needs and expectations.1, 2, 3, 4, 5

P2_3C1_YE4 My partner is more insensitive than caring.

1, 2, 3, 4, 5

P2_3C1_YE5 I am often forced to sacrifice my own needs to meet my partner's needs.

1, 2, 3, 4, 5

P2_3C1_YE6 My partner refuses to talk about problems that make him or her look bad.

1, 2, 3, 4, 5

P2_3C1_YE7 My partner withholds affection unless it would benefit her or him.

1, 2, 3, 4, 5

P2_3C1_YE8 It is hard to disagree with my partner because she or he gets angry.

1, 2, 3, 4, 5

P2_3C1_YE9 My partner resents being questioned about the way he or she treats me.

1, 2, 3, 4, 5

P2_3C1_YE10 My partner builds himself or herself up by putting me down.

1, 2, 3, 4, 5

P2_3C1_YE11 My partner retaliates when I disagree with him or her.

1, 2, 3, 4, 5

P2_3C1_YE12 My partner is always trying to change me.

1, 2, 3, 4, 5

P2_3C1_YE13 My partner believes he or she has the right to force me to do things.

1, 2, 3, 4, 5

P2_3C1_YE14 My partner is too possessive or jealous.

1, 2, 3, 4, 5

P2_3C1_YE15 My partner tries to isolate me from family and friends.

1, 2, 3, 4, 5

P2_3C1_YE16 Sometimes my partner physically hurts me.

1, 2, 3, 4, 5

FORM 3C-2: YOUR RELATIONSHIP EXPERIENCES (CO-PARENT)



P1_3C2_YE1 How safe do you feel in your relationship with your child(ren)’s other parent?

1, 2, 3, 4, 5, 6, 7, 8, 9, 10

P1_3C2_YE2 My co-parent never admits when she or he is wrong.

1, 2, 3, 4, 5

P1_3C2_YE3 My co-parent is unwilling to adapt to my needs and expectations.

1, 2, 3, 4, 5

P1_3C2_YE4 My co-parent is more insensitive than caring.

1, 2, 3, 4, 5

P1_3C2_YE5 I am often forced to sacrifice my own needs to meet my co-parent's needs.

1, 2, 3, 4, 5

P1_3C2_YE6 My co-parent refuses to talk about problems that make him or her look bad.

1, 2, 3, 4, 5

P1_3C2_YE7 My co-parent withholds affection unless it would benefit her or him.

1, 2, 3, 4, 5

P1_3C2_YE8 It is hard to disagree with my co-parent because she or he gets angry.

1, 2, 3, 4, 5

P1_3C2_YE9 My co-parent resents being questioned about the way he or she treats me.

1, 2, 3, 4, 5

P1_3C2_YE10 My co-parent builds himself or herself up by putting me down.

1, 2, 3, 4, 5

P1_3C2_YE11 My co-parent retaliates when I disagree with him or her.

1, 2, 3, 4, 5

P1_3C2_YE12 My co-parent is always trying to change me.

1, 2, 3, 4, 5

P1_3C2_YE13 My co-parent believes he or she has the right to force me to do things.

1, 2, 3, 4, 5

P1_3C2_YE14 My co-parent is too possessive or jealous.

1, 2, 3, 4, 5

P1_3C2_YE15 My co-parent tries to isolate me from family and friends.

1, 2, 3, 4, 5

P1_3C2_YE16 Sometimes my co-parent physically hurts me.

1, 2, 3, 4, 5

FORM 3D1: RESIDENT CHILD INFORMATIONVariable Name Question Response options



RC1 Resident Child #1 (RC2 = Resident Child #2)

Numeric

RC1_LName Last Name TextRC1_FName First Name TextRC1_MidIn Middle Initial Text (one letter)RC1_Part Whose child is this? 1- Participant 1

2- Participant 23- Both4- Fostered

RC1_Rel What is your relationship to this child?

1- Biological Parent2- Step-Parent3- Adoptive Parent4- Foster Parent5- Kinship Care Provider

RC1_DOB Date of Birth

RC1_Age_Yr Age (years)RC1_Age_Mth Age (months)RC1_Sex Child’s Sex 0- Female

1- Male2- Other

RC1_SexOth Child’s Sex Other TextRC1_ Race How would you describe your child’s

race?1- White/Caucasian2- African-American/Black3- Asian-American4- Native-American/ Alaskan Native5- Native Hawaiian/Other Pacific Islander6- Other

RC1_RaceOth Race Other TextRC1_Eth How would you describe your child’s

ethnicity?1- Non-Hispanic2- Hispanic3- Other

RC1_EthOth Ethnicity Other TextRC1_Grade What grade is your child currently

in? -1- Pre-K

0- Kindergarten1- 1st

2- 2nd

3- 3rd

4- 4th

5- 5th

6- 6th

7- 7th

8- 8th 9- 9th 10- 10th 11- 11th 12- 12th

RC1_HIns Does your child have health insurance?

0- No1- Yes

RC1_HInsTyp IF YES, what kind of health insurance does your child have?

