M14

MIECHV Baby’s Age 18 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

1.	In the past 6 months, have you (parent) taken your (index) child to the emergency department for an injury?

Yes (If yes, record the date)	No

NOTE: ER visits for illness should not be noted

Date: / / (month/day/year)

Date: / / (month/day/year)

Date: / / (month/day/year)

2.	Has child ever had any breast milk?	Yes → Go to Question 2a.	No → Go to Question 3.

2a.	If Yes, does child continue to get any breast milk?

Yes → Go to Question 3.	No → Go to Question 2b.

2b.	If No, date child stopped getting breast milk:	/ / 20

3.	Has your child had the following well-child visits?

12 months:	Yes	No

15 months:	Yes	No

4.	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