1- Medicaid2- PeachCare for Kids3- Through employer4- Other

RC1_HInsTyp_Oth Health Insurance Type Other TextRC1_SNeed Does your child have any special

needs?0- No1- Has a physical disability2- Has a developmental disability3- Has a medical illness4- Has a learning disability5- Has an individualized

Education Plan (IEP)6- Struggles to make good grades7- Has been diagnosed with a mental illness8- Other

RC1_SNeedOth Special Needs Other TextRC1_NRP_Have Does this child have a parent who

does not live in the home?0- No; 1- Yes

RC1_NRP_DPW On average, how many days per week does the non-resident parent see this child?

1, 2, 3, 4, 5, 6, 7

RC1_NRP_WPM How many weekends per month does the non-resident parent see this child?

0- 01- 12- 23- 34- Every

RC1_NRP_Consult How often do you consult with the non-resident parent on matters relating to this child?

1- Most of the time2- Some of the time3- Seldom4- Never

RC1_NRP_ContFin Does the non-resident parent contribute financially to support for this child?

0- No; 1- Yes

RC1_TimeHH_Yr What is the length of time this child has spent in your household (years)?

Numeric

RC1_TimeHH_Mth What is the length of time this child has spent in your household (months)?

Numeric

RC1_P1_Rel What is your (P1) relationship to this child?

1- Foster Parent2- Grandmother3- Grandfather4- Aunt5- Uncle6- Niece7- Nephew8- Sister9- Brother10- Cousin11- Family Friend12- Other

RC1_P1_RelOth P1 relationship to this child Other TextRC1_P2_Rel What is your (P2) relationship to this

child?Check Boxes:Foster Parent, Grandmother, Grandfather,Aunt, Uncle,

1- Foster Parent2- Grandmother3- Grandfather4- Aunt5- Uncle

Niece, Nephew,Sister, Brother,Cousin, Family Friend,Other (text box)

6- Niece7- Nephew8- Sister9- Brother10- Cousin11- Family Friend12- Other

RC1_P2_RelOth P2 relationship to this child Other TextRC1_P1_Adopt If this child were free to be legally

adopted, would you (P1) plan to adopt this child?


RC1_P2_Adopt If this child were free to be legally adopted, would you (P2) plan to adopt this child?


RC1_Attend To attend the Project F.R.E.E. program would you need to bring this child with you?

0- No; 1- Yes

RC1_DietRes Does your child have any dietary restrictions?

0- No1- Vegetarian2- Vegan3- Nut allergy4- Dairy allergy5- Other

RC1_DietResOth Dietary Restrictions Other TextRC1_Notes Is there anything else you would like

to share that would be helpful to our child care providers?

Text

RC1_CarSeat Do you have access to a car seat or booster seat for your child?

0- No; 1- Yes

FORM 3D2: NON-RESIDENT CHILD INFORMATIONVariable Name Question (Variable Label) Response options



NRC1 Non-Resident Child #1 (NRC2 = Non-Resident Child #2)

Numeric

NRC1_LName Last Name TextNRC1_FName First Name TextNRC1_MidIn Middle Initial Text (one letter)NRC1_Resp Whose child is this? 1- Participant 1

2- Participant 2NRC1_Rel What is your relationship to this

child?1- Biological Parent2- Step-Parent3- Adoptive Parent

NRC1_DOB Date of Birth NumericNRC1_Age_Yr Age (years) NumericNRC1_Age_Mth Age (months)NRC1_Sex Child’s Sex 0- Female

1- Male2- Other

NRC1_SexOth Child’s Sex Other TextNRC1_ Race How would you describe your child’s

race?1- White/Caucasian2- African-American/Black3- Asian-American4- Native-American/ Alaskan Native5- Native Hawaiian/Other Pacific Islander6- Other

NRC1_RaceOth Child’s Race Other TextNRC1_Eth How would you describe your

ethnicity?1- Non-Hispanic2- Hispanic3- Other

NRC1_EthOth Child’s Ethnicity Other TextNRC1_Grade What grade is your child currently

in? -1- Pre-K

0- Kindergarten1- 1st

2- 2nd

3- 3rd

4- 4th

5- 5th

6- 6th

7- 7th

8- 8th 9- 9th 10- 10th 11- 11th 12- 12th

NRC1_HIns Does your child have health insurance?

0- No; 1- Yes

NRC1_HInsTyp If yes, what kind of health insurance does your child have?

1- Medicaid2- PeachCare for Kids3- Through employer4- Other

NRC1_HInsTyp_Oth Health Insurance Type Other TextNRC1_SNeed Does your child have any special

needs?0- No1- Has a physical disability2- Has a developmental disability3- Has a medical illness4- Has a learning disability5- Has an individualized Education Plan (IEP)6- Struggles to make good grades

7- Has been diagnosed with a mental illness8- Other

NRC1_SNeedOth Special Needs Other TextNRC1_DPW On average, how many days per

week do you see this child?1, 2, 3, 4, 5, 6, 7

NRC1_WPM How many weekends per month do you see this child?

0- 01- 12- 23- 34- Every

NRC1_PRP_Consult How often do you consult with the primary residential parent on matters relating to this child?

1- Most of the time2- Some of the time3- Seldom4- Never

NRC1_ContFin Do you contribute financially to support for this child?

0- No; 1- Yes

Documents

UPDATED CMDB Field